Ridvan Atilla

Pan‐Asian Resuscitation Outcomes Study (PAROS): Rationale, Methodology, and Implementation

Disease-based registries can form the basis of comparative research to improve and inform policy for optimizing outcomes, for example, in out-of-hospital cardiac arrest (OHCA). Such registries are often lacking in resource-limited countries and settings. Anecdotally, survival rates for OHCA in Asia are low compared to those in North America or Europe, and a regional registry is needed. The Pan-Asian Resuscitation Outcomes Study (PAROS) network of hospitals was established in 2009 as an international, multicenter, prospective registry of OHCA across the Asia-Pacific region, to date representing a population base of 89 million in nine countries. The networks goal is to provide benchmarking against established registries and to generate best practice protocols for Asian emergency medical services (EMS) systems, to impact community awareness of prehospital emergency care, and ultimately to improve OHCA survival. Data are collected from emergency dispatch, ambulance providers, emergency departments, and in-hospital collaborators using standard protocols. To date (March 2011), there are a total of 9,302 patients in the database. The authors expect to achieve a sample size of 13,500 cases over the next 2 years of data collection. The PAROS network is an example of a low-cost, self-funded model of an Asia-Pacific collaborative research network with potential for international comparisons to inform OHCA policies and practices. The model can be applied across similar resource-limited settings.

Comparison of emergency medical services systems in the pan-Asian resuscitation outcomes study countries: Report from a literature review and survey

Asia–Pacific countries have unique prehospital emergency care or emergency medical services (EMS) systems, which are different from European or Anglo‐American models. We aimed to compare the EMS systems of eight Asia–Pacific countries/regions as part of the Pan Asian Resuscitation Outcomes Study (PAROS), to provide a basis for future comparative studies across systems of care.

Early-onset pancytopenia and skin ulcer following low-dose methotrexate therapy.

Pancytopenia is a rare but serious adverse effect of low-dose methotrexate (MTX) sodium therapy, and this case report describes a very early-onset of pancytopenia and cutaneous lesions after three days of ingestion. A 64-year-old man was presented to Emergency Department with weakness, fever, poor appetite, nausea, and vomiting after he had had accidentally ingested MTX tablets (2.5 mg) twice a day for the last three days. On initial examination, several painful lesions in his oral mucosa and a cutaneous ulceration on his right foot were also observed. He had severe pancytopenia, poor kidney functions, and abnormal coagulation parameters. The blood level of MTX was found to be within therapeutic range. He was treated with leucovorine, intravenous antibiotics, and appropriate blood transfusions; he was discharged from hospital without any sequela. Pancytopenia associated with low-dose (cumulative dose of 15 mg in 3 days) MTX therapy had not been reported previously. The Naranjo probability scale showed pancytopenia and skin ulcer associated with low-dose MTX therapy as probable adverse reactions. Risk factors for pancytopenia such as renal insufficiency, hypoalbuminemia, low folate levels, concomitant infections, concomitant use of drugs, and folate supplementation were not identified in our patient. Although pancytopenia associated with low-dose MTX therapy is not expected as early as 3 days after initiation of the therapy, physicians should also be aware of this life threatening adverse effect during the very first days of MTX therapy for rheumatoid arthritis patients.

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.

Effects of terlipressin in a rat model of severe uncontrolled hemorrhage via liver injury

BACKGROUND Animal experiments and clinical studies have shown that vasopressin infusion in cases of uncontrolled hemorrhagic shock is a promising treatment. However, there are only a few studies regarding the application of terlipressin in hemorrhagic cases. This study was designed to evaluate the effects of terlipressin vs controlled fluid resuscitation on hemodynamic variables and abdominal bleeding in a rat model of uncontrolled hemorrhage via liver injury. METHODS A total of 21 average weight 250 ± 30 g Wistar rats were used. A midline celiotomy was performed, and approximately 65% of the median and left lateral lobes were removed with sharp dissection. After creation of the liver injury, rats were randomized into 1 of 3 resuscitation groups, the control group, Lactated Ringers (LR) group, and terlipressin group, with 7 rats in each group. Blood samples were taken from rats for arterial blood gas analysis. At the end of the experiments, free intraperitoneal blood was collected on preweighed pieces of cotton, and the amount of free blood was determined by the difference in wet and dry weights. RESULTS In response to resuscitation, the terlipressin group demonstrated a significant elevation in mean arterial pressure (MAP). Blood loss was greater in the LR group compared with the control group (12.8 ± 1.9 mL vs 8.2 ± 0.7 mL, P < .05). At the end of the experiments, 5 rats in the control group, 5 in the LR group, and 2 in the terlipressin group died. The average survival rates were 28.6%, 28.6%, and 71.4%, respectively. CONCLUSIONS Compared with the control group, intravenous terlipressin bolus after liver injury contributed to an increase in MAP and survival rates without increasing abdominal bleeding.

Sedative-Hypnotic Medication Exposures and Poisonings in Izmir, Turkey*

The aim of this study was to analyse intoxications concerning sedative-hypnotic medication patients admitted to the Department of Emergency Medicine in Dokuz Eylul University Hospital (EMDEU) between 1993 and 2005. Demographics of the patients, characteristics of sedative-hypnotic exposures, performed treatment attempts and outcome of the poisoned patients were recorded on standard data forms that were later entered into a computerized database programme. Related to the sedative-hypnotic exposures, 686 poisoning cases were admitted to the EMDEU. Mean age was 10.8 +/- 6.5 years among the paediatric age group (<17 years old, 169, 24.6%) and 30.3 +/- 12.8 years among the adult group (>17 years old,509, 74.2%). The most common sedative-hypnotic agents were benzodiazepines (286, 35.8%), alprazolam accounted for41.6% of them (119). Most of the patients admitted to EMDEU were asymptomatic (61.7%). Observation alone was recommended in 53.9% of EMDEU cases. Although prescription of benzodiazepines is restricted, benzodiazepine was the most common cause of sedative-hypnotic medication exposures. As only a minority of patients (3%) had clinically serious signs and symptoms, most of the overdoses might be under toxic levels or the decontamination methods might be efficient. In this study, the clinical outcome of the patients is relatively better than previous results described in literature.

The comparison of the efficiency of traditional lectures to video-supported lectures within the training of the Emergency Medicine residents.

Objectives Recent developments in computer and video technology, multimedia resources enter quickest way possible into medical education and have started to gain popularity. The aim of this study is to evaluate the impact of video-supported lectures on leaning, with comparison to traditional lectures. Methods According to lecture techniques, two separate groups; one is the traditional lectures group (TLG) and the other is video-supported lectures group (VSLG), are formed. While the TLG is offered a traditional lecture the VSLG is offered a video-supported lecture with imbedded videos which are related to the topics in the traditional lecture. Both study groups take pretest and posttest with MCQs (multiple choice questions) and OSCEs (objective structured clinical examination). Results The study includes 30 volunteer residents in Dokuz Eylul University School of Medicine Department of Emergency Medicine. No difference is observed between TGL and VSLG in pretest and posttest scores (p = 0.949, p = 0.580). And additionally, comparing the scores of both groups, we cannot observe any difference between the pretest OSCE scores of each group (p = 0.300), however posttest OSCE scores shows a dramatic odd in-between (p = 0.010). When pretest MCQs and posttest MCQs mean scores are compared, both tests (TLG, VSLG) has not any significant difference (p=0.949, p = 0.580). Nevertheless, after comparing OSCEs pretest and posttest mean scores, we can see significant difference in mean scores of both (TLG, VSLG), (p = 0.011, p = 0.001). Conclusions Taken into consideration, the findings of this study shows possibility of improving educational techniques to acquire clinical skills by using local resources and low-cost technology.

A New Model in Reducing Emergency Department Crowding: The Electronic Blockage System

SUMMARY Objectives Emergency department (ED) crowding is a growing problem across the world. Hospitals need to identify the situation using emergency department crowding scoring systems and to produce appropriate solutions. Methods A new program (Electronic Blockage System, EBS) was written supplementary to the Hospital Information System. It was planned that the number of empty beds in the hospital should primarily be used for patients awaiting admission to a hospital bed at the ED. In the presence of patients awaiting admission at the ED, non-urgent admissions to other departments were blocked. ED overcrowded was measured in the period before initiation of EBS, the early post-EBS period and the late post-EBS period, of one-weeks duration each, using NEDOCS scoring. Results NEDOCS values were significantly lower in the early post-EBS period compared to the other periods (p≤0.0001). Although outpatient numbers applying to the ED and existing patient numbers at time of measurement remained unchanged in all three periods, the number of patients awaiting admission in the early post-EBS period was significantly lower than in the pre-EBS and late post-EBS periods (p=0.0001, p=0.001). Conclusions EBS is a form of triage system aimed at preventing crowding and ensuring the priority admission of emergency patients over that of polyclinic patients. In hospitals with an insufficient number of total beds it can be used to reduce ED crowding and accelerate admissions to hospital from the ED.

Acute Epiploic Appendicitis: A Diagnostic Dilemma

SUMMARY Primary epiploic appendicitis, also called appendicitis epiploica, is a rare condition characterized by inflammation of subserosal colonic adipose tissue. Patients with this condition usually present with complaints of sudden onset focal abdominal pain. No specific symptom or pathognomonic physical examination finding differentiates this condition from other acute abdominal pain etiologies. Patients are usually thought to have diverticulitis or appendicitis on initial evaluation. Use of contrast enhanced abdominal computed tomography on patients presenting with acute abdominal pain may reduce unnecessary surgery, hospitalization and health-associated costs by establishing a definite diagnosis, including rare causes of acute abdomen.

Comparison of near-infrared spectroscopy and head CT interpretations of the ED patients with minor head injury.

Abstract This study compares near-infrared spectroscopy device and brain computed tomography results in detection of intracranial hemorrhages of patients in an emergency department with minor head trauma and whose computed tomography scans were obtained. In our prospective and cross-sectional study, sociodemographic and clinical features, and brain computed tomography and near-infrared spectroscopy device data of patients diagnosed with minor head trauma were compared. Among 546 trauma patients diagnosed with minor head trauma, 151 of them met the criteria for inclusion in the study. When compared with brain computed tomography, near-infrared spectroscopy device data are 85.7% sensitive, are 66.6% specific, and have a negative predictive value of 98.9% and a positive predictive value of 11.1%. There was a statistically significant difference in rates of diagnosis of pathology between near-infrared spectroscopy device data and official radiologist decision of brain computed tomography results In our study, although we could not reach evidence showing that Infrascanner could be used as an alternative to cerebral computed tomography in intracranial hemorrhages, it is a valuable screening tool in some cases such as bedside monitoring, mass casualty events, remote areas, ambulance services, and others.