Traumatic Asphyxia

Traumatic asphyxia is a clinical syndrome related to cervicofascial cyanosis, petechiae, subconjunctival haemorrhages and neurological symptoms. This syndrome occurs after a transient, severe and compressive blunt thoracic trauma. Here, we presented two cases of traumatic asphyxia. They both had prominent petechiae on upper parts of their bodies. The prognosis was excellent in the boy. Contrary, second case was dead in emergency department due to subarachnoid haemorrhage and intracerebral petechial haemorrhages. Traumatic asphyxia alone does not predict morbidity and mortality. It is the concomitant cardiovascular, pulmonary and neurologic injuries that affect the outcome.

Cervical Spinal Injury and Hyoid Fracture in a Near-Hanging Victim

Hanging is a kind of strangulation that involves suspension by the neck. A case of near-hanging is reported. The patient was a 56-year-old man with incomplete hanging. His initial Glasgow Coma Scale score was 8. Mild elevation of cardiac biomarkers and hyperglycaemia were found. Hyoid fractures and a slight anterior dislocation of the C6 vertebra were observed. In near-hanging victims, all hypoxia-sensitive organs should be examined carefully. Notwithstanding the different types of hanging (complete vs. incomplete), all victims should be assumed to have cervical injury until proven otherwise.

Evacuation of Hospitals during Disaster, Establishment of a Field Hospital, and Communication

The buildings, working personnel, and patients and their relatives may directly or indirectly be affected by the disasters. Here we will discuss evacuation, establishing a field hospital, communication, the role of the media in disasters, and defending against sabotage. The affected individuals should be evacuated and transferred to secure zones safely and rapidly. How the decision for evacuation should be made and how the evacuation triage should be performed are important issues. Field hospitals should be established within the bounds of possibility for continuation of the treatments of evacuated people. The standards for the field hospitals and its sections that may be created according to the needs will be explained. Undoubtedly, since one of the most important subjects in disasters is communication, the types of communication in disasters and their significance will be mentioned. How the relationships with the media should be an aspect of communication and how they can be beneficially used will also be mentioned. As in all organizations and institutions, sabotage attempts may also be present concerning health facilities. For this reason, during the preparation of the hospital disaster plan, defending against sabotage will be discussed, and what should be done at that stage will be mentioned.

The Evaluation of Myocardial Damage in 83 Young Adults with Carbon Monoxide Poisoning in the East Anatolia Region in Turkey

Carbon monoxide (CO) poisoning is the leading cause of death from intoxication. In CO poisoning, it is important to know if there are any symptoms regarding myocardial damage, which are usually unobserved as a result of hypoxia. This study was planned to assess myocardial damage in young healthy patients with CO poisoning. Eighty-three young healthy cases who had been exposed to CO were included in this study. The demographic and clinical characteristics, the origin of CO gas and smoking habits of the patients were recorded. The evaluation of ECG, peripheral ABG, complete blood count and serial cardiac biomarkers (creatine kinase, creatine kinasemyocardial band and troponin I) measurements were performed in all cases. Additionally, echocardiogram (ECHO) and myocardial perfusion single-photon emission computed tomography (SPECT) were performed at the appropriate times in all cases. The mean age of the patients was 27.39 /10.9 years. The main complaint of the patients was loss of consciousness with a 62.7% rate. The average carboxyhaemoglobin level of the patients was 34.49 /15.9%. Sinus tachycardia was present in 26.5% of patients. Diagnostic ischaemic ECG changes were present in 14.4% of patients. In myocardial SPECT, myocardial ischaemic damage was observed in 9 cases, in 6 of whom ECHO findings were also confirmed. Myocar-dial damage due to CO poisoning should not be ignored. If patients are at risk in terms of myocardial damage, further studies, such as ECHO and scintigraphy are needed to determine myocardial damage resulting from CO poisoning. However, in the young adults of the risk group, if the baseline ECG and serial cardiac biomarkers are normal, further studies such as ECHO and scintigraphy, considering the length of exposure and the severity of poisoning, may not be necessary for the evaluation of myocardial damage due to CO poisoning.

Wildflower (Hyoscyamus reticulatus) causes QT prolongation

INTRODUCTION

In the environment, there are hundreds of poisonous and injurious plants with a wide variety of toxicity. Among all plants with anticholinergic effect, Hyoscyamus reticulatus is a species whose clinicopathological effects have been poorly described in literature. The paper is especially aimed at drawing attention to the possibly fatal syndrome of prolonged QT, as well as to clinical and laboratory changes in six members of a single family poisoned with this plant.

CASES

Six female patients aged from 19 to 49 presented to our emergency room with a suspicion of being poisoned after having ingested a plant known as 'the mad axe plant' (Hyoscyamus reticulatus). At least one of anticholinergic symptoms including flushing, mydriasis, dry mouth and tachycardia was present in all of the patients. In addition, different levels of agitation were observed in four of the patients. A euphoric emotional state was present in two patients. The corrected QT distances were found to be prolonged in three of the patients.

DISCUSSION AND CONCLUSION

Based on economical, social and cultural reasons, it is a very common habit in our country, especially in our region in spring and summer months, to consume some plants growing spontaneously in rural areas as food. Intoxication with Hyoscyamus reticulatus is a plant poisoning that is poorly described in literature. Its classical symptoms are predominantly anticholinergic. Although it is commonly self-limited and can be corrected with close observation and supportive treatments, it should be kept in mind that the prolongation of QT interval can accompany the symptoms of poisoning with this plant (Tab. 1, Fig. 3, Ref. 19).

Complete atrioventricular block due to overdose of pregabalin

Pregabalin, a synthetic derivate of the inhibitory neurotransmitter γ-aminobutyric acid, shows antiepileptic, analgesic, anticonvulsant, anxiolytic, and sleep-modulating activities. The major advantage of pregabalin is its relative reliability, easy use, high tolerance, and lack of negative interaction with other drugs. A 65-year-old woman with medical histories of diabetes mellitus, lumbar spondylosis, diabetic nephropathy, chronic renal failure, and anemia of chronic disease was admitted with the complaint of dizziness and syncope. She had been taking pregabalin 300 mg daily for 8 months. Electrocardiogram revealed complete atrioventricular (AV) block and right bundle-brunch block with a heart rate of 39 per minute. Her creatinine was 1.8 mg/dL, and creatinine clearance was 50 mL/min. Pregabalin treatment was discontinued. Four days later, the complete AV block resolved spontaneously to Mobitz type II block and to sinus rhythm with right bundle-brunch block on the seventh day. To our knowledge, this is the first case of complete AV block associated with pregabalin. We believe that AV block occurred as a result of pregabalin's effect on L-type Ca++ channels in the heart. Pregabalin's different effects on electrocardiogram and on the heart in different individuals may have an association with the patterns of distribution of the L-type calcium channels in myocardium.

Two questions for Kounis syndrome: can we use magnetic resonance imaging in the diagnosis and does ST elevation correlates with troponin levels?

Kounis syndrome (KS) is an acute coronary vasospasm after exposure to an allergen due to mast cell degranulation and existing mediators. Various drugs, conditions, and environmental exposures can cause KS. We presented 2 cases, 1 of whom had taken an antiflu drug (containing paracetamol, pseudoephedrine, and dextromethorphan). His electrocardiogram (ECG) showed inferior ST elevations (2 mm) with normal cardiac biomarkers. His cardiac magnetic resonance imaging showed hypokinesis and myocardial hibernation on apical septum and on the left ventricle. The second patient took a pill of naproxen sodium. The ECG showed 1-mm ST elevation in leads DII, V5, and V6. His troponin was markedly elevated. These cases showed that there seems to be no correlation with ECG and troponin levels in KS. In addition, for patients in whom KS type 1 is expected without troponin elevation, noninvasive cardiac magnetic resonance imaging study seems to be appropriate for the diagnosis of KS.

What are the predictors of scapula fractures in high-impact blunt trauma patients and why do we miss them in the emergency department?

AIM

To find out the predictors of scapula fractures in high-impact blunt trauma patients and the predictors of missing them in the emergency department (ED).

METHODS

This is a retrospective descriptive review of patients treated at a single hospital over a 3.5-year period. The study included 1,039 high-impact blunt trauma patients of any age. The patients were divided into two groups: patients with scapula fractures (the patient group) and others (the control group). The patient group was re-assessed into two subgroups: patients with and without missed scapula fractures. Logistic regression analysis was used to assess the predictors of a scapular fracture in the ED.

RESULTS

The incidence of scapula fractures was 4%. The Injury Severity Scores (ISS) of the scapula fracture group were significantly higher than those of the control group (P < 0.0001). Patients with scapula fractures were significantly older (P < 0.001). Patients with scapular body fractures stayed for significantly longer in the intensive care unit (ICU) (P = 0.039) and their mean Abbreviated Injury Scale (AIS)face score was higher (P = 0.04) compared to scapular fractures without body parts. Scapula fractures were missed in 35.7% of patients. All bilateral scapula fractures were missed. Computerized tomography showing shoulder region or scapula was obtained in 26.7% of missed injuries.

CONCLUSION

After matching for ISS, the mortality of patients with scapula fracture was significantly higher than the control group. We observed that fractures in the glenoid and scapular neck occurred higher than in the body region. We found that the seniority of the ED doctor, consultation ratio for orthopedics in ED, and the existence of brain contusion were important parameters for missing scapula fractures in ED.

The main differences in oral exposures in children and adults

OBJECTIVES

This study aimed to determine the epidemiological differences between children and adult oral exposures in patients admitted to the busiest emergency department (ED) in the Eastern Anatolia region of Turkey.

METHODS

The characteristics of 1950 patients were investigated retrospectively and in a cross-sectional manner in a two-year period.

RESULTS

The ratio of poisoning exposures among all emergency admissions was 0.6%. Of these, 44.5% were children, and 54.4% were unintentional. The mortality rate was 0.1% and the rate of hospitalization was 14.9%. Among the children and adults, 50.3% and 29.5% were male, respectively. While the first two causes of exposures in both children and adults were licit drugs and foods, there were differences in other causes. Among causes, licit drugs and corrosive materials constituted the forefront in the 0-1 and 1-5-year age groups. In parasuicidal causes, the most common exposure was found to be licit drugs, followed by organophosphates. The most common cause of hospitalization was plants (60.5%). The hospitalization rate was found to be significantly high in males and unintentional exposures. The rate of admissions to the psychiatry polyclinic following exposure was 15%.

CONCLUSION

This study hereby presents the original findings as to predict the problems in exposures. The distribution of etiological agents and suicidal intent rate may differ among pediatric and adult population (Tab. 4, Fig. 1, Ref. 50).

Factors Affecting the B-Type Natriuretic Peptide Levels in Stroke Patients

Introduction: This study aims to evaluate the relationship between increased B-type natriuretic peptide (BNP) levels in stroke patients and clinical parameters such as age, sex, medical history, blood pressure, Glasgow Coma Score (GCS) and National Institutes of Health Stroke Scale (NIHSS). Materials and Methods: This is a prospective study of 123 stroke patients at the Emergency Department. The patients were divided into 3 groups according to the NIHSS scores. The analysis of the mean difference between continuous variables and plasma BNP levels was assessed using the Mann-Whitney and Kruskal-Wallis. Spearman correlation analysis was performed for BNP and other clinical parameters. Results: The BNP levels of patients who had a medical history of hyperlipidaemia, chronic obstructive pulmonary disease, diabetes mellitus and coronary artery disease were significantly higher than in patients without these diseases. Patients who had atrial fibrillation (AF) in their electrocardiography had significantly higher BNP levels than patients with sinus rhythm. A positive correlation was found between plasma BNP levels with age, blood urea nitrogen (BUN) and NIHSS and a negative correlation was found between plasma BNP levels and GCS. There was a significant difference between the BNP levels of NIHSS groups. Conclusion: We consider that plasma BNP levels could help us in interpreting the general clinical severity, functional capacity and clinical progress of stroke patients at the time of admission in the Emergency Department. In evaluating the high BNP levels in stroke patients, we must keep in mind that age, AF, BUN and medical history can affect the BNP levels. Key words: Emergency Department, Progress, Relationship

Factors affecting the B-type natriuretic peptide levels in stroke patients

INTRODUCTION

This study aims to evaluate the relationship between increased B-type natriuretic peptide (BNP) levels in stroke patients and clinical parameters such as age, sex, medical history, blood pressure, Glasgow Coma Score (GCS) and National Institutes of Health Stroke Scale (NIHSS).

MATERIALS AND METHODS

This is a prospective study of 123 stroke patients at the Emergency Department. The patients were divided into 3 groups according to the NIHSS scores. The analysis of the mean difference between continuous variables and plasma BNP levels was assessed using the Mann-Whitney and Kruskal-Wallis. Spearman correlation analysis was performed for BNP and other clinical parameters.

RESULTS

The BNP levels of patients who had a medical history of hyperlipidaemia, chronic obstructive pulmonary disease, diabetes mellitus and coronary artery disease were significantly higher than in patients without these diseases. Patients who had atrial fibrillation (AF) in their electrocardiography had significantly higher BNP levels than patients with sinus rhythm. A positive correlation was found between plasma BNP levels with age, blood urea nitrogen (BUN) and NIHSS and a negative correlation was found between plasma BNP levels and GCS. There was a significant difference between the BNP levels of NIHSS groups.

CONCLUSION

We consider that plasma BNP levels could help us in interpreting the general clinical severity, functional capacity and clinical progress of stroke patients at the time of admission in the Emergency Department. In evaluating the high BNP levels in stroke patients, we must keep in mind that age, AF, BUN and medical history can affect the BNP levels.

An unusual etiology of fever of unknown origin: Foley catheter

Fever may appear due to known causes such as infections, but may sometimes occur as a result of unknown pathologies. These pathologies can be included in a miscellaneous group of fever of unknown origin. We report one case of bladder stone including a foreign body in a 40-year-old man with a stroke admitted for high fever, blocked miction and bladder symptoms.

Animal-related injuries: epidemiological and meteorological features

This is a retrospective and registry-based descriptive study including animal- related injuries represented by the most crowded Emergency Department (ED) in Eastern Turkey over a period of two years. Animal-related injuries were 0.2% of all ED admittances; dominant in males and were high in summer. 68% of the subjects were exposed to mammalians. Most prominent injuries were dog bites (30%), horse (22%) and livestock-related injuries (12%). Hospitalization was significantly higher in mammalian animal injuries compared to non-mammalian injuries. The highest hospitalization rate was measured for equine-related injuries (15%). In our bite series, dogs were the primary source (69%) while horse-bites (17%) took the second place and they were more than two fold more when compared with cats (7.5%). Dog bites were prominent in children, thus both parents and children should be educated. Insect and snake-related injuries were both low in number and relatively silent in prognosis. Highest temperatures on site were determined for tick-bites, unspecified insect stings and bee stings, respectively. The highest humidity was determined for dog-bites, cat-bites and scorpion stings, respectively. Nonmammalian and sting injuries had higher temperature and lower humidity measurements compared to mammalian and bite injuries. Geographical and meteorological factors may directly affect descriptive epidemiology of animal-related injuries.

The Osborn wave in accidental hypothermia

Hypothermia is generally defined as a core body temperature less than 35 degrees C (95 degrees F), and is one of the most common environmental emergencies encountered by emergency physicians. A 32-year-old male hunter was admitted to the hospital with altered mental status. He remained unconscious, Glasgow Coma Scale (GCS) score was recorded as 5/15, and pupils were dilated and unreactive. His vital signs showed a heart rate of 48 beats/min, respiratory rate of 10 breaths/min, blood pressure of 95/50 mm Hg, and rectal temperature of 31 degrees C. An electrocardiogram (ECG) was obtained and showed marked sinus bradycardia and J waves. His finger-stick glucose was 85. He was intubated. After 3 h of active rewarming, his temperature was 34 degrees C, and the repeat ECG showed near-complete resolution of the J waves and acceleration of the sinus rate to 68 beats/min. At the same time, emergency head computed tomography (CT) scan showed subarachnoid hemorrhage (SAH) and subdural hemorrhage. The patient died on the third day of admission. In this case we want to indicate that J waves and obtunded state could be due to either SAH or hypothermia, and SAH could have been missed if initial obvious hypothermia had been believed to cause all symptoms.

Air guns: toys or weapons?

Air guns and blank guns may appear relatively harmless at first glance, but they are, in fact, potentially destructive, even lethal, weapons. Approximately 2 to 2.5 million nonpowder firearms are sold annually, and again approximately 12.9 per 100,000 population are treated for such injuries in hospital emergency departments each year in the United States. Unfortunately, these guns are considered to be a toy for children. Therefore, incidents of air gun injuries are gradually increasing. Although such injuries may initially be considered trivial, it may signify severe internal tissue pathologies. These apparently trivial injuries may have catastrophic consequences if unnoticed. In this study, we report 4 cases with head injury due to a shot by these guns. The cases indicate that these people had used the guns belonging to their parents for the purpose of suicide. The cases also show that these machines are not innocent.

Amitraz: an unusual aetiology of Ogilvie's syndrome

Amitraz is an insecticide/acaricide of formamidine pesticides used worldwide for ectoparasites in animals. Because of its widespread use, amitraz poisoning is frequently encountered in Turkey.

CASE REPORT

A 36-year-old, comatose female was admitted to the hospital. Although it was stated that she had taken a glass of water containing amitraz, the exact volume of the substance was unknown. On admission, her Glasgow Coma Scale score was 10/15. Clinical findings were vomiting, miosis, bradycardia and hypotension. The patient's vital signs were body temperature 37.2 degrees C, pulse 54 bpm, blood pressure 80/50 mmHg and pulseoximetry 84%. Supportive treatment consisting of oxygen, fluid replacement and gastric lavage, activated charcoal and atropine was administered. On the second day, signs of Ogilvie's syndrome characterized by severe tenderness, distension and pain in the abdomen were seen. On the third day, the patient's condition improved except for abdominal distension and pain, inability to pass faeces or flatus through the anus. Although continuous nasogastric tube decompression was performed, her complaints were not resolved completely. Neostigmine was administered on the fourth day. On the fifth day, abdominal pain and distension were decreased, and stool passage began. She had a complete clinical and laboratory improvement, which warranted her discharge on the seventh day of admission.

Post-interval syndrome after carbon monoxide poisoning

Carbon monoxide (CO) exposure and toxicity is a potentially lethal disorder with immediate and delayed side effects. A 24-y-old driver was admitted to the University-based emergency department with altered mental status. He was found unconscious in the driver's seat of his vehicle in an indoor garage the morning before. An estimated 7 h later, he was comatose and taken to a nearby village clinic. Oxygen was administered immediately. Later, he was transferred to the university hospital. At the 12th h after exposure, the Glasgow Coma Scale score was 12/15 (E3, M5, V4). Co-oximetry disclosed a carboxyhemoglobin concentration of 10.5%. Normobaric oxygen was administered. He recovered completely the 3rd d after exposure; however, on the 7th d disorientation and agitation was noted, and the interval form of CO poisoning and leukoencephelopaty were suspected, for which he was readmitted the 10th d after exposure. Analysis of cerebrospinal fluid and blood revealed no abnormalities. Magnetic resonance imaging on the 11th d after exposure demonstrated an ischemic area in the posterior temporoparietal area. The patient continued improvement to discharge at 7th d of the second admission. Close follow-up should be scheduled for CO-poisoned patients to rule out the post-interval syndrome for at least 1 mo. This should also include those with apparent clinical and laboratory recovery.