Müge Günalp

The accuracy of ultrasound evaluation in foot and ankle trauma

OBJECTIVES Foot and ankle injuries that result in sprains or fractures are commonly encountered at the emergency department. The purpose of the present study is to find out the accuracy of ultrasound (US) scanning in injuries in the aforementioned areas. METHODS Ottawa Ankle Rules-positive patients older than 16 years who presented to the emergency department with foot or ankle injuries were eligible. For all patients, US evaluation of the whole foot and ankle was performed by an emergency physician before radiographic imaging. All radiographic images were evaluated by an orthopedic specialist and compared with the interpretations of the US. RESULTS One hundred thirty-one patients were included in the study. Radiographic evaluation enabled the determination of fractures in 20 patients, and all of these were identified with US imaging. Moreover, US evaluation radiographically detected a silent ankle fracture in 1 patient. The sensitivity of US scanning in detecting fractures was 100% (95% confidence interval [CI], 83.8-100), the specificity was 99.1% (95% CI, 95-99.8), the positive predictive value was 95.2% (95% CI, 89.6-98), and the negative predictive value was 100% (95% CI, 96.4-100), respectively. The most common fractures were detected at the lateral malleolus and at the basis of the fifth metatarsal. CONCLUSIONS Ultrasound imaging permits the evaluation of foot and ankle fractures. Because it is a highly sensitive technique, US can be performed in the emergency department with confidence.

Holter monitoring for 24 hours in patients with thromboembolic stroke and sinus rhythm diagnosed in the emergency department

It is well known that patients with ischemic stroke show ST-T abnormalities and various rhythm abnormalities on an electrocardiogram (ECG). The most commonly encountered rhythm abnormality is atrial fibrillation. It was recently shown that paroxysmal atrial fibrillation (PAF) is an important causative factor in patients with stroke. Detection of PAF is important in identifying the cause, prognosis, and treatment in patients with thromboembolic stroke. Investigators in the present study followed patients with thromboembolic stroke who had been admitted to the emergency department in sinus rhythm; 24-h Holter monitoring was used, and patients were assessed at referral and every 6 h for 24 h with ECG, which was used to detect rhythm disturbances, especially PAF. In 26 patients with stroke who came to the emergency department, acute thromboembolic stroke was diagnosed on the basis of magnetic resonance imaging; no rhythm abnormalities were noted on Holter monitoring. Eighteen patients were male and 8 were female (mean age: 66±13 y). Arrhythmia was identified on ECG in 3 patients (11%) and on 24-h Holter monitoring in 24 patients (92%). PAF was diagnosed in 3 patients (11%) on ECG and in 11 patients (42%) on Holter monitoring. In 2 patients, nonsustained ventricular tachycardia was detected only on Holter monitoring, which was found to be significantly superior to ECG for the detection of arrhythmias (P < .001). Investigators found no significant relationship between PAF and variables such as hypertension, diabetes, coronary artery disease, history of myocardial infarction, ST-T changes, and elevations in cardiac markers. However, a significant relationship (P < .01) was seen between nonsustained ventricular tachycardia and a history of myocardial infarction. No relationship was discerned between arrhythmia and stroke localization. Study results suggested that (1) PAF is a commonly diagnosed rhythm abnormality, and (2) Holter monitoring is superior to routine ECG for the detection of arrhythmias such as PAF in patients anticipated to have thromboembolic stroke with sinus rhythm.

Septic Pulmonary Embolism Associated with Renal Abscess: A Case Report

BACKGROUND Septic pulmonary embolism (SPE) is a rare condition that is difficult to diagnose. OBJECTIVES To describe the clinical course and diagnosis of a patient with SPE. CASE REPORT We report on a case of SPE diagnosed in the emergency department and review the current literature. CONCLUSION The diagnosis of SPE can be made using computed tomography scan. Early diagnosis and appropriate antibiotic therapy are important factors for the control of the infection.

Independent Factors for Prediction of Poor Outcomes in Patients with Febrile Neutropenia

Background Febrile neutropenia (FN) is a life-threatening condition that requires urgent management in the emergency department (ED). Recent progress in the treatment of neutropenic fever has underscored the importance of risk stratification. In this study, we aimed to determine independent factors for prediction of poor outcomes in patients with FN. Material/Methods We retrospectively evaluated 200 chemotherapy-induced febrile neutropenic patients who visited the ED. Upon arrival at the ED, clinical data, including sex, age, vital signs, underlying systemic diseases, laboratory test results, estimated GFR, blood cultures, CRP, radiologic examinations, and Multinational Association of Supportive Care in Cancer (MASCC) score of all febrile neutropenic patients were obtained. Outcomes were categorized as “poor” if serious complications during hospitalization, including death, occurred. Results The platelet count <50 000 cells/mm3 (OR 3.90, 95% CI 1.62–9.43), pulmonary infiltration (OR 3.45, 95% CI 1.48–8.07), hypoproteinemia <6 g/dl (OR 3.30, 95% CI 1.27–8.56), respiratory rate >24/min (OR 8.75, 95% CI 2.18–35.13), and MASCC score <21 (OR 9.20, 95% CI 3.98–21.26) were determined as independent risk factors for the prediction of death. The platelet count <50 000 cells/mm3 (OR 3.93, 95% CI 1.42–10.92), serum CRP >50 mg/dl (OR 3.80, 95% CI 1.68–8.61), hypoproteinemia (OR 7.81, 95% CI 3.43–17.78), eGFR ≤90 ML/min/1.73 m2 (OR 3.06, 95% CI 1.13–8.26), and MASCC score <21 (OR 3.45, 95% CI 1.53–7.79) were determined as independent risk factors for the prediction of poor clinical outcomes of FN patients. Platelet count, protein level, respiratory rate, pulmonary infiltration, CRP, MASCC score, and eGFR were shown to have a significant association with outcome. Conclusions The results of our study may help emergency medicine physicians to prevent serious complications with proper use of simple independent risk factors besides MASCC score.

Could Vital Signs Predict Carbon Monoxide Intoxication

OBJECTIVE: This retrospective study examined the correlation between carboxyhaemoglobin (COHb) levels and vital signs in patients with carbon monoxide (CO) intoxication. METHODS: Over a 10-year period, patients > 16 years of age who presented to the emergency department due to CO intoxication were included. Age, gender, comorbidities, month/year of presentation, presenting symptoms, vital signs, blood pH, COHb level, treatment and outcome were recorded. RESULTS: In total, 476 patients were included. The mean ± SD age was 36.22 ± 13.65 years; 96.4% of the patients had a normal Glasgow Coma Scale score, 91.0% had normal blood pressure and 80.0% had a normal heart rate. COHb levels were stratified into three groups: < 10% (n = 39), 10 – 20% (n = 106) and > 20% (n = 205); levels could not be obtained in the remaining 126 patients. In patients with COHb levels > 20%, 34 (16.6%) had alkalosis and nine (4.4%) had acidosis. Among patients with COHb levels > 20%, 140 (68.3%) had normal vital signs. CONCLUSIONS: Vital signs cannot be used as a prognostic marker of CO intoxication and, therefore, patients must be monitored closely.

Intraosseous access learning curve; is it really practical?

Success rate and time need for vascular access are crucial in the emergency patient. However, in many cases, peripheral intravenous accessmight be difficult [1]. Intraosseous (IO) infusion is the quickest way to establish access for rapid administration ofmedications and liquids in emergency situations, where vascular access is difficult to achieve. In recent years, it has beenwidely used in pediatric population. Intraosseous infusion is now recommended in adult resuscitation by the American Heart Association [2] and the European Resuscitation Council [3]. Our study aims to examine IO route, a practical and easy vascular access, in terms of rapidity of learning and practice. A total of 50 interns,whohave studied in the emergencydepartment of the university hospital and who have never established IO route of administration, were taught the method of establishing an IO route of administration in the tibias obtained from adult cadavers, and thereafter, the procedure was demonstrated to them in practice once. Then, the interns were asked to perform this procedure on the tibias for 10 times. The procedure was performed using Vidacare (Shavano Park, TX) EZ-IO Power Driver gun and Vidacare EZ-IO15-gauge IO cannula. During the intern practices, the timewasmeasured using the chronometer. All data were statistically evaluated. Repeated-measures analysis of variance test was used to determine the difference among 10 measurements. When the P value obtained from repeated-measures analysis of variance test was statistically significant, Bonferroni adjustment was performed to assess themeasurements, which showed a difference. For dichotomous variables, McNemar test was used. SPSS for Windows 11.5 was used for statistical analyses (SPSS, Chicago, IL). A P value less than .05 was considered statistically significant. The period was gradually shortened from the first practice to the eighth practice and was found to be statistically different between the practices (P N .05). After the eighth practice, no statistically significant difference of period was found between the practices (P b .001). Given the total duration, although the first practice lasted averagely 84.64 seconds, the interns completed the eighth practice averagely in 39.48 seconds, which corresponded to a period shorter than the half of the first practices duration (Table). Given the error that the interns did during the period, in which they ensured the sterile conditions, at a percentage of 46% in the first practice, of 40% in the second practice, and 4% in the fourth practice and taking into consideration the likelihood of the development of serious conditions such as osteomyelitis as a complication, it would be more appropriate that inexperienced practitioners perform at least the first 3 or 4 practices under the supervision of experienced physicians. Chatchawan Piyaskulkaew, MD Saif Al-najafi, MD Department of Cardiology Wayne State University/St. John Hospital & Medical Center Detroit, MI, USA

Abdominal pain: The black box. Retrospective evaluation of patients administered to the emergency department due to complicated lymphocyt

Lymphocyst is mainly observed following extraperitoneal surgery. In this retrospective study, we aimed to determine the results of patients treated with percutaneous catheter drainage who referred to the emergency department due to lymphocyst complications. The examined group was consisted of 17 patients. All patients admitted to the emergency were suffering from abdominal pain. Ultrasonography (USG) was performed to all patients. Computerized tomography (CT) and magnetic resonance imaging (MRI) were performed in 13 and 1 patient respectively. With the imaging evaluation complicated lymphocysts were detected. In 5 cases compression of urinary bladder, in 5 cases hydroureteronephrosis, in 2 cases compression of the left external iliac vein, in 1 case compression of the small and large intestine were observed. Percutaneous catheter drainage and sclerotherapy under ultrasonography and fluoroscopy guildance was performed to all cases in interventional radiology unit. To the best of our knowledge most of the lymphocysts were asymptomatic.Complicated lymphocysts may present as acute abdominal pain due to intraabdominal mass effect in patients having undergone surgery for gynecologic malignancy. If the lymphocyst is infected or becomes symptomatic due to compression of adjacent organ must be diagnosed and treated in early period. Clinical and radiological examinations are the key to the diagnosis of complicated lymphocyst. Emergency physicians should consider percutaneus catheter drainage as a treatment of choice.