Turk J Emerg Med 2014-1 by KAREPUBLISHING

ISSN 1304-7361

Turkish Journal of Emergency Medicine Türkiye Acil Tıp Dergisi VOLUME 14

NUMBER 1

YEAR 2014

Citation Abbreviation: Turk J Emerg Med

Visual Diagnosis Unstable Less Common Chance Fracture Riazi A, Vahdati SS, Tajlil A Sprain Injury in a Child: Where is the Fracture Line? Kalkan A, Bilir O ORIGINAL ARTICLES Factors Affecting the Length of Stay of Patients in Emergency Department Observation Units at Teaching and Research Hospitals in Turkey Mahsanlar Y, Parlak I, Yolcu S, Akay S, Demirtas Y, Eryigit V Incidental CT Findings of Patients Who Admitted to ER Following a Traffic Accident Yigit Y, Ayhan H Laboratory Risk Indicators for Necrotizing Fasciitis and Associations with Mortality Colak E, Ozlem N, Kucuk GO, Aktimur R, Kesmer S The Value of Ultrasonography, Leukocyte Count and Clinical Results in Diagnosis of Acute Appendicitis and the Duration of Stay of the Patients in Emergency Department Eryigit V, Mahsanlar Y, Demirtas Y, Parlak I Effect of End-Tidal Carbon Dioxide Measurement on Resuscitation Efficiency and Termination of Resuscitation Oztürk F, Parlak I, Yolcu S, Tomruk O, Erdur B, Kilicaslan R, Miran AS, Akay S CASE REPORTS Hemlock (Conium Maculatum) Poisoning In A Child Konca C, Kahramaner Z, Bosnak M, Kocamaz H ECG Changes Due to Hypothermia Developed After Drowning: Case Report Yılmaz S, Cakar MA, Vatan MB, Kilic H, Keser N Clozapine-Induced Febrile Neutropenia and Cellulitis Yaylaci S, Yilmaz EU, Guclu E, Akkisi Kumsar N, Tamer A, Karabay O

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Issued by The Emergency Medicine Association of Turkey This Journal is indexed in Turkish Medical Index of TÜBİTAK-ULAKBIM, EBSCOhost, Index Copernicus, DOAJ, Gale/Cengage Learning, SCOPUS, EMBASE and Turkiye Citation Index.

www.trjemergmed.com

ISSN 1304-7361

Turkish Journal of Emergency Medicine Türkiye Acil Tıp Dergisi VOLUME 14

NUMBER 1

YEAR 2014

Citation Abbreviation: Turk J Emerg Med

@TrJEmergMed

www.trjemergmed.com

Turkish Journal of Emergency Medicine EDITORS

ASSOCIATE EDITORS

Suleyman TUREDI, M.D.

Haldun AKOGLU, M.D.

Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine

Marmara University, Faculty of Medicine, Department of Emergency Medicine

Orhan CINAR, M.D.

Mersin University Faculty of Medicine, Department of Emergency Medicine

Gülhane Military Medical Academy (GMMA), Department of Emergency Medicine

Cem ERTAN, M.D. İzmir University Faculty of Medicine, Department of Emergency Medicine

Arzu DENIZBASI, M.D.

Nurettin Ozgur DOGAN, M.D.

Marmara University, Faculty of Medicine, Department of Emergency Medicine

Nese COLAK ORAY, M.D.

INTERNATIONAL EDITORIAL BOARD Matej MARINSEK, M.D. Jeffrey ARNOLD, M.D. Resmiye ORAL, M.D. Elizabeth DEVOS, M.D. C. James HOLLIMAN, M.D. Selim SUNER, M.D. Judith E. TINTINALLI, M.D. Mark LANGDORF, M.D. Frank LOVECCHIO, M.D.

Seyran BOZKURT, M.D.

Kocaeli University, Faculty of Medicine, Department of Emergency Medicine Dokuz Eylul University Faculty of Medicine, Department of Emergency Medicine

Mehmet Ali KARACA, M.D.

Hacettepe University Faculty of Medicine, Department of Emergency Medicine

Ozlem KOKSAL, M.D.

Uludağ University Faculty of Medicine, Department of Emergency Medicine

Serkan SENER, M.D.

Acıbadem University, Faculty of Medicine, Department of Emergency Medicine

Ibrahim TURKCUER, M.D.

Pamukkale University, Faculty of Medicine, Department of Emergency Medicine

CONSULTING EDITORS (2014, Number 1)

RESEARCH MEDHODOLOGY EDITOR

Gokhan Aksel, M.D. Yusuf Ali Altunci, M.D. Erdem Cevik, M.D. Yunsur Cevik, M.D. Oktay Eray, M.D. Bulent Erbil, M.D. Yalcin Golcuk, M.D. Asim Kalkan, M.D.

Levent DONMEZ, M.D.

Ozgur Karcioglu, M.D. Mutlu Kartal, M.D. Isa Kilicarslan, M.D. Ali Kocyigit, M.D. Gül Pamukcu Gunaydin, M.D. Mustafa Serinken, M.D. Umit Tural, M.D. Aslihan Yuruktumen, M.D.

Akdeniz University, Faculty of Medicine, Department of Public Health

FORMER EDITORS Rifat TOKYAY, M.D. (2001-2003), Hamit HANCI, M.D. (2003-2004), Oktay ERAY, M.D. (2004-2007), Sedat YANTURALI, M.D. (2006-2008), Cenker EKEN, M.D. (2007-2010, 2012), Ersin AKSAY, M.D. (2009-2011), Murat PEKDEMIR, M.D. (2010-2013)

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Turkish Journal of Emergency Medicine ISSN 1304-7361

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VOLUME 14 NUMBER 1 MARCH 2014

OWNER YILDIRAY CETE, MD., on behalf of the Emergency Medicine Association of Turkey

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@TrJEmergMed

Turkish Journal of

Emergency Medicine Contents

Publishing with the Turk J Emerg Med

MARCH 2014

vii

Instructions for Authors

Editorial

1 2

3 7

Visual Diagnosis Unstable Less Common Chance Fracture Riazi A, Vahdati SS, Tajlil A Sprain Injury in a Child: Where is the Fracture Line? Kalkan A, Bilir O

ORIGINAL ARTICLES Factors Affecting the Length of Stay of Patients in Emergency Department Observation Units at Teaching and Research Hospitals in Turkey Mahsanlar Y, Parlak I, Yolcu S, Akay S, Demirtas Y, Eryigit V Incidental CT Findings of Patients Who Admitted to ER Following a Traffic Accident Yigit Y, Ayhan H

Laboratory Risk Indicators for Necrotizing Fasciitis and Associations with Mortality Colak E, Ozlem N, Kucuk GO, Aktimur R, Kesmer S

The Value of Ultrasonography, Leukocyte Count and Clinical Results in Diagnosis of Acute Appendicitis and the Duration of Stay of the Patients in Emergency Department Eryigit V, Mahsanlar Y, Demirtas Y, Parlak I

Effect of End-Tidal Carbon Dioxide Measurement on Resuscitation Efficiency and Termination of Resuscitation Ozturk F, Parlak I, Yolcu S, Tomruk O, Erdur B, Kilicaslan R, Miran AS, Akay S

CASE REPORTS Hemlock (Conium Maculatum) Poisoning In A Child Konca C, Kahramaner Z, Bosnak M, Kocamaz H

ECG Changes Due to Hypothermia Developed After Drowning: Case Report Yilmaz S, Cakar MA, Vatan MB, Kilic H, Keser N

Clozapine-Induced Febrile Neutropenia and Cellulitis Yaylaci S, Yilmaz EU, Guclu E, Akkisi Kumsar N, Tamer A, Karabay O

Turkish Journal of

Emergency Medicine Publishing with the Turk J Emerg Med

1. The Turkish Journal of Emergency Medicine (Turk 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, Turk 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 Turk 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 Turk 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 Turk J Emerg Med are elected by the Board of the Emergency Medicine Association of Turkey once a year in January. The Turk J Emerg Med board consists of editor(s), assistant editors, a research methodology editor and a language editor. 12. All material published in the Turk 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 Turk J Emerg Med Assoc. Prof. Dr. Suleyman TUREDI Assoc. Prof. Dr. Orhan CINAR Prof. Dr. Arzu DENIZBASI

Turkish Journal of

Emergency Medicine Instructions for Authors Turk 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 Turkiye Citation Index. Turk 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 Turk 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 Turk 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 Turk 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 Turk 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.

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 Turk 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 Turk 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. Turk 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 Turk J Emerg Med and the board members of the Emergency Medicine Association of Turkey. Access to Data: Editors of the Turk 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.

Turkish Journal of

Emergency Medicine Editorial

Esteemed colleagues, With your support, the Turkish Journal of Emergency Medicine has now been in publication for over 10 years, never compromising on quality, scientificity or impartiality. We believe that our journal, which has carried more than 500 scientific studies, has come to represent Turkey’s scientific memory bank for emergency medicine. Our journal is part of the Tübitak-Ulakbim Turkish Medical Database and the Turkish Citation Database, the most prestigious database in the country. It also appears in the indices of such respected international databases as EBSCOhost, Index Copernicus, DOAJ, Gale/Cengage Learning, SCOPUS and EMBASE. The primary aim of our journal now is to join the category of journals scanned by SCI, SCI-E and PubMed and thus to speak to the entire scientific world. In order for that to happen, the editors and publication board in particular and our reviewers, authors and readers, whom we regard as one large family, all bear a major responsibility. In order for the journal to achieve that aim, it is not enough by itself for us just to write and publish valuable studies with a high citation potential. As we all now know, it is very important for this journal to be published in English in order for it to be read and shared more widely. To that end, the publication board of the Turkish Journal of Emergency Medicine has decided that the journal will be published entirely in English as of the first issue of 2014. Papers submitted in Turkish during 2014 will be accepted, but at the end of a one-year transitional period the journal will only accept submissions written in English. During that period we are obliged to adopt a policy of positive discrimination in favor of submissions written in English. We would ask for our authors’ understanding and for them to make as many submissions as possible in English. In addition, it is also of the greatest important for us to cite papers published in our journal for us to be able to join the prestigious indices mentioned. We regret to state that as Turkish scientists we do not always exhibit the sensitivity we demonstrate for the growth and development of our country when it comes to citing our national journals, one of the most important factors in their growth and development. This has been the main barrier in the face of previous applications to the databases listed above, and remains the main barrier to future ones. To that end, all papers on a subject published in our journal can be easily and freely accessed using the search minor on the journal home page. We would respectfully request you to examine our journal archives as you prepare your scientific papers and to support this journal with your citations. The journal will also be adopting a policy of a faster, constructive and instructive evaluation in the new publishing term. Thank you for your continuing support and interest. The editors of the Turkish Journal of Emergency Medicine Assoc. Prof. Dr. Suleyman TUREDI Assoc. Prof. Dr. Orhan CINAR Prof. Dr. Arzu DENIZBASI

VISUAL DIAGNOSIS

Unstable Less Common Chance Fracture Ali RIAZI,1 Samad Shams VAHDATI,2 Arezou TAJLIL3 Departments of 1Neurosurgery, 2Emergency, Tabriz University of Medical Science; 3Tabriz University of Medical Science, Tabriz, Iran

A 25-year-old boy presented to the emergency room with multiple trauma after a car crash in which the car had collided with a guardrail. The patient had been in the front passenger seat, wearing a seatbelt. At presentation, he was awake and complaining only of back pain. On examination, his vital signs were stable. He had tenderness over the vertebrae and a contusion where the seatbelt had been positioned over his trunk. His lungs were clear to auscultation bilaterally, and he had no respiratory distress. His heart sounds were normal, without a murmur or gallop. He had no tenderness over the sternum. His abdomen was soft to the touch with no abnormal findings. Cranial nerves were intact. Muscle strength was 5/5 for all limbs. Deep tendon reflexes (DTRs) were 2+.The patient did not have any motor or sensory deficits on neurological exam.

Due to his pain, the tenderness over the vertebrae, and the contusion over his trunk, a vertebral plain radiograph was obtained (Figure 1). Based on the plain radiography findings, a vertebral CT scan was performed (Figure 2). [see page 32 for diagnosis]

Due to his crash injury, focused assessment with sonography in trauma (FAST) was performed in the emergency room, and there were no abnormal findings. A brain computed tomography (CT) scan was performed, and the results were normal. Lateral neck radiography showed no abnormal findings.

Figure 1.

Figure 2. Submitted: 07.07.2012

Accepted: 17.02.2013

Published online: 18.07.2013

Correspondence: Dr. Samad Shams Vahdati. No 1, Gholestan 2, Pezeshkan Alley, Abrasani Street Tabriz, Iran. e-mail: sshamsv@yahoo.com

Turk J Emerg Med 2014;14(1):1 [32]

doi: 10.5505/1304.7361.2014.10327

VISUAL DIAGNOSIS

Sprain Injury in a Child: Where is the Fracture Line? Asım KALKAN, Ozlem BILIR Department of Emergency Medicine, Recep Tayyip Erdoğan University Faculty of Medicine, Rize

A 10-year-old male patient presented to the emergency department complaining of foot pain after sustaining a sprain injury. He could not bear weight on his right foot and there was swelling along the lateral aspect of his foot. On physical examination, there was tenderness to palpation on the proximal segment of the 5th metatarsal bone. A foot X-ray is shown in Figure 1. What is your diagnosis? [see page 33 for diagnosis]

Figure 1.

Submitted: 26.03.2013 Accepted: 02.04.2013 Published online: 18.07.2013 Correspondence (İletişim): Dr. Asım Kalkan. Recep Tayyip Erdoğan Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, 53100 Rize, Turkey. e-mail: drasimkalkan@hotmail.com

Turk J Emerg Med 2014;14(1):2 [33]

doi: 10.5505/1304.7361.2014.82612

ORIGINAL ARTICLE

Factors Affecting the Length of Stay of Patients in Emergency Department Observation Units at Teaching and Research Hospitals in Turkey Türkiye’de Bir Eğitim Araştırma Hastanesi Acil Servisinin Monitörize Birimindeki Hastaların Kalış Sürelerini Etkileyen Faktörler Yasin MAHSANLAR,1 Ismet PARLAK,1 Sadiye YOLCU,2 Serhat AKAY,1 Yoldas DEMIRTAS,1 Veysi ERYIGIT1 Department of Emergency Medicine, Bozyaka Training and Research Hospital, İzmir; 2 Department of Emergency Medicine, Bozok University Faculty of Medicine, Yozgat

SUMMARY

ÖZET

Objectives This study aimed to determine the reasons for long stays in monitoring units and to propose a solution.

Amaç Çalışmamız monitörlü gözlem birimde hastaların uzun kalış nedenlerinin belirlenip bunlara yönelik çözümler üretilmesi gerekliliğini amaçlamıştır.

Methods The patients who were followed in monitoring units of emergency service and the factors affecting the length of their hospital stay were analyzed retrospectively. Demographic features, their initial complaint that lead to monitoring, diagnosis, their means of arrival to emergency service, their admittance date and hour, medical history, basic vital signs, length of stay in emergency service, invasive interventions, intubation, mortality rates, consultations, and clinical results were evaluated.

Gereç ve Yöntem Acil Tıp Kliniği’ne başvurup monitörlü gözlem biriminde takip edilmiş olan hastalar ve bu hastaların kalış süreleri üzerine etkili faktörler geriye dönük incelendi. Bu hastaların demografik özellikleri, hangi şikayetlerle monitörlü gözleme alındıkları, aldıkları tanılar, acil servise nasıl getirildikleri, acil servise başvuru tarih ve saatleri, özgeçmişleri, geliş vital bulguları, acil serviste kalış süreleri, uygulanan invaziv girişimler, entübe edilip-edilmedikleri, mortalite durumları, konsültasyonlar ve klinik sonlanımları incelendi.

Results The study included 603 patients. Average emergency service stay in monitoring unit was found to be 6.5 hours. In addition, 15 patients (2.5%) stayed 24 hours or longer, and 78 patients (12.9%) stayed 12 to 24 hours. Of the 15 patients who stayed in emergency service for 24 hours or more, 8 (53.3%) stayed because there wasn’t enough space in intensive care units. The most prevalent complaint for admission to the emergency service was chest pain (25.5%), followed by dyspnea (21.9%) and tachycardia (11.6%).

Bulgular Çalışmaya 603 hasta alındı. Çalışmamızda monitörlü gözlemde takip edilen hastaların acil serviste ortalama kalış süresi 6.5 saat olarak bulundu. Ayrıca 15 hastanın (%2.5) 24 saat ve üzeri, 78 hastanın (%12.9) 12-24 saat aralığında acil serviste kaldığı görüldü. 24 saat ve üzeri acil serviste kalan 15 hastanın sekizinin (%53.3) kalış sebebi yoğun bakımlarda yer bulunmaması idi. Çalışmamızdaki hastaların acile başvuru şikayetleri incelendiğinde göğüs ağrısı (%25.5) en sık şikayet olurken, bunu nefes darlığı (%21.9) ve çarpıntı (%11.6) şikayetleri izledi.

Conclusions For real emergency conditions, monitoring units are necessary to follow patients closely and to perform immediate interventions. The fullness of the intensive care units primarily affects the emergency service and leads to long stays in emergency service as patients are waiting to be admitted to the intensive care unit. As the number of consultations increases, the monitoring period is prolonged.

Sonuç Acil servislere başvuran hastalar içinde çok acil tanımına uyan hastaların hemen ilk müdahalesinin yapılıp, yakından izlenebileceği monitörlü gözlem birimlerinin oluşturulup geliştirilmesi gerekmektedir. Yoğun bakımlarda yer olmaması durumunun acil servisleri primer düzeyde etkilediği ve yatış için yoğun bakımlarda yer bekleyen hastaların acil servislerde uzun kalışlarının nedeni olduğu sonucuna ulaşılmıştır. Konsülte edilen birim sayısı arttıkça hastanın monitörlü gözlemde kalış süresi uzamaktadır.

Key words: Emergency service; intensive care unit; monitorized observation unit.

Anahtar sözcükler: Acil servis; monitörlü gözlem birimi; yoğun bakım.

Submitted: 05.11.2013 Accepted: 14.01.2014 Published online: 16.01.2014 Correspondence: Dr. Sadiye Yolcu. Bozok Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Yozgat, Turkey. e-mail: sadiyeyolcu@yahoo.com

Turk J Emerg Med 2014;14(1):3-8

doi: 10.5505/1304.7361.2014.58224

Turk J Emerg Med 2014;14(1):3-8

Introduction Emergency departments must provide continuous healthcare services for 365 days a year and 24 hours a day for patients requiring urgent treatment. Following life-saving intervention in the emergency department, patients with serious conditions are admitted to the hospital and will continue treatment within a specialist department. Increased workload in the emergency department contributes to delays in treatment and the accumulation of patients, limiting the services that can be provided and the quality of these services; subsequently, declines in overall productivity may be expected.[1] These challenges may contribute to overall patient safety and satisfaction, as well as workplace psychology among care providers.[2-4] Factors contributing to increased patient volume within the emergency department include limited physical space, availability of bed space in the intensive care unit, increasing proportions of geriatric individuals in the general population, personnel shortages, delayed consultation with specialists, and delays in imaging and laboratory services. [4-6] Critical patients are followed closely within monitored observation units in the emergency department. Accumulation of patients in these specialized units can negatively impact the efficiency of the entire emergency department. In the present study, we investigated the factors that influence the length of stay within these monitored observation units.

Materials and Methods The study was conducted in the emergency department of the Bozyaka Research And Education Hospital hospital between 16.08.2011 and 16.09.2011. This emergency department uses a five-level triage system, with all patients who are classified in the first four levels treated in the monitored observation unit. The study protocol was reviewed and approved by the local education planning board. The study group included patients treated in the monitored observation unit during the study period. The study data were obtained retrospectively from the hospitalâ&#x20AC;&#x2122;s digital information management system (Probel) and from physical records maintained within the emergency department. Demographic data collected for the study included the means of arrival at the emergency department, times and dates of arrival, medical history, symptoms, vital signs upon arrival, length of stay within the emergency department, diagnoses, applied invasive procedures, use of dialysis, intubation status, mortality, medical consultations, use of imaging modalities such as CT (computed tomography) or MR (magnetic resonance), and clinical outcomes. MINDRAY PM9000 monitors located in the monitored observation units were used for regular monitoring of clinical parameters. The

Mortara Instrument ELI 250 was used for ECG (electrocardiogram) scans. Computed tomography images were captured using a Toshiba Asteio and Toshiba Aquilion 64 multislice device. A Philips Achieva device was used for magnetic resonance imaging, a Digi Prince DP-9900 was used for ultrasound imaging, and the Dynamic X-ray device was used in chest radiography. All statistical analyses were performed using SPSS (Statistical Package for Social Sciences) for Windows 15.0 software. The Studentâ&#x20AC;&#x2122;s t-test and one-way ANOVA (advanced analysis of binary comparisons, Bonferroni) were used for comparing the parameters between the groups when evaluating the descriptive statistics (mean, standard deviation) and quantitative data. Qualitative, categorical data was evaluated using the Chi-Square test and Fisherâ&#x20AC;&#x2122;s Exact Chi-square test. Results were evaluated at 95% confidence interval and p <0.05 was established as the threshold of statistical significance.

Results A total of 18,162 patients were admitted to the emergency department during the study period. Out of this population, 603 patients (3.3%) treated in the monitored observation unit. Male patients accounted for 54.7% (n=330) of the study group. Patients were subdivided into 8 groups according to their age (<18, 18-24, 25-34, 35-44, 45-54, 55-64, 65-74 and >75 years). The group with patients aged 75 years or greater constituted the largest proportion of the total study population (29.5% n=178). In addition, 52.4% (n=316) of the monitored patients were at least 65 years old. Chest pain was the most common complaint, reported by 154 patients (25.5%), followed by shortness of breath (21.9%, 132 patients), and heart palpitations (11.6%, 70 patients). After evaluating the time of admission in the study group, the fewest admissions and discharges occurred between the hours of 05:00 and 06:00, while the largest number of admissions and discharges occurred between hours of 22:00 and 23:00. The highest rate of admission to the monitored observation unit (253 patients, 43.6%) was between the hours of 16:00 and 00:00, which was approximately twice the number of patients admitted between the hours of 00:00 to 08:00 (n=118). Furthermore, the number of discharged patients was the greatest (42.1%) between 16:00 and 00:00. Only 15 patients (2.5%) remained in the monitored observation unit for more than 24 hours. There was no statistically significant relationship between the arrival times and the mean length of stay in the emergency department (p=0.303) (Table 1). Among the 15 patients remaining in the monitored observation unit for more than 24 hours, lack of space in the intensive care unit (n=8, 53.3%), lack of space in the emergency department (n=1, 6.7%), absence of a consulting physician

Factors Affecting the Length of Stay of Patients in Emergency Department Observation Units

Mahsanlar Y et al.

Table 1. Length of stay in the monitored observation unit according to emergency department arrival time

Length of stay (hour: min)

Mean±SD

08:00-16:00 222 36.8

07:06±08:10

16:00-00:00 263 43.6

07:16±07:04

00:00-08:00 118 19.6

08:22±07:09

Total

07:25±07:31

603 100

0.303

SD: Standard deviation.

Table 2. The diagnostic distribution of patients who stayed in the monitored observation unit for more than 24 hours Diagnosis

n %

Acute coronary syndromes (ACS)

6.7

Supraventricular tachycardia (SVT)/atrial fibrillation

20.0

with rapid ventricular response (AFRVR) Acute renal failure (ARF)

6.7

Chronic renal failure (CRF)

6.7

Cerebrovascular event (CVE)

6.7 6.7

Cardiac failure

Pneumonia

3 20.0

Hypoglycemia

1 6.7

Suicide

1 6.7

Non-specific chest pain

6.7

Epileptic attack

6.7

Cardio-pulmonary arrest

26.7

Electrolyte imbalance

26.7

Other

6.7

(n=4, 26.7%), failure to complete the diagnosis (n=2, 13.3%) and the conflict between the consultant and emergency physicians regarding the department to which the patient would be transferred (n=6, 40.0%) contributed to increased length of stay in the monitored observation unit. The diagnostic distribution of patients who stayed in the monitored observation unit for more than 24 hours is given in Table 2. Clinical outcomes of patients treated in the monitored observation unit for more than 24 hours were as follows:10 patients (66.7%) were hospitalized, 2 patients (13.3%) were transferred to another hospital, 1 patient (6.7%) was discharged, and 2 patients (13.3%) refused treatment and voluntarily left the emergency department . Among the 603 monitored patients, 221 patients (36.7%) were hospitalized, 82 patients

(13.5%) were transferred, 250 (41.5%) were discharged, 41 patients (6.8%) refused treatment and voluntarily left the emergency department, and 8 patients (1.3%) passed away. No medical consultation was required for 232 patients (38.5%). The mean length of stay in the emergency department among patients requiring consulting physicians was 397 min among the 262 patients (43.4%) seen by one consultant physician, 614 min among 73 patients (12.1%) that were seen by two consultant physicians, 515 min among the 24 patients (4.0%) seen by three consultant physicians, 510 min among the 11 patients (1.8%) seen by four consultant physicians. The most commonly requested consultations were internal medicine (n=219, 36.3%), neurology (n=78, 12.9%) and cardiology (n=49, 8.1%), respectively. A total of 221 patients (36.7%) were hospitalized. The rate

Turk J Emerg Med 2014;14(1):3-8

Table 3. The rate of hospitalization is according to length of stay in the emergency department Hosp.

Length of stay More than 24 hours

12 - 24 hours

6 - 12 hours n %

Total 3 - 6 hours

n %

Yes

10 66.7

43 55.1

66 33.3

5 33.3

35 44.9

132 66.7

Total

15 2.5

78 12.9

198 32.8

160 26.5

Less than 3 hours n %

n %

56 25.2

46 30.3

221 36.7

104 46.8

106 69.7

382 63.3

152 25.2

603 100.0

Hosp.: Hospitalization

of hospitalization is given according to length of stay in the emergency department in Table 3. A total of 43 hospitalized patients (19.5%) stayed in the monitored observation unit for 12-24 hours, while 10 patients (4.5%) stayed in the monitored observation for more than 24 hours. In total, 8 patients died in the emergency department. All of the deceased patients were intubated. Only 3 of the deceased patients (37.5%) were seen by a consulting physician. When examining patient vital signs, we observed a statistically significant difference in length of stay among patients classified as having high, low, and normal systolic blood pressure (p=0.016). Mean length of stay in the emergency department according to vital statistics is given in Table 4.

Discussion In the present study, we evaluated patients presenting to the emergency department and admitted to the monitored observation unit between 16.08.2011 and 16.09.2011. This is the first study of its kind to be conducted in this country.

ported that among their triage 1-grouped patients 37.1% were at least 65 years old.[7] In all of these studies it is apparent that geriatric patients constitute a major proportion of patients followed using monitored observation. Upon evaluation of the time of admission to the emergency department, we observed that the number of applicants dropped significantly between the hours 00:00 to 08:00. Kılıçaslan et al. have reported similar observations.[7] Efficient and effective emergency room services will need to account for day-night variations in the number of admissions. In the present study, 15 patients (2.5%) were treated in the monitored observation unit for more than 24 hours, while 78 patients (12.9%) stayed between 12-24 hours. The mean length of stay among all 603 patients followed in the monitored observation unit was 393 minutes.

A total of 18,162 patients were admitted to the emergency department during the one-month study period, and 603 of these patients (3.3%) were treated in the monitored observation unit. According to the 2005 data from the Center for Disease Control and Prevention, 5.5% of patients should be evaluated in the emergency department immediately. [5] A similar proportion of the present study population was treated without delay.

Out of 15 patients who remained under monitored observation more than 24 hours, 8 patients could not be transferred due to a lack of available space in the intensive care unit. A previous study also reported prolonged waiting times due to an absence of intensive care resources.[8] In the present study, the mean length of stay among 221 patients who were hospitalized after release from the monitored observation unit was 537 minutes. Aydin et al. have reported mean length of stay of 585.14 minutes in a similar patient group.[9] Meanwhile, according to the 2005 report of Center for Disease Control and Prevention, the mean length of stay is 210 minutes for emergency room patients in need of hospitalization.

The study group included 330 (54.7%) males and 273 (45.3%) females. Furthermore, individuals age 75 or greater, a total of 178 patients (29.5%), constituted the largest proportion of patients followed in the monitored observation unit. In addition, 316 (52.4%) of patients followed in the monitored observation unit were at least 65 years old. Of these patients, 49.7% were male and 50.3% were female. A study conducted by Taymaz et al. included patients age 65 and older, of which 46% were male and 54% were female.[6] Kılıçaslan et al. re-

We evaluated patient medical history in individuals monitored in the emergency department. The most common diseases were hypertension, coronary artery disease, diabetes, respiratory diseases, neurological diseases, and psychiatric disorders, respectively. Taymaz et al. reported the most commonly observed diseases as hypertension, ischemic heart disease, diabetes, respiratory disease, neurological disease, psychiatric disorders, respectively, in a similar study.[6] Improved patient education may result in better treatment

Mahsanlar Y et al.

Factors Affecting the Length of Stay of Patients in Emergency Department Observation Units

Table 4. Mean length of stay in the emergency department according to vital statistics

Mean±SD (hour: min)

0.8

03:51±04:16

0.016

Systolic pressure

Cardiopulmonary arrest

>140

163

27.0

08:38±08:39

90 - 140

393

65.2

06:47±06:25

<90

6.7

09:06±11:10

0.8

03:51±04:16

Diastolic pressure

Cardiopulmonary arrest

>90

112

18.6

08:18±09:01

60 - 90

422

69.9

07:02±06:44

<60

10.6

08:45±09:18

0.8

03:51±04:16

0.121

Breathing rate

Cardiopulmonary arrest

>25

6.3

10:58±12:06

12 - 25

543

90.1

07:09±06:40

<12

2.8

09:10±15:29

0.8

03:51±04:16

0.011

Pulse

Cardiopulmonary arrest

>100

196

32.5

08:51±09:10

60 - 100

376

62.4

06:45±06:31

<60

4.3

06:56±06:24

597

99.0

07:26±07:33

1.0

05:48±01:52

0.010

Blood glucose

60 and above

<60

0.598

Oxygen saturation

95 and above

424

70.3

06:32±05:32

90 - 94

16.3

09:44±10:50

80 - 89

8.5

09:45±08:11

<80

4.9

08:31±13:18

0.001

Temperature

>37.2

9.1

08:24±05:26

36 - 37.2

548

90.9

07:19±07:41

0.314

State of consciousness

Open

477

79.1

06:38±05:13

Confused

15.0

09:48±09:05

Closed

5.9

12:01±18:51

0.001

SD: Standard deviation.

compliance among patients with common diseases such as hypertension, coronary artery disease, and diabetes mellitus. The most common symptom at the time of presentation to the emergency department was chest pain, followed by shortness of breath and palpitations. Kekeç et al. reported that the most common symptoms at the time of presentation at the emergency department were various cardiac symptoms, fatigue and general poor health, pain and im-

paired consciousness.[10] The most frequently consulted specialties are cardiology, neurology and internal medicine, respectively, according to Taymaz et al.[6] In our study, internal medicine consultations occurred most frequently, while cardiology consultations were less frequent. During non-working hours internal medicine physicians perform the cardiology consultations at the hospital where the study was conducted.

Turk J Emerg Med 2014;14(1):3-8

In our study, patients who were admitted to intensive care had longer mean waiting times compared to patients who were admitted to another department. High occupancy rates in the intensive care unit are likely to contribute to this observation.[8] Increasing the capacity of the intensive care unit may be a highly effective means of decreasing delays for patients under observation in the emergency department.

Limitations

In our study, a lack of bed space in the intensive care unit was the most frequent cause of emergency room stays longer than 24 hours.[8]

Conflict of Interest

Patients with acute coronary syndrome accounted for the largest proportion of patients transferred to another facility. We are unable to perform PTCA (Percutaneous Coroner Transluminal angioplasty) in our hospital. The absence of angiography resources is a significant limitation to patient care. The age distribution of 103 patients admitted to the intensive care unit is as follows: 29 patients (28.2%) age 55-64, 20 patients (19.4%) age 65-74, and 42 patients (40.8%) age 75 and older. The mean age of patients admitted to the intensive care unit in a report by Ceylan et al. was 63.7.[11] These findings are comparable with our study data and it is notable that older patients are the most frequently admitted in both studies. Conclusion The presence and continuous improvement of monitored observation units is required for close follow-up and emergency interventions in critical patients admitted to the emergency department. In the present study we identified the time of day at which emergency room admission are the most frequent, and suggest that staffing and organization should be conducted in a manner that enables optimal response to anticipated patient volumes. In addition, space limitations are a fundamental challenge to emergency department care, and limitations in intensive care frequently exacerbate this problem by necessitating longer emergency department delays. Therefore, increased intensive care unit capacity is essential. Concomitant diseases are frequently observed among patients qualifying for monitored observation in the emergency department, and the medical history of each patient should be taken into consideration to avoid further complications. In addition, the establishment of angiography units in all level 3 health care centers, enabling the performance of PTCA procedures, may significantly decrease the rate of patient transfers from the emergency department.

The limited time period of data collection in this one-month cross-sectional study may limit the ability to apply the study conclusions to other populations; in addition, the study design cannot account for possible seasonal variations in disease incidence and, hence, emergency department patient populations.

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

References 1. Weiss SJ, Derlet R, Arndahl J, Ernst AA, Richards J, FernándezFrackelton M, et al. Estimating the degree of emergency department overcrowding in academic medical centers: results of the National ED Overcrowding Study (NEDOCS). Acad Emerg Med 2004;11:38-50. 2. Dickinson G. Emergency department overcrowding. CMAJ 1989;140:270-1. 3. Feferman I, Cornell C. How we solved the overcrowding problem in our emergency department. CMAJ 1989;140:273-6. 4. Derlet RW, Richards JR. Emergency department overcrowding in Florida, New York, and Texas. South Med J 2002;95:8469. 5. Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Adv Data 2007;386:1-32. 6. Taymaz T. Acil polikliniğinden yatırılan geriatrik hastaların ayrıntılı irdelenmesi. Akad Geriatri 2010;2:167-75. 7. Kılıçaslan İ, Bozan H, Oktay C, Göksu E. Demographic properties of patients presenting to the emergency department in Turkey. [Article in Turkish] Turk J Emerg Med 2005;5:5-13. 8. Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP; DELAY-ED study group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007;35:1477-83. 9. Aydın T, Aydın ŞA, Köksal Ö, Özdemir F, Kulaç S, Bulut M. Uludağ Üniversitesi Tıp Fakültesi hastanesi acil servisine başvuran hastaların özelliklerinin ve acil servis çalışmalarının değerlendirilmesi. JAEM 2010;9:163-8. 10. Kekeç Z, Koç F, Büyük S. Acil serviste yaşlı hasta yatışlarının gözden geçirilmesi. JAEM 2009;8:21-4. 11. Ceylan E, İtil O, Arı G, Ellidokuz H, Uçan ES, Akkoçlu A. İç hastalıkları yoğun bakım ünitesinde izlenmiş hastalarda mortalite ve morbiditeyi etkileyen faktörler. Toraks Dergisi 2001;2:6-12.

ORIGINAL ARTICLE

Incidental CT Findings of Patients Who Admitted to ER Following a Traffic Accident Acil Servise Trafik Kazası Sonucu Gelen Hastaların Çekilen BT’lerindeki İnsidental Bulguların Değerlendirilmesi

Yavuz YIGIT,1 Harun AYHAN2 Derince Training and Research Hospital, Kocaeli; Haydarpasa Numune Training and Research Hospital, İstanbul 1

SUMMARY

ÖZET

Objective The aim of this study was to investigate and analyze incidental CT findings of traffic injury patients discharged from the ER, and to determine overall notification rates.

Amaç Bu çalışmada ki amacımız trafik kazası ile acil servise başvuran hastalardan taburcu olanların BT’lerindeki rastlantısal bulguların analizi ve bunların hastalara bildirim oranlarının incelenmesidir.

Methods All traffic injury-related patient records between 01.06.2013-01.03.2013 were obtained from Derince Training and Research Hospital Emergency Service using patient files and the hospital database. Brain, thorax and/or abdominal CT images of 340 patients aged between 0 to 84 years were included in the study. ER observation forms were investigated for the patients who had incidental findings on CT scanning and overall notification rates were recorded.

Gereç ve Yöntem Çalışma 01.06.2013-01.03.2013 tarihleri arasında Derince Eğitim ve Araştırma Hastanesi Acil Servisi’nde trafik kazasına bağlı olarak takip edilen hastaların dosyalarından ve hastanemiz veri sisteminden elde edilen hasta bilgileri kullanılarak yapıldı. Çalışmaya beyin, toraks ve/veya abdominal BT görüntülemesi yapılan, 0-84 yaş arası 340 olgu alındı. Acil gözlem formları incelenerek rastlantısal bulgular saptanan hastalardan BT yorumlarının sonuçları hakkında bilgilendirilenler kaydedildi.

Results Mean age of the 363 cases was 31.2 (SD 17.9, min 0, max 84) and 35.5% of patients were female (n=129) and 64.5% were male (n=234). A total of 537 CT scans were performed on 363 patients. 147, 319 and 71 CT scans were performed on the thorax, brain and abdominal, respectively. 27.3% (n=99) of scan results showed the presence of a coincidental pathology. The most common disease on scans were bone lesions (8%, n=29), followed by sinus abnormalities (7.7%, n=28). Incidental findings ratio in patients aged over 60 was 60.8%, while under 60 was 24.8%. It was found that seven patients (7.1%) were informed about the imaging results.

Bulgular Üç yüz altmış üç olgunun yaş ortalaması 31,2 (SD17,9, min 0, maks 84) olarak bulunurken hastaların %35.5’i kadın (n=129), %64.5’i erkek (n=234) idi. 363 hastaya toplamda 537 BT görüntülemesi yapıldığı saptandı. Bunların 147’si toraks, 319’u beyin, 71’i abdominal görüntülemeydi. Tomografilerin %27.3’ünde (n=99) rastlantısal yakalanan bir patoloji vardı. En sık tespit edilen rastlantısal hastalık kemik patolojileri (%8, n=29), sonra sinüs anomalileridir (%7.7, n=28). Rastlantısal bulguların oranı 60 yaş üzerinde %60.8 olurken, 60 yaşın altında %24.8 olarak saptandı. Hastalardan yedisine (%7.1) görüntüleme sonucu hakkında bilgi verildiği saptandı.

Conclusion Most of the incidental findings were found to be benign; however, 16.5% of them were considered to require in-depth investigation. Further investigations are needed to understand the clinical relevance of these findings and their effects on patients.

Sonuç Çalışmamıza alınan hastalarda saptanan rastlantısal bulgular daha çok benign olmakla beraber, hastaların %16.5’inde ileri araştırma gerektirebilecek görece ciddi rastlantısal bulgular saptanmıştır. Ancak bu bulguların klinik öneminin ve hastalar üzerindeki etkilerinin araştırıldığı daha çok çalışmaya ihtiyaç olduğu kanaatindeyiz.

Key words: Incidental findings, tomography.

Anahtar sözcükler: Acil servis; rastlantısal bulgular; tomografi.

Submitted: 01.10.2013 Accepted: 13.12.2013 Published online: 07.01.2014 Correspondence: Dr. Yavuz Yiğit. Derince Eğitim ve Araştırma Hastanesi, Derince, Kocaeli, Turkey. e-mail: dryavuzyigit@gmail.com

Turk J Emerg Med 2014;14(1):9-14

doi: 10.5505/1304.7361.2014.13284

Turk J Emerg Med 2014;14(1):9-14

Introduction The use of computed tomography (CT) in the Emergency Room (ER) is increasing with its growing availability and diagnostic success. The impact of CT on ER physician has had undeniable success such as rapid diagnosis and efficiency in the treatment process. There are many publications that emphasize the importance of CT scans which may lead to significant changes in the treatment of patients with multiple traumas.[1-8] Along with the potential benefits of CT scans, risk factors are associated with the use of this technique such as the potential of high-doses of radiation and contrast-induced nephropathy.[9,10] With this in mind, CT scans constitute 13% of radiological diagnostic methods used the United States and is 70% of radiation source given to the patients.[11,12] The estimated cancer rates due to one-time whole body CT scan is fairly low at 0.08%, while in cases of annual CT scans this rate increases to approximately 2%.[13-16] Another potential issue related to CT scans is incidental findings. There advantages and disadvantages of incidental findings and remain a topic of debate. Many publications have come to fruition due to the incidental findings, independent from the patient’s main complaint.[17-23] Some of these publications indicated that incidental findings often result in unnecessary tests and spending.[18,23,24] Other publications reported that, in many cancer cases, further analysis of incidental findings lead to early stage cancer diagnosis. [20,25,26] The studies that examined incidental findings in the CT scans of trauma patients reported the rate of incidental findings to be between 34-43%.[17,27,28] The patient notification rates of the detection of incidental findings varied between 21-27%.[19,29] CT has become one of the more essential tools commonly used in the ER. The breadth of incidental pathologies have not been examined sufficiently in the literature. In addition, the issues on how to manage patients with these incidental findings needs clarity. The aim of this study was to investigate the incidental pathologies observed in CT scans. The frequency and notification rate in discharged patients admitted to the emergency department due to traffic accidents are discussed.

Materials and Methods This retrospective study was conducted by using files and patient information obtained from our hospital’s data processing system regarding patients admitted and followed at the ER of Derince Training and Research Hospital Emergency Service due to traffic accidents from January 2012 to January 2013. The study included 363 patients between the ages

of 0-84 whose brain, chest, and/or abdominal CT scans were taken. Patient ER observation forms and files from the hospital data processing system were screened and their age, gender, type of imaging, circumstances of hospital admission (referral or direct), post-treatment status (admission to another department, discharge or mortality during the follow-up), and comments on CT scans (made by hospital’s expert radiologists) were recorded. Findings from the CT scans that were considered to be unrelated to traffic accident injuries (bone changes, sinus changes, nephrolithiasis, renal simple cyst, hepatic steatosis, ovarian simple cyst, abdominal hernia, hiatal hernia, cholelithiasis, diverticulum, accessory spleen, hemangiomas, pulmonary fibrosis, pulmonary nodule, atherosclerosis, arachnoid cysts, aortic dilatation, hepatomegaly, hepatic mass, splenomegaly, hydronephrosis) were recorded under the heading of incidental findings. The incidental findings were divided into two groups according to their severity based on the classification proposed by Barrett et al.[30] Group 1 included incidental findings that did not require urgent intervention, but patients were still required to be notified, whereas Group 2 included findings that should be intervened immediately. The information from the CT review results of patients whose incidental findings were detected by examining the ER observation forms was recorded. The status of patient incidental finding notification was determined by looking at the records from the ER forms and consult notes. The cases in which notification status was not recorded were considered as not informed. Patients that were (1) hospitalized or transferred to any other department, (2) who lost their lives during the follow-up, (3) whose ER observation forms or hospital information system records were incomplete, or (4) who were referred to our department from another center were excluded from the study. The SPSS 16.0 software was used for statistical analyses of the data. The normally distributed continuous variables were expressed as mean and standard deviation (±), minimum (min) - maximum (max) values in brackets, while the qualitative variables were expressed as numbers and percentages (%). The ethics committee approved our study.

Results When the records of a total of 947 patients who were admitted to our ER due to traffic accident were examined, we determined the following: the CT scan was not done for 278 patients, 182 patients were hospitalized to another department, the records of 83 patients were incomplete, 37 patients were referred to our emergency service from another center, and 4 patients passed away during the follow-up in emergency service (Figure 1).

Yiğit Y et al.

Incidental CT Findings of Patients Who Admitted to ER Following a Traffic Accident

947 Total number of patients

363

278

182

Patients included in the study

Patients without CT scans

Hospitalized patients

4 Patients who died in the emergency room

Patients with incomplete records

Referred patients

Figure 1. Inclusion/exclusion criteria for patients in the study.

Requested CT types (%)

2.2 (n=8)

Abdomen + Brain Abdomen + Thorax

3.6 (n=13)

Abdomen + Thorax +

11.6 (n=42) 16.5 (n=60)

Brain + Thorax

19.6 (n=71)

Abdomen

40.5 (n=147)

Thorax

87.9 (n=319)

Brain 0

100

Figure 2. The distribution of CT scans requested from the emergency service.

The mean age of 363 patients whose CT scans were taken in the ER that showed incidental findings was 31.2±17.9 (min 0, max 84). Of those 363 patients, 35.5% were female (n=129), while 64.5% were male (n=234). A total of 537 CT scans (147 thorax, 319 brain, and 71 abdominal) were taken for 363 patients included in the study. There were incidentally caught pathologies in 27.3% (n=99) of tomography analyses. There was a single pathology in 17.1%, while multiple pathologies were determined in 10.2% (n=37) of the tomography reports. The most commonly detected incidental disease was bone pathology (8.0%, n=29) followed by the sinus abnormalities (7.7%, n=28). Group 1 incidental findings included bone changes, sinus changes, nephrolithiasis, renal simple cyst, hepatic steatosis, ovarian simple cyst, abdominal hernia, hiatal hernia, cholelithiasis, diverticulum, accessory spleen, and hemangioma. They constituted 55.8% (n=76) of all incidental findings and were observed in 20.9% (n=76) of patients (Table 1). All of the bone change cases in Group 1 findings were benign changes (osteophytic changes accompanied by or not accompanied by spinal stenosis) according to Barrett et al.’s

classification. None of the patients had bone cyst, lytic bone lesions, or bone masses. The other Group 1 findings did not require immediate intervention according to Barrett et al.’s classification. None of the Group 1 incidental findings were reported to the patients. Meanwhile, Group 2 findings accounted for 44.2% of all incidental findings and were observed in 16.5% of the patients (n=60). Only 11.7% of Group 2 incidental findings were reported to patients (Table 2). When the relationship between the age and incidental findings was examined, the rate of incidental findings in patients over 60 years of age was 60.8% compared with the rate of 24.8% in patients under the age of 60. According to the ER observation among the patients with incidental findings in the CT scans, only 7 patients (7.1%) were informed about the results of the imaging. The aortic dilatation was determined in 1 of these patients (50.0%), pulmonary nodule in 3 patients (23.0%), hepatic masses in 1 patient (16.6%), hydronephrosis in 1 patient (20.0%) and pulmonary fibrosis in 1 patient (5.50%).

Turk J Emerg Med 2014;14(1):9-14

Table 1. Group 1 incidental findings and their frequency Disease

Number

Percentage (%)

8.0

Sinus changes (sinusitis, sinus cysts)

7.7

Nephrolithiasis

5 1.4

Renal simple cyst

1.1

Hepatic steatosis

0.8

Ovarian simple cyst

0.3

Abdominal hernia

0.3

Hiatal hernia

0.3

Bone changes (osteophytic changes accompanied by or not accompanied by spinal stenosis)

Cholelithiasis

1 0.3

Diverticulitis

1 0.3

Accessory spleen

Hemangioma

1 0.3

0.3

Table 2. Group 2 incidental findings and their frequency Disease

Number

Percentage (%)

Pulmonary fibrosis

5.0

Pulmonary nodule

3.6

Atherosclerosis

10 2.8

Arachnoid cyst

1.7

Aorta dilation

0.5

Hepatomegaly

2 0.5

Hepatic mass

0.3

Splenomegaly

0.3

Hydronephrosis

1 0.3

Discussion The rate of the incidental findings in patients included in our study was found to be 27.3%. In previously conducted similar studies, this rate has been reported to vary between 30.6-35.0%.[17,27,31] Therefore, the rate of incidental findings in our study is consistent with previous studies. In our study, the rate of patient notification regarding the incidental findings was determined as 6.30%. In a similar study by Thompson et al., this rate was 9.80%, in Munk et al.â&#x20AC;&#x2122;s study it was 21.0%, while it was 27.0% in Messersmith et al.â&#x20AC;&#x2122;s study. When compared to these studies, the notification rates from our study are low. Messersmith and Mink studies both included hospitalized patients. A longer stay in the hospital might have increased the chances of patient notification. Similar to our study, Thompson et al. did not include

hospitalized patients for analysis and their notification rates were more similar our notification rates. In our study, we determined whether the patients had been notified about the incidental findings from the ER observation forms. The possibility of not recording the verbal notification of patients in the observation forms constitutes a limitation to our study as well as other similar studies. Another possible cause of the low rate of notification might be that the ER physicians did not think that incidental findings were significant enough to be reported. Both in our study as well as in other similar studies, the notification rates of relatively more significant incidental findings were higher. Mink et al. divided the incidental findings into three groups according to their severity. The group that had the most severe findings (possible fatal symptoms such as bone me-

Yiğit Y et al.

Incidental CT Findings of Patients Who Admitted to ER Following a Traffic Accident

tastasis, metastatic lung mass, and abdominal aortic aneurysm) was group 3. Although the notification rate of patients from group 3 was higher than the general notification rate (21.0%), it still was only 40.9%. Similarly in our study, the notification rates for relatively significant findings were higher than the overall notification rates. However, with the exception of aortic dilatation, they did not exceed 23.0% (lung nodules 23.0%, aortic dilatation 50.0%). On the other hand, Messersmith et al.’s study also classified incidental findings into three groups based on their severity. They did not find a significant difference between those three groups in terms of patient notification. As a result, it does not seem to be possible to create a definite opinion on this issue. There are several suggestions for increasing the patient notification rates. Ekeh et al.[27] proposed to notify discharged patients about incidental findings by mailing a letter. Another method is to directly inform the family physician rather than the patient regarding the detected incidental findings. With this method, family physicians will follow-up with the patient for the possibility to reduce unnecessary anxiety. Messersmith et al.[19] reported that, among all the patients that were notified about the incidental findings, only 11 patients (18.0%) later came for follow-up. No major diseases were detected in the follow-up of these patients. This shows that the path that emergency physicians choose to follow when informing patients is essential. Overburdening the patients may lead to negative consequences such as increasing the workload and developing complications during further tests. On the other hand, seriousness of the findings should be emphasized so that patients do not delay their follow-ups. Limitations In our study, we determined whether the patients were notified about the incidental findings by evaluating the ER observation forms. The possibility of not recording the verbal notification of patients into the observation file creates a limitation of our study and other similar studies. Therefore, based on our work it is not possible to reach a definitive conclusion about the patient notification rates. In addition, there is a need for a prospective study that would evaluate the contents of notifications, patient reactions to these notifications, and their efficacy. These considerations could not be assessed in this study. Conclusion Most of the incidental findings detected in the patients included in our study were benign, however incidental findings detected in 16.5% of the patients were relatively serious and required further investigation. Nonetheless, more studies are needed to determine the clinical importance on these incidental findings and their effect on patients.

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

References 1. Salim A, Sangthong B, Martin M, Brown C, Plurad D, Demetriades D. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study. Arch Surg 2006;141:468-75. 2. Rizzo AG, Steinberg SM, Flint LM. Prospective assessment of the value of computed tomography for trauma. J Trauma 1995;38:338-43. 3. Exadaktylos AK, Sclabas G, Schmid SW, Schaller B, Zimmermann H. Do we really need routine computed tomographic scanning in the primary evaluation of blunt chest trauma in patients with “normal” chest radiograph? J Trauma 2001;51:1173-6. 4. Brown CV, Antevil JL, Sise MJ, Sack DI. Spiral computed tomography for the diagnosis of cervical, thoracic, and lumbar spine fractures: its time has come. J Trauma 2005;58:890-6. 5. Wisbach GG, Sise MJ, Sack DI, Swanson SM, Sundquist SM, Paci GM, et al. What is the role of chest X-ray in the initial assessment of stable trauma patients? J Trauma 2007;62:74-9. 6. Sampson MA, Colquhoun KB, Hennessy NL. Computed tomography whole body imaging in multi-trauma: 7 years experience. Clin Radiol 2006;61:365-9. 7. Antevil JL, Sise MJ, Sack DI, Kidder B, Hopper A, Brown CV. Spiral computed tomography for the initial evaluation of spine trauma: A new standard of care? J Trauma 2006;61:382-7. 8. Larson DB, Johnson LW, Schnell BM, Salisbury SR, Forman HP. National trends in CT use in the emergency department: 1995-2007. Radiology 2011;258:164-73. 9. Merten GJ, Burgess WP, Gray LV, Holleman JH, Roush TS, Kowalchuk GJ, et al. Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial. JAMA 2004;291:2328-34. 10. Birck R, Krzossok S, Markowetz F, Schnülle P, van der Woude FJ, Braun C. Acetylcysteine for prevention of contrast nephropathy: meta-analysis. Lancet 2003;362:598-603. 11. Dixon AK, Goldstone KE. Abdominal CT and the Euratom Directive. Eur Radiol 2002;12:1567-70. 12. Mettler FA Jr, Wiest PW, Locken JA, Kelsey CA. CT scanning: patterns of use and dose. J Radiol Prot 2000;20:353-9. 13. Einstein AJ, Henzlova MJ, Rajagopalan S. Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. JAMA 2007;298:317-23. 14. Rice HE, Frush DP, Farmer D, Waldhausen JH; APSA Education Committee. Review of radiation risks from computed tomography: essentials for the pediatric surgeon. J Pediatr Surg 2007;42:603-7. 15. Brenner DJ, Elliston CD. Estimated radiation risks potentially associated with full-body CT screening. Radiology 2004;232:735-8.

Turk J Emerg Med 2014;14(1):9-14

16. Semelka RC, Armao DM, Elias J Jr, Huda W. Imaging strategies to reduce the risk of radiation in CT studies, including selective substitution with MRI. J Magn Reson Imaging 2007;25:900-9. 17. Paluska TR, Sise MJ, Sack DI, Sise CB, Egan MC, Biondi M. Incidental CT findings in trauma patients: incidence and implications for care of the injured. J Trauma 2007;62:157-61. 18. Maizlin ZV, Barnard SA, Gourlay WA, Brown JA. Economic and ethical impact of extrarenal findings on potential living kidney donor assessment with computed tomography angiography. Transpl Int 2007;20:338-42. 19. Messersmith WA, Brown DF, Barry MJ. The prevalence and implications of incidental findings on ED abdominal CT scans. Am J Emerg Med 2001;19:479-81. 20. Iezzi R, Cotroneo AR. Endovascular repair of abdominal aortic aneurysms: CTA evaluation of contraindications. Abdom Imaging 2006;31:722-31. 21. Chin M, Mendelson R, Edwards J, Foster N, Forbes G. Computed tomographic colonography: prevalence, nature, and clinical significance of extracolonic findings in a community screening program. Am J Gastroenterol 2005;100:2771-6. 22. Khan KY, Xiong T, McCafferty I, Riley P, Ismail T, Lilford RJ, et al. Frequency and impact of extracolonic findings detected at computed tomographic colonography in a symptomatic population. Br J Surg 2007;94:355-61. 23. Xiong T, Richardson M, Woodroffe R, Halligan S, Morton D, Lilford RJ. Incidental lesions found on CT colonography: their nature and frequency. Br J Radiol 2005;78:22-9. 24. Berlin L. Potential legal ramifications of whole-body CT

screening: taking a peek into Pandoraâ&#x20AC;&#x2122;s box. AJR Am J Roentgenol 2003;180:317-22. 25. Shetty SK, Maher MM, Hahn PF, Halpern EF, Aquino SL. Significance of incidental thyroid lesions detected on CT: correlation among CT, sonography, and pathology. AJR Am J Roentgenol 2006;187:1349-56. 26. Lumachi F, Borsato S, Tregnaghi A, Marino F, Fassina A, Zucchetta P, et al. High risk of malignancy in patients with incidentally discovered adrenal masses: accuracy of adrenal imaging and image-guided fine-needle aspiration cytology. Tumori 2007;93:269-74. 27. Ekeh AP, Walusimbi M, Brigham E, Woods RJ, McCarthy MC. The prevalence of incidental findings on abdominal computed tomography scans of trauma patients. J Emerg Med 2010;38:484-9. 28. Devine AS, Jackson CS, Lyons L, Mason JD. Frequency of incidental findings on computed tomography of trauma patients. West J Emerg Med 2010;11:24-7. 29. Munk MD, Peitzman AB, Hostler DP, Wolfson AB. Frequency and follow-up of incidental findings on trauma computed tomography scans: experience at a level one trauma center. J Emerg Med 2010;38:346-50. 30. Barrett TW, Schierling M, Zhou C, Colfax JD, Russ S, Conatser P, et al. Prevalence of incidental findings in trauma patients detected by computed tomography imaging. Am J Emerg Med 2009;27:428-35. 31. Thompson RJ, Wojcik SM, Grant WD, Ko PY. Incidental Findings on CT Scans in the Emergency Department. Emerg Med Int 2011;2011:624847.

ORIGINAL ARTICLE

Laboratory Risk Indicators for Necrotizing Fasciitis and Associations with Mortality Nekrotizan Fasiitli Olgularda Laboratuvar Risk Belirteçleri ve Mortalite ile İlişkisi Elif COLAK, Nuraydin OZLEM, Gultekin Ozan KUCUK, Recep AKTIMUR, Sadik KESMER Department of General Surgery, Samsun Training and Research Hospital, Samsun

SUMMARY

ÖZET

Objectives Necrotizing fasciitis (NF) is rare but life threatening soft tissue infection characterized by a necrotizing process of the subcutaneous tissues and fascial planes. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score has been verified as a useful diagnostic tool for detecting necrotizing fasciitis. A certain LRINEC score might also be associated with mortality. The aims of this study are to determine risk factors affecting the prognosis and to evaluate the prognostic value of the LRINEC score in NF.

Amaç Nekrotizan fasiit (NF) cilt altı dokular ve fasyal planlarda nekrozla karakterize nadir görülen ama hayatı tehdit eden bir yumuşak doku enfeksiyonudur. Nekrotizan fasiit için laboratuvar risk indikatör (LRINEC) skor, NF teşhisinde kullanılan yararlı bir tanısal yöntemdir. Belirli bir LRINEC skor mortalite ile de ilişkili olabilir. Bu çalışmanın amacı NF için LRINEC skorun prognostik değerini ortaya koymak ve prognozu etkileyen risk faktörlerini belirlemektir.

Methods Twenty-five patients with necrotizing fasciitis treated in Samsun Education and Research Hospital between January 2008 and April 2013 were enrolled in the study. Surviving and non-surviving patient groups were compared regarding demographic data, co-morbidity, predisposing factors, causative agents, number of debridements and LRINEC score.

Gereç ve Yöntem Ocak 2008-Nisan 2013 tarihleri arasında Samsun Eğitim ve Araştırma Hastanesi’nde tedavi edilen nekrotizan fasiit tanılı 25 hasta çalışmaya dahil edildi. Yaşayan ve ölen hastalar; demografik özellikler, yandaş hastalıklar, presidpozan faktörler, enfeksiyon etkeni, debridman sayısı ve LRINEC skorlar açısından karşılaştırıldı.

Results Mean age was 55.6±16.79 years (min: 17-max: 84), and the female/male ratio was 16/9. Mortality was observed in 6 (24%) patients. The most frequent comorbid diseases were diabetes mellitus (52) and peripheral circulatory disorders (24%), and the most frequent etiologies were cutaneous (32%) and perianal abscess (20%). Pseudomonas aeruginosa infection was higher in the non-surviving group (p=0.006). The mean number of debridements and LRINEC score were higher in the non-surviving group than in the surviving group ( p=0.003 and p=0.003, respectively).

Bulgular Ortalama yaş 55.6±16.70 yıl (min: 17-maks: 84), kadın/erkek oranı 16/9 idi. Altı (%24) hasta kaybedildi. En sık eşlik eden hastalıklar diabetes mellitus (%52) ve periferik vasküler hastalıklar (%24) idi. En sık etiyoloji ise kutanöz apseler (%32) ve perianal abse (%20) idi. Pseudomanas aeruginosa enfeksiyonu ölen hastalarda daha fazlaydı (p=0.006). Debridman sayısı ortancası ve LRINEC skor ölen hastalarda yaşayan hastalardan anlamlı olarak daha yüksek idi (sırasıyla p=0.003, p=0.003).

Conclusions Pseudomans aeruginosa infection and multiple debridements are related with mortality. The LRINEC score might help predict mortality in NF.

Sonuç Pseudomanas aeruginosa enfeksiyonu ve çoklu debridmanlar mortalite ile ilişkilidir. LRINEC skror NF için mortaliteyi tahmin etmede kullanılabilir.

Key words: Fasciitis; mortality; necrotizing; prognosis.

Anahtar sözcükler: Fasiit; mortalite; nekrotizan; prognoz.

Submitted: 21.09.2013 Accepted: 17.12.2013 Published online: 15.01.2014 Correspondence: Dr. Elif Colak. Fevziçakmak Mah., Odunpazarı Cad., Mıra Evleri Sitesi, A Blok, D: 21, İlkadım, Samsun, Turkey. e-mail: elifmangancolak@hotmail.com

Turk J Emerg Med 2014;14(1):15-19

doi: 10.5505/1304.7361.2014.55476

Turk J Emerg Med 2014;14(1):15-19

Introduction Necrotizing fasciitis (NF), which is characterized by progressive necrosis of the fascia, subcutaneous tissue and skin, is a life-threatening soft tissue infection. The disease was defined with its contemporary meaning in 1950 by Wilson, who observed that skin necrosis is a rare occurrence, but fascial necrosis is much more common.[1] Urogenital-anorectal infection and trauma plays an important role etiologically. [2-4] However, NF may be caused by minor injuries such as tissue abrasions and lacerations, insect bites, and intramuscular injection; it also should be considered that there may not always be a detectable cause.[5-8] Despite immediate surgical intervention and antibiotic therapy, the mortality rate is about 20-30%.[3,4,9] Diagnosis is made by physical examination, but may be difficult since it is frequently confused with the other skin and soft tissue infections. For this reason, the scoring system called Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) was developed in 2004 by Wong and colleagues, and was shown to be helpful for distinguishing NF from other soft tissue infections.[10] It was reported in further studies that this scoring system can be used for early diagnosis of NF.[11-15] To calculate the LRINEC score, C-reactive protein, hemoglobin, blood leukocyte count, serum glucose, serum creatinine, and serum sodium values of patients were measured at admission and scored as shown in Table 1. Then a certain score value is obtained for each patient. Values of six or higher indicate the most likely diagnosis of NF.[10-15] The aim of this study is the clinical evaluation of patients diagnosed with NF, for whom early diagnosis and intervention are vital, and to investigate the relationship between LRINEC score and mortality rate.

Materials and Methods The study was approved by the ethics committee of our hospital. The files of 31 patients, who were diagnosed with necrotizing fasciitis (M72.5) and were operated for Fournier gangrene with debridement (621470) code from January 2008 to April 2013, were examined retrospectively on automation system. Four patients who were initially debrided in another hospital and then sent to our hospital for follow-up or intensive care support and two patients whose data were inaccessible were excluded from the study. It was found that patients with skin redness, swelling, tenderness, skin necrosis, and subcutaneous crepitus had been diagnosed with NF. All the patients received antibiotic therapy just after the diagnosis and underwent debridement within the first 24 hours. Antibiotic treatment, which caused patients to be responsive to the factors reproduced in the deep tissue culture taken during debridement, was continued. Repeated debridement was implemented for the necessary patients.

Table 1. LRINEC (Laboratory risk indicator for necrotising fasciitis) score Parameters Score C-reactive protein (mg/dl) <150 0 >150

Leukocyte count (mm3) <15 0 15-25

>25

Hemoglobin (gr/dl) >13.5

11-13.5

<11 Serum sodium (mmol/l)

>135

<135

Serum creatinine (mmol/l) <141

>141

Serum glucose (mmol/L) <10 0 >10

Patient age, gender, co-morbidities, predisposing factors, number of debridement, and factors isolated in deep tissue culture were detected. The measured C-reactive protein, hemoglobin, blood leukocyte count, serum glucose, serum creatinine, and serum sodium values of patients were recorded to calculate LRINEC score for each patient. Patients were divided into two groups, alive (Group 1, n=19) and deceased (Group 2, n=6). Both groups were compared in terms of age, gender, co-morbidities, predisposing factors, number of debridement, and factors isolated in deep tissue culture. The LRINEC score difference between the groups was investigated. Statistical analysis Data was recorded in the pre-prepared forms and was uploaded to SPSS (Version 16, SPSS Inc. Chicago, IL) software. Studentâ&#x20AC;&#x2122;s t-test and Mann-Whitney U-test were conducted for comparison of continuous variables, and chi-square test was used for categorical variables. Statistical significance was considered to be p<0.05.

Results The distribution of the evaluation parameters included in this study is shown in Table 2. The average age is 55.6Âą16.79

Çolak E et al.

Laboratory Risk Indicators for Necrotizing Fasciitis and Associations with Mortality

Table 2. Comparison of the group Parameters Patients Group 1

Group 2

Total

n % Mean±SD n % Mean±SD n % Mean±SD

Gender (Female)

68.7

31.2

0.364

Age (Mean) 54.79±17.74 58.17±14.47 55.6±16.79 0.722 Risk factor

Soft tissue infection

Perianal apse

HVP

Number of debridement (Median)

0,936

3 60

2 40

5 20

0.562

0.959

1-3

1-4

0.003

LRINEC score (Mean)

4.6±2.7

9.6±2.87

5.8±3.49

0.003

HVP: Hollow Viscus Perforation; LRINEC: Laboratory risk indicator for necrotising fasciitis.

years old (min: 17, max: 84), and male/female ratio is 16/9. Six patients (24%) died and five of these patients (83.3%) were female. There was no statistically significant difference between groups in terms of average age and sex (p=0.722 and p=0.364, respectively). The most frequent co-morbid disease was diabetes mellitus (DM) in 13 patients (52%); the second most frequent disease was peripheral vascular disease (PVD) in 9 patients (24%). Other co-morbid diseases were chronic renal failure, chronic obstructive pulmonary disease, cerebrovascular disease, and hypertension. There was no difference between the groups in terms of DM as the most frequent co-morbid disease (p=0.645). The most common predisposing factors were as following: soft tissue infections (inguinal, femoral, parumbilical, and scrotal) in 8 patients (32%), perianal abscess in 5 patients (20%), and hollow organ perforation in 4 patients (16%). NF developed in the gluteal region after intramuscular injection in one patient; in the lower abdomen after wide skin, subcutaneous, and muscle laceration after vehicle traffic accident in another patient; and after arteriovenous fistula surgery conducted from the right femoral region in one other patient. Moreover, in the 17-year-old male patient, NF developed after orchitis in the scrotal area. Four (16%) patients did not show any predisposing factors (Table 3). There was no difference between the groups in terms of soft tissue infections and perianal abscesses as the most frequent etiologic factors (p=0.936 and p=0.562, respectively). The most frequently isolated microorganisms in deep tissue culture were Pseudomanas aeruginosa (32%), Escherichia coli (20%), and Staphylococcus aureus (16%). Klebsiella pneumonia, Proteus mirabilis and Acinetobacter baumannii were the other reproducing microorganisms. There was no reproduction in deep tissue culture of one patient, and another patient’s culture results could not be obtained. The number of pa-

tients who had reproduction of Pseudomanas aeruginosa in their deep tissue culture was significantly high in the deceased group compared to alive group (p=0.006). The most commonly used antibiotics were Carbapenems (imipenem or meropenem) and beta-lactam-beta-lactamase inhibitors (piperacillin-tazobactam or cefoperazone-sulbactam). LRINEC score averages were 4.6±2.75 in group 1, and 9.6±2.87 in group 2. LRINEC score average was significantly high in the deceased group compared to alive group (p=0.003). The median number of debridement implemented was 1 (min: 1, max: 4). Debridement median was 3 (min: 1, max: 4) in deceased patients and 1 (min: 1, max: 3) in alive patients. The difference was observed as significantly different (p=0.003). The defects were closed with fasciocutaneous flaps in 4 patients and with partial-thickness skin flap in 3 patients. Moreover, the defect of 4 patients was closed primarily. Images of a patient whose defect was closed with primary closure are shown in Figure 1.

Table 3. Predisposing factors Etiology

Soft tissue infection

Perianal apse Hollow viscus perforation

Unknown

Trauma

Gluteal injection

Surgery (A-V fistula)

Orchitis

Total 25

Turk J Emerg Med 2014;14(1):15-19

(a)

(b)

(c)

Figure 1. A 54-year-old female patient. (a) After debridement. (b) During daily wound care. (c) 15 days after primary closure.

Discussion The studies show that NF is more common in males aged 5060.[3,4,16] In our series, the average age of patients was 55.6; our study was found to be consistent with the literature. Although male patientsâ&#x20AC;&#x2122; rates are higher in case series, female patient dominance was observed in the series of Tilkorn and colleagues, similar to our series.[15] The most common co-morbid diseases observed in NF are DM, immunosuppression, chronic renal failure, the underlying malignancy, atherosclerosis , chronic obstructive pulmonary disease, and obesity.[2-4,15,16] In our study, the most common co-morbid disease was DM (52%). The common predisposing factors are trauma, previous operations, and perianal abscess; in addition, perforated appendicitis, burns, insect bites, intravenous injection, and intramuscular injection seen after NF cases are also reported.[2-4,15-18] In our study, we also detected soft tissue infections, perianal abscess, perforation of hollow organs, previous surgery, and trauma as the most common predisposing factors. In 4 patients who did not have detectible predisposing factors, we found the co-morbid diseases DM and PVH. Undetectable microtraumas due to neuropathy and loss of sensation can cause NF in some patients. Diabetes is one of the important underlying factors for patients with NF, but there is no evidence that the disease is more fatal for patients with diabetes. Kalaivani et al.[19] showed in a 60-patient series that diabetes is not a predictor for mortality as in our patients. According to the literature, the type and number of isolated microorganisms can vary. Factors are commonly polymicrobial, and the most common monomicrobial factors include Streptococcus pyojenes, Staphylococcus aureus, E. coli, Klebsiella, Bacteriodes, and Pseudomanas aeruginosa.[2-4,20] Pseudomanas aeruginosa was the most frequently detected factor in our study, is also the most common factor in the study by Ă&#x2013;zgenel and colleagues.[21] The probability of having NF in patients with a LRINEC score of 6 or higher was calculated as 92% in the study of Wong

et al.[10] Su et al.[13] reported that mortality also significantly increases in patients with LRINEC score of 6 or higher. Corbin[12] also showed in his study that the complication risk is higher in patients with LRINEC score of 6 or higher. Mortality is reported in the range of 20-30% in various series. The mortality rate in our study (24%) was consistent with the literature[3,4,9,20] Clayton et al.[22] presented that mortality is significantly lower in young patients, in patients with BUN of 50 mg/dl or below, and in patients without ongoing sepsis. Faucher et al.[5] proposed that co-morbid diseases do not affect mortality. On the other hand, Francis et al.[23] proposed that mortality is 50% in patients with 3 or more risk factors (being 50 years old or older, diabetes, malnutrition, hypertension, or intravenous drug abuse). As a result of this study, we propose that increased number of debridement due to severity of disease, factor grown in the deep tissue culture (Pseudomonas aeruginosa), and LRINEC scores might be relative to mortality. Our study was limited by being a single centered and small volume study as well as a lack of anaerobic culture. Conclusion Emergency clinicians have a great responsibility in differentiating NF, which is seen rarely but is a surgical emergency with the highest morbidity and mortality, arising from simple soft tissue infections. The diagnosis can be supported and clinical course can be predicted using the LRINEC scoring system, allowing necessary precautions to be conducted to reduce the mortality rate of this disease. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. Wilson B. Necrotizing fasciitis. Am Surg 1952;18:416-31. 2. Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P,

Çolak E et al.

Laboratory Risk Indicators for Necrotizing Fasciitis and Associations with Mortality

Goldstein EJ, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis 2005;41:1373-406. 3. Canbaz H, Cağlikülekçi M, Altun U, Dirlik M, Türkmenoğlu O, Taşdelen B, et al. Fournier’s gangrene: analysis of risk factors affecting the prognosis and cost of therapy in 18 cases. Ulus Travma Acil Cerrahi Derg 2010;16:71-6. 4. Turhan O, Büyüktuna SA, Inan D, Saba R, Yalçın AN. Clinical evaluation of forty-four patients with necrotizing fasciitis. Ulus Travma Acil Cerrahi Derg 2011;17:29-32. 5. Faucher LD, Morris SE, Edelman LS, Saffle JR. Burn center management of necrotizing soft-tissue surgical infections in unburned patients. Am J Surg 2001;182:563-9. 6. Wilson HD, Haltalin KC. Acute necrotizing fasciitis in childhood. Report of 11 cases. Am J Dis Child 1973;125:591-5. 7. Saz EU, Anik A, Tanriverdi HI, Anik A, Ergün O. Pseudomonas necrotizing fasciitis following an intramuscular injection in an immunocompetent child. Pediatr Int 2010;52:e114-6. 8. Taviloglu K, Cabioglu N, Cagatay A, Yanar H, Ertekin C, Baspinar I, et al. Idiopathic necrotizing fasciitis: risk factors and strategies for management. Am Surg 2005;71:315-20. 9. Young MH, Aronoff DM, Engleberg NC. Necrotizing fasciitis: pathogenesis and treatment. Expert Rev Anti Infect Ther 2005;3:279-94. 10. Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med 2004;32:1535-41. 11. Schuster L, Nuñez DE. Using clinical pathways to aid in the diagnosis of necrotizing soft tissue infections synthesis of evidence. Worldviews Evid Based Nurs 2012;9:88-99. 12. Corbin V, Vidal M, Beytout J, Laurichesse H, D’Incan M, Souteyrand P, et al. Prognostic value of the LRINEC score (Laboratory Risk Indicator for Necrotizing Fasciitis) in soft tissue infections: a prospective study at Clermont-Ferrand University hospital. [Article in French] Ann Dermatol Venereol 2010;137:5-11. [Abstract]

13. Su YC, Chen HW, Hong YC, Chen CT, Hsiao CT, Chen IC. Laboratory risk indicator for necrotizing fasciitis score and the outcomes. ANZ J Surg 2008;78:968-72. 14. Chao WN, Tsai SJ, Tsai CF, Su CH, Chan KS, Lee YT, et al. The Laboratory Risk Indicator for Necrotizing Fasciitis score for discernment of necrotizing fasciitis originated from Vibrio vulnificus infections. J Trauma Acute Care Surg 2012;73:157682. 15. Tilkorn DJ, Citak M, Fehmer T, Ring A, Hauser J, Al Benna S, et al. Characteristics and differences in necrotizing fasciitis and gas forming myonecrosis: a series of 36 patients. Scand J Surg 2012;101:51-5. 16. Das DK, Baker MG, Venugopal K. Risk factors, microbiological findings and outcomes of necrotizing fasciitis in New Zealand: a retrospective chart review. BMC Infect Dis 2012;12:348. 17. Fernandes C, Dâmaso C, Duarte R, Cardoso DS, Casella P. Necrotizing fasciitis post-acute appendicitis. [Article in Portuguese] Acta Med Port 2011;24 Suppl 3:621-6. [Abstract] 18. Wiberg A, Carapeti E, Greig A. Necrotising fasciitis of the thigh secondary to colonic perforation: the femoral canal as a route for infective spread. J Plast Reconstr Aesthet Surg 2012;65:1731-3. 19. Kalaivani V, Hiremath BV, Indumathi VA. Necrotising soft tissue infection-risk factors for mortality. J Clin Diagn Res 2013;7:1662-5. 20. Elliott DC, Kufera JA, Myers RA. Necrotizing soft tissue infections. Risk factors for mortality and strategies for management. Ann Surg 1996;224:672-83. 21. Ozgenel GY, Akin S, Kahveci R, Ozbek S, Ozcan M. Clinical evaluation and treatment results of 30 patients with necrotizing fasciitis. Ulus Travma Acil Cerrahi Derg 2004;10:110-4. 22. Clayton MD, Fowler JE Jr, Sharifi R, Pearl RK. Causes, presentation and survival of fifty-seven patients with necrotizing fasciitis of the male genitalia. Surg Gynecol Obstet 1990;170:4955. 23. Francis KR, Lamaute HR, Davis JM, Pizzi WF. Implications of risk factors in necrotizing fasciitis. Am Surg 1993;59:304-8.

ORIGINAL ARTICLE

The Value of Ultrasonography, Leukocyte Count and Clinical Results in Diagnosis of Acute Appendicitis and the Duration of Stay of the Patients in Emergency Department Akut Apandisit Tanısında Ultrasonografi, Lökosit ve Klinik Sonuçların Değerliliği ve Hastaların Acil Serviste Kalış Süreleri Veysi ERYIGIT,1 Yasin MAHSANLAR,2 Yoldas DEMIRTAS,3 Ismet PARLAK4 Department of Emergency Medicine, Bingol State Hospital, Bingol; Department of Emergency Medicine, Batman State Hospital, Batman; 3 Department of Emergency Medicine, Kartal Dr. Lütfi Kırdar Training and Research Hospital, Istanbul; 4 Department of Emergency Medicine, Bozyaka Training and Research Hospital, Izmir 1

SUMMARY

ÖZET

Objectives In this study, we aimed to compare the clinical data of patients diagnosed with acute appendicitis in our center with the literature.

Amaç Bu çalışmada, akut apandisit tanılı hastalarımızla ilgili elde ettiğimiz verileri literatürle karşılaştırmayı amaçladık.

Methods The patients who were diagnosed with acute appendicitis between 01.10.2010 and 01.10.2011 in Emergency Department of İzmir Bozyaka Training and Research Hospital were included in this study. Patient demographics, dates and times of emergency department application, dates and times of hospitalization in the general surgery ward, duration of stay in the emergency department, leukocyte count and its relationship with age, the perforation rate, the relationship of perforation with age and leukocyte count, and the final diagnosis and ultrasound findings were assessed in this study.

Gereç ve Yöntem Çalışmamız İzmir Bozyaka Eğitim ve Araştırma Hastanesi Acil Tıp Kliniği’ne 01.10.2010-01.10.2011 tarihleri arasında başvuran ve akut apandisit tanısı almış olan hastaları kapsamaktadır. Çalışmamızda hastaların demografik özellikleri, acil servise başvuru tarih ve saatleri, genel cerrahi servisine yatış tarih ve saatleri, acil serviste kalış süreleri, lökosit değerleri ve yaş ile ilişkisi, perforasyon oranı ve perforasyonun yaş ve lökosit değerleri ile ilişkisi ve alınan tanı ile ultrasonografi bulguları incelendi.

Results A total of 482 patients who were diagnosed with acute appendicitis [300 (62.2%) male, mean age 30.7±12.03; 182 (37.8%) female, mean age 31.17±13.22)] were enrolled. The duration of stay in the emergency department was between 0-6 and 6-12 hours in 320 (66.4%) and 143 (29.7%) patients, respectively. The ultrasonography findings were consistent with acute appendicitis in 366 (75.9%) patients, and the mean leukocyte count of these patients was 13.141/mm3. 46 (9.5%) of the patients were diagnosed with perforated appendicitis. The ultrasonography findings were not consistent with acute appendicitis in 36 (7.5%) patients and the leukocyte counts were less than 11.000/mm3 in these patients.

Bulgular Apandisit tanısı alan 482 hastanın 300’ü (%62.2) erkek, 182’si (%37.8) kadındı. Erkeklerin yaş ortalaması 30.7±12.03 iken kadınların yaş ortalaması 31.17±13.22 idi. Akut apandisit tanısı alan 482 hasta incelendiğinde; bunların 320’si (%66.4) acil serviste 0-6 saat kalırken, 143’ü (%29.7) 6-12 saat kalmıştır. Akut apandisit tanılı 482 hastanın 366’sında (%75.9) ultrasonografi bulguları akut apandisit lehineydi ve bunların da lökosit ortalaması 13.141/mm3 idi. Akut apandisit tanısı alan 482 hastanın 46’sı (%9.5) perfore apandisit tanısı almıştır. Akut apandisit tanısı alan 482 hastanın lökosit ortalaması 13.044/mm3 bulunmuştur. Akut apandisit tanılı 482 hastanın 36’sında (%7.5) hem ultrasonografi bulguları akut apandisiti desteklememiştir ve hem de lökosit değerleri 11.000/mm3 altında çıkmıştır.

Conclusions According to the present study results, acute appendicitis is commonly seen among the young adult male population. The coherence of ultrasonography findings with the diagnosis and its association with leukocytosis is significant and supportive. Additionally, the ultrasonography findings, leukocytosis, medical history and physical examination are important and essential factors for the diagnosis of acute appendicitis. A large number of patients with acute appendicitis were followed-up between 0-6 hours in the emergency department.

Sonuç Akut apandisit olgularının daha sıklıkla genç erişkin erkek popülasyonunda görüldüğü sonucuna ulaşılmıştır. Ultrasonografi bulgularının tanı ile uyumu ve lökositoz birlikteliği akut apandisit için anlamlı ve destekleyici bulunmuştur. Lökosit seviyesi ve ultrasonografi bulgularının yanında; anamnez ve fizik muayenenin de önemli ve temel olduğu sonucuna varılmıştır. Akut apandisit tanılı hastaların büyük bir bölümü acil serviste 0-6 saat takip edilmiştir.

Key words: Acute appendicitis; emergency department; general surgery.

Anahtar sözcükler: Akut apandisit; acil servis; genel cerrahi.

Submitted: 18.11.2013 Accepted: 20.12.2013 Published online: 07.01.2014 Correspondence (İletişim): Dr. Veysi Eryiğit. Bingöl Devlet Hastanesi, Acil Servis Kliniği, Bingöl, Turkey. e-mail: veryigit@yahoo.com

Turk J Emerg Med 2014;14(1):20-24

doi: 10.5505/1304.7361.2014.59251

Eryiğit V et al.

The Value of Ultrasonography, Leukocyte Count and Clinical Results in Diagnosis of Acute Appendicitis

Introduction Acute appendicitis often presents with subtle symptoms and may be confused with other conditions. However, acute appendicitis is one of the most frequent causes of acute abdominal pain. Among all the emergent intra abdominal operations in the world, appendectomies are the most commonly performed.[1-4] The sensitivity of the combination of diagnostic testing, physical examination, and imaging studies in diagnosing acute appendicitis is quite high.[5-7] Even though these diagnostic studies are noninvasive, their accuracy has been overestimated in several studies.[4,8] Therefore, performing a thorough history and physical examination remain very important in diagnosing acute appendicitis.[3,9] Currently, there are no diagnostic tools that when used in isolation would lead to a definitive diagnosis of acute appendicitis.[10,11] Research is ongoing so to better identify acute appendicitis with laboratory testing that is noninvasive, cost-effective and practical. The duration of time from diagnosing acute appendicitis in the emergency department (ED) to the operating table has been reported often in the literature. Yet, the time taken to determine a diagnosis of acute appendicitis by an ED physician has not yet been published. In this study, our aim was to compare length of stay in the ED for patients with acute appendicitis, and we assessed these patients’ demographic characteristics, clinical outcomes, abdominal ultrasonography results, and leukocyte counts.

Materials and Methods Our study included patients who presented to the İzmir Bozyaka Training and Research Hospital Emergency Medicine Clinic between January 10, 2010 and January 10, 2011 that had histologically confirmed diagnoses of appendicitis. This was a retrospective chart review that was evaluated and approved by the educational board of the hospital (meeting No.: 343). Medical records for all patients that presented to the ED within the designated time frame were accessed. Data including patient demographics, date and time of ED presentation, ED length of stay, admission date and time to the general surgery service, leukocyte count, appendix perforation rate, and ultrasound (US) imaging were investi-

gated. Leukocyte count and appendix perforation rate and their relation with patient age were also analyzed. US imaging results were saved in the hospital database and all images were obtained preoperatively. Various radiologists read the US images as they work shifts that switch daily. The Digi Prince DP-9900 ultrasonography device was utilized for imaging. Total blood count was performed with the LH780 device (Beckman Coulter). A leukocyte count over 11.000/ mm3 was defined as leukocytosis. The normal reference leukocyte count in our hospital laboratory ranged between 4.300-10.300/mm3. Statistical analysis Data were recorded and analyzed with Microsoft Office Excel 2007 and SPSS version 15.0 (SPSS Inc, Chicago). Categorical data was described as the quantity “n” and percentages, whereas continuous data were expressed as the mean ± one standard deviation with the range (minimum value-maximum value). Pearson’s test and the chi-squared test were used to compare categorical data between groups, and the Kolmogorov-Smirnov test and Mann-Whitney U-test were used to compare groups of continuous variables that were not normally distributed.

Results Of the 482 patients that were diagnosed with acute appendicitis, 62.2% were male and the mean age of the entire study sample was 30.88±12.48 years. The average age of the male patients was 30.7±12.03 years, and the average age of the female patients was 31.17±13.22 years. Most of the patients were between 20-29 years-old, and 38% of the study subjects fell within this age range. The length of ED stay was 0-6 hours for 66.4% of the patients and the remaining 29.7% stayed in emergency department for 6-12 hours. The mean ED length of stay was 5.45±3.46 hours. The average length of stay in the ED for patients with a perforated appendix was 5.58±4.33 hours, whereas the mean length of stay for patients without a perforated appendix was 5.44±3.36 hours (p=0.992, Table 1). US examination results supported a diagnosis of acute appendicitis in 75.9% of patients. In 77.2% of patients, both

Table 1. The average lenght of ED stay of the patients according to the perforation status of appendix Perforation

Mean±SD (hour)

Min

Max

Yes

436 90.5 5.44±3.36

0.22

22.28 0.992

46 9.54 5.58±4.33

0.36

28.83

Total

482 100 5.45±3.46

0.22

28.83

Turk J Emerg Med 2014;14(1):20-24

Table 2. The distribution of patients diagnosed as acute appendicitis according to the leukocytosis and US imaging suggesting US

Leukocytosis

Total

X2 p

>11.000 <11.000 n %

n %

US (–)

22.8

27.5

116

24.1

US (+)

271

77.2

72.5

366

75.9

Total

351 72.8

131 27.2

1.148

0.284

482 100.0

Table 3. Age, gender and leukocyte count of the patients according to the perforation status of appendix

Perforated

Not perforated

Total

Male, n (%)

35 (11.7)

265 (88.3)

300 (62.2)

0.042

Female, n (%)

11 (6.0)

171 (94.0)

182 (37.8)

37.2±17.24

30.21±11.7

30.88±12.48

Gender

Age Mean±Standard deviation Minimum-Maximum

0.014

16-80 14-75 14-80

Leukocytosis Mean±Standard deviation Minimum-Maximum

15.147.83±3.619.56 12.822.71±3.811.09 13.044.61±3.850.81 0.001 9.400-28.000 4.100-27.100 4.100-28.000

leukocytosis and suggestive US findings supported a diagnosis of acute appendicitis, but 72.5% of patients did not have leukocytosis but still demonstrated US results suggesting this diagnosis. There was no significant difference in the number of patients that demonstrated leukocytosis versus those that did not with US imaging suggesting acute appendicitis (X2=1.148, p=0.284, Table 2). For 27.2% of the patients, they had leukocyte levels below 11,000/mm3, and the mean age of this group was 30.79±13.18 years. Of these patients, 42.7% were between 20-29 years-old. Out of all the patients in our study, 9.5% were diagnosed with perforated appendicitis and their mean age was 37.2±17.24 years. The average age of patients that did not sustain an appendix perforation was 30.21±11.7 years, which differed significantly from the mean age of patients with appendix perforations (p=0.014). On average, the entire patient population had leukocyte levels of 13.044±3.850/mm3. For patients that did not sustain a perforation, the mean leukocyte level was 12.822±3.811/mm3, and the average level for patients with an appendix perforation was significantly higher at 15.147±3.619/mm3 (p=0.001, Table 3).

Discussion Körner et al.[12] demonstrated that appendicitis is diagnosed more often between the 2nd and 4th decades of life, and we obtained similar results in this study. There were more males than females in our study population, which suggests that a diagnosis of acute appendicitis should be considered especially in young adult male patients presenting with abdominal pain. Approximately one third of our patients remained in the ED for 6 or more hours. However there is no literature regarding the recommended time to diagnose patients that present to the ED with abdominal pain. When considering the high patient turnover rate in the ED, it is imperative that the source of the abdominal pain is identified and treated as rapidly as possible. Our study suggests that diagnosing ED patients with acute appendicitis within a 6-hour time frame is reasonable. Dikicier et al.[13] emphasized that leukocytosis is relevant in diagnosing acute appendicitis. Our study also supported that patients with appendicitis frequently have concurrent

Eryiğit V et al.

The Value of Ultrasonography, Leukocyte Count and Clinical Results in Diagnosis of Acute Appendicitis

leukocytosis, which aids in making the correct diagnosis. A thorough physical examination in addition to the presence of leukocytosis are important diagnostic indicators of acute appendicitis in the literature.[14] The rate of appendix perforation in our study was less than what other studies have previously reported.[15] A study conducted by Ezer et al.[16] revealed that the mean age of patients was higher for those with perforated appendicitis when compared to patients without a perforation. They also identified that males sustained appendix perforations more commonly than females, which was also observed in our study. Leukocyte levels were significantly higher in patients with perforated appendicitis when compared to patients without perforated appendicitis. This finding was comparable to other reports in the literature.[2,9,17] These data suggest that higher than expected leukocytes levels may indicate an appendix perforation and confirmatory imaging techniques should be used in these patients. We also compared ED length of stay for patients with and without appendix perforations. For patients with perforated appendicitis, it was anticipated that the length of stay would be shorter, but we determined that the duration of time spent in the ED did not significantly differ with patients without a perforation. Possible reasons for this are patients are being diagnosed with perforations relatively late during their ED stay and due to delays in physician consultation. In this study, we investigated the correlation between leukocyte levels, US examination findings, and length of ED stay. US imaging supported the diagnosis of acute appendicitis in the majority of the patients, and leukocytosis was also observed in the majority of these patients as well. These data suggest that leukocytosis and US findings together are more meaningful in making a definitive diagnosis. However, patients with acute appendicitis may present without leukocytosis or US imaging that suggests this diagnosis. Hence, we strongly recommend that a thorough history and physical examination are performed so to further reinforce diagnostic decision-making.[14] Study limitations A standard method to read US imaging was not used in this study as multiple radiologists are employed by the hospital and work in shifts. Moreover, we could not statistically compare the physical examination findings for patients with acute appendicitis as the physical examination records for ED patients could not be retrieved. Conclusion We identified that acute appendicitis often occurs in young adult male patients. US imaging that suggest appendicitis

concurrent with leukocytosis are most indicative of a diagnosis of acute appendicitis. Leukocyte levels were significantly higher in patients with perforated appendicitis. One out of every ten acute appendicitis patients exhibited normal leukocytes levels and US findings. In conclusion, US imaging, leukocyte levels, history, and physical examination must all be performed so to diagnose acute appendicitis most effectively. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. Anderson KD, Parry RL. Appendicitis. In: O’Neill JA, Rowe MI, Grosfeld JL, Fonkalsrud EW, Coran AG, editors. Pediatric surgery. 5th ed. Missouri: Mosby-Year Book; 1998. p.1369-79. 2. Cev M, Bozfakioğlu Y. Apendiks hastalıkları. In: Değerli Ü, editor. Cerrahi gastroenteroloji. 2nd ed. İstanbul: Nobel Tıp Kitapevi; 1989. p. 258-73. 3. Flum DR, Koepsell T. The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. Arch Surg 2002;137:799-804. 4. Bachmann LM, Bischof DB, Bischofberger SA, Bonani MG, Osann FM, Steurer J. Systematic quantitative overviews of the literature to determine the value of diagnostic tests for predicting acute appendicitis: study protocol. BMC Surg 2002;2:2. 5. Walker S, Haun W, Clark J, McMillin K, Zeren F, Gilliland T. The value of limited computed tomography with rectal contrast in the diagnosis of acute appendicitis. Am J Surg 2000;180:450-5. 6. Barron B, Hanna C, Passalaqua AM, Lamki L, Wegener WA, Goldenberg DM. Rapid diagnostic imaging of acute, nonclassic appendicitis by leukoscintigraphy with sulesomab, a technetium 99m-labeled antigranulocyte antibody Fab’ fragment. LeukoScan Appendicitis Clinical Trial Group. Surgery 1999;125:288-96. 7. Rypins EB, Kipper SL, Weiland F, Neal C, Line B, McDonald R, et al. 99m Tc anti-CD 15 monoclonal antibody (LeuTech) imaging improves diagnostic accuracy and clinical management in patients with equivocal presentation of appendicitis. Ann Surg 2002;235:232-9. 8. Blomqvist PG, Andersson RE, Granath F, Lambe MP, Ekbom AR. Mortality after appendectomy in Sweden, 1987-1996. Ann Surg 2001;233:455-60. 9. Başaklar C. Çocuklarda travma ve akut karın. 1st ed. Ankara: Palme Yayıncılık; 1994. p. 217-25. 10. Ilkhanizadeh B, Owji AA, Tavangar SM, Vasei M, Tabei SM. Spot urine 5-hydroxy indole acetic acid and acute appendicitis. Hepatogastroenterology 2001;48:609-13. 11. Marc IR, O’Neill JA, Grosfeld JI, Fonkalsrud EW, Coran AG (editors). Essentials of pediatric surgery appendicitis. 1st ed. Missouri: Mosby; 1995.

Turk J Emerg Med 2014;14(1):20-24

12. Körner H, Söndenaa K, Söreide JA, Andersen E, Nysted A, Lende TH, et al. Incidence of acute nonperforated and perforated appendicitis: age-specific and sex-specific analysis. World J Surg 1997;21:313-7. 13. Dikicier E, Altıntoprak F, Çakmak G ve ark. Akut apandisit tanısında ultrasonografinin yeri. Sakarya MJ 2011;2:64-6. 14. Zielke A, Sitter H, Rampp T, Bohrer T, Rothmund M. Clinical decision-making, ultrasonography, and scores for evaluation

of suspected acute appendicitis. World J Surg 2001;25:578-84. 15. Malt RA. The perforated appendix. NEJM 1986;315:1546-7. 16. Ezer A, Törer N, Calışkan K, Colakoğlu T, Parlakgümüş A, Belli S, et al. Use of drainage in surgery for perforated appendicitis: the effect on complications. Ulus Travma Acil Cerrahi Derg 2010;16:427-32. 17. Tehrani HY, Petros JG, Kumar RR, Chu Q. Markers of severe appendicitis. Am Surg 1999;65:453-5.

ORIGINAL ARTICLE

Effect of End-Tidal Carbon Dioxide Measurement on Resuscitation Efficiency and Termination of Resuscitation End Tidal Karbonmonoksit Ölçümünün Resüsitasyon Etkinliği ve Sonlandırılması Üzerine Etkisi Faruk OZTURK,1 Ismet PARLAK,1 Sadiye YOLCU,2 Onder TOMRUK,3 Bulent ERDUR,4 Rifat KILICASLAN,1 Ali Savas MIRAN,1 Serhat AKAY1 Department of Emergency Medicine, Bozyaka Training and Research Hospital, İzmir; 2 Department of Emergency Medicine, Bozok University Faculty of Medicine, Yozgat; 3 Department of Emergency Medicine, Suleyman Demirel University Faculty of Medicine, Isparta; 4 Department of Emergency Medicine, Pamukkale University Faculty of Medicine, Denizli 1

SUMMARY

ÖZET

Objectives In this study, the value of end-tidal carbon dioxide (ETCO2) levels measured by capnometry were evaluated as indicators of resuscitation effectiveness and survival in patients presenting to the emergency department with cardiopulmonary arrest.

Amaç Çalışmamızda acil servise kardiyopulmoner arrest ile gelen hastalarda kapnometre ile ölçülen endtidal karbondioksit seviyelerinin uygulanan KPR’nin etkinliği ve hasta sağkalımının göstergesi olarak kullanılabileceğinin araştırılması amaçlandı.

Methods ETCO2 was measured after 2 minutes of compression or 150 compressions. ETCO2 values were measured in patients that were intubated and in those who underwent chest compression. The following parameters were recorded for each patient: demographic data, chronic illness, respiration type, pre-hospital CPR, arrest rhythm, arterial blood gas measurements, ETCO2 values with an interval of 5 minutes between the measurement and the estimated time of arrest, time to return to spontaneous circulation.

Gereç ve Yöntem Acil servisimize göğüs kompresyonuna başlanarak entübe edilen (acil ambulansla getirilmişse tüp kontrolü yapılan) ve gögüs kompresyonun ikinci dakikanın sonunda ya da 150 bası sonrası ilk ölçülen end-tidal karbondioksit (ETCO2) değeri 0. dakika ETCO2 olarak kabul edildi. Daha sonra beşer dakika ara ile ETCO2 değerleri kaydedildi. Hastaların demografik verileri, kronik hastalık varlığı, 112 ile gelmişse neyle solutulduğu, hastane öncesi KPR uygulanması, hasta arrest ritmi, kan gazı değerleri, tahmini arrest süresi ile hastanın spontan dolaşımın dönme süresini içeren parametreler kaydedildi.

Results Cardiac arrest developed in 97 cases, including 56 who were out of the hospital and 41 who were in the hospital. Fifty of these patients returned to spontaneous circulation, and just one of these had an initial ETCO2 value below 10 mmHg. The mean of the final ETCO2 levels was 36.4±4.46 among Patients who Return to Spontaneous Circulation (RSCPs) and 11.74±7.01 among those that died. In all rhythms; Asystole, pulseless electrical activity (PEA) and VF/VT; Overall, RSCPs had higher ETCO2 levels than the cases who died. Among the PEA patients undergoing in-hospital arrests and those asystolic patients undergoing out of hospital arrest, the ETCO2 values of the RSCPs were significantly higher than those of the cases who died.

Bulgular Çalışmaya alınan 97 olgunun 56’sı hastane dışı (HDKA), 41’i hastane içi gelişen arrest (HİKA) hastalardan oluşmaktaydı. Spontan dolaşıma geri dönen (SDGD) 50 olgudan sadece bir tanesinin ilk ETCO2 düzeyi 10 mmHg nın altında olarak ölçüldü. Son ETCO2 düzeyi ortalamaları SDGD’lerde 36.4±4.46, hayatını kaybedenlerde 11.74±7.01 olarak bulundu. Asistoli, NEA, VF/VT ritimlerinin tamamında SGDG olgularında ETCO2 düzeyleri exitus olanlardan yüksekti (p=0.001). Hastane içi nabızsız elektriksel aktivite (NEA) hastaların ve hastane dışı asistolik hastaların, SDGD olgularında ETCO2 değerleri eksitus olan olguların ETCO2 değerlerinden yüksekti.

Conclusions ETCO2 levels predicted survival as well as the effectiveness of CPR for patients who received CPR and were monitored by capnometry in the emergency department. As a result, we believe that it would be suitable to use capnometry in all units where the CPR is performed.

Sonuç Acil servislerde KPR uygulanan ve kapnometre ile izlenen hastalarda ETCO2 düzeyi sağ kalım, KPR’nin etkinliği ve devamı açısından yol göstericidir bu yüzden KPR uygulanan tüm birimlerde kapnometre kullanımının uygun olacağını düşünüyoruz.

Key words: Capnography; capnometry; cardiopulmonary arrest; resuscitation.

Anahtar sözcükler: Kardiopulmoner arrest; kapnometre; resüsitasyon.

Submitted: 13.11.2013 Accepted: 15.01.2014 Published online: 16.01.2014 Correspondence: Dr. Sadiye Yolcu. Bozok Üniversitesi Tıp Fakültesi, Acil Tıp Anabilim Dalı, Yozgat , Turkey. e-mail: sadiyeyolcu@yahoo.com

Turk J Emerg Med 2014;14(1):25-31

doi: 10.5505/1304.7361.2014.65807

Turk J Emerg Med 2014;14(1):25-31

Introduction Modern cardiopulmonary resuscitation (CPR) began with airway opening methods by Peter Safar in 1959 and external cardiac compression by William Kouwen hoven in 1960. However, resuscitation trials have been reported for several centuries.[1,2] Since modern resuscitation applications have been used, researchers have been studying ways to prevent cardiac arrest and have been working to develop effective resuscitation techniques. Capnometry is a method used to verify the accuracy of the endotracheal tube placement in cardiopulmonary arrest patients.[3] High end-tidal carbon dioxide (ETCO2) level measurements by capnometry may be important to successful resuscitations.[4-6] In this study, we aimed to investigate the effect of quantitative ETCO2 measurement with capnometry during CPR to determine the effectiveness of CPR and patient prognosis in cardiopulmonary arrest patients.

Materials and Methods After obtaining approval from the ethics committee and conforming to the provisions of the Declaration of Helsinki in 1995 (as revised in Seoul 2008), non-traumatic out-of hospital and in-hospital cardiopulmonary arrest patients over 18 years of age were enrolled in this cross-sectional study between February 1, 2012 and June 30, 2012. Resuscitations were performed according to the American Heart Association (AHA) Advanced Cardiac Life Support (ACLS) guidelines. ETCO2 levels were measured and the time of admission to the emergency department was noted as was the time of intubation. ETCO2 values were recorded after the 6th ventilation in patients who underwent cardiopulmonary arrest during the emergency service follow-up. ETCO2 levels were measured and noted in five minute intervals starting at the time of resuscitation. Resuscitation time was determined by the responsible doctor who managed the resuscitation. Patients who underwent a second cardiopulmonary arrest and were resuscitated were excluded from the study. The patients were divided into two groups: 1. Exitus patients (EP), and 2. Returned to spontaneous circulation patients (RSCP). Demographic data, chronic disease, ventilation method in the ambulance, out-of hospital CPR application, arrest rhythm, blood gases, ETCO2 levels recorded at intervals of five minutes, predicted arrest time period and return time of spontaneous circulation were recorded. Patients brought by ambulance who then underwent cardiac arrest in the emergency department were accepted as in-hospital cardiac arrest patients.

We used a standard capnography device (Medilab Cap 10) for ETCO2 measurements. SPSS 15.0 for Windows program was used for statistical evaluation. Chi-square test and Fisher’s exact test was used to compare data between groups. One Way Anova and independent sample t-tests were used for parametric variables. Kruskal Wallis and Mann Whitney U-tests were used to compare nonparametric variables. Results were considered statistically significant at p<0.05.

Results In our study, 37 (38.1%) of the 97 patients were female, and 60 (61.9%) were male. The mean age of the males was 66.75±13.84 years (min: 56, max: 89) and was 71.57±11.52 years (47-87) for females. The overall mean age of males and females combined was 68.59±13.15 years (26-89). The ages of the males and females were not significantly different (p>0.05). Forty-one (42.3%) patients were In-hospital cardiac arrest patients (IHCAP) and 56 (55.7%) were Out-hospital cardiac arrest patients (OHCAP). Twenty two (75%) of the in-hospital arrest patients died and 19 (72%) of them returned to spontaneous circulation. Twenty-five (66.64%) out-of hospital patients (OHCAP) died and 31 (63.55%) returned to spontaneous circulation. The mean ages of the patients who died and those who returned to spontaneous circulation were not significantly different (p>0.05). Survival due to ventilation techniques (Laryngeal Mask Airway, Bad Valve, Combitube, etc.) performed on patients in the ambulance before admission to the emergency department admission of the IHCAPs and OHCAPs were not significantly different (p>0.05). In our study ages of 72 (74.6%) patients were over 60 years of age. Seventy-one (73.2%) patients were brought to our emergency department by ambulance. There were no significant differences in the survival of the groups with regards to admission time, arrival by ambulance, location of cardiac arrest, and the diagnosis and presence of chronic disease (p>0.05). However, the survival of the patients with regards to arrest time period were significantly different (p<0.05). CPR application ratios were not significantly different between the groups in OHCAPs (p>0.05). Survival due to arrest rhythm (p<0.05) and arrest time period ratios (p<0.05) were significantly different between groups (p=0.001). Eightyone percent of asystole patients, 36% of pulseless electric activity (PEA) patients and 58% of the VF/VT patients died. The exitus cases’ arrest rhythms were 36.2% (n=17) asystole, 40.4% (n=19) PEA, and 23.4% (n=11) VF/VT. Of 50 RSCPs, 27

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Effect of End-Tidal Carbon Dioxide Measurement

(54%) returned to spontaneous circulation in the first 15 minutes, 37 (74%) in first 20 minutes and 45 (90%) in the first 30 minutes. The mean first ETCO2 measurement of RTSC patients was 18.6±9.13 and the mean final ETCO2 was 36.4±4.46. The mean first ETCO2 value of exitus patients was 15.91±8.35 and the mean final ETCO2 value was 11.74±7.06 mm/Hg. The difference between the first ETCO2 (18.6±9.13) and the last ETCO2 (36.4±4.46) levels were significantly different in RSCPs (p<0.05) and in EPs (p<0.05). The ETCO2 levels of RSCPs varied between 26-48 mmHg (mean: 36.4±4.46). Age (p<0.05) and 45th min ETCO2 levels (p<0.05) of IHCAPs were higher than those of the OHCAPs in the EP group. The mean age of the IHCAPs was 75.0±7.0 years (57-87) and this value was 66.64±14.56 years (26-87) for OHCAPs. In the RSCP group, age (p<0.05), and the first (p<0.05), 5th (p<0.05), 10th (p<0.05), and 20th (p<0.05) ETCO2 levels were significantly higher in IHCAPs than in OHCAPs (Table 1). There were significant differences between the EP and RSCP groups with regards to gender, admission time, arrest rhythm, chronic disease and ventilation technique in the ambulance according to arrest place (in hospital/out-of hospital) (Table 2). ETCO2 levels of the RSCP group ranged between 26-48 mmHg (36.4±4.46), and this level for the EP group was 2-23 mmHg (11.74±7.01). The final ETCO2 level was related with survival (p<0.05). In the asystole patients, the 15th, 20th, and 25th min ETCO2 (p=0.009, p=0.028, p=0.033) levels were higher in RSCPs

than in EPs. In PEA patients, the 10th, 15th, 20th, and 30th min ETCO2 values (p=0.002, p=0.001, p=0.002, p=0.005) were higher in RSCPs than EPs, and in VF/VT patients, the 15th and 30th min ETCO2 values (p=0.044, p=0.038) were higher in RSCPs than in EPs (Table 3). In the IHCAPs, the PEA patients’ first, 5th, 10th, 15th, 20th and 30th min ETCO2 levels (p=0.034, p=0.014, p=0.001, p=0.001, p=0.002, p=0.013) were higher in RSCPs than EPs (Table 4). In the OHCAPs, the asystolic patients’ 15th, 20th and 25th min ETCO2 levels (p=0.011, p=0.033, p=0.038) were higher in RSCPs than in EPs (Table 5). The 5th, 10th, 15th, 20th, 25th, 30th, 35th, 40th and 45th min ETCO2 levels (p=0.001, p=0.001, p=0.001, p=0.001, p=0.001, p=0.001, p=0.003, p=0.001, p=0.030) of EPs were lower than those of the RSCPs. The mean final ETCO2 level of RSCPs was 36.4±4.46 mmHg.

Discussion Cardiopulmonary arrest cases are common in the emergency department and should be attended to immediately. Cardiopulmonary arrest can result in death without rapid and effective intervention.[7] Survival decreases 6-7% per minute in patients that did not undergo chest compression.[8,9] The IHCAPs’ rate of return to spontaneous circulation is high because they are diagnosed early. However, most of these patients are elderly so mortality does not decrease.[10] In our study, 56 (58%) of 97 cases were OHCAPs. Survival is related with pre-hospital factors in OHCAPs.[11-13] These factors include arrival time, basic life support education of the general public and medical service personnel,

Table 1. Age and ETCO2 level distributions of RSCPs and EPs according to place of arrest

Arrest place

Total

In-hospital Out-of-hospital Mean±SD Min. Max.

Mean±SD Min. Max.

66.64±14.56 26 87

70.55±12.28 26 87

EPs Age

75.0±7.0 57 87

ETCO2 45 min

22.5±6.36

9.25±4.5

11.9±7.17

0.038 0.044

RSCPs Age

71.95±12.4 47 89

63.55±13.81 39 86

66.74±13.79 39 89

0.047 0.001

5 36 ETCO2 0 min 24.47±8.79

15±7.38 3 35

18.6±9.13 3 36

ETCO2 5 min 25.84±7 6 35

19.13±5.89 7 35

21.68±7.08 6 35

0.001

18 44 ETCO2 10 min 30.17±8.33

23.57±7.86 13 48

26.04±8.58 13 48

0.011

20 43 ETCO2 20 min 33.88±8.64

25±7.57 14 36

28.09±8.88 14 43

0.023

Turk J Emerg Med 2014;14(1):25-31

Table 2. Gender, arrival time, arrest rhythm and chronic disease ratio distribution of RSCPs and EPs according to place of arrest

Arrest place

EPs Gender Female Male Arrival time 00:01-04:00 04:01-08:00 08:01-12:00 12:01-16:00 16:01-20:00 20:01-24:00 Arrest rthyhm Asystole NEA VF/VT Arrest time period 0 min 0-5 min 6-10 min 11-15 min 16-20 min Chronic disease No Yes RSCPs Gender Female Male Arrival time 00:01-04:00 04:01-08:00 08:01-12:00 12:01-16:00 16:01-20:00 20:01-24:00 Arrest rthyhm Asistoli NEA VF/VT Arrest time period 0 min 0-5 min 6-10 min 11-15 min 16-20 min Chronic disease No Yes

Total

In-hospital Ou-of-hospital n

8 14

47.1 46.7

9 16

52.9 53.3

17 30

36.2 63.8

0.979

2 1 9 4 4 2

28.6 25.0 69.2 44.4 44.4 40.0

5 3 4 5 5 3

71.4 75.0 30.8 55.6 55.6 60.0

7 4 13 9 9 5

14.9 8.5 27.7 19.1 19.1 10.6

0.486

1 18 3

5.9 94.7 27.3

16 1 8

94.1 5.3 72.7

17 19 11

36.2 40.4 23.4

0.001

22 0 0 0 0

100.0 0.0 0.0 0.0 0.0

0 2 7 13 3

0.0 100.0 100.0 100.0 100.0

22 2 7 13 3

46.8 4.3 14.9 27.7 6.4

0.001

7 15

43.8 48.4

9 16

56.3 51.6

16 31

34.0 66.0

0.763

8 11

40.0 36.7

12 19

60.0 63.3

20 30

40.0 60.0

0.812

1 1 2 4 5 6

16.7 20.0 33.3 40.0 50.0 46.2

5 4 4 6 5 7

83.3 80.0 66.7 60.0 50.0 53.8

6 5 6 10 10 13

12.0 10.0 12.0 20.0 20.0 26.0

0.716

0 18 1

0.0 52.9 8.3

4 16 11

100.0 47.1 91.7

4 34 12

8.0 68.0 24.0

0.006

18 1 0 0 0

100.0 6.3 0.0 0.0 0.0

0 15 10 4 2

0.0 93.8 100.0 100.0 100.0

18 16 10 4 2

36.0 32.0 20.0 8.0 4.0

0.001

5 14

35.7 38.9

9 22

64.3 61.1

14 36

28.0 72.0

0.836

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Effect of End-Tidal Carbon Dioxide Measurement

Table 3. ETCO2 levels of arrest rthyms’ according to survival

EPs

RSCPs

Total

n Mean±SD

Arrest rthyhm = Asystole

15 min

12.82±7.64

23.75±4.57

14.9±8.32

0.009

20 min

12.12±8.08

25.67±7.02

14.15±9.21

0.028

25 min

10.36±5.92

31±16.97

12.94±9.96

0.033

Arrest rthyhm = PEA 10 min

19 16.84±8.29

33 26.39±9.18

52 22.9±9.94

0.002

15 min

19 16.84±7.75

25 27.28±8.87

44 22.77±9.82

0.001

20 min

19 16.58±8.66

16 29.31±9.56

35 22.4±11.02

0.002

Arrest rthyhm = VF/VT

15 min

18.45±6.36

28.29±9.76

22.28±9.04

0.044

30 min

13.45±6.67

29.33±9.07

16.86±9.62

0.038

Table 4. ETCO2 levels of arrest rthyms’ in IHCAPs according to survival

EPs

RSCPs

Total

n Mean±SD Min. Max. n Mean±SD Min. Max.

n Mean±SD Min. Max.

18 18.56±8.1 5

36 21.39±8.9 5 36 0.034

Arrest rthyhm = PEA 0 min

34 18 24.22±8.974 5 36

5 min

18 18.56±8.09 5

30 18 25.39±6.912 6 35

36 21.97±8.19 5 35 0.014

10 min

18 17.56±7.91

17 30.12±8.587

35 23.66±10.32

0.001

15 min

30 22.67±9.54

0.001

12 30.42±6.788

20 min

18 17.28±8.34 5

17.5±7.41

7 34.43±9.181 20 43

25 22.08±11.5 5 43 0.002

30 min

16 17.31±7.64 4

2 35±1.414 34 36

18 19.28±9.18 4 36 0.013

Table 5. ETCO2 levels of arrest rthyms’ in OHCAPs according to survival

EPs

RSCPs

Total

n Mean±SD Min. Max. n Mean±SD Min. Max.

n Mean±SD Min. Max.

16 13.31±7.61

Arrest rthyhm = Asystole

20 min

15 min

16 12.69±7.98 2

3 25.67±7.024 19 33

19 14.74±9.07 2 33 0.033

13 10.85±5.86

15 13.53±10.01

25 min

3 2

presence of resuscitation centers, and the presence of automatic external defibrillator in public places. The duration between the time of cardiac arrest and alerting the emergency medical service is the first step of survival,

23.75±4.573 31±16.971

19 19

30 43

15.4±8.21

3 2

30 43

0.011 0.038

and is directly related to the long term prognosis of cardiac arrest patients. One study reported that survival significantly decreased if the emergency service was not called within 6 minutes in OHCAPs.[14] In our study, there was a significant difference between survival ratios of the groups according

Turk J Emerg Med 2014;14(1):25-31

to the period between arrest and the call to emergency services. In the meta-analysis by Sasson et al, although 53% (n=75.800) of 143.000 cases were reported as witnessed arrest cases, only 32% (n=24.250) of the cases were resuscitated at the arrest place by a rescuer.[15] In our study, 13 cases who were not brought to the hospital in an ambulance did not undergo cardiopulmonary resuscitation before arrival. Survival has been reported to be less than 5% in OHCAPs.[16] In our hospital, survival was 32% (n=31) in OHCAPs. In OHCAPs, low survival is related with the presence of asystole and PEA as the first rhythm.[16,17] In our study, there was no significant difference between the RSCP and EP groups according to arrest rhythm and arrest time period in IHCAPs. However, there was a significant difference between these groups in OHCAPs. In OHCAPs, 80% of asystolic patients died, while 94.1% of PEA patients and 57.9% of VF/VT patients returned to spontaneous circulation. Similar to the study by Takei et al.,[14] we also found a relationship between arrest time period and survival. Return to spontaneous circulation rate decreases and exitus ratio increases with a longer arrest time period. Mortality was high in asystole and PEA. In our study, 27 (54%) of 50 cases returned to spontaneous circulation within the first 15 mins, 37 (74%) returned in the first 20 mins, and 45 (90%) patients returned in the first 30 mins. The return to spontaneous circulation ratio decreased with longer cardiopulmonary resuscitation times. Hodgetts et al reported that survival of IHCAPs was high.[18] The presence of a chronic disease negatively effects survival, and the best chances at survival are provided with early defibrillation.[19] In our study, when we considered the arrest places of the EPs, age and 45th min ETCO2 levels of IHCAPs were significantly higher than those of OHCAPs. In RSCPs, the first, 5th, 10th and 20th min ETCO2 levels of IHCAPs were higher than those of OHCAPs. Similar to the literature, in our study, the ETCO2 level of RSCPs varied between 26-48 mmHg (36.4Âą4.46).[20] A sudden increase in ETCO2 indicates the return to spontaneous circulation.[4-6] White reported that rhythm changes and ETCO2 levels can be used as an early indication of pulmonary perfusion even in pulseless cases, but only in OHCAPs. [21] Also, a relationship between coronary perfusion pressure and ETCO2 has been reported.[22,23] If ETCO2 remains under 10 mmHg for a long time during CPR, it is quite likely that a return to spontaneous circulation will not occur.[24-28] One study reported that just one case survived whose ETCO2 level remained under 10 mmHg.[29] In our study, just one of

the RSCPsâ&#x20AC;&#x2122; ETCO2 levels was under 5 mmHg. Similar to the literature, we found a relationship between final ETCO2 level and survival. Heradstveit et al reported significant differences between RSCPs and ETCO2 in all asystole, PEA, and VF/VT rhythms.[30] When we grouped cases according to arrest rhythms, the 15th, 20th, and 25th min ETCO2 levels of asystole patients, the 10th, 15th, 20th, and 30th min ETCO2 levels of PEA patients, and the 15th and 30th min ETCO2 levels of VF/VT patients were higher in RSCPs than in EPs. When we considered the IHCAPs according to arrest rhythm, the first, 5th, 10th, 15th, 20th and 30th min ETCO2 levels of PEA patients were higher in RSCPs than in EPs. In OHCAPs, the 15th, 20th and 25th min ETCO2 levels of asystole patients were higher in RSCPs than in EPs. Conclusion As suggested in the guidelines, ETCO2 follow-up of the cardiopulmonary arrest patients with capnography would be helpful in the continuation of CPR and in predicting the survival of the patient. Capnography use is suitable in emergency services and in ambulances. Limitations Patients were excluded if they underwent a second cardiopulmonary arrest, and this limited our study, as we could not determine the effectiveness of ETCO2 measurements in these patients. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. Safar P, Escarraga LA, Chang F. Upper airway obstruction in the unconscious patient. J Appl Physiol 1959;14:760-4. 2. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA 1960;173:1064-7. 3. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 6: advanced cardiovascular life support: section 1: Introduction to ACLS 2000: overview of recommended changes in ACLS from the guidelines 2000 conference. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Circulation 2000;102(8 Suppl):186-9. 4. Entholzner E, Felber A, Mielke L, Hargasser S, Breinbauer B, von Hundelshausen B, et al. The determination of end-expiratory CO2 during resuscitation. Experience and results with the Normocap 200 (Fa. Datex) in preclinical resuscitation conditions. [Article in German] Anasthesiol Intensivmed Notfallmed Schmerzther 1992;27:473-6. [Abstract]

Öztürk F et al.

Effect of End-Tidal Carbon Dioxide Measurement

5. Garnett AR, Ornato JP, Gonzalez ER, Johnson EB. End-tidal carbon dioxide monitoring during cardiopulmonary resuscitation. JAMA 1987;257:512-5. 6. Bhende MS, Karasic DG, Karasic RB. End-tidal carbon dioxide changes during cardiopulmonary resuscitation after experimental asphyxial cardiac arrest. Am J Emerg Med 1996;14:349-50. 7. Walker WM. Dying, sudden cardiac death and resuscitation technology. Int Emerg Nurs 2008;16:119-26. 8. Srinivasan V, Nadkarni VM, Helfaer MA, Carey SM, Berg RA; American Heart Association National Registry of Cardiopulmonary Resuscitation Investigators. Childhood obesity and survival after in-hospital pediatric cardiopulmonary resuscitation. Pediatrics 2010;125:e481-8. 9. Jain R, Nallamothu BK, Chan PS; American Heart Association National Registry of Cardiopulmonary Resuscitation (NRCPR) investigators. Body mass index and survival after in-hospital cardiac arrest. Circ Cardiovasc Qual Outcomes 2010;3:490-7. 10. Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 1990;98:1388-92. 11. Hollenberg J, Lindqvist J, Ringh M, Engdahl J, Bohm K, Rosenqvist M, et al. An evaluation of post-resuscitation care as a possible explanation of a difference in survival after out-ofhospital cardiac arrest. Resuscitation 2007;74:242-52. 12. Herlitz J, Ekström L, Axelsson A, Bång A, Wennerblom B, Waagstein L, et al. Continuation of CPR on admission to emergency department after out-of-hospital cardiac arrest. Occurrence, characteristics and outcome. Resuscitation 1997;33:223-31. 13. van der Hoeven JG, Waanders H, Compier EA, van der Weyden PK, Meinders AE. Prolonged resuscitation efforts for cardiac arrest patients who cannot be resuscitated at the scene: who is likely to benefit? Ann Emerg Med 1993;22:1659-63. 14. Takei Y, Inaba H, Yachida T, Enami M, Goto Y, Ohta K. Analysis of reasons for emergency call delays in Japan in relation to location: high incidence of correctable causes and the impact of delays on patient outcomes. Resuscitation 2010;81:1492-8. 15. Sasson C, Rogers MA, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010;3:6381. 16. Bunch TJ, Hammill SC, White RD. Outcomes after ventricular fibrillation out-of-hospital cardiac arrest: expanding the chain of survival. Mayo Clin Proc 2005;80:774-82. 17. Weisfeldt ML, Everson-Stewart S, Sitlani C, Rea T, Aufderheide TP, Atkins DL, et al. Ventricular tachyarrhythmias after cardiac

arrest in public versus at home. N Engl J Med 2011;364:31321. 18. Hodgetts TJ, Kenward G, Vlachonikolis IG, Payne S, Castle N. The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team. Resuscitation 2002;54:125-31. 19. Peberdy MA, Kaye W, Ornato JP, Larkin GL, Nadkarni V, Mancini ME, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003;58:297-308. 20. Morgan GE, Mikhail MS. Clinical anesthesiology. 1st ed. Norwalk: Appleton & Lange; 1992. p. 90-2. 21. White RD, Asplin BR. Out-of-hospital quantitative monitoring of end-tidal carbon dioxide pressure during CPR. Ann Emerg Med 1994;23:25-30. 22. Lewis LM, Stothert J, Standeven J, Chandel B, Kurtz M, Fortney J. Correlation of end-tidal CO2 to cerebral perfusion during CPR. Ann Emerg Med 1992;21:1131-4. 23. Sanders AB, Atlas M, Ewy GA, Kern KB, Bragg S. Expired PCO2 as an index of coronary perfusion pressure. Am J Emerg Med 1985;3:147-9. 24. Grmec S, Kupnik D. Does the Mainz Emergency Evaluation Scoring (MEES) in combination with capnometry (MEESc) help in the prognosis of outcome from cardiopulmonary resuscitation in a prehospital setting? Resuscitation 2003;58:8996. 25. Callaham M, Barton C. Prediction of outcome of cardiopulmonary resuscitation from end-tidal carbon dioxide concentration. Crit Care Med 1990;18:358-62. 26. Grmec S, Klemen P. Does the end-tidal carbon dioxide (EtCO2) concentration have prognostic value during out-of-hospital cardiac arrest? Eur J Emerg Med 2001;8:263-9. 27. Levine RL, Wayne MA, Miller CC. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. N Engl J Med 1997;337:301-6. 28. Wayne MA, Levine RL, Miller CC. Use of end-tidal carbon dioxide to predict outcome in prehospital cardiac arrest. Ann Emerg Med 1995;25:762-7. 29. Ahrens T, Schallom L, Bettorf K, Ellner S, Hurt G, O’Mara V, et al. End-tidal carbon dioxide measurements as a prognostic indicator of outcome in cardiac arrest. Am J Crit Care 2001;10:3918. 30. Heradstveit BE, Sunde K, Sunde GA, Wentzel-Larsen T, Heltne JK. Factors complicating interpretation of capnography during advanced life support in cardiac arrest-a clinical retrospective study in 575 patients. Resuscitation 2012;83:813-8.

VISUAL DIAGNOSIS

[see page 1]

DIAGNOSIS: Chance Fracture A chance fracture, a type of fracture caused by a flexion distraction mechanism,[1] was identified. Missing chance fractures in a multiple trauma patient can cause future complications, such as kyphosis or pain. [2] Chance fractures are typically caused by seatbelts during car crashes.[1] If a fracture has been caused by a seatbelt, a contusion over the trunk may be present which can alert the physician to the possibility of a chance fracture.[3]

middle vertebra with anterior wedging. Due to the severe fracture, instability, and the probability of neurological consequences, operative management and internal fixation were performed without any complications. Conclusion

Severity and the probability of neurological consequences are the factors which determine the importance of considering surgical management for a Chance fractures extend horizontally from the tip of diagnosed chance fracture. the transverse process on one side through the pedicles and laminae to the tip of the opposite transverse References process. The fracture may involve the posterior part 1. Bernstein MP, Mirvis SE, Shanmuganathan K. Chancetype fractures of the thoracolumbar spine: imagof the vertebral body. However, involvement of the ing analysis in 53 patients. AJR Am J Roentgenol anterior part of the vertebral body is not common, 2006;187:859-68. and chance fractures with anterior involvement are usually not very severe.[4] In cases of fractures with 2. Schoenfeld AJ, Wood KB, Fisher CF, Fehlings M, Oner FC, Bouchard K, et al. Posttraumatic kyphosis: current flexion-distraction mechanisms, patients should be state of diagnosis and treatment: results of a multina[1,3,4] examined for intraabdominal injuries. tional survey of spine trauma surgeons. J Spinal Disord Tech 2010;23:1-8.

Chance-type fractures are unstable injuries that pres3. Banerjee A. Seat belts and injury patterns: evoluent without neurological deficit and may have subtle tion and present perspectives. Postgrad Med J radiographic signs.[1] CT can help in diagnosing ver1989;65:199-204. tebral column damage and identifying patients with 4. Greenbaum E, Harris L, Halloran WX. Flexion fracture risk of acute neurologic compromise.[1] The most of the lumbar spine due to lap-type seat belts. Calif commonly used treatment for chance fracture is Med 1970;113:74-6. closed management; however, open surgery has also 5. Yi L, Jingping B, Gele J, Baoleri X, Taixiang W. Operative been reported.[5] versus non-operative treatment for thoracolumbar In our case, we observed failure of the posterior and (a)

burst fractures without neurological deficit. Cochrane Database Syst Rev 2006;4:CD005079. (b)

(c)

Figure 1. (a) A thoracic wedge fracture of the T12 vertebra. (b, c) CT images of the fracture in three columns.

Turk J Emerg Med 2014;14(1):1 [32]

doi: 10.5505/1304.7361.2014.10327

VISUAL DIAGNOSIS [see page 2]

DIAGNOSIS: Fracture of the Proximal Part of 5th Metatarsal with a Normal Apophysis Of all metatarsal fractures, 45% are 5th metatarsal bone fractures. Fifth metatarsal bone fractures are observed most often in the proximal portion of the bone.[1] Foot Fractures are usually caused by extreme inversion or direct trauma. Physicians must be aware of the structure of 5th metatarsal bone in adolescents. On foot X-rays, the apophysial plate is observed on the tuberosity of 5th metatarsal bone during the ages of 9-14 years. The apophysis is parallel to the metatarsal bone shaft and is physically separate from the metatarsal bone. The apophysis of the metatarsal bone may be mistaken for a fracture in adolescents that are being evaluated for foot pain (Figure 2). It may take up to 19 years of age for the apophysis to become firmly attached to the 5th metatarsal bone.[2]

part of the 5th metatarsal bone may compromise the localized blood supply and may result in fracture malunion. A splint may be used for 4-6 weeks to allow the fracture to heal.[3] However, if a collapse of more than two millimeters is observed, then surgery is necessary to correct the defect. Missing a diagnosis of a 5th metatarsal bone fracture may cause permanent impairments in ambulation. Thus, the 5th metatarsal bone must be carefully examined on foot X-rays so to avoid overlooking a fracture in this location. References 1. Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int 2006;27:172-4.

2. Herrera-Soto JA, Scherb M, Duffy MF, Albright JC. Fractures of the fifth metatarsal in children and adolesThe tendon of the peroneus brevis attaches to the cents. J Pediatr Orthop 2007;27:427-31.

apophysis, making this structure especially important. 3. Malanga GA, Ramirez-Del Toro JA. Common injuries of This tendon contains vessels and nerves that supply the foot and ankle in the child and adolescent athlete. the 5th metatarsal bone. A fracture of the proximal Phys Med Rehabil Clin N Am 2008;19:347-71.

(a)

* (b)

(c) Figure 1. Foot X-ray of a 10 year-old male patient (white Figure 2. (a) Lateral X-ray of the patient. (b) Red line (*) denotes a fracture in the proximal part of the 5th metatarsal arrow indicates fracture). bone. Blue line (#) indicates a normal apophysis. (c) Normal 5th metatarsal bone in an adolescent. (Note that there are no fractures in the proximal portion of the bone and the apophysis line is normal). Turk J Emerg Med 2014;14(1):2 [33]

doi: 10.5505/1304.7361.2014.82612

CASE REPORT

Hemlock (Conium Maculatum) Poisoning In A Child Bir Çocuk Hastada Baldıran Otu (Conium Maculatum) Zehirlenmesi Capan KONCA,1 Zelal KAHRAMANER,1 Mehmet BOSNAK,2 Halil KOCAMAZ3 Department of Pediatrics, Adiyaman University Faculty of Medicine, Adiyaman; Department of Pediatrics, Gaziantep University Faculty of Medicine, Gaziantep; 3 Department of Pediatrics, Gaziantep Children Health and Diseases Hospital, Gaziantep 1

SUMMARY

ÖZET

Poison hemlock (Conium maculatum) is a plant that is poisonous for humans and animals. Accidental ingestion of the plant may result in central nervous system depression, respiratory failure, acute rhabdomyolysis, acute renal failure and even death. The main treatment of hemlock poisoning is supportive care. The case of a 6-year-old girl who was admitted to the emergency department with complaints of burning sensation in mouth, hypersalivation, tremor in hands and ataxia after ingestion of poison hemlock is presented here with clinical and laboratory features. In this case, we aim to report that accidental ingestion of plants resembling vegetables that are consumed daily can lead to serious complications and even death.

Baldıran otu (Conium maculatum) insanlar ve hayvanlar için zehirli bir bitkidir. Yanlışlıkla alımı sonucu merkezi sinir sistemi depresyonu, solunum yetersizliği, akut rabdomiyoliz, akut böbrek yetersizliği ve hatta ölüm meydana gelebilir. Conium maculatum zehirlenmesinde tedavi destekleyicidir. Baldıran otu alımı sonrası ağızda yanma, tükürük salgısında artış, ellerde titreme ve yürürken dengesizlik şikâyetleri ile acil servise başvuran 6 yaşında kız çocuğu klinik ve laboratuvar özellikleri ile sunuldu. Bu olgu, çevredeki bazı bitkilerin günlük tüketilen sebzelere benzerliği nedeni ile yanlışlıkla alımları sonucu ciddi zehirlenme belirtileri ve hatta ölüme neden olabileceğini vurgulamak amacı ile sunuldu.

Key words: Conium maculatum; childhood; poisoning; hemlock.

Anahtar sözcükler: Conium maculatum; çocukluk çağı; zehirlenme.

Introduction Poisonings are commonly seen during childhood and are associated with a high mortality rate. The vast majority of poisonings in children are due to taking medications; however, they may rarely be caused by petroleum products, caustic substances, and weeds. Conium maculatum, known popularly as hemlock in our country, is a poisonous plant belonging to the family Apiaceae, which grows in grasslands in damp places. Conium maculatum is poisonous not only for humans, but also for cattle, sheep, goats, pigs, rabbits, deer, poultry, and insects.[1] Poisoning in humans can be caused

by ingestion of the plant, but may also be caused by ingestion of meat from the aforementioned animals.[2] Piperidine alkaloids, such as coniine and γ-coniceine, contained within the plant play an important role in the development of poisoning.[2,3] Coniine is an alkaloid which is neurotoxic for humans and which causes death via respiratory paralysis. Famous philosopher Socrates died from hemlock poisoning in 399 BC.[3] We present the case of a six-year-old female patient who was referred to our clinic with symptoms of hypersalivation and

Submitted: 24.03.2013 Accepted: 18.04.2013 Published online: 18.07.2013 Correspondence: Dr. Çapan Konca. Adıyaman Üniversitesi Tıp Fakültesi, Çocuk Sağlığı ve Hastalıkları Anabilim Dalı Adıyaman, Turkey. e-mai: dr.capan@hotmail.com

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doi: 10.5505/1304.7361.2013.23500

Konca Ă&#x2021; et al.

Hemlock (Conium Maculatum) Poisoning In A Child

ataxia due to ingestion of hemlock. The hemlock was mistaken for parsley and consumed. The aim of this report was to emphasize that accidental ingestion of some plants in our environment which closely resemble edible vegetables may produce serious signs of poisoning and even lead to death.

Case Report In this report, we present the case of a six-year-old female patient. She ingested a weed found in a garden assuming it was parsley. Two hours later, she was referred to our emergency service due to complaints of burning in the mouth, increased salivation, trembling hands, and walking imbalance. Gastric lavage was performed, and activated carbon was administered in our emergency department. She was then hospitalized in the intensive care unit. The plant, which the family brought with her, was sent to the Faculty of Science, Department of Biology and was identified as Conium maculatum, known popularly as hemlock. In her first physical examination, she was fully conscious but agitated, and cooperation could not be established. The increased amount of saliva was too much for her to swallow. The patientâ&#x20AC;&#x2122;s vitals were as follows: arterial blood pressure, 105/65 mmHg; heart rate, 125/min; pulse, filiform; and peripheral oxygen saturation (SpO2), 97%. Her neurological examination revealed a tremor in both hands, loss of motor function in both lower limbs (4/5), limitations in the movement of tongue, ataxia, dilation in both pupils, and decreased response to light. The patient was monitored, intravenous (IV) crystalloid infusion was started, and emergent laboratory tests were studied immediately. Complete blood count, arterial blood gases, and biochemical tests did not reveal any pathologies. The results of the first coagulation tests were PTT, 20 seconds; INR, 2; and APTT, 50 seconds. Control coagulation test results were as follows: PTT, 25 seconds; INR, 2.3; and APTT, 54 seconds. Thus, a unit of fresh frozen plasma was administered to the patient. After transfusion, her coagulation test results were normal. Her ECG revealed no abnormalities except sinus tachycardia. Secretion crackles were observed during auscultation in both lungs, however, her chest radiography revealed no abnormalities. Repeated laboratory tests demonstrated no deterioration, and the patient did not develop respiratory distress. The tremor in her hands recovered after 6-8 hours, and the increased salivation diminished after 1214 hours. Limitations in tongue movement disappeared on the second day, and she started talking again. Difficulty in walking and ataxia disappeared. The symptoms which she presented at admission disappeared completely, her physical examination findings became normal, and she was discharged from the hospital three days after admission with full recovery.

Figure 1. Conium maculatum plant that the family brought with the patient.

Discussion Conium maculatum poisoning occurs due to some of its piperidine alkaloid contents which have nicotinic effects, such as coniceine, coniine, N-methyl coniine, conhydrine, and pseudoconhydrine. While every part of the plant is toxic, the highest alkaloid concentration exists in the seeds.[4] Ataxia and headache are the symptoms observed in the early stage of poisoning. Increased salivation, tachycardia, and pupillary dilation develop due to the effects of the plant on the autonomic ganglia. Muscle weakness or paralysis, bradycardia, and central nervous system depression may develop in some of the patients due to increased cholinergic stimuli.[5] Rhabdomyolysis and acute renal failure have also been reported in some cases as a consequence of Conium maculatum poisoning.[6] Each of these piperidine alkaloids is a kind of peripheral neurotoxin; the neurotoxins show curare-like effects in neuromuscular junctions and create nicotinic effects in the autonomic ganglia.[7] A previous report of two patients who were poisoned by accidental ingestion of the plant demonstrated that early stage symptoms recovered with symptomatic treatment.[8] However, two additional studies conducted in our country observed that respiratory depression developed immediately after early stage symptoms, and patients required mechanical ventilation.[9,10] In the present study, nicotinic symptoms, such as hand tremors, difficulty in walking, ataxia, and

Turk J Emerg Med 2014;14(1):34-36

excessive salivation were observed on admission. However, our patient did not develop acute kidney failure, rhabdomyolysis, or respiratory failure. Our patient exhibited prolonged coagulation tests, which have not been previously reported in the literature. This abnormality, observed in the early stage, may have developed due to the deterioration of factors in the intrinsic and extrinsic coagulation cascade or in the common pathway coagulation cascade. We did not have the opportunity to measure the patient’s blood factor levels and, therefore, could not reach a definitive conclusion. However, careful examination of coagulation tests in similar future cases may be useful. No specific antidote exists for the treatment of this toxin. Therefore, symptomatic treatment is the main treatment. Basic life support should be provided, followed by the administration of gastric lavage and activated carbon to reduce absorption. Fluid supplements should be administered to the patient via an intravenous access. Benzodiazepines or barbiturates should be used in the treatment if convulsions develop. Fluid supplementation and urine alkalinization should be provided in case of rhabdomyolysis or myoglobinuria. Hemodialysis and hemoperfusion are not reported to be useful in the treatment of rhabdomyolysis.[11] Close electrolyte and biochemical examinations and monitoring should be performed during intensive care unit follow-up. Death occurs mainly due to respiratory failure and paralysis of the respiratory muscles, thus continuous respiration should be ensured and mechanical ventilation support should be provided if necessary. Some previous studies in the literature have reported that children and adult patients required mechanical ventilation support after hemlock poisoning.[9,10,12] Our patient recovered completely without sequelae after receiving only supportive treatment. In conclusion, the aim of the present report was to emphasize that accidental ingestion of some plants in our environment which closely resemble edible vegetables may produce serious signs of poisoning and even lead to death.

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

References 1. Vetter J. Poison hemlock (Conium maculatum L.). Food Chem Toxicol 2004;42:1373-82. 2. López TA, Cid MS, Bianchini ML. Biochemistry of hemlock (Conium maculatum L.) alkaloids and their acute and chronic toxicity in livestock. A review. Toxicon 1999;37:841-65. 3. Reynolds T. Hemlock alkaloids from Socrates to poison aloes. Phytochemistry 2005;66:1399-406. 4. Leete EB. Becoming a hospice volunteer. Am J Hosp Palliat Care 1994;11:27-32. 5. Ferah AU, Dilek MO, Ercument Y, Oktay D. Hemlock poisoning (case report): die like socrates. Resuscitation 2006;70:337. 6. Rizzi D, Basile C, Di Maggio A, Sebastio A, Introna F Jr, Rizzi R, et al. Clinical spectrum of accidental hemlock poisoning: neurotoxic manifestations, rhabdomyolysis and acute tubular necrosis. Nephrol Dial Transplant 1991;6:939-43. 7. Krenzelok EP, Jacobsen TD, Aronin JM. Hemlock ingestions: The most deadly plant exposures. J Toxicol Clin Toxicol 1996;34:601-2. 8. Colombo ML, Marangon K, Locatelli C, Giacche M, Zulli R, Res tani P. Hemlock poisoning due to plant misidentification. J Pharm Sci Res 2009;1:43-7. 9. Erenler AK, Baydin A , Duran L, Yardan T, Turkoz B. A case of respiratory failure due to poison hemlock poisoning presented to an emergency department. Hong Kong J Emerg Med 2011;18:235-8. 10. Başgül A, Burgutoğlu B, Hancı A. Hayatı tehdit eden akut solunum yetmezliği: Yabani ot zehirlenmesi. Yoğun Bakım Dergisi 2003;3:204-6. 11. Froberg B, Ibrahim D, Furbee RB. Plant poisoning. Emerg Med Clin North Am 2007;25:375-433. 12. West PL, Horowitz BZ, Montanaro MT, Lindsay JN. Poison hemlock-induced respiratory failure in a toddler. Pediatr Emerg Care 2009;25:761-3.

CASE REPORT

ECG Changes Due to Hypothermia Developed After Drowning: Case Report Suda Boğulma Sonrası Gelişen Hipotermiye Bağlı EKG Değişiklikleri: Olgu Sunumu Sabiye YILMAZ,1 Mehmet Akif CAKAR,2 Mehmet Bulent VATAN,2 Harun KILIC,2 Nurgul KESER2 Department of Cardiology, Yenikent State Hospital, Sakarya; Department of Cardiology, Sakarya University Faculty of Medicine, Sakarya 1

SUMMARY

ÖZET

Drowning is one of the fatal accidents frequently encountered during the summer and is the most common cause of accidental death in the world. Anoxia, hypothermia, and metabolic acidosis are mainly responsible for morbidty. Cardiovascular effects may occur secondary to hypoxia and hypothermia. Atrial fibrillation, sinus dysrhythmias (rarely requiring treatment), and, in serious cases, ventricular fibrillation or asystole may develop, showing as rhythm problems on electrocardiogram and Osborn wave can be seen, especially during hypothermia. A 16-year-old male patient who was admitted to our hospital’s emergency service with drowning is presented in this article. In our case, ventricular fibrillation and giant J wave (Osborn wave) associated with hypothermia developed after drowning was seen. We present this case as a reminder of ECG changes due to hypothermia that develop after drowning. Response to cardiopulmonary resuscitation after drowning and hypothermia is not very good. Mortality is very high, so early resuscitation and aggressive treatment of cardiovascular and respiratory problems are important for life.

Suda boğulmalar özellikle yaz aylarında sıkça karşılaştığımız ölümcül kazalardandır, dünyada kaza ile ölümlerin en sık sebeplerinden biridir. Boğulmalardaki morbiditeden esas olarak anoksi, hipotermi ve sonucunda gelişen metabolik asidoz sorumludur. Kardiyovasküler etkiler hipoksi ve hipotermiye sekonderdir. Elektrokardiyografide (EKG) atriyal fibrilasyon, sinüs disritmileri (nadiren tedavi gerektirir), ciddi olgularda ventriküler fibrilasyon ya da asistol gibi ritim problemleri ve özellikle hipotermi sırasında sık karşılaşılan Osborn dalgaları izlenebilinir. Bu yazıda soğuk suda boğulma sonrasında hastane acil servisine getirilen 16 yaşında erkek hasta sunuldu. Olguda boğulma sonrası gelişen hipotermi ile ilişkili ventriküler fibrilasyon ve dev J dalgaları (Osborn dalgası) izlendi. Bu olguyu sunmamızın nedeni suda boğulma sonrası gelişen hipotermiye bağlı EKG değişikliklerini hatırlatmaktı. Suda boğulma ve hipotermi sonrası kardiyopulmoner resüsitasyona cevap çok iyi değildir. Mortalite oldukça yüksektir, erken resüsitasyon, agresif kardiyovasküler ve respiratuvar tedavi sağkalım için önemlidir.

Key words: Arrest; drowning; hypothermia; osborn wave; trauma.

Anahtar sözcükler: Arrest; suda boğulma; hipotermi; osborn dalgası; travma.

Introduction Drowning is one of the most common causes of accidental death in the world. Among adults between 20 and 44 years of age, drowning is the second most common cause of accidental death. Drowning is especially common for young

children (younger than five years old) and young adults (between 15 and 29 years old).[1] Anoxia, hypothermia, and metabolic acidosis are mainly responsible for morbidity in drowning. Hypothermia due to cold water drowning, can be monitored via various electrocardiographic changes: T wave

Submitted: 11.02.2013 Accepted: 15.05.2013 Published online: 18.07.2013 Correspondence: Dr. Sabiye Yılmaz. Korucuk Baytur Sitesi, Orkide 1, Daire 6, Sakarya, Turkey. e-mail: ssevincdr@gmail.com

Turk J Emerg Med 2014;14(1):37-40

doi: 10.5505/1304.7361.2014.60590

Turk J Emerg Med 2014;14(1):37-40

inversion; PR, QRS, and QT prolongation; Osborn waves; and dysrhythmias (sinus bradycardia, atrial fibrillation and flutter, nodal rhythm, AV block, ventricular premature beats, ventricular fibrillation, and asystole).[2] Osborn waves are dome-like deflections which are observed as late delta waves following the QRS complex or the small secondary R wave (R ‘) in electrocardiography (ECG).[3] Osborn waves and ST elevation usually return to normal as body temperature increases and hypoxia and acidosis regress. The current report presents the case of a patient who developed hypothermia after drowning and whose ECG results revealed Osborn waves and ST segment elevation.

Case Report A 16-year-old male patient was admitted to our emergency department after drowning in cold water. Cardiopulmonary resuscitation was initiated and the patient intubated within approximately 25 minutes at the scene. The patient’s relatives reported that he had no medical history and that he was in the water for approximately 10 minutes. The patient had ventricular fibrillation, and defibrillation was conducted during transport and in the emergency room. The patient was then taken to the intensive care unit and connected to a mechanical ventilator. Positive end-expiratory pressure (PEEP) was applied. Physical examination of the unconscious patient revealed mydriasis and flexor motor response in the form of retraction in the upper extremities. Transtympanic body temperature was 28˚C, heart rate was 82/min, blood pressure was 150/70 mmHg, and O2 saturation was 87%. ECG revealed sinus rhythm, Osborn waves with concave ST segment elevation in V3-6, and a significant J wave in V4-6 in the precordial leads (Figure 1). The following laboratory results were detected: troponin level, 5.08 ng/ml (normal range <0.1 ng/

Figure 2. After 24 hours, blood temperature and ECG results returned to normal.

ml); hypernatremia, 150.8 mmol/L (136-145 mmol/L); hypokalaemia, 2.9 mmol/L (3.5-5.1 mmol/L); urea, 77 mg/dL (16.648.5mg/dL); creatinine, 2.5 mg/dL (0.5- 0.9 mg/dl); glucose, 279 mg/dl (<105 mg/dl); aspartate aminotransferase (AST), 189 mg/dL (0-32 U/L); alanine aminotransferase (ALT), 116 mg/dL (0-33 U/L); hemoglobin (HGB), 15.7 g/dL (12.2-18.1 g/dL); and hematocrit (HTC), 51.8% (37.7-53.7). Respiratory acidosis (pH: 7.296) in arterial blood gas and retention of carbon dioxide (PCO2: 52.3) were observed. External and internal heating were immediately applied to the patient using heated intravenous infusion, moistening of the inspired gas, and heated blanket. When the patient’s blood temperature exceeded 32˚C, ST segment elevation began to decline and, after 24 hours, blood temperature and ECG results returned to normal (Figure 2). Treatment with positive inotropes (dopamine 5-10 mcg/kg/min) was started for the patient, who had no pulmonary edema. To control the convulsions which developed during follow-up in intensive care, valproic acid and prophylactic antibiotic treatment was started. On echocardiography, no regional wall motion abnormality was observed with the increase in cardiac enzyme levels. No pathology except anoxia-induced brain enema was identified on cranial CT. The patient experienced multiple organ failure during his follow-up in intensive care and died on the third day of hospitalization.

Discussion

Figure 1. Osborn waves with concave ST segment elevation in V36, and a significant J wave in V4-6 in the precordial leads.

Drowning is defined as death caused by the inability to breathe after submersion in water. Drowning is one of the most common causes of accidental death in the world, and is the second most common cause of accidental death among adults between the ages of 20 and 44 years. Drowning is especially common among young children (younger

Yılmaz S et al.

ECG Changes Due to Hypothermia Developed After Drowning

than five years old) and young adults (between 15 and 29 years).[1] Anoxia, hypothermia, and metabolic acidosis are mainly responsible for morbidity in drowning.[4] The human body must maintain a temperature of 37°C in order to perform normal functions. In cases of severe hypothermia, in which body temperature is below 30°C, critical bodily functions are significantly suppressed.[5] Resuscitation should be continued until body temperature exceeds 30°C.[6] If body temperature is below 25°C, cardiac arrest due to ventricular fibrillation is frequently observed. If body temperature is below 18°C, asystole occurs.[7] In drowning cases, cardiovascular effects are secondary to hypoxia and hypothermia. Heart rate and blood pressure first increase and then decrease. During hypothermia some ECG changes are observed, such as various dysrhythmias (including sinus bradycardia, atrial fibrillation and flutter, nodal rhythm, AV block, ventricular premature beats, ventricular fibrillation, and asystole) and T wave inversion; PR, QRS, and QT prolongation; and Osborn waves.[8] Hypothermia decreases cardiac conduction and extends all measured electrocardiographic intervals due to slowed repolarization. Hypothermia ultimately leads to the development of atrioventricular block. On the other hand, Osborn waves develop in hypothermic patients due to electrolyte or acid-base imbalance rather than lack of heat. Osborn waves may be detected in 80% of the patients whose body temperatures fall below 30ºC. Osborn waves and ST elevation usually return to normal as body temperature increases, and hypoxia and acidosis decrease.[9] The Osborn wave was defined for the first time in 1953 by Joseph Osborne[10] and is the positive deflection wave at the J point after the R wave. The amplitude of an Osborn wave is usually between 0.5 and 2 mm. Although observed frequently on 12-lead ECG, Osborn waves sometimes occur only in the anterolateral leads. Osborn waves are observed most frequently in hypothermia (hypothermic hump). Wave amplitude is related to the severity of hypothermia. Very small Osborn waves are observed in normothermic patients, especially in V5-6; after head trauma; after defibrillation; or in association with early repolarization; coronary heart disease and pericarditis; hypokalemia; hypercalcemia; hypoglycemia; diabetic ketoacidosis; or Brugada syndrome.[9,11-13] For example, in a previous report, Yalçın M. and his colleagues presented a case of sepsis-induced hypothermia and Osborn waves in association with hypokalemia.[14] ECG is the most commonly used non-invasive method for diagnosing cardiac disease. ECG changes, non-ischemic myocardial destruction, and increases in cardiac enzyme levels encountered in the emergency department may have a range of etiologies, including hypothermia, electric shock,

trauma, myocarditis, chemotherapy, and subarachnoid hemorrhage. The patient’s clinical condition, cardiovascular risk factors, specific ECG changes, and ECG course help to reveal the cause of myocardial destruction. Imaging methods, such as echocardiography, are also important in differential diagnosis of myocardial ischemia and other cardiac events. In the present case, Osborn waves in V4-6 and severe ST elevation were observed. The ST elevation and Osborn waves improved as the hypothermia declined. No pattern of ST elevation supporting MI and no reciprocal ECG changes were observed in the patient, whose increased cardiac enzyme levels were also monitored. No regional wall motion abnormalities matching any coronary perfusion area or supporting MI were observed with echocardiography. The absence of the Q wave after the decline of ST elevation suggested against atherosclerotic coronary artery disease. Based on the findings of this case, ECG changes and cardiac enzyme rise are interpreted as secondary to defibrillation, hypoxia, and hypothermia. Although the patient’s ECG changes returned to normal with recovery from hypothermia, he passed away on the third day of hospitalization as a result of multiple organ failure. In conclusion, drowning is a significant cause of morbidity and mortality. It is more common during adolescence and for men. The prognosis is determined by the damage to the myocardium and the brain, which are targeted primarily by hypoxia. Osborn waves detected on ECG are not pathognomonic, although Osborn waves are characteristic of hypothermia. Thus, other potential causes of Osborn waves should be investigated to achieve successful resuscitation. The best treatment for a hypothermic patient is body temperature regulation. If body temperature does not increase, resuscitation may not be successful. Early diagnosis of possible arrhythmias and ECG changes is very valuable in determining necessary interventions. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. Hwang V, Shofer FS, Durbin DR, Baren JM. Prevalence of traumatic injuries in drowning and near drowning in children and adolescents. Arch Pediatr Adolesc Med 2003;157:50-3. 2. Bessen HA. Hypothermia. In: Tintinalli JE, Kelen GD, Stapczynski JS, editors. Emergency medicine. A comprehensive study guide. 6th ed. New York: McGraw-Hill; 2003. p.1231-5. 3. Gussak I, Bjerregaard P, Egan TM, Chaitman BR. ECG phenomenon called the J wave. History, pathophysiology, and clinical significance. J Electrocardiol 1995;28:49-58. 4. Ibsen LM, Koch T. Submersion and asphyxial injury. Crit Care

Turk J Emerg Med 2014;14(1):37-40

6. 7. 8.

Med 2002;30:402-8. Holzer M, Behringer W, Schörkhuber W, Zeiner A, Sterz F, Laggner AN, et al. Mild hypothermia and outcome after CPR. Hypothermia for Cardiac Arrest (HACA) Study Group. Acta Anaesthesiol Scand Suppl 1997;111:55-8. Fiser DH. Near-drowning. Pediatr Rev 1993;14:148-51. Alhaddad IA, Khalil M, Brown EJ Jr. Osborn waves of hypothermia. Circulation 2000;101:E233-44. Wollenek G, Honarwar N, Golej J, Marx M. Cold water submersion and cardiac arrest in treatment of severe hypothermia with cardiopulmonary bypass. Resuscitation 2002;52:255-63. Vassallo SU, Delaney KA, Hoffman RS, Slater W, Goldfrank LR. A prospective evaluation of the electrocardiographic manifestations of hypothermia. Acad Emerg Med 1999;6:1121-6.

10. OSBORN JJ. Experimental hypothermia; respiratory and blood pH changes in relation to cardiac function. Am J Physiol 1953;175:389-98. 11. Patel A, Getsos JP, Moussa G, Damato AN. The Osborn wave of hypothermia in normothermic patients. Clin Cardiol 1994;17:273-6. 12. Martínez Martínez JA. Postoperative pericarditis and Osborn wave. [Article in Spanish] Medicina (B Aires) 1998;58:428. [Abstract] 13. Abbott JA, Cheitlin MD. The nonspecific camel-hump sign. JAMA 1976;235:413-4. 14. Yalçın M, Işılak Z, Uz Ö, Doğan M. Hipokalemi ve hipotermi ile ilişkili dev J dalgası (Osborn dalgası). Anadolu Kardiyoloji Dergisi 2012;12:698-703.

CASE REPORT

Clozapine-Induced Febrile Neutropenia and Cellulitis Klozapine Bağlı Febril Nötropeni ve Selülit Selcuk YAYLACI,1# Emine Ulku YILMAZ,1 Ertugrul GUCLU,2 Neslihan AKKISI KUMSAR,3 Ali TAMER,1 Oguz KARABAY2 Department of Internal Medicine, Sakarya University Faculty of Medicine, Sakarya; Department of Infectious Diseases and Clinical Microbiology, Sakarya University Faculty of Medicine, Sakarya; 3 Department of Physiciatry, Sakarya University Faculty of Medicine, Sakarya 1

SUMMARY

ÖZET

Clozapine is one of the atypical antipsychotics and is frequently prescribed to patients with treatment-resistant schizophrenia. Agranulocytosis is a major side effect that may lead to death, which limits its use. This is a case report of a patient that developed febrile neutropenia and cellulitis after treatment with clozapine for 20 weeks.

Klozapin atipik antipsikotik ilaçlardan biridir ve sıklıkla tedaviye dirençli şizofereni olgularında kullanılmaktadır. Kullanımını sınırlayan en önemli yan etkisi ölümcül olabilen agranülositozdur. Bu yazıda, 100 mg/gün klozapin tedavisinin 20. haftasında nötropenik ateş ve selülit gelişen olgu sunuldu.

Key words: Cellulitis; clozapine; febrile neutropenia; granulocyte colonystimulating factor.

Anahtar sözcükler: Selülit; klozapin; febril nötropeni; granulosit koloni stimüle edici faktör.

Introduction

of a right leg rash and fever for three days. His past medical history was notable for a diagnosis of schizophrenia when he was approximately 40 years-old. His symptoms of schizophrenia had not been successfully treated with olanzapine, quetiapine, and amisulpride, and so he was started on clozapine. However, he was advised to discontinue the drug once he developed neutropenia 19 weeks into treatment. However, the patient resumed taking the clozapine and developed a fever and a leg rash four days after he was diagnosed with neutropenia. Neither the patient nor his family had a history of blood dyscrasias. On physical examination his temperature was 38.6˚C, his blood pressure was 120/70 mmHg, and his pulse was 78 bpm. His heart and lungs were within normal limits on auscultation. His right leg however was warm to the touch (Figure 1). His laboratory testing revealed a white blood cell (WBC) count of 300/mm³, neutrophil count of 0/mm³, platelet (PLT) count of 186,000/mm³, hemoglobin (Hb) of 11.6 g/dL, glucose of 111 mg/dL, urea

Clozapine is one of the atypical antipsychotics and is frequently prescribed to patients with treatment-resistant schizophrenia. The most severe side effect of this medication is agranulocytosis, and the prevalence of developing this condition ranges between 0.7-4.1%.[1,2] Febrile neutropenia attributed to clozapine use occurs in 0.06% of patients.[3] There have been case reports that have demonstrated that atypical antipsychotics other than clozapine may also induce agranulocytosis.[4,5] In this case report, we present a patient that developed febrile neutropenia and cellulitis that was successfully treated 20 weeks after starting clozapine.

Case Report A 61-year-old male that had been taking 100 mg of clozapine daily for the past 20 weeks presented with complaints #

Current affiliation: Department of Internal Medicine, Fındıklı State Hospital, Rize

Submitted: 13.03.2013 Accepted: 18.04.2013 Published online: 18.07.2013 Correspondence: Dr. Selçuk Yaylacı. Fındıklı Devlet Hastanesi, İç Hastalıkları Kliniği, Rize, Turkey. e-mail: yaylacis@hotmail.com

Turk J Emerg Med 2014;14(1):41-43

doi: 10.5505/1304.7361.2014.83097

Turk J Emerg Med 2014;14(1):41-43

was 38.6˚C and so blood, throat, and urine cultures were obtained. We began intravenous meropenem at 3 grams/day. Also he was started on subcutaneous granulocyte colony stimulating factor (G-CSF) treatments with Filgrastim at 30 million units/day. All of the cultures were negative for infection. Lower extremity dopplers were performed via ultrasonography and there were no abnormal findings. His fever resolved on the third day of admission and his neutrophil levels began to increase. Meropenem was stopped after 14 days, and his laboratory values were within normal limits on day 14 (Table 1). The patient was referred to the psychiatry clinic so to titrate his antipsychotic medications to treat his schizophrenia.

Discussion Figure 1. Cellulitis of the right leg.

of 60 mg/dL, creatinine of 1.3 mg/dL, alanine transaminase (ALT) of 13 IU/L, aspartate aminotransferase (AST) of 22 IU/L, Na of 137 mmol/L, K of 4.3 mmol/L, and an albumin of 3.6 g/dL. Atypical cells were not observed on peripheral blood smear. According to these findings, we diagnosed the patient with febrile neutropenia and cellulitis. Clozapine treatment was immediately stopped and the patient was admitted into contact isolation. His MASCC (Multinational Association for Supportive Care in Cancer) score was 19 and his temperature

Neutropenia and agranulocytosis resulting from treatment with clozapine usually develops within the first three months of clozapine initiation. In the first 18 weeks of starting clozapine, a total blood count should be performed on a weekly basis. If the blood counts remain within normal limits, then total blood counts may be performed monthly. [1] Despite all of these precautions, agranulocytosis was observed after taking the drug for 11 years in a case report of a patient receiving clozapine treatment.[6] A study conducted with 2,404 patients that had been taking clozapine for 18 weeks reported that 0.9% exhibited neutropenia and 0.7% percent developed agranulocytosis. Yet, all of these patients fully recovered.[1] In another study of 917 patients that were treated with clozapine, it was found that neutropenia occurred in 4.1% of the patients.[2] Between the years of 2005-

Table 1. Laboratory values Date

WBC (/mm³)

Neutrophil (/mm³)

Hemoglobin (g/dL)

Platelet (/mm³)

(N=4.600-10.200) (N=2.000-6.900) (N=12.2-18.1) (N=14.2000-42.4000)

*14.06.2011 7.800

5.100

12.6

241.000

11.10.2011 6.100

3.100

14.2

217.000

18.10.2011 4.200

1.700

14.6

220.000

**25.10.2011 2.100

100

12.2

193.000

***01.11.2011 400

11.6

186.000

02.11.2011 500

9.6

195.000

04.11.2011 700

9.1

195.000

07.11.2011 1.000

200

7.9

224.000

11.11.2011 1.500

300

7.8

321.000

12.11.2011 2.100

600

8.9

362.000

13.11.2011 3.700

1.200

9.3

320.000

14.11.2011 4.800

2.100

8.5

317.000

*Date that clozapine treatment was initiated. **Date that cessation of clozapine was recommended. ***Date of admission to the hospital due to febrile neutropenia with cellulitis.

Yaylac覺 S et al.

Clozapine-Induced Febrile Neutropenia and Cellulitis

2009, side effects due to clozapine use occurred in 21,053 patients and 0.006% of them were diagnosed with febrile neutropenia.[3] We diagnosed this patient with neutropenia during the 19th week of treatment. However, his neutropenia worsened due to continuing clozapine against medical advice, and the patient presented with febrile neutropenia and cellulitis.

lulitis and to guide clinical treatment in case agranulocytosis does develop.

The pathophysiology of the development of agranulocytosis during clozapine treatment remains unclear. This side effect is not considered to be dose dependent, but it may be the result of an idiosyncratic drug reaction.[7,8] There are case reports in the literature of patients that developed agranulocytosis due to several other antipsychotic medications.[5,6] Clinical trials and case reports have demonstrated that G-CSF is useful in treating clozapine-induced granulocytopenia by stopping agranulocytosis and increasing the number of granulocytes and macrophage precursors in the bone marrow.[1,2,9] In this case report, the patient responded to G-CSF treatment. Because the patient developed neutropenia before the cellulitis was diagnosed, we concluded that the neutropenia developed from being treated with clozapine and that the cellulitis resulted from the neutropenia.

References

Conclusion In conclusion, white blood cell counts should be routinely performed in patients who are taking clozapine. It is imperative to detect neutropenia in patients taking atypical antipsychotics early on so to avoid complications such as cel-

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

1. Lambertenghi Deliliers G. Blood dyscrasias in clozapinetreated patients in Italy. Haematologica 2000;85:233-7. 2. Hamirani M, Naqvi A, Saleem SM, Siddiqui AI. Clozapine Induced Neutropenia in Patients Suffering from Schizophrenia: A Multi Centre Audit JPPS 2006;3:39-42. 3. h t t p : / / w w w . e h e a l t h m e . c o m / d s / c l o z a p i n e / febrile+neutropenia. Accessed April 01, 2013. 4. Thangadurai P, Jyothi KS, Gopalakrishnan R, Kuruvilla A, Jacob KS. Reversible neutropenia with olanzapine following clozapine-induced neutropenia. Am J Psychiatry 2006;163:1298. 5. Erbey F, R羹zgar H, Okur M. The risperidone-induced leukopenia and neutropenia: a case at 7 years old. Anatolian Journal of Psychiatry 2011;12:243-4. 6. Sedky K, Shaughnessy R, Hughes T, Lippmann S. Clozapineinduced agranulocytosis after 11 years of treatment. Am J Psychiatry 2005;162:814. 7. Pirmohamed M, Park K. Mechanism of clozapine-induced agranulocytosis: current status of research and implications for drug development. CNS Drugs 1997;7:139-58. 8. Solanki RK, Singh P, Swami MK. Clozapine: Current perspective. Indian J Psychiatry 2007;49:271-6. 9. Srinivasan TN, Thomas K. Clozapine-induced agranulocytosis and use of g-csf. Indian J Psychiatry 1998;40:70-2.

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