Multislice computed tomographic measurements of optic nerve sheath diameter in brain injury patients.

BACKGROUND: Currently, the measurement of optic nerve sheath diameter (ONSD) has been offered as a possible indicator of intracranial pressure (ICP). Increased ICP is observed during intracranial injury. The objective of this study was to evaluate the relationship between increased ONSD and positive intracranial findings from multislice computed tomography (CT) of the brain. METHODS: In total, CT scans of 161 patients were retrospectively reviewed. The image that showed the largest ONSD was magnified five times. RESULTS: The CT scan revealed intracranial lesions in 54 patients and no intracranial lesions in 107 patients. A significant relationship was observed between positive CT findings and increased ONSD: 5.60±0.75 mm vs. 5.35±0.75 mm (p=0.038). The area under the receiver operating characteristic curve was 0.600 (95% confidence interval, 0.508-0.692; p<0.039). A cut-off value of ≥5.0 mm had a sensitivity and specificity of 80% and 36%, respectively. CONCLUSION: This study demonstrated a significant yet poor relationship between intracranial injury and increased ONSD from the multislice CT scan. Severe structural changes in the brain and trauma that causes bleeding have only limited effects on the extension of the optic nerve.

Comparison of skin effects of immediate treatment modalities in experimentally induced hydrofluoric acid skin burns.

Hydrofluoric acid (HF) burns cause immediate damage and painful long-term sequellae. Traditionally, chelating agents have been used as the initial treatment for such burns. We have introduced epidermal growth factor (EGF) into an HF model to compare EGF with Ca(2+) and Mg(2+) treatments; 40 Sprague Dawley rats were divided into five groups. Each rat suffered a 6 × 4 cm(2) burn induced by 40% HF. Group 1 had no treatment, group 2 had saline injected beneath the burn, group 3 received magnesium sulphate injections, group 4 received calcium gluconate and group 5 received EGF. Specimens were evaluated via planimetry and biopsy at intervals of 4, 8, 24 and 72 hours. Fluid losses were significantly less in the Mg(2+) and EGF groups. The EGF group had the smallest burn area, least oedema, least polymorphonuclear granulocyte (PMN) infiltration, most angiogenesis and highest fibroblast proliferation of any group (P < 0·005). EGF limited HF damage morphologically and histologically more effectively than Ca(2+) or Mg(2+). This finding indicates that HF treatment via growth factors may be an improvement over chelation therapy.

De novo cerebral arteriovenous malformation: Pink Floyd's song "Brick in the Wall" as a warning sign.

BACKGROUND: Arteriovenous malformations are shunts between an artery and the venous system that lie within a nidus without an intervening capillary bed. These lesions are thought to be congenital, but recent reports have challenged this assumption. CASE REPORT: A 50-year-old man presented to the emergency department with a generalized tonic-clonic seizure. Before the onset of his seizure, he experienced a vivid auditory hallucination of his favorite song by the band Pink Floyd, "A Brick in the Wall." He had been diagnosed with epilepsy 25 years previously. On presentation, his neurological examination was normal, but a computed tomography scan of the brain revealed a large arteriovenous malformation (AVM) occupying the left temporal lobe. Upon more detailed questioning, he recalled that a brain angiogram had been performed 25 years before and was reported to be normal. Neurosurgery was not performed in view of the size of the malformation. The patient is being followed-up as an outpatient. CONCLUSION: AVMs may arise de novo and then spontaneously become symptomatic. Cerebral de novo AVM should be considered in the differential diagnosis in patients with complex auditory musical hallucinations or any new neuropsychiatric symptoms.

Agreement between axillary, tympanic, and mid-forehead body temperature measurements in adult emergency department patients.

OBJECTIVE: To assess the agreement between noncontact infrared thermometer (noncontact) with infrared tympanic thermometer (tympanic) and electronic axillary thermometer (axillary) in an adult emergency department population. MATERIALS AND METHODS: This is a single-center, cross-sectional, prospective trial carried out in a Joint Commission accredited private hospital in Turkiye. All consecutive patients above 16 years were included in the study. The agreements between three methods were analyzed by Bland-Altman analysis with MedCalc 11.0.4 statistical software. RESULTS: Body temperatures were measured on 400 patients (48% were men, mean 35.9±17.3°C). Mean noncontact, tympanic, and axillary measurements (±SD) were 37.22±1.03, 36.72±0.95, and 36.91±0.96°C, respectively, whereas Intraclass Correlation Coefficient of all measurements was 0.892 (95% confidence interval 0.821-0.929). Binary comparisons between body temperature measurements produced mean differences Δ axillary-tympanic, Δ axillary-noncontact, and Δ tympanic-noncontact as 0.5±0.63, 0.2±0.71, and 0.31±0.61°C, respectively. However, the agreement limits for axillary and noncontact was between -1.2 and 1.6°C; -1.74 and 0.74°C for tympanic and noncontact, and -1.52 and 0.9°C for tympanic and noncontact. CONCLUSION: There is a lack of agreement between body temperature measurements by noncontact, tympanic, and axillary in the adult emergency department population. The easy application may lead noncontact to be the preferable method for healthcare providers but large agreement limits should be considered.

Ketamine with and without midazolam for emergency department sedation in adults: a randomized controlled trial.

STUDY OBJECTIVE: We assess whether midazolam reduces recovery agitation after ketamine administration in adult emergency department (ED) patients and also compared the incidence of adverse events (recovery agitation, respiratory, and nausea/vomiting) by the intravenous (IV) versus intramuscular (IM) route. METHODS: This prospective, double-blind, placebo-controlled, 2×2 factorial trial randomized consecutive ED patients aged 18 to 50 years to 4 groups: receiving either 0.03 mg/kg IV midazolam or placebo, and with ketamine administered either 1.5 mg/kg IV or 4 mg/kg IM. Adverse events and sedation characteristics were recorded. RESULTS: Of the 182 subjects, recovery agitation was less common in the midazolam cohorts (8% versus 25%; difference 17%; 95% confidence interval [CI] 6% to 28%; number needed to treat 6). When IV versus IM routes were compared, the incidences of adverse events were similar (recovery agitation 13% versus 17%, difference 4%, 95% CI -8% to 16%; respiratory events 0% versus 0%, difference 0%, 95% CI -2% to 2%; nausea/vomiting 28% versus 34%, difference 6%, 95% CI -8% to 20%). CONCLUSION: Coadministered midazolam significantly reduces the incidence of recovery agitation after ketamine procedural sedation and analgesia in ED adults (number needed to treat 6). Adverse events occur at similar frequency by the IV or IM routes.

Glass foreign body in soft tissue: possibility of high morbidity due to delayed migration.

BACKGROUND: Soft tissue foreign bodies (FBs) are a common occurrence in emergency departments (EDs). Some FBs cause complications, whereas others are asymptomatic and remain undetected for months or years. CASE REPORT: A 32-year-old man presented to the ED with complaints of back pain in the area of a subcutaneous lump that had migrated toward the midline, nearly 25 cm from its former location, over the previous 2 weeks. Twelve years previously, after falling onto a glass door that shattered, he had gone to a local ED and had his wound sutured, but no X-ray studies were taken. Within a few months, he noticed a lump near his scapula, but he did not relate it to the fall and it did not bother him much. Physical examination revealed a normal neurological examination and a palpable mass in the right paraspinal area at the level of the tenth thoracic vertebra. An X-ray study showed a 34-mm-long sharp density in the vicinity of the spinal canal near T10. Efforts lasting almost 2 h to identify and remove the foreign body were unsuccessful. The following day, a 4 × 6 × 34 mm sharp glass fragment was removed in the operating room under fluoroscopy. CONCLUSIONS: Retained soft-tissue foreign bodies may migrate very late and can cause high morbidity or mortality. It is important to be diligent in the search for foreign bodies, using ultrasound, computed tomography scan, or magnetic resonance imaging in cases in which initial plain radiographs are negative.

Can D-dimer testing help emergency department physicians to detect acute aortic dissections?

OBJECTIVE: To determine the diagnostic accuracy of D-dimer testing for detection of acute aortic dissection. METHODS: This study is a retrospective chart review of patients who had been evaluated with suspicion of acute aortic dissection. All patients' D-dimer levels were determined prior to their further work up in the emergency department. The study was conducted in a tertiary care center between February 2006-August 2008. The D-dimer assay used was the immunoturbidimetric assay, with a normal range up to 0.246 µg/ml. Statistical analysis was accomplished using Chi-square test, Student's t-test and a receiver-operating characteristics (ROC) curve analysis. RESULTS: Ninety-nine patients were included in the study, 30 patients were diagnosed as having acute aortic dissection and 69 patients were evaluated in non-acute aortic dissection group. In comparison of the two groups, positive D-dimer results were found to be significantly higher in acute aortic dissection group than in non-acute aortic dissection group (p=0.001). Sensitivity of the D-dimer test in detection of acute aortic dissection was found as 96.6% and the negative predictive value of the test was 97.3%. Specificity and positive predictive value of the D-dimer test were 52.2% and 46.8%, respectively. The area under the ROC curve yielded an acceptable certainty for excluding acute aortic dissection on base of negative results (AUC: 0.764; CI 95%: 0.674-0.855; p=0.001). CONCLUSION: D-dimer testing is helpful for emergency physicians in detection of patients with suspected acute aortic dissection in the emergency department.

Cardiac tamponade via a fistula to the pericardium from a hydatid cyst: case report and review of the literature.

Although echinococcus is endemic in many sheep-raising areas of the world, cardiac involvement is rare. Cysts usually reach the heart by means of the coronary circulation, but other routes have been proposed. Pericardial tamponade due to a hydatid cyst has not yet been described in the literature. We present the case of a 46-year-old woman who presented to the Emergency Department with complaints of chest pain and mild dyspnea. Her medical history was positive for a liver hydatid cyst operation 26 years earlier. She was tachypneic, tachycardic, and hypotensive. Pleural and pericardial effusions were detected on transthoracic echocardiography. When she worsened clinically, pericardiocentesis was performed and she promptly improved. A fistula was detected between the liver and pericardium on computed tomography (CT) scan of the torso. Serologic test (agglutination) for Echinococcus granulosus was positive in a 1/32 dilution. A final diagnosis of mediastinal hydatic cyst was made, and a 4-week course of albendazol was given. Then the cyst was surgically excised, and the patient recovered without complications.

Red flag in the emergency department: fracture and primary failure of a prosthetic valve.

This case report concerns a patient with fracture and primary dysfunction of a prosthetic valve. A 40-year-old man presented to the Emergency Department with a chief complaint of breakthrough pleuritic back pain and shortness of breath. Past surgical history was significant only for an aortic valve replacement and mitral valve replacement performed 16 years prior. The transthoracic echocardiography raised suspicion of prosthesis malposition. The patient was taken to the operating room by cardiothoracic surgeons for valve replacement. Operative findings revealed that a prosthetic valve leaflet in the mitral position had broken off. Primary prosthetic valve failure should not be overlooked in the differential diagnosis of patients with valve replacement and a rapidly deteriorating clinical course. Emergency echocardiography is a guide to convenient diagnosis and management. Early surgical consultation and early reparative surgery might prevent unnecessary morbidity and mortality.

A model of standardized training in basic life support skills of emergency medicine residents.

This intervention study was designed to determine the current level of basic life support knowledge and skills of residents in a university-based emergency medicine residency program, and to investigate the potential benefit derived by these residents from a standardized theoretical and practical training session. All residents underwent tests before and after the training session. The residents were asked to perform basic life support on a recording cardiopulmonary resuscitation mannequin. Assessments were made using a 10-item checklist, with the highest score being 17. Each step performed by the resident was scored by an emergency physician for accuracy and effectiveness. Twenty-eight residents participated in the study. According to the modified Berden scale, the pretest and posttest scores were 11.2 +/- 2.9 and 15.6 +/- 1.0, respectively, and the mean difference was 4.36 +/- 2.9 (t test, P<.001). Only 11 residents (39.3%) were rated as "good" or "very good" in the pretest, whereas the corresponding figure in the posttest was 27 (96.4%) (P<.001). Skills, such as checking the airway patency (P<.001), checking breathing (P<.001), appropriate compression rate (P<.003), and delivering 2 effective breaths (P<.001), improved significantly. Depth of chest compression (P<.023) was improved significantly only in residents with fewer than 2 years of experience. The training process should comprise standardized courses to facilitate acquisition of the desired skills.

Acute coronary ischemia following centipede envenomation: case report and review of the literature.

This is the first known case report of electrocardiographic (ECG) changes suggestive of coronary vasospasm following a centipede envenomation. A 60-year-old man presented to the emergency department (ED) 1 hour after being stung by a 12-cm centipede. He complained of right great toe pain that did not radiate to his leg. The patient had no known ischemic heart disease. He did not describe any exertional symptoms but admitted experiencing weakness. During the ED course, concurrent with obtaining peripheral intravenous access, the patient experienced diaphoresis, dizziness, hypotension, and bradycardia. His ECG showed new ST-T wave changes, which suggested an acute ischemic process. The patient's blood pressure was 89/60 mm Hg, his pulse rate was 47 beats/min, and his respiration rate was 28 breaths/min. In the following hours, ECG findings returned to baseline. His blood pressure improved gradually with fluid resuscitation after approximately 5 hours. Cardiac markers returned to normal in the 13th hour after the event, and the patient underwent exercise stress testing, which was negative. The patient was discharged with cardiology follow-up. Adult patients with centipede envenomation should be closely monitored in anticipation of possible myocardial ischemia due to vasospasm, hypotension, and myocardial toxic effects of the venom. A child receiving the same amount of venom would be potentially at greater risk.

Massive intracranial hemorrhage associated with the ingestion of dimethyl sulfoxide.

Dimethyl sulfoxide (DMSO) has been widely used in the treatment of arthritis and certain inflammatory diseases, and is also considered an alternative remedy for cancer even if not supported by concrete evidence. This report illustrates the first case of a fatal complication following the illicit use of this agent. A 55-y-old man who reportedly ingested 500 mg acetaminophen and approximately 1 ml DMSO solution was brought to the emergency department after experiencing 2 tonic-clonic seizures. He had been diagnosed with lung mesotelioma with brain metastases which caused no neurologic deficit. The ingested DMSO was the first dose within the last 3 mo. Examination revealed right-sided hemiplegia. Unenhanced computed tomography of the head showed 3 hemorrhagic areas with blood-cerebrospinal fluid at the left parietal, occipital and frontal regions accompanied by a midline shift. Despite initial resuscitation, 2 units of fresh frozen plasma and antiedema treatment, the patient experienced cardiac arrest that did not respond to resuscitative measures. DMSO can cause massive intrametastatic hemorrhage, and neurologic deterioration can be profound in patients with metastatic brain lesions.

Analysis of factors affecting satisfaction in the emergency department: a survey of 1019 patients.

The objective of this study was to identify factors that affect overall satisfaction of patients admitted to the emergency department (ED). All consecutive adult patients in the ED during a 14-day period who could communicate well were enrolled into this cross-sectional analytic study. Patients' demographic data, information on care, and level of satisfaction were recorded. Patients were asked to rate specific issues concerning their satisfaction (good and excellent) on a 5-point Likert scale. Response to the survey was obtained from 1019 (91.6%) of 1113 patients for analysis during the study. Satisfaction with physician experience, physician attitude, triage, explanation of health status and treatment, and discharge instructions were found to have significant impact on satisfaction (P < .001 for each). Satisfaction with physician experience level was the most important factor affecting overall satisfaction. Patient perception of the total time spent in the ED as "short" and "very short" was not demonstrated to be significantly related to overall satisfaction (P = .162). Temporal perceptions as "long" and "very long" were shown to be significantly related to overall satisfaction (P < .001). Behavioral characteristics of the healthcare providers and the hospital itself were the factors that had the greatest impact on overall satisfaction of the ED population evaluated.