Which one predicts mortality better in acute ischemic stroke: negative vs positive acute-phase reactants

AIM

The aim of the study is to investigate the relationship between negative acute-phase reactants and positive acute-phase reactants with in-hospital mortality in patients diagnosed with acute ischemic stroke (AIS) in the emergency department (ED).

METHODS AND MATERIALS

Patients aged 18 and older who presented to the ED of a tertiary hospital with AIS were included in the study. Demographic and clinical characteristics, laboratory parameters, acute-phase reactants, National Institutes of Health Stroke Scale (NIHSS), and outcome data of the included patients were recorded on a standard data form.

RESULTS

A total of 588 patients were included in the study. When the in-hospital mortality of patients was examined, the mortality rate was 17.7%. In the analysis for predicting mortality, it was determined that albumin had the highest predictive power between the area under the curve (AUC) and the determined predictive values (AUC: 0.759, 95% CI 0.707-0.810, p < 0.001). The analyses of the study data revealed that albumin (<0.001) and TF (p = 0.049), which are negative acute-phase reactants, were independent predictors of mortality. According to our study data, in patients with AIS, for each unit decrease in albumin level at the time of ED admission, the risk of mortality increased by 0.868 times, and for each unit decrease in TF level, the risk of mortality increased by 0.593 times.

CONCLUSION

According to the study data, albumin and TF levels, which are negative acute-phase reactants, are independent determinants of in-hospital mortality in patients with acute ischemic stroke in the emergency department.

Dexketoprofen <em>versus</em> Tenoxicam in Acute Severe Pain Due to Primary Dysmenorrhea

OBJECTIVE

To evaluate the analgaesic efficacy of tenoxicam and dexketoprofen in patients admitted to the Emergency Medicine (EM) Clinic with severe acute pain due to primary dysmenorrhea (PD).

STUDY DESIGN

Randomised-controlled trial. Place and Duration of the Study: Emergency Medicine Clinic, Health Sciences University, Adana City Training and Research Hospital, Adana, Turkiye, from January to December 2022.

METHODOLOGY

Patients presenting with PD, were divided into two groups of 60 each, administered 50 mg dexketoprofen and 20 mg tenoxicam intravenously. Visual analogue scale (VAS) scores were recorded at the 15th, 30th, 60th, and 120th minutes. VAS scores and ΔVAS scores were compared with the effectiveness of drugs, the need for rescue drugs and its side-effects.

RESULTS

Intravenous (IV) dexketoprofen was administered to 60 of the patients and IV tenoxicam was administered to another 60. At the time of admission, mean VAS scores of the patients were 8.8 ± 0.9 for the dexketoprofen group and 8.6 ± 0.8 for the tenoxicam group. The VAS scores of the dexketoprofen group were found to be statistically significantly lower after 30 minutes with lower need for rescue analgaesics. ΔVAS scores of the dexketoprofen group were statistically significantly higher from the 30th minute.

CONCLUSION

According to the VAS scoring, IV dexketoprofen was a more effective drug than IV tenoxicam in patients who were admitted to the EM clinic with severe pain due to PD.

KEY WORDS

Dexketoprofen, Primary dysmenorrhea, VAS score.

Mortality predictors of patients diagnosed with severe hyponatremia in the emergency department

PURPOSE

To determine the factors affecting mortality as a result of the analysis of the demographic and clinical characteristics and laboratory parameters of patients whose serum Na value was determined to be 125 mEq/L or below at the time of admission to the emergency department (ED).

METHOD

Patients over 18 years of age who admitted to the ED of a tertiary hospital between September 2021 and September 2022 and whose serum sodium level was determined to be 125 mEq/L and below were included in the study. Demographic and clinical characteristics, admission complaints, medications used, Charles comorbidity index (CCI), laboratory parameters, and outcomes of the patients included in the study were recorded in the data form.

RESULTS

Three hundred ninety-nine patients were included in the study. When the 30-day mortality of the patients is examined, the mortality rate was found to be 21.6%. In the analyses performed for the predictive power of laboratory parameters for mortality, it was determined that the highest predictive power among the predictive values determined by the area under the curve (AUC) was the albumin level (AUC 0.801, 95% CI 0.753-0.849, p < 0.001). In the binary logistic regression analysis, urea and albumin were independent predictors of 30-day mortality.

CONCLUSION

According to study data, albumin and urea levels are independent predictors of 30-day mortality in patients diagnosed with severe hyponatremia in the emergency department.

Predictors of 30-day mortality in patients diagnosed with hepatic encephalopathy on admission to the emergency department

BACKGROUND

The aim of this study is to compare the laboratory findings and disease severity scores of patients diagnosed with hepatic encephalopathy (HE) in the emergency department (ED) to predict 30-day mortality.

METHOD

The patients over 18 years old and diagnosed HE in the ED of a tertiary hospital were included in the study. Demographic and clinical characteristics, laboratory parameters, predisposing causes and outcomes of the patients included in the study were recorded in the data form. Severity of liver disease was assessed by Child Pugh Score (CPS), End-stage liver disease model (MELD), MELD-Na and MELD-Lactate scores.

RESULTS

Two hundred fifty-four patients diagnosed with HE were included in the study. 59.1% of the patients were male. The mean age of the patients was 65.2 ± 12.6 years. The mortality rate of the patients was 47.2%. When the receiver operating characteristic (ROC) analysis, which determines the predictive properties of laboratory parameters and disease severity scores, was examined, the area under curve value of the MELD-Lactate score (0.858 95% CI 0.812-0.904, P  < 0.001) was the highest. Binary logistic regression analysis for the estimation of patients' 30-day mortality showed that CPS and MELD-Lactate scores and blood ammonia and B-type natriuretic peptide levels were independent predictors of mortality.

CONCLUSION

According to the study data, MELD-Lactate and BNP levels in patients diagnosed with HE in the ED may help the clinician in the prediction of 30-day mortality in the early period.

Comparison of syncope risk scores in predicting the prognosis of patients presenting to the emergency department with syncope

BACKGROUND

Various scores have been derived for the assessment of syncope patients in the emergency department (ED).

AIM

We aimed to compare the effectiveness of Canadian Syncope Risk Scores (CSRS), San Francisco Syncope Rules (SFSR), and Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk scores in predicting the risk of major adverse cardiac events (MACE) and mortality among syncope patients within 30 days of the initial ED visit.

METHODS

We performed a prospective, observational case series study of adults (≥ 18 years) with unexplained syncope/near-syncope who presented to ED. Demographic characteristics of the patients and clinical and laboratory data were recorded in the standard data collection form of the study. Our primary outcome was a 30-day mortality.

RESULTS

A total of 421 patients (mean age 50.9 ± 20.8, 51.5% male) were enrolled. The rate of MACE development in the 30-day follow-up of the patients was 12.8% (n = 54). While 20.2% (n = 85) of the patients were hospitalized, two of the patients died in the emergency room and the 30-day mortality was 5.5% (n = 23). CSRS was found to have the highest predictive power of mortality (AUC: 0.869, 95% CI 0.799-0.939, p < 0.001). If the cut-off value of CSRS was 0.5, the sensitivity was found to be 82.6% and the specificity was 81.9%. Also CSRS (OR: 1.402, 95% CI: 1.053-1.867, p = 0.021) was found to be an independent predictor of the 30-day mortality.

CONCLUSION

The CSRS may be used as a safety risk score for a 30-day risk of MACE and mortality after discharge from the emergency department.

Comparison of intravenous ibuprofen and tenoxicam efficiency in ankle injury: a randomized, double-blind study

BACKGROUND AND AIM

Pain after soft tissue injuries in and around the ankle is a troublesome process in terms of patient comfort and mobilization. The aim of this study was to compare the analgesic efficacy of intravenous ibuprofen and intravenous tenoxicam in patients with acute musculoskeletal pain due to ankle injury.

METHODS

We conducted a prospective, double-blind, randomized controlled study in a tertiary hospital. The patients were divided into two groups as those administered IV 400 mg ibuprofen and IV 20 mg tenoxicam. After the treatment of the patients, visual analog scale (VAS) scores were recorded at 15, 30, 60, and 120 min. VAS scores were compared with the effectiveness of drugs, their side effects, and the need for rescue drugs.

RESULTS

One hundred and twenty-four patients were included in the study. There were 62 patients in the tenoxicam group and 62 patients in the ibuprofen group. When VAS scores were compared, it was found that the VAS scores of the ibuprofen group were statistically significantly lower (p < 0.001). When the ΔVAS scores were compared, it was observed that the ΔVAS scores of the ibuprofen group were statistically significantly higher from 30 min (p < 0.001). There was a statistically significant difference in favor of ibuprofen between the two drug groups in terms of the need for rescue analgesics (p < 0.001). Conclusıon. The analgesic efficacy of intravenous ibuprofen and tenoxicam is equal after an ankle injury. However, after 30 min of drug administration, ibuprofen provides more effective analgesia than tenoxicam.

BUN/albumin ratio predicts short-term mortality better than SYNTAX score in ST-elevation myocardial infarction patients

OBJECTIVE

The aim of the study is to compare the prognostic power of the BUN/albumin ratio (BAR) calculated on admission to the emergency department and the SYNergy between Percutaneous Coronary Intervention with TAXus (SYNTAX) score calculated after coronary angiography (CAG) in predicting 30-day mortality in patients with ST-segment elevation myocardial infarction (STEMI).

METHOD AND MATERIAL

The study was conducted prospectively between March 2021 and March 2022 in the emergency department of a tertiary hospital. Patients over the age of 18 who underwent CAG with a diagnosis of STEMI were included in the study. Demographic charecteristics, comorbidities, laboratory parameters of the patients at the time of admission and SYNTAX (SX) score were recorded in the data form.

RESULTS

A total of 1147 patients (77% male) diagnosed with STEMI were included in the study. When the receiver-operating characteristic analysis for SX score and laboratory parameters' power to predict mortality was examined, it was found that the AUC value of the BAR level (AUC: 0.736; 95% confidence interval: 0.670-0.802, P  < 0.001) was the highest. If the threshold value of the serum BAR level, which was determined to predict mortality, was taken as 4, the sensitivity was found to be 76.7% and the specificity was 56.9%. With multivariate logistic analysis, it was determined that the risk of mortality increased by 1.25 for each unit increase in the BAR value in STEMI patients ( P  < 0.001).

CONCLUSION

According to the study data, the BAR may guide the clinician in the early period as a practical and valuable predictor of 30-day mortality in patients diagnosed with STEMI.

Acute pancreatitis due to hypertriglyceridemia: Plasmapheresis versus medical treatment

OBJECTIVE

Hypertriglyceridemia (HTG) is the third-most common cause of acute pancreatitis. Plasmapheresis is an extracorporeal treatment method used for treatment. This study aimed to investigate the efficacy of medical treatment and plasmapheresis in patients with acute pancreatitis due to HTG.

METHODS

This was a retrospective cross-sectional study. The patients were divided into two groups according to the treatment they received as those who received only medical treatment and those who performed plasmapheresis with medical treatment. According to the treatment received by the patients; clinical, demographic, and laboratory data, Ranson scores, and bedside index of severity in acute pancreatitis (BISAP) scores, decrease in triglyceride levels in 24 h, length of hospital stay, and outcomes were recorded.

RESULTS

Forty-seven patients were included in the study. The level of triglyceride decreases at the 24^th h was 59.7% ±17.3% in those who received medical treatment and was 70.4% ±15.1% in those who received plasmapheresis (P = 0.032). Receiver operating characteristic curve analysis was performed to predict the need for plasmapheresis treatment, area under the curve (AUC) value of the triglyceride level was the highest (AUC: 0.822, 95% confidence interval: [0.703-0.940]; P < 0.001), the sensitivity and specificity were 83.3% and 72.4%, respectively, and the cut-off value of triglyceride was accepted as 3079.5 mg/dL.

CONCLUSION

Plasma triglyceride levels and BISAP score on admission may help physicians to predict the need for plasmapheresis. Plasmapheresis helps to rapidly reduce triglyceride levels in patients with HTG-associated acute pancreatitis.

Hemodialysis treatment for poisoning patients in the emergency department

INTRODUCTION

We aimed to evaluate the hemodialysis (HD) use in adult patients after acute poisoning in the emergency department.

METHODS

The study was performed as a retrospective observational cohort study. We analyzed hospital electronic data system and patient files.

RESULTS

A total of 55 patients were included in the study. Among the 10 toxins exposed, the most common were methanol and metformin. The most common indications for HD treatment were: 67.3% (n = 37) for toxin elimination, 20% (n = 11) for treatment-resistant metabolic acidosis, hemodynamic disorder. The most common complication (50.9%) in all patients was central nervous system depression. Ten patients died from ingestion of methanol, one of aluminum phosphide, and one of opioid-sympathomimetic-hallucinogen agents.

CONCLUSION

HD is the most commonly used extracorporeal treatment method in the treatment of poisoning patients. HD should be considered without any delay in treating poisoned patients if there is no response to conventional treatments.

Blood urea nitrogen/albumin ratio on admission predicts mortality in patients with non ST segment elevation myocardial infarction

The aim of this study is to reveal the predictive power of biomarkers and SYNTAX (SX) score for short-term mortality in patients diagnosed with non-ST-segment elevation myocardial infarction (NSTEMI) in the emergency department. This is prospective observational cohort study. Demographic characteristics of the patients, laboratory parameters on admission, left ventricular ejection fraction (LVEF) percentages, affected vessels in angiography (CAG) and the treatment strategy [medical therapy, percutaneous transluminal coronary angioplasty (PTCA), coronary angio by-pass graft] and SX scores were recorded on the data collection form. ROC curve was used to investigate the predictivity of blood urea nitrogen/albumin ratio (BAR), procalcitonin, C-reactive protein (CRP), high sensitivity cardiac troponin I (Hs-cTnI), CRP to serum albumin ratio (CAR), neutrophil to lymphocyte ratio (NLR) and SX scores in mortality. Multivariate analysis of biomarkers and SX score was performed to estimate the patients' 30-day mortality. Of the 415 patients were included in the study. ROC analysis of BAR, CAR, CRP, Procalcitonin, Hs-cTnI, NLR and SX score to predict mortality was statistically significant. BAR (OR: 1.280, 95% CI: 1.113-1.472, p = .001) and SX score (OR: 1.071, 95% CI: 1.018-1.126, p = .007) were found to be independent predictors of 30 days mortality. LVEF reduction, SX score, the number of affected vessels and the frequency of LMCA lesions increase were found to be statistically significant in patients with BAR ≥4.8. BAR, which can be calculated easily and quickly on admission to the emergency department and in clinical practice, may be used to predict mortality in patients with NSTEMI.

Angina And Arrhythmia Symptoms Following Multiple Bee Stings: Kounis Syndrome

Kounis syndrome (KS) is an acute coronary syndrome including coronary spasm, acute myocardial infarction, and stent thrombosis preceded by an anaphylactic, anaphylactoid, allergic, or hypersensitivity injury. In this case presentation, we discussed Type I and Type II KS. Case 1 was a 72-y-old man who presented to the emergency department with allergic symptoms and chest pain that developed after multiple bee stings. Electrocardiography showed ST depression in the lateral leads. Case 2 was a 42-y-old woman who presented to the emergency department with complaints of chest pain, dizziness, and presyncope that developed after multiple bee stings. Mobitz Type II Block with right bundle branch block was observed in 42 beats·min^-1 in the electrocardiography. Both patients were first treated for allergic reaction. Although early percutaneous coronary intervention was performed for graft thrombosis in Case 1, a permanent pacemaker was inserted in Case 2. The patients were discharged without any complications. Increasing physician awareness towards the existence of KS can prevent fatal outcomes with early diagnosis and treatment.

Perfusion index versus visual analogue scale: as an objective tool of renal colic pain in emergency department

Background

Perfusion index (PI) has use to monitor sympathetic response changes to pain. In this study, we aimed to evaluate the utility of using perfusion index as an objective marker of pain relief and of the need for rescue analgesia in ED patients with documented renal colic.

Methods

We conducted a prospective observational study between January 2020 and December 2020. The demographic characteristics of the patients, their complaints, nephrolithiasis histories, vital signs, PI, and VAS scores (on admission and after treatment) were recorded.

Results

A total of 144 patients were included. All patients were administered 20 mg of Tenoxicam on admission. There was a statistically significant difference between the PI (<0.001) and VAS scores (<0.001) on admission and after the administration of Tenoxicam. 43.1% (n = 62) of the patients needed rescue analgesia. Accordingly to ROC curve, the ability of both PI₂ (AUC: 0.615, 95%CI 0.519-0.711, p = 0.018) and ΔPI (AUC: 0.601, 95%CI 0.508-0.694, p = 0.039) indices were determined as statistically significant. The cutoff value of the PI₂ level for the prediction of the needed rescue analgesia was 4.65 and the cutoff value for ΔPI (PI_2-PI₁) was 2. All patients had a pain VAS score of <3 and a mean PI of 5.7 ± 2.9 at discharge from the emergency department.

Conclusion

In patients presenting to the emergency department with renal colic, the PI value on admission and after analgesic therapy can be helpful in assessing the severity of pain and predict the need for rescue analgesia.

Do biomarkers have predictive value in the treatment modality of the patients diagnosed with bowel obstruction?

OBJECTIVES

This study aimed to investigate the ability of the biomarkers to predict the surgery treatment and mortality in patients above 18 years of age who were hospitalized with the diagnosis of bowel obstruction from the emergency department.

METHODS

This is a 2-year retrospective study. The patients' demographic data, laboratory parameters on admission to emergency department, treatment modalities, and the length of hospital stay were recorded. Patients were divided into two groups: conservative and surgical treatment. Statistical analysis was performed to investigate the value of biomarkers in predicting mortality and the need for surgery. Data were analyzed using IBM SPSS version 22.

RESULTS

A total of 179 patients were included in this study. Of these, 105 (58.7%) patients were treated conservative and 74 (41.3%) were treated operatively. The elevated procalcitonin (PCT) level, C-reactive protein, blood urea nitrogen-to-albumin ratio, and lactate-to-albumin ratio were significantly correlated with surgical treatment, length of hospital stay, and mortality. procalcitonin threshold value of 0.13 ng/mL was able to predict the need for surgical treatment, with a sensitivity of 79% and a specificity of 70.3%. Procalcitonin threshold value of 0.65 ng/mL was able to predict the mortality rate of the patients, with a sensitivity of 92.9% and a specificity of 78.1%.

CONCLUSIONS

Biomarkers, especially procalcitonin, may be useful in bowel obstruction treatment management and may predict mortality.

mNUTRIC tool is capable to predict nutritional needs and mortality early in patients suffering from severe pneumonia

Objective

This retrospective observational study aims to evaluate the prognostic accuracy of Modified Nutrition Risk in Critically ill (mNUTRIC) compared to Nutrition Risk Score-2002 (NRS-2002) in patients hospitalized in the intensive care unit due to severe pneumonia during the pandemic period.

Methods

RT-PCR test and Chest CT was performed in all patients in the emergency department pandemic area. The CURB-65 at the time of admission to the emergency department and Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential organ failure assessment score (SOFA), NRS-2002 and mNUTRIC scores 24 h after hospitalization in the intensive care unit were calculated. The analysis of the data was made in IBM SPSS Statistics Base 22.0 package program.

Results

One hundred and twenty-five patients found to have severe pneumonia based on the chest CT taken in the emergency department pandemic area and hospitalized in the intensive care unit were included in the study. A real-time reverse transcription PCR (RT-PCR) test was positive in 30.4% (n: 38) of the patients. Additional nutrition treatment was initiated in 54.4% of the patients. In the analytical evaluation to predict nutritional treatment needs, mNUTRIC's AUC value (AUC: 0.681, 95% 0.582–0.780, p < 0.001) was higher than NRS-2002. While 64.8% (n: 81) of the patients were discharged, 35.2% (n: 44) died. In the analytical evaluation to predict mortality, the AUC value of mNUTRIC had the highest value (AUC: 0.875, 95% CI 0.814–0.935, p < 0.001).

Conclusion

The mNUTRIC score can predict at an early period the nutritional needs and mortality of patients with severe pneumonia during the Covid-19 pandemic.

Evaluation of the frequency of patients with cancer presenting to an emergency department

OBJECTIVE

This study aims to determine the demographic characteristics of cancer patients admitted to an emergency department and determine the relationship between the frequency of admission to the emergency department and oncological emergencies and their effect on mortality.

METHODS

This observational, prospective, diagnostic accuracy study was performed in the ED of a tertiary care hospital. Patients over the age of 18 who were previously diagnosed with cancer and admitted to the emergency service for medical reasons were included in the study. We recorded baseline characteristics including age, gender, complaints, oncological diagnosis, metastasis status, cancer treatments received, the number of ED admissions, structural and metabolic oncological emergency diagnoses in the ED, discharge status, length of hospital stay, and mortality status.

RESULTS

In our study, 1205 applications related to the oncological diagnosis of 261 patients were examined. 55.6% of the patients were male, and 44.4% were female. The most common metabolic oncological emergency was anemia (19.5%), and the most common structural oncological emergency was bone metastasis-fracture (4.6%.) The mean score of admission of patients to the emergency department was four times (min: 1 max: 29) during the study period. A total of 49.4% (n: 129) of the patients included in the study died during follow-up, and the median time of death was 13 days after the last ED admission.

CONCLUSION

The palliation of patient symptoms in infusion centers that will be established in the palliative care center will contribute to the decrease in the frequency of use of emergency services.

Perfusion index: Could this be a new triage tool for upper gastrointestinal system bleeding in the emergency department? A prospective cohort study

BACKGROUND

Many scoring systems for predicting mortality, rebleeding and transfusion needs among patients with upper gastrointestinal bleeding (UGIB) have been developed. However, no scoring system can predict all these outcomes.

OBJECTIVE

To show whether the perfusion index (PI), compared with the Rockall score (RS), helps predict transfusion needs and prognoses among patients presenting with UGIB in emergency departments. In this way, critical patients with transfusion needs can be identified at an early stage.

DESIGN AND SETTING

Prospective cohort study in an emergency department in Turkey, conducted between June 2018 and June 2019.

METHODS

Patients' demographic parameters, PI, RS, transfusion needs and prognosis were recorded.

RESULTS

A total of 219 patients were included. Blood transfusion was performed in 174 patients (79.4%). The PI cutoff value for prediction of the need for blood transfusion was 1.17, and the RS cutoff value was 5. The area under the curve (AUC) value for PI (AUC: 0.772; 95% confidence interval, CI: 0.705-0.838; P < 0.001) was higher than for RS (AUC: 0.648; 95% CI: 0.554-0.741; P = 0.002). 185 patients (84.5%) were discharged, and 34 patients (15.5%) died. The PI cutoff value for predicting mortality was 1.1, and the RS cutoff value was 7. The AUC value for PI (AUC: 0.743; 95% CI: 0.649-0.837; P < 0.001) was higher than for RS (AUC: 0.725; 95% CI: 0.639-0.811; P < 0.001).

CONCLUSION

PI values for patients admitted to emergency departments with UGIB on admission can help predict their need for transfusion and mortality risk.

High-flow nasal cannula oxygen therapy in the management of acute respiratory distress syndrome secondary to opioid overdose

In this article, we discuss the successful treatment of acute respiratory distress syndrome (ARDS), a rare complication of opioid overdose, through high-flow nasal cannula oxygen therapy (HFNCOT). A 32-year-old male patient was referred to the emergency department with an ambulance due to a state of confusion following intravenous opioid intake. On arrival, the patient had an arterial blood pressure of 100/60 mmHg, pulse of 112 beats/min, respiratory rate of 8 breaths/min, and oxygen saturation (SpO₂) of 75%. On neurologic examination, he had miotic and isochoric pupils, and Glasgow Coma Score was 12 (E: 3 M: 5 V: 4). Cardiac examination showed that the heart was rhythmic and tachycardic. Chest examination revealed bibasilar crackles and wheezing. Naloxone was administered to the patient, and oxygen treatment was applied through a mask. Then, HFNCOT was commenced to the patient in whom the PaO₂/FiO₂ ratio in the blood gas was calculated as 141 following antidote treatment and whose chest radiograph showed bilateral infiltrations. The patient was discharged from the emergency critical care unit on the 3^rd day of his hospitalization because infiltrations in his chest radiograph regressed. HFNCOT can recover the patient's hypoxemia and help reduce the necessity of mechanical ventilation in patients with mild or moderate ARDS.

Benign paroxysmal positional vertigo in emergency department: How to treat?

Background:

The treatment of benign paroxysmal positional vertigo (BPPV) has not been well studied. Many clinicians are indifferent about canalith reposition maneuvers and frequently prefer medical treatments.

Objectives:

We aimed to detect efficacy of Epley maneuver in relieving symptoms of benign paroxysmal positional vertigo patients diagnosed in emergency department and if medical treatments are useful in patients whose symptoms were not relieved.

Methods:

The study was conducted as a prospective cohort study in the emergency department of a tertiary hospital. Patients who were over 18 years of age and presented to emergency department with complaints of vertigo symptoms and nausea and had a positive Dix–Hallpike test were included in the study. Patients’ demographic data, possible etiological factors, affected ear, and benign paroxysmal positional vertigo diagnosis in the history were recorded on the study data form. The European Evaluation of Vertigo scale and the Visual Analogue Scale (VAS) score of nausea and vertigo symptoms were graded and recorded for each patient before and after treatment.

Results:

Ninety patients were included in the study in total. Epley maneuver was carried out to all patients. Vertigo symptoms VAS (VASd) score (p < 0.001), nausea and vomiting VAS (VASnv) score (p < 0.001), and European Evaluation of Vertigo scale score (p < 0.001) of all patients showed a statistically significant decrease after Epley maneuver. A combination of dimenhydrinate and metoclopramide helped to reduce VASd (p = 0.048), VASnv (p = 0.031), and European Evaluation of Vertigo scale scores (p = 0.001) at a statistically significant level more than dimenhydrinate treatment alone.

Conclusions:

Epley maneuver may be applied to every patient with benign paroxysmal positional vertigo. Dimenhydrinate and/or metoclopramide helps to control patients’ symptoms whose symptoms remain despite Epley maneuver.

Methanol poisoning in Turkey: Two outbreaks, a single center experience

OBJECTIVES

Methanol poisoning is still one of the major causes of mortality due to intoxication because of the challenging diagnosis and late hospital admissions. We aimed to evaluate epidemiological data, clinical characteristics, laboratory findings, treatment protocols, and prognosis of patients in a tertiary hospital in two different methanol outbreaks occurring in a three-year interval.

METHODS

The study was planned as a single-center and retrospective observational case series study. Patients ≥18 years of age who were admitted to the hospital between 1 September 2016 and 1 September 2019 and diagnosed with methanol poisoning were included in the study.

RESULTS

Sixty-seven patients whose data were sufficient and accessible were included in the study. Thirty-five (52.2%) patients were discharged without sequelae, 14 (20.9%) patients were discharged with sequelae (both central nervous system sequelae and visual sequelae in 3 patients, only visual sequelae in 11 patients) and 18 (26.9%) patients died. High anion gap (AG) metabolic acidosis (pH < 7.07, AG > 26.7), low Glasgow Coma Score, and increased lactate (lactate > 2.55 mmol/L) levels were found to be associated with poor outcome. Folate use in treatment did not have a statistically significant effect (p = 0.087) on the prevention of visual sequelae development, but it had a statistically significant effect on mortality (p = 0.041).

CONCLUSIONS

State of consciousness and the severity of metabolic acidosis were significant parameters associated with mortality. In addition to antidote and elimination therapies, given the benefit on mortality and low risk of adverse events, folate therapy should be considered for all patients with significant toxic methanol exposures.

Treatment of carbon monoxide poisoning: high-flow nasal cannula versus non-rebreather face mask

OBJECTIVE

In this study, the aim was to compare the rate of decrease in carboxyhemoglobin (COHb) values at consecutive time points and calculate the half-life of COHb (COHb t½) in patients admitted to the emergency department (ED) with carbon monoxide (CO) poisoning and treated with either high flow nasal cannula oxygen therapy (HFNC) or non-rebreather face mask (NRFM).

METHODS

This retrospective, cohort study with historical controls was performed over a 2-year period and included adult patients with CO poisoning, whose COHb values were checked. The HFNC group consisted of patients admitted to the ED with CO poisoning when HFNC was available in the hospital, while the NRFM group consisted of patients who presented to the ED with CO poisoning before the availability of HFNC. The primary outcome of the study was to detect the COHb t½.

RESULTS

A total of 71 patients were enrolled in the study. While 35 patients received oxygen with NRFM, 36 patients received HFNC. The mean COHb t½ in the HFNC group was 41.1 min (95% CI: 31.0-58.4) and 64.0 min (95% CI: 43.5-114.4) in the NRFM group. We did not find a significant difference in the COHb t½ between the HFNC group and NRFM group (p = 0.099). COHb levels between treatment arms at serial time points showed a statistically significant difference at 60 min (p = 0.048). We compared the decay constant and half-life of COHb between groups according to gender. In both genders, COHb t½ was significantly different between groups, and COHb t½ was lower in the patients treated with HFNC.

CONCLUSION

HFNC was effective in reducing the half-life of COHb values in patients with carbon monoxide poisoning. Prospective studies to be conducted in larger groups are needed to fully understand the effect of HFNC on carbon monoxide poisoning.

Evaluation of Nutrition Risk in Patients Over 65 Years of Age With Nontraumatic Acute Abdominal Syndrome

BACKGROUND

The objective of this study is to investigate the power of CRP/Albumin ratio, NRS-2002, mNUTRIC scores to predict nutritional needs and mortality in patients over 65 years of age diagnosed with acute abdominal syndrome in the emergency department and then transferred to the surgical intensive care unit.

MATERIAL AND METHOD

CRP/Albumin ratio, APACHE II, SOFA, NRS-2002 and mNUTRIC scores were calculated. The analysis of the data was conducted in IBM SPSS Statistics Base 22.0 package program.

RESULTS

In the analytical evaluation made for nutritional needs, AUC value for mNUTRIC was found to be: 0,683, 95% CI 0,611-0,755, p < 0.001. It was found out that mortality of patients had a statistically significant and moderate correlation with mNUTRIC score (r = 0.537; p < 0.001). In the analytical evaluation made for mortality, mNUTRIC's AUC value (AUC: 0.808, 95% CI 0.736-0.880, p < 0.001) was found to be the highest. When the cut-off value determined to predict mortality was taken as 3.5 for mNUTRIC score, sensitivity was 75.9% and specificity was 69.4%.

CONCLUSION

The evaluation of the risk of malnutrition through nutritional risk tools in intensive care patients over 65 years of age with acute abdominal syndrome can also predict nutritional needs in the early period besides mortality. Based on our data, the fact that mNUTRIC score cut-off value in older patients hospitalized in intensive care is 3.5 and higher may be a predictor for ICU mortality.

Uncommon presentation of COVID-19: Gastrointestinal bleeding

The COVID-19 outbreak has become a pandemic that is threatening global health. The typical clinical manifestations were fever, cough, dyspnea, and myalgia or fatigue. Digestive symptoms such as nausea, vomiting, diarrhea, abdominal pain usually accompany respiratory symptoms. However gastrointestinal bleeding as the first symptom is not reported. Here we reported a case of COVID-19 with gastrointestinal bleeding as the initial symptom to the emergency department with a real-time reverse transcriptase polymerase chain reaction test positive, and normal thorax tomography. The case demonstrate that; clinicians should be alerted to patients about COVID-19 when referring to atypical symptoms and every patient undergoing endoscopy should be considered potentially infected or can infect others.

Evaluation of corrosive poisoning in adult patients

OBJECTIVE

To evaluate the demographic characteristics, endoscopy results, emerging complications and the final status of caustic intake cases admitted to our emergency department.

METHOD

This study is a retrospective one concerning patients admitted to our emergency department due to caustic ingestion. Demographic characteristics of the patients, complaints while applying to the hospital, physical examination findings, the purpose of caustic intake, the characteristics of corrosive substance taken, times of endoscopy following admission to the emergency department, follow-up times in the emergency department, endoscopic staging and outcome. The data were analyzed through IBM SPSS Statistics Base 22.0 package program.

RESULTS

Seventy four patients participated in the study. 83.8% of corrosive substance intake cases were accidental and 16.2% cases were suicidal intention. While 60.8% of the corrosive substances taken had alkaline property, 36.5% were acidic and 2.7% were found to be unknown substances. 50% of the corrosive substance intakes were sodium hypochlorite. It was seen that endoscopy was performed in 59 patients who accepted endoscopy within an average of 244.07 min after admission to the emergency department. While no damage could be seen in 55.9% of patients following endoscopy, the most common injury was Grade 1 (35.6%).

CONCLUSION

Corrosive substance intake is a rare but potentially devastating poisoning with high morbidity and mortality. Mucosal injury begins within minutes following corrosive intake. Therefore, early endoscopy is helpful in assessing the degree of injury and early discharge from hospital.

How to treat patients with acute respiratory failure? Conventional oxygen therapy versus high-flow nasal cannula in the emergency department

Objective:

To investigate whether high-flow nasal cannula oxygen therapy could reduce the rate of endotracheal intubation and improve arterial blood gas values, vital signs, and clinical outcomes of patients with hypoxemic acute respiratory failure as compared with conventional oxygen therapy alone.

Methods:

This retrospective, observational study was performed in the 15-month study period and included adult patients with tachypnea and hypoxemia, whose vital signs and arterial blood gas were monitored. The high-flow nasal cannula oxygen group consisted of patients admitted to the emergency department with acute respiratory failure when high-flow nasal cannula oxygen treatment was available in the hospital, while the conventional oxygen therapy group consisted of patients who have presented to the emergency department with acute respiratory failure in the absence of high-flow nasal cannula oxygen device in the hospital. The primary outcome of the study was improvement in vital signs and arterial blood gas values within first and fourth hours of the treatment. The second outcome was the need for intubation in the emergency department, length of hospital stay, and hospital mortality.

Results:

The decrease in the pulse and respiratory rate of high-flow nasal cannula oxygen–treated group was significantly greater than the conventional oxygen therapy group on the first and fourth hours of treatment (p < 0.001). PaO2 values were significantly higher in the high-flow nasal cannula oxygen group at the first and fourth hours of treatment (p ⩽ 0.001). Likewise, mean SaO2 levels of patients receiving high-flow nasal cannula oxygen treatment was significantly higher than those of patients in the conventional oxygen therapy group (p = 0.006 at 1 h and p < 0.001 at 4 h). In the hypercapnic patients, the decrease in PaCO2 and increase in pH and PaO2 values were significantly greater in high-flow nasal cannula oxygen group (p < 0.001). The difference between the groups regarding the need for invasive mechanical ventilation was not statistically significant (p = 0.179).

Conclusion:

High-flow nasal cannula oxygen treatment has been associated with favorable effects in vital signs and arterial blood gas values in patients with acute respiratory failure. High-flow nasal cannula oxygen might be considered as the first-line therapy for patients with hypoxemic and/or hypercapnic acute respiratory failure.

Adding lactate to SOFA and qSOFA scores predicts in-hospital mortality better in older patients in critical care

AIM

The aim of this study was to determine whether the addition of the lactate level to the SOFA score (SOFA-Laktat) and qSOFA Score (qSOFA-Laktat) improves the performance of the SOFA score and qSOFA score alone in predicting the hospital mortality of critically ill older patients.

MATERIAL AND METHOD

A total of 799 patients over 65 years of age admitted to Emergency Department and hospitalized to intensive care unit (ICU) of our hospital between May 1, 2016, and April 30, 2017, were included in this study. The parameters gender, age, initial complaint, duration of time between the start of their complaint and emergency admission, comorbidities, SOFA scores, qSOFA scores, arterial lactate (AL) values and reason for acute admission, which intensive care unit admitted to, length of stay and patients outcomes (discharge, exitus) were recorded. The primary outcome was to evaluate whether the addition of the evaluation of AL value increased the performance of the SOFA score and qSOFA score in predicting hospital mortality.

RESULTS

Data of 799 patients were analyzed, in which 52.8% (n = 422) were male and 47.3% (n = 377) were female. Most frequently hospitalized clinic was coronary ICU (34.7%, n = 277). Mean duration of hospitalization was 5.2 ± 8.7 days. Hospitalization was prolonged with increased lactate, SOFA and qSOFA levels. Cutoff value for lactate was 2.3 mmol/L in our ROC analyses. Predictive value of SOFA-Lactate_2.3 for mortality was significantly higher than SOFA score (p < 0.001). Also, predictive value of qSOFA-Lactate_2.3 for mortality was significantly higher than qSOFA score (p < 0.001).

CONCLUSION

The lactate 2.3 mmol/L threshold-based SOFA-Lactate_2.3 and qSOFA-Lactate_2.3 scores perform better than SOFA and qSOFA alone in identifying hospital mortality risks of patients over 65 who are admitted to the ICU.

Which one predicts mortality better? Hemogram and ST elevation myocardial infarction

Objective

The aim of this study was to determine the effectiveness of hematological parameters measured at the moment of admission to the emergency room in predicting in-hospital mortality and to determine cut-off values of strongly predictive values.

Subjects and Methods

The study began with approval of the ethics committee. In total, 1,929 patients over 18 years of age, whose date could be obtained, were included in the study. From the hemogram parameters, white blood cells (WBC), red cell distribution width, mean platelet volume, and ratio of neutrophils to lymphocytes (NLR) values were determined and recorded. CK-MB and high-sensitive Troponin T values were recorded as cardiac markers. For statistical analysis, "SPSS for Windows Version 21" package program was used.

Findings

About 71.7% (n = 1384) of the patients were male and 28.3% (n = 545) of the patients were female. About 92.5% of the patients (n = 1785) were discharged from the hospital, whereas the remaining 144 patients (7.5%) were exitus in the hospital. When the efficacy of hematological parameters and cardiac markers in predicting mortality was examined by receiver operating charecteristics analysis, NLR was found to be the strongest predictor (area under the curve [AUC], 0.772, standard deviation [SD] = 0.022, 95% confidence interval [CI]). It was found that the WBC value came in second place after NLR as a strong predictor of mortality (AUC, 0.749, SD = 0.024, % 95 CI).

Conclusion

The use of predictors for the prediction of mortality for ST elevation myocardial infarction patients is of great importance for faster implementation of treatment modalities. We found that WBC and especially NLR values obtained with a simple method can be used as powerful predictors.

Detection of the awareness rate of abuse in pediatric patients admitted to emergency medicine department with injury

Objective

It was aimed to investigate whether neglected and abused pediatric patients are properly recognized and reported by emergency physicians in the emergency department (ED).

Methods

This prospective study was conducted on patients between 0 and 6 years of age presenting with trauma to ED. Patients were examined again by an emergency medicine specialist independent from the physician who did the first intervention during clinical follow-up phase after notification of patients presenting with trauma to emergency physician. Asked radiological examinations and clinical follow-up were performed. The suspected abuse evaluation form, consisting 12 items, which was formed by considering the forms used in previous studies was used to examine the awareness of physicians in cases of abuse suspicion.

Results

A total of 126 patients were included in our study. 54% of cases (n = 68) were male and mean age was determined to be 31.3 ± 18.9 months. It was found that no judicial records were written to 35.7% (n = 45) of our patients and that 11.1% (n = 5) of these patients were hospitalized. In 51.1% (n = 23) of patients without judicial records, multiple suspected abuse findings were identified. According to evaluation of first physician, it was found that 75.9% (n = 41) of discharged patients had no judicial records and was not considered as neglect and abuse.

Conclusion

We conclude that detection rates of abuse can be increased by developing child abuse screening forms and ensuring the continuity of the necessary training programs.

The relationship between inferior vena cava diameter measured by bedside ultrasonography and central venous pressure value

Objective: We aimed to present inferior vena cava (IVC) diameter as a guiding method for detection of relationship between IVC diameter measured noninvasively with the help of ultrasonography (USG) and central venous pressure (CVP) and evaluation of patient's intravascular volume status.

Methods: Patients over the age of 18, to whom a central venous catheter was inserted to their subclavian vein or internal jugular vein were included in our study. IVC diameter measurements were recorded in millimeters following measurement by the same clinician with the help of USG both at the end-inspiratory and end-expiratory phase. CVP measurements were viewed on the monitor by means of piezoelectric transducer and recorded in mmHg. SPSS 18.0 package program was used for statistical analysis of data.

Results: Forty five patients were included in the study. The patients had the diagnosis of malignancy (35.6%), sepsis (13.3%), pneumonia, asthma, chronic obstructive pulmonary disease (11.1%). 11 patients (24.4%) required mechanical ventilation while 34 (75.6%) patients had spontaneous respiration. In patients with spontaneous respiration, a significant relationship was found between IVC diameters measured by ultrasonography at the end of expiratory and inspiratory phases and measured CVP values at the same phases (for expiratory p = 0.002, for inspiratory p= 0.001). There was no statistically significant association between IVC diameters measured by ultrasonography at the end of expiration and inspiration and measured CVP values at the same phases in mechanically ventilated patients.

Conclusions: IVC diameter measured by bedside ultrasonography can be used for determination of the intravascular volume status of the patients with spontaneous respiration.

Acute-phase reactants and cytokines in ischemic stroke: do they have any relationship with short-term mortality?

BACKGROUND

Many unknown risk factors play a role in the etiopathogenesis of stroke. The appearance of inflammatory cells within the damaged tissue after cerebral ischemia suggests that an inflammatory response may play a role in stroke pathogenesis. In our study, we examined whether an association exists between the acute-phase reactants and the levels of cytokines, the volume and diameter of the stroke, and short-term mortality in patients who were diagnosed as acute ischemic a stroke after admission to the Emergency Department.

PATIENTS AND METHODS

A total of 50 consecutive patients who applied to the Emergency Service with acute ischemic stroke were enrolled in the study. Their stroke volume were calculated and serum samples were obtained as soon as they arrived into the Emergency Service. The patients were evaluated according to the Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS).

RESULTS

There was no significant correlations between stroke volume and levels of cytokine and acute-phase reactants in dead patient group or in living patient group. A correlation and statistical significance was found between stroke volume and hospital stay time in living patient group. In addition, GCS and NIHSS scores were correlated with stroke volume and was found a significant statistically.

CONCLUSIONS

Scales such as GKS and NIHHS, which evaluate the functional state of patients, are the best indicators for defining prognosis in our daily practices. In addition, we found a positive correlation between levels of CRP (C reactive protein) and prognosis. However, we did not observe a statistically significant correlation between prognosis and other acute-phase reactants such as TNF-alpha, IL-6, IL-8, IL-10, fibrinogen, and leukocytes.