TATD 2012-4 by KAREPUBLISHING

ISSN 1304-7361

Türkiye Acil Tıp Dergisi

Türkiye

Acil Tıp Dergisi Turkish Journal of Emergency Medicine CİLT VOLUME 12

SAYI NUMBER 4

YIL YEAR 2012

Turkish Journal of Emergency Medicine

CiLT VOLUME 12 SAYI NUMBER 4 YIL YEAR 2012

Gebelerde İntihar Amaçlı İlaç Zehirlenmelerinin Gebe Olmayanlara Göre Farkı Var Mı? Suicide Attempts with Drug Intoxication in Pregnant and Non-Pregnant Women Uzkeser M, Sarıtemuz M, Aköz A, Bayramoğlu A, Emet M Urticaria-Angio Edema: Profile of Patients in the Emergency Department and Factors Affecting Revisits Ürtiker ve Anjiyoödem: Acil Servis Hasta Profili ve Tekrarlayan Başvurular Berk Y, Eray O, Yiğit Ö, Sayraç N, Alpsoy E OLGU SUNUMLARI CASE REPORTS Çarpan Balığı: Denizden Uzakta Deniz Canlıları ile Zehirlenme Vakası Greater Weever Fish: A Case of Poisoning with Sea Creatures Far Away from the Sea Bozkurt S, Güler S, Aksel G, Kılıçaslan İ Fokal Nörolojik Defisitli Hasta: Bir Karbonmonoksit Zehirlenmesi Olgusu The Patient with Focal Neurological Deficit: A Case of Carbonmonoxide Poisoning Özakın E, Çevik AA, Acar N, Çetinkaya O Water Intoxication Resulting in Ventricular Arrythmias Ventriküler Aritmilere Neden Olan Su Zehirlenmesi Türker Bayır P, Demirkan B, Duyuler S, Güray Ü, Kısacık HL Malign Arrhytmia Development Due to Propafenone Over Dose: A Case Report Propafenon Aşırı Dozuna Bağlı Gelişen Malign Aritmi: Olgu Sunumu Acar E, Duran L, Şahin Y, Akdemir HU, Ekiz M, Erenler AK

Türkiye Acil Tıp Derneği Bilimsel Yayınıdır Issued by The Emergency Medicine Association of Turkey Bu dergi TÜBİTAK-ULAKBİM Türk Tıp Dizini, EBSCOhost, Index Copernicus, DOAJ, Gale/Cengage Learning, SCOPUS, EMBASE ve Türkiye Atıf Dizini’nde yer almaktadır. This Journal is indexed in Turkish Medical Index of TÜBİTAK-ULAKBIM, EBSCOhost, Index Copernicus, DOAJ, Gale/Cengage Learning, SCOPUS, EMBASE and Turkish Citation Index.

www.trjemergmed.com

ISSN 1304-7361

Türkiye

Acil Tıp Dergisi Turkish Journal of Emergency Medicine CİLT VOLUME 12

SAYI NUMBER 4

YIL YEAR 2012

Editöre Mektup Letter to the Editor Vahdati SS, Moradi N Görsel Tanı Visual Diagnosis Doktor Gözlerimi Kontrol Edemiyorum! Dedeoğlu E, Bayram B KLİNİK ÇALIŞMALAR ORIGINAL ARTICLES The Effect of Cannula Material on The Pain of Peripheral Intravenous Cannulation in the Emergency Department: A Prospective, Randomized Controlled Study Acil Servisteki Periferik İntravenöz Kanül Uygulamalarında Kullanılan Kanül Materyalinin Girişim Ağrısı Üzerine Etkisi: Prospektif, Randomize Kontrollü Çalışma Özsaraç M, Dolek M, Sarsılmaz M, Sever M, Sener S, Kiyan S, Yürüktümen A, Yılmaz G Evaluation of Risk Factors and Clinical Characteristics of Elderly Patients with Acute Upper Gastrointestinal Hemorrhage Akut Üst Gastrointestinal Kanama Şikâyeti ile Başvuran Yaşlı Hastaların Klinik Özellikleri ve Risk Faktörlerinin Değerlendirilmesi Sayhan MB, Oğuz S, Ümit H, Secgin Sayhan E, Eralp MO, Akdur G, Kavalcı C, Sağıroğlu T Patient and Relative Complaints in a Hospital Emergency Department: A 4-Year Analysis Bir Hastane Acil Servisinde Hasta ve Yakını Şikâyetleri: 4 Yıllık Analiz Zengin S, Al B, Yavuz E, Şen C, Cindoruk Ş, Yıldırım C Gebelerde İntihar Amaçlı İlaç Zehirlenmelerinin Gebe Olmayanlara Göre Farkı Var Mı? Suicide Attempts with Drug Intoxication in Pregnant and Non-Pregnant Women Uzkeser M, Sarıtemuz M, Aköz A, Bayramoğlu A, Emet M Urticaria-Angio Edema: Profile of Patients in the Emergency Department and Factors Affecting Revisits Ürtiker ve Anjiyoödem: Acil Servis Hasta Profili ve Tekrarlayan Başvurular Berk Y, Eray O, Yiğit Ö, Sayraç N, Alpsoy E OLGU SUNUMLARI CASE REPORTS Çarpan Balığı: Denizden Uzakta Deniz Canlıları ile Zehirlenme Vakası Greater Weever Fish: A Case of Poisoning with Sea Creatures Far Away from the Sea Bozkurt S, Güler S, Aksel G, Kılıçaslan İ Fokal Nörolojik Defisitli Hasta: Bir Karbonmonoksit Zehirlenmesi Olgusu The Patient with Focal Neurological Deficit: A Case of Carbonmonoxide Poisoning Özakın E, Çevik AA, Acar N, Çetinkaya O Water Intoxication Resulting in Ventricular Arrythmias Ventriküler Aritmilere Neden Olan Su Zehirlenmesi Türker Bayır P, Demirkan B, Duyuler S, Güray Ü, Kısacık HL Malign Arrhytmia Development Due to Propafenone Over Dose: A Case Report Propafenon Aşırı Dozuna Bağlı Gelişen Malign Aritmi: Olgu Sunumu Acar E, Duran L, Şahin Y, Akdemir HU, Ekiz M, Erenler AK

www.trjemergmed.com

Türkiye

Acil Tıp Dergisi Turkish Journal of Emergency Medicine EDİTÖRLER EDITORS Dr. Cenker EKEN Akdeniz Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı

Dr. Murat PEKDEMİR Kocaeli Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı

EDİTÖR YARDIMCILARI ASSOCIATE EDITORS Dr. Ersin AKSAY S.B. İzmir Tepecik Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği

Dr. Neşe ÇOLAK ORAY Dokuz Eylül Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı

Dr. Orhan ÇINAR GATA, Acil Tıp Anabilim Dalı

Dr. Murat ERSEL Ege Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı

Dr. Mustafa SERİNKEN Pamukkale Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı

Dr. Süleyman TÜREDİ Karadeniz Teknik Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı

Dr. İbrahim TÜRKÇÜER

BİLİMSEL DANIŞMA KURULU (2012-4. Sayıda) CONSULTING EDITORS (2012, Number 4) Dr. Ali KOÇYİĞİT Dr. Aslıhan YÜRÜKTÜMEN Dr. Başak BAYRAM Dr. Bülent ERBİL Dr. Can AKTAŞ Dr. Cem ERTAN Dr. Cemil KAVALCI Dr. Haldun AKOĞLU Dr. Kemalettin ACAR Dr. Mehmet Mahir KUNT Dr. Mehtap BULUT

Dr. Murat ÖZSARAÇ Dr. Murat YEŞİLARAS Dr. Nurettin Özgür DOĞAN Dr. Okhan AKDUR Dr. Özgür KARCIOĞLU Dr. Özlem GÜNEYSEL Dr. Serkan ŞENER Dr. Seyran BOZKURT Dr. Süha TÜRKMEN Dr. Şule KALKAN Dr. Yusuf Ali ALTUNCİ

Pamukkale Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı

Dr. Mehmet Ali KARACA Hacettepe Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı

ARAŞTIRMA METODOLOJİSİ EDİTÖRÜ RESEARCH MEDHODOLOGY EDITOR Dr. Levent DÖNMEZ Akdeniz Üniversitesi Tıp Fakültesi, Halk Sağlığı Anabilim Dalı

DİL EDİTÖRÜ LANGUAGE EDITOR Gürkan ÖZEL Koçoğlu Hava Ambulans Operasyon Merkezi

ULUSLARARASI BİLİMSEL DANIŞMA KURULU INTERNATIONAL EDITORIAL BOARD Dr. Jeffrey ARNOLD Dr. Elizabeth DEVOS Dr. C. James HOLLIMAN Dr. Mark LANGDORF Dr. Frank LOVECCHIO Dr. Matej MARINSEK Dr. Resmiye ORAL Dr. Selim SUNER Dr. Judith E. TINTINALLI

GEÇMİŞ DÖNEM EDİTÖRLERİ FORMER EDITORS Dr. Rıfat TOKYAY (2001-2003), Dr. Hamit HANCI (2003-2004), Dr. Oktay ERAY (2004-2007), Dr. Sedat YANTURALI (2006-2008), Dr. Cenker EKEN (2007-2010), Dr. Ersin AKSAY (2009-2011)

www.trjemergmed.com

Türkiye

Acil Tıp Dergisi Turkish Journal of Emergency Medicine

ISSN 1304-7361 CİLT VOLUME 12 SAYI NUMBER 4 ARALIK DECEMBER 2012

TÜRKİYE ACİL TIP DERNEĞİ’NİN YAYIN ORGANI ISSUED BY THE EMERGENCY MEDICINE ASSOCIATION OF TURKEY SAHİBİ OWNER TÜRKİYE ACİL TIP DERNEĞİ Adına Sahibi Levent AVŞAROĞULLARI On behalf of the Emergency Medicine Association of Turkey Owner İLETİŞİM CORRESPONDENCE Türkiye Acil Tıp Derneği, Çankaya Mah., Cinnah Cad., No: 51/10 Çankaya, Ankara Tel: 0312 - 438 12 66 • Faks (Fax): 0312 - 438 12 68 e-posta (e-mail): aciltip@ttmail.com web: www.tatd.org.tr YAYINA HAZIRLAMA PUBLISHER KARE Yayıncılık | karepublishing Söğütlüçeşme Cad., No: 76/103, 34730 Kadıköy, İstanbul, Türkiye Tel: 0216 - 550 61 11 Faks (Fax): 0216 - 550 61 12 TASARIM DESIGN Ali CANGÜL BASKI PRESS Yıldırım Matbaası BASIM TARİHİ PRESS DATE Aralık December 2012 BASKI ADEDİ CIRCULATION 1500

Üç ayda bir yayınlanır. Published four times a year. Asitsiz kağıda basılmıştır Printed on acid-free paper Yaygın Süreli Yayın Periodical Bu dergide kullanılan kağıt ISO 9706: 1994 standardına uygundur. This publication is printed on paper that meets the international standard ISO 9706: 1994 Türkçe ve İngilizce tam metinlere internet ulaşımı ücretsizdir (www.trjemergmed.com). Free full-text articles in Turkish and English are available at www.trjemergmed.com.

Türkiye

Acil Tıp Dergisi Turkish Journal of Emergency Medicine

İçindekiler Contents

ARALIK DECEMBER 2012

vii

Türkiye Acil Tıp Dergisi Yayın İlkeleri

Yazarlara Bilgi

viii

Publishing with the Tr J Emerg Med

Instructions for Authors

149

151

Editöre Mektup Letter to the Editor

Görsel Tanı Visual Diagnosis

Vahdati SS, Moradi N 150 Doktor Gözlerimi Kontrol Edemiyorum! Dedeoğlu E, Bayram B

KLİNİK ÇALIŞMALAR ORIGINAL ARTICLES The Effect of Cannula Material on The Pain of Peripheral Intravenous Cannulation in the Emergency Department: A Prospective, Randomized Controlled Study Acil Servisteki Periferik İntravenöz Kanül Uygulamalarında Kullanılan Kanül Materyalinin Girişim Ağrısı Üzerine Etkisi: Prospektif, Randomize Kontrollü Çalışma Özsaraç M, Dolek M, Sarsılmaz M, Sever M, Sener S, Kiyan S, Yürüktümen A, Yılmaz G

157

163

Patient and Relative Complaints in a Hospital Emergency Department: A 4-Year Analysis Bir Hastane Acil Servisinde Hasta ve Yakını Şikâyetleri: 4 Yıllık Analiz Zengin S, Al B, Yavuz E, Şen C, Cindoruk Ş, Yıldırım C

169

175

OLGU SUNUMLARI CASE REPORTS

182

Çarpan Balığı: Denizden Uzakta Deniz Canlıları ile Zehirlenme Vakası Greater Weever Fish: A Case of Poisoning with Sea Creatures Far Away from the Sea Bozkurt S, Güler S, Aksel G, Kılıçaslan İ

185

Fokal Nörolojik Defisitli Hasta: Bir Karbonmonoksit Zehirlenmesi Olgusu The Patient with Focal Neurological Deficit: A Case of Carbonmonoxide Poisoning Özakın E, Çevik AA, Acar N, Çetinkaya O

188

Water Intoxication Resulting in Ventricular Arrythmias Ventriküler Aritmilere Neden Olan Su Zehirlenmesi Türker Bayır P, Demirkan B, Duyuler S, Güray Ü, Kısacık HL

191

Malign Arrhytmia Development Due to Propafenone Over Dose: A Case Report Propafenon Aşırı Dozuna Bağlı Gelişen Malign Aritmi: Olgu Sunumu Acar E, Duran L, Şahin Y, Akdemir HU, Ekiz M, Erenler AK

196

Düzeltme - Erratum

197

Türkiye Acil Tıp Dergisi 2012 Yılı 12. Cilt Konu ve Yazar Dizini Index of Volume 12

Türkiye

Acil Tıp Dergisi Turkish Journal of Emergency Medicine

Yayın İlkeleri

1. Türkiye Acil Tıp Dergisi, Türk Tıp Dizini koşullarına uygun olarak bir yıl içindeki toplam araştırma makalesi sayısı 15’den az olmayacak ve toplam makale sayısı (araştırma makalesi, olgu sunusu, editöre mektup, derleme) en az %50’sini oluşturacak şekilde yılda 4 kez yayımlanır. Her sayıda en az 4 araştırma makalesi yayınlanır. Dergimiz araştırma makalesi dışında, editör kurulunun görüşü dahilinde olgu sunum, olgu serisi, acil tıpta görsel tanı, editöre mektup, kısa rapor, derleme ve kanıta dayalı acil tıp kategorisinde yazılar yayınlar. Derlemeler editörün daveti üzerine hazırlanır. 2. Derginin elektronik arşiv sisteminde tüm hakem kararları, başvuru yazılarının imzalı örnekleri ve düzeltme yazıları en az beş yıl süreyle saklanır. 3. Türkiye Acil Tip Dergisi’ne gönderilen yazılar ilk olarak editör tarafından değerlendirilir. Editör her yazıyı değerlendirmeye alınıp alınmaması konusunda yazıyı gözden geçirir, gerekli görürse yazıya editör yardımcısı atar. Editör ve yazıya atanan editör yardımcısı en az iki hakem veya bir hakem ve bir editör yardımcısına yazıyı değerlendirmek üzere gönderir. Eğer her iki editör de yazının bilimsel değerliliğinin ve orijinalliğinin bulunmadığı ve acil tıp konusuna ve dergi okuyucu kitlesine hitap etmediğini düşünüyorsa yazıyı hakem kuruluna göndermeden direkt red edebilir. 4. Yazıların değerlendirilme sürecinde yazarların başvurularına yazının hakemlerce değerlendirme altına alındığına dair ilk yanıt için 14 gün, hakemlerin ilk değerlendirmesi için 21 gün, ayrıntılı değerlendirme sonucunun yazarlara bildirilmesi için 28 günlük süreye uyum amaçlanır. Dar kapsamlı düzeltme gereken yazılar için yazara 10 gün, geniş kapsamlı düzeltme gereken yazılarda yazarlara 20 günlük süre tanınır. Yazının basım için kabul edilmesinden sonraki 30 gün içerisinde basımevi editöründen yazarlara baskı öncesi son düzeltme önerileri gönderilir.

5. Editör yardımcısı metodolojik bir sorunu değerlendirme safhasında “araştırma metodolojisi editörlerine” danışabilir. Böyle bir danışma yapılmasa bile eğer yazı hakemler tarafından kabul edilmişse kabul yazısı gönderilmeden önce editörün isteği üzerine araştırma metodolojisi editörünün onayına sunulabilir. 6. Türkiye Acil Tıp Dergisi’ne gönderilen ve içerisinde ingilizce bölümler bulunan tüm yazılar, derginin dil editörü tarafından, basım öncesinde değerlendirilir. 7. Türkiye Acil Tıp Dergisi’nde yayınlanacak yazıların biyomedikal dergilerin ortak ihtiyaçlarını karşılaması ve Helsinki deklarasyonuna uyması aranır. 8. Dergide yayımlanan makaleler, içindekiler sayfasında ve makale başlık sayfalarında türlerine göre (araştırma, olgu sunusu, derleme gibi) sınıflandırılarak basılır. 9. Dergi basımında asitsiz kâğıt kullanılır. 10. Reklâmlara makale içinde yer verilmez. 11. Türkiye Acil Tıp Dergisi editörü veya editörleri Türkiye Acil Tıp Derneği Yönetim Kurulu tarafından, her yıl Ocak ayında belirlenir. Dergi yayın kurulunu editörler, editör yardımcıları, araştırma metodolojisi editörü ve dil editörü oluşturur. 12. Türkiye Acil Tıp Dergisi’nde yayımlanan tüm yazıların yayın hakkı Türkiye Acil Tıp Derneği’ne aittir. Bu dergiden kaynak gösterilmeden alıntı yapılamaz ve derginin hiçbir bölümü izinsiz çoğaltılamaz. Dergide yayımlanan yazılardaki görüşler, tümüyle yazarlarına aittir.

Türkiye Acil Tıp Dergisi Editörleri Doç. Dr. Cenker EKEN Doç. Dr. Murat PEKDEMİR

Türkiye

Acil Tıp Dergisi Turkish Journal of Emergency Medicine

Publishing with the Tr J Emerg Med

1. The Turkish Journal of Emergency Medicine (Tr J Emerg Med) is published four times per year. The total number of original research articles is 15 per year and research articles (including original research, case studies, letters to the editor and reviews) constitute at least 50% of the published material. Every issue published will contain a minimum of 4 research articles. Apart from the research articles, Tr J Emerg Med also publishes articles in the categories of case studies, case series, visual diagnoses in emergency medicine, letters to the editor, brief reports, reviews and evidence based emergency medicine in consultation with the editorial board. Reviews are presented upon invitation from the editor. 2. All reviewer comments, signed copies of manuscripts and corrections will be kept in digital format in the journal archives for a minimum period of 5 years. 3. The submitted manuscripts are first reviewed by the journal’s editor who determines whether the manuscript deserves further evaluation or not. For submissions that are granted further evaluation, the editor assigns the manuscript to one of the assistant editors. The editor and the assistant editor then forwards the manuscript to two reviewers or one reviewer and a member of the scientific board for evaluation. If both the editor and the assistant editor determines the manuscript is not scientifically valuable or not an original work, or if it does not relate to emergency medicine or does not address the journal’s target audience, then they reject the manuscript directly without forwarding it to the reviewers. 4. The goal of the Tr J Emerg Med is to notify the authors with the acceptance of their submission for peer review within 14 days, peer review period of 21 days and final evaluation and notification of 28 days from the receipt of the manuscript. The authors are given 10 days for minor revisions and 20 days for major revisions. The final page layout is provided to the authors within 30

days of the acceptance of the manuscript for publication, for final review and proof. 5. The assistant editor may consult the research methodology editor to clarify any problems in the statistical design and evaluation of the study during the peer review process. Even if such consultation is not sought during the review process, it can be implemented upon request of the editor in chief prior to the final acceptance of the manuscript. 6. All manuscripts containing material written in English will be evaluated by the language editor before the manuscripts are considered for publication. 7. Manuscripts submitted to the Tr J Emerg Med are expected to conform with the Helsinki Declaration and meet the common requirements of the biomedical journals. 8. Articles are listed on the content page and are published in appropriate sections (original research, case report, review, etc.). 9. The journal is printed on acid-free paper. 10. Advertisements are not allowed within articles. 11. The editor(s) of the Tr J Emerg Med are elected by the Board of the Emergency Medicine Association of Turkey once a year in January. The Tr J Emerg Med board consists of editor(s), assistant editors, a research methodology editor and a language editor. 12. All material published in the Tr J Emerg Med are the property of the Emergency Medicine Association of Turkey. This material may not be referred without citation nor may it be copied in any format. Authors are responsible for all statements made in their articles.

Editors of the Tr J Emerg Med Cenker EKEN, Assoc. Prof. Murat PEKDEMİR, Assoc. Prof.

Türkiye

Acil Tıp Dergisi Turkish Journal of Emergency Medicine

Yazarlara Bilgi Türkiye Acil Tıp Dergisi, Türkiye Acil Tıp Derneğinin resmi bilimsel yayın organıdır, ulusal ve uluslararası makaleleri yayımlayan, ön değerlendirmeli bir dergidir. Yayın hayatına 2000 yılında başlayan ve bu konuda ülkemizde yayınlanan ilk dergi olan Türkiye Acil Tıp Dergisi, Türk Tıp Dizini, EBSCOHost, Index Copernicus, DOAJ, Gale/Cengage Learning, SCOPUS, EMBASE ve Türkiye Atıf Dizini’nde indekslenmektedir. Türkiye Acil Tıp Dergisi acil tıp ve acil sağlık hizmetleri konusunda bilimsel içerikli araştırma makaleleri, olgu sunumu, olgu serisi, acil tıpta görsel tanı, derleme, kısa rapor, kanıta dayalı acil tıp makaleleri, tıbbi düşünceleri ve ilgili bilimsel duyuruları yayınlar. Dergi içeriğindeki temel bölümler acil tıp sistemleri, akademik acil tıp, acil tıp eğitimi, acil servis yönetimi, afet tıbbı, çevresel aciller, travma, resusitasyon, analjezi, pediatrik aciller, tüm tıbbi aciller, hastane öncesi bakım, toksikoloji, acil hemşireliği, sağlık politikaları, etik, yönetim, görüntüleme ve prosedürlerdir. Türkiye Acil Tıp Dergisi’nde yayınlanacak yazılarda öncelikle biyomedikal dergilerin ortak ihtiyaçlarını karşılaması ve Helsinki Deklarasyonu’na uyum aranmaktadır. Bu konu hakkındaki bilgiler aşağıdaki makaleden elde edilebilir. “Uniform requirements for manuscripts submitted to biomedical journals and declaration of Helsinki; Recommendations guiding physicians in biomedical research involving human subjects. JAMA 1997;277:927-934” Türkiye Acil Tıp Dergisi Yayın Kurulu yılda bir kez Aralık ayında Türkiye Acil Tıp Derneği Yönetim Kurulu tarafından belirlenir. KATEGORİLER Araştırma Makaleleri: Acil tıp konusunda yapılmış temel veya klinik araştırma makaleleridir. Türkçe ve İngilizce özet gereklidir. Giriş, gereç ve yöntem, bulgular, tartışma, kısıtlılıklar ve sonuç bölümleri içermelidir. En fazla 4000 kelime, altı tablo veya resim içerir. Tek merkezli çalışmalar için yazar sayısı en fazla sekiz kişi ile sınırlıdır. Çalışmaların yayımlanabilmesi için etik kurul onayı gereklidir. İlaç çalışmaları için ise merkez etik kurul onayı gereklidir. Olgu Sunumları: Acil tıpta nadiren karşılaşılan, eğitimsel yönü olan, hekimlere mesaj veren klinik vakaların veya komplikasyonların sunumudur. Bu bölüme yayın için gönderilen yazılarda daha önce bilimsel literatürde bildirilmemiş klinik durumları, bilinen bir hastalığın bildirilmemiş klinik yansımaları veya komplikasyonlarını, bilinen tedavilerin bilinmeyen yan etkilerini veya yeni araştırmaları tetikleyebilecek bilimsel mesajlar içermesi gibi özellikler aranmaktadır. Türkçe ve İngilizce özet gereklidir. Giriş, olgu sunumu ve tartışma bölümlerini içerir. Makalenin uzunluğu 1500 kelime ile sınırlıdır. On beş veya daha az kaynak, iki tablo veya resim içermelidir. Yazar sayısı en fazla beş kişi ile sınırlıdır. Olgu Serileri: Acil tıpta nadiren karşılaşılan eğitimsel yönü olan klinik vakaların veya komplikasyonların sunumudur. Yediden fazla olgunun sunulması gereklidir. Türkçe ve İngilizce özet gereklidir. Giriş, olgu sunumu ve tartışma bölümlerini içerir. Makalenin uzunluğu 2500 kelime ile sınırlıdır. On beş veya daha az kaynak, üç tablo veya şekil içermelidir. Yazar sayısı en fazla altı kişi ile sınırlıdır. Özet Raporlar: Ön çalışma verileri ve bulguları, daha ileri araştırmaları gerektiren küçük olgu sayılı araştırmalardır. Türkçe ve ingilizce özet gereklidir. Giriş, metod, bulgular, tartışma, kısıtlılıklar ve sonuç bölümlerini içermelidir. En fazla 4000 kelime, dört tablo veya resim içerir. Tek merkezli çalışmalarda yazar sayısı en fazla 6 kişi ile sınırlıdır. Etik kurul onayı gereklidir. İlaç çalışmaları için ise merkez etik kurul onayı gereklidir. Konseptler: Acil tıp ile ilgili ve acil tıp bilimini geliştirmeye yönelik klinik veya klinik olmayan konulardaki yazılardır. Türkçe ve İngilizce özet gereklidir. Makalenin uzunluğu 4000 kelime ile yazar sayısı ise en fazla 3 kişi ile sınırlıdır. İngilizce ve Türkçe özet içermelidir.

Derleme Yazıları: Acil tıp konusundaki güncel ulusal ve uluslar arası literatürleri içeren geniş inceleme yazılarıdır. Türkiye Acil Tıp Dergisi davetli derleme makaleleri yayımlamaktadır. Davetli olmayan derleme başvuruları öncesinde editör ile iletişime geçilmelidir. En fazla 4000 kelime olmalıdır. Kaynak sayısı konusunda sınırlama yoktur. Yazar sayısı en fazla 2 kişi ile sınırlıdır. Kanıta Dayalı Acil Tıp (Evidence-Based Emergency Medicine): Klinik ve tıbbi uygulamalara yönelik sorulara yanıt verebilen makalelerdir. Makale; klinik senaryo, soru (veya sorular), en iyi kanıtın araştırılması, en iyi kanıtın seçilmesi, kanıtın analiz edilmesi ve kanıtın uygulanması bölümlerini içermelidir. En fazla 4000 kelime olmalıdır. Türkçe ve İngilizce özet gereklidir. Yazarlar kullandıkları makalelerin kopyalarını da ekte editöre göndermelidir. Yazar sayısı en fazla 4 kişi ile sınırlıdır. Acil Tıpta Görsel Tanı: Görsel materyali eğitici ve ilgi çekici olan, kısa olgu sunumlarıdır. Yazı 2 bölümden oluşur. İlk bölümde olgu kısaca özetlenir ve görsel materyal sunulur. Bu bölümde görsel materyalin tanısı okurla paylaşılmaz. İkinci bölümde tanı başlık olarak verilir, olgunun yönetimi ve görsel materyalin özellikleri kısaca tartışılır. En fazla 500 kelime ve 5 kaynak olmalıdır. Yazar sayısı en fazla 2 kişi ile sınırlıdır. Özet gerekli değildir. Editöre Mektup: Acil tıp ile ilgili konulardaki görüşler, çözüm önerileri, Türkiye Acil Tıp Dergisinde veya diğer dergilerde yayımlanan makaleler hakkında yorumları içeren yazılardır. En fazla 1000 kelime ve 5 kaynak ile sınırlıdır. Tek yazarlı makalelerdir. Özet gerekli değildir. MAKALE BAŞVURUSU Türkiye Acil Tıp Dergisi’ne makale başvuruları çevrimiçi olarak kabul edilmektedir. Türkiye Acil Tıp Dergisi’nin web sayfasında “çevrim içi makale gönder” sekmesini kullanarak makale başvuru yapılabilir. MAKALE BAŞVURU İÇİN GEREKLİ BELGELER Makale Başvuru Mektubu (Cover Letter): Yazar bu mektupta makalenin başlığını, tipini, hangi kategori için gönderildiğini, daha önce bilimsel bir toplantıda sunulup sunulmadığını ayrıntısı ile belirtmelidir. Ek olarak yazı konusunda bağlantıya geçilecek kişinin adresi, telefon-faks numaraları ve varsa elektronik posta adresi mektubun alt bölümünde yer almalıdır. Başlık Sayfası (Title Page): Bu sayfada makalenin başlığı, sırasına göre yazar isimlerli (akademik titri ve kurum adresleri ile birlikte) bulunmalıdır. Bunu dışında kısa başlık (running title) ve yazı konusunda bağlantıya geçilecek yazarın iletişim bilgilerini içermelidir. Kör Ön Değerlendirme İçin: Makalenin sayfalarında ve Türkçe - İngilizce özet sayfalarında yazarların isminin, akademik derecesinin, adresinin, şehrinin yer almamasına dikkat edilmelidir. Bu şartı bulundurmayan makaleler geri gönderilir. MAKALE HAZIRLAMA DETAYLARI Türkçe ve İngilizce Özet: Orijinal makaleler, kanıta dayalı acil tıp ve özet raporlar için 250 kelime ile sınırlandırılmış özet gereklidir. Orijinal makaleler ve özet raporlar için amaç, gereç ve yöntem, bulgular ve sonuç olmak üzere 4 bölümden oluşmalıdır. Olgu sunumları için Türkçe ve İngilizce özet 150 kelimeyi aşmamalıdır. Anahtar sözcükler: Yazının niteliğine göre İngilizce; PubMed MeSH (www. nlm.nih.gov/mesh/MBrowser.html) veya Türkçe; Türkiye Bilim Terimleri (www.bilimterimleri.com) web sitelerinden yararlanarak özenle seçilmelidir. Araştırma Makalelerinin İçeriği: Araştırma makaleleri aşağıdaki bölümleri içermelidir; Giriş: Üç paragraf halinde yazılmalıdır. Çalışma konusu hakkında kısa bilgi (1. paragraf ), çalışmaya neden olan tartışma konusu (2. paragraf ) ve hipotez (çalışmanın amacı, son paragraf ) ayrı paragraflar halinde belirtilmelidir.

Türkiye

Acil Tıp Dergisi Turkish Journal of Emergency Medicine

Yazarlara Bilgi Gereç ve Yöntem: Araştırma makalelerinin en önemli bölümlerinden birisi olan metod, olabildiğince detaylı yazılmalıdır. Çalışmanın yöntemi, çalışma örneklemi, analiz yöntemleri, kullanılan ticari istatistik program, ölçme ve değerlendirme yöntemlerinin detayları (örneğin biyokimyasal testler için cihaz ve test kiti markası) açıkça belirtilmelidir. Çalışmaya alma ve dışlama kriterleri maddelenmelidir. Anket çalışmalarında, anketin kim tarafından nasıl doldurulduğu belirtilmelidir. Bulgular: Çalışma popülasyonun demografik özellikleri, çalışma hipotezini sınayan ana ve yan sonuçlar önem sırasına göre verilmelidir. Bu bölümde sonuçlar hakkında yorum yapılmasından ve literatür bilgilerinin tartışılmasından kaçınılmalıdır. Sonuçların grafikler, ortalama, ortanca, dağılım ve %95 güven aralığı ile sunulmasına özen gösterilmelidir. Tartışma: Çalışmanın ana ve yan sonuçları kısaca belirtilir ve literatürdeki benzer örnekler ile karşılaştırılır. Yoğun ve çalışmanın konusu dışındaki gereksiz ansiklopedik bilgi paylaşımından kaçınılmalıdır. Kısıtlılıklar: Çalışmanın kısıtlayıcı faktörleri, tartışma bölümünün sonunda “kısıtlılıklar” alt başlığı ile mutlaka belirtilmelidir. Sonuç: Çalışmanızdan ortaya çıkan veriler ışında, dergi okurları için uygun ve net bir sonuç çıkarılmalıdır. Bir cümle ile çalışma sonucunun, mevcut klinik uygulamalar üzerine olası etkileri belirtilmelidir. Çalışma verilerinin desteklemediği çıkarımlardan uzak durulmalıdır. Genel yazımda dikkat edilecek noktalar İstatistiksel testler: Çalışmalar istatistik alanında deneyimli kişilerin kontrolünde analiz edilmelidir. Değerler: Kullanılan madde, ilaç, laboratuvar sonuçları değerlerinde genel standartlara uyulmalıdır. Laboratuar sonuçlarının normal aralıkları belirtilmelidir. İlaçlar: Jenerik isimler kullanılmalıdır. İlaçların dozu, uygulama yolu belirtilmelidir. Türkçe kullanımı: Türkçe terminolojinin kullanılmasına (“Hospitalizasyon” yerine “hastaneye yatış”, suicid yerine “özkıyım” kullanımı gibi) ve Türkçe yazım kurallarına uyulmasına özen gösterilmelidir. Kaynaklar: Kaynaklar çift aralıkla yazılmalı ve makalenin sonunda yer almalıdır. Kaynakları makale içinde kullanım sırasına göre numara verilmeli, alfabetik sıralama yapılmamalıdır. “Abstract” olarak faydalanılmış makaleler için parantez içinde “abstract” yazılmalıdır. Bir kaynaktaki yazarların sadece ilk altısı belirtilmeli, geri kalanlar için “ve ark.” kısaltmasını kullanılmalıdır. Kaynakların doğruluğu yazarların sorumluluğundadır. Kaynak Örnekleri; Makale: Raftery KA, Smith-Coggins R, Chen AHM. Gender-associated differences in emergency department pain management. Ann Emerg Med 1995;26:414-21. Kitap: Callaham ML. Current Practice of Emergency Medicine. 2nd ed. St. Luis, MO: Mosby; 1991. Kitap Bölümü: Mengert TJ, Eisenberg MS. Prehospital and emergency medicine thrombolytic therapy. In: Tintinalli JE, Ruiz E, Krome RL, editors. Emergency Medicine: A Comprehensive Study Guide. 4th ed. New York, NY: McGraw-Hill; 1996. p. 337-43. Basılmamış kurslar, sunumlar: Sokolove PE, Needlesticks and high-risk exposure. Course lecture presented at: American College of Emergency Physicians, Scientific Assembly, October 12, 1998, San Diego, CA. İnternet: Fingland MJ. ACEP opposes the House GOP managed care bill. American College of Emergency Physicians Web site. Available at: http://

www.acep.org/press/pi980724.htm. Accessed August 26,1999. Kişisel görüşme: Kişisel danışmanları referans göstermekten kaçınılmalıdır. Ancak gerekli durumlarda kişinin adı, akademik derecesi, ay, yıl bilgilerine ek olarak kişiden yazılı olarak bu bilgiyi kullanabileceğinize dair mektubu makale ile birlikte gönderilmelidir. Tablolar: Verileri özetleyen kolay okunur bir formatta hazırlanmalıdır. Tabloda gösterilen veriler, makalenin metin kısmında ayrıca yer almamalıdır. Tablo numaraları yazıda ardışık yer aldığı biçimde verilmelidir. Metinde tabloları işaret eden cümleler bulunmalıdır. Şekiller/Resimler: Şeklin/Resmin içerdiği bilgi metinde tekrarlanmamalıdır. Metin ile şekilleri/resimleri işaret eden cümleler bulunmalıdır. Resimler JPEG, EPS veya TIF formatında kaydedilmelidir. Renkli resimler en az 300 DPI, gri tondaki resimler en az 300 DPI ve çizgi resimler en az 1200 DPI çözünürlükte olmalıdır. DERGİ POLİTİKALARI Orijinal Yazı: Dergimiz, randomize kontrollü çalışmaları kanıt değerinin daha yüksek olması nedeniyle yayınlamayı tercih etmektedir. Yeni bilgi ve veri içeren makaleler daha önce bir bilimsel dergide yayınlanmamış ve yayınlanması için aynı anda başvurulmamış olmalıdır. Bu sınırlama özet halinde bilimsel toplantı ve kongrelerde sunulmuş çalışmalar için geçerli değildir. Birden Fazla Yazar: Makalede yer alan tüm yazarlar makalenin içeriğindeki bilgilerin sorumluluğunu ve makale hazırlanma basamaklardaki görevleri paylaşırlar. İstatistik Danışmanı: İstatistiksel analiz içeren tüm makaleler istatistik konusunda deneyimli bir uzmana danışılmış olmalıdır. Yazarlardan biri ya da yazarların dışında belirlenmiş ve istatistik konusunda deneyimli ve yetki sahibi kişi, bu analizin sorumluluğunu üstlenmelidir. İzinler: Makalede yer alan herhangi bir resim, tablo vs. daha önceden başka bir bilimsel dergi veya kitapta yayınlanmış ise bu tablo ve resimlerin kullanılabilirliğine dair yazı alınması gerekmektedir. Araştırma makaleleri için etik kurul onayı, olgu sunumları, acil tıpta görsel tanı ve olgu serileri için hastalardan yazılı onam alınmalıdır. Aydınlatılmış onam formlarına http://www.trjemergmed.com/TATD_copyright_transfer_tur.pdf adresinden erişebilirsiniz. DEĞERLENDİRME VE BASIM SÜRECİ Ön Değerlendirme: Dergi kör ön değerlendirmeyi tüm makale kategorileri için uygulamaktadır. Tüm makaleler dergi editörü tarafından incelenir ve uygun bulunan makaleler ön değerlendirme amacıyla editör yardımcılarına iletilir. Tüm makaleler editörlerce dergi yazım kuralları ve bilimsel içerik açısından değerlendirilirler. Gerekli görüldüğünde yazıda istenen değişiklikler yazara editörlerce yazılı olarak bildirilir. Dergi editörü bazı makaleleri direkt olarak kabul ya da ret edebilir. Yazının Sorumluluğu: Yazarlar basılmış halde olan makalelerinde bulunan bilgilerin tüm sorumluluğunu üstlenirler. Dergi bu makalelerin sorumluluğunu üstlenmez. Basım Hakkı: Dergide basılmış bir makalenin tamamı veya bir kısmı, makaleye ait resimler veya tablolar Türkiye Acil Tıp Dergisi editörü ve Türkiye Acil Tıp Derneği Yönetim Kurulu, bilgisi ve yazılı izni olmadan başka bir dergide basılamaz. Gerekli Bilgiler: Dergi editörleri ön değerlendirme sürecinde gerek duyduklarında makalenin dayandırıldığı verileri incelemek için yazardan isteyebilirler. Bu nedenle yazara kolay ulaşımı sağlayacak adres ve diğer iletişim araçlarının başlık sayfasında yer alması önemlidir.

Türkiye

Acil Tıp Dergisi Turkish Journal of Emergency Medicine

Instructions for Authors Tr J Emerg Med is the official publication of the Emergency Medicine Association of Turkey. It is a peer-reviewed journal that publishes national and international articles. Founded in 2000, it is the first journal of its kind in Turkey and is indexed in the Turkish Medical Index, EBSCO Host, Index Copernicus, DOAJ, Gale/Cengage Learning, SCOPUS, EMBASE and Turkish Citation Index. Tr J Emerg Med publishes articles relevant to emergency medicine and emergency medical services such as; scientific research, case reports, case series, visual diagnoses, brief reports, evidence based emergency medicine articles, opinions and relevant scientific announcements. The main sections of the journal include emergency medicine systems, academic emergency medicine, emergency medicine education, emergency department management, disaster medicine, environmental emergencies, trauma, resuscitation, analgesia, pediatric emergencies, medical emergencies, pre-hospital medicine, toxicology, emergency nursing, health policy, ethics, management, imaging and procedures. The articles published in the Tr J Emerg Med are expected to conform with the Helsinki Declaration and meet the common requirements of biomedical journals. Further information can be found in the following article: “Uniform requirements for manuscripts submitted to biomedical journals and declaration of Helsinki; Recommendations guiding physicians in biomedical research involving human subjects. JAMA 1997;277:927-934” The editorial board of the Turkish Journal of Emergency Medicine is appointed by the Board of the Emergency Medicine Association of Turkey once a year in December. CATEGORIES Research Articles: Original studies of basic or clinical investigations in emergency medicine. Turkish and English abstracts are required. Articles must include introduction, material and method, results, discussion, limitations and conclusion sections. The maximum number of words is 4,000 with a total of six tables or figures are allowed. For single centre studies the number of authors is limited to eight. The approval from the Institutional Review Board (IRB) is required prior to publication. Pharmeceutical studies require approval from the Regional Ethics Board prior to publication. Case Reports: Brief descriptions of clinical cases or the complications that are seldom encountered in emergency medicine practice and have an educational value. Consideration will be given to articles presenting clinical conditions, clinical manifestations or complications previously undocumented in the existing literature and unreported side of adverse effects of the known treatment regimes or scientific findings that may trigger further research on the topic. Turkish and English abstracts are required. Case reports must include introduction, case presentation and discussion sections. They must be limited to 1,500 words, contain 15 references or less and two tables or figures. A maximum of five authors for a case study will be permitted. Case Series: Brief descriptions of clinical cases or the complications that are seldom encountered in emergency medicine practice and have educational value. Case series must include introduction, case presentation and discussion sections. They must be limited to 2,500 words, contain 15 references or less and three tables or figures. A maximum of six authors for a case series will be permitted. Brief Reports: Reports involving a small number of cases that require further investigation. Preliminary data and results are shared. Turkish and English abstracts are required. Reports must include introduction, methods, results, discussion, limitations and conclusion sections. They are limited to 4,000 words and four tables or figures. For single centre studies he number of authors are limited to six. Approval from the Institutional Review Board (IRB) is required prior to publication. Pharmeceutical studies require approval from the Regional Ethics Board approval prior to publication.

Concepts: Clinical or non-clinical articles related to the field of emergency medicine and detailing improvements to emergency medicine practice. Turkish and English abstracts are required. The manuscripts must not exceed 4,000 words and limited three authors per article. Review Articles: Comprehensive articles reviewing national and international literature related to current emergency medicine practice. Generally Tr J Emerg Med publishes invited review articles. Other authors should contact the editor prior to submission of review articles. Manuscripts must be limited to 4,000 words and a maximum two authors. There is no limit to the number of references. Evidence-Based Emergency Medicine: Articles seeking to detail clinical and medical practices should present a clinical scenario followed by the research question(s), followed by a selection of the best available evidence, analysis of the evidence and the application of the evidence. Turkish and English abstracts are required. The manuscript must be limited to 4,000 words and a maximum of four authors. The authors should also submit copies of the articles proposed as supporting evidence. Images in Emergency Medicine: Short case reviews with interesting and educative visual material. The case study is to be presented in two parts. In the first part, the case is summarized and the image is presented. In the second part, the diagnosis is provided in the heading, followed by a discussion of the management of the case and the specifications of the images. The review should consist of a maximum of 500 words and 5 references are allowed. The article should be prepared by no more than two authors. There is no need for abstract. Letter to the Editor: Opinions, comments and suggestions made concerning articles published in Tr J Emerg Med or other journals. Letters should contain a maximum of 1,000 words and 5 references are allowed for these single author submissions. No abstract is required. SUBMITTING MANUSCRIPTS Tr J Emerg Med accepts online manuscript submission. Users should go to the journal’s web site (http://www.journalagent.com/tatd/) and create an account before submitting their manuscripts. REQUIRED SUBMISSION DOCUMENTS Cover Letter: The author(s) should present the title, type and category of the article, and whether the submitted work had previously been presented in a scientific meeting. In addition, the full name of the corresponding author and his/her contact information including the address, phone number, fax number and email address should be provided at the bottom of the cover letter. Title Page: On the title page, the title of the article, and the names of the authors’, including their academic titles and institutions should be listed in order. In addition, the running title and the name of the corresponding author along with his/her contact information should be provided. For the Blind Initial Review: The names of the authors’, and any identifying information including the academic titles, institutions and addresses must be omitted. Manuscripts submitted with any information pertaining to the author(s) will be rejected. MANUSCRIPT PREPARATION Turkish and English Abstracts: Turkish and English abstracts containing a maximum of 250 words are required for original research articles, evidence based emergency medicine and brief reports. The abstracts for original research articles and brief reports must contain four sections including the aim, material and method, results and conclusion. For a case report of medical care the Turkish and English abstracts should not exceed 150 words.

Türkiye

Acil Tıp Dergisi Turkish Journal of Emergency Medicine

Instructions for Authors Key Words: Key words must be chosen carefully from PubMed MeSH (www. nlm.nih.gov) websites. Sections of Original Research Articles: Original research articles should contain the following sections: Introduction: A three-paragraph structure should be used. Background information on study subject (1st paragraph), context and the implications of the study (2nd paragraph) and the hypotheses and the goals of the study (3rd paragraph). Material and Method: The method section, is one of the most important sections in original research articles, and should contain sufficient detail. The investigation method, study sample, analyses performed, commercial statistical programs used, details of measurement and evaluation (e.g.: make and model of biochemical test devices and kits) should all be clearly stated. There should be a list of the inclusion exclusion criteria. In survey studies, information concerning who implemented the survey and how it was performed should be specified. Results: The demographic properties of the study population, the main and secondary results of the hypothesis testings must be provided. Commenting on the results and discussing the literature findings should be avoided in this section. The results should be presented with graphs, mean, median and standard deviation values as well as a 95% confidence interval. Discussion: The main and secondary results of the study should briefly presented and compared with similar findings in the literature. Providing intensive and encylopedical information should be avoided in this section. Limitations: The limitations of the study should be mentioned in a separate paragraph subtitled as the “Limitations” in the end of the discussion. Conclusion: A clear conclusion should be made in the light of the results of the study. The potential effects of the results of the study on the current clinical applications should be stated in a single sentence. Inferences that are not supported by the study results should be avoided. Points to be considered for general writing Statistical Analysis: All studies should be analysed in consultation with those experienced in statistical analysis. Units of Measure: Standard units of measure should be used when presenting the substances used, drugs and laboratory values. Normal limits should be provided for the laboratory values. Drugs: Generic names for drugs should be used. Doses and routes for the drugs should be stated. Use of Turkish/English: Proper use of Turkish/English terminology and grammar should be emplolyed. References: References should be written double spaced at the end of the article. They should be numbered in the order they appear in the text, and not listed alphabetically. The references that are used in the “Abstract” section should be stated as “(abstract)”. The names of the first three authors should be included in a given reference followed by “et al”. The authors are responsible for the accuracy of the references. Examples of Referencing Article: Raftery KA, Smith-Coggins R, Chen AHM. Gender-associated differences in emergency department pain management. Ann Emerg Med. 1995;26:414-21. Book: Callaham ML. Current Practice of Emergency Medicine. 2nd ed. St. Luis, MO: Mosby; 1991. Book Chapter: Mengert TJ, Eisenberg MS. Prehospital and emergency medicine thrombolytic therapy. In: Tintinalli JE, Ruiz E, Krome RL, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. New York, NY: McGrawHill;1996:337-343.

Courses and Lectures (unpublished): Sokolove PE, Needlesticks and high-risk exposure. Course lecture presented at: American College of Emergency Physicians, Scientific Assembly, October 12, 1998, San Diego, CA. Internet: Fingland MJ. ACEP opposes the House GOP managed care bill. American College of Emergency Physicians Web site. Available at: http:// www.acep.org/press/pi980724.htm. Accessed August 26, 1999. Personal Communication: Use of personal communications should be avoided. If necessary, the person’s name, academic title, and the month and year of the communication should be included in the reference. A letter of permission from the person refered to should accompany the manuscript. Tables: Tables summarizing the data should be clearly formatted. Data presented in the tables should not be included in its entireity in the text. Tables must be numbered consecutively. Each table must be referred to in the text. Figures / Pictures: The information contained in the figure/image should not be repeated in its entirety, however reference to the figure/image must be referred in the text. Pictures should be saved in JPEG, EPS or TIF format. Color and gray scaled pictures should have a minimum resolution of 300 dpi and the line art should be at least 1200 dpi. JOURNAL POLICY Original Content: The Tr J Emerg Med prefers publishing randomized controlled trials (RCTs) as they provide higher level of evidence. All articles containing original information and data must not have been published or simultaneously submitted for publication in another scientific journal. This restriction does not apply to an abstract presented in scientific meetings and congresses. Multiple Authors: All authors share the responsibilities of the content and duties in the preparation of the submitted material. Statistical Consultant: All articles containing statistical analysis must be prepared in consultation with an individual experienced in statistical analysis in the given subject. One of the authors or a person other than the author(s) who experienced in statistical analysis should claim responsibility for the correctness of the statistical information. Randomized Controlled Trials (RCTs): The journal prefers to publish RCTs. Permissions: Written consent for reproduction should accompany any submitted material, such as the tables and figures that have appeared in another journal or a book . Approval from the appropriate ethics board should be obtained for original research and written consent should be obtained from the patients refered to in case reports, images and case series. REVIEW AND PUBLICATION PROCESS Initial Review: A blind initial review is performed for all submitted material. The editor will review all the manuscripts for completeness and content. Then the material will be assigned to one of the assisstant editors for further evaluation. If required, requests for revisions are sent to the authors by the editors. The editor of the Tr J Emerg Med can on occasion accept or reject submitted material without sending it for further review. Responsibility for Published Information: The authors are responsible for all the information contained in the text. Tr J Emerg Med is not responsible for statements made by the author(s). Copyright: All or part of the published articles, including the tables and figures contained in them, may not be published elsewhere without the approval and written consent of the editor of the Tr J Emerg Med and the board members of the Emergency Medicine Association of Turkey. Access to Data: Editors of the Tr J Emerg Med may request the author(s) to submit the original data during the peer-review process in order to better assess the manuscripts. It is, therefore, vital to submit a full address and other contact information on the title page of the manuscript.

LETTER TO THE EDITOR EDİTÖRE MEKTUP

Scorpion Bite in North West Iran

Dear Editor, Contamination with scorpion venom is a common problem in many tropical and subtropical countries, and is an important cause of morbidity and mortality, particularly in children.[1] Failure to treat scorpion bites occurs frequently, mainly due to the peculiar distribution of scorpions to different parts of the world with inadequate access to medical treatment. This situation is very common in the tropics and subtropics, and in developing countries or under-developed countries where treatment with antidotes is difficult and records for estimating the number of cases are not available. [2] An epidemiological study of 11 regions of Saudi Arabia in a 5-year period reports 72,168 cases of scorpion sting. A study by K. Al-Asmani and colleagues conducted between 1986 and 2000 in Saudi Arabia found that scorpion stings occur most frequently in May (36%). Scorpion stings occur most frequently during summer (51%). Most scorpion stings reported in this study occured in adults.[3] Another study conducted in Turkey between 1995 and 2004 years including 930 cases of scorpion stings reported that the highest incidence occurrs in July and, with 45.48% of attacks occurring in men and 50.22% in women, with individuals 20-29 years old attacked at the highest frequency.[4] Global information about scorpion stings is poor and unreliable because most deaths caused by scorpion sting occur outside the hospital and among economically disadvantaged populations.[5] In a cross-sectional study in East Azarbaijan, Tabriz between 2008 and 201,1 the visitors to all hospitals in Tabriz reported 1439 scorpion bites, with 807 (56.1%) occurring in males and 632 (43.9%) in females and 102 (7.1%) bites occurring in children less than 10 years old. Individuals included in the study were between ages 2 months and 83 years, and the age 2130 years group had the highest frequency of scorpion bites at 484 (33.6%). The incidence of scorpion stings in urban ar-

eas is much more (1326, 92%) than in rural areas (112, 7.8%), occuring more frequently in the months of August (326, 22.7%) and July (322, 22.4%). Among these cases, 2 were fatal and the others were treated. Despite the number of scorpion stings in this area death is rare but the need for health education and methods for avoiding scorpion bites is great. Environmental hygiene is particularly important in urban areas where most scorpion bites occur. Acknowledgment Special thanks to Jamil Hemmat Ghadim to help us in gathering data. Dr. Samad Shams Vahdati1 Narges Moradi2 Emergency Department, Tabriz University of Medical Science, Iran 1

Nursing Faculty, Tabriz University of Medical Science, Iran

References 1. Fukuhara YD, Reis ML, Dellalibera-Joviliano R, Cunha FQ, Donadi EA. Increased plasma levels of IL-1beta, IL-6, IL-8, IL-10 and TNF-alpha in patients moderately or severely envenomed by Tityus serrulatus scorpion sting. Toxicon 2003;41:49-55. 2. Ismail M. The scorpion envenoming syndrome. Toxicon 1995;33:825-58. 3. Al-Asmari AK, Al-Saif AA. Scorpion sting syndrome in a general hospital in Saudi Arabia. Saudi Med J 2004;25:64-70. 4. Cesaretli Y, Ozkan O. Scorpion stings in Turkey: epidemiological and clinical aspects between the years 1995 and 2004. Rev Inst Med Trop Sao Paulo 2010;52:215-20. 5. Isbister GK, Volschenk ES, Balit CR, Harvey MS. Australian scorpion stings: a prospective study of definite stings. Toxicon 2003;41:877-83.

Submitted (Geliş tarihi): 07.07.2012 Accepted (Kabul tarihi): 14.10.2012 Published online (Online baskı): 14.10.2012 Correspondence (İletişim): Dr. Samad Shams Vahdati. No1, Gholestan 2, Pezeshkan Alley, Abrasani Street, Tabriz, Iran e-mail (e-posta): sshamsv@yahoo.com

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GÖRSEL TANI VISUAL DIAGNOSIS

Doktor Gözlerimi Kontrol Edemiyorum! Erhan DEDEOĞLU, Başak BAYRAM* Çanakkale Devlet Hastanesi, Acil Servis, Çanakkale

Yirmi dört yaşındaki kadın hasta, aniden başlayan gözlerinin yukarıya doğru kayması nedeni ile acil servise başvurdu (Şekil 1). Hastanın gözleri yukarıya deviye olup diğer sistem muayeneleri doğaldı. Nörolojik muayenesinde lateralizan bulgusu yok, vital bulguları stabildi. Tanı için, bkz. s. 195

Şekil 1. Hastanın klinik görünümü.

*Şimdiki kurumu: Dokuz Eylül Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, İzmir. Geliş tarihi (Submitted): 21.03.2011 Kabul tarihi (Accepted): 31.05.2011 İletişim (Correspondence): Dr. Başak Bayram. Dokuz Eylül Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, İzmir, Turkey e-posta (e-mail): basakdr@yahoo.com

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KLİNİK ÇALIŞMA ORIGINAL ARTICLE

The Effect of Cannula Material on The Pain of Peripheral Intravenous Cannulation in the Emergency Department: A Prospective, Randomized Controlled Study Acil Servisteki Periferik İntravenöz Kanül Uygulamalarında Kullanılan Kanül Materyalinin Girişim Ağrısı Üzerine Etkisi: Prospektif, Randomize Kontrollü Çalışma

Murat ÖZSARAÇ,1 Meral DOLEK,2 Münevver SARSILMAZ,1 Mustafa SEVER,3 Serkan SENER,4 Selahattin KİYAN,1 Aslihan YÜRÜKTÜMEN,5 Gülbin YILMAZ1 Department of Emergency Medicine, Ege University Medical Faculty Hospital, İzmir; Department of Emergency Medicine, Medical Park Izmir University Medical School Hospital, İzmir; 3 Izmir Tepecik Training and Research Hospital, Emergency Service, İzmir, 4 Department of Emergency Medicine, Acibadem University School of Medicine Hospital, İstanbul; 5 Department of Emergency Medicine, Akdeniz University Faculty of Medicine, Antalya, all in Turkey 1

SUMMARY

ÖZET

Objectives The present study was undertaken to compare the pain of peripheral IV cannulation (IVC) using a 20-G peripheral biomaterial PEU-Vialon cannula or the 20-G compound FEP-Teflon cannula widely used in clinical practice.

Amaç Bu çalışma, klinik pratikte yaygın olarak kullanılan, 20-G periferik FEPTeflon kanül ile 20-G PEU-biyomateryal Vialon kanülün, periferik IV yoldan uygulanması esnasında, hastalarda gelişen ağrıyı karşılaştırmak amacıyla yapıldı.

Methods A prospective, randomized, single-blinded, controlled trial was undertaken at the ED of University Hospital. Eighty-nine noncritically ill adult patients who were receiving an IV line as part of their care were enrolled. In each case cannulas were applicated to the antecubital area. Participants rated their pain on a visual analog scale (VAS). The primary outcome was patients pain score, and the secondary outcome was the provider’s perception of safety and satisfaction.

Gereç ve Yöntem Çalışma bir üniversite hastanesi acil servisinde prospektif, randomize, tek kör ve kontrollü olarak yapıldı. Acile kritik olmayan şikayetler ile başvuran, genel tıbbi bakımlarının bir parçası olarak IV yoldan damar yolu açılacak, seksen dokuz erişkin hasta çalışmaya alındı. Tüm IV damar yolu açılması uygulamaları antekübital alan üzerinden yapıldı. Çalışmaya katılanların işlem esnasındaki ağrıları görsel analog skala (VAS) ile değerlendirildi.

Results The two treatment groups did not differ in age, gender or cannulation indication (p>0.05). Mean VAS was 2.80 for PEU and 3.56 for FEP (p=0.061). Mean provider safety scores were 4.84 (4 to 5) in the PEU group and 4.00 (2 to 5) in the FEP group (p=0.0001). Mean provider satisfaction of application scores were 4.65 in the PEU group and 4.56 in the FEP group (p>0.05).

Bulgular İki tedavi grubunda yaş, cinsiyet veya kanülasyon göstergesi farklı değildi (p>0.05). Hastaların ortalama VAS skoru PEU kateter uygulananlar için 2.80, FEP kateter uygulananlar için 3.56 idi (p=0.061). Uygulayıcıların ortalama güvenlik algısı puanları PEU kateter uygulamaları için (4-5) 4.84, FEP kateter uygulamaları için (2-5) 4.00 olarak tespit edildi (p=0.001). Uygulayıcıların ortalama memnuniyet puanlarının; PEU kateter uygulamaları için 4.65 ve FEP için 4.56 olduğu belirlendi (p>0.05).

Conclusions Althogh provider safety perception is high, perception of pain has not reduced when inserting PEU-Vialon cannula compared with compound of FEP.

Sonuç İntravenöz yoldan kateter uygulamalarında, PEU-Vialon kateterlerin, FEPTeflon içerikli kateterler ile karşılaştırıldığında, hastalarda ağrı skorunu azaltmadığı ancak, mevcut güvenlik sağlayıcı kapaklarından dolayı, uygulayıcılarda yüksek işlem güvenliği algısı oluşturduğu belirlendi.

Key words: Analgesia; cannulation; emergency medicine; pain; pain measurement.

Anahtar sözcükler: Analjezi; kanülasyon; acil tıp; ağrı; ağrı ölçümü.

Submitted (Geliş tarihi): 27.06.2012 Accepted (Kabul tarihi): 01.10.2012 Correspondence (İletişim): Dr. Murat Özsaraç. Ege Üniversitesi Tıp Fakültesi Hastanesi, Acil Tıp Anabilim Dalı, Bornova, 35100 İzmir, Turkey e-mail (e-posta): mozsarac@msn.com

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Introduction Insertion of Intravenous Cannulas is probably the most commonly performed invasive medical procedure in emergency department (ED). A number of strategies to minimize the pain of intravenous cannulation (IVC) for patients include; local buffered lidocaine of skin infiltration, application of topical lidocaine,[1] liposomal lidocaine,[2] prilocaine, tetracain,[3-5] diclofenac patch,[6] ibuprofen, piroxicam,[7] myolaxin[8] and ice.[9] Examples of the latter alternatives include alkane vapocoolant spray[10,11] inhaled nitrous oxide,[12,13] jet injector lidocaine,[14,15] laser-assisted anesthesia,[16,17] low-frequency ultrasound[18] and distraction tactics as valsalva[19] and cough trick,[20] with variable results. Each technique has advantages as well as limitations, especially in the ED setting. Although pain and anxiety can be reduced by pretreating with local anesthetics, it is unclear which pretreatment technique is most effective. Application of anesthetic cream is one of the most popular technique for reducing pain during IV insertion, but the utility of these creams in a busy clinical setting such as the ED is limited by their delayed onset of action.[1] As a result, clinicians have continued to seek ways to reduce the pain of IVC.[16] The effect of the type of cannula material on the the pain of IVC has been less widely studied. Although most peripheral IVC’s are made of tetrafluoroethylene-hexafluoropropylene (FEP-Teflon), catheters made of polyurethanes (PEU-Vialon) are also available (Fig. 1). A catheteter material, polyetherurethane is based on polytetramethylene ether glycol, 4.4’-diphenylmethane diiosocyanate, and 1.4-butanediol. It has a

smoother microsurface, thermoplastic and more hydrophilic, makes it much more flexible than teflon at body temperature[21] (Fig. 2). The aim of this study was to compare the pain of IVC with FEP-Teflon and PEU-Vialon.

Materials and Methods Setting and Selection of Participants The study was conducted at a university ED which has emergency medicine residency program with an annual patient census of approximately 100.000. This was a prospective, randomized, controlled and single-blinded study designed to compare the pain of peripheral IVC between 20-G peripheral autoguard shielded PEU-Vialon (BD-Venflon, BectonDickinson, UK) and 20-G compound of FEP-Teflon cannula (Bicakcilar, Turkey) widely used in clinical practice in many ED. Patients were enrolled in January 2010 to December 2010 within weekdays and working hours. Historical and demographic information were recorded on a standardized data collection form. Eligible patients were 18 to 60 years requiring acute peripheral IVC as a component of their evaluation and treatment. Participants Canadian Emergency Department Triage and Acuity Scale (CTAS) were 4.5. Patients with any type of pain and the ones that take analgesics within 24 hours were excluded from the study. Patients were also excluded if the vein has been recently used for an infusion, with abnormal skin conditions (broken skin, infection, scar, eczema or urticaria) at the site of venous puncture, chronic renal or liver disease, malignancy, stroke, mental disorder and refusal to participate the study. The study was approved by the institutional review board. Informed consent was obtained from all volunteers prior to enrollment. We enrolled a convenience sample comprising patients who met the inclusion criteria during periods while the investigators were present in the ED (mainly 9 am to 5 pm on weekdays). Patients were assessed and managed according to

Figure 1. A. Polyurethane vialon catheter B. Teflon catheter.

Figure 2. Flexible thermoplastic PEU-Vialon peripheral intravenous catheters.

Ă&#x2013;zsaraĂ§ M et al.

The Effect of Cannula Material on the Pain of Peripheral Intravenous Cannulation in the ED

Table 1. Flow of patients through the trial Assessed for eligibility (n=105)

Excluded (n=5) Patient refused to participate or prefered to standart application (n=3) History of IV cannulation within the last 24 hours (n=2)

Randomized (n=100)

Applied PEU-Vialon cannula (n=50)

Applied FEP-Teflon cannula (n=50)

Excluded (n=5)

Excluded (n=6)

- Vein status neither visible nor palpable and initial cannulation failures (n=1)

- Vein status neither visible nor palpable and initial cannulation failures (n=2)

- Incomplete data or violation to protocol (n=4)

Analysed (n=45)

Analysed (n=44)

standard practice. After informing the patients and obtaining the written informed consents, series of opaque, consecutively numbered envelopes were opened to reveal the type of canulla to be applicated to the subjects. Participating patients were randomly assigned to apply PEU or FEP. Group assignment was determined by computer generated codes, thus ensuring an equal distribution of participants. Patients were randomized by an independent pharmacy assistant. Patients were unaware of the differences between cannula. Providers had no varying prominent experience in IVC. All cannula were inserted by four independent ED nurses with similar experience in the means of working years. Vein status was evaluated as veins neither visible nor palpable, veins visible but not palpable and veins clearly visible and easily palpable. Assessments and applications were made by the provider nurses. The providers choose the IVC site, applied a tourniquet, prepared the site with isopropyl alcohol, and inserted the cannula. All peripheral cannula were inserted using strict aseptic technique and secured using a sterile transparent dressing. For this study, insertion of the cannula

was limited to the antecubital fossa. In each case cannula were sited on antecubital area of approximately 10-12 cm2, at cephalic vein, median cephalic vein or accessory cephalic vein in the forearm. We measured the time from the start of searching for an appropriate vein (after the tourniquet was applied) to successful insertion of the cannula. Successful insertion was defined as free flow of blood out of the inserted IV catheter. Likewise, we recorded the number of failed first attempts. Following venous cannulation, patients were asked whether they experienced pain. Another nurse or staff who was also blinded to group allocation, collected data and recorded perception of the pain scores as rated by patients on a visual analogue scale (VAS) 0-100 mm (0=no pain, 100=most painful). Patients whose veins could not be cannulated successfully on the first attempt were considered as initial cannulation failures and withdrawn from the study analysis. Besides the subjects vein status neither visible nor palpable were also excluded from the study analysis. After each IVC attempt, providers assessed their level of perceptions in the means of safety and satisfaction on a five-point Likert scale.

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Primary outcomes were participants’ ratings of the pain of IVC by PEU or FEP groups. This was the pain measured immediately after cannulation using a validated visual analog pain scale marked ‘‘most pain’’ at the high end.[22] Secondary outcomes were the time for successful insertion and perceptions of the providers’ safety and satisfaction. The providers reported Likert scales on satisfaction (range, 1-5: 1=very dissatisfied and 5=very satisfied). Finally, they rated their overall perceptions of safety for the cannula they use on a five-point Likert scale from “not at all” to “very much”. All collected data were analyzed to reduce bias against participants who partially completed the study. Statistical Analysis Continuous data (the severity of pain, perception of provider’s safety and satisfaction) were summarized as means and 95% confidence intervals (95% CIs) and compared with Student t-test. Discrete variables (gender, vein status, clinical properties) were compared by chi-square statistics. SPSS 14.0 (SPSS Inc, Chicago, IL, U.S.A.) was used for statistical analysis. p<0.05 was considered as significant.

Results A total of 105 patients were enrolled over a 12 month period. Totally 16 subjects were excluded from the study (Table 1). Mean age was 33.38±11.4 years (range of 18-59); 32

subjects (36%) were man. Groups were similar with respect to demographic and clinical characteristics (Table 2). There were no statistically significant differences in these variables between the treatment groups. The mean duration of the vascular access procedure for each treatment group was approximately 5 to 10 seconds. There was no statistically significant difference in mean procedure duration between PEU and FEP groups (p=0.685). Most IVC (97%) were successful at the first attempt. Pain scores: The mean pain score of catheter insertion on FEP group was 3.56 mm (±2.02 mm); the mean pain score for the PEU group was 2.80 mm (±1.79 mm). The difference between the mean pain scores did not reach to statistical significance when compared by using the t-test (p=.061) Satisfaction and Safety: There was no difference in the perception of providers’ satisfaction between the FEP and PEU groups. However, there were remarkable difference in the perception of providers’ safety between the groups (p=.000) (Table 3).

Discussion IVC is a common procedure in the ED and it is also an uncomfortable experience for many patients.[11] Although guidelines call for multimodal management strategies for needlestick pain, compliance with recommendations is often poor in practice[23] Less than half of the medical doctors use local anesthetic for insertion of large bore intravenous cannula.

Table 2. Baseline characteristics of patients participating in the trial Characteristic

PEU (n=45)

FEP (n=44)

Demographic Age, mean (SD), yr Male, no. (%)

33.4 (11.6)

33.2 (11.5)

0.44

15 (37.8)

17 (34.1)

0.82

Clinical 0.08 Benign positional vertigo

Urticaria

11 13

Acute enteritis

Fever

–

Provider’s assessment of the vein 0.52 Veins clearly visible and easily palpable

Veins visible but not palpable

Table 3. Comparison of Material of Intravenous Insertion

PEU FEP p

Pain score (mean)

2.80

3.56

Perception of provider’s satisfaction (mean)

4.64

4.56

0.573

-0.566

Perception of provider’s safety (mean)

4.84

4.00

0.000*

-6.332

0.061

t 1.895

Özsaraç M et al.

The Effect of Cannula Material on the Pain of Peripheral Intravenous Cannulation in the ED

Furthermore, less than 20% of all doctors used any local anesthetic for the most commonly used cannula (20 Gauge). [24] Some reasons for caregivers overlooking a patient’s pain include the subjective nature of pain and the potential for caregivers to minimize the effect, or diminish the seriousness or psychological impact, of a patient’s pain.[25] Barriers to implementation of the guidelines are manifold and include a lack of knowledge among health care professionals regarding available pain assessment, as well as perceived time constraints and inconvenience for administering local anesthetics.[26] As a result, most ED patients have venous cannulation performed without any pretreatment with an anesthetic agent or device. Emergency practitioners should strive to reduce pain safely and effectively in all of their patients.[27] The ideal method for local anesthesia before IVC in the ED should be effective, fast, portable, require little training, cause no significant deviation from the usual routine, have no additional biologic or physical risks to the patient or the health care provider, and should eliminate sharps disposal and handling precautions. No commercially available modality has been shown to be as effective or faster.[14] This is the first study to assess the effect of canulla on the degree of pain experienced on IV insertion. We found PEU-Vialon cannula did not significantly reduce patients’ perception of pain when compared with compound of FEP. Nociceptors are sensory end organs in the skin, muscle, joints and viscera that selectively respond to noxious or potentially tissuedamaging stimuli. An important property of nociceptors is that they sensitize. Sensitization, which typically develops as a consequence of tissue insult and inflammation, is defined as a reduction in the threshold and an increase in the magnitude of a response to noxious stimulation.[28] Future investigation could aid in elucidating the role of the produce by means of nanotechnology products of related to cannula effect on mechanical tissue inflammation. Pain perception might influenced by anxiety, underlying conditions, culture and many other factors. However, strengths of this study are the use of blinding and enrolling only patients presenting with similar symptoms other than pain. More severe complaints might be more attentive to the pain of an IV insertion. Different locations in the body are more sensitive to pain than others. Clinical pain has an emotional component not present in experimental pain.[29] Another strength of this study is the IVC applied to the same location of all patients.

Commercially available intravenous catheters such as PEUViolan with self-capping needles have been associated with a significant reduction in the absolute number of inadvertent needlestick injuries. Related data could not be obtained in our country. In the era of human immunodeficiency virus (HIV) and hepatitis, safety of those placing IV lines cannot be overemphasized. Universal precautions must be applied to all patients, especially in emergency care settings in which the risk of blood exposure is increased and the infection status of patients is largely unknown. The protective IV catheter safety system has a protective sleeve that encases the sharp stylet as it is retracted from the catheter.[31] An PEU-Vialon catheters used in this study, needle shield once activated, the needle tip is fully encapsulated inside the protection mechanism, which is designed to minimize the risk of injuries. This study have shown that, perceive of safety during IV insertion by protective IV catheter system.

Health care is one of the areas scarcely subjected to research on work-related injuries in developing countries, especially in Turkey. These injuries commonly are overlooked and neglected by health care workers in the developing countries. Needlestick injuries and sharps injuries are the most common work-related injuries in EDs, where health care is incessant for 24 hours a day, 7 days a week. %14 of all work related injuries secondary to IV catheter applications.[30]

References

There are a couple of limitations that need to be acknowledged and addressed regarding the present study. First this study was not placebo controlled and independent providers were not blinded as to which cannula applied. Thereby any systematic bias could not be eliminated. Severity of anxiety of participant were also not recorded. The patient severity and status were all subacute and mild; CTAS 4 or 5, however, more severely anxious participant might be more reactive of an IVC. The relatively small sample size (105 patients) and relatively small number of hours analyzed (workhours between 08:00-17:00) could limit generalizability. Study population was composed of the subjects admitted in the emergency department within working hours and weekdays which may also cause bias.

Conclusions Althogh provider safety perception is high, perception of pain has not reduced when inserting PEU-Vialon cannula compared with compound of FEP. Acknowledgements We thank providers nurse in the emergency department and Gul Kitapcioglu in Biostatistics and Medical Informatics. BD Medical and (Selim Ates) BALKEM Medical provided the IV canulla material used in the study.

1. McNaughton C, Zhou C, Robert L, Storrow A, Kennedy R. A randomized, crossover comparison of injected buffered lidocaine, lidocaine cream, and no analgesia for peripheral intravenous cannula insertion. Ann Emerg Med 2009;54:214-20. 2. Eidelman A, Weiss JM, Lau J, Carr DB. Topical anesthetics for dermal instrumentation: a systematic review of randomized, controlled trials. Ann Emerg Med 2005;46:343-51.

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3. Sawyer J, Febbraro S, Masud S, Ashburn MA, Campbell JC. Heated lidocaine/tetracaine patch (Synera, Rapydan) compared with lidocaine/prilocaine cream (EMLA) for topical anaesthesia before vascular access. Br J Anaesth 2009;102:210-5. 3. Sawyer J, Febbraro S, Masud S, Ashburn MA, Campbell JC. Heated lidocaine/tetracaine patch (Synera, Rapydan) compared with lidocaine/prilocaine cream (EMLA) for topical anaesthesia before vascular access. Br J Anaesth 2009;102:210-5. 4. Yamamoto LG, Boychuk RB. A blinded, randomized, paired, placebo-controlled trial of 20-minute EMLA cream to reduce the pain of peripheral i.v. cannulation in the ED. Am J Emerg Med 1998;16:634-6. 5. Newbury C, Herd DW. Amethocaine versus EMLA for successful intravenous cannulation in a children’s emergency department: a randomised controlled study. Emerg Med J 2009;26:487-91. 6. Predel HG, Koll R, Pabst H, Dieter R, Gallacchi G, Giannetti B, et al. Diclofenac patch for topical treatment of acute impact injuries: a randomised, double blind, placebo controlled, multicentre study. Br J Sports Med 2004;38:318-23. 7. Dutta A, Puri GD, Wig J. Piroxicam gel, compared to EMLA cream is associated with less pain after venous cannulation in volunteers. Can J Anaesth 2003;50:775-8. 8. Agarwal A, Yadav G, Gupta D, Tandon M, Dhiraaj S, Singh PK. Et al. Comparative evaluation of myolaxin and EMLA cream for attenuation of venous cannulation pain: a prospective, randomised, double blind study. Anaesth Intensive Care 2007;35:726-9. 9. Richman PB, Singer AJ, Flanagan M, Thode HC Jr. The effectiveness of ice as a topical anesthetic for the insertion of intravenous catheters. Am J Emerg Med 1999;17:255-7. 10. Hijazi R, Taylor D, Richardson J. Effect of topical alkane vapocoolant spray on pain with intravenous cannulation in patients in emergency departments: randomised double blind placebo controlled trial. BMJ 2009;338:b215. 11. Hartstein BH, Barry JD. Mitigation of pain during intravenous catheter placement using a topical skin coolant in the emergency department. Emerg Med J 2008;25:257-61. 12. Gerhardt RT, King KM, Wiegert RS. Inhaled nitrous oxide versus placebo as an analgesic and anxiolytic adjunct to peripheral intravenous cannulation. Am J Emerg Med 2001;19:492-4. 13. Robinson PA, Carr S, Pearson S, Frampton C. Lignocaine is a better analgesic than either ethyl chloride or nitrous oxide for peripheral intravenous cannulation. Emerg Med Australas 2007;19:427-32. 14. Peter DJ, Scott JP, Watkins HC, Frasure HE. Subcutaneous lidocaine delivered by jet-injector for pain control before IV catheterization in the ED: the patients’ perception and preference. Am J Emerg Med 2002;20:562-6. 15. Auerbach M, Tunik M, Mojica M. A randomized, double-blind controlled study of jet lidocaine compared to jet placebo for pain relief in children undergoing needle insertion in the emergency department. Acad Emerg Med 2009;16:388-93.

16. Singer AJ, Regev R, Weeks R, Tlockowski DS. Laser-assisted anesthesia prior to intravenous cannulation in volunteers: a randomized, controlled trial. Acad Emerg Med 2005;12:8047. 17. Singer AJ, Weeks R, Regev R. Laser-assisted anesthesia reduces the pain of venous cannulation in children and adults: a randomized controlled trial. Acad Emerg Med 2006;13:6238. 18. Becker BM, Helfrich S, Baker E, Lovgren K, Minugh PA, Machan JT. Ultrasound with topical anesthetic rapidly decreases pain of intravenous cannulation. Acad Emerg Med 2005;12:289-95. 19. Agarwal A, Sinha PK, Tandon M, Dhiraaj S, Singh U. Evaluating the efficacy of the valsalva maneuver on venous cannulation pain: a prospective, randomized study. Anesth Analg 2005;101:1230-2. 20. Usichenko TI, Pavlovic D, Foellner S, Wendt M. Reducing venipuncture pain by a cough trick: a randomized crossover volunteer study. Anesth Analg 2004;98:343-5. 21. Maki DG, Ringer M. Risk factors for infusion-related phlebitis with small peripheral venous catheters. A randomized controlled trial. Ann Intern Med 1991;114:845-54. 22. Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med 2001;8:1153-7. 23. Bhargava R, Young KD. Procedural pain management patterns in academic pediatric emergency departments. Acad Emerg Med 2007;14:479-82. 24. Sado DM, Deakin CD. Local anaesthesia for venous cannulation and arterial blood gas sampling: are doctors using it? J R Soc Med 2005;98:158-60. 25. Walco GA, Cassidy RC, Schechter NL. Pain, hurt, and harm. The ethics of pain control in infants and children. N Engl J Med 1994;331:541-4. 26. Zempsky WT. Pharmacologic approaches for reducing venous access pain in children. Pediatrics 2008;122:140-53. 27. Oakbrook Terrace. Joint Commission on Accreditation of Healthcare Organizations. Improving the quality of pain management through measurement and action. Mar 2003. 28. Gold MS, Gebhart GF. Nociceptor sensitization in pain pathogenesis. Nat Med 2010;16:1248-57. 29. Fatovich DM, Jacobs IG. A randomized controlled trial of buffered lidocaine for local anesthetic infiltration in children and adults with simple lacerations. J Emerg Med 1999;17:2238. 30. Serinken M, Karcioglu O, Kutlu SS, Sener S, Keysan MK. A survey of needlesticks and sharp instrument injuries in emergency health care in Turkey. J Emerg Nurs 2009;35:205-10. 31. Liu SW, Zane R. Peripheral intravenous access. In: Roberts JR, Hedges JR, editors. Roberts clinical procedures in emergency medicine. 5th ed., Philadelphia, PA: Saunders; 2009. p. 402-12.

ORIGINAL ARTICLE KLİNİK ÇALIŞMA

Evaluation of Risk Factors and Clinical Characteristics of Elderly Patients with Acute Upper Gastrointestinal Hemorrhage Akut Üst Gastrointestinal Kanama Şikâyeti ile Başvuran Yaşlı Hastaların Klinik Özellikleri ve Risk Faktörlerinin Değerlendirilmesi Mustafa Burak SAYHAN,1 Serhat OĞUZ,2 Hasan ÜMİT,3 Esin SECGİN SAYHAN,4 Mustafa Onur ERALP,1 Gökhan AKDUR,1 Cemil KAVALCI,5 Tamer SAĞIROĞLU2 Departments of 1Emergency Medicine, 2General Surgery, 3Internal Medicine, 4Public Health, Trakya University Faculty of Medicine, Edirne; 5 Department of Emergeny Medicine, Ankara Numune Training and Research Hospital, Ankara, all in Turkey

SUMMARY

ÖZET

Objectives Acute upper gastrointestinal hemorrhage (AUGIH) is a life-threatening emergency problem in the elderly population. In this study, we aimed to determine the sociodemographic characteristics, clinical features and the risk factors of the elderly patients presenting to the Emergency Department (ED) with AUGIH.

Amaç Akut üst gastrointestinal sistem kanamaları yaşlı popülasyonda yaşamı tehdit eden acil bir tıbbı sorundur. Çalışmamızda akut üst gastrointestinal kanama nedeniyle acil servise başvuran 65 yaş ve üzeri popülâsyonda sosyodemografik ve klinik özelliklerin yanı sıra risk faktörlerinin değerlendirilmesi amaçlandı.

Methods A cross-sectional study was conducted in a university-based hospital. One hundred and ninety-four patients were divided into two groups: Group A (n=128); elderly group (65-79 years) and Group B (n=66); very elderly group (>79 years).

Gereç ve Yöntem Bu kesitsel çalışma üniversite merkezli hastanede gerçekleştirildi. Yüz doksan dört hasta Grup A (n=128) ve B (n=66) olarak ikiye ayrıldı. Grup A’da yaşları 65-79 arasındaki hastalar (yaşlı grup) ve Grup B’de 79 yaş üzeri hastalar (çok yaşlı grup) değerlendirmeye alındı.

Results The mean age was 76.34±7.91 years. The most frequently presenting symptom was melena (87.1%). Fourteen patients (7.2%) were in shock at the time of bleeding. One hundred and thirty-three patients (68.5%) had a history of rebleeding. Underlying comorbidities were detected in 171 patients (88.1%). There was a significant difference in terms of alcohol abuse and coronary artery disease between the two groups (p=0.038 and p=0.049 respectively). The most frequent endoscopic lesions were peptic ulcer and gastroduodenal erosions in both groups. Conservative medical treatments were applied in most of the patients in both groups, but there were no statistically significant differences in terms of response to conservative medical treatment between the two groups (p=0.892). The overall mortality rate was 11.7% in group A and 19.7% in group B. There were no statistically significant differences in mortality between the two groups (p=0.134).

Bulgular Çalışmaya alınan 194 hastanın yaş ortalaması 76.34±7.91 olarak bulundu. Tüm hastalarda en sık başvuru şikayeti melena idi (%87.1). Yüz otuz üç hastada (%68.5) gastrointestinal sistem kanama öyküsü varken, 14 hastada (%7.2) ise geliş anında şok mevcuttu. Yüz yetmiş bir hastada (%88.1) komorbid hastalık tespit edildi. Alkol kötüye kullanımı ve koroner arter hastalık mevcudiyeti Grup A’da Grup B’ye göre anlamlı oranda yüksek bulundu (sırasıyla, p=0.038. p=0.049). Her iki çalışma grubunda da endoskopik olarak en sık peptik ülser ve eroziv gastrit tespit edildi. Her iki grupta da en sık konservatif medikal tedavi uygulanırken gruplar arasında tedaviye yanıt açısından anlamlı fark tespit edilmedi (p=0.892). Mortalite oranları Grup A’da %11.7 iken Grup B’de %19.7 olarak bulundu. Mortalite açısından gruplar arasında anlamlı fark tespit edilmedi (p=0.134).

Conclusions Evaluation of risk factors and clinical characteristics of elderly patients with upper gastrointestinal hemorrhage is extremely important. Comorbid diseases and multiple drug use are commonly observed in the elderly patients.

Sonuç Üst gastrointestinal sistem kanaması şikâyeti ile başvuran yaşlı hastaların klinik özellikleri ve risk faktörlerinin değerlendirilmesi oldukça önem kazanmaktadır. Yaşlı popülasyonda yandaş hastalıklar ve çoklu ilaç kullanımı oldukça sık gözlenmektedir.

Key words: Elderly patients; emergency department; gastrointestinal hemorrhage.

Anahtar sözcükler: Geriatrik hasta; acil servis; gastrointestinal sistem kanaması.

Submitted (Geliş tarihi): 31.07.2012 Accepted (Kabul tarihi): 13.10.2012 Correspondence (İletişim): Dr. Mustafa Burak Sayhan. Trakya Üniversitesi Tıp Fakültesi Acil Tıp Anabilim Dalı, Edirne, Turkey e-mail (e-posta): mustafaburak@yahoo.com

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doi: 10.5505/1304.7361.2012.71354

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Introduction Acute upper gastrointestinal hemorrhage (AUGIH) represents a major medical emergency problem in public health. [1] AUGIH is one of the most significant causes of morbidity and mortality in hospitalized patients. The overall mortality rate associated with AUGIH is nearly 10-15%.[2] Recently life expectancy in developed countries has increased significantly. The elderly population is increasing in developing countries such as Turkey due to advances in life standards. In Turkey, the percentage of people above the age of 65 is 8%; however. This rate is expected to reach 12.2% in the year 2020.[3,4] It is a known fact that elderly people need ED and intensive care units more often than the other age groups. [5] The incidence of AUGIH increases with age[3] and the percentage of patients aged 60 and older with a diagnosis of AUGIH increased from 46.1% in 1987 to 63.2% in 2001.[6] Age also has been considered as a meaningful prognostic factor for mortality of patients after AUGIH.[6,7]

modalities such as endoscopic and surgical prosedures were also recorded and the mortality rates calculated. The presence of hemodynamic instability was defined as systolic blood pressure <90 mmHg and heart rate >100 beats/min.[10] Rebleeding was defined as a new bleeding episode within the first 3 days after the initial hemorrhage has stopped.[3] Patients with the following features were excluded from the study; aged <65 years (n=176), hematemesis caused by swallowing caustic agents (n=1) or foreign bodies (n=6), hemorrhage from upper respiratory tract (n=2), nose bleeding (n=7) and those who had inflammatory bowel disease (n=19). Statistical analysis

In this study, we aimed to determine the sociodemographic characteristics, clinical features and risk factors of the elderly patients presenting to the ED with AUGIH.

All data obtained in the present study were analysed using SPSS for Windows Version 15 (SPSS Inc. Chicago, IL, USA). Numerical variables are given as means and standard deviation (SD). while categorical variables are given as frequencies (n) and percentages. Categorized data were compared with the χ2 test. A “One Sample Kolmogorov Smirnov Test” was used to decide whether the values defined by the measurement fit the normal distribution. The comparison of the data found to fit the normal distribution was made with “Independent Samples T-test” and the comparison of the data did not fit the normal distribution were made using the “MannWhitney-U Test”. Differences were considered as statistically significant at p<0.05.

Material and Method

Results

A historical cohort study was conducted in a universitybased hospital. All patients aged ≥65 presenting to the ED with AUGIH between January 01, 2010 and June 30, 2011 were included. The study was approved by the Ethical Committee of the Faculty of Medicine.

Demographic features

There has been significant developments in the management of AUGIH. However this condition is still a critical problem for the elderly.[3,8] There is limited information on sociodemographic features, etiological characteristics and clinical outcomes of the very elderly patients presenting to ED with AUGIH in Turkey.

Patients were divided into two groups: Group A; the elderly group (65-79 years) and Group B; the very elderly group (>79 years). We defined “elderly” as those between 65 and 79 years of age[9] and “very elderly” as those older than 79 years of age.[3] Data was collected from medical records of all patients using computerized hospital database (according to ICD-10 ‘‘International Statistical Classification of Diseases and Related Health Problems’’K52, K92, K25, K92.1, K92.2) and a standard form that included demographic features, clinical characteristics and risk factors. Details like initial vital signs and presence of hemodynamic instability, rebleeding, history of operation, comorbidities, presence of alcohol abuse (social drinkers were excluded) and transfusion requirements were recorded. In addition initial laboratory findings, findings of urgent upper digestive endoscopy (UDE), treatment

A total of 38.006 patients presented to the ED between January 01, 2010 and June 30, 2011. The percentage of patients aged ≥65 was 18.0% (n=6.861) during the study time. A total of 194 patients with AUGIH were identified (2.8%). 128 patients (66.0%) were in group A and 66 (34.0%) were in group B. The mean age was 76.34±7.91 years (range 65-97). The percentage of male patients was higher in group A (67.2%) than group B (51.5%) and this difference was statistically significant (p=0.033). Clinical characteristics and risk factors Melena was the most frequent initial symptom. It was detected in 117 patients in Group A (91.4%), and 52 (78.8%) patients in Group B. Fourteen (7.2%) patients were in shock and hemodynamically unstable at the time of bleeding. One hundred and thirty-three (68.6%) patients had rebleeding. Comorbidities were detected in 171 patients (88.1%). Coronary artery disease was found in 23 (18.0%) patients in Group A, and 5 (7.6%) patients in Group B (p=0.049). Twelve

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(9.4%) patients in Group A and one (1.5%) patient in Group B had a history of alcohol abuse (p=0.038). There were significant differences between the two groups in terms of the presence of melena, alcohol abuse, and coroner artery disease (p=0.013, p=0.038 and p=0.049 respectively). No significant difference for transfusion requirements (p=0.721) and the other factors was observed (Table 1). Initial laboratory values The only significant difference was that, initial serum hemoglobin and hematocrit levels were higher in group A than in group B (p=0.010, p=0.002, respectively). There were no statistically significant differences between two groups at other

laboratory parameters (Table 2). Endoscopic findings All patients presenting with AUGIH had been examined with UDE by gastroenterologists to detect the source of hemorrhage within the first 24 hours. The most frequently observed endoscopic lesions were peptic ulcer and gastroduodenal erosions in both groups. The most frequent cause of bleeding was gastric ulcer (GU) in group A (29.7%), and duodenal ulcer (DU) in group B (33.3%). Oesophagogastric tumours (OGTâ&#x20AC;&#x2122;s) were more frequent in group A (14.8%) than in group B (4.5%) (p=0.032). No statistically significant differences were observed with other endoscopic lesions except for OGTâ&#x20AC;&#x2122;s between both groups (Table 3).

Table 1. Clinical characteristics and risk factors Variable

Group A (Elderly) (n=128) n (%)

Group B (Very Elderly) (n=66) n (%)

Clinical characteristics* Melena

117 (91.4)

52 (78.8)

Haematemesis

50 (39.1)

32 (48.5)

Hematochezia

15 (11.7)

8 (12.1)

Altered mental status

11 (8.8)

7 (10.9)

Abdominal pain

48 (37.4)

22 (33.4)

Weakness

40 (31.7)

21 (32.6)

Dizziness

47 (36.8)

26 (39.7)

Risk factors Presence of hemodynamic instability

11 (8.6)

3 (4.5)

Rebleeding

86 (67.2)

47 (71.2)

Comorbidities**

Diabetes mellitus

33 (25.8)

11 (16.7)

Coronary artery disease

23 (18.0)

5 (7.6)

Chronic renal disease

10 (7.8)

9 (13.6)

Congestive heart failure

16 (12.5)

10 (15.2)

Chronic liver disease

13 (8.6)

8 (6.1)

Neoplasia

8 (6.3)

2 (3.0)

Hypertension

71 (55.5)

41 (62.1)

Atrial Fibrilation

19 (14.8)

9 (13.6)

Cerebrovascular disease

17 (13.3)

11 (16.7)

Drugs

NSAID

25 (19.5)

10 (15.2)

Asetil salisilic acid

29 (22.7)

14 (21.2)

Warfarine

33 (25.8)

13 (19.7)

Previous history of operation

13 (10.2)

9 (13.6)

Alcohol abuse

12 (9.4)

1 (1.5)

*All patients had one or more complaint; **All patients had one or more comorbidities.

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Table 2. Initial laboratory values Variable

Group A (Elderly) Group B (Very Elderly) (n=128) (n=66) Mean±SD Mean±SD

Serum hemoglobin levels (12-16 g/dL)

8.07±1.84

7.33±1.8

0.010a

Serum hematocrit levels (% 37-47)

24.4±5.6

21.4±4.6

0.002a

Serum urea levels (19-50 mg/dL)

72.3±48.6

80.2±64.5

0.598b

Serum creatinine levels (0.5-1.1 mg/dL)

1.23±1.2

1.4±1.4

0.587b

Serum platelet counts (130-400 103/μL) 226.8±96.8 198.4±95.6 0.054a Serum leucocyte levels (5.2-12.4 103/μL) 10930.5±10454.4 9196.9±4344.9 0.277b International normalized ratio values (1-1.5) a b

2.40±3.6

2.1±2.9

0.881b

Independent Simple T test; Mann-Whitney U-test.

Treatment modalities and outcome Conservative medical treatments were applied in most of the patients in two groups but there were no statistically significant differences in terms of response to conservative

medical treatment between two groups (p=0.892). Only two (1.03%) patients in Group A underwent emergency surgical intervention due to hemostatic inefficacy or recurrent bleeding. The overall mortality rate was 11.7% in Group A and 19.7% in Group B (p=0.134) (Table 4).

Table 3. Findings of urgent upper digestive endoscopy (UDE) Group A (Elderly) Group B (Very Elderly) Variable (n=128) (n=66) p n (%) n (%) Gastric ulcers

38 (29.7)

18 (27.3)

0.725

Duodenal ulcers

29 (22.7)

22 (33.3)

0.109

Gastroduodenal erosions

27 (21.1)

9 (13.6)

0.206

Mallory-Weiss tear

4 (3.1)

2 (3.0)

0.971

Oesophagogastric tumour

19 (14.8)

3 (4.5)

0.032

No source of bleeding

18 (14.1)

15 (22.7)

0.128

Table 4. Treatment modalities and outcomes Variable

Group A (Elderly) Group B (Very Elderly) (n=128) (n=66) p n (%) n (%)

Conservative pharmacological treatment

100 (78.1)

51 (77.3)

0.892

Endoscopic band ligation

6 (4.7)

0 (0.0)

0.097

Endoscopic sclerotherapy

20 (15.6)

15 (22.7)

0.223

Surgery

2 (1.6)

0 (0.0)

0.549

Mortality

15 (11.7)

13 (19.7)

0.134

Transfusion requirements ES transfusions

104 (81.3)

55 (88.3)

0.721

Fresh frozen plasma transfusions

28 (21.9)

17 (25.8)

0.544

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Elderly Patients with Acute Upper Gastrointestinal Hemorrhage

Discussion Most researchers have reported an increase in the incidence of AUGIH in the elderly population.[3] It was reported in previous studies that the incidence of AUGIH was higher among the female elderly and very elderly patients compared to their male counterparts.[6] Opposition to; our study showed that the percentage of male patients was higher in both groups. AUGIH seen in the elderly population is a potential life-threatening clinical condition that requires immediate treatment.[3] The related mortality rates among those aged ≥60 years and those aged ≥80 years are 12-25% and ~35% respectively.[7] Like in previous studies, the rate of mortality among the very elderly patients was found to be higher in our study; however this difference was statistically non-significant. The rate of mortality was determined to be higher among the very elderly patients, which was not statistically significant. Alcohol abuse is one of the most important risk factors for AUGIH.[11] According to a report by Fiore et al.[12] 70% of AUGIH cases had a history of alcohol abuse. In the present study the rate of alcohol abuse among the patients was 6.7%. The study showed that the incidence of hemorrhage due to alcohol abuse was reduced significantly among the very elderly patients; and we assume that alcohol abuse lessens with increasing age owing to a variety of health problems. The elderly patients had complex and serious clinical presentations of AUGIH were different from those seen among younger patients.[13] In addition, there tends to be a delay in diagnosis of AUGIH in the elderly patients because of atypical signs and symptoms.[8] Hematochezia is observed in AUGIH at the rate of 5%, and considered to be a sign of serious bleeding in elderly patients.[14] Compared to reported rates, the rate of hematochezia in our series was two-fold higher. But there were no significant differences between these groups. Upper digestive endoscopy was diagnostic in 90% to 95% of AUGIH cases.[15] In the literature review done, we found PU disease to be a major cause of AUGIH among both the elderly and very elderly people. Our study was similar to other studies in PU being the most common cause of AUGIH in both groups.[3,6,15] Furthermore, according to various series in literature the occurrence of PU is observed more frequently in duodenum than in the gastric region.[3,15] In our study, GU was mostly observed in the elderly group while DU was mostly diagnosed in the very elderly group. Certain habits and specific diseases are seen in different social and geographical regions. It is therefore difficult to make a statement regarding the frequency ranking of the possible reasons for AUGIH. Oesophagogastric tumours are a relatively uncommon cause of AUGIH. Primary or metastatic tumors can be a

source of bleeding. Approximately 3-5% of acute AUGIH’s are a result of either benign or malignant neoplasm.[16] In our study OGT’s were observed at the rate of 11.3%. OGT’s are diagnosed at a significantly higher rate in the elderly group compared to the very elderly group. This is associated with the fact that the patients with OGT’s pass away before they reach their 80’s. In the literature, there are investigations indicating that rebleeding increases with advancing age. Prior use of gastrotoxic agents or anticoagulants is a very common risk factor especially in elderly patients with past AUGIH.[17] This situation should be considered in this age group. Fiore et al.[12] reported the rate of patients with a previous bleeding as 1923%. Timraz et al.[11] reported past AUGIH in 12% of patients in their study. The rate was observed to be comparatively higher (68.6%) among the patients in our study. This could be due to the fact that patients participating in the study were elderly patients. Patients presenting with major AUGIH are often elderly and have significant cardiorespiratory, renal and cerebrovascular co-morbidity. It is essential for these conditions to be recognized and taken under control. In elderly patients, intravenous fluid maintain to ensure hemodynamic stability, monitored with blood pressure and urine output, in addition to coupled with appropriate management of cardiac and respiratory disease are the first step in the management of AUGIH.[16] As well, pharmacological therapy should be administered. Consequently, arrangements for endoscopy must be done as soon as possible and a final diagnosis must be established.[17] Pharmacological therapy decreases the risk of rebleeding need for surgery and blood transfusions. [15] In our study, bleeding stopped after medical treatment in 77.8% of the cases. The reason of successful results in the medical treatment given to the elderly people is the fast and accurate diagnosis of hemodynamic instability in the ED. If there is hemodynamic instability, intravenous infusion solutions or erythrocyte transfusions are necessary to control intravascular volume. Erythrocyte transfusion was administered to patients in shock who were bleeding actively with haemoglobin concentrations less than 10 g/dl, and with symptoms such as angina pectoris.[16] Following the level of hemoglobin would be more helpful in observing the severity of bleeding and deciding therefore the need for a transfusion.[18] In our study, while only 7.2% of all the patients showed hemodynamic instability when they first applied for medical help. the rate of erythrocyte transfusion was determined to be 82%. This could be associated with the gradual decrease in the hemoglobin level following the admittance of the patient leading to the emergence of the transfusion need in later stages, rather than at the beginning. Urgent surgical therapy should be considered if hemody-

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namic instability or gastrointestinal bleeding is refractory to endoscopic and pharmacological treatment.[16,17] In literature the rate of patients who are directed to the surgery ranged between 1-10%. however this rate was found to be only 1.03%[3,7,17] in our study. This difference may be due to efficiency with the endoscopic treatment is administered in addition to the medical treatment. Limitations Our study was designed as a retrospective nature. We think that it would be more appropriate if the results were supported by a larger, prospective study. Furthermore, as our research is a single-centre research. The results obtained could not be generalized because the features of the patients included predisposed factors for the bleeding, and many other factors could differ. Upper digestive endoscopy results couldn’t be classified in order to the Forrest Classification as a consequence of incompletion of the patient files.

Conclusion The number of elderly patients that seek help from ED due to upper gastrointestinal system haemorrhage is in increase. Evaluation of risk factors and clinical characteristics of elderly patients with upper gastrointestinal hemorrhage are very significant. Comorbid diseases and multiple drug use are commonly observed in the elderly patients. Conflicts of interest The authors had no conflicts of interest to declare in relation to this article.

References 1. Paspatis GA, Matrella E, Kapsoritakis A, Leontithis C, Papanikolaou N, Chlouverakis GJ, et al. An epidemiological study of acute upper gastrointestinal bleeding in Crete, Greece. Eur J Gastroenterol Hepatol 2000;12:1215-20. 2. Katschinski B, Logan R, Davies J, Faulkner G, Pearson J, Langman M. Prognostic factors in upper gastrointestinal bleeding. Dig Dis Sci 1994;39:706-12. 3. Ben Chaabane N, Ben Youssef H, Loghmeri H, Helara O, Melki W, Bdioui F, et al. Upper gastrointestinal bleeding in elderly patients in a Tunisian hospital: A retrospective study. Arab J Gastroenterol 2011;12:158-61. 4. Guneytepe UI, Aydın ŞA, Gökgöz Ş, Ozguç H, Ocakoğlu G, Aktaş H. Yaşlı travma olgularında mortaliteye etki eden fak-

törler ve skorlama sistemleri. Uludağ Üniversitesi Tıp Fakültesi Dergisi 2008;34:15-9. 5. Mert E. Use of Emergency Departments by Elderly Patients. Turkish Journal of Geriatrics 2006;9:70-4. 6. Alkhatib AA, Lam A, Shihab F, Adler DG. RIFLE criteria accurately identifies renal dysfunction and renal failure in elderly patients with upper gastrointestinal hemorrhage: a pilot study. South Med J 2009;102:580-4. 7. Charatcharoenwitthaya P, Pausawasdi N, Laosanguaneak N, Bubthamala J, Tanwandee T, Leelakusolvong S. Characteristics and outcomes of acute upper gastrointestinal bleeding after therapeutic endoscopy in the elderly. World J Gastroenterol 2011;17:3724-32. 8. Holt PR. Gastrointestinal diseases in the elderly. Curr Opin Clin Nutr Metab Care 2003;6:41-8. 9. Koç F, Kekeç Z. Neurologic Evaluation of Geriatric Cases Admitted to The Emergency Department. Turkish Journal of Geriatrics 2011;14(2) 117-21. 10. González-González JA, Vázquez-Elizondo G, García-Compeán D, Gaytán-Torres JO, Flores-Rendón ÁR, Jáquez-Quintana JO, et al. Predictors of in-hospital mortality in patients with nonvariceal upper gastrointestinal bleeding. Rev Esp Enferm Dig 2011;103:196-203. 11. Timraz A, Khannoussi W, Ajana FZ, Essamri W, Benelbarhdadi I, Afifi R, et al. Acute upper gastro-intestinal bleeding in morocco: what have changed? ISRN Gastroenterol 2011;2011:457946. 12. Di Fiore F, Lecleire S, Merle V, Hervé S, Duhamel C, Dupas JL, et al. Changes in characteristics and outcome of acute upper gastrointestinal haemorrhage: a comparison of epidemiology and practices between 1996 and 2000 in a multicentre French study. Eur J Gastroenterol Hepatol 2005;17:641-7. 13. Sanders AB. The elderly patient. In: Tintinalli JE, Kelen GD, Stapczynski JS, editors. Emergency medicine: a compehensive study guide. New York: Mc Graw Hill; 2000. p. 2001-6. 14. Albeldawi M, Qadeer MA, Vargo JJ. Managing acute upper GI bleeding, preventing recurrences. Cleve Clin J Med 2010;77:131-42. 15. Chak A, Cooper GS, Lloyd LE, Kolz CS, Barnhart BA, Wong RC. Effectiveness of endoscopy in patients admitted to the intensive care unit with upper GI hemorrhage. Gastrointest Endosc 2001;53:6-13. 16. Palmer K. Acute upper gastrointestinal haemorrhage. Br Med Bull 2007;83:307-24. 17. Gralnek IM, Barkun AN, Bardou M. Management of acute bleeding from a peptic ulcer. N Engl J Med 2008;359:928-37. 18. Cappell MS, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. Med Clin North Am 2008;92:491-509, xi.

ORIGINAL ARTICLE KLİNİK ÇALIŞMA

Patient and Relative Complaints in a Hospital Emergency Department: A 4-Year Analysis Bir Hastane Acil Servisinde Hasta ve Yakını Şikâyetleri: 4 Yıllık Analiz Suat ZENGİN, Behçet AL, Erdal YAVUZ, Cem ŞEN, Şener CİNDORUK, Cuma YILDIRIM Gaziantep University Faculty of Medicine, Gaziantep

SUMMARY

ÖZET

Objectives Complaints by patients and their relatives are an important source of information for service improvement. In order to take remedial measures, the present study evaluated the complaints of patients and their relatives about our emergency department (ED).

Amaç Hasta ve yakınlarının şikâyetleri, hizmet iyileştirmeleri için önemli bir bilgi kaynağıdır. Bu çalışmada; düzeltici önlemler almak amacıyla, hasta ve yakınlarının acil servis hakkında şikâyetleri değerlendirildi.

Methods Records of all patient complaints, from June 2008 to June 2012, were retrieved from the Quality Improvement Unit (QIU) archives. All complainants were contacted by phone. The socio-demographic profiles of complainants, their reasons for complaints, and the outcomes were analyzed using the SPSS statistical package.

Gereç ve Yöntem Kalite Geliştirme Birimi (KGB) arşivinden Haziran 2008 ile Haziran 2012 yılları arasındaki tüm hasta şikâyetlerinin kayıtları alındı. Tüm şikâyetçilerle telefonla bağlantı kuruldu Şikâyetçilerin sosyo-demografik profilleri, şikâyet nedenleri ve sonuçları SPSS istatistiksel paket programı kullanılarak analiz edildi.

Results The results revealed that 54 complaints have been made against our ED over four years relating to medical care, staff attitudes, waiting time, and financial reasons. Of the complainants, 75.9% were male (n=41), and 24.1% (n=13) were female. The majority (29.7%, 20.4%) of the complaints were due to medical care and attitude problems. Most complaints were made for green code patients (55.6%). The majority of complaints were about emergency physicians (38.9%). Complaint frequency was 0.18 per 1.000 visits.

Bulgular Sonuçlar, dört yılda tıbbi bakım, personel tutumu, bekleme süresi ve mali sebeplerle ilgili acil servise karşı yapılmış 54 şikâyetin olduğunu ortaya çıkardı. Şikâyetçilerin, %75.9’u (n=41) erkek, %24.1’i (n=13) kadındı. Şikâyetlerin büyük bir kısmı (%29.7-%20.4) tıbbi bakım ve davranış problemlerine bağlıydı. Çoğu şikâyet yeşil kodlu hastalar için yapılmıştı (%55.6). Şikâyetlerin çoğu acil doktorları hakkındaydı (%38.9). Şikâyet sıklığı; her 1.000 başvuruya 0.18 idi.

Conclusions Complaints are potentially useful quality assurance tools, and can identify remediable system flaws. The main causes of complaints are medical care, staff attitude, and waiting time, and many of these causes are remediable.

Sonuç Şikâyetler potansiyel olarak kullanışlı kalite ölçme araçlarıdır ve sistemin düzeltilebilir kusurlarını belirleyebilir. Şikâyetlerin ana nedenleri tıbbi bakım, personel tutumu ve bekleme süresidir ve bu nedenlerin çoğu düzeltilebilir.

Key words: Complaint rate; emergency department; patient complaints; staff-patient communication.

Anahtar sözcükler: Şikayet oranı; acil servis; hasta şikâyetleri; personel-hasta iletişimi.

Submitted (Geliş tarihi): 29.08.2012 Accepted (Kabul tarihi): 07.11.2012 Correspondence (İletişim): Dr. Suat Zengin. Osmangazi Mah., 88. Sok., Çamlıca Sitesi F Blok., Kat 14, No: 28, Gaziantep, Turkey e-mail (e-posta): zengins76@gmail.com

Türkiye Acil Tıp Dergisi - Tr J Emerg Med 2012;12(4):163-168

doi: 10.5505/1304.7361.2012.55823

163

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Türkiye Acil Tıp Dergisi - Tr J Emerg Med 2012;12(4):163-168

Introduction There is an apparent perception that the emergency department (ED) is one the most difficult departments of a hospital, therefore it is not a preferred workplace. However, the ED is a very important department as it is the “shop window and front door” of the hospitals. In 2009, 27% of the total hospital admissions in Turkey were through the ED and this rate is increasing.[1] Complaints against ED staff are not rare. EDs with long waiting times, junior staff, and a focus on acute care have the potential to generate significant patient complaints. Patients complain for various reasons if they become dissatisfied with the service. These complaints may result from unmet expectations or may reflect poor service quality. Health practitioners often perceive them in a negative light, and complaints can sometimes have a devastating effect on individuals and organizations. However, complaints can be seen as an advantage, acting as a benchmark to assess quality of care, make interventions, and minimize the number of complaints. Quantitative measurement of patient complaints is a comparative measure of service quality, and several authorities believe quality assurance measures should include patient satisfaction and an analysis of patient complaints.[2] However, it is evident that the hospitals do not use patient complaints as a source of learning to promote higher standards of care.[3] Consumers are becoming better informed and more aware of their rights, leading to a rise in complaints about the quality of healthcare. It is therefore necessary to encourage further research to ensure more appropriate use of patient complaints. Our hospital has 940 beds and three intensive care units with 110 beds. We have 20 sedan chairs (12 for first examination, 2 in resuscitation room, 2 in surgery intervention room, 2 in cardiologic observation room, one orthopedic and gynecologic room, one in ultrasonography room) and 12 beds ( 6 for females and 6 for males) in our ED. Approximately 75.000 patients are admitted to the ED annually. This number does not include pediatric (<16 year-old) patients. Currently, 20 physicians, 12 intern doctors, 16 nurses, and 25 non-medical staff working in the ED. We analyzed data on patient complaints relating to our ED between June 2008 and June 2012. The purposes of this study are to analyze the types of complaints received by the ED so steps can be taken to minimize them in future, to enable hospital administration to understand the difficulties faced by the ED, and to let new physicians in the ED know the pitfalls involved in the practice of emergency medicine.

Materials and Methods The study entailed a retrospective analysis of complaints relating to the care of patients seen in Gaziantep University

ED between 1 June 2008 and 1 June 2012. The study was approved by the Medical Ethics Committee of Gaziantep University. In May 2004, the hospital set up a complaint department as part of a quality improvement system that deals with all formal complaints, whether made verbally, in writing, by telephone, or through other forms of electronic communication received by the Health Ministry Communication Center (HMCC) and Prime Minister’s Communications Center (PMCC). The complaint department benefits from a civil servant who is selected from the experienced employees according to the following criteria: • Being familiar with the work flow of different hospital units; • Good public relations and desirable work relations with the majority of the staff; • Being tolerant and a good listener. Information relating to the origin, nature, and outcome of complaints is entered into a computerized database by this civil servant. The complaint data for the current study were obtained from the Quality Improvement Unit (QIU) archives of our hospital. The socio-demographic profiles of complainants, their reasons for complaints, and the outcomes were recorded and analyzed. The diagnosis of patients were received the hospital automation records, and the triage code was made by using these diagnosis. In triage evaluation, code yellow and red patients were categorized as emergency patients, and code green patients were categorized as non-emergency. All complainants were contacted by phone. These complaints were categorized under the following headings: I. Medical care (dissatisfaction with examination and treatment, misdiagnosis) II. Long waiting time III. Medical and paramedical staff-patient and patient-relatives relationships IV. Financial affairs V. Other The frequencies of the data were analyzed using SPSS for Win. Ver. 18.0 (SPSS Inc., Chicago, Illinois, USA).

Results Between 1 June 2008 and 1 June 2012, 300.417 patients were admitted our ED. In the period, 2.212.697 patients were admitted to the hospital, and the hospital received 489 complaints, 54 (11%) of which concerned the ED. For ED, while complaint frequency was 0.18 per 1.000 visits, for hospital was 0.22 per 1.000 visits. Of complaint applications,

Zengin S et al.

165

Patient and relative complaints in a hospital emergency department: a 4-year analysis

41 were made to QIU, 9 to the HMCC, and 4 to the PMCC. Of complainants, 41 (75.9%) were male and 13 (24.1%) were female (Table 1). The majority of complainants were

Table 1. The demographic distribution of complainants The relationship between gender and complaints Gender n %

Complaint case rate (per 1.000 visits)

Male

41 75.9

0.14

Female

13 24.1

0.04

The relationship between age and complaints Age n %

Complaint case rate (per 1.000 visits)

≤20

8 15

0.03

21-40

33 61

0.11

41-60

12 22

0.04

≥61

1 2

0.00

The relationship between occupation of complainants and complaints Occupation n %

Complaint case rate (per 1.000 visits)

27.8

civil servants (27.8%, n=15), and had graduated from high school (40.7%, n=22) (Table 1). The majority of complaints were made about emergency physicians (38.9%) (Table 2). The majority (42.7%) of the complaints were due to medical care and communication problems (Table 2). The number of staff that worked in ED according to years are: June 2008May 2009; 14 physicians, 15 nurses, 20 non-medical staff, June 2009-May 2010; 12 physicians, 15 nurses, 20 non-medical staff, June 2010-May 2011; 10 physicians, 14 nurses, 20 non-medical staff, and June 2011-May 2012; 17 physicians, 16 nurses, 25 non-medical staff. The majority of complaints (33.3%, n=18) were made between June 1 2010 and May 31 2011 (Table 3). Most complaints were made for green code patients (55.6%). The majority of complaints (59.3%, n=32) occurred on days that the patients were examined more than the mean of month (Table 4). Complainants stated the names of 13 physicians out of 21 they complained about. Six of these complaints were about X, 4 were about Y, and 3 were about Z-named physicians.

Table 2. The staff who were complained and causes of complaint The staff who were complained

Civil servant

0.05

Staff

n %

Worker

11 20.4

0.04

Student

10 18.5

0.03

Physician

21 38.9

Self-employed

7 13

0.00

Consultant

11 20.4

Retired

0.02

Cashier

7 13

Housewife

2 3.7

Nurse

5 9.3

0.02

The relationship between educational status and complaints Educational status n %

Complaint case rate (per 1.000 visits)

High school

40.7

0.07

University

18 33.3

0.06

Primary school

16.7

0.03

Secondary school

7.4

0.01

Military academy

0.00

Relationship between the complainant and patient Kinship n %

Complaint case rate (per 1.000 visits)

Self

25 46.3

0.08

Child

8 14.8

0.03

Spouse

7 13

0.02

Friend

7 13

0.02

Other

5 9.3

0.02

Parent

1 2

0.00

Sibling

1 2

0.00

Other

Hospital administration

1.9

CT technician

9.3

Security personnel

5.6

Auxiliaries

1 1.9

Main issues of the complaints Reason

16.7

Misdiagnosis

7.4

5.6

Poor attitude

20.4

Long waiting time

Financial affair

9.3

Medical care

Dissatisfaction with treatment Dissatisfaction examination

Other

The lack of an empty bed

18.5

Poor physical environment

5.6

Loss of patient files

1.9

QIU: Quality Improvement Unit; HMCC: Health Ministry Communication Center; PMCC: Prime Minister’s Communications Center.

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T羹rkiye Acil T覺p Dergisi - Tr J Emerg Med 2012;12(4):163-168

Table 3. Distribution of complaints according to years Complainants per year and rates per 1.000 new cases Year n %

Total no. of patients seen

Complaint case rate (per 1.000 visits)

June 1 2008-May 31 2009

16.7

57455

0.16

June 1 2009-May 31 2010

24.1

66622

0.20

June 1 2010-May 31 2011

33.3

79943

0.23

June 1 2011-May 31 2012

25.9

96397

0.14

Table 4. The relationship between triage code, examination day, examination time and complaints The relationship between triage code and complaints Triage code

Complaint case rate (per 1.000 visits)

Green

30 55.6

0.10

Yellow

8 14.8

0.03

Red

16 29.6

0.05

The relationship between examination day and complaints Day

Complaint case rate (per 1.000 visits)

Monday

18 33.3

0.06

Tuesday

6 11.1

0.02

Wednesday

6 11.1

0.02

Thursday

5 9.3

0.01

Friday

9 16.7

0.03

Saturday

4 7.4

0.01

Sunday

6 11.1

0.02

The relationship between examination time and complaints Hour

Complaint case rate (per 1.000 visits)

08:00-16:00

21 38.9

0.07

16:00-00:00

30 55.6

0.10

00:00-08:00

3 5.6

0.01

The status of patients examined daily according to a monthly average the seen per day and complaints Number of patients seen per a day

Complaint case rate (per 1.000 visits)

Less than monthly average

40.7

0.07

More than monthly average

59.3

0.11

Discussion A complaint is a condition or expression of dissatisfaction with, for example, staff, procedures, fees, and quality care. In this study, we investigated the proportion of admissions with written and electronic complaints, the type of complaint, and the outcomes of the complaint process in the ED over a 48-month period. Other investigators have reported ED complaint rates rang-

ing from 0.16 to 3.8 complaints/1.000 patients.[2,4-7] For example, while Ooi et al. found this ratio 0.26 per 1.000, Schwartz et al. found 3.8 per 1.000. The complaint case rate found in this study (0.18 per 1.000) is comparable with rates reported by others. In contrast to other studies, the men in our study complained significantly more frequently than women.[2,4-7] The reasons for this apparent gender difference are not clearly known and, as the data were only available in summary form, it precludes further analysis. However we think it may

Zengin S et al.

Patient and relative complaints in a hospital emergency department: a 4-year analysis

be associated with us not treating patients under 16 years old. In addition, the finding that close relatives and friends were the complainants in half of the cases was surprising, and is not consistent with the findings of others.[2,4-7] While complaints over the last 4 years show a rise to 18 between June 2010 and June 2011, the numbers of complaints between June 2011 and June 2012 has declined. While there were 10 physicians working between June 2010 and June 2011 in the ED, there were 17 physicians working between June 2011 and June 2012. This decline in the number of complaints could be related to the number of physicians working. The majority of the complaints were directly related to medical care. Also, a significant amount of complaints was about poor attitude of staff, and most of these complaints were made about the emergency physicians. These results are similar with rates reported by others.[2,4-7] In most cases we can prevent patientsâ&#x20AC;&#x2122; complaints through careful examination and a good communication. We believe that communication issue should be included in medical education and in ED orientation programs to educate physicians on appropriate communication skills between patients and physicians. The majority of the complaints were about patients treated between 16:00 and 00:00 hours, the period most ED admissions occur. There were more complaints about patients who examined on Mondays and Fridays compared to other days. It appears this may be because patients arrive in the ED on Monday if they have not made an appointment with a polyclinic and on Friday if they could not complete their polyclinic examinations. These factors increase complaints. Therefore, in these times, the number of the staffs working in the ED should be increased to decrease complaints. For this purpose, more staff should be requested from hospital administration. Complaints were higher from code green patients (55.6%, n=30) than others. Patients often expect prompt service in the ED as they tend to view their complaints (however minor from a medical standpoint) to be an emergency. Many patients do not understand the concept of triage in the ED. We think staffs not showing enough attention to patients who are not emergent increases complaints. Approximately one-sixth of the complaints were related to waiting time. In many healthcare systems, there are waiting lists, and normally the main reason for the waiting time is a lack of resources. Therefore, a proportion of these complaints may be the result of an unrealistic expectation by the patient, but because patientsâ&#x20AC;&#x2122; overall satisfaction is partly determined by the perceived rather than actual waiting time, this is important to consider and to explain to the patients.[4] We believe that the number of complaints may be decreased by increasing the number of staffs working in the

ED or making an explanation about the capacity of ED. According to many studies; although there are many causes, the main cause for complaint is staff attitude towards patients and their relatives.[8-11] In our study, 20.4% of complaints were about the attitude of staffs. Improper attitudes affect patient satisfaction and compliance to treatment. Therefore the staff should communicate sufficiently with the patient, inform them about the process, and avoid unnecessary arguments with those who arrive at the ED in a state of panic. Only 17 of 48 (all electronic applications) complainants who could be reached by phone had received feedback about their complaints. None of the 31 complainants who applied in writing had received feedback. These 31 complainants expressed dissatisfaction due to no feedback. To increase satisfaction of patients and relatives, about complaints should be made feedback to the complainants. The results of our study were presented the as an outcome report to the hospital management, and correction of deficiencies related to the hospital administration was requested from administration (increasing number of staff, increasing the number of patient beds etc.). The training courses related to communication and attitude were planned for all ED staffs. An education was given to all staffs about the problems of the patients and relatives. In addition, the physicians those were complained frequently were warned, and individual conversations were carried out with them. Limitations The present study has several limitations. First, complaints are often complex and some may have been incorrectly categorized, leading to measurement bias. No objective standard to classify complaints is available. Second, the results are subject to selection bias. It is possible that some complaints were not passed on to hospital complaint department officers, and that the data underrepresents the true complaint rates.

Conclusion Complaints are potentially useful quality assurance tools. A study of complaints may help identify gaps in our services in order to make necessary corrections to policies or procedures. The main causes of the complaints were insufficient medical care, appropriate attitude and long waiting time which are result of high number of patients, insufficient of staff and patients with green code. Many of these causes can be resolved. Conflict and Interest The authors declare that there is no potential conflict of interest.

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References 1. Arslanhan S. Muayene sayısındaki artış, anlamlı bir erişim artışını mı ifade ediyor? Available at: http://www.tepav.org.tr/ upload/files/1284627104-1. Muayene_sayisindaki_artis_anlamli_bir_erisim_artisini_mi_ifade_ediyor.pdf. Accessed July 3.2012. 2. Taylor DM, Wolfe RS, Cameron PA. Analysis of complaints lodged by patients attending Victorian hospitals, 1997-2001. Med J Aust 2004;181:31-5. 3. Hsieh SY, Thomas D, Rotem A. The organisational response to patient complaints: a case study in Taiwan. Int J Health Care Qual Assur Inc Leadersh Health Serv 2005;18:308-20. 4. Wong LL, Ooi SB, Goh LG. Patients’ complaints in a hospital emergency department in Singapore. Singapore Med J 2007;48:990-5. 5. Schwartz LR, Overton DT. Emergency department complaints: a one-year analysis. Ann Emerg Med 1987;16:857-61.

6. Salazar A, Ortiga B, Escarrabill J, Corbella X. Emergency department complaints: a 12 year study in a university hospital. Ann Emerg Med 2004; 44: Supp1 ACEP Research Forum. 7. Ooi SB. Emergency department complaints: a ten-year review. Singapore Med J 1997;38:102-7. 8. Hunt MT, Glucksman ME. A review of 7 years of complaints in an inner-city accident and emergency department. Arch Emerg Med 1991;8:17-23. 9. Bazrafkan L, Shokrpour N, Tabeie SZ. A survey of patients’ complaints against physicians in a five year period in Fars province: implication for medical education. Journal of Medical Education Winter and Spring 2008;12:23-8. 10. Wong LL, Ooi SB, Goh LG. Patients’ complaints in a hospital emergency department in Singapore. Singapore Med J 2007;48:990-5. 11. Kadzombe EA, Coals J. Complaints against doctors in an accident and emergency department: a 10-year analysis. Arch Emerg Med 1992;9:134-42.

KLİNİK ÇALIŞMA ORIGINAL ARTICLE

Gebelerde İntihar Amaçlı İlaç Zehirlenmelerinin Gebe Olmayanlara Göre Farkı Var Mı? Suicide Attempts with Drug Intoxication in Pregnant and Non-Pregnant Women Mustafa UZKESER, Murat SARITEMUR, Ayhan AKÖZ, Atıf BAYRAMOĞLU, Mücahit EMET Atatürk Üniversitesi Tıp Fakültesi Acil Tıp Anabilim Dalı, Erzurum

ÖZET

SUMMARY

Amaç Ülkemizde gebelerde intihar girişimiyle ilgili yeterli çalışma yoktur. Çalışmanın amacı acil servisimize intihar amaçlı oral aşırı ilaç alımı ile başvuran gebe hastalar ile aynı yaş grubunda intihar amaçlı oral aşırı ilaç alımı ile başvuran gebe olmayan kadın hastaların yatış oranlarını, zehirlendiği ilaç tiplerini ve maliyet farklarını karşılaştırmaktır.

Objectives Insufficient data are available comparing medical costs, hospitalization or admission rate, and drugs used for the treatment of pregnant and nonpregnant women admited to the emergency department (ED) due to suicide attempts following drug intoxication. We sought to evaluate these differences in our ED.

Gereç ve Yöntem Atatürk Üniversitesi Tıp Fakültesi Acil servisine oral ilaç alarak intihar teşebbüsü (parasuisid) nedeniyle başvuran kadın hastalar kesitsel ve prospektif olarak incelendi. 2008 ve 2011 yılları arasında acil servise başvuran her iki grubun tedavi planları, tahmini maliyetleri ve hastane yatış oranları ile ilgili verilerini toplayıp karşılaştırdık.

Methods This is a prospective, cross-sectional study; hence we attempted to follow all pregnant and non-pregnant women who were admitted in our ED at Ataturk University, Erzurum-Turkey, due to suicide attempt with drug intoxication. We have obtained records of management plans, estimated costs and hospital admission rate in the ED from 2008 to 2011 and compared in both groups.

Bulgular Gebe grubunda 23 (%7.4) hasta ve kontrol grubunda 286 (%92.6) olmak üzere toplam 309 hasta çalışmaya alındı. Gebe hastalarda gebe olmayanlara göre daha önceden psikiyatrik hastalık öyküsü olması anlamlı olarak daha düşüktür (%4.3 ve %26.2; p=0.019). Gebe hastalarda gebe olmayanlara göre organofosfat (%34.8 ve %39.1; p<0.001) ve parasetamol (%39.1 ve %19.9; p=0.031) zehirlenmesi daha sık görülmekte iken çoklu ilaç alımına bağlı zehirlenme daha az oranda görülmektedir (%39.1 ve %67.8; p=0.005). Gebe hastaların acil serviste müşahede oranları gebe olmayanlara göre daha düşük olup (%56.5 ve %77.6), dahili servislere (%13 ve %6.3) ve yoğun bakım ünitesine yatış oranları (%13’e karşı %3.1) daha yüksektir (p=0.039). Buna bağlı olarak tedavi maliyetleri de gebe hastalarda daha yüksektir (2553.5±6206.7 TL ve 581.3±490.3 TL; p<0.001).

Results A total of 309 women were registered as suicide attempts with drug intoxication. Out of these, 23 (7.4%) were pregnant and 286 (92.6%) were non-pregnant. The pregnant women had lower rate of past history of psychiatric illness as compared to non-pregnant women (4.3% vs. 26.2%; p=0.019). Comparison of drug intoxication revealed a higher rate of intake of organophosphate (39.1%; vs. 34.8% p<0.001) and paracetamol (39.1% vs. 19.9%; p=0.031), but a lower rate of multidrug ingestion (39.1% vs. 67.8%; p=0.005) in pregnant women. Furthermore, pregnant women have a lower rate of hospitalization in ED (56.5% vs. 77.6%), but higher rates of hospitalization in internal services (13% vs. 6.3%), and intensive care units (13% vs. 3.1%; p=0.039) compared to non-pregnant women. Consequently, the cost of therapy was also higher in pregnant (2553.5±6206.7 TL vs. 581.3±490.3 TL; p<0.001).

Sonuç Gebe olmayan bayan hastalarla karşılaştırıldığında gebelerde ilaç ile intihar teşebbüsü daha nadir görülmesine rağmen, yüksek hospitalizasyon oranları ve yüksek maliyet nedeniyle daha yüksek öneme sahiptir. Bu nedenle girişim öncesi dönemde gebe hasta grubunun intihar riskini belirlemek için acil olarak özel tarama programlarına ihtiyaç vardır.

Conclusions Though pregnant women were admitted less frequently compared to non-pregnant women, suicide attempts with drug intoxication among pregnant women have increased consequences in terms of hospitalization rate and cost. Thus there is an urgent need to incorporate a special screening program to measure suicide risk followed by counseling for pregnant women during post-conceptual care.

Anahtar sözcükler: Gebe; özkıyım girişimi; ilaç; intihar teşebbüsü; yüksek doz; zehirlenme.

Key words: Pregnancy; suicide attempt; drug; parasuicide; overdose; poisoning.

Geliş tarihi (Submitted): 17.05.2012 Kabul tarihi (Accepted): 28.09.2012 İletişim (Correspondence): Dr. Mustafa Uzkeser. Atatürk Üniversitesi Araştırma Hastanesi Acil Servis, 25240 Erzurum e-posta (e-mail): mustafauzkeser@gmail.com

Türkiye Acil Tıp Dergisi - Tr J Emerg Med 2012;12(4):169-174

doi: 10.5505/1304.7361.2012.58661

169

170

Türkiye Acil Tıp Dergisi - Tr J Emerg Med 2012;12(4):169-174

Giriş Özellikle bir insanın en verimli olduğu yaş aralığında gerçekleştirilen intihar teşebbüsü, acil servislerde önemli oranda başvuru sebebi olduğu kadar pek çok sosyoekonomik sonuçları da olan önemli bir sağlık sorunudur. Her ne kadar intihar girişimi gebelikte hayatın diğer dönemlerine göre daha düşükse de, iki yaşamı -hem anneyi, hem de fetüsürisk altında bıraktığı için önemli sonuçları vardır.[1] Son yıllarda yapılan çalışmalarda özellikle yüksek risk grubunda olan gebe kadınların %5’inde intihar girişimi olduğu bulunmuştur.[2] Gebelik döneminde ölümcül intihar girişimi oranları ise %0.4 ile %6.7 arasında değişmektedir.[3] 2000’li yıllarda gebe hastaların hastaneye yatış nedenleri arasında motorlu trafik kazaları ve düşmelerden sonra zehirlenmeler %16.4 ile 3. sırada yer almaktayken günümüzde bu oran %31 ile ilk sıraya yükselmiştir.[4,5] Toplumda kadınlar arasında ölümcül olmayan kendine zarar verme davranış tipi olarak en sık zehirlenmeler görülmektedir.[4,6] Ülkemizde gebelik döneminde görülen intihar girişimleriyle ilgili yeterli çalışma bulunmamaktadır. Çalışmanın ilk sonlanım noktası acil servise intihar amaçlı ağız yoluyla aşırı ilaç alımı nedeniyle başvuran gebe hastalar ile aynı yaş grubunda intihar amaçlı ağız yoluyla aşırı ilaç alımı nedeniyle başvuran gebe olmayan kadın hastaların yatış oranlarını, zehirlendiği ilaç tiplerini ve maliyet farklarını karşılaştırmaktır. İkincil sonlanım noktası bu iki grubun epidemiyolojik özelliklerini karşılaştırmaktır.

Gereç ve Yöntem 01 Ocak 2008-31 Aralık 2011 tarihleri arasında Atatürk Üniversitesi Tıp Fakültesi Acil Servisi’ne ağız yoluyla aşırı ilaç alarak intihar teşebbüsü (parasuisid) nedeniyle başvuran 15 yaş üstü kadın hastalar etik kurul onayı alındıktan sonra çalışmaya alındı ve prospektif-kesitsel olarak incelendi. İntihar maksadı olmayan ilaç zehirlenmeleri, kaza ile yaralanmalar ve kazalar çalışma dışı bırakıldı.

Çalışmaya 321 hasta alındı, fakat hastaların 7’si daha sonra çalışmadan çıkmak istemeleri, 2 hastanın şuuru kapalı olması nedeniyle yeterli veri elde edilememesinden, 3 tanesi aynı anda ilaç zehirlenmesi ve bilekte kesi veya başka bir travma ile geldikleri için toplam 12 hasta çalışma dışı bırakıldı. Demografik, klinik, sosyokültürel ve psikiyatrik özellikleri acil servis doktoru tarafından daha önceden oluşturulan matbu çalışma formlarına kaydedildi. Bilgiler hasta, hasta yakınları, adli rapor ve sevk epikrizlerine göre kayıt altına alındı. İntihar nedeniyle ilgili literatürde kabul edilmiş bir sınıflama yoktur. Hastalara intihar girişimi nedenleri soruldu ve sınıflamaya tabi tutulmadan cevapları forma kaydedildi. Acil servisimize ağız yoluyla aşırı ilaç alımına bağlı intihar girişimi nedeniyle başvuran kadın hastalar iki gruba ayrıldı: Gebe olanlar ile gebe olmayanlar. Kontrol grubu olarak gebe olmayan ve intihar amacıyla aşırı ilaç alımına bağlı acil servise başvuran doğurganlık çağındaki kadın hastalar alındı. Gecikme süresi, intihar amaçlı aşırı ilaç alımından acil servise başvuru anına kadar geçen zamanın dakika cinsinden ölçülerek hesaplandı. Tedavi maliyetleri hesaplanırken sosyal güvenlik kurumuna bildirilmiş olan toplam tedavi ücreti esas alındı. Maliyet kalemleri içinde hasta muayene ücreti, tıbbi sarf malzeme giderleri, ilaç giderleri, yatak ücreti ve yapılan müdahale ücretleri yer almaktadır. Hastaların verileri “SPSS.20 for Mac” programına kaydedildi. Bu iki grup arasındaki farklılıklar ki-kare testi, Mann-Whitney U-testi ile incelendi. Ortalamalar standart sapmayla birlikte verildi. p<0.05 değeri anlamlı kabul edildi.

Bulgular Gebe grubunda 23 (%7.4) hasta ve kontrol grubunda 286 (%92.6) olmak üzere toplam 309 hasta çalışmaya alındı. Hastaların demografik ve klinik özellikleri Tablo 1 ve Tablo 2’de gösterilmiştir. İlaç zehirlenmesi olan gebe hastaların tedavi maliyeti gebe olmayanlara göre belirgin olarak daha yüksek

Tablo 1. Hastaların yaş, Glasgow koma skoru (GKS), tedavi maliyeti ve gecikme sürelerinin karşılaştırılması Gebelik

Özellik

Yok

Yaş

22 23.1-24.7 24 22.6-28.8 >0.05*

Glasgow koma skoru (GKS) Tedavi maliyeti** Gecikme dakikası***

%95 GA

Var

%95 GA

13.5-15.1

13.0-15.4

>0.05*

488.6

523.2-637.4

595

-130.5-5237.5

<0.001*

240 268.4-329.6 330 241.1-452.9 >0.05*

*** İlaç alındıktan sonra acil servise ulaşana kadar geçen süre. ** (Hasta muayene ücreti + tıbbi sarf malzeme giderleri + ilaç giderleri + yatak ücreti + yapılan müdahale ücreti, TL) * Mann-Whitney U-testi; GA: Güven Aralığı.

Uzkeser M ve ark.

Gebelerde İntihar Amaçlı İlaç Zehirlenmelerinin Gebe Olmayanlara Göre Farkı Var Mı?

Tablo 2. Hastaların sosyoekonomik özellikleri Gebelik

Özellik

Yok

Var p

N (%)

%95 GA

N (%)

%95 GA

Medeni durum

Evli

107 (37.4)

28.2-46.6

20 (87.0)

72.3-101.7

Bekar

179 (62.6)

55.5-69.7

3 (13.0)

-25.1-51.1

88 (30.8)

21.2-40.5

6 (26.1)

-9.0-61.2

>0.05* 0.099*

Erzurum İl sınırları dışından gelme

<0.0001*

Yerleşim yerine göre

Köy

27 (8.5)

-2.0-19.0

1 (4.4)

-35.5-44.1

İlçe

45 (14.1)

3.9-24.3

7 (30.4)

-3.7-64.5

İl merkezi

247 (77.4)

72.2-82.6

15 (65.2)

41.1-89.3

Prognoz

Taburcu

49 (17.1)

6.6-27.6

0 (0)

Yatış

206 (72.0)

65.9-78.1

21 (91.3)

79.3-103.4

Tedavi reddi

31 (10.7)

-0.2-21.6

2 (8.7)

-30.4-47.8

0.078**

Yattığı servis

Acil müşahede

222 (77.6)

72.1-83.1

13 (56.5)

29.6-83.5

Dahili servisler

18 (6.3)

-4.9-17.5

3 (13.0)

-25.1-51.1

Yoğun bakım

9 (3.2)

-8.3-14.7

3 (13.0)

-25.1-51.1

Kadın hastalıkları

37 (12.9)

2.1-23.7

4 (17.5)

-19.7-54.8

0.039**

İç hastalıkları, Psikiyatri. *Ki-kare testi; ** Fischer’in kesin testi; GA: Güven Aralığı. 1

bulunmuştur [ortanca=595 TL’ye (ortalama=2553.5±6206.7) karşılık ortanca=488.6 TL (ortalama=580.3±490.3), p<0.001] (Tablo 1). Gebe olan hastaların acil servise gelene kadar geçen süre (ortanca=240 dakika), gebeliği olmayan hastalardan (ortanca=330 dakika) daha kısa olmasına rağmen istatiksel olarak bu fark anlamlılığa ulaşmamıştır (p>0.05) (Tablo 1). Hastalarımızdan 23 yaşında organofosfat zehirlenmesi ile başvuran bir gebe anestezi yoğun bakım ünitesine yatırıldıktan 10 gün sonra hayatını kaybetmiştir. Çalışmamızda gebelerde mortalite oranı %4.4’dür. Hasta gruplarının aldığı ilaçlar Tablo 3’de belirtilmiştir. Her iki grupta bulantı, kusma, mide ağrısı, letarji, şuur kaybı, baş ağrısı, ajitasyon, baş dönmesi ve idrar retansiyonu görülme sıklığı bakımından anlamlı bir fark bulunamamıştır (her bir parametre için p>0.05). İntihar girişimi nedenleri gebe olanlarda %60.9 (n=14) ailesel problemler, %8.7 (n=2) evlilik, %8.7 (n=2) ruhsal problemler, %4.3 (n=1) yalnızlık, %4.3 (n=1) iletişim problemleri, %4.3 (n=1) iş problemleri, %4.3 (n=1) ekonomik sorunlar ve %4.3 (n=1) belirtilmeyen olarak sıralanırken gebe olmayan

grupta ise en sık 3 neden %39.2 (n=112) ailesel problemler, %11.2 (n=32) ruhsal hastalık, %10.1 (n=29) karşı cinsle yaşanan sorunlardır. Acil serviste gebe hastalarda kadın hastalıkları ve doğum kliniğinden konsültasyon isteme oranı gebe olmayanlara göre anlamlı olarak yüksektir [%91.3’e (n=21) karşı %0.3 (n=1); p<0.0001]. Gebe olmayan bir hastanın acil serviste kadın hastalıkları ve doğum konsültasyonu isteme nedeni aile içi şiddetle birlikte vajinal kanamanın olmasıdır. Acil serviste psikiyatri konsültasyonu isteme oranları her iki grup arasında farklı bulunmamıştır (gebeler için n=14, %60.9; kontrol grubu n=211, %73.8; p=0.181). Acil serviste gebe hastalara istenen psikiyatri konsültasyonu sonucu 16 (%69.6) hastaya tanı konulamamış, 5 (%21.7) hastaya impulsif intihar girişimi tanısı ve 2 (%8.7) hastaya ise majör depressif bozukluk tanısı konmuştur. Kontrol grubundaki kadın hastalarda ise 142 (%49.7) hastaya tanı konamamış, 115 (%40.2) hastaya impulsif intihar girişimi tanısı, 25 (%8.7) hastaya majör depressif bozukluk, 1 (%0.3) hastaya obsessif kompulsif bozukluk, 1 (%0.3) hastaya bipolar affektif bozukluk, 1 (%0.3) hastaya psikoz ve 1 (%0.3) hastaya da şizofreni tanısı konmuştur. Hasta gruplarının psikiyatrik özellikleri incelendi-

171

172

Türkiye Acil Tıp Dergisi - Tr J Emerg Med 2012;12(4):169-174

Tablo 3. Aldıkları ilaca göre her iki grubun incelenmesi Gebelik

Özellik

Yok

Var p

n (%)

%95 GA

n (%)

%95 GA

Çoklu ilaç alımı

194 (67.8)

61.2-74.4

9 (39.1)

7.2-71.0

0.005*

Antidepresan

98 (34.3)

24.9-43.7

4 (17.4)

-19.8-54.6

0.098**

Analjezik1

64 (22.4)

12.2-32.6

4 (17.4)

-19.8-54.6

>0.05**

Parasetamol

57 (19.9)

9.5-30.3

9 (39.1)

7.2-71.0

0.031*

Antibiyotik

46 (16.1)

5.5-26.7

3 (13.0)

-25.1-51.1

>0.05**

Organofosfat

26 (9.1)

-2.0-20.2

8 (34.8)

1.8-67.8

<0.001*

Antihipertansif

11 (3.8)

-7.5-15.1

1 (4.3)

-35.5-44.1

>0.05**

Benzodiazepin

8 (2.8)

-8.6-14.2

0 (0)

>0.05**

Salisilat

6 (2.1)

-9.4-13.6

2 (8.7)

-30.4-47.8

0.055**

THC

4 (1.4)

-10.1-12.9

1 (4.3)

-35.5-44.1

>0.05**

Etanol

2 (0.7)

-10.9-12.3

0 (0)

>0.05**

Parasetamol ve salisilat hariç; 2 Tetrahidrocannabinol; *Ki-kare testi; ** Fischer’in kesin testi; GA: Güven aralığı.

ğinde daha önceden psikiyatrik hastalık öyküsünün gebe hastalarda anlamlı derecede daha az olduğu görülmüştür (p=0.019) (Tablo 4). Daha önceden intihar girişimi öyküsü de gebe hastalarda hiç görülmemiş olup gebe olmayan hastalarda %14 gibi yüksek oranda olmasına rağmen istatiksel olarak anlamlı bulunmamıştır (p=0.055).

ilk çalışmadır. Bu popülasyonunun özelliklerinin bilinmesi tedavi ve izlemde acil doktorlarına ışık tutacaktır. Literatürde gebelerde görülen intihar amaçlı zehirlenmelerle ilgili çok fazla çalışma bulunmamaktadır. Dört yıl süresince zehir danışma merkezine telefonla yapılan başvuruların değerlendirildiği bir çalışmada bildirimlerin %0.07’sinin gebe zehirlenmelerine bağlı olduğu görülmüştür. Hastaların %98’inde hastanın aldığı yabancı madde bilinmekte olup bunların büyük çoğunluğunun tek bir ilaç olduğu bildirilmiştir. Gebelerin almış oldukları 50 farklı ilaç tiplerinden en sık analjezikler (en sık asetaminofen), vitamin-demir preperatları, antibiyotikler, antihistaminikler ve dekonjes-

Tartışma Çalışmamız bölgemizde intihar amaçlı ilaç zehirlenmesiyle başvuran gebe hastaların sosyodemografik özelliklerini belirleyen ve intihar amaçlı ilaç zehirlenmesiyle başvuran gebe olmayan kadın hastalarla temel farklarını vurgulayan

Tablo 4. Hastaların psikiyatrik özelliklerine göre incelenmesi Gebelik

Özellik

Yok n (%)

%95 GA

n (%)

Var p %95 GA

Daha önceden intihar girişimi

40 (14.0)

3.3-24.8

0 (0)

0.055**

Ailede intihar öyküsü

16 (5.6)

-5.7-19.9

0 (0)

>0.05**

Daha önceden psikiyatrik hastalık öyküsü

75 (26.2)

16.3-36.2

1 (4.3)

-35.5-44.1

0.019**

Ailede psikiyatrik hastalık öyküsü

38 (13.3)

2.5-24.1

4 (17.4)

-19.8-54.6

>0.05**

Son 6 ay içinde psikiyatri poliklinik başvurusu

68 (23.8)

13.7-33.9

2 (8.7)

-30.4-47.8

0.096**

İntihar girişiminden sonra psikiyatri poliklinik başvurusu

155 (54.2)

46.4-62.0

11 (47.8)

18.3-77.3

>0.05*

Tekrar özkıyım girişiminde bulunma

13 (4.5)

-6.8-15.8

0 (0)

>0.05**

Anne baba akraba evliliği

25 (8.7)

-2.4-19.8

0 (0)

>0.05**

*Ki-kare testi; **Fischer’in kesin testi; GA: Güven aralığı.

Uzkeser M ve ark.

Gebelerde İntihar Amaçlı İlaç Zehirlenmelerinin Gebe Olmayanlara Göre Farkı Var Mı?

tanlardır. Bu çalışmada maternal ölüm hiç bildirilmemiştir. Hastaların %55’inde belirti ve bulgular yok veya hafifken %45’inde majör veya ‘hayatı tehdit edici’ bulgular bildirilmiştir.[7] Polonya’da 2005 yılında yapılmış ve gebelerde intihar amaçlı ağız yoluyla alınan ilaç zehirlenmelerini inceleyen 3 yıllık bir çalışmada 19 gebe hasta incelenmiş olup %63.2’sinin ilk gebelik olduğu rapor edilmiştir. Hastaların intihar amaçlı kullandığı en popüler ilaç %36.8 ile benzodiazepinler olmuştur. İntihar girişimi için en sık ileri sürülen neden %47.4 ile plansız gebeliktir. İzlenen gebeliklerin 2’si düşükle, 1’i de prematür doğumla sonuçlanmıştır. Gebelerden hiçbiri intihar girişimi nedenini abortus indüksiyonu olarak belirtmemiştir.[8] Bizim çalışmamızda intihar amaçlı ağız yoluyla en sık alınan ilaçlar; parasetamol (%39.1), çoklu ilaç alımı (%39.1) ve organofosfatlardır (%34.8). Çalışmamızda gebelerde organofosfat ile zehirlenmenin yüksek olmasının nedeni, hastalarımızın tarımla uğraşan kırsal alanlardan daha fazla gelmesi olabilir. Czeizel’in[3] yapmış olduğu bir çalışmada, gebelik süresince intihar teşebbüsünde bulunan hastalarda diazepam, prometazin ve folik asitin zehirlenme aracı olarak sık kullanılan ilaçlar olduğu belirlenmiştir. Bunun sebebi, Macaristan’da düşük tehdidi ve preterm eylem tedavisinde diazepam ve prometazin doktorlar tarafından gebelere sık olarak reçete edilmesi ve kolay erişilebilmeleri olarak ifade edilmiştir. Ayrıca çalışmalarında gebe olanlar ile olmayanlar arasındaki ikinci önemli farklılık da gebe kadınların intihar amaçlı aldıkları ilaç dozları gebe olmayanlara göre anlamlı olarak daha düşük olmasıdır. Bizim çalışmamızda ise gebelikte kadın hastalıkları ve doğum uzmanı tarafından sık reçete edilen ilaçların intihar amaçlı kullanılmadıklarını tespit ettik. Bunun nedeni bu hastaların gebelik izlemlerinin yapılmaması veya hastaların istenmeyen gebelik olduğu için yakınlarına gebeliği ile ilgili bilgi vermemesi olabilir. Çalışmamızdaki ilgi çeken bir diğer bulgu da gebelerin intihar girişiminde düşüğe neden olan ilaç kullanmamalarıdır. Kliniğimizde yapılmış bir tez çalışmasında çoklu ilaç alarak intihar girişiminde bulunan hastaların tek tip ilaç alanlara göre acil servise daha geç başvurdukları görülmüştür. Bu durum çoklu ilaç alanlarda potansiyel olarak intihar isteğinin daha yüksek olmasına bağlanmıştır.[9] Bizim çalışmamızda gebelerde çoklu ilaç intihar girişiminin gebe olmayan gruba göre anlamlı olarak daha düşük olması gebeliğin kadınlarda intihar girişiminin derecesi için daha koruyucu rol oynadığını düşündürmektedir. Macaristan’da yapılmış bir çalışmada ağız yoluyla alınan ilaç zehirlenmesi ile başvuran 137 gebe hasta incelenmiş olup %68.6’sı intihar girişimi, %21.2’si kaza ile aşırı ilaç alımı ve %8’inin abortus indüksiyonu amacıyla olduğu bulunmuştur. Zehirlenmeden sonra intihar amaçlı ilaç alan gebelerin

%33’ünde abortus gerçekleşmişken kazayla olan zehirlenmelerde abortus oranı %3 olarak saptanmıştır. Abortus indüksiyonu için ilaç alanlarda abortus oranı %91 ile en yüksek olarak bulunmuştur. Yazarlar bu çalışmada zehirlenme ile intihar teşebbüsünde bulunan gebelerin abortus isteğinin yüksek olduğunu vurgulamaktadırlar. İntihar girişimi grubundakilerin %25’i 1. trimesterde yaşamlarına son vermeye çalışmışken %43’ü 2. trimesterde ve %31’i de 3. trimesterde intihar girişiminde bulunmuşlardır.[10] İlaçlarla intihar girişiminin hamilelikte en sık olduğu dönem bir araştırmada postkonsepsiyonel 4. hafta ve gebeliğin 2. ayı olarak bulunmuştur.[3] Bir başka çalışmada gebelik esnasında en sık intihar girişiminin 3. gebelik ayında pik yaptığı bildirilmiştir.[11] Bizim çalışmamızda 23 gebe hastanın 12’sinde (%52.2) gebelik dönemi bilinmemektedir. Bilinen 11 hastanın altısı ilk trimester (%47.8) gebelikte iken, üçer hasta ise ikinci ve üçüncü trimester gebelikte idi (%26.1’er). İlk trimester gebelikte intihar girişiminin daha sık görülmesinin nedeni bu gebeliklerin istenmemesi veya abortus isteği olabilir. Budapeşte’de 1960-1993 yılları arasında, intihar amaçlı ilaç alımı sonrası zehirlenme nedeniyle başvuran 1444 gebe hastanın incelenmesinde hastalarda ölüm oranı %1.8 olarak tespit edilmiştir. Genel olarak hastaların pik yaşının 18-20 arası olduğu, %62’sinin ilk gebeliği olduğu, %55’inin evli olmadığı, genellikle düşük sosyoekonomik seviyede oldukları ve depresyon panik bozukluk tanısının hastaların sadece %1.8’sinde olduğu bulunmuştur.[3] Çalışmamızda gebe hastalarda tanısı konulmuş psikiyatrik bozukluk oranı gebe olmayan hastalarla karşılaştırıldığında anlamlı oranda daha düşüktür. 2010 yılında bipolar bozukluğu olan bireylerde intihar girişimlerinin maliyetlerini inceleyen bir çalışmada, intihar teşebbüsünü takip eden yıldaki toplam sağlık harcamaları ortalaması yaklaşık 25000 dolar olup bu şahısların intihar girişiminden önceki yılda yapılan toplam sağlık harcamaları yaklaşık 11500 dolardır. İntihar teşebbüsünden sonraki yılda yapılan sağlık harcamaları yaklaşık %29’u ilk bir ay içinde yapılmıştır.[12] Kendine zarar verme davranışında bulunan 98 hastanın incelendiği bir çalışmada, acil servisten taburcu olan ve hastaneye yatırılan hastaların ortalama tedavi maliyetleri sırasıyla 55.6 dolar ve 255 dolar olarak bulunmuştur. Çalışmada maliyetin önemli belirleyicisi hastanede kalış süresi olduğu bulunmuştur.[13] İngiltere’de 1993 yılında yapılmış bir çalışmada acil servise başvurudan taburculuğa kadar geçen sürede bir hasta için ortalama tedavi maliyeti 425 pounddur.[14] Bizim çalışmamızda ilaç zehirlenmesi olan gebe hastaların tedavi maliyeti gebe olmayanlara göre belirgin olarak daha yüksek bulunmuştur. Bu durum gebelerdeki ilaç zehirlenmelerinde daha çok tetkik istenmesine (obstetrik ultrasonografisi gibi), daha uzun süre acil serviste müşahade edilmesine veya yatış oranlarının daha yüksek olmasına bağlı olabilir.

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Gebe olan hastaların acil servise gelene kadar geçen süre, gebeliği olmayan hastalara göre daha kısa olarak bulunmuştur. Acil servislere başvuru anına kadar geçen sürelerle ilgili literatürde yapılmış bir çalışma yoktur. Bizim çalışmamızda gebe hastaların çift can taşımaları sebebiyle hasta yakınları tarafından Acil servise daha hızlı ulaştırma isteği olduğunu düşünüyoruz.

Kaynaklar

Kısıtlılıklar

4. McClure CK, Katz KD, Patrick TE, Kelsey SF, Weiss HB. The epidemiology of acute poisonings in women of reproductive age and during pregnancy, California, 2000-2004. Matern Child Health J 2011;15:964-73.

Çalışmamızda hastaların kendi bildirdikleri ve doğru kabul edilen bilgiler temel alınmıştır. Çalışmamızda kullandığımız veriler hastadan, hastanın ailesinden, akrabalarından veya arkadaşlarından temin edilerek doğruluk oranları arttırılmaya çalışılmıştır. Bu nedenle yanlış bilgilendirmeler olabilir. Çalışmamız tek merkezlidir. Bu nedenle veriler tüm bölgeye ve Türkiye’ye genellenmemelidir. Hastanın ve/veya hasta yakınlarının intihar girişimini saklama düşüncesi nedeniyle bazı vakalar atlanmış olabilir. Bu çalışma, acil servis doktorlarının bakış açısı ile acil servise intihar girişimi nedeniyle başvuran hastaları inceleyen bir çalışma olduğu için psikiyatrik tanılar ve duygu durum bozuklukları ayrıntılı olarak incelenememiştir.

Sonuç Gebe olanlarla gebe olmayan kadın hastalar karşılaştırıldığında gebeler daha çok evli hastalardan oluşmakta olup acilde müşahede oranları daha düşük, dahili servislere ve yoğun bakıma yatış oranları daha yüksektir. Organofosfat, salisilat ve parasetamol ile zehirlenme oranları gebe olmayanlara göre daha yüksek olup, çoklu ilaç alımı ise daha az görülmektedir. Gebelerdeki tedavi maliyetleri gebe olmayanlara göre yaklaşık 4 kat artmaktadır. Çıkar Çatışması Yazar(lar) çıkar çatışması olmadığını bildirmiş(lerdir)tir.

1. Lara MA, Letechipia G. Suicidal ideation and suicidal behavior in pregnancy. Salud Ment 2009;32:381-7. 2. Benute GR, Nomura RM, Jorge VM, Nonnenmacher D, Fráguas Junior R, Lucia MC, et al. Risk of suicide in high risk pregnancy: an exploratory study. Rev Assoc Med Bras 2011;57:583-7. 3. Czeizel AE. Attempted suicide and pregnancy. J Inj Violence Res 2011;3:45-54.

5. Weiss HB. Pregnancy-associated injury hospitalizations in Pennsylvania, 1995. Ann Emerg Med 1999;34:626-36. 6. Schnitzer PG, Runyan CW. Injuries to women in the United States: an overview. Women Health 1995;23:9-27. 7. Rayburn W, Aronow R, DeLancey B, Hogan MJ. Drug overdose during pregnancy: an overview from a metropolitan poison control center. Obstet Gynecol 1984;64:611-4. 8. Sein Anand J, Chodorowski Z, Ciechanowicz R, Klimaszyk D, Lukasik-Głebocka M. Acute suicidal self-poisonings during pregnancy. Przegl Lek 2005;62:434-5. 9. Gür STA. Acil servise intihar girişimi nedeni ile yapılan başvuruların demografik ve klinik özellikleri. [Uzmanlık Tezi] Erzurum: Atatürk Üniversitesi; 2012. 10. Lester D. The timing of attempted suicide during pregnancy. Acta Paediatr Hung 1987;28:259-60. 11. Appleby L. Suicide during pregnancy and in the first postnatal year. BMJ 1991;302:137-40. 12. Stensland MD, Zhu B, Ascher-Svanum H, Ball DE. Costs associated with attempted suicide among individuals with bipolar disorder. J Ment Health Policy Econ 2010;13:87-92. 13. Shahid M, Khan MM, Naqvi H, Razzak J. Cost of treatment of deliberate self-harm. A study from Pakistan. Crisis 2008;29:213-5. 14. Yeo HM. The cost of treatment of deliberate self-harm. Arch Emerg Med 1993;10:8-14.

ORIGINAL ARTICLE KLİNİK ÇALIŞMA

Urticaria-Angio Edema: Profile of Patients in the Emergency Department and Factors Affecting Revisits Ürtiker ve Anjiyoödem: Acil Servis Hasta Profili ve Tekrarlayan Başvurular Yeliz BERK,1 Oktay ERAY,2 Özlem YİĞİT,2 Neslihan SAYRAÇ,2 Erkan ALPSOY3 Adana Numune Hospital, Adana; Department of Emergency Medicine, Akdeniz University Faculty of Medicine, Antalya; 3 Department of Dermatology, Akdeniz University Faculty of Medicine, Antalya, Turkey 1

SUMMARY

ÖZET

Objectives The precise definition of the acute urticaria patients presenting to emergency department will improve the clinical approach to the urticaria patient. The aim of this study is to define the demographic features of urticaria patients visiting the emergency department and to find the factors that affect emergency department revisits due to urticaria symptoms.

Amaç Acil servise başvuran akut ürtiker hastalarının tam olarak tanımlanması, klinik yaklaşımı geliştirecektir. Çalışmadaki amacımız acil servise başvuran ürtiker hastalarının demografik özelliklerini ve ürtiker semptomlarına bağlı tekrarlayan acil servis başvurularını etkileyebilecek faktörleri tanımlamaktır.

Methods This was a retrospective case control study. Patients aged 16 and older were enrolled to the study. The number of revisits for the same complaints in the five days following the first visit was determined and the factors affecting the number of recurrent visits was searched.

Gereç ve Yöntem Bu çalışma geriye dönük bir vaka kontrol çalışması olarak yapıldı. On altı yaş ve üzerindeki hastalar çalışmamıza alındı. Beş gün içinde aynı şikâyetlerle acil servise tekrar başvuran hastalar belirlendi ve hastaların tekrarlayan başvurularını etkileyebilecek faktörler araştırıldı.

Results The mean age of 3813 urticaria patients was 40.2±15.8, 2304 of whom were female. 2940 were triaged as non-urgent and 3787 were discharged from the emergency department. The 78 patients with recurrent visits were identified and there was no significant difference between the sex, urticaria or allergy history in the past, receiving H1 and H2 receptor blockers together or receiving two different H1 receptor blockers, the season of the year, comorbid diseases, or medicines for chronic illness between patients who visited the emergency department once and those who visited the emergency department repeatedly. The presence of a possible cause for the urticaria symptoms and chronic urticaria diagnosis were found to be more common in the revisit group.

Bulgular Çalışmamıza alınan 3813 ürtiker hastasının, ortalama yaşı 40.2±15.8, 2304’ü (%60.4) kadın, 2940’ı (%77.1) az acil triyaj kategorisindeydi ve hastaların 3787’si (%98.8) acil servisten taburcu edilmişti. Acil servise tekrarlayan başvurularda bulunan 78 hasta kontrol grubuyla karşılaştırıldığında, cinsiyet, alerji ve/veya ürtiker öyküsü, eşlik eden hastalık veya bu nedenle kullanılan kronik ilaç varlığı, başvurdukları mevsim, taburculuk tedavilerinde H1 reseptör antagonistine H2 veya ikinci bir H1 reseptör antagonistinin eklenmesi arasında fark bulunmadı. Ürtikere yol açan olası bir neden saptanması ve kronik ürtikere dönüşüm tekrarlayan başvuru grubunda daha sık görülmekteydi.

Conclusions This study has pointed out that scores of urticaria patients are entering emergency departments and these patients may have life-threatening problems. This information can be used to modify emergency clinic curriculum and can contribute to the standardization of urticaria management and follow up. Future prospective studies may be conducted for urticaria management in light of our results.

Sonuç Bu çalışma acil servise çok sayıda ürtiker hastasının acil servise başvurduğunu göstermiştir ve bu hastaların hayatı tehdit eden problemleri olabilir. Bu bilgi acil sağlık hizmeti veren hekimlerin eğitim müfredatlarının düzenlenmesi ve ürtiker yönetimi ve takibinin standart hale getirilmesi için kullanılabilir. Çalışmamızın sonuçlarının ışığında gelecekte ileriye dönük çalışmalar planlanabilir.

Key words: Emergency department; urticaria, treatment, outcome.

Anahtar sözcükler: Acil servis; ürtiker, tedavi, prognoz.

Submitted (Geliş tarihi): 11.09.2012 Accepted (Kabul tarihi): 11.10.2012 Correspondence (İletişim): Dr. Ozlem Yiğit. Akdeniz Üniversitesi Tıp Fakültesi Acil Tıp Anabilim Dalı, Antalya e-mail (e-posta): ozlemyigit@akdeniz.edu.tr

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doi: 10.5505/1304.7361.2012.58751

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Introduction Urticaria represents the most frequently observed skin disorder (35%) presenting in an emergency department.[1] Acute urticaria or acute exacerbations of chronic urticaria constitute the emergency department visits. The concomitant factors for urticaria can change the management of urticaria in emergency departments. The recurrence of the urticaria symptoms despite of emergency treatment is the cause of emergency department revisits. Acute urticaria may progress to life-threatening angioedema and/or anaphylactic shock in a very short period of time and basic aim of an emergency physician is to realize the presence of anaphylaxis or to prevent its occurrence. Concurrently with anaphylaxis, emergency physicians should treat the urticaria symptoms and give information to the patient about the disease. The etiology, pathophysiology and treatment of urticaria still remain numerous discrepancies and knife edge. The recurrence of symptoms in spite of treatment and avoidance of new attacks have not been demystified.[2] Considering the emergency department visits, the profile of acute urticaria patients in our population has not been described with adequate patient number. Finding out the demographics and distributions of acute urticaria patients in emergency departments can affect the patient care and department preparations. Acute urticaria patients have been thought to seek treatment generally from the dermatology or allergy-immunology clinics. However these clinics are rare in some parts of the country and the patients usually prefer to visit the dermatology or allergy-immunology clinics for further evaluation after they are treated in an emergency department for acute attacks. In fact, urticaria is the most common cutaneous disease treated in the emergency departments and defining the patient population can give useful information about acute urticaria. This information can be used for modifying emergency clinics curriculum, as well as the public health statistics and can contribute to the standardization of the urticaria management and follow up. The aim of this study is to define the demographic features of urticaria patients visiting the emergency department and to find the factors which can affect the emergency department revisits due to urticaria symptoms.

Materials and Methods Prior to beginning of the study, the ethic approval was received from Akdeniz University Faculty of Medicine local ethical committee. By searching the previous seven years’ emergency department hospital records, a special patient subgroup was constituted and a retrospective case control

study was developed with this subgroup. For this reason, the study could be assessed in two stages. At the first stage, all patients aged 16 and older, visiting the emergency department with different complaints between 01 January 2001-30 April 2008 and which were coded as urticaria (L50) according to the to ICD-10 (International Classification of Diseases 10th revision and Clinical Modification) codes in Akdeniz University Emergency Department database were found. The age and gender of the patients, application date, emergency department triage category, and referral type after emergency treatment were enrolled. The application dates were assessed in two different categories as months and seasons. All patients were triaged with triple triage system, used in our emergency department. According to this system, patients with rash and systemic involvement were triaged as ‘urgent’, patients only having rash triaged as ‘non-urgent’, and patients with shock or difficulty in breathing triaged as ‘emergent’. Referral type after treatment was classified as ‘hospitalized’ or ‘discharged’. All data were recorded to SPSS 16.0 for windows. At the second stage, patient revisits with same symptoms within the first 5 days after emergency department treatment and discharge, were found in all urticaria records. Limiting the revisit time as the following 5 days was determined with a thought that this period could reflect the patients’ dissatisfaction and inadequate treatment. This subgroup was classified as ‘revisit group’. The detailed records of 102 patients in revisit group were searched in Akdeniz University Hospital database archives and full records of 78 patients were attained and these patients were enrolled to the study. In the SPSS 16.0 for windows program, 102 ‘revisit’ patients were deleted from the total of 3813 patients and 4% of remained patients were randomized automatically for the ‘control group’. There were 141 patients in the ‘control group’ and detailed records of 91 patients were found, therefore 91 patients were enrolled to the study. From the detailed records; patients’ age, gender, application date, allergy history in the past, comorbid diseases and medicines for chronic illness, the presence of a possible reason for the urticaria symptoms, experienced urticaria and prescribed medications on discharge were recorded. Furthermore, it was also searched if these patients turned to dermatology or allergyimmunology clinics for check examinations and if they were diagnosed as ‘chronic urticaria’. All these data were enrolled to SPSS 16.0 for windows too. Basic descriptive statistics were used to analyze the data collected at the first stage. Chi-square test was used for the distributions, medians, comparisons of the seasons and the categorical evaluations of the parameters of the data collected at the second stage. T-test was used to compare the evaluation values.

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Results The results were collected at two stages. At first stage, 3813 patients found from the Akdeniz University Emergency Department database according to the ICD-10 codes were evaluated. Patient flow chart was shown in Fig. 1. From the total of 3813 patients, 1509 (39.6%) were male and the remained 2304 (60.4%) were female. According to the triple triage system, 2940 (77.1%) patients were triaged as ‘nonurgent’, 821 (21.5%) patients as ‘urgent’, and 52 (1.4%) as ‘emergent’. The application dates were classified as seasons. December-January-February was categorized as group 1, March-April-May was categorized as group 2, June-JulyAugust was categorized as group 3, and September- October- November was categorized as group 4. There were 889

(23.3%) patients in group 1, 970 (25.4%) patients in group 2, 1015 (26.6%) patients in group 3, and 939 (24.6%) patients in group 4. While 46 patients (1.2%) were hospitalized either in dermatology or internal medicine-allergy clinic wards, 3767 patients (98.8%) were discharged from the emergency department (Table 1). There was not any significant statistical difference between the sex and emergency department referral type (p=0.951). 102 patients returned to emergency department with same complaints within the following 5 days after discharge. The revisit ratio was calculated as 2.6% from total patient number. The data of the ‘revisit group’ and ‘control group’ were analyzed and two groups were compared to search the factors which can affect the emergency department revisits due to

n=3813

Hospitalized (n=46)

Discharged (n=3767)

Revisit group (n=102)

Control group (n=141)

Missing data

Detailed full data

Missing data

Detailed full data

(n=24)

(n=78)

(n=50)

(n=91)

n=3813

Hospitalized (n=46)

Discharged (n=3767)

Revisit group

Control group

(n=102)

(n=141)

Missing data

Detailed full data

Missing data

(n=24)

(n=78)

(n=50) Detailed full data (n=91)

Figure 1. Patient flow chart.

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Table 1. The demographics of the urticaria patients

Discussion Acute urticaria is the most frequent skin disorder (35%)

Characteristics Patient presenting in an emergency department.[1] Although the number % prevalence of urticaria in the population differs in various (n=3813) Gender Male Female Triage Non-urgent Urgent Emergent Season* 1. group 2. group 3. group 4. group Emergency department referral type Discharged Hospitalized Revisit No Yes

1509 2304

39.6 60.4

2940 821 52

77.1 21.5 1.4

889 970 1015 939

23.3 25.4 26.6 24.6

3767 46

98.8 1.2

3711 102

98.0 2.6

Season*= December-January-February group 1; March-April-May group 2; June-July-August group 3; September-October-November group 4.

urticaria symptoms. When compared with chi-square test there was not any significant statistical difference between the two groups for gender (p=0.940). The mean age was 40.34±18.28 in control group and 42.28±15.59 in revisit group. There was not any significant difference between the allergy history in the past (p=0.826), urticaria history (p=0.323), comorbid diseases (p=0.7), medicines for chronic illness (p=0.652), the season of the year (p=0.954). The presence of a possible cause for the urticaria symptoms (p<0.001) and conversion to chronic urticaria (p=0.021) were found to be statistically different in revisit group (Table 2). According to the patients’ anamnesis, 7 patients reported a suspected food and 39 patients reported a suspected drug. All 7 patients reported a suspected food were in revisit group. In the emergency department, all patients were treated with intravenous antihistaminic and steroid therapy and due to the clinical necessity epinephrine was given. All discharged patients were prescribed an H1 antagonist. Comparing the patients who had H1 antagonist alone or with a H2 antagonist revealed no significant differences (p=0.784). There was not any significant difference between the patients who were prescribed a second H1 antagonist regardless of whether an H2 antagonist was given or not (p=0.936).

sources, it has been changing between 15-25%.[3] During the study period, approximately 300.000 patients entered to the Akdeniz University Emergency Department and the prevalence of acute urticaria in our population was calculated as 1.3%, which was lower than the general population. Since they have learned many things about their illnesses during their previous attacks, many of the urticaria patients may not prefer to go to an emergency department or any other doctor’s office. Concurrently with this fact, the patients may also prefer the primary care clinics where they can get care quickly and easily to a university hospital. Since urticaria is a common disease and it is a main topic in the curriculum of medicine faculties, all primary care physicians learn the standard urticaria management before graduation and they

Table 2. Comparisons of the data of the ‘revisit group’ and ‘control group’

Revisit group Control group Q-square

Data

Patient Patient number % number % (n=78) (n=91)

Gender Female 51 65.4 Male 27 34.6 Seasonal distributions 1. group 15 19.2 2. group 18 23.1 3. group 25 32.1 4. group 20 25.6 Allergy history No 58 74.4 Yes 20 25.6 Comorbid diseases No 44 56.4 Yes 34 43.6 Medicines for chronic illness No 55 70.5 Yes 23 29.5 Urticaria history No 52 66.7 Yes 26 33.3 Possible cause for urticaria No 44 56.4 Yes 34 43.6 Conversion to chronic urticaria No 68 87.2

59 64.8 0.940 32 35.2 17 18.7 0.954 22 24.2 26 28.6 26 28.6 69 75.8 0.826 22 24.2 54 59.3 00.7 37 40.7 67 73.6 0.652 24 26.4 67 73.6 0.323 24 26.4 75 82.4 p<0.001 16 17.6 88 96.7 0.021

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may care the urticaria patients with confident information. All these reasons can be shown as an explanation for the low urticaria prevalence in our university hospital population. Many of the urticaria patients prefer to turn to an emergency department when they seek treatment for their acute attacks. This is because of the fact that the emergency departments are the only places where they can get treatment at night and other extraordinary times. Furthermore the difficulty of getting an appointment waiting for a long time at allergy-immunology or dermatology clinics make emergency department more preferential. For all these reasons, emergency physicians need expert opinion about urticaria management and treatment. When the literature has been searched from PubMed and Turkish database ‘Ulakbim’, with ‘urticaria’ and ‘allergic reaction’ keywords, an article describing the urticaria patients in Turkish population and emergency departments cannot be found. Gaig et al.[4] conducted an epidemiological populationbased study among adults. After calculating a sample size from a population of 105.603 individuals for maximum variability, they randomly chose 5.003 individuals who were questioned by phone calls for depicting demographic distribution and prevalence of chronic urticaria. The average age of onset was 40 years. They found a 0.6% (95% CI: 0.4-0.8) prevalence of chronic urticaria. The prevalence of chronic urticaria was significantly higher in women (0.48%) than in man (0.12%) with an OR=3.82 (95%CI 1.56-9.37). Acute urticaria episodes in the population were 18.72% (95% CI: 22.3-15.19) and acute urticaria prevalence was also higher in women than in man with an OR=1.64 (95%CI 1.4-1.9). Humpreys and Hunter[5] collected the data of 390 consecutive patients between 8 and 80 ages, seen in dermatology clinics between 1977-1979 and 1989-1993 with two separate cohorts. They found that 230 (61%) of the patients were women and the median age at the onset of symptoms was 40 years. 61 patients (16%) was diagnosed as acute urticaria. Simonart et al.[1] retrospectively analyzed the records of 676 patients admitted to emergency department for acute urticaria in order to know the particularities and the main etiologies. They found that the mean age was 28 and females were affected more than males. Nettis et al.[6] carried out a prospective study on 562 consecutive patients who had been referred to an allergy-immunology clinic with urticaria and/or angioedema between 1996 and 1999 and analyzed the prevalence of various forms of urticaria according to an etiological and clinical classification. The mean age was 35±16 years and 384 (68%) were female. Many of the patients were diagnosed as chronic urticaria (55%) while only 7.6% of them diagnosed as acute urticaria. The four study results aforementioned above stated that urticaria was seen more in women in population-based stud-

ies, dermatology and allergy immunology clinics and emergency departments. We searched 3813 urticaria patients retrospectively and found the similar gender and age rates with all these studies except the study reporting the mean age as 28, conducted by Simonart et al.[1] Acute and chronic urticaria separation is done due to the duration of the symptoms. Symptoms lasting more than 6 weeks are assessed as chronic urticaria. Chronic urticaria is seen in only a subgroup of patients and progresses in a long course with relapsing acute attacks. Despite the higher prevalence of acute urticaria in population-based studies, chronic urticaria prevalence is found to be higher in dermatology and allergy-immunology clinics.[6] This data offer that acute urticaria patients commonly admit to emergency department and primary care units. Chronic urticaria patients can manage their acute attacks at home without coming to a clinic, using their experience from the previous attacks. The etiologic triggering factors for acute urticaria or personal history of an allergic disease were searched in various studies. A study conducted by Zuberbier et al.[7] in 1996 showed that 50.2% of acute urticaria patients had an allergic asthma or atopic dermatitis in the past medical history. In their study Humpreys and Hunter reported that, 103 patients (26%) from a total of 390 suffered from an atopic or asthmatic disease and the etiologic factors could not be shown in 217 patients (56%)[5] Nettis et al. reported family atopy history in 197 patients (35%) from a total of 562 patients, in their prospective study of urticaria and/or angioedema patients. Due to the patient’s anamnesis, 105 patients (19%) reported a history of reactions to drugs, 66 patients (12%) had a history of food reactions. In addition, urticaria reactions in 8% of the patients resulted from IgE-mediated type I allergic reactions due to drugs, foods, inhalants and Hymenoptera while 6% of the cases were caused urticaria by non-immunological pathways triggered by drugs, foods or additives.[6] In the present study, 169 patients in control group and revisit group were detected and found out that 42 patients (24.9%) had previous allergy history and 50 patients (29.6%) had previous urticaria history. These results were similar with the previous studies mentioned above. However past medical history of urticaria or allergy did not significantly affect the revisits. It is well-established that food allergies are common causes of acute urticaria in children however this is not clear for adults.[8] Simons et al.[9] found a common association with food ingestion and urticaria episodes in children. Legrain et al.[10] reported food, mainly cow’s milk, to be relevant for acute urticaria in 10 of 12 infants. However in adults, especially in chronic urticaria, the pseudoallergens are more common than the direct allergic role of the food.[11] For example

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Aoki et al.[12] searched 50 adult patients in a prospective epidemiologic study and none of the patients had a food allergy, whereas 62% of patients had an upper respiratory tract infection. Zuberbier et al.[13] evaluated the possible benefits of a stringently controlled pseudoallergen-free diet in a prospective study and in 73% of patients; symptoms ceased or were greatly reduced within 2 weeks on diet. These results were confirmed by Pigatto and Valsecchi[14] who investigated a group of 202 patients with chronic urticaria using the same diet. In this study 126 (62.4%) patients improved on diet.In light of the foregoing, it can be foreseen that restricting pseudoallergens from the diet can improve the symptoms at various degrees in chronic urticaria patients. In the present study, the presence of a possible cause for the urticaria symptoms was found to be statistically significant in revisit group. The high levels in this group may be related to the food and/or additives. The higher chronic urticaria conversion in the revisit group may also support this claim. Since all patients did not visit the dermatology clinic after the emergency department visits, the data on patients at the hospital database were not sufficient. Therefore, we could not be able to confirm the certain etiologic role of food or other factors on urticaria. The data of a prospective designed study for investigating the etiologic agents will give more useful and confidential information. The patients triaged as ‘emergent’ according to triple triage system we used in our emergency department can be thought to have serious systemic urticaria. Stewart and Evan,[15] in a retrospective study conducted in an emergency department with 55.000 annual visits, found 9 (0.16%) severe anaphylaxis reaction from a total of 24 (0.4%) generalized allergic reactions. Bellou et al.[16] reported 1% generalized reaction incidence and 0.037% anaphylactic shock incidence in their retrospective study. In the present study, patient ratio triaged as ‘emergent’ was found 1.4%. This high rate can be explained by the general classification of patients rather than urticaria classification. However, despite this classification difference, the high hospitalized patient ratio as 1.2%, can predict that our patient population cover more serious patient than other studies. Since our hospital is a reference center in a region with 2-3 million people, we could see more serious patients than other hospitals, as well as patients may prefer us at their serious attacks. Bellou et al.[16] observed that nearly half the ED visits took place in summer which suggested that there was a seasonal factor. This could be due to the high frequency of allergies to hymenoptera registered in summer, which is consistent with the life cycle of this type of insect. In the present study, there was not any difference between the seasons of the year, between the patient demographics and revisits. Except the study mentioned above, other papers remarked seasonal

difference as an unforeseen circumstance for urticaria, so our data was compatible with general literature. Unascertained possible causes of urticaria also support this information. Acute urticaria treatment with combined H1 and H2 blockade has been shown to have advantages over H1 blockade alone. Bleehen et al.[17] used chlorpheniramine+cimetidine or chlorpheniramine+placebo in the treatment of chronic idiopathic urticaria, in a multi-centre randomized double-blind study for 120 chronic idiopathic urticaria patients. There was a statistically significant difference between the average response in the two treatment groups in favor of chlorpheniramine plus cimetidine after 4 and 8 weeks’ treatment. In a randomized, double-blind, placebo-controlled trial, Lin et al.[18] treated 91 adult patients with acute allergic syndromes with either 50 mg of diphenhydramine and saline solution (control group) or with 50 mg of diphenhydramine and 50 mg of ranitidine (active group). Both groups had similar proportions of urticaria at baseline. There were significantly more patients without urticaria in 2 hours among the patients in the active group compared with those in the control group. In the present study, there was not any significant difference between the patients in revisit or control group, who received H1 antagonist alone or with a H2 antagonist in the prescription. Even though we could not be able to confirm the advantage of receiving H1 and H2 receptor blockers together, combined therapy is 2C level evidence according to SIGN (Scottish Intercollegiate Guidelines Network).[19] A prospective randomized double-blind placebo controlled study will give useful information about this treatment options. Limitations One of the limitations for the present study is because of the retrospective design: we were not able to check the patients if they used their prescribed medications regularly as we taught them or if they used any other medicines. The second limitation is that: if the patient went to another medical center instead of our clinic for ongoing urticaria symptoms within the 5 days, than we did not have them in our revisit group. Therefore our revisit group could be higher than detected.

Conclusion Before all else, this study has pointed out the scores of urticaria patients entering to emergency departments. Besides, these patients may have life-threatening problems or sometimes may need hospitalization. This information can be used for modifying emergency clinics curriculum and can contribute to the standardization of the urticaria management and follow up. Since there is quite similarity between our results and the international literature, this study might blaze a trail for new prospective studies about urticaria. When the literature searched, standard diagnostic tests and treatment mo-

Berk Y et al.

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dalities cannot be found especially for emergency department patients. Future prospective studies can be conducted for urticaria management in light of our results. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. Simonart T, Askenasi R, Lheureux P. Particularities of urticaria seen in the emergency department. Eur J Emerg Med 1994;1:80-2. 2. Dibbern DA Jr. Urticaria: selected highlights and recent advances. Med Clin North Am 2006;90:187-209. 3. Kaplan AP. Urticaria and angioedema. In: Adkinson NF, Yunginger JW, Busse WW editors. Middleton’s allergy: principles and practice. Vol. 2., 6th ed., Philadelphia: Mosby; 2003. p. 1537-58. 4. Gaig P, Olona M, Muñoz Lejarazu D, Caballero MT, Domínguez FJ, Echechipia S, et al. Epidemiology of urticaria in Spain. J Investig Allergol Clin Immunol 2004;14:214-20. 5. Humphreys F, Hunter JA. The characteristics of urticaria in 390 patients. Br J Dermatol 1998;138:635-8. 6. Nettis E, Pannofino A, D’Aprile C, Ferrannini A, Tursi A. Clinical and aetiological aspects in urticaria and angio-oedema. Br J Dermatol 2003;148:501-6. 7. Zuberbier T, Iffländer J, Semmler C, Henz BM. Acute urticaria: clinical aspects and therapeutic responsiveness. Acta Derm Venereol 1996;76:295-7. 8. Zuberbier T. Urticaria. Allergy 2003;58:1224-34.

9. Simons FE. Prevention of acute urticaria in young children with atopic dermatitis. J Allergy Clin Immunol 2001;107:7036. 10. Legrain V, Taïeb A, Sage T, Maleville J. Urticaria in infants: a study of forty patients. Pediatr Dermatol 1990;7:101-7. 11. Khalaf AT, Li W, Jinquan T. Current advances in the management of urticaria. Arch Immunol Ther Exp (Warsz) 2008;56:103-14. 12. Aoki T, Kojima M, Horiko T. Acute urticaria: history and natural course of 50 cases. J Dermatol 1994;21:73-7. 13. Zuberbier T, Chantraine-Hess S, Hartmann K, Czarnetzki BM. Pseudoallergen-free diet in the treatment of chronic urticaria. A prospective study. Acta Derm Venereol 1995;75:484-7. 14. Pigatto PD, Valsecchi RH. Chronic urticaria: a mystery. Allergy 2000;55:306-8. 15. Stewart AG, Ewan PW. The incidence, aetiology and management of anaphylaxis presenting to an accident and emergency department. QJM 1996;89:859-64. 16. Bellou A, Manel J, Samman-Kaakaji H, de Korwin JD, Moneret-Vautrin DA, Bollaert PE, et al. Spectrum of acute allergic diseases in an emergency department: an evaluation of one years’ experience. Emerg Med (Fremantle) 2003;15:341-7. 17. Bleehen SS, Thomas SE, Greaves MW, Newton J, Kennedy CT, Hindley F, et al. Cimetidine and chlorpheniramine in the treatment of chronic idiopathic urticaria: a multi-centre randomized double-blind study. Br J Dermatol 1987;117:81-8. 18. Lin RY, Curry A, Pesola GR, Knight RJ, Lee HS, Bakalchuk L, et al. Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists. Ann Emerg Med 2000;36:462-8. 19. Zuberbier T, Bindslev-Jensen C, Canonica W, Grattan CE, Greaves MW, Henz BM, et al. EAACI/GA2LEN/EDF guideline: management of urticaria. Allergy 2006;61:321-31.

CASE REPORT OLGU SUNUMU

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Çarpan Balığı: Denizden Uzakta Deniz Canlıları ile Zehirlenme Vakası Greater Weever Fish: A Case of Poisoning with Sea Creatures Far Away from the Sea Sezin BOZKURT,1 Sertaç GÜLER,2 Gökhan AKSEL,2 İsa KILIÇASLAN1 Gazi Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Ankara; 2 Mardin Devlet Hastanesi, Acil Servis, Mardin

ÖZET

SUMMARY

Çarpan balığı olarak bilinen Trachinus Draco ile olan zehirlemeler, muhtemelen rapor edildiğinden çok daha sık görülmektedir. Ancak literatürde Trachinus türlerinin zehirlenmelerini tanımlayan oldukça az sayıda klinik vaka bildirilmiştir. Biz bu olgumuzda çarpan balığı ile zehirlenen bir vakanın bulgularını ve tedavi yöntemlerini tanımlamaya ve denizden uzakta ölü deniz canlıları ile zehirlenmelerin olabileceğini vurgulamaya çalıştık.

Trachinus Draco, known as greater weever fish, probably seen more frequently than has been reported. However, only a few clinical cases have been reported in the literature that describes Trachinus species envenomation. Here, we presented a case poisoned by a weever fish and tried to describe the signs/symptoms and treatment modalities of the weever fish envenomation and also tried to emphasize poisonings that could be far from the sea with dead sea creatures.

Anahtar sözcükler: Acil servis; çarpan balığı; Trachinus Draco; zehirli balık.

Key words: Emergency; greater weever; Trachinus Draco; venomous fish.

Giriş

Olgu Sunumu

Deniz canlılarıyla zehirlenmelere, balıkçılığın ve deniz turizminin yoğun olduğu kıyı kesimlerinde sıkça rastlanmaktadır. Bu vakalar basit bir lokal deri enfeksiyonundan anafilaksiye kadar ilerleyen geniş bir klinik spektrum ile başvurabilirler. Çarpan balığı olarak bilinen Trachinus Draco ile olan zehirlemeler ise, muhtemelen rapor edildiğinden çok daha sık görülmektedir. Ancak literatürde Trachinus zehirlenmelerini tanımlayan oldukça az sayıda klinik vaka bildirilmiştir.

Balık restoranında çalışan 30 yaşındaki erkek hasta, sağ el 3. parmağında ağrı, şişlik ve kızarıklık şikayetleri ile acil servisimize başvurdu. Hastanın beraberinde baş dönmesi, sağ kolda şiddetli ağrı, bulantı ve terleme şikâyetleri vardı. Hastanın anamnezinde başvurusundan 20 dakika önce, restoranda çarpan balığı temizlerken, omurgasındaki dikeninin eline battığı öğrenildi. Hasta başvuru sırasında ağrıya neden olan balığı da beraberinde getirmişti (Şekil 1a).

Biz bu olgu sunumu ile hem çarpan balığı ile zehirlenme belirti/bulgularını ve tedavi seçimlerini tartışmayı hedefledik, hem de denizden uzakta ölü deniz canlıları ile zehirlenmelerin olabileceğini vurgulamaya çalıştık.

Yaralanmadan birkaç dakika sonra şiddetli bir ağrı hissettiğini, sonrasında şişlik ve kızarıklık geliştiğini belirtti. Hastanın geliş vital bulgularında kan basıncı 190/90 mmHg, nabzı 46 atım/dk ve solunum sayısı 16/dk idi. Fizik muayenede sağ el

6. Ulusal Acil Tıp Kongresi’nde poster bildiri olarak sunulmuştur (6-9 Mayıs 2010, Antalya). Geliş tarihi (Submitted): 17.09.2012 Kabul tarihi (Accepted): 22.10.2012 Online baskı (Published online): 22.10.2012 İletişim (Correspondence): Dr. İsa Kılıçaslan. Birlik Mah., 439. Sok., Tunalı Hilmi Apt. No: 1/3, Çankaya, 06650 Ankara e-posta (e-mail): isakilicaslan@hotmail.com

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doi: 10.5505/1304.7361.2013.54227

Bozkurt S ve ark.

Çarpan Balığı: Denizden Uzakta Deniz Canlıları ile Zehirlenme Vakası

3. parmak pulpasında dikenin giriş yeri görüldü. Parmak şiş, ödemli ve eritemli idi. Palpasyonda belirgin hassasiyet ve ısı artışı mevcuttu (Şekil 1b). Çekilen elektrokardiyografisi bradikardik (44 atım/dk), sinüs ritminde idi ve akut patoloji saptanmadı. Hastanın tam kan sayımında, böbrek ve karaciğer fonksiyon testlerinde, kardiyak enzim ve kanama profilinde herhangi bir patolojiye rastlanmadı. Ağrı şikâyetine yönelik olarak, sağ eline yaklaşık 42oC derece sıcak su ile 30 dakika suya daldırma şeklinde uygulama yapıldı. Gözlemde el dorsumunda ödem, eritem, ısı artışı gelişti. Sıcak su uygulaması ile ağrısı kontrol edilemeyen hastaya intravenöz non-steroid antienflamatuvar (NSAID) ilaç uygulandı. Tedaviye tetanoz profilaksisi, 80 mg metil prednizolon, 45.5 mg feniramin ve profilaktik 1 gram iv sefamezin eklendi.

(a)

(b)

Şekil 1. (a) Çarpan balığı olarak bilinen Trachinus Draco. Yeşilimsi sarı rengi ve omurgası üzerinde 3-4 adet zehirli dikenler dikkat çekmektedir. (b) Çarpan balığının dikeninin batması sonucu sağ el 3. parmak pulpasındaki giriş deliği, parmakta ödem, eritem ve şişlik dikkati çekmektedir.

NSAID uygulamasından 1 saat sonra ağrı şiddetinin değişmemesi üzerine, intravenöz infüzyon olarak 100 mikrogram fentanil ile ağrı kontrol altına alındı. Acil servis takibinin 4. saatinde, hastanın bradikardisinin düzeldiği ve tansiyonunun ise normale döndüğü gözlendi. Parmaktaki ödemde gerileme saptandı. Ağrısı ise minimum düzeylerdeydi. Hasta başvurusundan 5 saat sonra ağrısının geçmesi ve ödeminin önemli ölçüde azalması, genel durumunun tamamen düzelmesi sonrasında acil servisten taburcu edildi. Taburculuk esnasında ekstremite elevasyonu önerilirken, yara yeri enfeksiyonu hakkında hastaya bilgi verildi. Hastanın kontrollere gelmemesi ve hastaya ulaşılamaması nedeniyle hasta takibi yapılamadı.

Tartışma Çarpan balığı olarak bilinen Trachinus Draco, Akdeniz, Avrupa Kıyıları, Doğu Atlantik Okyanusu ve Karadeniz’de yaşar.[1] Yeşilimsi sarı renktedir ve erişkin çarpan balığının ortalama boyu 20-40 cm’dir. Omurgasının üzerinde 3-4 adet zehirli diken içeren bir balıktır. Su dışında uzun süre canlı kalır ve öldükten sonra bile dikenlerindeki zehir etkisini korur.[2] Bu zehir histamin, katekolamin, noradrenalin, 5-hidroksitriptamin ile membran stabilizasyonu ve hemolitik aktiviteye sahip çeşitli enzimler içerir.[3] Tipik olarak zehirlenme balıkçılar ve yüzücülerde görülür. Hastaların en sık başvuru şikayeti çok şiddetli ağrıdır[4] ve hemen müdahale gerektirir. Ağrı birkaç dakikada en yüksek seviyeye ulaşır ve 24 saatte geçer. Ancak aylar sonra ağrı şikâyetinin devam ettiği olgular da bildirilmiştir.[5] Semptomlar genellikle etkilenen ekstremitede lokalizedir. Ödem, ekimoz, ısı artışı, eritem, bölgesel lenfanjit sık görülen bölgesel semptomlardır. Sistemik belirtiler oldukça nadir görülür.[2] En sık sistemik belirti, hipotansiyon ve solunum depresyonudur. Ancak enzimin bifazik kardiyovasküler yanıtından dolayı, önce hipertansiyon, sonrasında hipotansiyon bildirilmiş çok nadir olgular da vardır.[3] Bu olguda da hastanın başvurusunda ciddi hipertansif ve bradikardik olduğu, takibinde ise normotansif olduğu gözlenmiştir. Olgumuzun ilk başvurusunda ciddi hipertansif olması ve bradikardik seyretmesi çeşitli mekanizmalar ile açıklanabilir. Bu tür balık zehirlenmelerinde, balık zehrine bağlı kardiyovasküler yanıtlar değişebilmektedir. İlk olarak, tüm zehirler düz kas kasılmasına, ardından endotel bütünlüğün tam olması durumunda vazodilatasyonla sonuçlanmaktadır. İkinci olarak, tüm balık zehirlerinin negatif ve pozitif inotrop etkilerin kombinasyonuna sahip olduğu gösterilmiştir. [3] Bu etki bifazik kardiyovasküler etki olarak tanımlanmaktadır. Negatif etkiler muskarinik reseptörler üzerinden bazen zehrin içeriğindeki kolinomimetikler aracılığıyla bazen de indirekt olarak endojen asetilkolin aracılığıyla olmaktadır.

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Pozitif etkilerin kısmi olarak adrenoreseptörler aracılığıyla olduğu düşünülmektedir. “Drakotoksin” olarak bilinen bu zehrin içeriğindeki yüksek konsantrasyondaki katekolamin ve noradrenalinin adrenoreseptörler aracılığıyla bu hastanın hipertansif seyretmesine neden olurken, kolinomimetik içerik nedeniyle bradikardik olduğu düşünüldü. Tedavinin temel ilkesi analjezi sağlamaktır. Çoğu hasta orta derecede analjeziklere yanıt vermez ve opioid analjezik gerekir.[4] 1782 yılında, çarpan balığı ile zehirlenen bir balıkçının şiddetli ağrı sebebi ile parmağını kestiği bildirilmiştir.[2] Bu olguda da NSAID ile yanıt alınamamış olup, opioid analjezik kullanılmıştır. Sistemik analjezik etki ortaya çıkana kadar, etkilenen ekstremiteye sıcak su uygulaması tarihsel bir değere sahip olsa da hasta konforu açısından oldukça önemlidir.[2] Etkilenen ekstremitenin hastanın tolere edebileceği kadar bir sıcaklıkta (genellikle 40-42 derece) 30 dakika kadar sıcak suya batırılması önerilmektedir.[2,6,7] Ağrı yönetiminde lokal anestezik ve sinir blokajı denenmiş, hasta açısından tercih edilen bir uygulama olmasa da başarı sağlanmıştır.[1,8] Profilaktik antibiyotik uygulamaları literatürde tartışmalıdır. [1] Nekrozu olmayan, yabancı cisim görülmeyen, küçük lezyonlara profilaktik antibiyotik genel olarak önerilmemektedir.[6] Literatürde steroid ve antihistaminik uygulaması alternatif tedavi seçenekleri arasındadır. Olgumuzda steroid ve antihistaminik tedavi uygulanmıştır. Bunun nedeni drakotoksinin içeriğinde histamin bulunması ve hastamızın sistemik semptomları olması nedeniyledir. Hem ısırık yarası, hem de travmatik yaralanma olduğundan, her hastaya tetanoz profilaksisi önerilir.[3] Zehir açıkça tanımlansa da antitoksin çalışmaları deneysel aşamada kalmıştır. [2] Gecikmiş sekeller hakkında bilgi azdır, ancak nadir görülmektedir. Yaraların geç dönemde iyileştiği bildirilmiştir.[5] Bu nedenle balık ısırığına bağlı yaralanmalarda hastalar komplikasyonlar hakkında bilgilendirilmelidir.[9]

Sonuç Literatürde az sayıda vaka bildirimi olmasına rağmen, Trachinus türleri ile zehirlenmeler nadir bir zehirlenme türü değildir. Deniz canlılarıyla zehirlenmelere kıyı kesimlerinde sıkça rastlanmasına karşın, denizden uzak iç kesimlerde de bu tür vakalarla karşılaşılabilir. Bunun sebebi, çarpan balığında olduğu gibi zehrin toksik etkisinin, balık öldükten sonra da devam ediyor olmasıdır. Sonuç olarak bir acil tıp hekiminin, Trachinus türleri gibi zehirli deniz canlıları ile zehirlenme vakaları ile karşı karşıya kaldığında özel tedavi yöntemleri konusunda yeterli bilgi birikime sahip olması gerektiği düşüncesindeyiz. Çıkar Çatışması Yazar(lar) çıkar çatışması olmadığını bildirmiş(lerdir)tir.

Kaynaklar 1. Çete Y, Göksu E. Suda yaşayan canlılara bağlı yaralanma ve zehirlenmeler. İçinde: Satar S, editör. Acilde klinik toksikoloji. 1. Baskı, Adana: Nobel Kitabevi; 2009. s. 80:631. 2. Halpern P, Sorkine P, Raskin Y. Envenomation by Trachinus draco in the eastern Mediterranean. Eur J Emerg Med 2002;9:274-7. 3. Church JE, Hodgson WC. The pharmacological activity of fish venoms. Toxicon 2002;40:1083-93. 4. Cain D. Weever fish sting: an unusual problem. Br Med J (Clin Res Ed) 1983;287:406-7. 5. Dekker CJ. Chronic pain and impairment of function after a sting by the great weaver fish (Trachinus draco). [Article in Dutch] Ned Tijdschr Geneeskd 2001;145:881-4. [Abstract] 6. Isbister GK. Venomous fish stings in tropical northern Australia. Am J Emerg Med 2001;19:561-5. 7. Atkinson PR, Boyle A, Hartin D, McAuley D. Is hot water immersion an effective treatment for marine envenomation? Emerg Med J 2006;23:503-8. 8. Davies RS, Evans RJ. Weever fish stings: a report of two cases presenting to an accident and emergency department. J Accid Emerg Med 1996;13:139-41. 9. Eryılmaz M, Durusu M, Menteş MÖ, Yiğit T, Zeybek N, Öner K. Envenomation caused by weever fish. Turk J Emerg Med 2006;6:142-5.

OLGU SUNUMU CASE REPORT

Fokal Nörolojik Defisitli Hasta: Bir Karbonmonoksit Zehirlenmesi Olgusu The Patient with Focal Neurological Deficit: A Case of Carbonmonoxide Poisoning Engin ÖZAKIN, Arif Alper ÇEVİK, Nurdan ACAR, Osman ÇETİNKAYA Osmangazi Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Eskişehir

ÖZET

SUMMARY

Zehirlenme nedeniyle meydana gelen ölümlerin en önemli sebeplerinden birisi karbonmonoksit zehirlenmeleridir. Hastalar baş ağrısı, bulantı ve kusma gibi şikayetler yanı sıra, inmeyi taklit edebilecek şekilde fokal nörolojik defisit, nöbet ya da bilinç durum değişikliği ile de başvurabilirler. Bu yazıda, yeni ortaya çıkan fokal nörolojik bulgu nedeniyle trombolitik tedavi için acil servise getirilen 81 yaşındaki olgu sunuldu.

Carbon monoxide (CO) poisoning is one of the most frequent causes of death resulting from poisoning. Patients suffering from CO poisoning present to the emergency department with the complaints of headache, nausea and vomiting. Focal neurological deficits mimicking stroke, convulsion or coma may also be seen. We present a 81 year old woman who was brought to the emergency department for thrombolitic treatment following a new onset focal neurological deficit who was eventually diagnosed with CO poisoning.

Anahtar sözcükler: Ayırıcı tanı; inme; karbonmoksit; nörolojik defisit.

Key words: Differential diagnosis; stroke; carbonmonoxide; neurological deficit.

Giriş

tedir. Biz yazıda, acil servise trombolitik tedaviye aday olarak getirilen, yeni fokal nörolojik defisitli bir karbonmonoksit zehirlenmesi olgusu sunuldu.

Karbonmonoksit zehirlenmesi, zehirlenmeye bağlı ölümlerin en önemli nedenlerinden birisidir. Beyin ve kalp hipoksiye en duyarlı organlar olması nedeniyle olgular sıklıkla nöropsikiyatrik ve kardiyovasküler semptomlarla acil servise başvururlar. Geniş semptom yelpazesi bazı hastaların yanlış ya da gecikmiş tanı almasına neden olabilir. Özellikle baş ağrısı, senkop, bilinç durum değişikliği, nörolojik acillerle karışabilir. Literatürde sınırlı sayıda fokal nörolojik bulgu ile başvuran karbonmonoksit zehirlenmesi olgusu bulunmaktadır.[1] Hastanemizde, iskemik inmeli hastalar için özel bir “Beyin ve Kalp Krizi Protokolü’’ uygulanmakta ve erken başlangıçlı nörolojik bulgusu olan hastalar acil servisimize yönlendirilmek-

Olgu Sunumu Seksen bir yaşında kadın hasta, acil servise 112 il ambulans servisi tarafından inme protokolü çerçevesinde bilinç değişikliği ve fokal nörolojik defisit ile getirildi. En son 4 saat önce yakınları tarafından sağlıklı olarak görülen hasta getirilmeden 20 dakika önce evde baygın halde bulunmuştu. Başvuru anında kan basıncı 80/50 mmHg, nabız 109/dakika, solunum sayısı 20/dakika, Glaskow Koma Skoru 11 (E3V3M5) saptandı. Özgeçmişinde hipertansiyonu olan hastanın, 80 mg/gün

Geliş tarihi (Submitted): 22.09.2011 Kabul tarihi (Accepted): 26.03.2012 Online baskı (Published online): 26.03.2012 İletişim (Correspondence): Dr. Engin Özakın. Eskişehir Osmangazi Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, 26000 Eskişehir e-posta (e-mail): enginozakin@hotmail.com

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telmisartan kullandığı öğrenildi. Muayenede iki taraflı üst ekstremite fleksiyon, sol alt ekstremitede 2/5 kas gücü kaybı, solda alt ekstremitede derin tendon refleksine ekstensör tipte yanıt ve sol santral fasiyal paralizi saptandı. Diğer sistem muayeneleri doğal olarak değerlendirildi. Klinik tablo ile hastada serebrovasküler olay düşünüldü. Hasta güvenlik çemberine alınarak 4 lt/dk’dan oksijen, 1000 cc hızlı infüzyonu takiben, 150 cc/saatten %0.9’luk NaCl başlandı. Yatak başı kan glukozu 225 mg/dl ölçüldü. EKG’de sinüs ritmi, hipertansiyon ve santral sinir sistemi etkilenimine bağlı olduğunu düşündüğümüz V4 ve V5 derivasyonlarında ST depresyonu görüldü. Hastanın hipotansif olması nedeniyle gerçekleştirilen yatak başı ultrasonografide anormal bir bulgu saptanmadı. Beyin tomografisinde her iki hemisferde ödem, sulkuslarda hafif silinme ve periventriküler hipoksik iskemik değişiklikler görüldü. Takipte nörolojik defisitinin gerilemesi, hastanın 81 yaşında olması, en son normal görüldüğü saatin 4 saat öncesi olması nedeniyle hasta trombolitik protokolünden çıkarıldı. Bu sırada elde edilen tam kan sayımı ve kardiyak parametreleri normaldi. Takibinde bilinci açılan hastanın tekrar alınan öyküsünde evinin sobalı olduğu ve evde yalnız başına yaşadığı öğrenildi. Ölçülen COHb düzeyi %28 saptanması üzerine hasta karbonmonoksit zehirlenmesi tanısı anestezi yoğun bakım ünitesine yatırıldı.

Tartışma Karbonmonoksit renksiz, kokusuz, tatsız ve irritan olmayan bir gazdır. Yanan organik maddelerin bir ara ürünüdür. Gelişmekte olan ülkelerde zehirlenme ve yangınla bağlantılı ölümlerin en sık sebebidir.[2] Ülkemizin, özellikle de ilimizin kış aylarında soğuk ve rüzgarlı olması nedeniyle, acil servislerde karbon monoksit zehirlenmelerine sıkça rastlanmaktadır. Karbonmonoksit vücutta doğal yollarla üretilmekte ve kanda %1’den daha az oranda bulunmaktadır.[3] Karbonmonoksitin hemoglobüline affinitesinin oksijenden 220 kat fazla olması ve doku düzeyinde hipoksi oluşturması karbonmonoksit zehirlenmelerindeki semptomların ortaya çıkışından sorumludur. Klinik durumun en önemli nedeni santral sinir sistemi ve kardiyovasküler sistem dokularında oluşan hipoksi ve inflamatuvar cevaptır.[4] Karbonmonoksit trombositlerde proteinine bağlanarak trombosit ve nötrofil agregasyonu, nötrofil degradasyonu ayrıca damar yatağına nötrofil adezyonuna neden olur. Bu sebeple tromboembolik olaylara neden olabilir. Santral sinir sistemi etkilenmesinin diğer bir sebebi de kardiyovasküler yetersizlik ve yüksek miktarda karbonmonoksitin düz kaslara etkisi ile oluşturduğu hipotansiyondur. Karbonmonoksit maruziyetlerinde hastalar genelde özgün olmayan şikayetler ile acil servislere başvururlar, en sık rastlanan semptomlar baş ağrısı, sersemlik ve bulantı olurken bu gibi durumlar özellikle kış aylarında gribal enfeksiyonlar ile

karıştırılabilmektedir.[5] Maruziyetin uzaması halinde COHb düzeyinden bağımsız olarak anoksik ensefalopatiye bağlı inme benzeri bulgular, nöbet, senkop, bilinç bulanıklığı ve konfüzyon görülebilir. Hipoksik serebral lezyonlar özellikle globus pallidusda olmak üzere, serebral korteks, serebral beyaz cevher ve bazal ganglionda görülür.[6] Tanı ve tedavi de COHb düzeyleri kadar hastanın kliniği de prognoz açsından önemlidir. Beyin tomografisi sıklıkla anormal bulgu sergilememektedir. Hastamızın beyin tomografisinde ödem ve hipoksik değişiklikler dışında spesifik bulguya rastlanılmamıştır. Magnetik rezonans görüntülemesinde iki taraflı globus pallidus nekrozu önemli ipucu olmasının yanı sıra beyaz cevher değişiklikleri ve demiyelinizasyon sık rastlanan bulgulardır.[7] Tedavide amaç karbonmonoksit eliminasyonu ve hemodinamik stabilizasyondur.[8] Hastanın COHb düzeyi göz önünde bulundurularak semptomlar ve muayene bulgularına göre eliminasyonu arttırmak için %100 oksijen ve hiperbarik oksijen tedavisi tercih edilmektedir.[9] Özellikle hiperbarik oksijen terapisi tedavi protokolleri açısından klinik çalışmaların azlığı nedeniyle tartışmalıdır. Genel olarak kabul edilen objektif ölçütler olmasa da her türlü nörolojik defisit, bilinç bozukluğu durumlarında, anjina, senkop, ritim bozukluğu, görme bozukluğu, konfüzyon, konvülsiyon, COHb düzeyinin %40’ın, iskemik kalp hastalarında %20’nin, gebelerde %15’in üzerinde ve 3 hafta içinde tekrarlayan bulguların olması halinde düşünülmelidir. İlimizde imzalanan protokole göre hastalar 112 ambulans hizmeti ile ya da ilk başvurduğu merkezden en kısa sürede trombolitik veya girişimsel trombektomi ya da embolektomi tedavileri için hastanemiz acil servisine getirilmektedir. Olgumuz, ilk bulguları nedeniyle inme olarak değerlendirilmiş trombolitik tedavi için en kısa sürede acil servise getirilmiştir. Protokol çerçevesinde getirilen hasta yaşının 81, en son sağlıklı görülme zamanın 4 saat olması nedeniyle trombolitik protokolünden çıkarılmıştır. CO zehirlenmeleri çok çeşitli nörolojik bulgu ile karşımıza gelebilir. Hastamızda başlangıçta var olan defisitleri nedeniyle, uygun endikasyonda olması halinde günümüzde yaygınlaşmakta olan trombolitik tedavi uygulanabilirdi. Literatüre bakıldığında nadir de olsa CO zehirlemesi sonucu iskemik inme olguları görülmüştür.[9,10] CO maruziyeti ile infarkt arasında belirgin korelasyon bulunamamıştır. Ancak hiçbir hastaya mevcut bulguları nedeniyle trombolitik tedavi başlanmamıştır. Acil şartlar altında çekilen beyin manyetik rezonans görüntülemede iskemik nedene bağlı ve trombolitik tedavi endikasyonu olması durumunda trombolitik tedavinin verilmesi yönünde literatürde yayına rastlanmamıştır. Bu nedenle bu konu ile ilgili daha fazla araştırmaların yapılması gerekmektedir.

Özakın E ve ark.

Fokal Nörolojik Defisitli Hasta: Bir Karbonmonoksit Zehirlenmesi Olgusu

Sonuç CO zehirlenmeleri inme kliniğini taklit eden nörolojik bulgularla karşımıza gelebilir. Bu nedenle serebrovasküler olay tablosu nedeniyle gelen nörolojik defisitli hastalarda mutlaka detaylı öykü alınmasının yanı sıra çevresel etkenlerinde araştırılması akılda tutulmalıdır. Çıkar Çatışması Yazar(lar) çıkar çatışması olmadığını bildirmiş(lerdir)tir.

Kaynaklar 1. Chang JB, Jeong HW, Kim KN, Kim DW, Kim CS. Acute carbon monoxide intoxication: The relation between MR findings and clinical outcome. J Korean Radiol Soc 1999;40:633-8. 2. Girman JR, Chang YL, Hayward SB, Liu KS. Causes of unintentional deaths from carbon monoxide poisonings in California. West J Med 1998;168:158-65. 3. Hee J, Callais F, Momas I, Laurent AM, Min S, Molinier P, et

al. Smokers’ behaviour and exposure according to cigarette yield and smoking experience. Pharmacol Biochem Behav 1995;52:195-203. 4. Weaver LK. Clinical practice. Carbon monoxide poisoning. N Engl J Med 2009;360:1217-25. 5. Centers for Disease Control and Prevention (CDC). Unintentional non-fire-related carbon monoxide exposures-United States, 2001-2003. MMWR Morb Mortal Wkly Rep 2005;54:369. 6. Prockop LD, Chichkova RI. Carbon monoxide intoxication: an updated review. J Neurol Sci 2007;262:122-30. 7. Roos RAC. Neurological complications of carbon monoxide intoxication. In: Vinken PJ, Bruyn GW, editors. Handbook of clinical neurology. Intoxication of the nervous system. Amsterdam: Elsevier; 1994. p. 31-8. 8. Tomaszewski CA, Thom SR. Use of hyperbaric oxygen in toxicology. Emerg Med Clin North Am 1994;12:437-59. 9. Gülbay BE, Önen ZP. Carbon monoxide poisoning. Turkiye Klinikleri J Surg Med Sci 2006;2:109-12. 10. Kim K, Na JY. Acute cerebral infarction in carbon monoxide poisoning. Korean J Stroke 2011;13:92-5.

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CASE REPORT OLGU SUNUMU

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Water Intoxication Resulting in Ventricular Arrythmias Ventriküler Aritmilere Neden Olan Su Zehirlenmesi Pınar TÜRKER BAYIR, Burcu DEMİRKAN, Serkan DUYULER, Ümit GÜRAY, Halil Lütfi KISACIK Department of Cardiology, Turkiye Yuksek Ihtisas Hospital, Ankara

SUMMARY

ÖZET

Water intoxication, defined as excessive water ingestion within a short period of time, may cause severe neurologic and cardiac symptoms. This condition is commonly seen in psychiatric patients, however the ingestion of excessive water is an infrequent method for attempting suicide. In this case report we present a 51-year-old woman with ventricular fibrillation due to electrolyte imbalance caused by excessive water ingestion during a suicide attempt. The patient was admitted to our emergency clinic with altered consciousness and agitation. She was hypertensive and neurological examination revealed no lateralizing signs. Ventricular arrhythmias, cardiopulmonary arrest and tonic-clonic seizure were observed during hospitalization. Blood chemistry showed hyponatremia and hypokalemia relevant to the patient’s history of ingestion of 12 liters of water in 4 hours time. After electrolyte disturbances were corrected, ventricular arrhythmias and seizure did not recur. The patient was referred for psychiatric evaluation and was discharged with antidepressive medication. Although water intoxication is well described in psychiatric disorders such as schizophrenia, it has not been previously reported in depressive patients with suicidal thought. Awareness of the clinical presentation of this rare situation may prevent potentially fatal complications.

Ağız yoluyla kısa sürede aşırı su alımı ciddi nörolojik ve kardiyak semptomlara yol açabilir ve su zehirlenmesi olarak adlandırılır. Bu durum psikiyatrik hastalarda sıklıkla görülmektedir ancak intihar amaçlı aşırı su alımı oldukça enderdir. Bu olgu sunumunda intihar amaçlı aşırı su alımının yol açtığı elektrolit dengesizliğine bağlı ventriküler fibrilasyon gelişen 51 yaşındaki hastayı sunuyoruz. Hasta acil kliniğimize bilinç değişikliği ve ajitasyon ile başvurdu. Hasta hipertansifti ve nörolojik muayenesinde lateralizasyon bulgusu yoktu. Hastanede takibi esnasında ventriküler aritmi kardiyopulmoner arrest ve tonik klonik nöbet gözlendi. Kan biyokimyasında hastanın 4 saat içerisinde 12 litre su içmesiyle uyumlu olan hiponatremi ve hipokalemi mevcuttu. Elektrolit bozukluğunun düzeltilmesinden sonra ventriküler aritmi ve nöbet tekrarlamadı. Hasta psikiyatrik değerlendirmeye yönlendirildi ve antidepresan tedavi ile taburcu edildi. Su zehirlenmesi şizofreni gibi psikiyatrik bozukluklarda iyi bilinse de intihar düşüncesi olan depresif hastalarda daha önce bildirilmemiştir. Bu nadir durumun klinik sunumuna olan farkındalık potansiyel olarak ölümcül seyredebilen komplikasyonları önleyebilir.

Key words: Suicide; ventricular arrythmia; water intoxication.

Anahtar sözcükler: Özkıyım; ventriküler aritmi; su zehirlenmesi.

Introduction

toxication is also reported in child abuse cases, in urology patients after uroflowmetry evaluation, and occasionally in otherwise healthy individuals.[3,4] However, excessive water ingestion with suicidal purpose is an extremely rare clinical presentation. Here, a female patient who attempted suicide

Excessive water ingestion in a short period of time may cause severe cardiac and neurologic symptoms. This condition, known as ‘water intoxication’, is generally encountered in psychiatric illnesses such as schizophrenia.[1,2] Water in-

Submitted (Geliş tarihi): 11.03.2012 Accepted (Kabul tarihi): 14.05.2012 Correspondence (İletişim): Dr. Pınar Türker Bayır. Gayret Mah. A.O.Ç Toki Bloklar Ck 1 No: 42, Yenimahalle, Ankara, Turkey e-mail (e-posta): turkerpinar1982@hotmail.com

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Türker Bayır P et al.

Water Intoxication Resulting in Ventricular Arrythmias

by excessive water ingestion over a short period of time is presented with clinical and laboratory findings.

Case Report A 51-year-old female patient was admitted to our emergency clinic with altered consciousness and agitation. She had a complaint of severe headache before alteration of consciousness. On admission her her body temperature was 36.7°C, blood pressure was 240/140 mmHg, pulse rate was 84 beats per minute, and respiratory rate was 24 per minute. On physical examination, mucosal membranes were wet and normal in color. Auscultation revealed a loud S2 and with no murmur and the lungs were clear. Neurological examination revealed that she was confused and disoriented. She was not cooperating during examination. Pupillas were isocoric and no lateralizing sign was observed. Deep tendon reflexes were mildly depressed in a generalized manner. During initial examination, the patient went into cardiovascular arrest and observed ventricular fibrillation was successfully terminated with defibrillation (Fig. 1). Electrocardiogram revealed sinus rhythm with a cQT interval of 510 milliseconds and prominent U wave. Patient was intubated since respiration was depressed. The patient’s family claimed that patient had no known physical or mental illness except hypertension and she was taking olmesartan 20 mg daily. To the best of their knowledge, she was not taking any other medication or exposed to toxic substances. She had no known suicide attemt, but they also claimed she was under emotional stress and she had ingested several liters of tap water in a short period of time. Blood chemistries revealed sodium was 107 mmol /l, potassium was 2.7 mmol/l, calcium was 2.0 mmol/l, magnesium was 1.25 meq/l and pH was 7.28. Complete blood count, urea, creatinine, alanine aminotransferase and aspartate aminotranferase levels were within normal ranges. Although neurological findings and hypertension were mimicking hypertensive encephalopathy, the patient’s history, electrolyte levels, and clinical manifestations were consistent with water intoxication. The patient was referred to

the intensive care unit. Intravenous magnesium (1 gr) slow bolus was applied and 3% NaCl (0.5 ml/kg/hour) and KCl (6 meq/hour) infusion was initiated immediately to correct the electrolyte imbalance. Meanwhile the patient’s cardiac rhythm deteriorated into torsade des pointes, causing hemodynamic compromise which was corrected successfully by 100 Joule direct current cardioversion. In the second hour of hospitalization, the patient developed tonic clonic seizure which was terminated with 10 mg intravenous diazepam administration. A consultant neurologist concluded that this seizure was secondary to electrolyte disturbance owing to patient’s neurologic examination and normal cranial computed tomography findings. In the 24th hour after electrolyte replacement, blood chemistry revealed sodium was 128 mmol/l and potassium was 4.1 mmol/l. During follow up, the patient’s level of consciousness normalized and she was extubated. Blood electrolytes were stable and arrhythmias did not recur during monitorization. Patient confirmed that she had ingested 12 liters of tap water in 4 hours time with suicidal purpose. Consultant psychiatrist diagnosed major depression and patient was discharged with anti-depressive medication.

Discussion Excessive water intake in a short period of time may result in severe deteriorations in electrolyte balance leading to cardiac and neurologic symptoms.[1,2] This rare entity known as ‘water intoxication’ was first described by Barahal in 1938[5] This disorder presents a variety of clinical signs and symptoms which may be challenging for clinician who is not aware of this rare situation. In the literature, the majority of water intoxication cases are described in the psychiatric disorders, particularly in schizophrenia. Polydypsia with unknown etiology, which is not infrequent in schizophrenic patients, may lead to water intoxication.[6] Iatrogenic water intoxication may be secondary to excessive irrigation during uroflowmetry, transurethral prostate resection or gastric lavage.[7] Forced water intoxication was also reported in a fa-

Figure 1. Monitor recording of ventricular fibrillation observed during patient’s examination

in the emergency room.

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tal child abuse case.[3] Moreover, water intoxication may be encountered in individuals after marathon runs, heat strokes or during over-hydration of patients with gastroenteritis or urinary tract infection[1,3,4] Water intoxication as a suicide method is a very extraordinary situation.

in depressive patients with suicidal thought as we report in this case. Electrolyte imbalance secondary to water intoxication may cause severe neurologic and cardiac disturbances. Early recognition of this rare situation may avoid potentially fatal complications.

Excessive water intake primarily affects sodium concentration in body fluids. Symptoms usually develop at serum sodium concentrations under 120 mmol/l secondary to dilutional hyponatremia. Initial symptoms are mild nausea and vomiting. Severe symptoms such as confusion, agitation, sleepiness, coma and epileptic seizures develop at serum concentrations under 115 mmol/l.[4] Hypokalemia promotes arrhythmias by decreasing K+ conductance through voltage-gated channels, decreasing the hyperpolarization effect of the ion during the repolarization phase in cardiac tissue. A partly depolarized membrane potential promotes automaticity, leading to ventricular arrhythmias. Hypokalemia also provokes changes in ST-segment, decrease in T wave amplitude, T wave inversion, elongation in QTsegment and prominent U wave. Hypokalemia also causes ventricular fibrillation and respiratory depression.[8,9] Acute severe electrolyte imbalance leading to fatal arrhythmia and neurologic disturbances is the main cause of death in water intoxication. In our case we observed agitation, confusion, epileptic seizure secondary to dilutional hyponatremia and ventricular arrhythmias caused by hypokalemia. These neurologic and cardiac findings totally reverted after correction of electrolyte imbalance. To the best of our knowledge, this is the first case of ingestion of excess water with suicidal purpose resulting in water intoxication.

Conflict of Interest

In conclusion, excessive water ingestion over a short period of time may result water intoxication. This clinical presentation is common in schizophrenia. However it may be seen

The authors declare that there is no potential conflicts of interest.

References 1. Hiramatsu R, Takeshita A, Taguchi M, Takeuchi Y. Symptomatic hyponatremia after voluntary excessive water ingestion in a patient without psychiatric problems. Endocr J 2007;54:643-5. 2. Santos-Soares PC, Bacellar A, Povoas HP, Oliveira-Filho J, Filgueiras NM, Brito AF. Excessive water ingestion and repeated seizures: the domino effect. Arq Neuropsiquiatr 2008;66:552-3. 3. Arieff AI, Kronlund BA. Fatal child abuse by forced water intoxication. Pediatrics 1999;103:1292-5. 4. Farrell DJ, Bower L. Fatal water intoxication. J Clin Pathol 2003;56:803-4. 5. Barahal HS. Water intoxication in a mental case. Psychiatr Q 1938;12:767-71. 6. Vishwajeet S, Aneesh S. Water intoxication leading to hyponatremia and seizures: a rare complication of uroflowmetry. Int Urol Nephrol 2005;37:275-6. 7. Hayashi T, Ishida Y, Miyashita T, Kiyokawa H, Kimura A, Kondo T. Fatal water intoxication in a schizophrenic patient--an autopsy case. J Clin Forensic Med 2005;12:157-9. 8. Boetzkes S, Van Hoeck K, Verbrugghe W, Ramet J, Wojciechowski M, Jorens PG. Two unusual pediatric cases of dilutional hyponatremia. Pediatr Emerg Care 2010;26:503-5. 9. Kluger MT, Szekely SM, Singleton RJ, Helps SC. Crisis management during anaesthesia: water intoxication. Qual Saf Health Care 2005;14:23.

OLGU SUNUMU CASE REPORT

Malign Arrhytmia Development Due to Propafenone Over Dose: A Case Report Propafenon Aşırı Dozuna Bağlı Gelişen Malign Aritmi: Olgu Sunumu Ethem ACAR,1 Latif DURAN,2 Yahya ŞAHİN,2 Hızır Ufuk AKDEMİR,2 Mehmet EKİZ,2 Ali Kemal ERENLER3 Department of Emergency Medicine, Erzurum Region Training and Research Hospital, Erzurum; 2 Department of Emergency Medicine, Ondokuz Mayıs University Faculty of Medicine, Samsun; 3 Department of Emergency Medicine, Corum State Hospital, Corum, all in Turkey

SUMMARY

ÖZET

Propafenone is a group 1C antiarrhytmic agent. It is an agent used in patients with symptomatic supraventricular tachycardia requiring treatment, such as atrioventricular node tachycardia, Wolff-Parkinson-White Syndrome and paroxysmal atrial fibrillation. It is also used in life-threatining symptomatic ventricular tachycardia requiring treatment and with excessive intake it has serious side effects on cardiovascular, gastrointestinal, nervous, haematological and dermatological systems. In this report, we present a case of propafenone intake with suicidal purpose and we aim to share our experience with malign arrhytmia development and arrhytmia management. A 22-year-old female patient presented to our emergency department with complaints of general situation distortion and feeling sick after ingesting 20 pills (6 g) of her friend’s Propafenone HCl 300 mg for suicidal purpose one hour previously. In the electrocardiography (ECG), regular rhythm, wide QRS and the absence of P-wave was observed. Pulseless ventricular tachycardia developed and defibrillation with 360 joule was performed followed by cardiopulmonary resuscitation. NaHCO3 administration of 1 mEq/kg every 4 hours was initiated. After the therapy, QRS duration shortened. The patient became conscious with spontaneous ventilation. Early diagnosis and appropriate resuscitative interventions can be vital in propafenone intoxication. NaHCO3 administration in the presence of hypotension and ECG abnormalities are vital.

Propafenon grup 1C antiaritmik ajandır. Atriyoventrikül düğümü taşikardileri, Wolff-Parkinson-White sendromu veya paroksismal atriyal fibrilasyonu olan hastalardaki supraventriküler taşikardiler gibi tedavi gerektiren semptomatik supraventriküler taşiaritmiler ve tedavi gereği görülen, yaşamı tehdit eden semptomatik ventriküler taşiaritmilerde kullanılan; yüksek doz alımında kardiovasküler sistem, gastrointestinal sistem, sinir sistemi, hematolojik sistem ve deri üzerinde ciddi yan etkisi olan bir ilaçtır. Bu yazıda, intihar amaçlı propafenon alan bir olguyu sunarak, malign aritmi gelişimi ve yönetimi hakkındaki deneyimimizi paylaşmak istedik. Yirmi iki yaşında kadın hasta yaklaşık 1 saat önce arkadaşının propafenon HCL 300 mg’lık ilacından intihar amaçlı 20 tb (6 g) aldıktan sonra genel durum bozukluğu şikayeti ile acil servisimize başvurdu. Çekilen elektrokardiografisinde (ECG) ritmin düzenli, QRS’in geniş ve P dalgasının olmadığı görüldü. Sonrasında nabızsız ventriküler taşikardi (VT) gelişti ve kardiopulmoner resüsitasyon ve 360 joul ile defibrilasyon yapıldı. 1 mEq/kg dan NaHCO3 her 4 saatte bir verildi, bu tedaviden sonra QRS süresinin kısaldığı hastanın spontan solumaya başladığı görüldü. Propafenon zehirlenmesinde erken tanı ve uygun resüsitasyon girişimlerinin yapılması hayat kurtarıcı olabilmektedir. Hipotansiyon ve EKG bulguları varlığında NaHCO3 tedavisi verilmesi gerekmektedir.

Key words: Intoxication; malign arrhytmia; prorafenon.

Anahtar sözcükler: İntoksikasyon; maling aritmi; propofenon.

Submitted (Geliş tarihi): 27.01.2012 Accepted (Kabul tarihi): 29.03.2012 Correspondence (İletişim): Dr. Ethem Acar. Erzurum Bölge Eğitim ve Araştırma Hastanesi, Acil Tıp Kliniği, 25040 Erzurum, Turkey e-mail (e-posta): dr.ethemacar@hotmail.com

Türkiye Acil Tıp Dergisi - Tr J Emerg Med 2012;12(4):191-194 doi: 10.5505/1304.7361.2012.56689

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Introduction Propafenone is a group 1C antiarrhytmic agent.[1] It is an agent used in patients with symptomatic supraventricular tachycardia requiring treatment such as atrioventricular (AV) node tachycardia and paroxysmal atrial fibrillation. It is also used in life-threatining symptomatic ventricular tachycardia requiring treatment. With excessive intake propafenone has serious side effects on cardiovascular, gastrointestinal, nervous, haematological and dermatological systems.[2,3] In propafenone intoxication, wide complex tachycardias, right bundle branch blocks, first degree AV block, prolonged QT interval, and generalized seizures can be observed.[3,4] Even though propafenone is a widely used class 1C antiarrhytmic, cases of fatal acute propafenone intake are rarely reported in the literature.[1] In this report, we present a case of excess propafenone hydrocloride (HCl) intake with suicidal purpose and we aim to share our experience with malign arrhytmia development and arrhytmia management.

Case Report A 22-year-old female patient presented to our emergency department with complaints of general situation distortion and generalized discomfort after ingesting 20 pills (6 g) of

aVR

aVL

her friend’s Propafenone HCl 300 mg for suicidal purpose one hour previously. On admission to emergency service, she had a general situation distortion with a consciousness level of stupor. She also had a superficial ventilation of 12/ min, pulse of 64/min and blood pressure of 80/60 mmHg. Other physical examination findings were normal. The patient was transferred to the resuscitation room, supplemental oxygen therapy was initiated, an intrvenous (IV) route was obtained and endotracheal intubation was performed because of patient’s inability to maintain an open airway. Blood glucose level checked from the finger tip was normal. The patient was given 1000 cc physiological saline in 15 minutes. In the electrocardiography (ECG), regular rhythm, wide QRS and the absence of p- wave was observed. We identified this as accelerating idioventricular rhythm. QRS duration was 148 ms and heart rate (HR) was 80 beats per minute (Fig. 1). Then 1 mEq/kg NaHCO3 was administered by IV. A cardiology consultation was performed. The patient developed a generalized tonic-clonic epileptic seizure in the following one or two minutes which was ceased with 5 mg IV diazepam. Pulseless ventricular tachycardia developed and defibrillation with 360 joule was performed followed by cardiopulmonary resuscitation (CPR) (Fig. 2). After a 30 minute period of CPR in which pulseless VT develpoed five times and defibrillation with 360 joules was applied, pulsed rhytm was obtained. Heart rate was 90/min and blood pressure

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aVF

Figure 1. Accelerate idioventricular rhythm.

Figure 2. Ventricular tachycardia.

Acar E et al.

Malign Arrhytmia Development Due to Propafenone Over Dose: A Case Report

was 110/60 mmHg. In ECG, a sinus rhytm with a rate of 90/ min was identified and the QRS duration was 134 ms. Laboratory findings were otherwise normal. NaHCO3 administration of 1 mEq/kg every 4 hours was continued. After therapy, QRS duration shortened. The patient became conscious with spontaneous ventilation. She was then extubated and transferred to the coronoary intensive care unit. After a 3 day follow up in the coronary intensive care unit without additional problems, the patient was discharged with a total recovery.

Discussion Propafenone may cause cardiac arrest through its proarrhytmic effects, either by causing new arrhytmias or worsening the present arrhytmia. These proarrhytmic effects may also be observed as bradicardias, conduction abnormalities (sinoatrial, atrioventricular or intraventricular blocks) or tachycardia (ventricular tachycardia). Rarely, ventricular flutter and/or fibrillation can be observed.[5,6] Thus, in this case malign arrhytmias were determined first as an accelerating idioventricular rhythm then as pulseless VT. It has been previously reported that intoxication with Group 1C antiarrhytmic agents has a higher mortality compared to many other types of intoxication.[7] In a study of 120 patients, Köppel et al.[8] reported that 34 of these patients were intoxicated with propafenone. Cardiac arrest developed in 29 of these patients and 27 of them did not respond to CPR. Stancak et al.[9] reported a 28 year old male with 4500 mg propafenone ingestion with suicidal intention. They reported that cardiopulmonary arrest developed in this case and no response to CPR was achieved. In a case reported by Üstündağ et al.,[7] a female patient with 7500 mg propafenone ingestion was presented. In this case cardiopulmonary arrest developed in 2 hours after admission and the patient died after 45 minutes of resuscitation. Available data reveals that hemodynamically unstable patients who need resuscitation have higher mortality rates. Even in our case, cardiopulmonary arrest developed. The patient responded to our early, effective and long lasting CPR. Seizures may be seen with propafenon overdose, especially in high dose ingestions. Rambourg-Schepens et al.[4] reported a case with generalized seizure after 1 hour following propafenone intoxication. Our case presented with a depressed consciousness and developed an epileptic seizure. Early monitoring, early diagnosis and early treatment was important to this patient’s survival. Brubacher reported[10] that HCO3 is considered by most toxicologists to be the treatment of choice for cardiac toxicity in the setting of sodium-channel blocker poisoning. It is reasonable to suspect that HCO3 would benefit patients with propafenone toxicity, but the literature in this setting is limited. Ovaska et al.[11]

reported a patient that was was managed with intravenous glucagon, sodium bicarbonate, hypertonic saline and this treatment was associated with a good outcome. Recently D’Orazio[12] reported that sodium bicarbonate bolus and infusion shortened the QRS length to 90 ms. To avoid persistent hypotension and ECG abnormalities, 1 mEq/kg sodium bicarbonate administration in every 4-6 hours is recommended.[13,14] In another study, Yi et al reported that Insulin treatment improved survival and delayed the hemodynamic and electrocardiographic consequences of propafenone toxicity. They reported that insulin prevented the decline of mean arterial pressure and heart rate. Insulin also prevented the increase of PR interval and QRS duration.[15] In our case, NaHCO3 in an appropriate dosage was initiated IV for hypotension and QRS widening. NaHCO3 therapy was maintained to retain ph of 7.50-7.55 until hypotension and QRS widening resolved. When seizures occur, intervention with diazepam is recommended. In our case generalized tonic clonic type epileptic seizure was observed and treated with 5 mg diazepam. Additional seizures were not observed. Efficacy of external or internal pacemaker implementation in propafenone intoxication is controversial because it is known that electrical pacing threshold increases due to this drug.[16] There are also reports that recommend hemodyalisis for treatment.[17] Our case improved both electrocardiographically and clinically after resuscitation, so cardiac pacing and hemodyalisis were not considered and the patient was evaluated by clinical follow-up.

Conclusion Sodium bicarbonate administration in the presence of hypotension and QRS widening are vital. 1 mEq/kg sodium bicarbonate administration every 4-6 hours is recommended until hypotension and QRS widening rsolve. Early diagnosis, aggressive treatment, meticulous monitoring and supportive care can be vital in propafenone intoxication. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. Clarot F, Goullé JP, Horst M, Vaz E, Lacroix C, Proust B. Fatal propafenone overdoses: case reports and a review of the literature. J Anal Toxicol 2003;27:595-9. 2. Vaughan Williams EM. Relevance of cellular to clinical electrophysiology in interpreting antiarrhythmic drug action. Am J Cardiol 1989;64:5J-9J. 3. Kerns W 2nd, English B, Ford M. Propafenone overdose. Ann

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Emerg Med 1994;24:98-103. 4. Rambourg-Schepens MO, Grossenbacher F, Buffet M, Lamiable D. Recurrent convulsions and cardiac conduction disturbances after propafenone overdose. Vet Hum Toxicol 1999;41:153-4. 5. Kolecki PF, Curry SC. Poisoning by sodium channel blocking agents. Crit Care Clin 1997;13:829-48. 6. Henry JA, Cassidy SL. Membrane stabilising activity: a major cause of fatal poisoning. Lancet 1986;1:1414-7. 7. Üstündağ M, Orak M, Güloğlu C, Özhasenekler A, Durgun HM. Lethal toxicity of propafenone in a case of suicidal attempt. Turk J Emerg Med 2007;7:132-5. 8. Köppel C, Oberdisse U, Heinemeyer G. Clinical course and outcome in class IC antiarrhythmic overdose. J Toxicol Clin Toxicol 1990;28:433-44. 9. Stancak B, Markovic P, Rajnic A, Petrikova V. Acute toxicity of propafenone in a case of suicidal attempt. Bratisl Lek Listy 2004;105:14-7. 10. Brubacher J. Bicarbonate therapy for unstable propafenone-

induced wide complex tachycardia. CJEM 2004;6:349-56. 11. Ovaska H, Ludman A, Spencer EP, Wood DM, Jones AL, Dargan PI. Propafenone poisoning-a case report with plasma propafenone concentrations. J Med Toxicol 2010;6:37-40. 12. D’Orazio JL, Curtis JA. Overdose of propafenone surreptitiously sold as “Percocet”. J Emerg Med 2011;41:172-5. 13. Brazil E, Bodiwala GG, Bouch DC. Fatal flecainide intoxication. J Accid Emerg Med 1998;15:423-5. 14. Lovecchio F, Berlin R, Brubacher JR, Sholar JB. Hypertonic sodium bicarbonate in an acute flecainide overdose. Am J Emerg Med 1998;16:534-7. 15. Yi HY, Lee JY, Lee SY, Hong SY, Yang YM, Park GN. Cardioprotective effect of glucose-insulin on acute propafenone toxicity in rat. Am J Emerg Med 2012;30:680-9. 16. Eray O, Fowler J. Severe propafenone poisoning responded to temporary internal pacemaker. Vet Hum Toxicol 2000;42:289. 17. Burgess ED, Duff HJ. Hemodialysis removal of propafenone. Pharmacotherapy 1989;9:331-3.

GÖRSEL TANI VISUAL DIAGNOSIS [150. sayfanın devamıdır.]

TANI: Metoklopramid Kullanımına Bağlı Gelişen Okulogirik Kriz Hastanın öyküsünde yolculuğa çıkmadan önce taşıt tutması nedeni ile bir adet metoklopramid tablet metoklopramid tablet (metoklopramid HCl, [Metpamid®, Sifar İlaçları Tic. ve San. AŞ, İstanbul, Türkiye]) aldığı öğrenildi. İlacı aldıktan yaklaşık 18 saat sonra şikayetleri başlamıştı. Hastamızda metoklopramide bağlı okülogirik kriz düşünüldü ve 50 mg difenhidramin IV verildi. Şikayetleri 15 dakika sonra geçen hasta 6 saat izlem sonrası acil servisten taburcu edildi.

lopramid aldıktan sonra okulogirik kriz görülmüştür.

Distonik reaksiyon, yüz, boyun, gövde, pelvis ve ekstremite kaslarının aralıklı veya sürekli istemsiz kasılmalarıyla karakterize bir hareket bozukluğudur. Çok sayıda ilaç tedavi dozunda akut distonik reaksiyonlara neden olabilir. En sık antipsikotik, antidepresanlar ve antiemetik ilaçlara bağlı olarak gelişmektedir. Metoklopramidin dopamin reseptör antagonizmasına bağlı ortaya çıkan ekstrapiramidal semptomlar en önemli yan etkileridir.[2] Bu nedenle tedavi dozlarında dahi yan etkiler ortaya çıkabilir. Akut distonik reaksiyonlar, metoklopramid tedavisinin sıklıkla 1-3. günlerinde, özellikle çocuklarda ve genç erişkinlerde görülen bir yan etkidir ve yüz, boyun ve sırt kaslarında kontraksiyonlar, opistotonus, tortikolis, okulogirik kriz ve trismus ile kendini gösterebilir.[3]

cüdür. Bu sebeple sık reçete edilen ve acil serviste sık kullanılan bu ilacın olası yan etkilerinin bilinmesi, ilacın getirdiği faydalar yanında risklerinin de göz önünde bulundurularak önerilmesi ve hastaların ilacın yan etkileri konusunda bilgilendirilmeleri gerekmektedir.

Akut gelişen distonik reaksiyonların farklı klinik seyri nedeniyle tanı koymakta zorluk çekilebilir, yanlış tanı konabilir veya gözden kaçabilir. Distoninin bir kısmı ileri yaşlarda ortaya çıkar ve genellikle primer hastalığın bir parçasıdır ve tedaviye de dirençlidir. Özellikle bu yaş grubunda ayırıcı tanısının dikkatle yapılması gerekmektedir.[5] Ayırıcı tanıda tetanoz, konversiyon, hipokalsemi, hipomagnezemi, menenTartışma jit, iskemik veya hemorajik inme, status epileptikus gibi birçok durumu ekarte etmemiz gerekmektedir. Metoklopramid, 30 yıldan uzun süredir kullanlan Bu nedenle ilaç öyküsünün sorgulanması ve eşlik santral ve periferik antidopaminerjik etkisi olan bir eden diğer nörolojik bulgular açısından dikkatli fizik dopamin reseptör antagonistidir.[1] Acil serviste başmuayene yapılması önemlidir. ta gastrointestinal sistem hastalıkları olmak üzere bulantı ve kusma ile seyreden pek çok hastalıkta kul- Metoklopramide bağlı yan etkiler hastalar için dralanılan bir antiemetiktir. matik, tedavisi düşünüldüğünde ise yüz güldürü-

Kaynaklar 1. Rao AS, Camilleri M. Review article: metoclopramide and tardive dyskinesia. Aliment Pharmacol Ther 2010;31:11-9. 2. Pasricha PJ, Pehlivanov N, Sugumar A, Jankovic J. Drug Insight: from disturbed motility to disordered movement-a review of the clinical benefits and medicolegal risks of metoclopramide. Nat Clin Pract Gastroenterol Hepatol 2006;3:138-48. 3. Bateman DN, Rawlins MD, Simpson JM. Extrapyrami-

Cezard ve ark.[4] yaptıkları çalışmada, metoklopramid dal reactions with metoclopramide. Br Med J (Clin Res intoksikasyonlu 184 çocuk hastanın 13’ünde oküloEd) 1985;291:930-2. girik kriz geliştiğini saptamışlardır. Okulogirik krizin 4. Cézard C, Nisse P, Quaranta S, Peucelle D, Mathieunedeni tam olarak bilinmemekle birlikte ektraoküler Nolf M. Acute dystonia from metoclopramide in chilkasların kasılmasına bağlı olabilir. Sıklıkla gözlerin yudren. [Article in French] Therapie 2003;58:367-70. karıya spazmodik deviasyonu görülmektedir. Bu du- 5. Grimes JD, Hassan MN, Preston DN. Adverse neurorum birkaç dakika ile birkaç saat arasında sürebilir ve logic effects of metoclopramide. Can Med Assoc J tekrarlayabilir. Bizim vakamızda hasta tek doz metok1982;126:23-5.

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doi: 10.5505/1304.7361.2012.85530

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DÜZELTME ERRATUM

Türkiye Acil Tıp Dergisi, Cilt 12, 3. sayısında, sayfa 103-111’de “Acil Tıpta Uzmanlık Öğrencilerinin Girişim Becerileri Üzerine Düşünceleri: Türkiye Acil Tıp Klinikleri Çalışması” adıyla yayımlanan makalenin “Sonuç” bölümü hatalı basılmıştır. Doğrusu: “Sonuç: Bu çalışmada sık yapılan önemli resüsitatif girişimler dışında, acil tıp müfredatında yer alan birçok girişim konusunda, ATUÖ’lerinin kendilerini yetersiz hissettiği gösterilmiştir. TF’lerindeki ATUÖ’lerinin yeterli beceriyi kazanmak için yapılan girişim sayısı ve girişim beceri algı düzeyi ortalamaları, EAH’lerindeki ATUÖ’lerine göre daha yüksek olarak bulunmuştur.” olacaktır. Meydana gelen hata nedeniyle yazar ve okurlardan özür dileriz.

DİZİN INDEX

Türkiye Acil Tıp Dergisi 2012 Yılı 12. Cilt Konu Dizini Abdominal ağrı bkz. 2012;12(3):140-143 Abdominal bilgisayarlı tomografi bkz. 2012;12(3):140-143 Acil bkz. 2012;12(3):112-116 Acil servis bkz. 2012;12(1):29-33 bkz. 2012;12(2):62-68 bkz. 2012;12(3):117-122 bkz. 2012;12(3):123-128 bkz. 2012;12(4):157-162 bkz. 2012;12(4):163-168 bkz. 2012;12(4):175-181 bkz. 2012;12(4):182-184 Acil tedavi bkz. 2012;12(2):96-98 Acil tıp bkz. 2012;12(1):41-44 bkz. 2012;12(4):151-156 Acil tıp eğitimi bkz. 2012;12(2):69-76 Acil tıpta uzmanlık eğitimi bkz. 2012;12(1):8-14 bkz. 2012;12(3):103-111 Acil tıpta uzmanlık öğrencisi bkz. 2012;12(3):103-111 Adli vaka bkz. 2012;12(1):29-33 Afet bkz. 2012;12(1):15-19 Afet hazırlık bkz. 2012;12(1):15-19 Afet planı bkz. 2012;12(1):15-19 Ağrı bkz. 2012;12(4):151-156 Ağrı ölçümü bkz. 2012;12(4):151-156 Ağrı yönetimi bkz. 2012;12(2):69-76 Akademik ilerleme bkz. 2012;12(2):77-81 Akademik yayın üretimi bkz. 2012;12(2):77-81 Akut koroner sendrom bkz. 2012;12(3):117-122 Analjezi bkz. 2012;12(4):151-156 Auralı migren bkz. 2012;12(3):144-146 Ayırıcı tanı bkz. 2012;12(4):185-187 Baş ağrısı bkz. 2012;12(3):144-146 Bekleme süresi bkz. 2012;12(2):62-68 Beyin natriüretik peptid bkz. 2012;12(3):112-116 Bilgisayarlı tomografi bkz. 2012;12(1):38-40 Bisiklet kazası bkz. 2012;12(1):48-50 Büyüme hormonu bkz. 2012;12(1):3-7 C1 esteraz inhibitör bkz. 2012;12(1):45-47 Cezaevi bkz. 2012;12(1):20-24 Çarpan balığı bkz. 2012;12(4):182-184 Çene çıkığı bkz. 2012;12(2):90-92 Çocuklar bkz. 2012;12(1):48-50 Çoklu organ yetmezliği bkz. 2012;12(1):34-37

Depresyon bkz. 2012;12(2):93-95 Derin ven trombozu bkz. 2012;12(2):82-86 Diyet bkz. 2012;12(1):41-44 Doçentlik bkz. 2012;12(2):77-81 Doktor davranışı bkz. 2012;12(2):62-68 Eğitim bkz. 2012;12(1):8-14 Ektopik gebelik bkz. 2012;12(3):134-136 Epilepsi bkz. 2012;12(1):25-28 Epiploik apandisit bkz. 2012;12(3):140-143 Gastrointestinal sistem kanaması bkz. 2012;12(4):157-162 Gebe bkz. 2012;12(4):169-174 Gebelik bkz. 2012;12(3):144-146 Geriatrik hasta bkz. 2012;12(3):123-128 bkz. 2012;12(4):157-162 Girişimsel beceriler bkz. 2012;12(3):103-111 Girişimsel becerilerin etkinliği bkz. 2012;12(3):103-111 Gögüs ağrısı bkz. 2012;12(3):117-122 Görsel analog skala bkz. 2012;12(3):103-111 Hasta memnuniyeti bkz. 2012;12(2):62-68 Hasta şikâyetleri bkz. 2012;12(4):163-168 Herediter anjioödem bkz. 2012;12(1):45-47 Hiperkalemi bkz. 2012;12(1):41-44 Hipokalemi bkz. 2012;12(3):137-139 Hipokalsemi bkz. 2012;12(2):90-92 İlaç bkz. 2012;12(4):169-174 İlkyardım bkz. 2012;12(1):20-24 İnme bkz. 2012;12(1):3-7 bkz. 2012;12(4):185-187 İnsülin benzeri büyüme faktörü bağlayıcı protein-3 bkz. 2012;12(1):3-7 İnsülin benzeri büyüme faktörü-1 bkz. 2012;12(1):3-7 İnternet bkz. 2012;12(2):54-61 İntihar teşebbüsü bkz. 2012;12(4):169-174 İntoksikasyon bkz. 2012;12(4):191-194 İskemik kalp hastalığı bkz. 2012;12(2):93-95 Juvenil polip bkz. 2012;12(2):87-89 Kafa travması bkz. 2012;12(3):112-116 Kalp masajı bkz. 2012;12(3):129-133 Kanülasyon bkz. 2012;12(4):151-156 Karbonmoksit bkz. 2012;12(4):185-187 Karın ağrısı bkz. 2012;12(2):87-89

197

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Türkiye Acil Tıp Dergisi - Tr J Emerg Med 2011;11(4)

Karın ağrısı bkz. 2012;12(3):134-136 Kazalar bkz. 2012;12(1):20-24 Kitlesel kaza bkz. 2012;12(1):29-33 Klinik özellikler bkz. 2012;12(3):123-128 Kola bkz. 2012;12(3):137-139 Künt travma bkz. 2012;12(3):123-128 Mahkum bkz. 2012;12(1):20-24 Maling aritmi bkz. 2012;12(4):191-194 Mesleksel temas bkz. 2012;12(2):96-98 Metabolik değişiklikler bkz. 2012;12(1):25-28 Miyopati bkz. 2012;12(3):137-139 Nörolojik defisit bkz. 2012;12(4):185-187 Ortalama trombosit hacmi bkz. 2012;12(2):82-86 Otomatik eksternal defibrilasyon bkz. 2012;12(3):129-133 Özkıyım bkz. 2012;12(2):93-95 bkz. 2012;12(4):188-190 Özkıyım girişimi bkz. 2012;12(4):169-174

Rektus kılıf hematomu bkz. 2012;12(1):38-40 Rotasyon etkinliği bkz. 2012;12(1):8-14 Rotasyonlar bkz. 2012;12(1):8-14 Sağlık personeli bkz. 2012;12(3):129-133 Sosyodemografik özellikler bkz. 2012;12(3):117-122 Su zehirlenmesi bkz. 2012;12(4):188-190 Suni solunum bkz. 2012;12(3):129-133 Şikayet oranı bkz. 2012;12(4):163-168 Tedavi bkz. 2012;12(4):175-181 Temel afet bilinci bkz. 2012;12(1):15-19 Temel yaşam desteği bkz. 2012;12(3):129-133 Tetani bkz. 2012;12(2):90-92 Toluen bkz. 2012;12(2):96-98 Trachinus Draco bkz. 2012;12(4):182-184 Trakeostomi bkz. 2012;12(1):45-47 Travma bkz. 2012;12(2):69-76 Trombosit aktivasyonu bkz. 2012;12(2):82-86 Tüp ligasyonu bkz. 2012;12(3):134-136 Ürtiker bkz. 2012;12(4):175-181

Pankreas yaralanması bkz. 2012;12(1):48-50 Paramedikal personel bkz. 2012;12(2):54-61 Paraquat bkz. 2012;12(1):34-37 Parmakla rektal muayene bkz. 2012;12(2):87-89 Personel-hasta iletişimi bkz. 2012;12(4):163-168 Problem çözme bkz. 2012;12(2):54-61 Prognoz bkz. 2012;12(4):175-181 Propofenon bkz. 2012;12(4):191-194 Ramazan ayı bkz. 2012;12(1):25-28 Rektum tümörü bkz. 2012;12(2):87-89

Varfarin doz aşımı bkz. 2012;12(1):38-40 Ventriküler aritmi bkz. 2012;12(4):188-190 Yaşlılık bkz. 2012;12(2):93-95 Yerel seçim bkz. 2012;12(1):29-33 Yüksek doz bkz. 2012;12(4):169-174 Zehirlenme bkz. 2012;12(1):34-37 bkz. 2012;12(4):169-174 Zehirli balık bkz. 2012;12(4):182-184

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Türkiye Acil Tıp Dergisi 2012 Yılı 12. Cilt Konu ve Yazar Dizini

Türkiye Acil Tıp Dergisi 2012 Yılı 12. Cilt Yazar Dizini Acar E bkz. 2012;12(4):191-194 Acar N bkz. 2012;12(4):185-187 Akdemir HU bkz. 2012;12(4):191-194 Akdur G bkz. 2012;12(3):112-116 Akdur G bkz. 2012;12(4):157-162 Akın Ş bkz. 2012;12(3):123-128 Akıncı E bkz. 2012;12(1):25-28 Akıncı E bkz. 2012;12(1):3-7 Akıncı E bkz. 2012;12(2):90-92 Akkaya C bkz. 2012;12(2):62-68 Aköz A bkz. 2012;12(4):169-174 Aksay E bkz. 2012;12(1):8-14 Aksay E bkz. 2012;12(2):77-81 Aksay E bkz. 2012;12(3):103-111 Aksay E bkz. 2012;12(3):123-128 Aksel G bkz. 2012;12(4):182-184 Al B bkz. 2012;12(4):163-168 Albayrak L bkz. 2012;12(3):137-139 Alpsoy E bkz. 2012;12(4):175-181 Atilla R bkz. 2012;12(3):140-143 Aydın Y bkz. 2012;12(1):25-28 Bademkıran E bkz. 2012;12(1):38-40 Bayram B bkz. 2012;12(3):134-136 Bayram B bkz. 2012;12(3):140-143 Bayram B bkz. 2012;12(4):150 [195] Bayramoğlu A bkz. 2012;12(4):169-174 Berk Y bkz. 2012;12(4):175-181 Bilge A bkz. 2012;12(1):8-14 Bilge A bkz. 2012;12(3):103-111 Bilir Ö bkz. 2012;12(2):82-86 Bozkurt S bkz. 2012;12(4):182-184 Bulut M bkz. 2012;12(2):62-68 Cindoruk Ş bkz. 2012;12(4):163-168 Coşkun F bkz. 2012;12(1):25-28 Çalışkan Tür F bkz. 2012;12(2):77-81 Çalışkan Tür F bkz. 2012;12(3):103-111 Çalışkan Tür F bkz. 2012;12(3):123-128 Çeçen F bkz. 2012;12(1):45-47 Çelikli S bkz. 2012;12(3):129-133 Çetinkaya O bkz. 2012;12(4):185-187 Çevik AA bkz. 2012;12(4):185-187 Çiftçi H bkz. 2012;12(1):25-28 Çolak Oray N bkz. 2012;12(1):34-37

Çolak Oray N bkz. 2012;12(3):140-143 Çorbacıoğlu ŞK bkz. 2012;12(1):41-44 Dedeoğlu E bkz. 2012;12(3):134-136 Dedeoğlu E bkz. 2012;12(4):150 [195] Demir ÖF bkz. 2012;12(2):69-76 Demirkan B bkz. 2012;12(4):188-190 Doğan NÖ bkz. 2012;12(3):144-146 Doğan T bkz. 2012;12(3):123-128 Dolek M bkz. 2012;12(4):151-156 Duman Atilla Ö bkz. 2012;12(3):123-128 Duran L bkz. 2012;12(4):191-194 Duyuler S bkz. 2012;12(4):188-190 Ekiz M bkz. 2012;12(4):191-194 Ekşi A bkz. 2012;12(3):129-133 Emet M bkz. 2012;12(4):169-174 Eralp MO bkz. 2012;12(4):157-162 Eray O bkz. 2012;12(4):175-181 Erbil B bkz. 2012;12(2):69-76 Erdoğan MÖ bkz. 2012;12(1):29-33 Erdoğan MÖ bkz. 2012;12(2):93-95 Erenler AK bkz. 2012;12(4):191-194 Erkek A bkz. 2012;12(2):90-92 Ersunan G bkz. 2012;12(2):82-86 Evcim S bkz. 2012;12(1):34-37 Eyler Y bkz. 2012;12(3):123-128 Gökdemir MT bkz. 2012;12(1):29-33 Gökdemir MT bkz. 2012;12(2):93-95 Gökdemir MT bkz. 2012;12(3):137-139 Gölcük Y bkz. 2012;12(1):38-40 Güler S bkz. 2012;12(1):41-44 Güler S bkz. 2012;12(4):182-184 Güllüpınar B bkz. 2012;12(1):34-37 Güllüpınar B bkz. 2012;12(1):48-50 Gültekin Akkaya E bkz. 2012;12(2):62-68 Güneş H bkz. 2012;12(1):34-37 Güray Ü bkz. 2012;12(4):188-190 Halhallı HC bkz. 2012;12(1):3-7 İnal E bkz. 2012;12(1):15-19 Kalkan A bkz. 2012;12(2):82-86 Kara B bkz. 2012;12(2):54-61

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Karakaya P bkz. 2012;12(1):48-50 Karasu M bkz. 2012;12(1):29-33 Karatağ G bkz. 2012;12(3):134-136 Karbek Akarca F bkz. 2012;12(2):69-76 Karcıoğlu Ö bkz. 2012;12(2):69-76 Kavalcı C bkz. 2012;12(3):112-116 Kavalcı C bkz. 2012;12(4):157-162 Kaya H bkz. 2012;12(1):29-33 Kaya H bkz. 2012;12(2):93-95 Kaya H bkz. 2012;12(3):137-139 Kılıçaslan İ bkz. 2012;12(1):41-44 Kılıçaslan İ bkz. 2012;12(4):182-184 Kısacık HL bkz. 2012;12(4):188-190 Kim CH bkz. 2012;12(2):87-89 Kiyan S bkz. 2012;12(4):151-156 Kocagöz S bkz. 2012;12(1):15-19 Köksoy S bkz. 2012;12(1):20-24 Korkmaz T bkz. 2012;12(2):69-76 Kutlu R bkz. 2012;12(2):82-86 Kutlucan A bkz. 2012;12(1):45-47 Limon Ö bkz. 2012;12(3):140-143 Memetoğlu ME bkz. 2012;12(2):82-86 Moradi N bkz. 2012;12(4):149 Oğuz S bkz. 2012;12(4):157-162 Oray D bkz. 2012;12(1):38-40 Öncü E bkz. 2012;12(1):20-24 Özakın E bkz. 2012;12(4):185-187 Özdemir D bkz. 2012;12(1):48-50 Özen M bkz. 2012;12(3):117-122 Özen Ş bkz. 2012;12(3):117-122 Özsaraç M bkz. 2012;12(4):151-156 Pekdemir M bkz. 2012;12(2):96-98 Ramadan H bkz. 2012;12(1):25-28 Sağıroğlu T bkz. 2012;12(4):157-162 Sarıhan A bkz. 2012;12(1):34-37 Sarıtaş A bkz. 2012;12(1):45-47 Sarıtemuz M bkz. 2012;12(4):169-174 Sarsılmaz M bkz. 2012;12(4):151-156 Sayhan MB bkz. 2012;12(1):29-33 Sayhan MB bkz. 2012;12(3):112-116 Sayhan MB bkz. 2012;12(4):157-162

Sayraç N bkz. 2012;12(4):175-181 Secgin Sayhan E bkz. 2012;12(4):157-162 Sener S bkz. 2012;12(4):151-156 Serinken M bkz. 2012;12(3):117-122 Sever M bkz. 2012;12(4):151-156 Sezik S bkz. 2012;12(1):8-14 Sezik S bkz. 2012;12(3):103-111 Söğüt Ö bkz. 2012;12(1):29-33 Söğüt Ö bkz. 2012;12(2):93-95 Söğüt Ö bkz. 2012;12(3):137-139 Sungur MA bkz. 2012;12(1):20-24 Şahin Y bkz. 2012;12(4):191-194 Şen C bkz. 2012;12(4):163-168 Şermet Ş bkz. 2012;12(1):20-24 Taş M bkz. 2012;12(2):93-95 Temizyürek Z bkz. 2012;12(1):8-14 Tuncok Y bkz. 2012;12(1):34-37 Turan H bkz. 2012;12(1):45-47 Turan M bkz. 2012;12(1):15-19 Türker Bayır P bkz. 2012;12(4):188-190 Tutar N bkz. 2012;12(2):82-86 Ulusoy E bkz. 2012;12(1):48-50 Uzkeser M bkz. 2012;12(4):169-174 Üçöz Kocaşaban D bkz. 2012;12(1):3-7 Ülker V bkz. 2012;12(1):41-44 Ümit H bkz. 2012;12(4):157-162 Vahdati SS bkz. 2012;12(4):149 Yağmur D bkz. 2012;12(1):41-44 Yaka E bkz. 2012;12(2):96-98 Yanık ME bkz. 2012;12(1):45-47 Yavuz E bkz. 2012;12(4):163-168 Yemenici S bkz. 2012;12(3):112-116 Yiğit Ö bkz. 2012;12(4):175-181 Yıldırım C bkz. 2012;12(4):163-168 Yıldırım GÖ bkz. 2012;12(3):129-133 Yılmaz A bkz. 2012;12(3):117-122 Yılmaz G bkz. 2012;12(4):151-156 Yılmaz S bkz. 2012;12(2):96-98 Yürüktümen A bkz. 2012;12(4):151-156 Zengin S bkz. 2012;12(4):163-168