Expectations and needs of relatives of critically ill patients in the emergency department

Background:

The care of critically ill patients is a strong indicator of service quality provided in the emergency department. Since families are the major social support sources, assessing the family members’ needs may reduce their anxiety and depression owing to the acute situation of their loved ones while improving the patients’ recovery.

Objective:

We aimed to evaluate the expectations and needs of relatives of critically ill patients to formulate solutions to improve the quality of emergency department service.

Methods:

We conducted a prospective, cross-sectional survey of 873 relatives of nontraumatic, critically ill patients who completed the Turkish version of the Critical Care Family Needs Inventory in the emergency department of a university hospital in Turkey. The needs statements were evaluated under five subheadings: meaning, proximity, communication, comfort, and support.

Results:

In total, 249 (28.5%) participants were females and 624 (71.5%) were males (mean age, 41.79 years). The “meaning” category was given the highest priority, followed by “communication,” with average points of 3.75 and 3.57, respectively. The most important needs were being informed regularly about the patient’s condition and being assured that the patient is under the best possible care, whereas personal, physical, and emotional needs were the least important.

Conclusion:

Relatives of critically ill patients primarily focus on the quality of patients’ care. Creating a positive rapport based on trust and providing a healthcare environment where the expectations and needs of relatives are met should be prioritized by emergency department physicians, nurses, and other staff while caring for critically ill patients.

BNP shows myocardial injury earlier than Troponin-I in experimental carbon monoxide poisoning

OBJECTIVE

In this study, our purpose was to determine whether plasma BNP level can be useful or not in determining the severity of myocardial injury formed by CO poisoning and to compare plasma BNP level with serum cTnI level.

MATERIALS AND METHODS

In the study, 46 female Wistar Albino rats were used. Rats were divided into four groups, one control group and three poisoning groups. The mixture of pure CO and air was injected for 60 minutes to provide 3000 ppm CO concentration. Blood samples of groups were collected to measure COHb, BNP and cTnI levels. Blood samples of poisoning groups were collected at the 1st, 6th and 12th hours after poisoning. After biochemical procedures, findings were analysed statistically and compared with each other.

RESULTS

Eight rats which died in poisoning groups were excluded and 38 rats were evaluated. BNP levels were high in all poisoning groups compared to control group and the difference between them was statistically significant (p < 0.05). cTnI levels were high in 6th and 12th hours poisoning groups compared to control and 1st hour group but only 12th hour group had statistically significant difference (p < 0.05). A statistically positive relation was established between BNP and cTnI levels in 6th and 12th hour groups (R: 0.76 - p < 0.05 - n:38).

CONCLUSIONS

It was found that BNP levels increased earlier than cTnI levels in acute severe CO poisoning. BNP levels of the cases which were determined to have increased cTnI levels showing myocardial injury increased as well. BNP can show myocardial injury and its severity in acute CO poisoning.

Prevalence and risk factors for methicillin resistant Staphylococcus aureus carriage among emergency department workers and bacterial contamination on touch surfaces in Erciyes University Hospital, Kayseri, Turkey

OBJECTIVE

The aim of this study was to determine Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) nasal carriage among emergency department (ED) workers, and bacterial contamination on hand-touch surfaces at ED.

METHODS

This single-centered study enrolled 105 ED workers and 190 hand-touch surfaces at ED in June 2014. Nasal and environmental samples for S. aureus carriage and for bacterial contamination were obtained. For isolation swabs were cultured on ChromAgar S. aureus and environmental samples first cultured in broth and antibiogram obtained by clinical and Laboratory Standards Institute guidelines. A questionnaire was completed for each subject.

RESULTS

The S. aureus carriage rate was 18.1% (n=19), with 2.9% (n=3) MRSA positivity. There were two (1.9%) mobile phone positivities for S. aureus, one of them was MRSA, and a computer keyboard contamination for MRSA was also detected. All MRSA isolates were susceptible for the tested antibiotics. There was significant difference between gender (p=0.044) in terms of nasal carriage of S. aureus and MRSA, all three MRSA isolates were from females.

CONCLUSION

Our study showed that the carriage of MRSA was not affected by clinical exposure in the hospital because of the existing infection control policy in our hospital.

Emergency medicine as a specialty in Asia

Aim

We aim to examine the similarities and differences in areas of EM development, workload, workforce, and capabilities and support in the Asia region. Emerging challenges faced by our EM community are also discussed.

Methods

The National Societies for Emergency Medicine of Hong Kong, India, Japan, Malaysia, Philippines, Singapore, South Korea, Taiwan, Thailand and Turkey participated in the joint Japanese Association of Acute Medicine (JAAM) and Asian Conference of Emergency Medicine (ACEM) Special Symposium held in October 2013 at Tokyo, Japan. The findings are reviewed in this paper.

Results

Emergency medicine (EM) has over the years evolved into a distinct and recognized medical discipline requiring a unique set of cognitive, administrative and technical skills for managing all types of patients with acute illness or injury. EM has contributed to healthcare by providing effective, safe, efficient and cost-effective patient care. Integrated systems have developed to allow continuity of emergency care from the community into emergency departments. Structured training curriculum for undergraduates, and specialty training programs for postgraduates are in place to equip trainees with the knowledge and skills required for the unique practice of EM.

Conclusion

The practice of EM still varies among the Asian countries. However, as a region, we strive to continue in our efforts to develop the specialty and improve the delivery of EM.

The Effects of the Sleep Quality of 112 Emergency Health Workers in Kayseri, Turkey on Their Professional Life

Objectives

Sleep adequacy is one of the major determinants of a successful professional life. The aim of this study is to determine the sleep quality of emergency health workers and analyze its effects on their professional and social lives.

Methods

The study was carried out on 121 voluntary emergency health workers in 112 Emergency Aid Stations in Kayseri, Turkey, in 2011. The data was collected through the Socio-Demographics Form and the Pittsburgh Sleep Quality Index (PSQI) and analyzed via SPSS 18.00. The statistical analysis involved percentage and frequency distributions, mean±standard deviations, a chi-square test, correlations, and logistic regression analysis.

Results

The mean score of the participants according to the Pittsburgh Sleep Quality Index was 4.14±3.09, and 28.9% of participants had poor sleep quality. Being single and being a woman accounted for 11% (p=0.009, 95% CI: 0.111–0.726) and 7% (p=0.003, 95% CI: 0.065–0.564) of poor sleep quality respectively. There was a positive correlation between sleep quality scores and negative effects on professional and social life activities. Negative effects on professional activities included increased loss of attention and concentration (40.0%, p=0,016), increased failure to take emergency actions (57.9%, p=0.001), reduced motivation (46.2%, p=0.004), reduced performance (41.4%, p=0.024), and low work efficiency (48.1%, p=0.008). Poor sleep quality generally negatively affected the daily life of the workers (51.6%, p=0.004), restricted their social life activities (45.7%, p=0.034), and caused them to experience communication difficulties (34.7%, p=0.229).

Conclusions

One third of the emergency health workers had poor sleep quality and experienced high levels of sleep deficiency. Being a woman and being single were the most important factors in low sleep quality. Poor sleep quality continuously affected daily life and professional life negatively by leading to a serious level of fatigue, loss of attention-concentration, and low levels of motivation, performance and efficiency.

Does usage of peritonism tests in an emergency department have any benefit?

AIM

To evaluate the usage of inspiration, expiration, cough, and heel drop jarring tests that are applied for determination of peritonism in cases with acute abdominal pain.

METHODS

A prospective study based on observation of patients between 16-65 years of age and presented to the Emergency Department within a 3-month period starting from June 2007, was conducted. The patients were asked to rate their pain level between "0" and "10". Following the measurement of the vital signs, 4 tests were conducted by an emergency medicine resident. The medical records of all the patients were reviewed after 3 months. Data concerning clinical diagnosis, hospital admission and discharge processes, and surgical results, were all recorded.

RESULTS

Seventy-seven patients had peritonism tests performed. Inspiration test was positive in 29 (of 51, 56.9%) patients admitted to the hospital. However, there was no correlation between the cases admitted to the hospital and the other 3 tests (p more than 0.05). Twenty-one (of 34, 61.8%) patients which have been subjected to surgical treatment, showed positive inspiration test results. Surgical treatment was performed on nine (of 11, 81.8%) patients who showed positive results for all 4 tests.

CONCLUSION

The applied tests are helpful in determining a serious abdominal disease, particularly alongside findings of rebound, tenderness, and laboratory results.

Characteristics of acute adult poisonings in a university hospital emergency department in central Turkey: a three-year analysis

OBJECTIVE

To evaluate the etiologic and demographic characteristics of acute adult poisoning cases and to obtain up-to-date information on acute poisonings.

METHODS

A retrospective study was conducted to evaluate 1254 adults who presented with acute poisoning to the Emergency Department of our tertiary care university hospital in central Turkey from January 2007 to December 2009. The data extracted from each chart related to age, gender, marital status, agent involved in the poisoning, season of event, route of poisoning, time between ingestion or exposure and arrival at the casualty ward, mechanism of toxic exposure (unintentional or intentional), level of consciousness, length of stay in the ward, and outcome.

RESULTS

Acute poisonings comprised 1.40% of Emergency Department patients; 65% were female, while 47% were between the ages of 16 and 25 years. Medicinal drugs were the most common cause of poisonings (68%), followed by gases (9.5%). Antidepressants were the most frequent drug ingested (18%), followed by analgesics (16%). Intentional poisonings constituted the majority of cases (78%). Most suicide attempts were made by women (68%) and majority of the patients were married (57%). Twenty patients (1.6%) died during their hospital stay, with organophosphate pesticides being the most common agent (n = 8) involved in fatal poisonings.

CONCLUSION

Pharmaceutical agents, carbon monoxide and pesticides are the three most common poisoning agents. Deliberate self-poisoning is common in adults in the area of the study; the risk being highest in females and younger adults. These up-to-date data provide important information on the characteristics of acute poisonings and can guide activities such as professional training, preventive measures, community education and new research.

Poisoning severity score, Glasgow coma scale, corrected QT interval in acute organophosphate poisoning

The aim of this study was to investigate effectiveness of the poisoning severity score (PSS), Glasgow coma scale (GCS), and corrected QT (QTc) interval in predicting outcomes in acute organophosphates (OP) poisoning. Over a period of 2 years, 62 patients with OP poisoning were admitted to emergency department (ED) of Erciyes University Medical School Hospital. The age, sex, cause of contact, compound involved, time elapsed between exposure and admission to the ED, duration of hospital stay, and cardiac manifestations at the time of presentation were recorded. GCS and poisoning severity score (PSS) was calculated for each patient. Electrocardiogram (ECG) analysis included the rate, rhythm, ST-T abnormalities, conduction defects, and measurement of PR and QT intervals. Sixty-two patients with OP poisoning presented to our ED from January 2007 to December 2008 from which 54 patients were included in the study. The mean age was 34.1 +/- 14.8 years. Of the cases, 53.7% were female. Twenty-six patients had a prolonged QTc interval. Mean PSS of men and women was 1.8 +/- 1.0. No statistically significant correlation was found between the PSS and QTc intervals of the cases. A significant correlation was determined between the GCS and PSS of grade 3 and grade 4 cases. GCS is a parameter that helps clinician to identify advanced grade OP poisoning patients in the initial assessment in the ED. However, ECG findings, such as prolonged QTc interval, are not effective in determination of short-term prognosis and show no relationship with PSS.

Machine-related farm injuries in Turkey

Traumas connected with agricultural production can result in serious injuries and mortality. The objective of the study was to describe the characteristics of agricultural machines related work injury cases admitted to the Emergency Department, and to asses factors related to injury severity and hospital admission in the Central Anatolian Region of Turkey. All the cases presented related to injuries caused by work with agricultural machines between January 2006-November 2007 were included in the study. Information was collected concerning the demographic structures of the patients. Injury sites, injury types, and clinical features were recorded. Initial injury severity scores of all the cases were diagnosed at hospital admission. 91.9 percent of the cases were male. Mean age was 35.8 +- 17.0. The most common machine causing injuries was a tractor with 46 percent of cases, and all of these were fall traumas. 18.9 percent of the cases was considered as slight injury, 43.2 percent as moderate, and 37.9 percent as severe. Two male cases resulted in fatality. Our findings suggest that tractors are the most dangerous agricultural machines, and falls from tractors as the most common injury mechanism among machine-related injuries, especially for young people. In the rural areas of our country, Turkey, agricultural machines cause serious injuries that require hospitalization.

Acute Amitraz Poisoning in Adults: Clinical Features, Laboratory Findings, and Management

BACKGROUND

Amitraz is a formamidine pesticide widely used in agriculture and veterinary medicine as an insecticide and acaricide. Reports on amitraz poisoning in humans are not as prevalent as those in animals. Of human intoxications in the medical literature, the majority of intoxications are in children. The number of adult intoxications with amitraz is limited.

METHODS

In this study, we discuss the clinical features, laboratory findings, and management of 23 adults with amitraz poisoning cared for in our center. Data were extracted from the charts retrospectively, and included age, gender, mode of poisoning, initial symptoms, time to appearance of initial symptoms, clinical and laboratory findings, management, and prognosis.

RESULTS

Fourteen of 23 patients were female (61%). Ages ranged from 16 and 78 years (mean 38.6 +/- 19.8 years). Twenty-one patients ingested amitraz orally while one was exposed through skin contact and one probably through skin contact and/or inhalation. Seven patients ingested amitraz with intent to commit suicide and 11 patients accidentally. Vomiting, altered consciousness, and drowsiness were the predominant initial symptoms. Initially, hypotension was present in seven patients (30%), bradycardia in two (8.7%), myosis in six (26%), and mydriasis (without atropine administration) in three (13%). Time to appearance of the initial symptoms ranged from 5 to 120 minutes. Laboratory findings included an initial blood glucose level higher than 120 mg/dL in 62% of patients (mean 191 +/- 70 mg/dL) and elevations in AST levels in four patients (81 +/- 28 U/L) and ALT levels in three (60 +/- 14 U/L). Ten patients had central nervous system depression, which resolved spontaneously. Five patients required mechanical ventilation for respiratory depression (mean duration of mechanical ventilatory support: 50 +/- 16 hours). Six patients were thought to have been poisoned with an organophosphate and three with a carbamate pesticide due to confusing clinical picture; four of these nine patients received pralidoxim.

CONCLUSIONS

In spite of a rapidly progressing and life-threatening clinical picture, amitraz intoxication in humans carries a low morbidity and mortality when appropriate supportive treatment is given. No antidote has been developed for use in more serious cases. To prevent accidental ingestions, prominent and clear warning labels should be placed on its containers.

Effect of Interleukin-10 on Tissue Damage Caused by Organophosphate Poisoning

Organophosphate poisoning is a common cause of severe morbidity and mortality among patients admitted to emergency departments. Tissue damages as a consequence of organophosphate poisoning are frequently reported, but preventing this potentially severe complication has not been the subject of much research. We tested whether interleukin-10, a cytoprotective agent, could prevent or diminish pathological signs of tissue damages caused by organophosphate poisoning. Thirty rats were divided into three equal groups (n = 10). Group 1 (sham) did not receive any agent during the experiment. Group 2 (control) received 0.8 g/kg of fenthion intraperitoneally, followed by 6 ml/kg of intraperitoneal normal saline 30 min and 3 hr later. Group 3 (treatment) received 0.8 g/kg of fenthion intraperitoneally, followed by 2 microg/kg of interleukin-10 intraperitoneally 30 min and 3 hr later. All rats were killed under anaesthesia after 6 hr and tissue samples were obtained from liver, kidneys and lungs. Even organophosphate poisonings do not cause significant clinical problems; several degrees of damages could be observed in liver, kidneys and lungs. These damages could be reduced by interleukin-10 treatment.

Acute organophosphate poisoning in university hospital emergency room patients

OBJECTS

In the present study, we evaluated patients who were admitted to our emergency department with a diagnosis of organophosphate poisoning and discussed clinical, social and demographic features.

METHODS

A retrospective study was conducted with organophosphate poisoning patients admitted to our emergency department between January 1995 and December 2004. Data regarding the age, sex, occupation, type of agent, route of poisoning, clinical effects of cholinergic overactivity, laboratory findings, and mortality rate were obtained from the patient files.

RESULTS

During the study period, 220 patients who had organophosphate poisoning with a known agent were admitted to the ED. The estimated mean admission time to the ED after the exposure was 3.9 +/- 3.1 (1-14) hours. There were 131 (59.5%) female and 89 (40.5%) male patients. The most affected age group was 15-24 years (40.5%), in both sexes. Oral ingestion (86.5%) was found to be the most common route of poisoning. The most frequent reason for poisoning was attempted suicide (75.9%). The most common organophosphate compounds exposed were dichlorvos, diazinon and parathion-methyl. The most frequent clinical signs were miosis, respiratory system findings, tachycardia, loss of consciousness, and hypertension. Twenty patients (9.1%) died due to sudden respiratory and cardiac arrest (45%), respiratory failure (25%), CNS depression (5%) and septic shock (25%).

CONCLUSION

We think that the appropriate use of these compounds, instruction of the public about their harmful effects and restriction of their uncontrolled sales by legal regulations can reduce the incidence of organophosphate poisoning.

A rare complication of chlorine gas inhalation: pneumomediastinum

Chlorine gas is a potent pulmonary irritant that causes acute damage in both the upper and lower respiratory tract.

Bleeding due to a medicinal leech bite

This paper reports a case of prolonged bleeding following application of leeches to treat chronic pain. The paper discusses the characteristics of the wounds and possible complication of prolonged bleeding following medicinal leech application. The principles of treatment are also described.

Treatment of midclavicular nonunion: comparison of dynamic compression plating and low-contact dynamic compression plating techniques

In this study a comparison of patients with midclavicular nonunion, treated by a combination of internal fixation with dynamic compression plate (DCP) or low-contact DCP (LC-DCP) and application of autogenous corticocancellous chips or sculptured graft on nonunion areas, was performed. Time to union in the patients treated with LC-DCP fixation was shorter than in those treated with DCP fixation (P <.001). Union was obtained in all patients treated with LC-DCP fixation and in 87.5% of those treated with DCP fixation. All of those treated with LC-DCP fixation returned to their original jobs, whereas two patients treated with DCP fixation had to change jobs. According to the Disabilities of the Arm, Shoulder, and Hand functional score, at the last follow-up visit, functional outcomes of the patients treated with LC-DCP fixation were more satisfactory (P <.001). The addition of internal fixation of the clavicle with DCP or LC-DCP to application of autogenous corticocancellous chips, or sculptured graft on nonunion areas in patients with midclavicular nonunion, shortens the time to union, increases union rates, and provides satisfactory functional outcomes.

Blood levels of acute phase reactants with traffic accidents

Emergency departments are generally the first treatment places for the trauma victims. Evaluating the traumatised patients by objective criteria are of great importance in diagnosis, treatment and prognosis. This prospective study was conducted at the Medical School of Erciyes University. Blood levels of Ceruloplasmin, Haptoglobulin and Transferrin, which are known as acute phase reactants, were obtained. 60 trauma patients were included in this study. 19 (31.6%) females and 41 (68.4%) males. 15 patients were operated. 4 (26%) patients died during the postoperative follow-up period. When compared with ceruloplasmin values obtained on all of the groups this they were statistically significant except that two day-control group. All of the haptoglobulin groups were statistically significant. When compared with transferin values obtained on first-two day, first-seven day and two-seven day, they were statistically significant (P < 0.05). As a results, We might say that the changes in the blood levels of all three biochemical parameters are related to the severity of the trauma. Taking advantage of all such changes we might predict both the severity of the trauma and the prognosis of traumatic episodes. This gives us an opportunity to define better strategies for the follow-up and treatment of our trauma patients.

Functional outcome of open reduction and internal fixation for completely unstable pelvic ring fractures (type C): a report of 40 cases

OBJECTIVES

To evaluate functional outcomes, morbidity and mortality rates, and psychological and psychosomatic status in patients treated for completely unstable pelvic injuries (Tile class C).

DESIGN

Prospective clinical study.

SETTING

University hospital.

PATIENTS/PARTICIPANTS

Forty patients treated with anterior and posterior internal fixation for unstable pelvic ring fractures between January 1992 and August 1999.

INTERVENTION

Open reduction and anterior and posterior internal fixation of the pelvic ring.

MAIN OUTCOME MEASUREMENTS

The data were analyzed as follows: pelvic fracture classification, Tile classification; severity of trauma, Injury Severity Score (ISS); functional outcomes, the Majeed Outcome Scale; psychological and psychosomatic status, Hamilton Depression and Anxiety Rating Score (HDARS).

RESULTS

Preoperatively the average ISS was 29.4 (range 12-66). There was a statistically significant positive correlation between anxiety and ISS (r = 0.536, P < 0.01). Two patients died during the early postoperative period. Two additional patients were lost to follow-up, leaving 36 patients followed for an average of 45 months (range 21-116 months). Deep infections developed in three patients with a posterior pelvic ring injury who had been treated with percutaneous fixation techniques. These were treated successfully with débridement. Nine patients complained of pain of pelvic origin. Nerve deficits recovered completely in four of the seven patients with preoperative neurologic deficiency. Moderate or major depression was diagnosed in sexually dysfunctional patients in the 12th postoperative month according to HDARS (r = -0.559, P < 0.001). At the last visit, there was an inverse correlation between ability to work and depression and anxiety (r = -0.551, r = -0.391). An inverse correlation was found between pain and ability to work (r = 0.597, P < 0.001). Of the 36 patients, 26 returned to their original jobs at the last follow-up visit.

CONCLUSIONS

Morbidity and mortality rates are higher in patients with a completely unstable pelvic ring injury. Emergency department stabilization and reconstruction of the pelvic ring with optimal operative techniques in these patients can reduce morbidity and mortality rates. Anterior and posterior internal fixation results in satisfactory clinical and radiologic outcomes. The affective status of patients is an important aspect that should be considered during the entire care of the patient.

Role of oxygen free radical scavengers in acute renal failure complicating obstructive jaundice

Obstructive jaundice is associated with high morbidity and mortality. Major complications such as pulmonary dysfunction, renal failure and sepsis are frequently encountered. Recent studies and observations suggest that the free oxygen radicals (FORs) produced in obstructive jaundice may play a significant role in the etiopathogenesis of acute renal failure (ARF). Thirty rats were divided into three groups, as sham, control and treatment groups containing 10 rats each. Laparatomy was performed on each animal in the control and treatment groups and common bile ducts were ligated. Common bile duct was observed but was not ligated for the rats in the sham group. Saline solution injection was begun on the first day of surgical procedure and repeated once a day during the following 5 days. The same procedure was performed with oxygen radical scavenger dimethyl sulfoxide (1.5 mg/kg/day i.p.) instead of saline in the treatment group. The rats were sacrificed on the 7th postoperative day. On the 7th postoperative day, the bilirubin, urea and creatinine levels of the control and treatment groups were significantly higher in comparison with the sham group (p < 0.01). Although there was no statistically significant difference between the bilirubin levels of the control and treatment groups (p > 0.05), the urea and creatinine levels in the treatment group were significantly lower (p < 0.01). On the 7th postoperative day, the erythrocyte superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) levels of the control and treatment groups were significantly lower than those of the sham group (p < 0.01), whereas renal and erythrocyte malondialdehyde (MDA) levels were significantly higher (p < 0.01). Although SOD and GSH-Px levels did not differ significantly between the treatment and control groups (p > 0.05), renal and erythrocyte MDA levels of the treatment group were significantly lower than those of the control group (p < 0.01). The histopathological scores were significantly higher in the control and treatment groups (p < 0.01); there was no significant difference between the control and treatment groups (p > 0.05). FORs seem to play a significant role in the etiopathogenesis of renal failure in obstructive jaundice. Antioxidant treatment may decrease oxidative damage due to FORs and may prevent renal failure.