Ersin Aksay

The interrater reliability of ultrasound imaging of the inferior vena cava performed by emergency residents.

OBJECTIVE Ultrasonography (US) has gained popularity in the emergency medicine to assess intravascular volume status in critically ill patients. However, there are a limited number of studies on the interrater reliability of US examination of the inferior vena cava (IVC) by emergency residents. METHOD One hundred eighty US examinations were performed on 90 emergency critical care unit patients by 6 emergency medicine residents. Minimum and maximum IVC diameters during normal passive inspiration were measured, and the IVC index was calculated. The interrater reliability of the measurable data was analyzed using intraclass correlation coefficients. RESULTS The measurements of minimum and maximum IVC diameters were moderately reliable by emergency residents (κ = 0.60 [95% confidence interval {CI}, 0.45-0.72] and κ = 0.56 [95% CI, 0.41-0.69], respectively). In the patients with moderate IVC depth (8.5-12.5 cm), the interrater reliabilities of sonographers were κ = 0.51 (95% CI, 0.30-0.67) for maximum diameter and κ = 0.43 (95% CI, 0.21-0.61) for minimum diameter. In patients with superficial (≤8.5 cm) and profound located (≥12.5 cm) IVC, the interrater reliabilities of sonographers for maximum and minimum diameters were κ = 0.69 (95% CI, 0.29-0.89) and κ = 0.75 (95% CI, 0.4-0.91), and κ = 0.58 (95% CI, 0.09-0.85) and κ = 0.76 (95% CI, 0.39-0.92), respectively. CONCLUSION The measurement of the IVC is moderately reliable by emergency residents. The interrater reliability of measurements in patients with profound and superficial located IVC is higher than that of measurements in patients with moderate-depth located IVC.

Massive hydroxychloroquine overdose

We report a case presenting with massive overdose of hydroxychloroquine who survived without any sequelae. A 17‐year‐old girl presented to the Emergency Department 45 min after the ingestion of 22 g of hydroxychloroquine in a suicide attempt. We believe this is highest dose yet reported in the medical literature. The patient developed hypotension, life‐threatening ventricular arrhythmias and mild hypokalemia. She was managed with saline infusion and dopamine for hypotension, gastric lavage and activated charcoal for decontamination, lidocain, magnesium sulfate and defibrillation for pulseless ventricular tachycardia. Potassium replacement and bicarbonate administration were performed. Quick treatment of hypotension, gastric decontamination, continuous long‐term cardiac monitoring, and treatment of arrhythmias are the cornerstones of hydroxychloroquine overdose management.

The accuracy of bedside ultrasonography as a diagnostic tool for the fifth metatarsal fractures

OBJECTIVES Musculoskeletal ultrasonography is a technique that is becoming more popular in diagnosing injuries of emergency department (ED) patients especially for the diagnosis of fractures. In this study, we determined the reliability of ultrasonography for the diagnosis of fractures of the fifth metatarsal. METHOD This is a prospective blind study. Patients over 14 years old who were admitted to the ED with acute foot injury and who had tenderness on the fifth metatarsal were consecutively enrolled into the study. A bedside ultrasonography exam was performed by an emergency physician, and antero-posterior and oblique views were obtained. X-rays were blindly evaluated by an orthopedic surgeon and were considered to be the gold-standard for diagnosing fractures. In patients with noncomminuted fractures, bone displacement was measured by both radiologically and sonographically. RESULTS Eighty-four patients were included in this study. Their mean age was 36.0, and 42.9% were male. Fractures were diagnosed by both x-ray and ultrasonography in 33 patients. In one patient, the x-ray was positive for fracture, while ultrasonography yielded a negative result. For the fractures of fifth metatarsal, the diagnostic sensitivity of ultrasonography was 97.1%, the specificity was 100%, the positive likelihood ratio was infinity, the negative likelihood ratio was 0.03. Mean displacement was 1.2 ± 0.7 mm with x-ray and 1.8 ± 1.5 mm with ultrasonography. The intraclass correlation coefficient of displacement measured by x-ray and ultrasonography was κ: 0.388. CONCLUSION Ultrasonography is a reliable diagnostic tool for acute fifth metatarsal fractures.

Current status of emergency residency training programs in Turkey: after 14 years of experience.

Objective Emergency residency training programs, which have been developing in Turkey over the last 14 years, have been improving emergency health services by training each year a significant number of emergency medicine specialists. Sufficient data about these emergency residency training programs is not currently available. The purpose of this study is to determine (i) the structure of emergency residency training programs and (ii) trainer and resident views concerning these programs. Methods The data in this cross-sectional study was gathered by means of questionnaires. Three different forms of questionnaires were used for residents, trainers, and heads of departments. Results This study covers 20 emergency medicine departments and 261 physicians. It was determined that written rotational objectives have been indicated in 17 of the emergency medicine departments and log books are used in 16 departments. Although 60% of resident views on ‘practical skills’, 23% on ‘the contribution of rotations to the training’, and 44% on ‘the level of residency training programs’ were rated as ‘sufficient’, trainers indicated ‘sufficiency’ on these subjects as 78, 37, and 77%, respectively. Regarding theoretical and practical skills, residents and trainers, respectively rated as ‘sufficient’ following subjects: cardiovascular 74, 91%; neurology 68, 86%; resuscitation 83, 98%; trauma 76, 87%; orthopedics 56, 75%; pediatrics 16, 27%; and toxicology 63, 82%. Conclusion Most of the departments have developed the basic components for resident education. Residents and trainers frequently had different views on their own level of knowledge, practical skills, and the content of their training.

Sensitivity and specificity of bedside ultrasonography in the diagnosis of fractures of the fifth metacarpal

Objectives Ultrasonography is becoming increasingly common in the diagnosis of fracture in emergency medicine. The aim of our study was to investigate the diagnostic accuracy of sonographic examinations for diagnosing fifth metacarpal fractures. Methods A prospective study was performed of consecutive patients aged >14 years admitted to the emergency department with hand trauma and tenderness over the fifth metacarpal. Anteroposterior and oblique plain x-rays were taken on all patients. Emergency physicians performed bedside sonographic examination. The x-rays were reported by an orthopaedic surgeon who was blinded to the sonographic examination findings. The orthopaedic surgeon’s report was considered the gold standard unless a CT scan was performed. In the single case where this occurred, the CT scan report was considered the gold standard. Results Eighty one patients were included in the study, 39 of whom had fractures. Sonographic examination identified the fractures in 38 patients. One occult fracture undetected by plain radiography, later shown on CT scan, was identified by sonographic examination. There were three cases with false positive ultrasound findings. The sensitivity of the diagnosis of fifth metacarpal fractures by ultrasonography was 97.4% (95% CI 84.9% to 99.9%), specificity was 92.9% (95% CI 79.4% to 98.1%), positive likelihood ratio (LR) was 14 (95% CI 4.58 to 41), negative LR was 0.03 (95% CI 0.00 to 0.19), negative predictive value was 97.5% (95% CI 85.3% to 99.9%) and positive predictive value was 92.6% (95% CI 79% to 98.1%). Conclusions Sonographic examination can be used as an effective diagnostic tool in patients with fifth metacarpal trauma.

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.

Brugada syndrome, manifested by propafenone induced ST segment elevation

We report a case of a 43 year old man who was diagnosed with Brugada syndrome after propafenone administration for chemical cardioversion of new onset atrial fibrillation. Brugada syndrome has been described in the medical literature and is thought to be responsible for the majority of sudden cardiac deaths in patients without ischaemic heart disease. This syndrome has not yet been extensively discussed in the emergency medicine literature despite its importance. Emergency physicians should consider Brugada syndrome in patients who present to the emergency department with right bundle branch block and ST segment elevation in the right precordial leads, which is the classic electrocardiographic pattern of this syndrome.

Retrograde cerebral air embolism.

Pneumocephalus is a clinical condition caused by dysbarism, trauma, and iatrogenic causes. The most common iatrogenic causes of pneumocephalus are major interventions as a neurosurgery and cardiovascular operations, endoscopy, and minor interventions as a peripheral and central venous access. Especially during insertion of central venous line and intravenous drug and fluid infusion, the venous air embolism may occur in emergency department. In these patients, retrograde pneumocephalus occurs as a result of the air entering the right atrium to the brain. Clinical effects of the air delivery rates are known to be more specific than the total amount of air. In general, intravenous administration of 300 to 500 mL air in the speed of 100 mL/min is considered to be lethal. Large amounts of air embolism can cause hypotension and acute circulatory collapse with intracardiac obstruction. The most common symptoms of venous air embolism are anxiety, dyspnea, chest pain, cyanosis, tachycardia, tachypnea, headache, confusion, agitation, syncope, slurred speech, blurred vision, seizures, and ataxia. The mortality of pneumocephalus caused by central venous catheters in patients presented with symptoms of focal neurologic was 8%, whereas the mortality of pneumocephalus in patients presented with encephalopathy was 36%. In our report, a case of pneumocephalus secondary to disconnection of catheter cap in chronic renal failure patient who has hemodialysis via catheter has been presented.

A comparison of the prophylactic uses of topical mupirocin and nitrofurazone in murine crush contaminated wounds.

OBJECTIVES This work was conducted to study the prophylactic efficacy of 2 topical antibiotic ointments (mupirocin and nitrofurazone) against wound infection in experimental contaminated crush wounds. METHODS Male Wistar rats underwent two 2-cm incisions at the back side and randomized into 3 groups--placebo (n = 14), mupirocin (n = 14), and nitrofurazone (n = 14)--and infected with either Staphylococcus aureus or S. pyogenes. All wound edges were crushed for 5 seconds with hemostats to simulate crush injury before inoculation of the microorganisms. Half of the wounds were sutured and the other half left open. These wounds were treated 3 times daily for 6 days with topical mupirocin, nitrofurazone, or petrolatum (as placebo). At the end of 6 days, excisional biopsies were taken from wound edges and histopathologic assessments were made based on neutrophilic infiltration, edema formation, myofibroblastic proliferation, and granulation tissue formation. For the microbiologic assessments, quantitative tissue cultures were made. RESULTS In S. aureus-inoculated wounds, mupirocin showed higher antibacterial activity against bacterial colonization and reduced infection rates compared to placebo groups. The same effect was observed for the infection rates in S. pyogenes-inoculated wounds. In S. pyogenes-inoculated open wounds, nitrofurazone showed higher antibacterial activity against infection, but this effect was not observed in closed wounds. In S. pyogenes- and S. aureus-infected wounds, mupirocin treatment significantly lowered infection rates compared to nitrofurazone treatment. Histopathologic examination showed higher myofibroblastic proliferation and higher volume of granulation tissue in the nitrofurazone groups compared to the mupirocin groups. CONCLUSION Topical mupirocin application was effective against crush wound infections inoculated with S. pyogenes and S. aureus. Nitrofurazone provides better granulation tissue formation, but did not effectively prevent bacterial colonization and infection in crush contaminated wounds.

Carbon monoxide poisoning in patients presenting to the emergency department with a headache in winter months

Background Carbon monoxide (CO) poisoning is an important reason for emergency department (ED) visits during winter months, but because there are no specific symptoms it can be difficult to diagnose. We aimed to determine the frequency of CO poisoning in patients presenting to the ED with headaches during winter months and evaluate the ability of non-invasive carboxyhaemoglobin measurement (SpCO) to screen for CO poisoning in these patients. Methods SpCO measurement values of adult patients were measured non-invasively with a Rad-57 Pulse CO-Oximeter. Patients whose initial SpCO reading was over 10% underwent a venous blood draw for laboratory determination of invasive carboxyhaemoglobin (COHb) measurement. Patients with a invasive COHb level of over 10% were diagnosed with CO poisoning. Percentage of screened patients with suspected and occult CO poisoning, the distribution of patients with CO poisoning by time of day of the ED visit and the positive predictive value of SpCO to detect CO poisoning were calculated. Results 483 patients presenting with headaches were screened with SpCO measurement. Thirty-eight had a mean SpCO value of over 10%, 31 (6.4% of the study population) of which had elevated COHb confirmed by laboratory determination. SpCO measurement, therefore, had a positive predictive value of 82% for CO poisoning. Twenty-four (77%) of the CO poisoning cases were suspected and seven (23%) were occult. CO poisoning was detected more frequently in patients visiting the ED after midnight and during morning hours. Conclusions CO poisoning should be kept in mind in patients presenting to the ED with a headache. SpCO is an effective screening tool to detect CO poisoning in these patients.