Point-of-Care Emergency Ultrasonography in Non-Traumatic Cardiac Arrest and Near-Arrest Emergency Patients; A Pilot Trial

Background: In this study, we evaluated the applicability and interpretation of point-of-care emergency ultrasound (POCEUS) performed by an emergency physician (EP) in non-traumatic adult cardiac arrest and near-arrest patients at presentation to the Emergency Department (ED).   Methods: POCEUS was performed in 5 steps on 73 adults to assess; 1. Qualitative global cardiac function, cardiac chambers and presence of pericardial effusion; 2. Presence of pleural sliding, B-lines, A-lines or consolidation on anterior-superior; 3. Presence of an abdominal aorta aneurysm and pelvic free fluid; 4. Presence of pleural effusion, consolidation, free fluid on lateral-inferior; 5. Qualitative width and collapsibility of the inferior vena cava. A fulfilled checklist and real-time images of ultrasonography were sent by WhatsApp to the head of the study to generate the evidence and collect the data. The process of patient care, in-hospital diagnosis and survival were retrieved from digital hospital records. This prospective multicenter sample study was conducted from November 16, 2015, to January 5, 2016.   Results: The most common findings of POCEUS were performed and interpreted to have a first prediction of patients’ acute clinic problem by EPs were compatible with global systolic dysfunction (n = 16, 22.9%), pulmonary edema (n = 17, 23.3%), pulmonary embolus (n = 6, 8.2%), distributive/hypovolemic shock (n = 12, 16.4%), cardiac tamponade or pericardial effusion (n = 5, 6.8%), and pneumonia (n = 31, 42.5%) at presentation. The kappa correlation coefficient value of the POCEUS at presentation versus the final, traditional clinical diagnosis of the admitted ward, was 0.773 (95% CI, 0.747–0.892; p = 0.064, McNemar).   Conclusions: POCEUS performed by an EP at presentation had a good agreement between in qualitative prediction of the first differential diagnosis in life-threatened patients and the last diagnosis obtained during hospitalization. Furthermore, this study showed the requirement of evidence in comparison of measurements to the qualitative manner and new descriptive processes in POCEUS for unexplained situations and questions

Acil servise pnömoni şüphesi ile başvuran hastalarda akciğer ultrasonunun tanısal ve prognostik etkinliğinin değerlendirilmesi

Amaç Acil servise başvuran ve pnömoni şüpheli bulguları olan hastalarda, akciğer ultrasonografisinin tanısal ve prognostik değerliliğinin araştırılması amaçlandı. Materyal ve Metod Prospektif ve metodolojik nitelikte dizayn edilen çalışmada, Ege Üniversitesi Tıp Fakültesi Acil Servisi’ne 20 Şubat-20 Mayıs 2020 tarihleri arasında pnömoni şüphesi ile başvuran 18 yaş üstü 330 hasta akciğer ultrasonu ile değerlendirilmiştir. Ultrason ile elde edilen bulgular toplanmış ve veriler çalışma formu aracılığıyla kaydedilmiştir. Bulgular Çalışmaya dahil edilen hastaların tamamına akciğer ultrasonu yapılmış ve tamamına akciğer grafisi çekilmiştir. Hastaların %63,6’sına klinik izlemi sırasında toraks bilgisayarlı tomografisi çekilmiştir. Hastaların %68,2’sinde ultrasonografik olarak pnömoni saptanmıştır. Hastaların %70’inin klinik son tanısının pnömoni olduğu saptanmıştır. Hastaların %32,7’si acil servisten taburcu olurken, %37,0’sine servis yatışı, %29,1’ine ise yoğun bakım yatışı gerçekleştirilmiştir. Hastaların hastaneye başvuruyu takip eden bir ay içerisinde mortalite oranı ise %25,5’dir. Pnömoni son tanılı hastalarda ultrason bulguları incelendiğinde ise en yaygın bulguların sırası ile konsolidasyon (%93,1), B çizgilerinin varlığı (%68,4), shred bulgusu (%64,9) ve plevral düzensizlik (%59,7) olduğu saptanmıştır. Sırasıyla diğer bulgular vaskülaritede artış (%48,1), hava ve sıvı bronkogramları (%46,3), dinamik hava bronkogramları (%37,7), plevral efüzyon (%19,9), vertebra bulgusu (%14,3), jellyfish bulgusu (%8,2), plankton bulgusu (%3,9) olarak saptanmıştır. Yaş gruplarına göre ultrason bulgularının dağılımı incelendiğinde yalnızca plevral düzensizlik (p=0.002) bulgusunda istatistiksel açıdan anlamlı fark saptanmıştır. Ultrasonografinin pnömoni tanısı için duyarlılığı %96,5 özgüllüğü ise %98,0 olarak saptanmıştır. Akciğer grafisinin pnömoni tanısı için duyarlılığı %82,7 ve özgüllüğü %92,9 olarak saptanmıştır. Bilgisayarlı tomografi çekilen 210 hastada ultrasonografinin pnömoni tanısı için duyarlılığı %96,9 özgüllüğü ise %95,8 olarak, akciğer grafisinin duyarlılığı %77,2 ve özgüllüğü %85,4 olarak saptanmıştır. Ultrason bulgularının pnömoni tanısında duyarlılık ve özgüllükleri sırasıyla bakıldığında shred bulgusu için %64,9 - %99,0, hava ve sıvı bronkogramı için %46,3 - %100, dinamik hava bronkogramı için %37,7 - %100, konsolidasyon için %93,1 - %94,9, vaskülarite artışı için %48,1 - %98,0, B çizgileri için %68,4 - %53,5, plevral efüzyon için %19,9 - %85,9, plevral düzensizlik için %59,7 - %75,8, vertebra bulgusu için %14,3 - %98,0, jellyfish bulgusu için %8,2 - %99,0, plankton bulgusu için %3,9 - %100 olarak izlenmiştir. Son tanısı pnömoni olan hastalarda ultrason bulgularıyla bir aylık mortalite arasındaki ilişki değerlendirildiğinde hava sıvı bronkogramları (p=0.042) ve plevral düzensizlik (p0.001) ile bir aylık mortalite arasında istatistiksel açıdan anlamlı ilişki saptanmıştır. Mortalite üzerine en yüksek risk oluşturan bulguların plevral düzensizlik (OR: 4.462, %95; 2.268-8.776) ve hava sıvı bronkogramları (OR: 1.791, %95; 1.019-3.149) olduğu görülmüştür. Klinik son tanısı pnömoni olan hastalarda ultrason bulgularının Pnömoni Ağırlık Skoru ile ilişkisi değerlendirildiğinde konsolidasyon (p=0.004), plevral efüzyon (p=0.005) ve plevral düzensizlik (p0.001) bulgularının varlığında Pnömoni Ağırlık Skoru’nun daha yüksek olduğu gözlemlenmiştir. Klinik son tanısı pnömoni olan hastalarda ultrason bulgularının CURB-65 ile ilişkisi değerlendirildiğinde konsolidasyon (p=0.025), plevral efüzyon (p=0.035) ve plevral düzensizlik (p0.001) bulgularının varlığında CURB-65 skorunun daha yüksek olduğu gözlemlenmiştir. Sonuç Akciğer ultrasonu, pnömoni tanısı koymada akciğer grafisine göre duyarlılığı ve özgüllüğü yüksek bir incelemedir. Akciğer ultrasonu, toplumda gelişen pnömoni tanısında akciğer grafisinin ayırt edemediği hastalarda yol gösterici olabilir ve gereksiz bilgisayarlı tomografi çekiminin önüne geçmek için kullanılabilecek bir yöntemdir. Akciğer ultrasonu noninvaziv, taşınabilir ve radyasyon barındırmayan bir tetkik olması nedeni ile tekrarlayan görüntülemeye imkan sağlar ve izlemde kullanılabilir. Akciğer ultrasonu pnömoni tanılı hastalarda prognostik bir gösterge olabilir.Aim It was aimed to investigate the diagnostic and prognostic value of lung ultrasonography in patients admitted to the emergency department with suspicious findings of pneumonia. Material and Method The study was designed as a prospective and methodological study. 330 patients aged 18 and over who were admitted to Ege University Faculty of Medicine Emergency Department between February 20 and May 20, 2020 with suspected pneumonia were evaluated by lung ultrasound. Results Lung ultrasound was performed in all patients included in the study, and chest radiography was obtained for all patients. Computed tomography of the thorax was obtained in 63.6% of the patients during clinical follow-up. Pneumonia was detected ultrasonographically in 68.2% of the patients. It was found that the final clinical diagnosis of 70% of the patients was pneumonia. While 32.7% of the patients were discharged from the emergency service, 37.0% were hospitalized in the service and 29.1% were hospitalized in intensive care unit. The mortality rate is 25.5% within one month following the admission to the hospital. The ultrasound findings were examined in patients with the last diagnosis of pneumonia. It was found that the most common findings were consolidation (93.1%), presence of B lines (68.4%), shred sign (64.9%), and pleural irregularity (59.7%), respectively. Other findings, respectively, increase in vascularity (48.1%), air and fluid bronchograms (46.3%), dynamic air bronchograms (37.7%), pleural effusion (19.9%), spine sign (14.3%), jellyfish sign (8.2%), plankton sign (3.9%). The difference of ultrasound findings by age groups was examined, and a statistically significant difference was found only in the finding of pleural irregularity (p = 0.002). The sensitivity of ultrasonography for the diagnosis of pneumonia was 96.5% and the specificity was 98.0%. The sensitivity of chest radiography for the diagnosis of pneumonia was 82.7% and specificity was 92.9%. In 210 patients who underwent computed tomography, the sensitivity of ultrasonography for the diagnosis of pneumonia was 96.9%, specificity was 95.8%, and the sensitivity of chest radiograph was 77.2% and specificity was 85.4%. When the sensitivity and specificities of ultrasound findings in the diagnosis of pneumonia are examined, respectively, 64.9% - 99.0% for shred finding, 46.3% - 100% for air and fluid bronchogram, 37.7% - 100% for dynamic air bronchogram,% for consolidation 93.1-94.9%, for increased vascularity 48.1% - 98.0%, for B lines 68.4% - 53.5%, for pleural effusion 19.9% - 85.9%, pleural irregularity 59.7% - 75.8% for spine sign, 8.2% - 99.0% for jellyfish sign, 3.9% - 100% for plankton sign. The correlation between ultrasound findings and one-month mortality in patients with the last diagnosis of pneumonia was evaluated. A statistically significant relationship was found between air-fluid bronchograms (p = 0.042) and pleural irregularity (p 0.001) and one-month mortality. The findings that pose the highest risk of mortality were pleural irregularity (OR: 4.462, 95%; 2.268-8.776) and air-fluid bronchograms (OR: 1.791, 95%; 1.019-3.149). Ultrasound findings and Pneumonia Severity Index were compared in patients with the last diagnosis of pneumonia. Pneumonia Severity Index was observed to be higher in the presence of consolidation (p = 0.004), pleural effusion (p = 0.005) and pleural irregularity (p 0.001). CURB-65 score was compared with ultrasound findings in patients with the last diagnosis of pneumonia. It was observed that the CURB-65 score was higher in the presence of consolidation (p = 0.025), pleural effusion (p = 0.035) and pleural disorder (p 0.001). Conclusion Lung ultrasound is an examination with high sensitivity and specificity compared to chest radiography in the diagnosis of pneumonia. Lung ultrasound can be a guide in the diagnosis of pneumonia in patients who cannot be distinguished by chest radiography, and it is a method that can be used to avoid unnecessary computed tomography. Since lung ultrasound is a noninvasive, portable, and radiation-free examination, it allows for repeated imaging and can be used in the follow-up. Lung ultrasound may be a prognostic indicator in patients diagnosed with pneumonia

Retrospective Evaluation of Patients with Angioedema Treated with C1 Inhibitors in an Emergency Department

Aim: We aimed first to investigate patients who received C1 inhibitor therapy in the emergency department (ED). The patients' complaints, examination findings, length of stay in the ED and whether the patients were treated with anything other than C1 inhibitor were investigated. Next, we examined the response of patients who received C1 inhibitor therapy in the presence of angiotensin converting enzyme inhibitor (ACEI)-induced angioedema. Materials and Methods: A retrospective descriptive study was designed. Patients who received C1 inhibitor therapy between January 2011 and February 2018 were reviewed using the hospital's records on file. Results: Data were evaluated from 62 admissions for 23 different patients. The diagnosis of hereditary angioedema (HAE) was present in 65.2% (n=15) of the patients, and 85.5% (n=53) of the admissions were related to acute HAE episodes. The main complaints of these patients were nausea, vomiting and abdominal pain and swell of the face, lips, throat and extremities. It was determined that C1 inhibitor treatment was given to 8% (n=5) admissions due to ACEI-induced angioedema. The complaints of these patients (5 admissions for 4 patients) were swelling of the tongue (n=3), lip (n=1) and face (n=1). Clinical improvement was observed in admission symptoms after treatment of C1 inhibitor in all patients with angioedema induced by HAE episodes or ACEIs. Conclusion: C1 inhibitor treatment is effective in treating acute HAE episodes. Although more evidence is needed for the treatment of ACEI-induced angioedema attacks, C1 inhibitor therapy may be considered in patients who do not respond to classical treatment

Treatment of Amlodipine Intoxication with Intravenous Lipid Emulsion Therapy: A Case Report and Review of the Literature

WOS: 000411104600013PubMed ID: 28766181We report the case of a 25-year-old female presenting to the emergency department after committing suicide by ingesting 100 mg amlodipine. The patient was initially treated with intravenous fluids, calcium gluconate, catecholamines and glucagone without effect. The clinical condition of the patient improved quickly and dramatically on the 20th minute of intravenous lipid emulsion (ILE) therapy. Different treatment methods have been developed for calcium channel blocker intoxication over the last years. Among these, lipid emulsion therapy has risen over the last decade as a salvation in cases which do not respond to other treatments. However, given the paucity of data, there are conflicting recommendations about the indications, dose and timing of ILE in the literature. In the light of this case report, we review the literature and discuss whether ILE therapy can find itself a place among first-line therapy recommendations

The effect of the use of ultrasound in the success of peripheral venous catheterisation

WOS: 000354139000009PubMed ID: 25175514The aim of this study was to investigate the effect of ultrasound-guided peripheral venous catheterisation in patients where difficulty was experienced in peripheral venous catheterisation. The study was conducted in the emergency department at a university hospital in Izmir Turkey. After obtaining institutional review board approval and written informed consent, 60 patients with a history or suspicion of difficult cannulation were enrolled with 30 patients in traditional and 30 in ultrasound group. In the ultrasound group, peripheral intravenous catheterisation was performed using a portable ultrasound device with 13.5 MHz ultrasound probe and 20 gauge intravenous catheter. The success rate of peripheral venous catheterisation was 30% in the control group and 70% in the treatment group. The success rate was significantly higher among the treatment group. The mean intensity of felt pain was 6.00 +/- 1.98 in the control group and 4.77 +/- 1.74 in the treatment group. The mean intensity of felt pain was significantly lower in the treatment group. The state of chronic disease affected the success rate in patients in the treatment group. (C) 2014 Elsevier Ltd. All rights reserved

Tek doz duloksetin genç erkek hastada hiponatremiye neden olabilir mi?

Somatik semptomları olan orta yaşlı bir erkek hastada tek doz duloksetin tedavi sonrası hızlıca gelişen bir hiponatremi olgusunu rapor ettik. Yirmi sekiz yaşında erkek hasta halsizlik ve başdönmesi şikayeti ile başvurdu. Duloksetinin kesilmesi ve normal salin tedavisinden üç gün sonra tamamen normale döndü. Duloksetin ile tedavi edilen hastaların hiponatremi açısından yakın takiplerinin yapılması gereklidir.We report a case of duloxetine-induced hyponatremia which developed rapidly with somatic symptoms in a middleaged male after a single dose of medication. A 28-year-old male patient presented with fatigue and dizziness. The patient's presenting complaints completely resolved after duloxetine was ceased and normal saline treatment was given. When treating patients with duloxetine, close monitoring for hyponatremia is essential

Nivolumab, a new immunomodulatory drug, a new adverse effect; adrenal crisis

WOS: 000424190600010PubMed ID: 29464222Owing to the advancements in medicine, new information is obtained regarding cancer, new antineoplastic agents are developed. Frequent use of these new pharmacological agents emergency physicians to be vigilant about their side effects. We present a case of adrenal crisis in a patient with non-small cell lung cancer (NSCLC), caused by an immunomodulatory drug; nivolumab. While adverse events are related to other immunomodulatory drugs have been reported in literature, our case is the first nivolumab-related adrenal failure to be reported. A patient with lung cancer presented to the emergency room(ER) with nausea and vomiting. Hyponatremia, hyperkalemia, persistent hypoglycemia led to the diagnosis of adrenal crisis. Having direct effect on the immune system, these drugs were claimed to be highly reliable. However, there is no reliable data on the side effect profile of these agents. It should be kept in mind that life-threatening auto-immune reactions may occur. Copyright (C) 2017 The Emergency Medicine Association of Turkey. Production and hosting by Elsevier B.V. on behalf of the Owner. This is an open access article under the CC BY-NC-ND license