Emine Akinci

Prognostic importance of neutrophil-lymphocyte ratio in critically ill patients: short- and long-term outcomes

STUDY OBJECTIVE The number of critically ill patients admitted to the emergency department increases daily. To decrease mortality, interventions and treatments should be conducted in a timely manner. It has been found that the neutrophil-lymphocyte ratio (NLR) is related to mortality in some disease groups, such as acute coronary syndrome and pulmonary emboli. The effect of the NLR on mortality is unknown in critically ill patients who are admitted to the emergency department. Our aim in this study is to evaluate the effect of the NLR on mortality in critically ill patients. METHODS This study was planned as a prospective, observational cohort study. Patients who were admitted to the emergency department because they were critically ill and required the intensive care unit were included in the study. Demographic characteristics, Acute Physiology and Chronic Health Evaluation II (APACHE II), Sepsis-related Organ Failure Assessment, Glasgow Coma Score, and NLR values were recorded upon emergency department admission. The patients were followed up for sepsis, ventilator-associated pneumonia, multiorgan failure, in-hospital mortality, and 6-month mortality. RESULTS The median (interquartile range) age of the 373 patients was 74 (190) years, and 54.4% were men. Neutrophil-lymphocyte ratio values were divided into quartiles, as follows: less than 3.48, 3.48 to 6.73, 6.74-13.6, and more than 13.6. There was no difference among these 4 groups regarding demographic characteristics, APACHE II score, Sepsis-related Organ Failure Assessment score, Glasgow Coma Score, and length of hospital stay (P>.05). In the multivariable Cox regression model, in-hospital mortality and 6-month mortality NLR were hazard ratio (HR), 1.63 (1.110-2.415; P=.01) and HR, 1.58 (1.136-2.213; P=.007), respectively, and APACHE II scores were detected as independent indicators. CONCLUSION The NLR is a simple, cheap, rapidly available, and independent indicator of short- and long-term mortalities. We suggest that the NLR can provide direction to emergency department physicians for interventions, particularly within a few hours after admission, in the critically ill patient group.

Acil serviste yeni steteskopumuz: El ultrasonu

BACKGROUND The concept of Focused Assessment with Ultrasound for Trauma (FAST), which was introduced by Rozycki et al. in 1996, has started a new era in the management of trauma patients. Today, Advanced Trauma Life Support (ATLS) suggests bedside ultrasonography (USG) evaluation of trauma patients. We aimed to investigate the usability and the reliability of handheld ultrasound (Vscan) in determining free fluid during the initial evaluation of trauma patients. METHODS This was a multi-center, prospective study involving multiple trauma patients who presented to three hospital emergency departments (EDs). FAST was completed using Vscan by an emergency physician and an abdominal USG was performed by a radiologist on all patients. Results of Vscan, abdominal USG and other radiological studies, if performed, were compared. RESULTS A total of 216 patients were included in the study. Of those, 203 had negative Vscan results, while 13 had positive results. When USG performed by a radiologist was considered as the gold standard, Vscan sensitivity for FAST was 88.9%, specificity was 97.6%, negative predictive value was 99.5%, and positive predictive value was 61.5% in our study. CONCLUSION Vscan, as the smallest portable imaging device, seems to have a promising future as an indispensable gadget, equal to stethoscopes, in evaluating trauma and other critical patients.

A new marker for myocardial injury in carbon monoxide poisoning: T peak-T end

OBJECTIVES Carbon monoxide (CO) poisoning frequently affects repolarization, resulting in abnormal electrocardiography findings. The goal of this study was to examine the effect of CO poisoning on the novel transmyocardial repolarization parameters T peak-T end (Tp-e), Tp-e dispersion, and Tp-e/QT and the relationship of these parameters to myocardial injury (MI). METHODS This prospective study included 94 patients with CO poisoning and 40 healthy controls. Participants received an electrocardiography and had their blood drawn at admission and 6 and 24 hours after admission. The QT, Tp-e, Tp-e dispersion, and the Tp-e/QT ratio were calculated. Myocardial injury was determined based on an elevation in troponin any time during the first 24 hours. The patients were divided into 2 subgroups: those with and without MI. RESULTS T peak-T end, Tp-e dispersion, and the Tp-e/QT ratio were higher at admission than after 6 and 24 hours of hospitalization and were higher than the control group (P < .001). There was a correlation between the carboxyhemoglobin level at admission and Tp-e and Tp-e dispersion (P < .001). The MI subgroup (n = 14) had a higher Tp-e at admission than did the non-MI subgroup (n = 80) (96 [11] milliseconds vs 87 [12] milliseconds, P = .03). There were no any significant differences in the Tp-e dispersion or the Tp-e/QT ratio between the 2 MI subgroups. Receiver operating characteristic analysis showed that a Tp-e cutoff value for MI of 91.5 milliseconds had a sensitivity of 72.7% and a specificity of 67.2%. CONCLUSION Transmyocardial repolarization parameters indicative of arrhythmia were prolonged in patients with CO poisoning. T peak-T end was associated with MI.

Hemodialysis as an alternative treatment of mexiletine intoxication

Mexiletine is a class IB antiarrhythmic agent. Although it is primarily used in treating ventricular arrhythmias, recent indications for use of mexiletine include chronic and neuropathic pains. At high doses, mexiletine causes drowsiness, confusion, nausea, hypotension, sinus bradycardia, paresthesia, seizures, bundle branch block, atrioventricular heart block, ventricular arrhythmias, asystole, cardiovascular collapse, and coma. A 23-year-old male patient presented to the emergency department with intentional ingestion of high-dose mexiletine. Despite decontamination and supportive treatment, his vitals deteriorated during the observation period; and he developed stupor and dysarthria. Patient then underwent hemodialysis. His vital signs and overall condition improved rapidly following hemodialysis treatment. In this case report, we aimed to emphasize hemodialysis as a useful alternative therapy for severe mexiletine intoxications.

Comparison of end-tidal carbon dioxide levels with cardiopulmonary resuscitation success presented to emergency department with cardiopulmonary arrest.

Objective: To measure end-tidal carbon dioxide pressure (PetCO2) in preset interval in order to evaluate the efficiency of cardiopulmonary resuscitation (CPR) performed on patients in cardiopulmonary arrest, evaluate the validity of PetCO2 in predicting the mortality and finally assess the PetCO2 levels of the patients in cardiopulmonary arrest based on the initial presenting rhythm. Methods: This prospective study was conducted at the Ankara Training and Research Hospital on patients who presented with cardiopulmonary arrest. Standard ACLS (Advanced Cardiac Life Support) protocols were performed. Patients were categorized in two groups based on their rhythms as Ventricular Fibrillation and Asystole. Patients’ PetCO2 values were recorded. Results: PetCO2 levels of the Return of Spontaneous Circulation (ROSC) group in the 5th, 10th, 15th and 20th minutes were significantly higher compared to the exitus group (p<0.001). In distinguishing ROSC and exitus, PetCO2 measurements within 5-20 minute intervals showed highest performance on the 20th and lowest on the 5th minutes. Conclusion: PetCO2 values are higher in the ROSC group. During the CPR, the most reliable time for ROSC estimation according to PetCO2 values is 20th minute. None of the patients who had PetCO2 levels less than 14 mmHg survived.

The Experiences in a Toxicology Unit: A Review of 623 Cases

Background To evaluate the etiological and demographic characteristics of adult poisoning patients followed up in a toxicology unit in Konya, Turkey. Methods Patients (≥ 15 years old) followed up with the diagnosis of poisoning in our toxicology unit in 2011 were included in this retrospective study. The patients’ medical records were investigated. Age, gender, medical history, the first medical center the patient had been admitted to, the routes and causes of poisoning, the toxins involved, the number of the pills taken, treatments, complications, the length of stay in the hospital and the outcome were recorded. Results A total of 623 patients were included in the study. The mean age of patients was 28.1 ± 15.1. Four hundred and forty-five (71.4%) of patients were female, 541 (86.9%) of them were poisoned via the oral route and 75 (12.0%) of them were poisoned by inhalation. The causes of poisoning were drugs in 408 (65.5%) patients, pesticides/insecticides in 58 (9.3%) patients and carbon monoxide in 49 (7.9%) patients. The commonly used drugs were as follows: analgesics (57.2%), antidepressants (25.4%) and gastrointestinal system drugs (15.8%). The poisonings were suicidal in 489 (78.5%) patients, accidental in 120 (19.3%) patients and overdose in 14 (2.2%) patients. The number of women was higher in the suicide group. At the end of the treatment, 604 (97.0%) of the patients were discharged and 3 (0.4%) of them died. The duration of follow-up was 39.2 ± 37.5 h. Conclusion The most common causes of poisoning are drugs, pesticides/insecticides and carbon monoxide. Health and educational policies at a national level are needed in order to prevent this medicosocial problem. Furthermore, specially equipped toxicology units should be constructed for the treatment and follow-up of the poisoned patients in order to reduce the morbidity and mortality to a significant extent.

Antiepileptic drug poisoning: Three-year experience

Introduction Antiepileptic drugs, which are also called anticonvulsants, are used in the therapy and prophylaxis of epileptic seizures. The purpose of this paper was to investigate the relevant epidemiological data and to determine which of these drugs was the most frequent cause of intoxication. Another purpose of this study was to determine the neurological, cardiac, and biochemical problems caused by antiepileptics. Material and method This retrospective study included 95 consecutive patients under 18 years of age with antiepileptic intoxication, presenting to and being followed-up in, the Toxicology Unit between January 2010 and February 2013. The data were obtained by screening the patient files. Results Of the cases, 67 (70.5%) were self-poisoned by first generation antiepileptics (FGAEs) and 28 (29.5%) by second generation antiepileptics (SGAEs). The Glasgow Coma Scale (GCS) scores and the serum lactate levels of the patients poisoned by FGAEs and SGAEs on admission to emergency department were 15 (25th: 12; 75th: 15; 95th: 15; IQR: 3) and 1.9 (25th: 1.4; 75th: 3.1; 95th: 5.6; IQR: 1.7), and 15 (25th: 14.3; 75th: 15; 95th: 15; IQR: 0.75) and 1.07 (25th: 0.9; 75th: 1.6; 95th: 5.5; IQR: 0.71), respectively. The serum lactate levels of patients poisoned by FGAEs were significantly higher (p < 0.001). Among the cases poisoned by carbamazepine, the most frequent cause of intoxication, the GCS score was significantly lower and serum lactate level was significantly higher in the group with high serum levels of carbamazepine (p = 0.004 and p < 0.001, respectively). In cases poisoned by valproic acid (VPA), the second frequent cause of intoxication, there was neither a significant association between the serum VPA level and the GCS score, nor between the serum lactate level and the systolic blood pressure (p = 0.470, p = 0.897, and p = 0.088, respectively). However, there was a positive correlation between the serum VPA level and the serum ammonia level (kk = 0.742, p < 0.001). Conclusion First generation antiepileptics are more toxic than SGAEs. In patients with serum carbamazepine level, particularly those over 30 mg/L, serious disorders of consciousness, cardiovascular toxicity, and metabolic disorders may occur. In VPA intoxication, there is a positive correlation between the serum VPA levels and ammonia levels. On account of this finding, one should be more careful about hyperammonemic hepatic encephalopathy as the serum VPA level rises.

Successful resuscitation of a patient with continuous venovenous hemodiafiltration following intoxication from verapamil and trandolapril.

The incidence of accidental or intentional intoxication resulting from calcium channel blockers (CCBs) overdose has increased in recent years. We herein present the case of a female patient whose condition deteriorated even after she had received the maximum possible medical treatments following intoxication, but was successfully resuscitated following continuous hemodiafiltration (CHDF). A 26-year-old female patient had received 4.8 g of verapamil and 80 mg of trandolapril (Tarka Forte). No abnormality was noted in the systemic examination, and gastric lavage was performed. Four hours after admission, the patient began to develop hypotension. Dopamine infusion was started. The patient was given intravenous infusion of calcium, 2 mg glucagon, 20% intralipid solution infusion, and 20 U/hour insulin, along with 30% dextrose solution. However, even though vasopressor agents were continued at the maximum dose, hypotension persisted, and she subsequently developed bradycardia with thirddegree atrioventricular block. The patient was intubated and a transvenous pacemaker was inserted. Her blood analysis revealed the following measurements: pH, 7.14; PCO2, 35 mmHg; HCO3, 7.1 mmol/L; and lactate, 8 mmol/L. Continuous venovenous hemodiafiltration (CVVHDF) was initiated. The patient’s condition improved, with systolic blood pressure reaching 80e90 mmHg. She was extubated 12 hours later.

The role of blood S100B and lactate levels in minor head traumas in children and adults and correlation with brain computerized tomography

BACKGROUND In this study, we aimed to set levels of blood S100B and lactate and to determine any correlation with brain computerized tomography in minor head traumas in children and adults. METHODS This clinical trial is a prospective study including 100 head trauma patients who applied to Ankara Training and Research Hospital emergency service. RESULTS In this study, cut-off ranges of 0.0-0.15 ug/ml and 0.9-1.7 mmol/L for blood S100B and lactate levels, respectively, were used. S100B level was higher than the cut-off range in 42% of patients and lactate level was higher in 56% of patients. No significant differences were determined between age groups. When the relation between S100B and lactate levels with brain CT was evaluated, no statistically significant relation was determined. CONCLUSION According to our results, in minor head traumas, the determination of elevated serum S100B and lactate levels cannot take the place of clinical examination and the use of cranial CT. Although the patients in our study group had minor head trauma, we do not consider S100B and lactate to be reliable markers for estimating progression.

Can we use serum gamma-glutamyl transferase levels to predict early mortality in stroke?

Objective: Serum gamma-glutamyl transferase (GGT) is a marker for alcohol consumption and hepatobiliary diseases. There are reports on the prognostic role of GGT in coronary artery diseases and stroke. The aim of our study was to identify the potential differences in GGT levels in different types of stroke, and to evaluate the correlation between GGT and 30-day mortality. Method: Patients diagnosed with stroke in emergency department between 01.01.2010 and 30.12.2012 was included in the study. Imaging techniques were used to distinguish between hemorrhagic and ischemic stroke. Ischemic strokes were further classified as either atherosclerotic/lacunar or embolic. Parameters including age, gender, vital signs (systolic and diastolic blood pressure), comorbid diseases (HT, DM, CAD, smoking and alcohol consumption), used medications, previous history of stroke, NIHSS score at the time of admission to emergency department, laboratory parameters (glucose, white blood cell count, hemoglobin, platelet, total cholesterol, creatinine) and duration of hospitalization were recorded. Death records were obtained from patients’ medical records. Results: One thousand eighty six patients were included in the study. GGT levels were not significantly different between ischemic and hemorrhagic strokes (p=0.435). On the other hand, GGT levels in embolic strokes were significantly higher compared to atherosclerotic/lacunar strokes (p=0.001). GGT levels [median 24.50 (16.00-43.00)] in Intensive Care Unit patients were significantly higher compared to GGT level [22.00 (15.00-34.25)] in admitted to service beds patients (p=0.015). Median GGT level of deceased patients was 24.00 (16.00-41.25) and median GGT level of alive patients was 22.00 (15.00-35.00). GGT level of deceased patients was significantly higher compared to GGT levels of alive patients (p=0.048). Conclusion: There was no difference in GGT levels between ischemic and hemorrhagic strokes; however, GGT levels in embolic strokes were significantly higher compared to atherosclerotic/lacunar strokes. High GGT levels are correlated with early mortality in stroke. We believe that GGT may be used as a predictor of mortality in future studies.