Ozlem Yigit

The utility of EEG in the emergency department.

Background and aim Seizure-related visits are common in the emergency department (ED) but the clinical situations for ordering emergency electroencephalography (EEG) are unclear. The aim of this study is to identify which clinical conditions meet with the pathological EEG and whether patient management is changed by abnormal results. Methods A retrospective chart review study of all patients visiting the ED with a seizure or symptoms mimicking a seizure was performed. Patients who recorded an EEG within 16 h after the initial event were enrolled. Demographic data and EEG results of patients with provoked and unprovoked seizures were recorded and related factors were analysed. Results A total of 449 patients (219 men) of mean±SD age of 45.48±21.83 years were evaluated. The seizure was thought to be provoked in 98 patients (21.8%) and unprovoked in 352 (78.2%) patients (31.2% remote symptomatic and 47.4% idiopathic). The EEG results of 281 patients (62.6%) revealed an abnormality, and the abnormal EEG ratio was high in patients with presumed seizure (p<0.001). One hundred and thirty-eight patients (30.7%) were hospitalised and the remainder (n=311, 69.3%) were discharged from the ED. An abnormal EEG was found in 98 (71%) of the hospitalised patients and in 183 (59.5%) of those discharged (p=0.019). Conclusion EEG provides useful diagnostic information and should be considered in all patients presenting to the ED with a seizure. Since the timing of the study affects the diagnostic efficacy of the test, EEG recordings might be done within 24 h either in the ED or epilepsy clinic.

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.

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.

Pseudoaneurysm of the anterior tibial artery detected by emergency medicine physician performing bedside ultrasound.

We present the case of an anterior tibial artery pseudoaneurysm secondary to lacerating trauma caused by a straight-edge trimming blade. A 56-year-old man presented to emergency department (ED) with 1-month history of left calf pain. Thirty days before presentation, the patient lacerated his left lateral pretibial area with a cutting blade--similar to a machete--while cutting grass. He was seen at the state hospital, and primary suture was performed. Ten days later, the suture was removed. A week later, the patient revisited his physician, complaining of swelling and tenderness in the left calf. Hematoma formation of the calf was suspected and aspirated by syringe. Three days later, the patient presented to the ED with a repeat of his symptoms. On physical examination, the calf was swollen and tender. The vascular examination revealed a palpable dorsalis pedis and diminished posterior tibialis pulse. Localized swelling was present, and circumference of the affected calf was increased. No pulsatile mass was palpated. Ultrasound (US) performed at the bedside revealed a pulsating anechoic lesion surrounded by a hypoechoic lesion suggestive of thrombus formation. Doppler US of the patient showed 4.5x2.5-cm partially thrombosed pseudoaneurysm of the anterior tibial artery. In this case, the pseudoaneurysm was believed to be compressing the posterior tibial artery, resulting in a diminished pulse on examination. Emergency US use may enhance emergency physician performance by the shortening of the length of stay in the ED, reduce the number of unnecessary tests to be ordered, and hasten critical therapeutic interventions.

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.

Inhalational and dermal injury due to explosion of calcium hypochlorite

Calcium hypochlorite is a yellow-white powder widely used as a disinfectant in swimming pools. It releases chlorine gas when added to water and can cause respiratory effects. Dermal and eye injury can occur because of the caustic nature of chlorine. We report a case of chlorine toxicity and burns on a man’s face due to the explosion of calcium hypochlorite while he was mixing it into the water.

EEG as a part of the decision-making process in the emergency department.

Study objective Although electroencephalography (EEG) is a useful diagnostic tool for patients with a suspected seizure, its value in informing the acute care of patients in the emergency department (ED) remains unclear. The aim of this study is to determine the effects of EEG results on subsequent patient management in or from the ED. Materials and methods This prospective observational study was carried out in the ED of a tertiary-care university hospital. All patients presenting to the ED with seizure or seizure-mimicking symptoms were included in the study. EEG was advised for all patients after an initial evaluation. Before EEG, the ED physician and neurologist were asked clinical questions about the patient. The consistency between the clinical decision of emergency physicians before the EEG report and the final management of patients determined by the consultant neurologist was analyzed. The interobserver reliability of the physicians was determined. Results Overall, 110 patients were enrolled in the study. The sensitivity and specificity of ED physicians’ diagnosis of the presence of seizure were both 88% (95% confidence interval, 79–93 and 62–97%). The interobserver reliabilities and &kgr; values of ED physicians and neurologists were found to be ‘moderate’. Patients with abnormal EEG results were prescribed new medication (P=0.003) and changes in therapy (P=0.59) were more than for patients with normal results. Conclusion As seizure is a clinical event, EEG is not essential for diagnosing the presence of a seizure clinically in the ED. However, the results of EEG provide useful information especially for treatment choices. As the timing of the study affects the diagnostic efficacy of the test, EEG recordings should be performed within 24 h either in ED or in the epilepsy clinic.

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.

An unusual syncope cause in the ED: Favism

Favism is an acute hemolytic syndrome occurring in glucose-6-phosphate dehydrogenase (G6PD)-deficient individuals after the consumption of fava beans. The highest incidence is in boys aged 2-6 years. We report a 56-year-old man presented to the emergency department (ED) with recurrent syncope attacks due to favism. In our knowledge, this is the first report of favism-caused syncope in an adult patient without a G6PD deficiency diagnosis in the past and diagnosed in ED.

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.