Ahmet Demircan

Carbon monoxide poisoning: how many patients do we miss?

Introduction Carbon monoxide (CO) is a colorless, odorless and nonirritating gas. CO poisoning is a preventable cause of morbidity and mortality. After the late diagnosis of some CO-poisoned patients, we undertook a chart review to identify characteristics of patients with CO poisoning to help with management of future patients. Methods We retrospectively evaluated the charts of 323 adult emergency department patients diagnosed with CO poisoning between January 2002 and December 2003. Demographic, clinical and laboratory findings were extracted. Chi square test was used to evaluate the correlation between carboxyhemoglobin (COHb) levels and syncope; and between syncope and sex. Results The mean age of the 323 patients was 29±17 years, and most (64%) were females. All of the poisonings were unintentional, and most patients presented during the winter months. The most common sources of CO were coal stoves (29%) and water heaters (24%). Complaints were headache in 55%, nausea in 49%, dizziness in 44%, syncope in 28%, and seizures in 4%. Abnormal physical findings included tachypnea in 79% and tachycardia in 47%. The mean COHb value was 26.3±11.5%. Syncope occurred more frequently in patients with high COHb levels (P<0.001) and was more common among females (P=0.003). Seizures occurred significantly more often in patients with a COHb level of ≥20%. Conclusion CO exposure in our patients was acute, accidental, and occurred during the winter months. Serious symptoms, such as syncope, occurred more often in patients having increased COHb levels, but normal COHb levels could not be used to rule out CO poisoning.

Glass Foreign Body in Soft Tissue: Possibility of High Morbidity Due to Delayed Migration

BACKGROUND Soft tissue foreign bodies (FBs) are a common occurrence in emergency departments (EDs). Some FBs cause complications, whereas others are asymptomatic and remain undetected for months or years. CASE REPORT A 32-year-old man presented to the ED with complaints of back pain in the area of a subcutaneous lump that had migrated toward the midline, nearly 25 cm from its former location, over the previous 2 weeks. Twelve years previously, after falling onto a glass door that shattered, he had gone to a local ED and had his wound sutured, but no X-ray studies were taken. Within a few months, he noticed a lump near his scapula, but he did not relate it to the fall and it did not bother him much. Physical examination revealed a normal neurological examination and a palpable mass in the right paraspinal area at the level of the tenth thoracic vertebra. An X-ray study showed a 34-mm-long sharp density in the vicinity of the spinal canal near T10. Efforts lasting almost 2 h to identify and remove the foreign body were unsuccessful. The following day, a 4 × 6 × 34 mm sharp glass fragment was removed in the operating room under fluoroscopy. CONCLUSIONS Retained soft-tissue foreign bodies may migrate very late and can cause high morbidity or mortality. It is important to be diligent in the search for foreign bodies, using ultrasound, computed tomography scan, or magnetic resonance imaging in cases in which initial plain radiographs are negative.

Pulmonary embolism presenting as syncope: a case report.

IntroductionDespite the high incidence of pulmonary embolism its diagnosis continues to be difficult, primarily because of the vagaries of symptoms and signs in presentation. Conversely, syncope is a relatively easy clinical symptom to detect, but has varied etiologies that lead to a documented cause in only 58% of syncopal events. Syncope as the presenting symptom of pulmonary embolism has proven to be a difficult clinical correlation to make.Case presentationWe present the case of a 26-year-old Caucasian man with pulmonary embolism induced-syncope and review the pathophysiology and diagnostic considerations.ConclusionsPulmonary embolism should be considered in the differential diagnosis of every syncopal event that presents at an emergency department.

Efficacy of Triage by Paramedics: A Real-Time Comparison Study

OBJECTIVES Triage has evolved as an effective method of separating patients who require immediate medical attention from patients with non-urgent problems. The aim of this study was to assess the agreement between paramedics and emergency residents about triage decisions using the 3-level triage (3L) system and the 5-level (5L) Australian triage scale in real time. METHODS All patients who presented to a central triage area during a 1-week period were triaged by paramedics and emergency residents. The chance-adjusted measure of agreement kappa (κ) was calculated to evaluate the agreement between triage decisions made by paramedics and by emergency residents. RESULTS A total of 731 patients were included in the final data analysis. Admitting time and waiting time were significantly consistent in the triage area. Agreement between the triage decisions made by paramedics and by emergency residents was 47% (κ = 0.47) when using the 3L triage scale and 45% (κ = 0.45) when using the 5L triage scale across all cases. A strong correlation existed among the general conditions of the patients, the 3L triage scale, and the 5L triage scale. DISCUSSION Triaging is commonly performed by nurses in the American emergency system, and triage by paramedics is not common. Few studies are available about triage by paramedics, and more studies are necessary. A new triage scale may be necessary for untrained personnel so that all emergency departments can conduct simple triage.

The Need for First Aid Awareness among Candidate Teachers

SUMMARY Objectives Students at schools may require first aid due to illness, deterioration in their condition, or accidents. Therefore, educators should know first aid procedures and be able to put them into practice. In this study, the objective was to determine the level of first aid knowledge among students at a Faculty of Education and evaluate the efficacy of the first aid training (FAT) provided to them. Methods This study included 88 students at Gazi University, Faculty of Education (Ankara). All students were provided 20 hours of FAT over a period of three months. Participants completed pre- and post-FAT questionnaires and a final examination. Results Sixty-one percent of participants (n=54) had attended FAT within the previous five years. Average pre- and and post-test scores were 47.89±11.29 and 75.28±12.62, respectively. There was a significant increase between the average scores (p<0.001). The proportion of correct responses on basic life support issues was also significantly higher after the training. Significantly more participants felt they had sufficient first aid knowledge and skills after the training (58%) compared to pre-training (8%) levels (p<0.001). Conclusions First aid knowledge among students at a Faculty of Education was considered to be insufficient. FAT should be standard in educational programs at all teacher training schools and the results show such training needs to be updated regularly.

Contact with wet cement: report of a case

Contact dermatitis ranks high in occupational disease statistics in many countries. Its aetiology may be allergic or irritant, sometimes combined, and often aggravated because of constitutional factors. A very high proportion of men and a relatively high proportion of patients with occupational skin disease and with hand dermatitis, respectively, are evident among construction workers. The prevalence of work-related hand dermatitis (allergic or irritant) was found to be 6.8% among construction workers and 8.9% among concrete element prefabrication workers according to a Finnish cross-sectional study performed in 1987 (1). A review of the available literature suggests that cement has constituents that produce irritant contact dermatitis and corrosive effects (from alkaline ingredients such as lime) as well as sensitization leading to allergic contact dermatitis (from chromate) (2). Chemical burns from cement produce erythema, oedema, vesicles, bullae, and weeping and can be considered to be a more severe form of acute irritant reaction; they have been described as acute ulcerative dermatitis. Chemical burns caused by cement are associated with the amateur user working in a short ready-mix timeframe with poor protective measures. These burns can result in significant morbidity and often require skin grafting but can initially be associated with minimal discomfort (3). Here, we report a case presented to our ED with acute ulcerative dermatitis related to working with wet cement without protection. This case also illustrates the potential hazards as a result of working with cement.

Delay in Diagnosis of Pulmonary Thromboembolism in Emergency Department Is it Still a Problem

Background and Aim: Pulmonary embolism (PE) is a common and serious disease that can result in death unless emergent diagnosis is made and treatment is initiated. In this study, we aimed to identify whether there is still a delay in the diagnosis of PE and to identify the time to delay in diagnosis and factors leading to this delay. Methods: This is a prospective observational cohort study performed in an emergency department (ED) of a tertiary care university hospital between September 2008 and September 2010. The rate and cause of delay in diagnosis were analyzed among patients with PE. The “delay” was defined as diagnosing after first 24 hours of symptom onset. Results: Among the 53 patients who were diagnosed with PE, a delay in diagnosis was present in 49 (93%) of them. Total delay time was 6.8 ± 7.7 days. In 33 (62%) patients, there was a delay of 4.6 ± 6.5 days due to patient-related factors. Delay in diagnosis after admission to hospital was 2.2 ± 2.9 days in 40 (75%) patients. In multivariate regression analysis, being female and having chest pain and cough were identified as significant factors causing patient-related delay. Unilateral leg edema, recent operation, and previous venous thromboembolism (VTE) history were the significant factors causing PE diagnosis without a delay. On the other hand, systemic hypertension as comorbidity was the only factor leading to physician-related delay. Conclusion: The delay in diagnosis of PE in EDs still remains as an important problem. While being female and having chest pain and cough are significantly and independently associated with patient delay in diagnosis, the unilateral leg edema, recent operation, and previous VTE history cause physicians to diagnose on time. On the other hand, having hypertension as comorbidity may lead to physician delay. In order to prevent the delay in diagnosis, hospital-associated factors must be elucidated totally and more interventions must be made to increase public and professional awareness of the disease.

Serum tau protein level for neurological injuries in carbon monoxide poisoning

Abstract Introduction. Carbon monoxide (CO) poisoning causes hypoxia that results tissue injury, especially in the brain and heart. Delayed neurologic sequela is one of the most serious complications that may occur up to 40% of severe CO poisoning cases. Objective. The aim of the study was to determine an association between the serum tau protein and severe neurologic symptoms/signs upon presentation. Methods. Seventy-eight patients with CO poisoning were evaluated in this cross-sectional study. The patients were divided into two groups, Group 1: those with loss of consciousness (LOC)/syncope, seizure, coma, altered mental status (n = 19), and Group 2; without LOC (n = 59). Serum tau protein levels were studied on admission. Results. Mean age of the patients was 37.3 ± 15.4 and 53.6% were male. Headache was the most common presenting symptom observed among 67 patients (86%). The median serum tau protein level was 76.54 pg/mL (35.56–152.65) within group 1, 64.04 pg/mL (23.85–193.64) in patients within group 2 (p = 0.039), respectively. The median serum tau protein levels were 79.80 pg/mL (35.56–193.64) in patients who received HBO therapy and 65.79 pg/mL (23.85–167.29) in patients who did not receive HBO therapy (p = 0.032). The value of area under the curve was 0.642 for detecting CO poisoning with severe neurological symptoms. Conclusion. Although tau protein levels were significantly higher in patients with severe neurological symptoms; the difference did not reach a clinical significance. Further studies are needed in order to reveal the validity of tau protein for detecting neurological injuries in patients with CO toxicity.

Endogenous carboxyhemoglobin concentrations in the assessment of severity in patients with community-acquired pneumonia☆ , ☆☆

INTRODUCTION Previous studies have shown that carbon monoxide, which is endogenously produced, is increased in community-acquired pneumonia (CAP). However, it has not been studied enough whether severity of pneumonia is correlated with increased carboxyhemoglobin (COHb) concentrations in CAP. The aim of this study was to determine whether endogenous carbon monoxide levels in patients with CAP were higher compared with the control group and, if so, to determine whether COHb concentrations could predict severity in CAP. MATERIALS AND METHODS Eighty-two patients with CAP were evaluated in this cross-sectional study during a 10-month period. Demographic data, pneumonia severity index and confusion, uremia, rate respiratory, pressure blood, age>65 (CURB-65) scores, hospital admission or discharge decisions, and 30-day hospital mortality rate were recorded. In addition, 83 control subjects were included to study. The COHb concentration was measured in arterial blood sample. RESULTS The levels of COHb in patients with CAP were 1.70% (minimum-maximum, 0.8-3.2), whereas those in control subjects, 1.40% (minimum-maximum, 0.8-2.9). The higher COHb concentrations in patients with CAP were statistically significant (P < .05). Concentration of COHb correlated with pneumonia severity index (P = .04, r = 0.187); however, it did not correlate with CURB-65 (P = .218, r = 0.112). CONCLUSION Although COHb concentrations show an increase in patients with pneumonia, it was concluded that this increase did not act as an indicator in diagnosis process or prediction of clinical severity for the physicians.

Painless aortic dissection presenting with acute ischaemic stroke and multiple organ failure

Acute aortic dissection is an uncommon, life‐threatening catastrophe, and early diagnosis is essential for the best chance of survival. Although acute onset of severe chest or back pain is the most common presenting symptom, some patients might present with atypical symptoms and findings such as acute stroke and mesenteric ischaemia related to the involving arterial segment. Establishing the diagnosis of aortic dissection can be difficult in the presence of atypical symptoms, especially in the absence of pain. Here, we report a case of acute, painless aortic dissection presenting with multiple organ failure and neurological deficits suggesting acute ischaemic stroke.