Search

The increasing number of patients admitted to emergency departments (EDs) and overcrowding of EDs lead to a global problem. Advanced nursing triage is an important solution in facilitating patient and time management, also increasing the efficiency of the ED. This study was conducted to predict the possible effects of applying advanced nursing triage modeling with predetermined protocols during the current nursing triage in the ED.This was a descriptive and cross-sectional study. An advanced "triage assessment protocol," which was developed previously, was hypothetically applied for 5 days by triage nurses in the adult ED of a university hospital. The hypothetical application was tested by triage nurses in all shifts. The nurses recorded the examination or treatment options which they thought to apply for the patient on the study form. The data recorded on the advanced triage evaluation protocol form by the triage nurses were compared with the patient outcomes and physician examination/treatment requests in the Hospital Information Management System by the researchers.In the study, it was determined that the rate of examination/treatment that could be requested according to the advanced nursing triage protocol was 46%. There were a good level of agreement on X-ray and a moderate level of agreement on urinary test and urinary beta- Human chorionic gonadotropin (hCG) test between physicians and triage nurses regarding examination/treatment requests. In addition, it was found that there was a 61.2% of agreement on decisions made for patients aged between 18 and 35. The rate of agreement between doctors and nurses regarding a gluco-stick request for patients admitted outside the prime time (92.2%) was found to be significantly higher (87.9%) than for patients admitted during prime time ("Advanced triage" practices recommended for busy EDs were tested "hypothetically" at the national level due to the lack of legal regulations and were found to be compatible with the actual results of physicians' practices at an acceptable level, especially for selected medical conditions. The method used in this study can be useful in planning the transition to "advanced triage" practices. These results can show the readiness of nurses for the transition to this practice.

The performance of the Quick Sequential Organ Failure Assessment (qSOFA) score needs to be explored further in the emergency triage room. This study aims to explore the performance of triage (tqSOFA) versus the dichotomized triage score (DTS) in patients admitted to the emergency room triage with fever.This research was designed as a prospective, observational study within a six-month period, including patients who presented to the emergency room triage with infrared fever ≥ 37.5 °C.771 patients were analyzed.The highest sensitivity for predicting overall hospitalization and intensive care admission was seen for DTS (95.4 %, 100 %; p lt; 0.0001, p lt; 0.0001, respectively) (AUC:0.697, 95 % CI 0.663 to 0.730; AUC:0.684, 95 % CI 0.650 to 0.717, respectively). The highest sensitivity for predicting 1st week and 1st month mortality was found for DTS (100 %, 96.3 %; p lt; 0.0001, p lt; 0.0001, respectively). However, the highest specificity for predicting 1st week and 1st month mortality was observed in tqSOFA (94.1 %, 95.16; p = 0.0845, p lt; 0.0001, respectively) (AUC:0.658, 95 % CI 0.623 to 0.691; AUC:0.698, 95 % CI 0.664 to 0.730, respectively).We found DTS to be as effective as tqSOFA and SIRS in determining all hospitalization times and mortality.

BACKGROUND: Venous oxygen saturation reflects venous oxygenation status and can be used to assess treatment and prognosis in critically ill patients. A novel method that can measure central venous oxygen saturation (ScvO2) non-invasively may be beneficial and has the potential to change the management routine of critically ill patients. OBJECTIVE: The study aims to evaluate the potential of sublingual venous oxygen saturation (SsvO2) to be used in the estimation of ScvO2. METHODS: We have developed two different approaches to calculate SsvO2. In the first one, near-infrared spectroscopy (NIRS) measurements were performed directly on the sublingual veins. In the second approach, NIRS spectra were acquired from the sublingual tissue apart from the sublingual veins, and arterial oxygen saturation was measured using a pulse oximeter on the fingertip. RESULTS: Twenty-six healthy subjects were included in the study. In the first and second approaches, average SsvO2 values were 75.0% ± 1.8 and 75.8% ± 2.1, respectively. The results of the two different approaches were close to each other and similar to ScvO2 of healthy persons (> 70%). CONCLUSION: Oxygen saturation of sublingual veins has the potential to be used in intensive care units, non-invasively and in real-time, to estimate ScvO2.

For identifying hemorrhagic shock in trauma patients, some objective data are needed. The use of base excess (BE) and lactate values have been originated. In this study, it was aimed to determine the usability of end tidal carbon dioxide (ETCO₂) in patients with multiple trauma for recognizing hemorrhagic shock.Patients who were admitted to the emergency department between June 2019 and February 2020 with highenergy multiple trauma were included in the study. ETCO₂ and BE values were measured. Correlation coefficients were calculated to determine correlations between ETCO₂ and BE levels.One hundred and twenty-two patients were included in the study. Eighty-nine (73%) were men and 33 (27%) were women, and the mean age of the study population was 38.70 ± 19.18. The mortality rate was 14.8% in the study population. The correlation between ETCO₂ and BE values was significant (r: 0.27) and in the same range in the Bland-Altmann analysis. ETCO₂ levels above 35 were specific for stage 1 hemorrhagic shock. ETCO2 levels below 30 were sensitive for stage 2 and 3 hemorrhagic shocks and when the levels were measured below 22 it was found specific for stage 4 shock. The specificity increased to 99% at levels below 18. The sensitivity for ETCO₂ values below 22 for predicting mortality was 33.33%, the specificity was 89.42%, the positive predictive value was 35.29% and the negative predictive value was 88.57%. The sensitivity for BE values below -10 for predicting mortality was 50%, the specificity was 93.27%, the positive predictive value was 56.25% and the negative predictive value was 91.51%.

Background/aim For identifying hemorrhagic shock in trauma patients, some objective data are needed. The use of base excess (BE) and lactate values have been originated. In this study, it was aimed to determine the usability of End Tidal Carbon Dioxide (ETCO2) in patients with multiple trauma for recognizing hemorrhagic shock. Materials and methods Patients who were admitted to the emergency department between June 2019 and February 2020 with high-energy multiple trauma were included in the study. ETCO? and BE values were measured. Correlation coefficients were calculated to determine correlations between ETCO2 and BE levels. Results 122 patients were included in the study. 89 (73%) were men and 33 (27%) were women, and the mean age of the study population was 38.70±19.18. The mortality rate was 14.8% in the study population. The correlation between ETCO2 and BE values was significant (r: 0,27) and in the same range in the Bland-Altmann analysis. ETCO2 levels above 35 was specific for stage 1 hemorrhagic shock. ETCO2 levels below 30 were sensitive for stage 2 and 3 hemorrhagic shock and when the levels were measured below 22 it was found specific for stage 4 shock. The specificity increased to 99% at the levels below 18. The sensitivity for ETCO? values below 22 for predicting mortality was 33.33%, the specificity was 89.42%, the positive predictive value was 35.29% and the negative predictive value was 88.57%. The sensitivity for BE values below -10 for predicting mortality was 50%, the specificity was 93.27%, the positive predictive value was 56.25% and the negative predictive value was 91.51%. Conclusion ETCO2 measurement can be a useful parameter as a non-invasive and simple technique in predicting and classifying hemorrhagic shock, which is the leading cause of mortality in trauma patients. Mortality rates increased when ETCO2 was measured below 22 and these patients are more likely to be in the critical hemorrhagic shock state.

Objective: Overcrowding is a challenge for emergency departments throughout the world. Triage systems categorize the patients based on medical emergencies in order to avoid the malpractices. The present study aimed to test the validity of an artificial intelligence tool, ‘Decision Trees’, in emergency medicine triage. Methods: This prospective, cross-sectional, clinical study was conducted in an emergency department of a tertiary care hospital. A total of 1999 patients over 18 years were included into the study. The triage stuff were trained before the study with the Australasian Triage Scale. Two independent observers rate the ultimate triage category of study patients. A new algorithym by ‘Decision Trees’ was constructed at the end of the study. Results: The mean age of the study patients were 41.1±17,2 and 49.1 % of them (n=981) were male. There were 867 patients (43.3%) with triage category of five and 14 (0.7%) patients with triage category one. The most common clinical descriptors of the patients were minimal pain with no high risk features 20.5% of them (n=409) and minor symptoms of low risk conditions 18.1% of them (n=362). There was an excellent consistency between two independent observers (kappa value: 0.997. The new algorithm by ‘Decision Trees’ rated wrong in only one patient. The accuracy rate was 99.9%. The consistency between ATS and ‘Decision Trees was excellent (kappa value: 0.999). There was average consistency between physicians and paramedics. (kappa value: 0.541).Conclusion: Decision trees as an artificial intelligence model should be used for producing practical triage algorithms as a decision support tool in emergency departments.

Background Assessment of nurse triage decision accuracy and triage times is currently carried out through paper-based methods. This quality improvement study aims to develop a method that can assess the accuracy and duration of nurse triage decisions based on a computerized system and to share an example of the application of this method. Methods This is a descriptive quality improvement study. The study was carried out in two stages between March and May 2019. The functionality of the developed method was examined using 3835 patients' triage data, which were obtained between June 1 and 14, 2019. Results With this study, the determination of the accuracy and duration of nurse triage decisions was accomplished with a computerized process based on real patient outputs, and the accuracy and duration of these decisions were continuously measured, monitored, and assessed, which is different from paper-based methods. The functionality of the method was evaluated with data from 3835 real patients. The triage decision accuracy rate was 64.4%, and the average duration of triage was 81.3s. Positive feedback on the method was received from all triage nurses. Conclusion The study result outputs can be integrated into quality processes and can be used internationally as performance assessment criteria and quality indicators for triage nursing.

Background Chronic obstructive pulmonary disease (COPD) is associated with high mortality and morbidity. Objective The aim of the present study was to determine the role of nitric oxide (NO) and other possible factors in predicting the revisit of patients with COPD exacerbation to the emergency department (ED). Methods This is a prospective cohort study on patients with exacerbated COPD in the ED setting. Bedside nasal NO values were measured with a hand-held analyzer device. Revisit to the ED has been defined as any unscheduled visit to an ED or to primary physician's office within 2 weeks of the initial ED visit for worsening COPD symptoms. A follow-up survey via telephone was conducted on all patients at the end of 2 weeks. Results The data from 64 patients who visited the ED once was compared to 28 revisits. Total of 92 patients were analyzed and variables were compared. The rate of revisits to the ED was 30%. Nasal NO measurement could not predict the revisits of patients with COPD exacerbation to the ED. The mean respiratory rate, exacerbations in previous year, home nebulizer therapy, prescribed antibiotic at discharge, home oxygen therapy, and abnormal chest x-ray studies were associated with increased rate of revisits to ED in univariate analysis. After multivariate analysis, only the mean respiratory rate at presentation and the prescribed antibiotic at discharge were significant determinants. Conclusions There was no statistically significant difference measured in NO level at presentation or before discharge between the groups. The mean respiratory rate at presentation and the prescribed antibiotic at discharge may predict the return of a COPD-exacerbated patient within 14 days to ED.

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 κ 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.

PubMed ID: 25957144, Objective Critically ill patients have high mortality and admission rates requiring early recognition and a rapid management. In the present study, we evaluated the prognostic parameters in these patients and the value of perfusion index measurement as a novel tool for accomplishing emergency department (ED) triage. Methods Seven hundred seventy patients admitted to the critical care area of the ED in a month composed the study population. Perfusion index and vital signs (blood pressure, pulse rate, body temperature, pulse oximeter, and respiration rate) of the study patients were recorded to the study form. The communication data, admitting time, comorbidities, capillary refilling time, and blood gas analysis findings if obtained were recorded. Outcome of patients at the end of the ED period such as discharge, admission to the hospital, and death were also recorded. Outcome of patients at 15th and 30th days was identified by telephone call follow-up or from hospital records. Results Two hundred seventy-eight patients (36.1%) were admitted to the hospital, 454 patients (59%) were discharged, 3 patients (0.4%) died in the ED, 25 patients (3.2%) were transferred to another hospital, and 10 patients (1.3%) refused treatment and left the ED. Sixty patients (7.8%), 39 (5.1%) of whom had died in 15 days' period, were dead at the end of 30-day follow-up period. Respiratory rate and pulse oximetry were significant parameters in hospital admission. Systolic blood pressure, diastolic blood pressure, pulse rate, respiratory rate, pulse oximetry, lactate levels in blood gas analysis, and ED length of stay were significant variables in 30-day mortality rate. Patients who were admitted to the hospital had higher rates of fever and diabetes. Patients who had died in the 30-day follow-up period had higher rates of diabetes and malignancy. In logistic regression analysis, the predictors of hospital admission were hypotension, fever, and pulse oximetry, whereas the predictors of 30-day mortality were systolic blood pressure, respiratory rate, pulse oximetry, and presence of malignancy. Conclusions Perfusion index as a novel triage instrument was found to be an insignificant tool in predicting hospital admission and mortality of critically ill patients in the ED. However, diabetes and malignancy were found to be independent factors in determining the prognosis of these patients in addition to vital signs and should be considered by ED physicians either in triage field or inside the ED. © 2015 Elsevier Inc., This study was supported by the Akdeniz University Research Foundation.

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.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.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 (p0.001). 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).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.

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.

Objectives The purpose of this study is to examine the relation between end-tidal carbon dioxide (ETco 2 ) measurement and bicarbonate (HCO 3 ) level reflecting the patient's metabolic status. Method This prospective cross-sectional study has been carried out during a 3-month period in a tertiary care university hospital's 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 ETco 2 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 ETco 2 and HCO 3 levels ( r = 0.506). The mean ETco 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 ETco 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 ETco 2 less than or equal to 25 was 2.7, and the (−) likelihood ratio for ETco 2 greater than or equal to 36 was 0.05. Conclusion ETco 2 values correlate moderately with HCO 3 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.

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.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.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.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.

OBJECTIVE The aim of this study was to determine the factors most affecting emergency physicians' decisions in the management of chest pain patients. METHODS This prospective randomized cross-sectional study was carried out between March 2004 and September 2004 in an urban university hospital emergency department. Residents collected data on patients' demographic features, chest pain characteristics, electrocardiography, cardiac enzymes and outcome of patients. RESULTS Five hundred and sixty-two patients were enrolled in the study; 389 (69.2%) patients were classified as having cardiac chest pain. Of the 389 patients suggested to have cardiac chest pain, 369 (94.4%) were classified as probable acute coronary syndrome; 286 (50.9%) patients were seen by cardiologists and 187 (33.3%) were admitted to the cardiology ward. The logistic regression analysis revealed that angina equivalents (P

Objective: The purpose of this study was to validate an algorithm recommended by current literature for the patients with acute flank pain and evaluate the validity of bedside ultrasonography (US) performed by emergency physicians (EP) as a part of this algorithm. Materials and methods: This prospective validation study was carried out over a 5 month period in a tertiary care hospital adult emergency department (ED) with annual attendance of 55 000. Adult patients presenting to the ED with unilateral acute flank pain during the study period were enrolled into the study consecutively. Oral consent was obtained after the protocol was briefly explained to the patient and before the administration of analgesia. A protocol form was recorded for each patient enrolled into the study, and patients were followed up under the guidance of a previously designated algorithm in the ED. Data were analysed with SPSS software. The χ2 test was used to compare the dichotomised data of patients, diagnosed with and without stones, and to select the significant parameters to be used in the logistic regression. Results: Of the 227 patients enrolled, 176 were proven to have urinary tract stones. There were 122 patients discharged from ED without further investigation except urinalysis and bedside US. Of these 122 directly discharged patients, 99 had a urinary stone, and the others did not have a life threatening disorder. Four of the 227 patients were admitted to the hospital. The remaining 51 patients did not have stones detected, and their pain subsided. Having a previous history of stones, radiation of pain to the groin, accompanying nausea, and detection of pelvicalyceal dilatation using bedside US performed by the EPs were found to be the most significant parameters in determining urinary stones in logistic regression analysis. Sensitivity and specificity of these parameters were: previous history of stones 59% and 66%, radiating pain to the groin 68% and 49%, nausea 71% and 51%, and detection of pelvicalyceal dilatation by bedside US 81% and 37%. Conclusion: Bedside US performed by EPs could be used safely in the evaluation of patients with acute flank pain as a part of a clinical algorithm. Previous history of urinary stones, radiation of pain to the groin, accompanying nausea. and detection of pelvicalyceal dilatation are major parameters and symptoms of urinary stone disease, and could be used in the algorithms.

Patients presenting to the emergency department with chest pain are evaluated by emergency physicians in hospitals without cardiology cover 24 h a day. The purpose of this study is to determine the consistency of electrocardiography (ECG) interpretation and chest pain likelihood classification between emergency physicians and cardiologists. This randomised prospective cross-sectional study was performed in a tertiary care university hospital emergency department. The study form included ECG interpretation and chest pain likelihood classification according to American College of Cardiology (ACC)/American Heart Association (AHA) guideline which were recorded by emergency physicians and cardiologists separately in a blinded fashion. All chest pain patients who consulted with a cardiologist were enrolled into the study during the study period. The consistency between the two groups and the kappa value were calculated. Recorded study forms of 133 patients with cardiology consultations were evaluated. The consistency in the interpretation of ECG between the emergency physicians and cardiologists was found to be 94.6% (kappa = 0.85) for ST segment elevation, 78.6% (kappa = 0.57) for ischaemic ECG findings and 79.3% (kappa = 0.36) for dynamic ECG changes. The consistency for the likelihood classification between two groups for predicting the pain as angina or non-cardiac was 90.8% (kappa = 0.30), for classifying as acute coronary syndrome or stable angina pectoris (SAP) was 95.6% (kappa = 0.26) and for classifying patients as low likelihood or intermediate-high likelihood was 86.3% (kappa = 0.61). A strong consistency was shown between the emergency physicians' and cardiologists' ECG interpretation especially in determining the ST segment elevation. And also, there is a strong concordance in the likelihood classification of chest pain patients.

Aim. Although the safety of ketamine for pediatric procedural sedation and analgesia is well established, use of concurrent benzodiazepines and atropine to diminish the adverse events is still controversial. We wanted to determine whether the adjunctive midazolam reduces the recovery agitation and to compare the incidence of adverse events with those reported in the literature. In particular, we wanted to assess whether adjunctive atropine can diminish salivation in order not to cause compromise of the airways. Methods. This prospective study was conducted in the Emergency Department of Akdeniz University Hospital. A detailed conscious sedation protocol was developed, and emergency physicians and nurses were educated regarding its contents. All patients who underwent procedural sedation and analgesia were evaluated by using a standardized conscious sedation form. Patients presenting with any trauma who were aged 15 or younger and requiring sedation and analgesia were evaluated. Results. During a ...

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 (> or =200 mg/dL) were eligible for inclusion. Capillary blood beta-hydroxybutyrate (beta-HBA), venous blood beta-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 (> or =200 mg/dL) and a positive capillary blood beta-HBA (> or =0.1 mmol/L) were included in the study. Hyperketonemia (> or =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 beta-hydroxybutyrate levels were not statistically different from each other (P = 0.824). There was a positive correlation between capillary and venous blood beta-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 beta-HBA can accurately measure blood concentrations of beta-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.

The purpose of this study is to examine the relation between end-tidal carbon dioxide (ETCO₂) measurement and bicarbonate (HCO₃) level reflecting the patient's metabolic status.This prospective cross-sectional study has been carried out during a 3-month period in a tertiary care university hospital's 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.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.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.

Tourists are exposed to traditional health problems of the host country, such as trauma and the exacerbation of previously existing illnesses during their travels.The purpose of this study is to determine the clinical characteristics of tourist patients and any predictors of hospital admission.This retrospective observational study was carried out in the tertiary care hospital emergency department (ED) of a Mediterranean destination city, Antalya, Turkey. Hospital data from all tourist patients presenting or transferred to the ED between August 2003 and September 2004 were evaluated. Tourist patients were defined as all non-Turkish citizens.A total of 961 tourist patients was studied, of whom 295 (31%) were admitted and 666 (69%) were discharged. Fifteen patients died in the hospital, 49 critically ill patients were transferred back to their home country, and 153 patients underwent a surgical intervention. The most common discharge diagnoses were trauma (405, 42%), nonspecific symptoms (106, 11%), and circulatory disorders (108, 11%). Admitted tourist patients were significantly older than those discharged; however, there were no differences in sex among the groups. Applying a logistic regression model, age, tachycardia, mode of arrival, and triage category were all found to be significant predictors of admission, but only the initial Glasgow Coma Scale was found to be a significant predictor of mortality. In total, 347 patients were from European Union (EU) countries, and 614 were from non-EU countries. A significant difference was found between the EU and non-EU patient groups according to age, mortality, admission rate, exposure to trauma, ED length of stay, hospital length of stay. Tourist patients from EU countries were older, had higher mortality, lesser trauma exposure, longer ED, and hospital length of stay.EDs can be expected to manage tourist patients presenting for traumatic injuries and circulatory disorders. Clinical differences relating to patients' nationality might help in the development of targeted patient education and injury-prevention programs. Emergency physicians and the tourism industry should recognize the challenges of caring for this growing and aged patient population.

The aim of this study was to reveal the effects of anxiety and depression on pain perception in the emergency setting. This randomized prospective study was performed in an urban tertiary care hospital emergency department (ED). Consecutive patients presenting to the ED with pain who had an intramuscular injection of diclofenac sodium were enrolled in the study. The prevalence of anxiety and depressive disorders in study subjects was determined by using the Hospital Anxiety and Depression Scale. A total of 302 patients were included. Study subjects had a mean age of 41.3 +/- 13.7 years and 35.4% (n = 107) were male. Pain perception in women was significantly higher than in men (median 8.5 vs. 5, respectively; p = .033). Pain perception in elderly patients, >/=65 years old, was found to be lower than in patients

We aimed to determine the local and systemic effects of widely available household cleaners, namely 45% nitric acid (NHO(3)), and 18% hydrochloric acid (HCl), in a rat model.This prospective, experimental, placebo-controlled trial was carried out in the Animal Research Laboratory of Akdeniz University hospital. Commonly available solution of 45% NHO(3) and 18% HCl were tested against normal saline. Each solution was administrated orally to groups consisting of ten rats. The metabolic changes were determined by measuring the pH and calcium (Ca) levels before and after the administration of solutions. In addition, the pathological changes and mortality rates were determined for each group.There was a statistically significant increase in the post-ingestion (30 minutes later) Ca levels and a decrease in the post-ingestion pH levels after the administration of test solution in the NHO(3) (p=0.006 for Ca increase, p=0.001 for pH decrease) and HCl (p=0.007 for Ca increase, p=0.023 for pH decrease) groups. There was also a statistically significant difference between groups for Ca increase (p=0.000) and pH decrease (p=0.006). In post hoc analysis, the difference between the groups was found to be originated from the placebo group. In the pathological evaluation of esophagus and stomach, there was a statistically significant difference between groups (p=0.009 (E) and p=0.016 (S)) and the difference was found to be originated from the control group (p=0.543 (E), p=0.244 (S) for NHO(3) and HCl). The 30-minute mortality rates were 0,2 in the NHO(3) group, 0,6 in the HCl group and 0 in the control group.Serious metabolic and mild local pathological changes can occur after the ingestion of household NHO3 and HCl solutions. Further studies should be performed to elucidate the causes of death following oral ingestion of these compounds and appropriate public health warnings should be taken.

To determine the patterns and appropriateness of patients' use of a university hospital emergency department.During a 14-day period in November 1998, we collected demographic and socio-economic data, reasons for preferring emergency department care, and patient visit data from consecutive patients visiting our tertiary-care university hospital emergency department. The principle investigator reviewed the study information forms and classified visits according to the classification of Afilalo into three categories: category I--emergent emergency department visits; category II--needing evaluation within 6 hours, either in emergency department or elsewhere; or category III--needing evaluation after more than 6 hours. Three emergency medicine residency-trained physicians determined the appropriateness of emergency department evaluation. Patients in the categories II and III were retrospectively reclassified as appropriate or inappropriate, according to availability of care at the outpatient facility at the hour of initial emergency department presentation.Complete data were collected from 1,155 (96.2%) of 1,201 patients visiting our emergency department during the study period. There were 69% (n=795) appropriate of visits. The mean stay at emergency department of inappropriate users lasted 66 min. The main reasons of inappropriate users to prefer emergency department care were its proximity, satisfaction with care, worsening symptoms, and unavailability of care in a regular clinic.Although inappropriate emergency department usage was high, these patients had relatively short emergency department stays. The impact on emergency department resource utilization and "over-crowding" by these patients may not be as great as commonly perceived.

We determined the diagnostic value of urinalysis and plain films in patients with suspected renal colic presenting to an emergency department (ED). Over a 1-year period, 138 patients presented to the ED during the daytime with suspected renal colic, but for technical reasons the diagnostic modalities used in the study could be completed for only 99 patients, and 34 patients were lost to follow-up. A urinalysis; kidney, ureter, and bladder film; and spiral computed tomography (CT) were performed on each patient. The presence of urinary tract stones was determined by their definite presence on helical CT and/or passage of a stone on clinical follow-up (average follow-up = 3 months). A urinary stone was visualized on spiral CT or passed in the urine in 54 of the patients. Using helical CT findings or passage of a stone as the gold standard, plain radiography had a sensitivity of 69% and specificity of 82%. Urinalysis had a sensitivity of 69% and specificity of 27%. The sensitivity increased to 89% if either test was positive, but the specificity remained low at 27%. The sensitivity and specificity of CT in the diagnosis of urinary stones was 91%. Urinalysis and plain films are much less accurate than helical CT for confirming the diagnosis of acute urolithiasis. Further evaluation of the clinical and cost-effectiveness of helical CT should be done to determine its role in the work-up of these patients.

Background and objective: Comparison of the effectiveness of tramadol with meperidine given intravenously to emergency patients with suspected renal colic. Methods: A double-blind, randomized clinical trial was performed in the Emergency Department of a tertiary-care university hospital. Consecutive patients with suspected renal colic (n = 47) were randomized to receive intravenously an initial dose of tramadol 50 mg (n = 23) or meperidine 50 mg (n = 24). After 30 min, additional doses of meperidine 50 mg were given intravenously as a rescue medication in an open fashion. Pain relief was assessed using a 10 cm visual analogue scale, the primary outcomes being pain relief at 15 and 30 min after the analgesics. Secondary outcomes were the frequency of rescue meperidine use and the development of side-effects. Results: Visual analogue scale pain scores after 15 and 30 min decreased in both tramadol and meperidine groups (P < 0.05). However, pain relief was better in the meperidine group at the 15 and 30 min evaluations (P < 0.05). Only 11 patients (48%), initially receiving meperidine, needed more meperidine compared with 16 patients (67%) initially receiving tramadol. Both drugs were well tolerated with no adverse effects occurring in either group. Conclusions: Meperidine 50 mg was superior to tramadol 50 mg for acute pain relief in patients with suspected renal colic when given intravenously. Because many patients in both groups received supplemental meperidine and the response to tramadol alone cannot be predicted, clinicians may want to choose higher doses of meperidine alone or other alternative combinations.

Ecbalium elaterium or squirting cucumber is a plant growing in the Mediterranean region, belong to Cucurbitaceae family. Its juice has been used as an herbal medicine since ancient times because of its cathartic and anti-inflammatory effects. It has been reported to cause upper airway edema, especially after the administration of its undiluted form. It has generally been attributed to allergic reaction. In this case report we aimed to interrogate this anticipation by presenting a case of severe uvular edema and nasal mucosal necrosis after dripping undiluted Ecbalium elaterium juice that did not improved by anti-allergic therapies.

Objective: The purpose of this study was to validate an algorithm recommended by current literature for the patients with acute flank pain and evaluate the validity of bedside ultrasonography (US) performed by emergency physicians (EP) as a part of this algorithm. Materials and methods: This prospective validation study was carried out over a 5 month period in a tertiary care hospital adult emergency department (ED) with annual attendance of 55 000. Adult patients presenting to the ED with unilateral acute flank pain during the study period were enrolled into the study consecutively. Oral consent was obtained after the protocol was briefly explained to the patient and before the administration of analgesia. A protocol form was recorded for each patient enrolled into the study, and patients were followed up under the guidance of a previously designated algorithm in the ED. Data were analysed with SPSS software. The x test was used to compare the dichotomised data of patients, diagnosed with and without stones, and to select the significant parameters to be used in the logistic regression. Results: Of the 227 patients enrolled, 176 were proven to have urinary tract stones. There were 122 patients discharged from ED without further investigation except urinalysis and bedside US. Of these 122 directly discharged patients, 99 had a urinary stone, and the others did not have a life threatening disorder. Four of the 227 patients were admitted to the hospital. The remaining 51 patients did not have stones detected, and their pain subsided. Having a previous history of stones, radiation of pain to the groin, accompanying nausea, and detection of pelvicalyceal dilatation using bedside US performed by the EPs were found to be the most significant parameters in determining urinary stones in logistic regression analysis. Sensitivity and specificity of these parameters were: previous history of stones 59% and 66%, radiating pain to the groin 68% and 49%, nausea 71% and 51%, and detection of pelvicalyceal dilatation by bedside US 81% and 37%. Conclusion: Bedside US performed by EPs could be used safely in the evaluation of patients with acute flank pain as a part of a clinical algorithm. Previous history of urinary stones, radiation of pain to the groin, accompanying nausea. and detection of pelvicalyceal dilatation are major parameters and symptoms of urinary stone disease, and could be used in the algorithms.

Background Logistic 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. Aims The purpose of this study was to perform artificial intelligence models on a medical data sheet and compare to logistic regression. Methods ANN, 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. Results The 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. Conclusion Data 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. © 2009 Springer-Verlag London Ltd., Acknowledgement This study was supported by Akdeniz University Investigation Foundation. We are also grateful to the residents and physicians in the emergency department.

We assessed the effect of magnesium sulphate (MgSO4) on lowering the rate in ventricular atrial fibrillation (AF), and evaluated the effect of this therapy in magnesium (Mg) deficient and nondeficient patients. This experimental clinical study was performed on 34 patients with rapid AF (ventricular rate [VR]120/minute) presenting to the emergency department of a tertiary care university hospital. Patients with systolic blood pressureor = 100 mmHg, Hb levelor = 11.8, saO2 ofor = 96%, BUNor = 40 or creatineor = 1.8 were excluded (n = 15). Nineteen patients were given an initial 2 g MgSO4 bolus i.v. and a 1 g/hour continuous infusion over 6 hours. To evaluate the presence of Mg deficiency, urine was collected from the onset of treatment and continued for the next 24 hours, and the excretion rate of administered Mg was calculated. Ventricular rates were obtained at baseline, after MgSO4 bolus, and every 15 minutes for the first hour. The decrease in the VR was statistically significant at 15, 30 and 60 minutes after Mg therapy (p = 0.0025, p0.001, p0.001). There was no difference in the response to Mg therapy between Mg deficient and nondeficient patients at 15, 30 or 60 minutes after therapy (p = 0.41, p = 0.28, p = 0.08). It is concluded that i.v. MgSO4 has a statistically significant but clinically limited effect on VR and this effect did not differ between patients with and without Mg deficiency.