Perfusion Index Measurement in Predicting Hypovolemic Shock in Trauma Patients.

BACKGROUND: Perfusion index (PI) derived from pulse oximeter shows the ratio of the pulsatile blood flow to the nonpulsatile blood flow or static blood in peripheral tissue. OBJECTIVES: The aim of this study was to investigate the relationship between PI and blood transfusion necessity in 24 h and stage of hemorrhagic shock, as well as the utility of PI according to laboratory and clinical parameters, and determining the major risk of hemorrhage. METHODS: PI was measured with a pulse oximeter in 338 patients (235 males, average age 41.8 ± 17.94 years). Laboratory parameters (hemoglobin, hematocrit, lactate, base deficits, pH) and clinical parameters (pulse rate, respiratory rate, SpO2, systolic blood pressure [SBP] and diastolic blood pressure [DBP]), shock index (SI) and revised trauma score (RTS) were recorded. Univariate analysis was used to determine major risk for bleeding, and the receiver operating characteristic curves were performed to compare parameters. RESULTS: PI was < 1 in 39 (11.5%) patients. Positive correlation between PI and hemoglobin (p < 0.001; r: 0.320), hematocrit (p < 0.001; r: 0.294), base deficit (p < 0.001; r: 0.315), pH (p < 0.05; r: 0.235), SBP (p < 0.001; r: 0.146), DBP (p < 0.001; r: 0.259), SpO2 (p < 0.001; r: 0.197), RTS (p < 0.001; r: 0.344), and negative correlation with lactate (p < 0.05; r: -0.117), pulse (p < 0.001; r: -0.326), respiratory rate (p < 0.001; r: -0.231), and SI (p < 0.001; r: -0.257) were detected. A difference was detected between class 1 and 2, and class 1 and 3 (both p < 0.05) in hemorrhagic shock. Thirty-one with PI < 1 had blood transfusion within 24 h (p < 0.001; odds ratio 111.98, sensitivity 75.6%, specificity 97.3, positive predictive value 79.5%, negative predictive value 96.7%). The main risk factors of the need for blood transfusions were PI, pulse rate, and SpO2. PI was more significant than lactate, base deficit, RTS, and SI measurements. CONCLUSION: PI might be beneficial in the detection and exclusion of critical patients and blood transfusion needs in the emergency department. PI can be used with vital signs and shock parameters in the early diagnosis of hemorrhage.

An analysis of patients that underwent computed tomography pulmonary angiography with the prediagnosis of pulmonary embolism in the emergency department.

INTRODUCTION: The purpose of this study is to analyze the frequency of other diagnoses and findings in patients that were diagnosed with or not diagnosed with PE following the CTPA in the ED and to analyze the relationship between diagnosis and D-dimer. INSTRUMENT AND METHOD: This study involves all patients that presented to the ED that underwent CTPA with the prediagnosis of PE. The items considered in this study were their reason for presenting to the ED and pretest clinical risks for PE, D-dimer, and CTPA results. FINDINGS: Of the 696 cases, the most common cause was shortness of breath (59.3%). The CTPA showed that 145 (20.83%) patients were suffering from PE. Among the remaining cases, 464 (66.66%) patients had pathological findings other than PE and 87 (12.5%) patients were reported as normal. The most common pathological results other than PE found in CTPA were atelectasis in 244 (39.9%) and ground glass in 165 (23.7%), as well as nonpulmonary results in 70 (10.05%) patients. The differences in D-dimer results of patients diagnosed with PE, patients diagnosed with another pathology, and patients with normal CTPA results were statistically significant (P < 0.001). CONCLUSION: CTPA scanning, performed on the basis of assessment scoring, helps in discovering other fatal pathologies in addition to PE.

The Flatness Index of Inferior Vena Cava can be an Accurate Predictor for Hypovolemia in Multi-Trauma Patients.

INTRODUCTION: Shock is the leading cause of death in multi-trauma patients and must be detected at an early stage to improve prognosis. Many parameters are used to predict clinical condition and outcome in trauma. Computed tomography (CT) signs of hypovolemic shock in trauma patients are not clear yet, requiring further research. The flatness index of inferior vena cava (IVC) is a helpful method for this purpose. METHODS: This is a prospective, cross-sectional study which included adult multi-trauma patients (>18 years) who were admitted to the emergency department (ED) and underwent a thoraco-abdominal CT from 2017 through 2018. The main objective of this study was to investigate whether the flatness index of IVC can be used to determine the hypovolemic shock at an early stage in multi-trauma patients, and to establish its relations with shock parameters. The patients' demographic features, trauma mechanisms, vitals, laboratory values, shock parameters, and clinical outcome within 24 hours of admission were recorded. RESULTS: Total of 327 (229 males with an average age of 40.9 [SD = 7.93]) patients were included in the study. There was no significant difference in the flatness index of IVC within genders (P = .134) and trauma mechanisms (P = .701); however, the flatness index of IVC was significantly higher in hypotensive (systolic blood pressure [SBP] ≤90 mmHg and/or diastolic blood pressure [DBP] ≤60 mmHg; P = .015 and P = .019), tachycardic (P = .049), and hypoxic (SpO2 ≤%94; P <.001) patients. The flatness index of IVC was also higher in patients with lactate ≥ 2mmol/l (P = .043) and patients with Class III hemorrhage (P = .003). A positive correlation was determined between lactate level and the flatness index of IVC; a negative correlation was found between Glasgow Coma Scale (GCS) and Revised Trauma Score (RTS) with the flatness index of IVC (for each of them, P <.05). CONCLUSION: The flatness index of IVC may be a useful method to determine the hypovolemic shock at an early stage in multi-trauma patients.

Factors Affecting Mortality in Patients Admitted to the Hospital by Emergency Physicians despite Disagreement with Other Specialties.

BACKGROUND: Emergency physicians (EPs) face critical admission decisions, and their judgments are questioned in some developing systems. This study aims to define the factors affecting mortality in patients admitted to the hospital by EPs against in-service departments' decision and evaluate EPs' admission diagnosis with final discharge diagnosis. METHODS: This is a retrospective analysis of prospectively collected data of ten consecutive years (2008-2017) of an emergency department of a university medical center. Adult patients (≥18 years-old) who were admitted to the hospital by EPs against in-service departments' decision were enrolled in the study. Significant factors affecting mortality were defined by the backward logistic regression model. RESULTS: 369 consecutive patients were studied, and 195 (52.8%) were males. The mean (SD) age was 65.5 (17.3) years. The logistic regression model showed that significant factors affecting mortality were intubation (p < 0.0001), low systolic blood pressure (p = 0.006), increased age (p = 0.013), and having a comorbidity (p = 0.024). There was no significant difference between EPs' primary admission diagnosis and patient's final primary diagnosis at the time of disposition from the admitted departments (McNemar-Bowker test, p = 0.45). 96% of the primary admission diagnoses of EPs were correct. CONCLUSIONS: Intubation, low systolic blood pressure on presentation, increased age, and having a comorbidity increased the mortality. EPs admission diagnoses were highly correlated with the final diagnosis. EPs make difficult admission decisions with high accuracy, if needed.

Bradyarrhythmia due to mirtazapine overdose: A case of serious adverse event in a suicidal patient.

There are a limited number of studies on postoverdose clinical findings of mirtazapine in the literature. Our case presented an unlikely junctional rhythm, which we have not seen in the previous studies, in a patient who had bradycardia and hypotension following mirtazapine intake. A 37-year old male was admitted to the emergency department (ED) after his suicide attempt with 300 mg PO of mirtazapine tablets. He took the drug 2 h prior to his ED visit. He did not have any complaints after the mirtazapine intake. His complete physical examination and electrocardiography (ECG) revealed no pathological findings. He was observed in the ED. The results were in the normal range in his blood test and he has 0 mg/dl of blood ethanol. He experienced dizziness after 5 h and 30 min. The blood pressure was 60/30 mmHg. The heart rate was 34 beats/min. The simultaneous ECG showed junctional bradycardia. 0.5 mg atropine IV was given two times at intervals. Norepinephrine infusion was initiated after normal saline therapy. Forty-five minutes later, he did not have any clinically significant complaint. There are no pathological findings in his follow-up ECG and physical examination. He was discharged of his own accord 10 h after his ED admission. His initial mirtazapine level was 145 ng/ml when he came to the ED. Mirtazapine was known to have a safe cardiac profile both for regular dose and overdose. However, physicians should consider that it might induce a life-threatening bradyarrhythmia.

Plasma Procalcitonin Is Useful for Predicting the Severity of Acute Cholecystitis.

BACKGROUND: Acute cholecystitis is a common complication of cholelithiasis. Delayed diagnosis may constitute morbidity and mortality; therefore, early diagnosis and determining the severity of acute cholecystitis are crucial. OBJECTIVES: This study aimed to determine the validity of blood procalcitonin (PCT) levels in assessing the severity of acute cholecystitis. METHODS: The Emergency Department (ED) patients diagnosed as acute cholecystitis were included in the study. Patients were allocated into three severity grades according to the Tokyo Guidelines 2013. PCT level was measured after the clinical and radiological diagnosis of acute cholecystitis in the ED. RESULTS: Ninety-five patients diagnosed with acute cholecystitis, among them 48 of were male. Forty patients (42.1%) were allocated to grade 1, 19 (20%) to grade 2, and 36 (37.9%) to grade 3. The median values of PCT were 0.104 ng/ml, 0.353 ng/ml, and 1.466 ng/ml for grade 1, 2, and 3 patients, respectively (p < 0.001). CONCLUSION: Blood procalcitonin levels can be used to determine the severity of acute cholecystitis effectively.

Injury, hospitalization, and operation rates are low in aerial sports.

OBJECTIVESS: Aerial sports can cause serious injuries. The rate of injuries is nevertheless reasonably low, contrary to popular belief. This study aimed to evaluate the rate and severity of injuries to ASI patients presented to our Emergency Department (ED). MATERIAL AND METHODS: The study was held at a university medical center. The patients who were presented or transferred to the ED in a four year period were retrospectively reviewed. RESULTS: 73.2% of patients were male. The mean age of patients was 28.6. The distribution of injury rates by activity was as follows: 1.46% in parachuting, 0.35% in paragliding, and 0.04% in hang-gliding. 75.6% of patients were trainees. In 82.9% of patients, the injury occurred during the practical session of training. The most common injury is soft tissue and ligamentous (ST/L) injury (41.5%). 25 patients (61%) had isolated lower extremity injuries (13 of them had fractures). Other isolated injuries were head trauma in 2 (4.9%) and vertebral fractures in 3 (7.3%) patients. 4 (9.8%) patients were diagnosed with multiple injuries. The overall rate of hospitalization was 0.07% (0.16% in parachuting, 0.08% in paragliding, and 0.03% in hang-gliding). The need for operation in overall activities was 0.04% (0.08% in parachuting, 0.03% in paragliding, and 0.03% in hang-gliding). The mortality rate was found to be zero in the region. CONCLUSION: Aerial sports are considered dangerous sports activities, but the injury, hospitalization, and operation rates are low.