Erdem Cevik

Efficacy of high-flow oxygen therapy in all types of headache: a prospective, randomized, placebo-controlled trial ☆

OBJECTIVE We aimed to assess the efficacy of oxygen inhalation therapy in emergency department (ED) patients presenting with all types of headache. METHOD We performed a prospective, randomized, double-blinded, placebo-controlled trial of patients presenting to the ED with a chief complaint of headache. The patients were randomized to receive either 100% oxygen via nonrebreather mask at 15 L/min or the placebo treatment of room air via nonrebreather mask for 15 minutes in total. We recorded pain scores at 0, 15, 30, and 60 minutes using the visual analog scale. At 30 minutes, the patients were assessed for the need for analgesic medication. Patient headache type was classified by the treating emergency physician using standardized diagnostic criteria. RESULTS A total of 204 patients agreed to participate in the study and were randomized to the oxygen (102 patients) and placebo (102 patients) groups. Patient headache types included tension (47%), migraine (27%), undifferentiated (25%), and cluster (1%). Patients who received oxygen therapy reported significant improvement in visual analog scale scores at all points when compared with placebo: 22 mm vs 11 mm at 15 minutes (P < .001), 29 mm vs 13 mm at 30 minutes (P < .001), and 55 mm vs 45 mm at 60 minutes (P < .001). When questioned at 30 minutes, 72% of patients in the oxygen group and 86% of patients in the placebo group requested analgesic medication (P = .005). CONCLUSION In addition to its role in the treatment of cluster headache, high-flow oxygen therapy may provide an effective treatment of all types of headaches in the ED setting.

Evaluation of mid-regional pro-atrial natriuretic peptide, procalcitonin, and mid-regional pro-adrenomedullin for the diagnosis and risk stratification of dyspneic ED patients☆☆☆★★★

OBJECTIVE The aim of this study was to evaluate the diagnostic and the prognostic value of a laboratory panel consisting of mid-regional pro-atrial natriuretic peptide (MR-proANP), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) for patients presenting to the emergency department (ED) with acute dyspnea. METHODS We prospectively enrolled ED patients who presented with a chief complaint of dyspnea and who had an uncertain diagnosis after physician evaluation. Final primary diagnosis of the cause of shortness of breath was confirmed through additional testing per physician discretion. We recorded inpatient admission and 30-day mortality rates. RESULTS One hundred fifty-four patients were enrolled in the study. Congestive heart failure exacerbation was the final primary diagnosis in 42.2% of patients, while infectious etiology was diagnosed in 33.1% of patients. For the diagnosis of congestive heart failure exacerbation, MR-proANP had a sensitivity of 92.7% and specificity of 36.8%, with a negative likelihood ratio (LR-) of 0.16 and a positive likelihood ratio (LR+) of 1.44 (cut-off value: 120 pmol/L). For the diagnosis of an infectious etiology, PCT had a 96.5% specificity and 48.8% sensitivity (LR-: 0.58, LR+: 13.8, cutoff value: 0.25 ng/mL). As a prognostic indicator, MR-proADM demonstrated similar values: odds ratio for 30-day mortality was 8.5 (95% CI, 2.5-28.5, cutoff value: 1.5 nmol/L) and the area under the receiver operating characteristic curve in predicting mortality was 0.81 (95% CI, 0.71-0.91). CONCLUSION The good negative LR- of MR-proANP and the good positive LR+ of PCT may suggest a role for these markers in the early diagnosis of ED patients with dyspnea. Furthermore, MR-proADM may assist in risk stratification and prognosis in these patients..

Comparison of ketamine–low-dose midozolam with midazolam-fentanyl for orthopedic emergencies: a double-blind randomized trial

OBJECTIVE Most of the fractures and dislocations are reduced in the emergency setting. Many drugs are available for procedural sedation and analgesia in the emergency department (ED); however, the adverse effects are still a common problem. The aim of our study was to compare the 2 drug combinations. METHOD We performed a prospective, randomized, double-blinded, placebo-controlled trial of patients presenting to the ED after a traumatic event and required urgent reduction either for a fracture or dislocation. Patients were randomized to midazolam-fentanyl (MF) group or ketamine-low-dose midazolam (KM) group. Hypoxia, duration of hypoxia, need for oxygen, time to onset of sedation, recovery time, pain scores during reduction, and sedation depth were set as primary outcome measures and were recorded. RESULTS A total of 498 patients who presented to ED with extremity injury and required closed reduction were assessed; 130 of them were approached for eligibility and 69 patients were excluded. The remaining 61 patients were randomized to either KM group (n = 31) or MF group (n = 30). Hypoxia and duration of hypoxia were significantly lower in the KM group compared with the MF group. Patients in the KM group reported significantly lower pain scores during reduction; however, adverse effects were higher compared with MF group. CONCLUSION Both drug combinations can be effectively used for procedural sedation and analgesia; however, with lower risk for hypoxia and lower pain scores, KM combination stands as a reasonable choice for orthopedic interventions in the emergency unit.

Comparison of GlideScope video laryngoscope and intubating laryngeal mask airway with direct laryngoscopy for endotracheal intubation.

The aim of this study was to determine whether GlideScope video laryngoscope (GVL) and intubating laryngeal mask airway (i-LMA) improve the intubation success rate and could be easily learned and performed by paramedic students when compared with the direct laryngoscopic (DL) method. The study was designed as a prospective randomized crossover trial that included 121 paramedic students. All participants were asked to intubate each Ambu Airway Management Trainer manikins after the lecture and demonstration. Successful intubation was defined as the passage of the tube through the vocal cord within 60 s. At the end of the study, a questionnaire survey was given to all participants about their preferences, and they were requested to define each method on an easy–difficult scale. Successful intubation was achieved by 95 students (78.5%) with DL, 112 students (92.6%) with i-LMA, and 111 students (91.7%) with GVL. Mean time of intubation was 25.06±14 s for DL, 22.32±12 s for i-LMA, and 22.63±10 s for GVL. Success rates of i-LMA and GVL were significantly higher compared with DL (P=0.005 and P=0.006, respectively). No significant difference was determined between i-LMA and GVL in terms of successful intubation (P>0.05). This study showed that GVL and i-LMA provided better intubation success rates and were easier for paramedic students when compared with the classic DL method.

Comparing the efficacy of intravenous tenoxicam, lornoxicam, and dexketoprofen trometamol for the treatment of renal colic

STUDY OBJECTIVE The aim of this study was to compare the efficacy and safety of 3 nonsteroidal anti-inflammatory drugs-intravenous tenoxicam, lornoxicam, and dexketoprofen trometamol-for the treatment of patients with renal colic. METHODS We conducted a prospective double-blind randomized trial of consecutive adult patients who presented to the emergency department with a chief complaint of acute flank pain and had a clinical diagnosis of suspected acute renal colic. Patients were randomly allocated to receive an intravenous bolus of tenoxicam, lornoxicam, or dexketoprofen trometamol in a blinded fashion. Primary outcome measure of the study was visual analog scale (VAS) score difference at 30 minutes. Secondary outcome measures were VAS scores at 5, 15, and 120 minutes as well as rescue analgesic need at 30 minutes and adverse events during the follow-up period. RESULTS A total of 445 patients were screened, and 123 patients were enrolled in the study. The mean age was 36 ± 10 years. The mean reduction in VAS pain scores at 30 minutes was 42 ± 26 mm for tenoxicam, 57 ± 23 mm for lornoxicam, and 52 ± 25 mm for dexketoprofen (P = .047). Lornoxicam demonstrated the fastest rate of VAS score reduction over the first 30 minutes. The mean reduction values in VAS pain scores at 5, 15, and 120 minutes were similar among the 3 groups. Rescue analgesics at 30 minutes were required by 16 patients (39%) receiving tenoxicam, 10 patients (24%) receiving lornoxicam, and 8 patients (19%) receiving dexketoprofen (P = .121). No serious adverse events were observed. CONCLUSIONS Intravenous tenoxicam, lornoxicam, and dexketoprofen are all effective in the treatment of renal colic, although lornoxicam appears to reduce VAS pain scores with the fastest rate in this comparison.

A life-threatening complication of warfarin therapy in ED: diffuse alveolar hemorrhage.

Warfarin have some serious adverse effects, and bleeding is one of the most serious and frequent of them. In this case report, we present the diffuse alveolar hemorrhage case as a rare and life-threatening complication of warfarin.

Acute Psychotic Symptoms due to Benzydamine Hydrochloride Abuse with Alcohol

Benzydamine hydrochloride is a locally acting nonsteroidal anti-inflammatory drug. Benzydamine hydrochloride overdose can cause stimulation of central nervous system, hallucinations, and psychosis. We presented a young man with psychotic symptoms due to benzydamine hydrochloride abuse. He received a total dose of 1000 mg benzydamine hydrochloride with alcohol for its hallucinative effects. Misuse of benzydamine hydrochloride must be considered in differential diagnosis of first-episode psychosis and physicians should consider possibility of abuse in prescribing.

Ecchymosis Due to Sertraline Use: A Case Report

Sertraline is a widely used antidepressant due to its low adverse effect profile. Hematological adverse effects related to sertraline are uncommon. This report includes a case which presented to an emergency department with a large ecchymotic lesion on the left flank due to sertraline use and a review of the relevant literature.

Savaş alanında hayat kurtarıcı prosedürlere yeni bir bakış: Gece görüş gözlükleri ile acil krikotroidotomi, iğne torakostomi ve göğüs tüp torakostomi

BACKGROUND In the patients with multiple and serious trauma, early applications of life-saving procedures are related to improved survival. We tried to experimentally determine the feasibility of life-saving interventions that are performed with the aid of night vision goggles (NVG) in nighttime combat scenario. METHODS Chest tube thoracostomy (CTT), emergency cricothyroidotomy (EC), and needle thoracostomy (NT) interventions were performed by 10 combatant medical staff. The success and duration of interventions were explored in the study. Procedures were performed on the formerly prepared manikins/models in a bright room and in a dark room with the aid of NVG. Operators graded the ease of interventions. RESULTS All interventions were found successful. Operators stated that both CTT and EC interventions were more difficult in dark than in daytime (p<0.05). No significant difference was observed in the difficulty in the NT interventions. No significant difference was observed in terms of completion times of interventions between in daytime and in dark scenario. CONCLUSION The operators who use NVGs have to be aware of that they can perform their tactic and medical activities without taking off the NVGs and without the requirement of an extra light source.

Transpulmonary hypothermia with cooled oxygen inhalation

We read the article of Kumar et al. titled “Transpulmonary ypothermia: a novel method of rapid brain cooling through augented heat extraction from the lungs” in article in press section f your journal.1 In this experimental study, Kumar et al. reported hat they had managed to reach to the target brain temperature 32 ◦C) in 90 min using cooled helium–oxygen mixture (heliox) and erfluorocarbon aerosol in a pig model. In this correspondence we imed to share our preliminary results, and discuss which gas or as combination should be used in transpulmonary hypothermia nd if there is a side effect of this technique to any organ or system. In this preliminary study we tested the idea which is hypothsized and published by us previously that whether just cooled xygen inhalation can maintain hypothermia in a short period of ime.2 In preliminary study we obtained ethical approval from thical committee of Bagcilar Education and Training Hospital. ix rats were given general anesthesia with ketamine–xylazine 50–10 mg/kg) combination and ventilated with 100% oxygen 10 L/min) which is standardized at the temperature of 14 ± 2 ◦C. ooling the oxygen was enabled by a novel device which was develped especially for this study and temperature standardized by eat sensors. We were able to continue hypothermia below 34 ◦C or 1-h without additional hypothermia technique. Then the cooled xygen inhalation was stopped and rats were rewarmed to initial ectal temperature levels in room temperature without any addiional rewarming technique. Our preliminary results showed that it s possible to reach to the targeted rectal temperature (34 ◦C) with ust cooled 100% oxygen inhalation in 22 ± 4 min. In histopathologic xamination, trachea, lungs, kidneys, brain, and liver did not show ny pathologic changes. Just serum amylase levels were elevated ut other routine biochemical parameters were in normal ranges. We wonder whether Kumar et al. have tried cooled 100% oxyen inhalation in any phase of their study, and whether they have tudied biochemical parameters.