Aslıhan Yürüktümen

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

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 (χ2 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.

Syrian rue tea: A recipe for disaster

Peganum harmala, commonly called “Syrian rue,” is native to countries around the Mediterranean sea and western United States. Known for its sedative effects when consumed by farm animals, its seeds have stimulant and hallucinogenic effects at low doses (3–4 g when eaten) in humans. Its active ingredients harmaline and harmine have monoamine oxidase inhibitor properties. A 41-year-old female prepared a hot drink by boiling approximately 100 g of P. harmala seeds in water (10–20 times the recommended dose for “calming ones nerves”). Upon presentation to the emergency department, she was unconscious and had hypertension, tachycardia, and tachypnea. Hepatic and renal function markers were grossly elevated. After intubation, she improved with supportive care over the course of five days. Her level of consciousness, renal and hepatic markers gradually returned to normal. Poisoning with high doses of Peganum harmala can be life-threatening, although patients usually recover with supportive therapy alone.

A rare diagnosis in emergency department: Spontaneous spinal epidural hematoma

We report a case of a 32-year-old man who presented to the emergency department (ED) with a sudden onset of paraplegia due to spontaneous spinal epidural hematoma. Although the patient had a poor neurological condition on presentation, he was successfully operated and discharged without any neurological sequel. Spontaneous spinal epidural hematoma is a rarely seen clinical entity, especially in the ED. Magnetic resonance imaging is the best choice for early diagnosis, and urgent surgical decompression is essential to prevent serious neurological deficits.

Traumatic Pseudoaneurysm and Arteriovenous Fistula Detected by Bedside Ultrasound

BACKGROUND The case of late presentation of a pseudoaneurysm and an arteriovenous fistula (AVF) of the common femoral artery and vein secondary to penetrating trauma is reported. Traumatic AVF and pseudoaneurysm may be present within a variety of clinical conditions, which sometimes makes it difficult to detect them clinically. Undiagnosed AVF can lead to clinical manifestations mostly secondary to increased output generated by the fistula. CASE REPORT A 31-year-old man presented to the Emergency Department (ED) for wound care follow-up. A week before, he had suffered a stab wound to the medial thigh and the primary suture was performed in our ED. During his first visit to our ED, the vascular examination revealed palpable dorsalis pedis and tibialis posterior pulses. The formal Doppler ultrasound was negative. During his second presentation, however, the physical examination was remarkable for a palpable thrill and continuous bruit in the left mid-thigh region. Also, an ultrasound with a 7.5-MHz linear probe demonstrated a pseudoaneurysm and an AVF between the femoral artery and vein. CONCLUSION The mechanism of the injury, wound location and tract, and physical findings after a penetrating thigh trauma can help to predict femoral artery injury. Also, occult injuries to the medial thigh after penetrating trauma may be easily overlooked on the physical examination. Furthermore, bedside ultrasound performed by an emergency physician may be helpful in diagnosing occult vascular injuries.

Modified hair apposition technique as the primary closure method for scalp lacerations

OBJECTIVE The aim of this study is to report the usability of our modified hair apposition technique (modHAT) in repairing scalp lacerations. METHODS Data were collected prospectively over a 36-month period regarding our routine repair of scalp lacerations: those in areas with hair 1 cm or longer were repaired with our modHAT technique (10-15 hairs bundled and twisted with clamps) using cyanoacrylate glue, whereas wounds in areas with hair less than 1 cm long, with irregular wound edges, or which continued to bleed after pressure, were repaired with sutures or staples. Two days later, a wound check was performed. At least 30 days later, all patients were contacted again by telephone to assess satisfaction with care, preference regarding the method of repair in the future, and occurrence of any complication, infection, or need for additional health care. RESULTS One hundred two consecutive patients (ages 2-92 years) with scalp lacerations (mean length, 24 mm; range, 4-100 mm) presented for care. Wound closure was accomplished with the modHAT technique in 66%. Sutures were used in 32% and staples in 2% because of baldness/short hair in 6% and continued bleeding after pressure in 28%. Satisfaction in both hair apposition technique and suture groups was high, and no patient sought further health care. CONCLUSION Most scalp lacerations can be repaired with the modHAT technique primarily. Care should be taken to apply the glue to the twist of hair only and avoid excess glue running onto the scalp or into the wound. Wider use of this inexpensive, quick technique should be encouraged.

Are emergency department visits really a teachable moment? Smoking cessation promotion in emergency department.

Objective To compare the effectiveness of smoking cessation counseling in the emergency department (ED) versus in outpatient clinics (OCs) setting. Methods Over a 3-month period, smokers and recent quitters presenting to ED or OCs were questioned about their smoking habits and desire to quit. They also completed the Fagerstrom Test for Nicotine Dependence (FTND) questionnaire and Prochaskas stages of change (PSC) survey. Standardized 5 min counseling session was carried out, and stop smoking pamphlet and phone number of the hospitals smoking cessation unit were given. One month after initial counseling, patients were telephoned, FTND, PSC, desire to quit, and daily cigarette consumption were asked. Data from those unable to be contacted within 6 weeks were excluded from analysis. Results Of the 392 patients (197 ED, 195 OC) counseled initially, 340 (87%) were reached for telephone follow-up. Counseling was effective in both groups: FTND and PSC scores had improved, and daily cigarette consumption decreased significantly (17.17–12.49 cigs/day; P = 0.000). Smokers counseled in the ED were found more inclined to stop smoking compared with smokers who counseled in OCs, after 1 month of the intervention (95% confidence interval = 14.7–7.5%; P = 0.051). Only one patient (0.6%) from the ED and 10 (6.6%) from the OC attended the smoking cessation program. Conclusion ED-based counseling for smoking cessation was as effective as that performed in the OC setting. Referral of smokers from the ED to a smoking cessation program was unsuccessful in our patient population.

Acute renal failure associated with dysfunctioning detrusor muscle in multiple sclerosis

Patients with multiple sclerosis (MS) typically have neurogenic lower urinary tract dysfunction. Most patients present with bladder hyperreflexia and failure to empty the bladder secondary to detrusor-distal sphincter dyssynergia. This case study is unique in the literature in reporting on a patient presenting with acute renal failure (ARF) due to vesico-sphincter dysfunction associated with MS. A 64-year-old man with MS presented in the emergency department with the chief complaint of a marked decrease in urinary output for 2 days and weakness. He had been treated for MS for 7 years. A mass compatible with a full bladder was palpated in the suprapubic region on examination. Digital rectal examination disclosed grade I-II prostate hypertrophy. Urinary catheters were inserted and urinary output was monitored. The residual urine was drained and recorded as 1100 mL. Initial laboratory findings, such as the BUN/creatinine ratio, urinary sodium concentration, and urine gravity, were compatible with ARF. The patient recovered rapidly in 24 hours following urinary catheterization and prompt medication in the emergency department. He was admitted to the neurology ward with a diagnosis of acute urinary outflow obstruction resulting in ARF due to detrusor dysfunction complicating an MS attack. ARF may complicate the course of patients with MS and associated detrusor-external sphincter dyssynergia. Renal recovery of these patients may be facilitated by urinary catheterization and supportive treatment.

Acute Hepatitis Associated with Thymus Vulgaris Oil Ingestion; Case Report

SUMMARY Many plants traditionally used in folkloric medicine can cause poisoning. Typically known as “thyme”, “Thymus Vulgaris” continues to be one of the most commonly used folkloric herbs in Turkey. Here, we report a case of toxic hepatitis due to the ingestion of concentrated thyme oil. The patient was reported to have ingested a total of 25 ml of thyme oil which was routinely sold in the local market. The total dose was taken in two consecutive days in different amount. The pa tient then developed nausea, vomiting and diarrhea, and he was subsequently admitted to the emergency unit, with high transaminase levels. He was placed on observation unit for two days. His elevated aminotransferase levels and symptoms gradually decreased during the observation period. Thyme, which is known to be a nonpoisonous plant, is one of the most commonly used herbs; however, plants similar to thyme are not necessarily as harmless as they seem to be.

Pain Perception in Emergency Department Patients with and without Headache

Objectives Adequate pain management of emergency department (ED) patients is an important clinical goal. Pain perception in ED patients with headache has been reported to differ from that of other patients with pain. If this were true in our setting, we might interpret pain scores and response to analgesics differently. We compared pain perception in ED patients without pain, patients with headache, and patients with non-headache pain who had blood pressure (BP) measurement and intravenous (IV) cannulation for any reason. Methods The study design was approved by our hospitals Ethics Committee. The patients were asked to describe their pain while undergoing BP measurement and IV cannulation with a 0 through 10 (11-point) numerical rating scale. Pain scores were analysed according to the patients group: no pain, headache pain, or non-headache pain. Results For the 278 participating patients (95 patients without pain, 77 patients with headache, and 106 patients with non-headache pain), the pain scores as reported during BP measurement and IV cannulation was not significantly different between the patient groups. On sub-group analysis, females reported higher pain scores during IV cannulation than males (2.8±2.6 vs. 2.3±1.9, p=0.06). In addition, married patients had higher pain scores than unmarried patients during both BP measurement (1.31 vs. 1.03, p=0.004) and cannulation (2.73 vs. 2.16, p=0.089). Conclusion The differences in pain experienced in patients with or without headache or other causes of pain during IV cannulation and BP measurement were minor. Based on our findings, gender and marital status should be recorded during studies recording pain levels in ED patients.