Contribution of verbal suggestion to the therapeutic efficacy of an analgesic agent for acute primary headache.

OBJECTIVE: The therapeutic response of a patient cannot purely be explained by the method of therapy or the efficacy of a drug. Clinician-patient interaction, psychosocial factors, patients' expectations, hopes, beliefs and fears are all related to the healing outcome. Malleability and suggestibility are also important in the placebo or nocebo effect. The purpose of this study was to evaluate whether adding brief verbal suggestions for pain relief could change the magnitude of an analgesic's efficacy. METHODS: This prospective study was performed in the emergency department of a university hospital. Patients who were ordered analgesia with diclofenac sodium for primary headache were divided into three groups. All groups were informed that they would be administered a pain killer by intramuscular injection. The second and third groups were given positive and reduced treatment expectations about the therapeutic efficacy, respectively. Patients were asked to rate their pain on a VAS at 0 and 45 minutes and if they needed any additional analgesic 45 minutes after the injection. RESULTS: A total of 153 patients were included in the study. The paired univariate analyses showed significant differences for all groups between 0- and 45-minute VAS scores. However, there was no difference between the three groups according to the differences in VAS scores between 45 and 0 minutes and according to the administration of an additional drug. CONCLUSION: Simple verbal suggestions did not alter the efficacy of an analgesic agent for headache in an emergency setting. The contributions of suggestibility, desire and expectation in acute primary headache patients should be further investigated.

Prospective, multicenter, Turkish out-of-hospital cardiac arrest study: TROHCA.

OBJECTIVES: There is no sufficient data to provide a clear picture of out-of-hospital cardiac arrest (OHCA) across Türkiye. This study is the first to present the prognostic outcomes of OHCA cases and the factors associated with these outcomes. MATERIALS AND METHODS: The study was conducted in a prospective, observational, multicenter design under the leadership of the Emergency Medicine Association of Turkey Resuscitation Study Group. OHCA cases aged 18 years and over who were admitted to 28 centers from Türkiye were included in the study. Survived event, return of spontaneous circulation (ROSC), survival to hospital discharge, and neurological outcome at discharge were investigated as primary outcomes. RESULTS: One thousand and three patients were included in the final analysis. 61.1% of the patients were male, and the average age was 67.0 ± 15.2. Cardiopulmonary resuscitation (CPR) was performed on 86.5% of the patients in the prehospital period by emergency medical service, and bystander CPR was performed on only 2.9% by nonhealth-care providers. As a result, the survived event rate was found to be 6.9%. The survival rate upon hospital discharge was 4.4%, with 2.7% of patients achieving a good neurological outcome upon discharge. In addition, the overall ROSC and sustained ROSC rates were 45.2% and 33.4%, respectively. In the multiple logistic regression analysis, male gender, initial shockable rhythm, a shorter prehospital duration of CPR, and the lack of CPR requirement in the emergency department were determined to be independent predictors for the survival to hospital discharge. CONCLUSION: Compared to global data, survival to hospital discharge and good neurological outcome rates appear to be lower in our study. We conclude that this result is related to low bystander CPR rates. Although not the focus of this study, inadequate postresuscitative care and intensive care support should also be discussed in this regard. It is obvious that this issue should be carefully addressed through political moves in the health and social fields.

Repeat CT after blunt head trauma and Glasgow Coma Scale score 13-15 without neurological deterioration is very low yield for intervention.

PURPOSE: Due to the increase in accessibility of computed tomography (CT), repeat head CT scans are routinely ordered for patients with minor head injuries. The aim of this study is to evaluate the necessity and outcomes of routine repeat head CT in patients with GCS score of 13-15 who presented to the emergency department (ED) of Antalya University Hospital in Turkey with blunt head trauma. METHODS: We retrospectively reviewed the charts of patients with minor head trauma that received initial and repeat head CT results from July 1, 2013 to June 30, 2015. Clinical characteristics of patients were compared for two groups of patients: those with neurological deterioration, and those who had routine head CT not required by change in neurological status. Repeat head CT results were analyzed for radiological worsening and the necessity of a surgical or medical intervention such as craniotomy, ICP monitoring, VP shunt and mannitol or hypertonic saline administration. RESULTS: Of 3578 patients with blunt head trauma, 656 (18.3%) patients had repeat head CT; 449 of these (68.4%) had a GCS score of 13-15. We analyzed 441 patients for CT and clinical changes. Eight patients were excluded because of poor image quality and/or penetrating injury. Neurological deterioration was the reason for repeat head CT in 73 (16.5%) patients Rates of medical (mannitol treatment) or surgical (craniotomy) intervention in this group were 26% (95% Confidence Interval [95% CI], 15.7-36.3%) in contrast to 0.8% (95% CI 0.1-1.7%) in the group of patients with routinely ordered head CT but without clinical deterioration. The following factors were statistically associated with need for intervention: use of anticoagulant or antithrombotic medication, fracture in middle meningeal artery territory, even a single point decrease in GCS score, increased headache, recurrent vomiting, neurological deficit, and finally, changes in repeat head CT. CONCLUSIONS: In patients with minor head injuries, those without neurological deterioration have a very low risk of need for medical or surgical intervention. Routinely ordering repeat head CT scans in this group may not be routinely indicated.

How stylet use can effect confirmation of endotracheal tube position using ultrasound.

INTRODUCTION: None of the techniques used for confirmation of endotracheal tube (ET) placement are proven reliable 100% of the time. The purpose of our study is to determine whether ultrasound can accurately detect the passage of ET through the trachea and esophagus and to see whether this visualization is augmented with the use of a metal stylet. METHODS: A total of 7 physicians made assessments of ET positions using an ultrasound during their passage through the trachea or esophagus. A total of 40 esophageal and 40 tracheal intubations were performed randomly in a blinded fashion on a fresh, unfrozen human cadaver. Half were performed with a metal stylet and the other half without a stylet. RESULTS: During transtracheal assessment regardless of stylet use, correct identification of ET position was achieved in 275 of 280 esophageal intubations and 268 of 280 tracheal intubations. The overall sensitivity was 95.7%, and specificity was 98.2%. The presence and the absence of stylet was identified in 109 of 280 and in 155 of 280 attempts, respectively. Correct identification of stylet presence yielded a sensitivity of 38.9% and a specificity of 55.4%. Ultrasound can be used by emergency physicians to accurately detect the passage of ET through the trachea and esophagus; however, stylet use did not augment ET visualization.

Pseudoephedrine-induced paroxysmal supraventricular tachycardia: a case report.

Palpitation is a common chief complaint among emergency department patients, and is often associated with a tachydysrhythmia. Tachydysrhythmia is classified as supraventricular tachycardia or ventricular tachycardia. Reentry in a normal or accessory pathway is one of the most frequently seen mechanisms explaining the tachydysrhythmia. In the present case, we report an unusual cause of atrioventricular paroxysmal supraventricular tachycardia due to pseudoephedrine intake.

Anxiety and depressive disorders in patients presenting with chest pain to the emergency department: a comparison between cardiac and non-cardiac origin.

OBJECTIVE: The aim of this study was to determine the prevalence of anxiety and depressive disorders in patients presenting with chest pain to the Emergency Department (ED) and determine if there is a relationship between these and cardiac vs. non-cardiac chest pain. METHODS: This prospective cross-sectional study was performed in an urban tertiary care hospital between March and October 2005. Consecutive patients presenting with chest pain were enrolled in the study. The prevalence of anxiety and depressive disorders in patients with chest pain were determined by using the Hospital Anxiety and Depression Scale. RESULTS: A total of 324 patients presented to the ED with chest pain during the study period. The mean age of the patients studied was 50.5 +/- 14 years; 67% were men and 33% were women. Of the 324 study patients, 194 (59.9%) patients were diagnosed with non-cardiac chest pain, 16 (4.9%) with stable angina, 84 (25.9%) with unstable angina, and 30 (9.3%) with acute myocardial infarction. No statistically significant differences were determined between patients with cardiac and non-cardiac chest pain both for anxiety (40% vs. 38.1%, respectively; p = 0.737) and depressive disorders (52.3% vs. 52.1%, respectively; p = 0.965). CONCLUSION: Anxiety and depressive disorders are common among patients presenting with chest pain to the ED. However, the prevalence of anxiety and depressive disorders is similar between patients with chest pain of cardiac and non-cardiac origin. Chest pain should not be attributed to an anxiety or depressive disorder before organic etiologies are excluded.

[Analysis of motorcycle accident victims presenting to the emergency department]. / Acil servise basvuran motosiklet kazasi olgularinin özellikleri.

BACKGROUND: Motorcycle accidents are one of the major causes of traumatic injuries and deaths. The purpose of this study was to analyze the features of the victims presenting with motorcycle-related injuries. METHODS: This study was conducted prospectively from July 1 to September 30, 2005 at the Emergency Department (ED) of Akdeniz University Hospital. RESULTS: During the study period, 142 patients presented to the ED with motorcycle-related injuries. Sixteen patients were excluded from the analysis because their forms were incomplete and four were still under treatment in the hospital. Of the 122 injured, 72 (59.0%) were discharged and 40 (32.8%) were admitted. Only 11 patients declared use of a helmet. Median length of stay in the hospital was five days. CONCLUSION: Motorcycle accidents result in more serious injuries than motor vehicle accidents due to the limited safety precautions and the difference in injury mechanism. The frequency of accidents, higher admission rates, longer periods of admissions, and higher total hospital costs highlight motorcycle accidents as a major public health issue and an economical burden. To prevent accidents, compliance with the legal requirements should be regularly audited. Studies should be done to increase motorcycle safety precautions, and education programs should be organized for motorcyclists. The effects of these interventions should be analyzed.

Pain perception of patients predisposed to anxiety and depressive disorders in emergency department.

The aim of this study was to reveal the effects of anxiety and depression on pain perception in the emergency setting. This randomized prospective study was performed in an urban tertiary care hospital emergency department (ED). Consecutive patients presenting to the ED with pain who had an intramuscular injection of diclofenac sodium were enrolled in the study. The prevalence of anxiety and depressive disorders in study subjects was determined by using the Hospital Anxiety and Depression Scale. A total of 302 patients were included. Study subjects had a mean age of 41.3 +/- 13.7 years and 35.4% (n = 107) were male. Pain perception in women was significantly higher than in men (median 8.5 vs. 5, respectively; p = .033). Pain perception in elderly patients, >/=65 years old, was found to be lower than in patients <65 years old (median 1 vs. 6.5, respectively; p = .02). Anxiety was found to be related to higher pain perception after adjusting for confounding variables (13.8 vs. 7.6, respectively; adjusted p = .022). Gender, age, and anxiety, but not depression, are possible factors related to pain perception in the emergency setting. Further studies are needed to reveal the factors affecting pain perception and the complex relationship between psychiatric status and pain.

Abamectin intoxication with coma and hypotension.

Abamectin is a potent antihelmintic, insecticide, and miticide used to control pests of humans, veterinary animals, and crops. The toxic effects of abamectin are usually seen after oral ingestions. These are altered mental status, respiratory failure, and hypotension. We report a case of acute abamectin intoxication who presented with altered mental status to the emergency department after oral ingestion.

[The evaluation of academic emergency department design]. / Ulkemizde Acil Tip Anabilim Dallari'nda acil servislerin fonksiyonel mimari açisindan degerlendirilmesi.

BACKGROUND: In our study which was based upon a questionnaire, the inner and outer architectural designs of emergency services of Emergency Medicine Departments were investigated. METHODS: In this descriptive study, a standard questionnaire was sent to 26 Emergency Medicine Departments which were operating at that time. In the questionnaire, the internal, external architectural and functional features were questioned. Answers of 22 Emergency Medicine Departments were analysed. Two Emergency Medicine Departments that were not operating at that time were not included in the study. RESULTS: The analysis of the replies revealed that only 59% (n=13) of the Emergency Medicine Departments were designed as an emergency service prior to the construction. The ambulance parking areas were not suitable in 77% of the emergency units while only 54.5% (n=12) had protection against adverse weather conditions. In only 59% (n=13) of the emergency units, a triage unit was present and in only one of the in only one (4.5%), a decontamination room was available. It was understood that only 32% (n=8) of the emergency units were appropriate in enlarging their capacity taking the local risk factors into consideration. There was a toilette for disabled patients in only 18% (n=4) of the units as well. Considering a 12-year of history of the Emergency Medicine in Turkey, the presence of a lecture room is still 68% (n=15) in emergency departments which reflects that academic efforts in this field is emerging in challenging physical conditions. CONCLUSION: The results of our study revealed that emergency service architecture was neglected in Turkey and medical care given was precluded by the insufficient architecture. The design of emergency services has to be accomplished under guidance of scientific data and rules taking advices of architects who have knowledge and experience on this field.

Utility of 360-degree assessment of residents in a Turkish academic emergency medicine residency program.

OBJECTIVES: This study was designed to test a 360-degree assessment tool for four of the emergency medicine resident competencies as outlined by the Council of Residency Directors in Emergency Medicine on patient care, communication skills, professionalism and system based practice in an academic Emergency Department. MATERIAL AND METHODS: Using the competency framework of the American Accreditation Council for Graduate Medical Education, a 57 item-containing assessment tool was created. Based on the different exposure aspects of the involved evaluator groups, the items were integrated into seven different evaluation forms. All sixteen of 16 residents and members from each evaluator group voluntarily participated in the study. Internal consistency scores, multilayer and multilevel Kappa values were measured. Evaluator group scores and resident ranks in competency areas were compared. All evaluators were asked to comment on the applicability and usefulness of the assessment tool in emergency medicine. RESULTS: Seven groups completed a total of 1088 forms to evaluate 16 residents. The reliability coefficient for the faculty members was 0.99 while it was 0.60 for the ancillary staff. The interrater Kappa values for faculty members, nurses and peer assessment were relevant with a value of greater than 70%. DISCUSSION AND CONCLUSION: Our results showed that the 360-degree assessment did meet expectations by the evaluator group and residents, and that this method was readily accepted in the setting of a Akdeniz University Emergency Medicine residency training program. However, only evaluations by faculty, nurses, self and peers were reliable to have any value. Doing a 360° evaluation is time and effort consuming and thus may not be an ideal tool for larger programs.

The prevalence of asymptomatic pyuria in diabetic patients: comparison of the Sysmex UF-100 automated urinalysis analyzer with Fuchs-Rosenthal hemacytometer.

OBJECTIVE: We investigated the prevalence of asymptomatic pyuria (ASP) in diabetic patients and compared the Sysmex UF-100 with Fuchs-Rosenthal hemacytometer. DESIGN AND METHODS: ASP prevalence was investigated in 227 diabetic patients. Imprecision, accuracy and correlation of UF-100 with hemacytometer in measuring leukocyte counts were determined. RESULTS: Diabetic women and men had significantly higher ASP prevalence than non-diabetic women (21.4 vs. 8.7%) and men (12.2 vs. 3.4%). Disease duration and HbA(1C) levels were similar in diabetic patients with and without ASP. UF-100 and hemacytometer readings correlated significantly (r=0.88) without a significant bias. Within-run coefficients of variations for UF-100 (8.14, 6.35 and 12.18%) and hemacytometer (5.14, 5.18 and 8.03%) did not differ significantly. CONCLUSIONS: Prevalence of ASP is increased in diabetic patients and not affected by duration of disease or control of hyperglycemia. UF-100 seemed to be a reliable, precise and accurate system to determine pyuria.

Comparison of systemic and local effects of nitric acid and hydrochloric acid: an experimental study in a rat model.

BACKGROUND: We aimed to determine the local and systemic effects of widely available household cleaners, namely 45% nitric acid (NHO(3)), and 18% hydrochloric acid (HCl), in a rat model. METHODS: This prospective, experimental, placebo-controlled trial was carried out in the Animal Research Laboratory of Akdeniz University hospital. Commonly available solution of 45% NHO(3) and 18% HCl were tested against normal saline. Each solution was administrated orally to groups consisting of ten rats. The metabolic changes were determined by measuring the pH and calcium (Ca) levels before and after the administration of solutions. In addition, the pathological changes and mortality rates were determined for each group. RESULTS: There was a statistically significant increase in the post-ingestion (30 minutes later) Ca levels and a decrease in the post-ingestion pH levels after the administration of test solution in the NHO(3) (p=0.006 for Ca increase, p=0.001 for pH decrease) and HCl (p=0.007 for Ca increase, p=0.023 for pH decrease) groups. There was also a statistically significant difference between groups for Ca increase (p=0.000) and pH decrease (p=0.006). In post hoc analysis, the difference between the groups was found to be originated from the placebo group. In the pathological evaluation of esophagus and stomach, there was a statistically significant difference between groups (p=0.009 (E) and p=0.016 (S)) and the difference was found to be originated from the control group (p=0.543 (E), p=0.244 (S) for NHO(3) and HCl). The 30-minute mortality rates were 0,2 in the NHO(3) group, 0,6 in the HCl group and 0 in the control group. CONCLUSION: Serious metabolic and mild local pathological changes can occur after the ingestion of household NHO3 and HCl solutions. Further studies should be performed to elucidate the causes of death following oral ingestion of these compounds and appropriate public health warnings should be taken.

[A second-degree burn related to air bag deployment: a case report]. / Hava yastigina bagli ikinci derece yanik: Olgu sunumu.

Although air bags have been shown to reduce mortality and morbidity in motor vehicle crashes, they are associated with specific injuries. Burns due to air bag deployment account for more than 5% of all air bag injuries and typically involve upper extremities or head and neck. Aside from friction burns, thermal and chemical burns are also seen resulting from the use of certain chemicals for the deployment mechanism. We reported a female patient who presented to the emergency department with a second-degree burn in her left breast, six days after a motor vehicle crash. She was treated with irrigation with saline solution and 2% sodium fusidate ointment. The burn area healed within a week, without any further treatment. Only a slight scar tissue remained after a six-month follow-up.

Pancreatic Injury Caused By A Fall From Height: Transection at the Tail.

Isolated pancreatic injury due to blunt abdominal trauma is rare and may be clinically difficult to diagnose. Parenchymal injuries may not be recognized during initial evaluation. We report the case of a 30-year-old male presented to the Emergency Department (ED) with the complaint of persistent abdominal pain, nausea, and vomiting. His medical history revealed that he fell from a height of approximately 1.5 meters 1 day ago and hit an iron block. He was presented and discharged from another hospital ED. Contrast enhanced computerized tomography (CECT) of the abdomen was ordered during his second presentation and revealed pancreatic parenchymal contusion, laceration, and transection at the tail of pancreas. Our findings suggest that, when there is high index of suspicion for pancreatic injury, a CECT should always be ordered.

Personnel response during an internal emergency-unexpected release of an irritant gas in a hospital.

Internal emergencies can occur at any time and location in a hospital. Planning, training, and exercises can prepare personnel to respond effectively to internal emergency situations. All hospital staff should be trained to recognize an internal incident and activate the hospital emergency management system. Maintaining the health and safety of patients, employees, and visitors is paramount. Training and exercises also encourage staff to act with competence and confidence during an untoward incident to mitigate or avert possible catastrophe. This article describes an incident in which 12 hospital employees presented to the emergency department after exposure to a potent pulmonary irritant gas, chlorine, following an unfortunate accident. These cases are used to illustrate how planning, training, and exercises assisted health care personnel in responding to a potentially catastrophic internal emergency.

Using n-Grams for Syndromic Surveillance in a Turkish Emergency Department Without English Translation: A Feasibility Study.

INTRODUCTION: Syndromic surveillance is designed for early detection of disease outbreaks. An important data source for syndromic surveillance is free-text chief complaints (CCs), which are generally recorded in the local language. For automated syndromic surveillance, CCs must be classified into predefined syndromic categories. The n-gram classifier is created by using text fragments to measure associations between chief complaints (CC) and a syndromic grouping of ICD codes. OBJECTIVES: The objective was to create a Turkish n-gram CC classifier for the respiratory syndrome and then compare daily volumes between the n-gram CC classifier and a respiratory ICD-10 code grouping on a test set of data. METHODS: The design was a feasibility study based on retrospective cohort data. The setting was a university hospital emergency department (ED) in Turkey. Included were all ED visits in the 2002 database of this hospital. Two of the authors created a respiratory grouping of International Classification of Diseases, 10th Revision ICD-10-CM codes by consensus, chosen to be similar to a standard respiratory (RESP) grouping of ICD codes created by the Electronic Surveillance System for Early Notification of Community-based Epidemics (ESSENCE), a project of the Centers for Disease Control and Prevention. An n-gram method adapted from AT&T Labs' technologies was applied to the first 10 months of data as a training set to create a Turkish CC RESP classifier. The classifier was then tested on the subsequent 2 months of visits to generate a time series graph and determine the correlation with daily volumes measured by the CC classifier versus the RESP ICD-10 grouping. RESULTS: The Turkish ED database contained 30,157 visits. The correlation (R (2)) of n-gram versus ICD-10 for the test set was 0.78. CONCLUSION: The n-gram method automatically created a CC RESP classifier of the Turkish CCs that performed similarly to the ICD-10 RESP grouping. The n-gram technique has the advantage of systematic, consistent, and rapid deployment as well as language independence.

Factors affecting revisit of COPD exacerbated patients presenting to emergency department.

The primary purpose of this prospective cohort study was to characterize the use of the Emergency Department (ED) in patients with chronic obstructive pulmonary disease (COPD) exacerbations and determine the factors affecting the revisit of COPD patients. This is a prospective cohort study on ambulatory patients with exacerbated chronic bronchitis in an ED setting. Patients included in the study were above 18 years of age, had a previous diagnosis of COPD, and presented to the ED for the treatment of COPD exacerbation. All the information relevant to the study was collected during the patient's visit to the ED. Revisit was defined as an unscheduled visit to an ED or primary physician within 2 weeks of initial ED visit for worsening COPD symptoms. Telephone follow-up was done on all patients at the end of 2 weeks. Variables of 26 revisit cases versus 78 nonrevisit cases were compared. Home oxygen therapy, intensive care admission, previous intubation, increased cough, and the number of ED visits in the previous year were associated with increased risk of revisit in the univariate analysis. Increased cough (odds ratio: 0.232; 95% confidence interval: 0.063-0.853) and the number of ED visits in the previous year (odds ratio: 1.166; 95% confidence interval: 1.005-1.353) were still significant after multivariate analysis. In conclusion, the number of ED visits previous year and increased cough can predict the revisit of a COPD exacerbated patient within 14 days of an ED visit.

Seizure or syncope: the diagnostic value of serum creatine kinase and myoglobin levels.

OBJECTIVE: To determine if the serum levels of creatine kinase and myoglobin can be used to differentiate the grandmal tonic-clonic seizure and syncope activities in the emergency department (ED). METHODS: Consecutive patients over 16 years old who presented to an ED of a tertiary care hospital with a witnessed tonic-clonic seizure activity and a history of a transient loss of consciousness with normal neurological exams in the ED were selected to either seizure or syncope groups. Patients with an unclear history of seizure or syncope with more than 4 h of the activity and with any conditions that could elevate creatine kinase and myoglobin levels were excluded. Serum samples were drawn at presentation and at the fourth hour of the event. RESULTS: Thirty-seven syncope and 26 generalized tonic-clonic seizure patients with a definite history were assigned to study groups. There was not a statistically significant difference in the time of drawing of the first serum sample among groups. No statistically significant differences were determined with the first samples of creatine kinase and myoglobin for both groups. Serum levels of creatine kinase drawn at the fourth hour of the activity were significantly higher in favor of the seizure group. However, myoglobin levels were insignificant at the fourth hour. CONCLUSION: Serum creatine kinase measured at the fourth hour of loss of consciousness may be a potentially useful laboratory test to differentiate tonic-clonic seizure from syncope. Patently, it requires and warrants further study.