Who takes care of intensive care? Changes over the last two decades

OBJECTIVE

Intensive care units are very important across various fields of medicine, and there are many high-quality journals that publish about intensive care. However, there is a lack of information regarding which disciplines publish the most in these journals. We aim to evaluate the intensive care literature.

MATERIALS AND METHODS

We searched the papers published in the American Journal of Respiratory and Critical Care Medicine, Intensive Care Medicine, Critical Care Medicine and Critical Care to gain information regarding authors' specializations. We collected specialization data from PubMed, Google Scholar, and also from various journal websites. We examined the changes in the proportion of disciplines that are actively contributing to intensive care literature.

RESULTS

Regardless of the year and the journal, intensivists were the most common writers (1,047/4,807, 21.8%) overall. This was followed by pulmonology (843, 17.5%), anesthesia (827, 17.2%), others (602, 12.5%), and pediatrics (374, 7.8%). The United States of America (1,470/30.8%), France (573/11.2%), and Germany (332/6.9%) were at the top of the list in terms of productivity.

CONCLUSIONS

With the increase in the number of intensive care units and the development of an understanding of intensive care, we observed that intensivists are publishing more in intensive care literature.

Street drug use among emergency patients in a Public Hospital in Turkey

BACKGROUND

Country-specific numbers of street drug (SD) users are well documented. However, little data exists regarding these patients' clinical presentations and outcomes in the emergency department (ED). Therefore, management of these patients in the emergency setting is still a subject of debate.

OBJECTIVES

The aim of this study is to determine the symptoms and signs of SD users presenting to the ED, and to report the substances, treatments, and outcomes.

MATERIALS AND METHODS

In this single-center study, symptoms, clinical findings, diagnoses, and outcomes of patients who reported to have used SDs or were diagnosed as SD users were investigated within a 1-year study period. Chi-square and Mann-Whitney U tests were performed to compare independent variables.

RESULTS

Mean age of the 425 study patients was 25 ± 9 years (range: 12-64 years), and 6.1% (n = 26) of the patients were females. SDs used before presentation to the ED were mostly synthetic cannabinoids and "ecstasy." Overall prevalence of SD user admissions in ED was 0.24%. The most common presenting complaint was weakness/faintness in 21.1% (n = 90). Depressed level of consciousness was the most common physical sign (33.3%, n = 142). Incidences of altered mental status were significantly higher among ecstasy and/or bonsai users (n = 14, 27.5%; P = 0.027 and n = 46, 64.8%; P < 0.001, respectively), compared to other SD users. While 23.1% (n = 98) of the SD users did not warrant any medical intervention, 6.6% of the users (n = 28) underwent advanced life support.

CONCLUSIONS

Self-reported SD users were mostly young males who were treated symptomatically and discharged. Almost one-third-mostly ecstasy and bonsai users-had depressed level of consciousness and required resuscitation.

Nonspecific abdominal pain: A follow-up survey

Introduction

Little data have been published on the outcome of patients discharged from the emergency department (ED) after being diagnosed with nonspecific abdominal pain (NSAP). This study aimed to investigate short-term follow-up of patients discharged with a diagnosis of NSAP from the ED.

Materials and Methods

This prospective, observational study was conducted in the University-based ED and enrolled all consecutive adult patients who were diagnosed as NSAP out of patients presented with abdominal pain (AP). The main outcome measure was the presence of recurrent AP resulting in referral to the ED and specific diagnoses within the first 3- and 90-day postdischarge. On the 3^rd and 90^th days, all patients discharged with NSAP from the ED were asked questions, and their response entered into a questionnaire.

Results

A total of 684 patients presented with AP, of which 299 (46%) had a diagnosis of NSAP within the 4-month period. Fifty cases (16%) could not be included due to inability to access. Eighty-one out of 249 patients (32.5%) complained of recurrent AP within the first 3 days. Twenty-two cases (8.8%) were readmitted to ED once again in the meantime, and ten received specific diagnoses including three with acute abdomen. Within 90 days, additional nine patients out of 20 (45%) with recurrent AP received specific diagnoses including two with acute abdomen.

Conclusions

Certain specific underlying entities can be missed in patients considered to have NSAP and discharged from the ED. Adherence to timely follow-up and repeated examinations are of vital importance in these patients.

Accidental Use of Sodium Hypochlorite Instead of Haemodialysis Solution: A Case Report

Haemodialysis that involves diffusion of solutes across a semi-permeable membrane allows excretion of harmful solutes and excess fluids. All dialysis machines are disinfected by chemical agents (e.g. sodium hypochlorite, formaldehyde, glutaraldehyde, peroxyacetic acid). Sodium hypochlorite (NaOCl), which is known as household bleach, is a whitening agent and used in medical treatment and disinfection of tap water. Herein, we present a 66-year-old female patient who was inadvertently connected to NaOCl solution infusion in a routine haemodialysis session. By the time the accident was noticed, approximately 200 ml of undiluted NaOCl cleaning solution (concentration 1.21-1.23 g/ml) had been added to the dialysis bath, soaking the membrane fibres. The patient was admitted to the hospital about 30 minutes after the exposure, and her Glasgow Coma Scale score was recorded as 5/15 (E1, V1, M3). In conclusion, more stringent standards should be enforced in the sterilization of haemodialysis machines and related equipments. Accidental contacts with disinfectants should be prevented in dialysis units.

Prognostic Value of Avr Lead and the Well-Known Risk Factors in Acute St-Segment Elevated Myocardial Infarction

Objective

The present study was designed to analyse the effect of ST segment changes in aVR lead and the well-known risk factors in ST-segment elevated myocardial infarction (STEMI) patients.

Materials and Methods

A total of 250 patients who were admitted between 2009 and 2010 with STEMI and ≥1 mm ST-segment elevation in aVR lead were enrolled in the study. The patients were followed for life-threatening events like acute pulmonary oedema, atrial fibrillation, AV block, ventricular tachycardia, length of stay in hospital and death.

Results

Among the enrolled patients, 222 were discharged and 28 died. Pulmonary oedema and mortality rates were significantly higher in patients with ST-segment elevation in aVR lead (both p=0.001).

Conclusions

There is a correlation of ST-segment elevation in aVR lead with poor outcome in STEMI. Therefore aVR lead must be analysed as well as the other leads and well-known risk factors while it estimates the prognosis.

A retrospective analysis of antidepressant poisonings in the emergency department: 11-year experience

Between 1993 and 2004, patients with antidepressant poisoning admitted to an emergency department (ED) were analysed retrospectively with regard to demographics, clinical findings and treatment attempts. Age, gender, suicide attempts, classification of antidepressants, Glasgow Coma Scale (GCS) score, ECG findings, need for endotracheal intubation, follow-up period and Antidepressant Overdose Risk Assessment (ADORA) criteria were analysed by SPSS software. A total of 356 antidepressant poisoning cases were evaluated. Tricyclic antidepressants (TCA), especially opipramol and amitriptyline, were the most common agents (58.4%). The most frequent ECG finding was sinus tachycardia (40.7%, n=145). Endotracheal intubation was required in 9.6% of cases. Patients with TCA ingestion had a longer observation time in the ED, abnormal ECG findings, abnormal physical examination findings and more ADORA criteria, than patients who ingested selective serotonin re-uptake inhibitors (SSRI) (P=0.008, P=0.008, P<0.001, P<0.001). It was found that the patients who ingested TCA (P=0.001), poisoned with amitriptyline (P=0.001), patients with GCS scores of 8 and less (P=0.001), patients with two or more ADORA criteria (P=0.001), with seizures (P=0.001), with abnormal ECG (P=0.012), and patients with a history of two or more suicide attempts were intubated more frequently. Suicide attempts, classification of the antidepressant, ECG findings, seizure, GCS score and number of detected ADORA criteria affect the need for intubation in patients with antidepressant poisoning.

Oxidative Status and DNA Damage Following Analgesic Treatment in Patients with Acute Pancreatitis

BACKGROUND

This study is designed to investigate the effect of three different analgesics, used to treat pain in AP, on oxidative stress, DNA damage in mononuclear leukocytes, and on oxidative status.

METHODS

This parallel design randomized controlled trial is composed of three treatment arms, intravenous paracetamol, intravenous dexketoprofen, and intravenous tramadol.

RESULTS

A total of 107 patients were diagnosed with acute pancreatitis within the study period in the ED. Seventyseven of them were included in the study; 26 patients for the paracetamol group, 24 patients for the dexketoprofen group, and 27 patients for the tramadol group. The mean age of study subjects was 52.73 ± 15.38 and 66% (n = 51) of them were men. At the beginning of the study (before treatment), mean levels of DNA damage, TOS, and OSI levels were significantly higher and TAS was significantly lower in the acute pancreatitis groups than in the control group. DNA damage and OSI in HAPS-positive patients were found to be significantly greater than HAPS-negative patients (p = 0.046). DNA damage and oxidative stress were compared between the three groups. There were no differences between the groups in terms of DNA damage (p = 0.42) and also for the oxidatif stress parameters (OSI,TAS,TOS had p-values of p = 0.26, p = 0.78, p = 0.35, respectively).

CONCLUSIONS

There is no difference between the effects of paracetamol, dexketoprofen, and tramadol, which are commonly used to manage acute pain in AP, on DNA damage in human T-lymphocytes and on serine parameters of oxidative status.

Mad honey intoxication: what is wrong with the blood glucose? a study on 46 patients

OBJECTIVE

This study was designed to analyze the characteristics of adult patients with mad honey intoxication, with special emphasis on its effects on vital signs and blood glucose levels.

METHODS

Patients admitted to the Emergency Department of urban hospital in the Black Sea region of Turkey over the 16-months study period due to mad honey intoxication were included. Patients' demographic and clinical characteristics, including age, sex, systolic and diastolic blood pressure, rhythm at ECG, heart rate, blood glucose levels and clinical outcomes were recorded and analyzed.

RESULTS

Forty-six patients with a presumptive diagnosis of mad honey poisoning were recruited. Mean age was 52.2 (±17.2). Blood glucose level was normal in 28 cases (60.9%) and high in 18 (39.1%). Systolic blood pressure (SBP) was low in 40 patients (87%) and normal in six (13%). Diastolic blood pressure (DBP) was low in 42 cases (91.3%) and normal in four (8.7%). Mean glucose level in patients with low SBP was 116.1 (±52.9) mg/dL, vs. 120.7 (±23.0) mg/dL in those with normal or high SBP (p = 0.389). Mean glucose level in patients with low DBP was 118.7 (±51.4) mg/dL, compared to 96.0 (±22.8) mg/dL in those with normal or high DBP (p = 0.146). Heart rate was below or equal to 45 bpm in 28 patients (60.9%). Complete (third degree) heart block was diagnosed in one case.

CONCLUSION

Mad honey was found not to cause significant decreases in blood glucose levels in humans. Hypotension, bradycardia and related clinical consequences are commonly encountered in patients diagnosed with mad honey or grayanotoxin poisoning.

Raynaud's phenomenon--or just skin with dye?

Munchausen's syndrome is a factitious disorder resulting in unnecessary investigations and operative treatments in a small and well-defined population. Autobiographical falsification is the characteristic of the entity. The case history is presented of a 28-year-old woman admitted to the emergency department with severe pain of acute onset in her fingers and discoloration while washing dishes. She had been diagnosed with Raynaud's phenomenon and had been on antiepileptic drugs. The fingertips of both hands looked cyanotic. Radial and ulnar pulses were intact. She had argued with the personnel obtaining vital signs and had a tendency to hide her right hand, which raised the suspicion that a psychiatric disorder was the primary cause of the visit to the emergency department. A blue piece of dirt on the left shoulder had also augmented these concerns. Munchausen's syndrome was suspected after careful handshaking with hands soaked in alcohol resulted in a blue discoloration on the doctor's palm and fingers. Emergency and primary care physicians should be alert to this type of situation, with a myriad possible scenarios to be differentiated from real conditions.

Ruptured hydatid cyst following minimal trauma and few signs on presentation

Hydatid disease is a parasitic infection caused by Echinococcus granulosus characterised by cyst formation in any organ, although the liver is the most commonly involved. Hydatid cysts can rupture either spontaneously or following trauma. Surgical treatment can be life-saving. This paper reports the atypical presentation of a young girl admitted to the emergency department. She presented with pain on her palms due to falling down a few steps. Because of the rebound tenderness on the right upper quadrant of her abdomen on physical examination, bedside ultrasonography was performed to identify the underlying cause, and promptly revealed a 62 x 72 mm lobular cyst on the right lobe of the liver with free fluid in the subcapsular area. Shortly afterwards, urticaria developed. Fluid resuscitation, methylprednisolone and diphenylhydramine were administered intravenously. Afterwards she was taken to the operation room for unroofing, drainage and capitonage. In conclusion, primary care and emergency physicians should perform a complete physical examination on all admitted patients with vague symptoms and a high index of suspicion for a ruptured hydatid cyst, even following trivial trauma, especially in endemic regions.

Succinylcholine or rocuronium? A meta-analysis of the effects on intubation conditions

This meta-analysis was undertaken to compare the effects of succinylcholine (SCH) and rocuronium (RCR) on endotracheal intubation (ETI) conditions. Eligible randomised controlled trials (RCTs) were identified via medline and a manual search of references. The frequencies of excellent and unacceptable ETI conditions in subjects receiving SCH 1.0-1.5 mg/kg and RCR 0.6-1.2 mg/kg were determined using standard statistical methods. Inclusion criteria were met by 16 RCTs, representing 1362 subjects. SCH was associated with a 17.7% increase (95% CI = 13-22) in the frequency of excellent ETI conditions and a 5.1% decrease (95% CI = -7.3 to -2.9) in the frequency of unacceptable ETI conditions, when compared with RCR. In the subgroup undergoing true rapid sequence intubation, SCH was associated with a 19.1% increase (95% CI = 13.7-24.5) in the frequency of excellent ETI conditions. SCH appears to be superior to RCR in creating excellent ETI conditions and avoiding unacceptable ETI conditions.

Seeing the invisible: painless aortic dissection in the emergency setting

Acute dissection of the aorta can be one of the most dramatic cardiovascular emergencies. Classically, aortic dissection presents as sudden, severe chest, back, or abdominal pain that is characterised as ripping or tearing in nature. However, a timely diagnosis can be elusive in the event of an atypical presentation. In this report, the authors present two patients with painless aortic dissection who were misdiagnosed during their initial evaluation in the emergency department.

Painless aortic dissection with bilateral carotid involvement presenting with vertigo as the chief complaint

A 63 year-old woman was admitted to the emergency department with vertigo, nausea, and vomiting. On arrival, she was fully oriented and cooperative. She denied any pain in her chest, neck, back, or abdomen. A bruit was heard on both sides of her neck. Cranial computed tomography (CT) revealed no abnormality, while thoracic CT disclosed dissection in the ascending aorta, aortic arch, and bilateral common carotid arteries. After several hours, the patient underwent vascular surgery. She had an uneventful course and was discharged without any sequelae after 10 days. Vertigo is a rare presentation of aortic dissection with carotid involvement. Elderly patients presented with vertigo and nausea/vomiting should be evaluated for the condition and carotid dissection should be ruled out. Carotid bruit may be a clue to the diagnosis.

An investigation of the anger levels of residents: medical compared with surgical disciplines

OBJECTIVE

To evaluate medical and surgical residents' anger levels with regard to the department in which they worked, seniority, sex, satisfaction with their work environment, and the number of nightshifts worked per month. The specific situations and persons at whom residents reacted with anger were also investigated.

METHODS

116 randomly selected residents staffed in a university hospital (62 medical and 54 surgical residents) were enrolled. The trait anger and anger expression scale was used to find out the personal anger levels of each participant. The participants also clarified the persons and situations that made them angry at work.

RESULTS

Trait anger levels were greater in the surgical residents in their first two years when compared with levels of their senior colleagues (p = 0.033). Mean trait anger levels were greater in the residents who were not satisfied with their department (p = 0.004). Anger levels were not found to be related to the number of shifts per month. Male residents had higher levels of anger than female colleagues (p = 0.019).

CONCLUSION

Residents in clinical sciences seem to have the potential to benefit from a screening process in terms of anger and its subcomponents by means of a tool such as the trait anger and anger expression scale during their residency.

Anxiety disorder in patients with non-specific chest pain in the emergency setting

OBJECTIVES

Many patients who have been discharged from the emergency department (ED) with a diagnosis of "non-specific chest pain" (NSCP) have anxiety disorder (AD), a commonly missed entity in acute care. The objective of this study was to delineate characteristic properties that could enhance recognition of AD in ED patients admitted with NSCP.

METHODS

All patients between 18 and 65 years of age diagnosed with NSCP were enrolled. The Hospital Anxiety and Depression Scale (HADS) anxiety subscale was used as a screening test for AD. The patients with high HADS scores (> or = 10) were evaluated by a psychiatrist for AD.

RESULTS

In total, 157 patients were enrolled in the study. HADS scores were found to be "high" (> or = 10) in 49 patients (31.2%). Patients with high HADS scores had a higher frequency of associated symptoms (p = 0.004). Dizziness or lightheadedness, chills or hot flushes, and fear of dying were found to have been reported more frequently by patients with high anxiety scores. Of the group with high score, 33 patients (67.3%) were interviewed by a psychiatrist, and 23 (69.7%) of these patients were diagnosed with AD. Associated symptoms were described by 21 patients with AD (91.3%). Of those with AD, 18 (78.3%) had been previously admitted to the ED with chest pain. Atypical chest pain was described by 21 patients (91.3%).

CONCLUSIONS

Physicians should always consider AD in patients presenting to the ED with chest pain after ruling out organic aetiology. Patients' definition of atypical pain, recurrent admissions to ED, and presence of associated symptoms such as dizziness, chills or hot flushes, and fear of dying could aid in considering AD.

Impact of Ramadan on demographics and frequencies of disease-related visits in the emergency department

Summary The objective of this study was to determine whether Ramadan is changing frequencies and demographics of visits due to certain diseases. Data obtained from the charts of the adult patients admitted into the emergency department (ED) due to 10 predetermined entities between 2000 and 2004 were analysed. Demographic variables analysed separately for certain entities visiting the ED in Ramadan were not found to be different from visits in other times of year. Visit frequencies for hypertension and uncomplicated headache in Ramadan were significantly higher than in non-Ramadan months (chi(2) test, p = 0.015 for hypertension, p < 0.001 for uncomplicated headache). Mean age of the patients admitted to the ED due to diabetes-related conditions in Ramadan was significantly lower than in pre- and post-Ramadan months (59.91 +/- 14.60 and 62.11 +/- 14.61, respectively) (Mann-Whitney U-test, p = 0.032). The patients with diabetes presenting in Ramadan were found significantly younger than their peers in the rest of the year. For other diseases, Ramadan does not appear to be a risk factor.

Analysis of factors affecting pain in intravenous catheter placement: a survey of 925 patients

The aim of the study was to determine some factors affecting pain during intravenous (i.v.) catheter placement in an emergency department (ED). A cross-sectional, observational study was conducted at an academic ED. Nine hundred and twenty five adult patients who had a 20 gauge i.v. catheter placed were enrolled the study. Patients were excluded for the following conditions: more than one i.v. attempt, altered mental status, head trauma, lack of contact due to visual impairment, hearing or speech disorder, intoxication, distracting injury or physical abnormality at the i.v. site. The magnitude of pain of i.v. catheter placement was not related to age, sex, experience of the individual placing the i.v. catheter, site of i.v. catheter insertion and use of analgesic or antidepressive drugs (p > 0.05). Patients with a history of depression reported significantly higher pain than non-depressive patients (p = 0.001). Depressive patients reported higher severity of pain during i.v. catheter placement than nondepressed ones. This may influence the decision on whether or not to use local anaesthesia for catheter insertion.

Factors affecting pain in intravenous catheter placement: role of depression illness

The aim of the study was to examine factors affecting pain during intravenous (IV) catheter placement in an emergency department. A cross-sectional, observational study was conducted at an academic emergency department. Nine hundred and twenty-five adult patients who had a 20-gauge IV catheter placed were enrolled in the study. Patients were excluded for the following conditions: more than one IV attempt, altered mental status, head trauma, lack of contact due to visual impairment, hearing or speech disorder, intoxication, distracting injury or physical abnormality at the IV site. The magnitude of pain in IV catheter placement was not related to age, sex, experience of the individual placing the IV catheter, site of IV catheter insertion and use of analgesic or antidepressant drugs (p > 0.05). Patients with a history of depression reported significantly higher pain than non-depressed patients (p = 0.001). Depressed patients reported higher severity of pain during IV catheter placement than non-depressed ones. This may influence the decision on whether or not to use local anaesthesia for catheter insertion.

Prospective, randomised, double blind, controlled comparison of metoclopramide and pethidine in the emergency treatment of acute primary vascular and tension type headache episodes

STUDY OBJECTIVE

To compare analgesic effects of metoclopramide (MTP), pethidine (PET), and combination of metoclopramide-pethidine (M-PET) in the treatment of adult patients with acute primary vascular and tension type headache admitted in the emergency department (ED).

METHODS

All consecutive adult patients admitted into a university hospital ED in six months with acute vascular and tension type headache were recruited. The patients whose complaints had lasted no longer than seven days were randomised to four groups and thereby received 10 mg MTP intravenously plus placebo intramuscularly (MTP), 10 mg MTP intravenously plus 50 mg PET intramuscularly (M-PET), 50 mg PET intramuscularly plus placebo intravenously (PET); and intramuscular and intravenous placebo (PLC) in a blinded fashion. The patients were asked to report the degree of pain at 0, 15, 30, and 45 minutes on visual analogue scale (VAS) and demographic data and any side effects encountered were recorded. Rescue medication was used if required by the patient because of poor pain relief.

RESULTS

Data regarding 336 patients meeting inclusion criteria were analysed. Mean VAS values recorded at 45 minutes were significantly higher in PLC group than in others (p = 0.000). When the PLC group was excluded, VAS scores in MTP and M-PET groups were significantly lower than in PET group (p = 0.038). Though unimportant, the incidence of side effects recorded in PET group was found to be significantly higher than in the other groups (p = 0.003).

CONCLUSION

These data suggest that MTP produces more effective analgesia than PET in both vascular and tension type headache in patients with acute primary headache episodes.

Comparison of tissue adhesive and suturing in the repair of lacerations in the emergency department

The objective of this study was to compare the applications of Histoacryl Blue (HAB) and suturing regarding cosmetic outcome, cost and patient and physician satisfaction in the emergency department (ED). A total of 92 consecutive adult patients with lacerations equal to or shorter than 5 cm were enrolled in the study. Patients were randomized to either HAB or suturing. Ten-day and three-month cosmetic outcomes were evaluated via visual analogue scale (VAS) by a blinded surgeon. Cosmetic outcome, cost and patient and physician satisfaction of both groups were compared. Only 52 patients completed the follow-up at three months. Twenty-eight had been repaired with sutures and 24 with HAB. The differences regarding ten-day and three-month cosmetic outcome scales between the patients repaired with HAB and sutures were not statistically significant. Application of HAB resulted in greater satisfaction of the patient and the physician (p=0.007 and p=0.0001, respectively). Costs of HAB were significantly lower than sutures (p=0.0001). It is concluded that HAB is a cheaper method of laceration repair and results in greater satisfaction of both patients and physicians, while cosmetic outcomes were comparable. These results suggest that HAB is a viable alternative to suturing for selected lacerations in the ED.

Acute renal failure following latrodectism

Latrodectism is considered dangerous for human beings. Acute renal failure after envenomation is not common and usually results from prerenal failure. We report a 59-y-o man with acute oliguric renal failure due to a combination of prerenal and renal causes after being bitten by a black Latrodectus spider. He had the characteristic anxiety, severe hypertension, tremor, facial edema, and generalized diaphoresis. The patient recovered within a week without sequelae. Clinicians should not overlook the possibility of acute renal failure in latrodectism.