Ebru Unal Akoglu

Determination of the appropriate catheter length and place for needle thoracostomy by using computed tomography scans of pneumothorax patients

INTRODUCTION The primary goal of this study was to compare the chest wall thicknesses (CWT) at the 2nd intercostal space (ICS) at the mid-clavicular line (MCL) and 5th ICS at the mid-axillary line (MAL) in a population of patients with a CT confirmed pneumothorax (PTX). This result will help physicians to determine the optimum needle thoracostomy (NT) puncture site in patients with a PTX. MATERIALS AND METHODS All trauma patients who presented consecutively to A&E over a 12-month period were included. Among all the trauma patients with a chest CT (4204 patients), 160 were included in the final analysis. CWTs were measured at both sides and were compared in all subgroup of patients. RESULTS The average CWT for men on the 2nd ICS-MCL was 38mm and for women was 52mm; on the other hand, on the 5th ICS-MAL was 33mm for men and 38mm for women. On the 2nd ICS-MCL 17% of men and 48% of women; on the 5th ICS-MAL 13% of men and 33% of women would be inaccessible with a routine 5-cm catheter. Patients with trauma, subcutaneous emphysema and multiple rib fractures would have thicker CWT on the 2nd ICS-MCL. Patients with trauma, lung contusion, sternum fracture, subcutaneous emphysema and multiple rib fractures would have thicker CWT on the 5th ICS-MAL. CONCLUSIONS This study confirms that a 5.0-cm catheter would be unlikely to access the pleural space in at least 1/3 of female and 1/10 of male Turkish trauma patients, regardless of the puncture site. If NT is needed, the 5th ICS-MAL is a better option for a puncture site with thinner CWT.

Utility of cervical spinal and abdominal computed tomography in diagnosing occult pneumothorax in patients with blunt trauma: Computed tomographic imaging protocol matters.

BACKGROUND Small pneumothoraces (PXs), which are not initially recognized with a chest x-ray film and diagnosed by a thoracic computed tomography (CT), are described as occult PX (OCPX). The objective of this study was to evaluate cervival spine (C-spine) and abdominal CT (ACT) for diagnosing OCPX and overt PX (OVPX). METHODS All patients with blunt trauma who presented consecutively to the emergency department during a 26-months period were included. Among all the chest CTs (CCTs) (6,155 patients) conducted during that period, 254 scans were confirmed to have a true PX. The findings in their C-spine CT and ACT were compared with the findings in CCTs. RESULTS Among these patients, 254 had a diagnosis of PX confirmed with CCT. OCPXs were identified on the chest computed tomographic scan of 128 patients (70.3%), whereas OVPXs were evident in 54 patients (29.7%). Computed tomographic imaging of the C-spine was performed in 74% of patients with OCPX and 66.7% of patients with OVPX trauma. Only 45 (35.2%) cases of OCPX and 42 (77.8%) cases of OVPX were detected by C-spine CT. ACT was performed in almost all patients, and 121 (95.3%) of 127 of these correctly identified an existing OCPX. Sensitivity of C-spine CT and ACT was 35.1% and 96.5%, respectively; specificity was 100% and 100%, respectively. CONCLUSION Almost all OCPXs, regardless of intrathoracic location, could be detected by ACT or by combining C-spine and abdominal computed tomographic screening for patients. If the junction of the first and second vertebra is used as the caudad extent, C-spine CT does not have sufficient power to diagnose more than a third of the cases. LEVEL OF EVIDENCE Diagnostic study, level III.

The effects of adrenomedullin in traumatic brain injury.

Traumatic brain injury (TBI) is a common cause of death and disability throughout the world. A multifunctional peptide adrenomedullin (AM) has protective effects in the central nervous system. We evaluated AM in an animal model as a therapeutic agent that reduces brain damage after traumatic brain injury. A total of 36 rats was divided into 3 groups as sham, head trauma plus intraperitoneal (ip) saline, and head trauma plus adrenomedullin ip. The diffuse brain injury model of Marmarou et al. was used. Blood samples were taken from all groups at the 1st, 6th and 24th hours for analysis of TNF-α (tumor necrosis factor-α), IL-1β (interleukin-1β) and IL-6 (interleukin-6) levels. At the end of the study (at the 24th hour) a neurological examination was performed and half of the rats were decapitated to obtain blood and tissue samples, the other half were perfused transcardiacally for studying the histopathology of the brain tissue. There were no statistically significant changes in plasma levels of IL-1β, IL-6 and TNF-α relative to the sham group. Also, changes in tissue levels of malonedialdehyde, myeloperoxidase and glutathione were not statistically significant. However, neurological scores and histopathological examinations revealed healing. AM individually exerts neuroprotective effects in animal models of acute brain injury. But the mechanisms of action remain to be assessed.

Heading the ball: a case of a Le Fort II fracture in a football match

Facial injuries can impair a patient’s ability to eat, speak and interact with others. Severe injuries occur as a result of interpersonal or domestic violence, or in motor vehicle collisions, including those involving motorcycles and all-terrain vehicles. The authors present a case of LeFort II fracture caused by a collision of opponents while heading the ball in a football match.

A challenging differential diagnosis of optic neuropathy in ED: CSD

Optic neuropathy due to cat scratch disease (CSD) is a rare occurrence associated with macular star formation and is characterised by sudden mostly unilateral painless loss of vision. The aetiological agent in CSD is Bartonella henselae. Ocular complications present in up to 10% of patients and include neuroretinitis, conjunctivitis or uveitis. Ocular bartonelosis is usually self-limited. A case of a man patient with neuroretinitis caused by B. henselae is reported.

Diagnostic value of Tei index for acute myocardial infarction in patients presenting to emergency department with ischemic chest pain and correlation with Hs-troponin

Background: Acute myocardial infarction is one of the most common causes of mortality in developed countries, and high-sensitive troponin test usually becomes positive within 3 h from the onset of symptoms. Myocardial perfusion index (Tei index) is a parameter measured during the echocardiographic examination. Objectives: The aim of this study is to investigate the diagnostic value of the Tei index for early diagnosis of acute myocardial infarction in the emergency department and to evaluate the correlation between the Tei index and Hs-Troponin value. Materials and Methods: A total of 129 cases were evaluated, and patients were divided into two groups according to their final diagnosis as “acute myocardial infarction (non-ST segment elevation myocardial infarction)” and “non-acute myocardial infarction” groups. Baseline and third-hour Hs-Troponin levels and Tei index values were determined, and their correlation was analyzed. Results: A total of 84 cases were diagnosed with acute myocardial infarction (non-ST segment elevation myocardial infarction), 84.5% had positive Tei index results at the time of admission while the remaining 45 patients were diagnosed as non-acute myocardial infarction and only 48.9% of them had positive Tei index. The diagnostic value of the Tei index and Hs-troponin were calculated as 79.8% and 60%; 67.9% and 60%, respectively. Also, we found that a 0.02 or more increase in the Tei index value has a 97.6 sensitivity and 97.5 specificity for the diagnosis of non-ST segment elevation myocardial infarction. A weak correlation was found between the Tei index and Hs-Troponin values in the acute myocardial infarction group (r = 0.425) and a negative correlation in non-acute myocardial infarction patients at presentation. Conclusion: It is suggested that the use of Tei index might be used as a supportive measure for the early diagnosis of acute myocardial infarction, and the deterioration of Tei index seems to be more significant than Hs-Troponin especially in ruling out acute myocardial infarction.

Diagnostic utilities of tracheal ultrasound and USB-endoscope for the confirmation of endotracheal tube placement: A cadaver study

Objectives: Confirmation of the endotracheal tube placement (CoETP) has the utmost importance in the management of an airway. Visualization of tracheal rings or carina with a fiber‐optical bronchoscope (FOB) has considered to be a reliable method for the CoETP. However, FOB is expensive, time‐consuming, and not always practical. Inexpensive endoscopic USB‐cameras were shown to aid intubation successfully and reliably. On the other hand, there have been no studies investigating their use for the CoETP. Tracheal ultrasonography (TUS) is also a new, inexpensive and widely available alternative. A cadaver study has planned to evaluate the diagnostic utility of TUS and a USB‐camera. Methods: This study was conducted in the Anatomy Lab of a University on a fresh frozen female cadaver. Three senior Emergency Physicians have intubated the cadaver, and performed TUS or USB‐endoscopy. We have prepared a randomized intubation list (n = 96) in three blocks (3 times 32) as to include equal number of esophageal and tracheal intubations (48 for each). Each EP is performed all three interventions (intubation, TUS and USB‐endoscopy) in consecutive blocks of 32 intubations, in turn. The position of the tube has been verified from a 2 cm wide ostium on the proximal trachea. Results: In this study, all intubations (n = 96, 100%) were correctly identified as tracheal or esophageal with both TUS and USB‐camera. Both the sensitivity and specificity of TUS and USB‐endoscopy for the CoETP were 100.0%. Conclusion: The perfect accuracy of TUS and USB‐endoscopy, have placed those techniques in a unique position as an alternative in resource‐poor situations.

Predictors of false negative diffusion-weighted MRI in clinically suspected central cause of vertigo

Introduction: Vertigo is classified as peripheral and central. Differentiation of stroke mimics is the most important diagnostic challenge. There is no clinical guidance for the indications of neuroimaging in isolated vertigo patients. The primary aim of this study is to test the diagnostic value of a DWI‐MRI protocol to rule‐out a central cause in patients with acute isolated vertigo in the ED. Methods: We prospectively enrolled 144 patients who were presented with isolated vertigo to the ED. A detailed neurological examination and maneuvers were performed for differential diagnosis. All patients underwent CT and/or DW‐MRI either during ED visit or at the follow‐up, if necessary. Out‐patient follow‐up exams and evaluations were repeated until all patients had a definitive diagnosis. Results: In the study, 137 of the 144 patients completed the follow‐up period, and 34 of 137 patients were diagnosed with central vertigo. Six of 34 central vertigo patients had normal DW‐MRI findings. One was diagnosed with migraine headache and five with vertebra‐basilar insufficiency during the out‐patient follow‐up. One of the 28 patients with a pathological MRI was diagnosed with mass and the rest was stroke. The utility of DW‐MRI in vertigo patients was moderately high (sensitivity: 82%, specificity: 100%). We found that age, history of HT, history of CAD and vertigo unresponsive to ED treatment were significantly associated with a central cause of vertigo. Conclusion: We suggest that unresponsiveness to ED treatment, especially in patients with a history of HT and CAD, should alert physicians for central causes and warrant DW‐MRI imaging.

Electrocardiographic clue for a mid-LAD lesion

ECG is still the first diagnostic tool for coronary artery disease. It is possible to predict the localisation of affected vessel(s) through ST and T changes on ECG. Sometimes, reciprocal changes may be the only marker of acute myocardial ischaemia, as single T-wave inversion in lead aVL may represent a coronary artery lesion in the left anterior descending (LAD). A 49-year-old woman presented to the emergency department, with left-sided chest pain. Her initial ECG showed no ischaemic changes. On the third hour ECG there was T-wave inversion in leads aVL and V2, and troponin turned positive. Coronary angiography showed 90% mid-LAD occlusion. The importance of this case is that patients with ischaemic chest pain should be followed with serial ECG. Also, emergency physicians should be alert to identify new changes on ECG, as isolated T-wave inversion in lead aVL can be the only finding to take the patient into the catheterisation laboratory.

Details of motorcycle accidents and their impact on healthcare costs.

BACKGROUND Of overall traffic accidents in 2011 in Turkey, 7.58% (n=21,107) were motorcycle accidents. Motorcycle accidents and their impact on healthcare costs are investigated in our study. METHODS Motorcycle accidents that occurred with/without a collision between 1 July 2010 and 30 June 2011 were studied prospectively through the inspection of patients visiting the Emergency Service. The healthcare costs relevant to each person injured in a motorcycle accident were investigated via forms. Data were analyzed using frequencies, Kolmogorov-Smirnov, Mann-Whitney U, and chi-square tests on the SPSS v16.0 program. RESULTS Ninety-one people involved in accidents, with a mean age of 28.47 years, were studied. The average healthcare expenditure for the 91 patients studied between reception and discharge was US