External validation of the "deformity, edema, and pain in pronation" model for predicting wrist fractures.

BACKGROUND: The aim of this study is to externally validate the "Deformity, Edema, and Pain in Pronation" model, which determines the necessity for radiography in patients with wrist trauma. METHODS: This prospective, cross-sectional study was performed in a tertiary emergency department (ED). All patients admitted to the ED with wrist trauma aged 18 years and older were included in the study. Patients who did not have acute and blunt wrist trauma, those who could not be fully examined due to various reasons, and patients who did not wish to participate were excluded. Each patient was examined by their responsible physician, and imaging tests were requested based on the indications. All radiographic images were evaluated by an orthopedic surgeon who was blinded to the clinical information. This evaluation was accepted as the standard reference for diagnosing fractures. RESULTS: 391 patients were included in the study. 170 patients (43.5%) had at least one fracture. The sensitivity and specificity of the model formed in our study in predicting wrist fractures were 98.77% (95% CI: 95.61-99.85) and 27.60% (95% CI 21.82-34.00), respectively. The area under the receiver operating characteristic curve (AUC) on external validation of the model was 0.878 (p < 0.001; 95% CI: 0.844-0.913). With the practice of this rule, there would be a 16% decrease in X-ray imaging request, while only 0.5% patients would have missed inoperable fractures. CONCLUSION: The "deformity, edema, and pain in pronation" model is a reliable and practical clinical decision rule for determining the necessity of radiography in wrist trauma.

The evaluation of the sensitivity and specificity of wrist examination findings for predicting fractures.

BACKGROUND: The aim of this study was to evaluate the sensitivity and specificity of physical examination findings and functional tests in adult acute wrist trauma patients who presented to the emergency department (ED) and to create a reliable and practical clinical decision rule for determining the necessity of radiography in wrist trauma. METHODS: This prospective observational study was conducted in a tertiary ED. Each patient was checked for 18 physical examination findings and functional tests. Patients with suspected fracture were enrolled consecutively. Antero-posterior and lateral wrist views were performed for each patient. All radiographical studies were interpreted by an orthopedic surgeon. The prevalence, sensitivity and specificity, negative and positive predictive values of each finding were calculated. A modeling for predicting fractures was created using computer. RESULTS: 207 patients were evaluated and 69 patients (33.3%) had fractures. The most common encounterd fracture site was distal radius (29.5%). The most sensitive examination finding was pain in dorsiflexion (95.7%) and the most specific finding was ecchymosis (97.8%). Wrist edema, deformity and pain aggravated by pronation were found to be strong predictors of fracture. The area under the receiver operating characteristic curve at internal validation for a prediction model based on these three predictors was 0.88 (95% CI: 0.83-0,93). The overall sensitivity and specificity of this model were 94% (95% CI: 85-98%) and 51% (95% CI 43-60%) respectively. According to the model created in this study, 34% of acute blunt wrist trauma patients do not require any X-ray imaging. CONCLUSIONS: This triple modeling may be used as an effective decision rule for predicting all wrist fractures in the ED and in the disaster setting.

Accuracy of bedside ultrasonography for the diagnosis of finger fractures.

OBJECTIVE: Diagnosis of bone fractures by ultrasonography is becoming increasingly popular in emergency medicine practice. We aimed to determine the diagnostic sensitivity and specificity of point-of-care ultrasonography (PoCUS) compared with plain radiographs in proximal and middle phalanx fractures. METHODS: Between August 2012 and July 2013, adult patients presenting to our emergency department with a possible (by clinical evaluation) proximal or middle phalanx fracture of finger were invited to participate in this prospective cohort study. From those granting consent to participate, anteroposterior and lateral radiographs were obtained. PoCUS was then performed by emergency physicians blinded to the radiograph results. The criterion standard test for diagnosis was radiograph interpretation by an orthopedic surgeon blinded to the ultrasonographic findings. RESULTS: During the study period, 212 patients with an injury to the proximal or middle phalanx presented to the emergency department. Of these, 93 patients met exclusion criteria; thus, data were analyzed from the remaining 119 patients. Fracture prevalence was 24.3%. Diagnostic sensitivity of PoCUS was 79.3% (95% confidence interval [CI], 59.7%-91.2%), specificity was 90% (95% CI, 81.4%-95.0%), positive predictive value was 71.8% (95% CI, 53.0%-85.6%), negative predictive value was 93.1% (95% CI, 85.0%-97.1%), positive likelihood ratio was 7.93 (95% CI, 4.15-15), and negative likelihood ratio was 0.23 (95% CI, 0.11-0.47). CONCLUSION: Emergency physician-performed PoCUS was moderately sensitive and specific for diagnosing proximal and middle phalanx fractures.

Sensitivity and specificity of bedside ultrasonography in the diagnosis of fractures of the fifth metacarpal.

OBJECTIVES: Ultrasonography is becoming increasingly common in the diagnosis of fracture in emergency medicine. The aim of our study was to investigate the diagnostic accuracy of sonographic examinations for diagnosing fifth metacarpal fractures. METHODS: A prospective study was performed of consecutive patients aged >14 years admitted to the emergency department with hand trauma and tenderness over the fifth metacarpal. Anteroposterior and oblique plain x-rays were taken on all patients. Emergency physicians performed bedside sonographic examination. The x-rays were reported by an orthopaedic surgeon who was blinded to the sonographic examination findings. The orthopaedic surgeon's report was considered the gold standard unless a CT scan was performed. In the single case where this occurred, the CT scan report was considered the gold standard. RESULTS: Eighty one patients were included in the study, 39 of whom had fractures. Sonographic examination identified the fractures in 38 patients. One occult fracture undetected by plain radiography, later shown on CT scan, was identified by sonographic examination. There were three cases with false positive ultrasound findings. The sensitivity of the diagnosis of fifth metacarpal fractures by ultrasonography was 97.4% (95% CI 84.9% to 99.9%), specificity was 92.9% (95% CI 79.4% to 98.1%), positive likelihood ratio (LR) was 14 (95% CI 4.58 to 41), negative LR was 0.03 (95% CI 0.00 to 0.19), negative predictive value was 97.5% (95% CI 85.3% to 99.9%) and positive predictive value was 92.6% (95% CI 79% to 98.1%). CONCLUSIONS: Sonographic examination can be used as an effective diagnostic tool in patients with fifth metacarpal trauma.

The accuracy of bedside ultrasonography as a diagnostic tool for the fifth metatarsal fractures.

OBJECTIVES: Musculoskeletal ultrasonography is a technique that is becoming more popular in diagnosing injuries of emergency department (ED) patients especially for the diagnosis of fractures. In this study, we determined the reliability of ultrasonography for the diagnosis of fractures of the fifth metatarsal. METHOD: This is a prospective blind study. Patients over 14 years old who were admitted to the ED with acute foot injury and who had tenderness on the fifth metatarsal were consecutively enrolled into the study. A bedside ultrasonography exam was performed by an emergency physician, and antero-posterior and oblique views were obtained. X-rays were blindly evaluated by an orthopedic surgeon and were considered to be the gold-standard for diagnosing fractures. In patients with noncomminuted fractures, bone displacement was measured by both radiologically and sonographically. RESULTS: Eighty-four patients were included in this study. Their mean age was 36.0, and 42.9% were male. Fractures were diagnosed by both x-ray and ultrasonography in 33 patients. In one patient, the x-ray was positive for fracture, while ultrasonography yielded a negative result. For the fractures of fifth metatarsal, the diagnostic sensitivity of ultrasonography was 97.1%, the specificity was 100%, the positive likelihood ratio was infinity, the negative likelihood ratio was 0.03. Mean displacement was 1.2 ± 0.7 mm with x-ray and 1.8 ± 1.5 mm with ultrasonography. The intraclass correlation coefficient of displacement measured by x-ray and ultrasonography was κ: 0.388. CONCLUSION: Ultrasonography is a reliable diagnostic tool for acute fifth metatarsal fractures.

The interrater reliability of ultrasound imaging of the inferior vena cava performed by emergency residents.

OBJECTIVE: Ultrasonography (US) has gained popularity in the emergency medicine to assess intravascular volume status in critically ill patients. However, there are a limited number of studies on the interrater reliability of US examination of the inferior vena cava (IVC) by emergency residents. METHOD: One hundred eighty US examinations were performed on 90 emergency critical care unit patients by 6 emergency medicine residents. Minimum and maximum IVC diameters during normal passive inspiration were measured, and the IVC index was calculated. The interrater reliability of the measurable data was analyzed using intraclass correlation coefficients. RESULTS: The measurements of minimum and maximum IVC diameters were moderately reliable by emergency residents (κ = 0.60 [95% confidence interval {CI}, 0.45-0.72] and κ = 0.56 [95% CI, 0.41-0.69], respectively). In the patients with moderate IVC depth (8.5-12.5 cm), the interrater reliabilities of sonographers were κ = 0.51 (95% CI, 0.30-0.67) for maximum diameter and κ = 0.43 (95% CI, 0.21-0.61) for minimum diameter. In patients with superficial (≤8.5 cm) and profound located (≥12.5 cm) IVC, the interrater reliabilities of sonographers for maximum and minimum diameters were κ = 0.69 (95% CI, 0.29-0.89) and κ = 0.75 (95% CI, 0.4-0.91), and κ = 0.58 (95% CI, 0.09-0.85) and κ = 0.76 (95% CI, 0.39-0.92), respectively. CONCLUSION: The measurement of the IVC is moderately reliable by emergency residents. The interrater reliability of measurements in patients with profound and superficial located IVC is higher than that of measurements in patients with moderate-depth located IVC.

[Familial Mediterranean fever with pulmonary manifestations alone; early diagnosis with genetic analysis]. / Yalniz pulmoner bulgulari olan ailesel Akdeniz atesi; genetik analizle erken tani

Painful pleural effusion and fever are the only presenting clinical features in 5-10% of patients with familial Mediterranean fever (FMF). We report the results of genetic analysis that have confirmed the diagnosis of FMF in six patients who presented with fever and pleuritic pain alone. At time of presentation, all six patients received antibiotic treatment for suspected infectious etiology following routine laboratory and microbiologic evaluation. Gene analysis was performed when other diagnostic studies had failed to uncover the etiology and patients did not respond to conventional treatment. Mutation analysis for MEFV gene performed from genomic DNA by the direct DNA sequence method. Half of the patients were male. Five were older than 50, one was 33 years old. All of the patients had fever and pleuritic pain; none had the typical abdominal symptoms. Erythrocyte sedimentation rates and C-reactive protein levels were high. Pericardial effusion was discovered in three patients. Genetic analysis confirmed; R202Q/R202R, E148V/E148E, R314R, E474E, Q476Q, D510D, E148Q/E148E heterozygote polymorphisms with and M694V/M694V mutations were determined on the MEFV gene. In five patients an improvement has been observed with colchicine therapy. In one patient steroid treatment was needed because of no response to colchicine and clinical deterioration. Rapid improvement was observed in this case with steroid therapy. But after cessation of steroid therapy new flare developed that responded to new colchicine therapy. In patients who present with pleuritic chest pain and fever without an identifiable etiology, genetic analysis help making the diagnosis of FMF, especially in certain ethnic populations where FMF is relevant. This should help patients receive specific treatment without unnecessary delay. Thus, by making early diagnosis and timely delivery of treatment, disease progression is delayed and development of secondary amyloidosis avoided.

A 10-year retrospective analysis of intimate partner violence patients in the emergency department.

BACKGROUND: Intimate partner violence (IPV) is an important human rights problem faced by one in three women worldwide. The aim of this study is to evaluate the demographic, trauma, and radiological characteristics of patients admitted to a tertiary emer-gency department due to IPV. METHODS: Sociodemographic characteristics (age, gender, education level, and marital status), trauma characteristics (severity, type, and location), radiological imaging findings (radiography, computed tomography, and magnetic resonance imaging) of patients diagnosed with IPV were evaluated. RESULTS: In the study, 1225 patients were evaluated, and 98.7% of them were women (mean age 35 [IQR: 17] years). Of the pa-tients, 63.1% were high school and university graduates. The rate of married women was 74.6%. No relationship was found between gender, age, educational status, and marital status (p>0.05). Most of the traumas were minor (85.4%) and blunt (81.9%) trauma, and the most common types of trauma were kicking (49.9%) and punching (47.3%). It was found that the most frequently affected areas of the patients were the head and neck (76.7%), and the frequency of pelvic trauma was high in male patients (p<0.05). The most com-mon bone fracture was nasal (40.5%) followed by ulna fractures (14.5%). The left-sided diaphyseal fractures were the most common in patients exposed to IPV. In our study, the frequency of mortality was 12.9%, and it was found to be significantly higher in males (p<0.05). CONCLUSION: Female patients are more frequently exposed to IPV. Specific injury characteristics can be detected in patients diagnosed with IPV and old fractures detected in these patients should alert the clinician about IPV.

[An evaluation of the pediatric medico-legal admissions to a tertiary hospital emergency department]. / Bir üçüncü basamak hastane acil servisine basvuran adli nitelikli çocuk hastalarin degerlendirilmesi.

BACKGROUND: This study aimed to determine the demographic and epidemiological characteristics and to investigate the outcomes of pediatric medico-legal cases who admitted to the emergency department. It was also aimed to contribute to the national survey. METHODS: Medico-legal charts of the pediatric cases were reviewed retrospectively. Patients were allocated into two groups as traumatic (Group 1) and non-traumatic (Group 2). Age, sex, presenting complaint and frequencies, local or multiple trauma frequencies, and localizations (based on the Abbreviated Injury Scale) and also admission, discharge and mortality rates were ascertained. Data were evaluated by descriptive methods, Kolmogorov-Smirnov and chi-square tests. Values of p<0.05 were accepted as significant. RESULTS: There were a total of 486 eligible patients. The mean age was 8.91+/-5.08 years (95% confidence interval [CI]). The majority (66.3%) were male. The group aged 5-9 years was larger (33.3%) than the others (in Kolmogorov-Smirnov test, p=0.000). Summer was the most common season for admissions. There were 153 patients in Group 1, and the most common complaint was accidental drug intake (13.8%). In Group 2, the most common reason for admission was motor vehicle accident (32.5%). CONCLUSION: Motor vehicle and home accidents in childhood are preventable health problems. To ensure a safe environment, continuous health education programs on injury and prevention for parents and children and legal controls will be effective in injury control.

Can venous blood gas analysis be used for predicting seizure recurrence in emergency department?

BACKGROUND: Epileptic seizures account for 1%-2% of all admissions of patients to the emergency department (ED). The present study aimed to determine whether venous blood pH, bicarbonate, base excess, and lactate levels taken within 1 hour of the last seizure episode help to determine seizure recurrence in emergency departments. METHODS: A cross-sectional study was conducted in the emergency department (ED) between January and July, 2012. Patients who were admitted to the emergency department consecutively were included in the study if they were 14 years or older and within 1 hour after last seizure. Demographics, seizure type, use of antiepileptic drugs, observation period at the emergency department, seizure recurrence, pH, bicarbonate, base excess, and lactate levels from venous blood gas analysis were determined. RESULTS: A total of 94 patients aged 14 years or older were included in the study. Of these patients, 10.6% (n=10) experienced recurrent seizures in the observation period at the emergency department. To predict recurrent seizures in ED, threshold venous blood gas values were determined as follows: pH<7.245 [sensitivity 80% (95%CI: 44-96), negative predictive value 96.9% (95%CI: 88.3-99.4)], bicarbonate<17.1 mmol/L [sensitivity 80% (95%CI: 44-96), negative predictive value 97% (95%CI: 89-99.5)], base excess<-11.1 mEq/L [sensitivity 80% (95%CI: 44-96), negative predictive value 97% (95%CI: 89-99)], and lactate>7.65 mmol/L [sensitivity 80% (95%CI: 44-96), negative predictive value 96.6% (95%CI: 87-99)]. CONCLUSION: If venous blood gas analysis is made on pH, base excess, lactate and bicarbonate immediately one hour after the last epileptic seizure episode, it is possible to predict whether the patient will have seizure recurrence.

Comparing Finger-stick ß-Hydroxybutyrate with Dipstick Urine Tests in the Detection of Ketone Bodies.

OBJECTIVES: Blood ketone (beta-hydroxybutyrate) measurements are suggested instead of urine ketone (acetoacetate) measurements in the diagnosis of diabetic ketoacidosis. Urine ketone examination is difficult and time consuming, and may result in an incorrect interpretation. Studies performed in emergency departments on blood ketones are limited. Our objective is to compare urine ketones and capillary blood ketones in patients whose serum glucose levels were ≥150 mg/dl. METHODS: In our cross-sectional prospective study, finger-stick blood beta-hydroxybutyrate, arterial blood gas and urine ketone measurements of patients whose serum glucose levels were 150 mg/dL and higher were performed in the emergency department. RESULTS: A total of 265 patients were included in the study. The mean age of the patients was 62.4±14.9 years, and 65.7% of them were female. The mean of the capillary blood ketone levels of the patients was determined to be 0.524±0.9 mmol/L (min: 0 mmol/L, max: 6.7 mmol/L). In 29 (13.1%) of the 221 patients whose urine ketone levels were negative, the finger-stick blood ketone levels were positive. Three of these patients were severely ketonemic, six were moderately ketonemic, and 20 were mildly ketonemic. CONCLUSIONS: In patients admitted to the emergency department with a blood glucose level of 150 mg/dL or higher, performing a capillary blood ketone measurement instead of a urine ketone measurement was a better predictor of ketonemia.

The accuracy of bedside ultrasonography as a diagnostic tool for fractures in the ankle and foot.

OBJECTIVES: Ultrasonography (US) has been shown to be helpful in diagnosing fractures in the emergency department (ED) setting. The aim of this study was to determine the diagnostic accuracy of US for fractures in patients presenting to the ED with foot and/or ankle sprain and positive Ottawa foot and ankle rules. METHODS: This was a prospective study of consecutive patients aged 18 years and over were admitted to the ED with acute foot and/or ankle sprain and positive Ottawa foot and ankle rules. After the patients by were examined by bedside US, anteroposterior and lateral ankle radiographs were obtained, as well as anteroposterior and oblique foot radiographs. The films were evaluated by an orthopedic surgeon who was blinded to the US examination results. The orthopedic surgeon's evaluation was considered the criterion standard for diagnosing a fracture. RESULTS: A total of 246 patients were included in the study. In 76 (30.9%) of the patients, a total of 79 fractures were detected by radiography. Ten false-negative and nine false-positive results were obtained by US examination. Only one patient, whose US showed a fracture but whose radiographs were normal, had a fracture detected by computed tomography (CT). The sensitivity and specificity of US scanning in detecting fractures were 87.3% (95% confidence interval [CI] = 77.5% to 93.4%) and 96.4% (95% CI = 93.1% to 98.2%), respectively. CONCLUSIONS: Ultrasound had good sensitivity and specificity for diagnosing fifth metatarsal, lateral, and medial malleolus fractures in the patients with foot and/or ankle sprain. However, sensitivity and specificity of US for navicular fractures were low.

Accidental chlorine gas intoxication: evaluation of 39 patients.

BACKGROUND: Chlorine is a known pulmonary irritant gas that may cause acute damage in the respiratory system. In this paper, the socio-demographic and clinical characteristics of 39 accidentally exposed patients to chlorine gas are reported and different emergency treatment modalities are also discussed. METHODS: Two emergency departments applications were retrospectively analyzed for evaluation of accidental chlorine gas exposure for year 2007. Patients were classified into 3 groups according to severity of clinical and laboratory findings based on the literature and duration of land of stay in the emergency department. The first group was slightly exposed (discharged within 6 hours), second group moderately exposed (treated and observed for 24 hours), and third group was severely exposed (hospitalized). Most of the patients were initially treated with a combination of humidified oxygen, corticosteroids, and bronchodilators. RESULTS: The average age was 17.03 ± 16.01 years (95% CI). Seven (17.9%) of them were female and 29 (74.4%) were children. Twenty-four patients (61.5%) were included in the first, nine (23.1%) were in second and six (15.4%) were in the third group. The presenting symptoms were cough, nausea, and vomiting and conjunctiva hyperemia for the first group, first groups symptoms plus dyspnea for the second group. Second groups symptoms plus palpitation, weakness and chest tightness were for the third group. Cough and dyspnea were seen in 64.1% and 30.8% of the patients respectively. No patients died. CONCLUSIONS: The authors recommend that non symptomatic or slightly exposed patients do not need any specific treatment or symptomatic treatment is sufficient. KEYWORDS: Accidental; Chlorine exposure; Chlorine gas; Chlorine intoxication; Emergency department.