Firat Bektas

Intravenous paracetamol or morphine for the treatment of renal colic: a randomized, placebo-controlled trial.

STUDY OBJECTIVE This randomized, placebo-controlled trial evaluates the analgesic efficacy and safety of intravenous single-dose paracetamol and morphine for the treatment of renal colic. METHODS We conducted a randomized, double-blind, placebo-controlled clinical trial comparing single intravenous doses of paracetamol (1 g), morphine (0.1 mg/kg), and placebo (normal saline solution) for patients presenting to the emergency department (ED) with suspected renal colic. Subjects with inadequate pain relief at 30 minutes received rescue fentanyl (0.75 microg/kg). We compared changes in pain intensity 30 minutes after treatment among the 3 arms, as well as the need for rescue medication and the presence of adverse effects. RESULTS Six hundred forty-five consecutive patients were screened for study and 165 were entered. Eight subjects were subsequently excluded from analysis because of protocol violations and 11 were excluded because of uncertain diagnoses, leaving 146 subjects available for analysis. The mean reduction in visual analogue scale pain intensity scores at 30 minutes was 43 mm for paracetamol (95% confidence interval [CI] 35 to 51 mm), 40 mm for morphine (95% CI 29 to 52 mm), and 27 mm for placebo (95% CI 19 to 34 mm). Statistically significant mean differences in pain intensity reductions compared with those for placebo were observed for paracetamol (16; 95% CI 5 to 27; P=.005) and morphine (14; 95% CI 0.4 to 27; P=.05); however, no difference was found between paracetamol and morphine (2; 95% CI -13 to 16; P=.74). Rescue analgesics at 30 minutes were required by 21 subjects (45%) receiving paracetamol, 24 subjects (49%) receiving morphine, and 34 subjects (67%) receiving placebo (P=.08). At least 1 adverse effect was experienced by 11 (24%) receiving paracetamol, 16 (33%) receiving morphine, and 8 (16%) in the placebo group (P=.14). There were no serious adverse events. CONCLUSION Intravenous paracetamol is an efficacious and safe treatment for ED patients with renal colic.

Point of Care Blood Ketone Testing of Diabetic Patients in the Emergency Department

The aim of our study was to determine the utility of point‐of‐care blood ketone testing in diabetic patients presenting to the emergency department. In this prospective, observational clinical study, patients with known or newly diagnosed diabetes mellitus presenting to our tertiary care university emergency department with any nontrauma related medical complaint and a high fingerstick glucose (≥ 200 mg/dL) were eligible for inclusion. Capillary blood β‐hydroxybutyrate (β‐HBA), venous blood β‐HBA level, venous blood glucose level, arterial blood gas analysis, and urine ketone dipstickstick were measured in each patient as primary outcome measures. Of the 479 diabetic patients presenting during the study period, a total of 139 diabetic patients with high capillary blood glucose level (≥ 200 mg/dL) and a positive capillary blood β‐HBA (≥ 0.1 mmol/L) were included in the study. Hyperketonemia (≥ 0.42 mmol/L) was found in 48 of these patients by Sigma Diagnostics reference testing (diabetic ketosis in 35%). The calculated blood pH was less than 7.3 in 18 of these 48 patients (ketoacidosis in 31%). Capillary and venous blood β‐hydroxybutyrate levels were not statistically different from each other (P = 0.824). There was a positive correlation between capillary and venous blood β‐HBA levels (r = 0.488, P < 0.001). The sensitivity and specificity of urine ketone dipstick testing and capillary blood ketone testing in determining diabetic ketoacidosis were 66% and 78%, and 72% and 82%; and in determining hyperketonemia (both in diabetic ketosis and diabetic ketoacidosis) were 82% and 54%, and 91% and 56%, respectively. A rapid, bedside capillary blood ketone test for β‐HBA can accurately measure blood concentrations of β‐HBA in diabetic patients in an emergency department setting. This device can be used as a reliable diagnostic test to detect emergency metabolic problems in diabetic patients, such as diabetic ketosis or ketoacidosis.

ETco2: a predictive tool for excluding metabolic disturbances in nonintubated patients

OBJECTIVES The purpose of this study is to examine the relation between end-tidal carbon dioxide (ETCO₂) measurement and bicarbonate (HCO₃) level reflecting the patients metabolic status. METHOD This prospective cross-sectional study has been carried out during a 3-month period in a tertiary care university hospitals emergency department (ED). During the study period, every spontaneously ventilating ED patient requiring arterial blood gas analysis for any medical indication, regardless of presenting symptoms, had a simultaneous ETCO₂ measurement using a Medlab Cap 10 side stream capnograph. The demographics and clinical outcomes of the patients were recorded. RESULTS Of 399 eligible patients, 240 with possible metabolic disturbance were enrolled into the study. There was a statistically significant correlation between the value of ETCO₂ and HCO₃ levels (r = 0.506). The mean ET(CO)₂ level was statistically significantly lower in patients who died (26.5 ± 7.2, 95% confidence interval [CI], 24.2-28.6, vs 30 ± 7.5, 95% CI, 29-31; P = .007) and who had low bicarbonate levels (25.7 ± 6.7, 95% CI, 24.3-27.1, vs 31.6 ± 7.1, 95% CI, 30.4-32.8; P = .000). The value of ET(CO)₂ measurement to detect low bicarbonate level was found to be significant. The area under the receiver operating characteristic curve was 0.734, the (+) likelihood ratio for ETCO₂ less than or equal to 25 was 2.7, and the (-) likelihood ratio for ETCO₂ greater than or equal to 36 was 0.05. CONCLUSION ETCO₂ values correlate moderately with HCO₃ levels and thus might predict mortality and metabolic acidosis. Therefore, side stream capnograph can be used as a noninvasive diagnostic tool for ruling out suspected severe metabolic disturbance in the ED.

Sonographic diagnosis of epiglottal enlargement

The case is presented of epiglottal and pre-epiglottal oedema secondary to infection of the pharyngolaryngeal area. The purpose of this report was to assess the utility of ultrasonography to image epiglottal and pre-epiglottal oedema. Bedside emergency department ultrasonography could be a valuable tool to detect pathological enlargement of the epiglottis. Ultrasonography may be used in unstable patients for diagnosing epiglottitis because it is cheap, rapid, non-invasive and does not aggravate the patients symptoms.

Pseudoephedrine-Induced Paroxysmal Supraventricular Tachycardia: A Case Report

Palpitation is a common chief complaint among emergency department patients, and is often associated with a tachydysrhythmia. Tachydysrhythmia is classified as supraventricular tachycardia or ventricular tachycardia. Reentry in a normal or accessory pathway is one of the most frequently seen mechanisms explaining the tachydysrhythmia. In the present case, we report an unusual cause of atrioventricular paroxysmal supraventricular tachycardia due to pseudoephedrine intake.

Contribution of goal-directed ultrasonography to clinical decision-making for emergency physicians.

Objective: To determine the contribution of goal-directed right upper quadrant (RUQ) ultrasonography (US) on real-time decision-making of attending emergency physicians by evaluating their level of certainty for admission, surgery, medical treatment, additional laboratory and radiological investigations and discharge. Methods: The study was conducted at an urban university tertiary care emergency department with an annual census of 60 000 adult patients. Patients with acute non-traumatic RUQ pain presenting to the emergency department during the 8-month study period were enrolled into the study. Primary outcome measures were level of certainty for admission to the hospital, emergency surgery, medical treatment, additional laboratory and radiological analyses and discharge from the emergency department. Results: There was a significant difference between the pre-US and post-US certainty of the decision to perform additional diagnostic studies (56 vs 72, p = 0.01) but not in the other outcomes (treatment, admission, surgery and discharge). After categorising the physicians’ decisions into low, intermediate and high, US had an effect on all primary outcomes and on all categories. This effect was most evident in the moderate category where the physicians were undecided for all primary outcomes. Conclusion: US performed by emergency department physicians affects the certainty of their decisions in patients presenting with RUQ pain. This effect is more evident on the decision to perform additional diagnostic studies and in patients about whom physicians are undecided.

The Value of Procalcitonin, a Novel Inflammatory Marker, in the Diagnosis of Myocardial Infarction and Evaluation of Acute Coronary Syndrome Patients

BACKGROUND Procalcitonin is a calcitonin precursor that is used as an inflammatory biomarker in the plasma of patients with sepsis. OBJECTIVE The aim of this study was to determine the diagnostic accuracy of emergency department (ED) point-of-care blood procalcitonin testing in identifying myocardial infarction (MI) in patients with chest pain of presumed ischemic origin. METHODS Patients over 18 years of age who presented to the ED with MI-typical chest pain of presumed ischemic origin were included in the study. An initial point-of-care blood sample was drawn from each study patient for testing procalcitonin, troponin T, myoglobin, and creatine kinase-MB levels. A second sample was taken 4h after admission for a procalcitonin test. Finally, a 6-h post-admission blood sample was taken to measure troponin T, myoglobin, and creatine kinase-MB levels in each study patient who had an initial negative cardiac marker test. RESULTS A total of 1008 patients with chest pain were admitted to the ED during the study period, and a total of 141 patients met study criteria and were entered into the study. ED point-of-care blood procalcitonin testing to identify myocardial infarction in patients with chest pain of presumed ischemic origin had a sensitivity of 38.3% (95% confidence interval [CI] 28.8-47.3%) and a specificity of 77.8% (95% CI 70.0-84.4%), a positive likelihood ratio (LR+) of 1.725 and a negative likelihood ratio (LR-) of 0.792. The 4th hour diagnostic values (sensitivity, specificity, LR+ and LR-) of procalcitonin semi-quantitative (PCT-Q) testing were 90% (95% CI 80.9-95.7%), 59.3% (95% CI 52.5-63.5%), 2.2, and 0.16, respectively. CONCLUSION ED point-of-care testing for procalcitonin had poor diagnostic accuracy for predicting myocardial infarction.

Fire-eater’s Pneumonia: Two Case Reports of Accidentally Aspirated Paraffin Oil

BACKGROUND Fire-eaters pneumonia is a chemical pneumonitis that can develop after accidental aspiration of liquid hydrocarbon-based fuel during a flame-blowing or a fire-eating performance. Typical findings of the patient are similar with any infectious pneumonia: chest pain, shortness of breath, cough, fever, and hemoptysis can be seen. CASE REPORTS We report two cases of acute paraffin oil-induced pneumonia due to accidental aspiration during fire-eating performance. CONCLUSION The symptoms and course of respiratory manifestations and the treatment strategies of fire-eaters pneumonia are reviewed.

Pseudoaneurysm of the superficial femoral artery detected by emergency medicine bedside ultrasound

BackgroundFemoral artery pseudoaneurysm following by cardiac catheterization is a serious groin complication requiring careful assessment and prompt intervention.AimsRisk of femoral artery pseudoaneurysm is estimated at 0.6 to 17 following diagnostic and interventional procedures.MethodsThe clinical usage of bedside ultrasonography as part of the physical examination by attending emergency physicians has increased significantly over recent years.ResultsBedside Emergency Department ultrasonography provides the clinician with critical information noninvasively, rapidly determining various anatomical structures.ConclusionsWe presented the case of a femoral artery pseudoaneurysm detected by the bedside emergency department ultrasonography secondary to angiographic catheterization.

Abdominal Wall Hematoma Caused by an Exploded Phone and a Review of Mobile Phone-Related Hazards

With rapid developments in computers and other electronic technologies, telecommunications have become much easier. As a result, in the last 15 years, mobile phones have become a necessity in our lives. As almost everybody has a mobile phone, there has been increasing public interest in the potential health risks associated with their use. Since these devices have become an indispensable part of our lives, some new hazards directly or indirectly caused by mobile phones should be highlighted.