Mutlu Kartal

Comparison of the Full Outline of Unresponsiveness Score Coma Scale and the Glasgow Coma Scale in an emergency setting population.

Background The Glasgow Coma Scale (GCS) is the most widely used tool for the evaluation of the level of consciousness. The Full Outline of Unresponsiveness (FOUR) Score is a new coma Scale that was developed considering the limitations of the GCS, and has been found to be useful in an intensive care setting. We aimed to compare FOUR Score and GCS in the emergency setting. Methods All patients older than 17 years who presented with an altered level of consciousness, after any trauma to the head or with neurological complaints were included in this study. Three-month mortality, in-hospital mortality, and poor outcome using a Modified Rankin Scale (MRS) of 3–6 points were used as the primary outcome measures. Results A total of 185 patients were included in the study. Area under the curve (AUC) values in predicting 3-month mortality for GCS was 0.726 [P=0.0001 and 95% confidence interval (CI): 0.656–0.789] and 0.776 (P=0.0001 and 95% CI: 0.709–834) for FOUR Score. AUC in predicting hospital mortality for GCS was 0.735 (P=0.0001 and 95% CI: 0.655–0.797) and 0.788 (P=0.0001 and 95% CI: 0.722–0.844) for FOUR Score. AUC in predicting poor outcome (Modified Rankin Scale: 3–6) was 0.720 (P=0.001 and 95% CI: 0.650–784) for GCS and 0.751 (P=0.0001 and 95% CI: 0.682–0.812) for FOUR Score. Conclusion The new coma Scale, FOUR Score, is not superior to the GCS. However, the combination of the eye and motor components of FOUR Score is a valuable tool that can be used instead of either the FOUR Score or GCS.

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.

Artificial neural network, genetic algorithm, and logistic regression applications for predicting renal colic in emergency settings

BackgroundLogistic regression is the most common statistical model for processing multivariate data in the medical literature. Artificial intelligence models like an artificial neural network (ANN) and genetic algorithm (GA) may also be useful to interpret medical data.AimsThe purpose of this study was to perform artificial intelligence models on a medical data sheet and compare to logistic regression.MethodsANN, GA, and logistic regression analysis were carried out on a data sheet of a previously published article regarding patients presenting to an emergency department with flank pain suspicious for renal colic.ResultsThe study population was composed of 227 patients: 176 patients had a diagnosis of urinary stone, while 51 ultimately had no calculus. The GA found two decision rules in predicting urinary stones. Rule 1 consisted of being male, pain not spreading to back, and no fever. In rule 2, pelvicaliceal dilatation on bedside ultrasonography replaced no fever. ANN, GA rule 1, GA rule 2, and logistic regression had a sensitivity of 94.9, 67.6, 56.8, and 95.5%, a specificity of 78.4, 76.47, 86.3, and 47.1%, a positive likelihood ratio of 4.4, 2.9, 4.1, and 1.8, and a negative likelihood ratio of 0.06, 0.42, 0.5, and 0.09, respectively. The area under the curve was found to be 0.867, 0.720, 0.715, and 0.713 for all applications, respectively.ConclusionData mining techniques such as ANN and GA can be used for predicting renal colic in emergency settings and to constitute clinical decision rules. They may be an alternative to conventional multivariate analysis applications used in biostatistics.

Comparison of the C-MAC video laryngoscope to the Macintosh laryngoscope for intubation of blunt trauma patients in the ED

Objectives We aimed to compare the performance of the C-MAC video laryngoscope (C-MAC) to the Macintosh laryngoscope for intubation of blunt trauma patients in the ED. Material and methods This was a prospective randomized study. The primary outcome measure is overall successful intubation. Secondary outcome measures are first attempt successful intubation, Cormack–Lehane (CL) grade, and indicators of the reasons for unsuccessful intubation at the first attempt with each device. Adult patients who suffered from blunt trauma and required intubation were randomized to video laryngoscopy with C-MAC device or direct laryngoscopy (DL). Results During a 17-month period, a total of 150 trauma intubations were performed using a C-MAC and DL. Baseline characteristics of patients were similar between the C-MAC and DL group. Overall success for the C-MAC was 69/75 (92%, 95% CI 0.83 to 0.96) while for the DL it was 72/75 (96%, 95% CI 0.88 to 0.98). First attempt success for the C-MAC was 47/75 (62.7%, 95% CI 0.51 to 0.72) while for the DL it was 44/75 patients (58.7%, 95% CI 0.47 to 0.69). The mean time to achieve successful intubation was 33.4 ± 2.5 s for the C-MAC versus 42.4 ± 5.1 s for the DL (p = 0.93). There was a statistically significant difference between the DL and C-MAC in terms of visualizing the glottic opening and esophageal intubation in favor of the C-MAC (p = 0.002 and p = 0.013 respectively). Discussion and conclusion The overall success rates were similar. The C-MAC demonstrated improved glottic view and decrease in esophageal intubation rate.

Factors affecting revisit of COPD exacerbated patients presenting to emergency department.

The primary purpose of this prospective cohort study was to characterize the use of the Emergency Department (ED) in patients with chronic obstructive pulmonary disease (COPD) exacerbations and determine the factors affecting the revisit of COPD patients. This is a prospective cohort study on ambulatory patients with exacerbated chronic bronchitis in an ED setting. Patients included in the study were above 18 years of age, had a previous diagnosis of COPD, and presented to the ED for the treatment of COPD exacerbation. All the information relevant to the study was collected during the patients visit to the ED. Revisit was defined as an unscheduled visit to an ED or primary physician within 2 weeks of initial ED visit for worsening COPD symptoms. Telephone follow-up was done on all patients at the end of 2 weeks. Variables of 26 revisit cases versus 78 nonrevisit cases were compared. Home oxygen therapy, intensive care admission, previous intubation, increased cough, and the number of ED visits in the previous year were associated with increased risk of revisit in the univariate analysis. Increased cough (odds ratio: 0.232; 95% confidence interval: 0.063–0.853) and the number of ED visits in the previous year (odds ratio: 1.166; 95% confidence interval: 1.005–1.353) were still significant after multivariate analysis. In conclusion, the number of ED visits previous year and increased cough can predict the revisit of a COPD exacerbated patient within 14 days of an ED visit.

The value of ETCO2 measurement for COPD patients in the emergency department.

We aimed to determine the value of sidestream end-tidal carbon dioxide (SS-ETCO2) measurement in patients with chronic obstructive pulmonary disease (COPD) in the emergency department. Cross-sectional associations between ETCO2 and PaCO2 were examined in the study. This prospective cross-sectional study has been carried out over a 3-month period in a tertiary care university hospital emergency department with an annual census of 75 000 visits. During the study period, simultaneous SS-ETCO2 measurement using a Medlab Cap 10 sidestream capnograph was performed on every COPD patient requiring arterial blood gas analysis. The demographics, diagnosis, vital signs, laboratory test results and clinical outcomes of the patients were recorded. SS-ETCO2 measurement and arterial blood gas analysis were carried out on 118 patients. Mean arterial PCO2 levels were 43.24±14.73 and mean ETCO2 levels were 34.23±10.86 mmHg. Agreement between PCO2 and ETCO2 measurements was 8.4 mmHg and a precision of 11.1 mmHg. As there is only a moderate correlation between PCO2 and ETCO2 levels in COPD patients, ETCO2 measurement should not be considered as a part of the decision-making process to predict PaCO2 level in COPD patients.

Seizure or syncope: the diagnostic value of serum creatine kinase and myoglobin levels.

Objective To determine if the serum levels of creatine kinase and myoglobin can be used to differentiate the grandmal tonic–clonic seizure and syncope activities in the emergency department (ED). Methods Consecutive patients over 16 years old who presented to an ED of a tertiary care hospital with a witnessed tonic–clonic seizure activity and a history of a transient loss of consciousness with normal neurological exams in the ED were selected to either seizure or syncope groups. Patients with an unclear history of seizure or syncope with more than 4 h of the activity and with any conditions that could elevate creatine kinase and myoglobin levels were excluded. Serum samples were drawn at presentation and at the fourth hour of the event. Results Thirty-seven syncope and 26 generalized tonic–clonic seizure patients with a definite history were assigned to study groups. There was not a statistically significant difference in the time of drawing of the first serum sample among groups. No statistically significant differences were determined with the first samples of creatine kinase and myoglobin for both groups. Serum levels of creatine kinase drawn at the fourth hour of the activity were significantly higher in favor of the seizure group. However, myoglobin levels were insignificant at the fourth hour. Conclusion Serum creatine kinase measured at the fourth hour of loss of consciousness may be a potentially useful laboratory test to differentiate tonic–clonic seizure from syncope. Patently, it requires and warrants further study.

The Factors Influencing Relapse in Patients Presenting to the Emergency Department with COPD Exacerbation

SUMMARY Objectives Chronic Obstructive Pulmonary Disease (COPD) is associated with high mortality and morbidity and is projected to be the third most common cause of death worldwide by 2020. For a variety of reasons, there is a drive to manage a greater number of individuals as outpatients. Preventing readmissions can reduce associated morbidity and subsequent healthcare costs. Methods The aim of the present study was to determine the factors affecting the relapse of COPD exacerbated patients in the emergency department (ED). This study combines data from two prospective cohort studies. Patients included in the study were above 18 years of age, had a previous diagnosis of COPD, and presented to the ED for the treatment of acute exacerbation. All the information relevant to the study was collected during the patients visit to the ED. Relapse was defined as an unscheduled visit to an ED or primary physician within 2 weeks of initial ED visit for worsening COPD symptoms. Telephone follow-up was done on all patients at the end of 2 weeks. Results The cohort consists of 196 patients. Relapse rate in this study was 27%. Mean respiratory rate, exacerbations in previous year, home nebulizator therapy, home oxygen therapy, admission to intensive care or hospital ward due to COPD exacerbation, previous intubation and abnormal chest x-ray were associated with increased re-visit in univariate analysis. However, after multivariate analysis, exacerbations in previous year (OR: 1.08, 95%CI: 1.01–1.15) and abnormal chest X-ray (OR: 2.5, 95%CI: 1.10–6.11) were still significant. Conclusions In conclusion, the number of ED visits previous year and abnormal chest x-ray can predict the revisit of a COPD exacerbated patient within 14 days of an ED visit.

Randomized controlled trial of morphine in elderly patients with acute abdominal pain

BACKGROUND The objective of this study was to determine the clinically important change in diagnostic accuracy and physical examination in the morphine vs. placebo group. METHODS Subjects were randomized in a 1:1 ratio to receive a single dose intravenous morphine or placebo in a blinded fashion. Primary outcome measure was to determine if there was a clinically important change in diagnostic accuracy and physical examination in the morphine vs. placebo group. RESULTS 80 subjects (39 were assigned to morphine and 41 to placebo) were included in the final analysis. Clinically important diagnostic accuracy rate was found to be 80% in the morphine group (31/39) and 78% in the placebo group (32/41), with a difference rate of 2% (95% CI -7% to 13%, p=0.9802. There was a statistically significant change in abdominal rigidity finding (15%) in morphine group in all of the abdominal physical examinations findings; however there was no change in placebo group (0%). The difference between two groups was also statistically significant (95% CI 2.3% to 30.5%, p= 0.031). CONCLUSION Administration of opioid analgesia is safe and does not seem to impair clinical diagnostic accuracy in elderly patients with acute undifferentiated abdominal pain. Nevermore, opioids may change the physical examination findings such as abdominal rigidity.