Turkish Journal of Emergency Medicine最新文献

Objectives: The National Institutes of Health Stroke Scale (NIHSS) is used to determine the severity of the disease and to make treatment decisions in ischemic stroke patients. However, the need for a neurologist to assess NIHSS before thrombolytic therapy may prolong the treatment process.

Methods: This prospective, single-center, observational, planned study included patients who presented to the emergency department in the first 24 h after the onset of symptoms and were diagnosed with ischemic stroke between September 2022 and June 2023. The NIHSS was evaluated by the emergency medicine physicians and neurologists who evaluated the patients in the emergency department, and the decisions on whether to administer thrombolytics and the time taken for this decision were recorded and compared.

Results: A very high agreement was found when the total NIHSS scores of emergency medicine physicians and neurologists were compared (intraclass correlation coefficient = 0.947 [95% confidence interval 0.92-0.96]). Emergency medicine physicians and neurologists showed high agreement with thrombolytic therapy decisions. In patients given thrombolytic therapy, emergency medicine physicians made the decision earlier than neurologists, and there was a significant difference of 14 ± 12 min between the decisions of emergency physicians and those of neurologists.

Conclusions: There is high agreement between emergency medicine physicians and neurologists in the NIHSS evaluation and thrombolytic decisions for patients with acute ischemic stroke. According to our results, emergency medicine physicians can provide thrombolytic treatment in accordance with neurologists, thus shortening the time for thrombolytic treatment.

Pain is a leading cause of emergency department (ED) visits globally, yet certain patient populations experience persistent disparities in their pain management due to physiological complexities, comorbidities, and gaps in evidence-based guidelines. This clinical review focuses on individualized, evidence-based approaches to ED pain management in four vulnerable groups: pregnant and breastfeeding patients, patients with sickle cell disease, geriatric populations, and patients with cancer pain and requiring palliative care. The practical recommendations presented in this review for optimal ED pain management in these special populations call for timely, effective, and multimodal analgesia; prioritization of nonpharmacologic and pain syndrome-targeted techniques; awareness of drug-disease and drug-drug interactions; interdisciplinary coordination; and education to mitigate ED clinicians' biases. This review emphasizes the importance of tailoring pain strategies to population-specific needs to improve outcomes, reduce harm, and advance equity in emergency care delivery.

Objectives: Emergency physicians may experience intense fatigue and burnout due to factors related to occupational conditions. The group experiencing burnout most frequently among physicians is emergency medicine (EM) physicians, with 63%. They also endure high levels of fatigue. This study evaluated the fatigue levels and factors of fatigue in EM residents nationwide. It aimed to determine the factors affecting fatigue.

Methods: The study includes EM residents working across the country between January 2024 and April 2024. It was conducted using a survey. The survey included the Maslach Burnout Inventory (MBI), the Chalder Fatigue Scale, and questions about demographic characteristics. Multivariate logistic regression analysis was used to analyze the data.

Results: The median age of participants was 28 years (interquartile range = 3), and 203 (56.4%) were male. Factors affecting the level of fatigue were analyzed by multivariate logistic regression analysis. The gender (male) (odds ratio [OR] =0.322, 95% confidence interval [CI] =0.128-0.812) and the daily sleep duration (OR = 0.589, 95% CI = 0.423-0.822) variables had a negative effect on fatigue. Depression in medical history increased the likelihood of fatigue (OR = 3.515, 95% CI = 0.930-13.287). Emotional exhaustion (EE) (OR = 1.082, 95% CI = 1.037-1.130) and depersonalization (OR = 1.097, 95% CI = 1.015-1.186) increased the fatigue level. However, personal accomplishment had no significant effect on fatigue (OR = 1.019, 95% CI = 0.966-1.075).

Conclusions: Being female gender, having shorter daily sleep duration, having a diagnosis of depression in medical history, and having higher levels of depersonalization and EE from MBI subdimensions increase the level of fatigue. Optimizing the sleep duration of EM residents and supporting their psychological health will prevent fatigue and fatigue-related problems.

Extracorporeal cardiopulmonary resuscitation is being increasingly used to treat refractory in-hospital cardiac arrest (IHCA). Etiologies of IHCA may differ from etiologies of out-of-hospital cardiac arrest. We report a case of a 50-year-old man who was admitted to a local hospital, presenting with drowsiness, hypotension, and severe metabolic acidosis. After being transferred to our tertiary center, he quickly progressed to cardiac arrest and required extracorporeal cardiopulmonary resuscitation (eCPR) with veno-arterial extracorporeal membrane oxygenation (VA ECMO). Initially, due to high levels of inflammatory markers, sepsis became the most probable diagnosis. The patient responded well to antibiotics and supplemental corticosteroid therapy. Subsequent investigation revealed sepsis-induced absence of cortisol based on previously unknown hypopituitarism. Following corticoid administration, rapid myocardial recovery occurred with successful ECMO weaning. The patient was discharged from the ICU after 13 days with a favorable neurological outcome. Therefore, VA ECMO seems to be a feasible method to provide a bridge to recovery in patients with sudden hemodynamic collapse due to an adrenal crisis.

Artificial intelligence (AI) is increasingly improving the processes such as emergency patient care and emergency medicine education. This scoping review aims to map the use and performance of AI models in emergency medicine regarding AI concepts. The findings show that AI-based medical imaging systems provide disease detection with 85%-90% accuracy in imaging techniques such as X-ray and computed tomography scans. In addition, AI-supported triage systems were found to be successful in correctly classifying low- and high-urgency patients. In education, large language models have provided high accuracy rates in evaluating emergency medicine exams. However, there are still challenges in the integration of AI into clinical workflows and model generalization capacity. These findings demonstrate the potential of updated AI models, but larger-scale studies are still needed.

Lumbar paraspinal compartment syndrome is a rare pathology, with only 40 reported cases resulting from an increase in pressure within the muscle compartment. Symptoms typically involve pain and sometimes muscular deficits. The typical patient is a man who has undergone strenuous exercise, with few cases linked to the use of recreational drugs, such as cocaine or ketamine. We report the case of a 25-year-old man presenting to the emergency room with severe diffuse back pain who had recently consumed large amounts of cocaine, ketamine, and alcohol. The patient had diffuse muscular pain, increased serum creatine kinase (CK) levels, and a negative noncontrast abdominal computed tomography (CT), leading to the suspicion of crush syndrome. Over the following days, the patient's pain became more localized to the right paraspinal region, prompting a contrast-enhanced CT. This revealed signs of muscle swelling and edema of the paraspinal muscle, leading to a suspicion of compartment syndrome, which was confirmed by an intramuscular pressure measurement. The patient underwent a surgical fasciotomy. The patient went on to have an unremarkable recovery. Lumbar paraspinal compartment syndrome is exceedingly rare. Cocaine is known to cause rhabdomyolysis both indirectly, due to behavioral disturbances, and directly due to muscle toxicity. Similarly, ketamine use has also been associated with rhabdomyolysis. The rhabdomyolysis results in greatly increased CK levels, sometimes rising up to 100 00 U/L, which should normalize over the following days. A few cases of compartment syndrome, often localized in extremities, have been reported in patients presenting cocaine or ketamine-induced rhabdomyolysis. In this patient, the muscle swelling of the paraspinal muscle resulted in compartment syndrome. Patients who experience cocaine-related rhabdomyolysis have a tendency for nonspecific symptoms, which would match our patient's initial presentation. Although radiology's contribution to the diagnosis is limited, patients suffering from back pain or nonresolving rhabdomyolysis should be submitted to imaging, which may show signs of muscle swelling and edema on CT and magnetic resonance imaging. Diagnosis of compartment syndrome should be confirmed by measurement of muscle pressure, and if elevated, the patient should be proposed for fasciotomy.

Objective: The management of traumatic brain injury in elderly patients remains a topic of conflicting evidence in the literature. While some studies suggest that surgical intervention is beneficial, others indicate increased mortality and morbidity. Therefore, we conducted this retrospective matched cohort study to further investigate the role of surgical and conservative management for traumatic brain injury in elderly individuals.

Methods: The authors conducted a retrospective review comparing patients with traumatic brain injury who underwent nonoperative management (NOM) versus those who underwent operative management (OM). Case matching was employed to create an artificial control group matched for age, sex, noncontrast computed tomography (NCCT) findings, and symptoms at a 1:1 ratio of treatment to control. The inclusion criteria included patients aged 60 years and above who presented to the emergency medicine department with head injuries resulting from various causes, such as road traffic accidents, falls, or assault, whereas the exclusion criteria included polytrauma, severe hypovolemic shock, and referrals to other institutions. The outcomes of interest included all-cause mortality and Glasgow Outcome Scale (GOS) scores, with statistical significance set at P < 0.05.

Results: Optimal case matching was achieved for 52 out of 96 patients who underwent surgical management. There was no statistically significant difference in all-cause mortality between patients who underwent surgical management (32.69%) and those who did not (28.82%). Similarly, there was no statistically significant difference in the GOS score at 1 month between the two groups. A subgroup analysis based on the severity of traumatic brain injury and radiological diagnosis of intracranial injury revealed no difference between the OM and NOM groups, except for patients who underwent midline shift surgery.

Conclusion: There was no difference in all-cause mortality among elderly patients with traumatic brain injury regardless of whether they received conservative or surgical management, except for patients who underwent midline shift surgery.

Objectives: Various studies have delved into its incidence and risk factors, but a comprehensive meta-analysis exploring this life-threatening complication during emergent endotracheal intubation has been lacking. This study quantitatively assesses the global incidence and associated risk factors of peri-intubation cardiac arrest (PICA).

Methods: We conducted a systematic literature search on PubMed, Embase, Web of Science, and Cochrane Library from inception to October 28, 2024. Two independent authors searched, reviewed, and evaluated selected studies. Any peer-reviewed published studies reporting the incidence of PICA among adults (≥18 years) outside of the operating theater were included. Studies reporting incidence within heterogeneous populations or from overlapping groups were excluded. The primary outcome focused on determining the global incidence of PICA, while the secondary outcome addressed associated risk factors. A random-effects model was used to aggregate overall incidence rates. Subgroup analysis and meta-regression were conducted to examine PICA incidence in different locations and with the study's sample size. The publication bias was assessed via Egger's test and visualization of the funnel plot. The risk of bias was evaluated using the Joanna Briggs Institute Critical Appraisal Checklist.

Results: Fifteen articles met the inclusion criteria for the meta-analysis. PICA incidence varied from 0.5% to 23.3%. The estimated pooled incidence was 2.7% (95% confidence interval [CI]: 1.9-3.6) across PICA in the emergency department (ED) (2.5%, 95% CI: 1.4-3.7) and outside of the ED (2.9%, 95% CI: 2.2-3.6). Egger's test yielded P = 0.009, indicating potential publication bias due to small-study effects, as suggested by the funnel plot. Meta-regression analysis revealed higher incidence in studies with smaller populations. Notably, preintubation hypotension, hypoxemia, and body mass index were found to be the most associated risk factors for PICA. Additionally, there was significant variability in PICA definitions, ranging from immediate to occurrences within 60 min after intubation.

Conclusion: PICA occurrences during emergent endotracheal intubation reached up to 3%, showing a similar rate both within and outside the ED. While limitations such as heterogeneity and potential bias exist, these findings underscore the imperative for prospective research. Prospective studies are warranted to further delineate this critical aspect of emergent intubation.

Objectives: Effective sedation and analgesia during procedures not only provide relief of suffering but also frequently facilitate the successful and timely completion of the procedure. The aim of the study was to evaluate the efficacy of fentanyl and dexmedetomidine compared to fentanyl and midazolam in procedural sedation for tube thoracostomy in the emergency department (ED) in terms of analgesia and patient satisfaction with sedation during the procedure using Pain Numerical Rating Scale and a 7-point Likert-like verbal rating scale for comfort rating of sedation.

Methods: A randomized control study was conducted in 64 subjects admitted to the ED. Tube thoracostomy was performed in patients after the decision for Intercostal drain (ICD) placement taken on radiographic and clinical assessment depending on their condition warranting it and after optimally stabilizing the patient in the ED. Of the total study participants that met the inclusion criteria, 32 participants randomly received dexmedetomidine and the other 32 received midazolam.

Results: Pain rating scale means were 2.3 ± 1.12 and 4.4 ± 1.72, respectively (P < 0.001), in dexmedetomidine and midazolam groups. With regard to adverse effects, a statistically significant difference was seen with dexmedetomidine causing hypotension (P = 0.04) and midazolam causing desaturation (P = 0.008). The results also suggested that midazolam achieved sedation levels quicker than dexmedetomidine and this finding was statistically significant (P < 0.001). A statistically significant difference was observed (P < 0.001) with regard to mean patient verbal ratings at recovery of sedation satisfaction between the two groups, 6 ± 0.77 (dexmedetomidine group) versus 4.7 ± 0.8 (midazolam group).

Conclusions: When observed in terms of analgesia, anxiolysis, and better sedation, dexmedetomidine proved to be superior. Our study shows that this drug could be a better alternative to traditional benzodiazepines for procedural sedation in ED.