Turk J Emerg Med 2014 / 4 by KAREPUBLISHING

ISSN 1304-7361

Turkish Journal of Emergency Medicine

Turkish Journal of Emergency Medicine Türkiye Acil Tıp Dergisi VOLUME 14

NUMBER 4

YEAR 2014

Citation Abbreviation: Turk J Emerg Med

ORIGINAL ARTICLES Türkiye Acil Tıp Dergisi

Serum S100B Protein as an Outcome Prediction Tool in Emergency Department Patients with Traumatic Brain Injury Abbasi M, Sajjadi M, Fathi M, Maghsoudi M First Aid Knowledge of University Students in Poisoning Cases Goktas S, Yıldırım G, Kose S, Yıldırım S, Ozhan F, Senturan L The Analysis of Poisoning Cases Presented to the Emergency Department within a One-Year Period Sari Dogan F, Ozaydin V, Varisli B, Incealtin O, Ozkok Z Emergency Department During Long Public Holidays Dagar S, Sahin S, Yilmaz Y, Durak U The Effects of the Sleep Quality of 112 Emergency Health Workers in Kayseri, Turkey on Their Professional Life Senol V, Soyuer F, Guleser GN, Argun M, Avsarogullari L CASE REPORTS

VOLUME 14 NUMBER 4 YEAR 2014

An Adult Patient who Presented to Emergency Service with a Papular Purpuric Gloves and Socks Syndrome: A Case Report Ozaydin V, Eceviz A, Sari Dogan F, Dogan A Retropharyngeal Hematoma due to Oral Warfarin Usage Toker I, Duman Atilla O, Yesilaras M, Ursavas B Cost of Beauty; Prilocaine Induced Methemoglobinemia Kilicli E, Aksel G, Akbuga Ozel B, Kalvalci C, Suveren Artuk D Spinal Trauma is Never without Sin: A Tetraplegia Patient Presented Without any Symptoms Efeoglu M, Akoglu H, Akoglu T, Eroglu SE, Onur OE, Denizbasi A REVIEW Some Ethical Issues in Prehospital Emergency Medicine Erbay H

@TrJEmergMed

Issued by The Emergency Medicine Association of Turkey This Journal is indexed in Turkish Medical Index of TUBITAK-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 4

YEAR 2014

Citation Abbreviation: Turk J Emerg Med

ORIGINAL ARTICLES Serum S100B Protein as an Outcome Prediction Tool in Emergency Department Patients with Traumatic Brain Injury Abbasi M, Sajjadi M, Fathi M, Maghsoudi M First Aid Knowledge of University Students in Poisoning Cases Goktas S, Yıldırım G, Kose S, Yıldırım S, Ozhan F, Senturan L The Analysis of Poisoning Cases Presented to the Emergency Department within a One-Year Period Sari Dogan F, Ozaydin V, Varisli B, Incealtin O, Ozkok Z Emergency Department During Long Public Holidays Dagar S, Sahin S, Yilmaz Y, Durak U The Effects of the Sleep Quality of 112 Emergency Health Workers in Kayseri, Turkey on Their Professional Life Senol V, Soyuer F, Guleser GN, Argun M, Avsarogullari L CASE REPORTS An Adult Patient who Presented to Emergency Service with a Papular Purpuric Gloves and Socks Syndrome: A Case Report Ozaydin V, Eceviz A, Sari Dogan F, Dogan A Retropharyngeal Hematoma due to Oral Warfarin Usage Toker I, Duman Atilla O, Yesilaras M, Ursavas B Cost of Beauty; Prilocaine Induced Methemoglobinemia Kilicli E, Aksel G, Akbuga Ozel B, Kalvalci C, Suveren Artuk D Spinal Trauma is Never without Sin: A Tetraplegia Patient Presented Without any Symptoms Efeoglu M, Akoglu H, Akoglu T, Eroglu SE, Onur OE, Denizbasi A REVIEW Some Ethical Issues in Prehospital Emergency Medicine Erbay H

@TrJEmergMed

www.trjemergmed.com

Test early. Treat right. Save lives. Her testin arkasında kurtarılacak bir yaşam vardır

Dispne ile başvuran hastalarda erken ve doğru tanı sonuçları iyileştirir ve hayat kurtarır NT-proBNP testi akut kalp yetersizliğinin tanısında/ihtimal dışı bırakılmasında ve prognozunda güçlü bir belirteçtir.1,2,3

1 Januzzi et al. (2005). Am J Cardiol. 95(8), 948-54 2 Moe et al. (2007). Circulation. 115(24), 3103-10 3 Januzzi et al. (2006). Eur Heart J. 27(22), 2619-20

Roche Diagnostics Turkey A.Ş. Esentepe Mah. Kırgülü Sok. No:4 34394 Şişli, İstanbul / Türkiye Tel 0212 306 06 06 Fax 0212 216 73 51 www.roche.com.tr

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

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

Cem ERTAN, M.D. Izmir 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 Jeffrey ARNOLD, M.D. Elizabeth DEVOS, M.D. Geijsel FEMKE, M.D. C. James HOLLIMAN, M.D. Monseireus KOEN, M.D. Mark LANGDORF, M.D. Frank LOVECCHIO, M.D. Matej MARINSEK, M.D.

Resmiye ORAL, M.D. Pini RICARDO, M.D. Petrina ROBERTA, M.D. Brown RUTH, M.D. Lemoyne SABIN, M.D. Selim SUNER, M.D. Judith E. TINTINALLI, 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.

Uludag University Faculty of Medicine, Department of Emergency Medicine

Serkan SENER, M.D.

Ac覺badem 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 4)

RESEARCH MEDHODOLOGY EDITOR

Ersin AKSAY, M.D. Yusuf Ali ALTUNCI, M.D. Basak BAYRAM, M.D. Mehtap BULUT, M.D. Erdem CEVIK, M.D. Ozge DUMAN ATILLA, M.D. Murat DURUSU, M.D. Ozge ECMEL ONUR, M.D.

Levent DONMEZ, M.D.

Serkan Emre EROGLU, M.D. Betul GULALP, M.D. Tolga GUVEN, M.D. Asim KALKAN, M.D. Sule KALKAN, M.D. Isa KILICARSLAN, M.D. Murat OZSARAC, M.D. Murat YESILARAS, 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

ISSUED BY THE EMERGENCY MEDICINE ASSOCIATION OF TURKEY

VOLUME 14 NUMBER 4 DECEMBER 2014

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

CORRESPONDENCE Turkiye Acil Tip Dernegi, Cankaya Mah., Cinnah Cad., No: 51/10 Cankaya, Ankara, Turkey Tel: +90 - 312 - 438 12 66 • Fax: +90 - 312 - 438 12 68 e-mail: bilgi@tatd.org.tr, editor@trjemergmed.org Published four times a year.

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@TrJEmergMed

Turkish Journal of

Emergency Medicine Contents viii

Publishing with the Turk J Emerg Med

DECEMBER 2014

Instructions for Authors

ORIGINAL ARTICLES

147

Serum S100B Protein as an Outcome Prediction Tool in Emergency Department Patients with Traumatic Brain Injury Abbasi M, Sajjadi M, Fathi M, Maghsoudi M

153

First Aid Knowledge of University Students in Poisoning Cases Goktas S, Yıldırım G, Kose S, Yıldırım S, Ozhan F, Senturan L

160

The Analysis of Poisoning Cases Presented to the Emergency Department within a One-Year Period Sari Dogan F, Ozaydin V, Varisli B, Incealtin O, Ozkok Z

165

Emergency Department During Long Public Holidays Dagar S, Sahin S, Yilmaz Y, Durak U

172

The Effects of the Sleep Quality of 112 Emergency Health Workers in Kayseri, Turkey on Their Professional Life Senol V, Soyuer F, Guleser GN, Argun M, Avsarogullari L

CASE REPORTS

179

An Adult Patient who Presented to Emergency Service with a Papular Purpuric Gloves and Socks Syndrome: A Case Report Ozaydin V, Eceviz A, Sari Dogan F, Dogan A

182

Retropharyngeal Hematoma due to Oral Warfarin Usage Toker I, Duman Atilla O, Yesilaras M, Ursavas B

185

Cost of Beauty; Prilocaine Induced Methemoglobinemia Kilicli E, Aksel G, Akbuga Ozel B, Kalvalci C, Suveren Artuk D

188

Spinal Trauma is Never without Sin: A Tetraplegia Patient Presented Without any Symptoms Efeoglu M, Akoglu H, Akoglu T, Eroglu SE, Onur OE, Denizbasi A

193

199

REVIEW Some Ethical Issues in Prehospital Emergency Medicine Erbay H

Turkish Journal of Emergency Medicine, Index of Vol. 14

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.

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.

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.

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.

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.

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.

ORIGINAL ARTICLE

Serum S100B Protein as an Outcome Prediction Tool in Emergency Department Patients with Traumatic Brain Injury Travmatik Beyin Hasarı olan Acil Servis Hastalarında Sonucu Öngörme Aracı Olarak Serum S100B Protein Mohsen ABBASI,1 Mahmoudreza SAJJADI,1 Marzieh FATHI,2 Mohammadreza MAGHSOUDI1 Iran University of Medical Sciences, 2Shiraz University of Medical Sciences, Iran

SUMMARY

ÖZET

Objectives Traumatic brain injury is a common cause of death and disability worldwide. Early recognition of patients with brain cellular damage allows for early rehabilitation and patient outcome improvement.

Amaç Travmatik beyin travması dünya ölçeğinde olağan bir ölüm ve özürlülük nedenidir. Beyin hücre hasarı olan hastaların erkenden tanınması erkendsen rehabilitasyon ve hasta sonuçlarında iyileşmeye olanak tanır.

Methods

Gereç ve Yöntem Bu prospektif çalışmada hafif-orta derecede travmatik beyin hasarı (TBH) olan hastaların klinik durumları değerlendirildi ve hastaların serum S100B düzeyleri ölçüldü. Hastalar bir ay sonra takip edildi, bilinç düzeyleri, travma sonrası baş ağrısı olup olmaması ve günlük aktivite performansı (Barthel ölçeğini kullanarak) açısından değerlendirildi. Veri analizinde SPSS yazılımı ile Student t-testi ve ki-kare testi kullanıldı.

In this prospective study, the clinical conditions of patients with mild to moderate traumatic brain injury (TBI) were assessed, and patient serum S100B levels were measured. Patients were followed up one month later and evaluated for level of consciousness, presence or absence of post-traumatic headache, and daily activity performance (using the Barthel scale). Student’s t-test and the chi-square test were used for data analysis, which was performed using SPSS software. Results The mean serum S100B value was significantly lower for patients with minor TBI than for patients with moderate TBI (23.1±14.2 ng/dl and 134.0±245.0 ng/dl, respectively). Patients with normal CT scans also had statistically significantly lower serum S100B levels than patients with abnormal CT findings. The mean S100B value was statistically significantly higher for patients with suspected diffused axonal injury (632.18±516.1 ng/dl) than for patients with other abnormal CT findings (p=0.000): 24.97±22.9 ng/dl in patients with normal CT results; 41.56±25.7 ng/dl in patients with skull bone fracture; 57.38 ±28.9 ng/ dl in patients with intracranial hemorrhage; and 76.23±38.3 ng/dl in patients with fracture plus intracranial hemorrhage).

Bulgular Orta derecede TBH geçirmiş olanlara göre hafif derecede TBH geçirmiş hastalarda ortalama serum S100B değeri anlamlı derecede daha düşüktü (sırasıyla, 134,0±245,0 ng/dl ve 23,1±14,2 ng/dl). BT taramaları normal olmayan hastalara göre normal olanlarda serum S100B düzeyleri istatistiksel açıdan anlamlı derece daha düşüktü. Ortalama S100B değeri yaygın akson hasarından kuşkulanılan hastalarda (632,18±516,1 ng/dl) başka anormal BT bulguları olan hastalardan anlamlı derecede daha düşük idi (p=0.000). Normal BT sonuçları olan hastalarda, 24.97±22.9 ng/dl; kafatası kemiği kırıkları olanlarda 41.56±25.7 ng/dl; intrakraniyal kanaması olanlarda 57.38±28.9 ng/dl, kırıkla birlikte intrakraniyal kanaması olanlarda 76.23±38.3 ng/dl.

Conclusions Serum S100B levels increase in patients with minor to moderate TBIs, especially in those with diffused axonal injury. However, serum S100B values cannot accurately predict one-month neuropsychological outcomes and performance.

Sonuç Hafif ve orta derecede TBH özellikle yaygın akson travması olanlarda serum S100B düzeyleri yükselmektedir. Ancak serum S100B değerleri 1 ay sonrasının nöropsikolojik sonuçları ve performansını doğru biçimde öngörememektedir.

Key words: Biomarker; head trauma; S100B protein; traumatic brain injury.

Anahtar sözcükler: Biyobelirteç; kafa travması; S100B proteini; travmatik beyin hasarı.

Submitted: June 08, 2014 Accepted: October 10, 2014 Published online: November 30, 2014 Correspondence: Dr. Marzieh Fathi. Emergency Department, Rasoul-e-akram Hospital, Niyayesh St, Sattarkhan Ave, Tehran, Iran. e-mail: Marziehfathi@yahoo.com

Turk J Emerg Med 2014;14(4):147-152

doi: 10.5505/1304.7361.2014.74317

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Turk J Emerg Med 2014;14(4):147-152

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Introduction Traumatic brain injury (TBI) is a common cause of death and disability worldwide. TBI is a public health priority because it is associated with extensive physical, psychological and social impacts and a high economic burden.[1] Some studies have demonstrated that more than 10-40% of patients with TBI are still disabled 6-12 months after trauma, including those with mild TBI and unremarkable neuroimaging findings. Although early recognition and proper management of patients with TBI may result in better rehabilitation and substantial outcome improvement, assessing different cellular and clinical aspects and effects of TBI is still less than optimal.[2-4] S100B, a calcium binding protein highly expressed in astroglial cells of the brain and released in cerebrospinal fluid (CSF) and blood, can be measured by available immunoassay kits. Different studies have evaluated S100B as a biomarker for different brain injuries, such as stroke[5,6], bacterial meningitis[7], carbon monoxide poisoning[8] and TBI[9-12]. Some recent studies have also highlighted the complex release pattern of S100B and its potential role in brain tissue repair processes[13-17] This prospective study evaluates the diagnostic and prognostic roles of serum S100B protein in emergency department (ED) patients with minor to moderate TBI.

Materials and Methods Patients were enrolled conveniently between March and May 2012 at two teaching hospitals with a total annual census of 80,000 adult patients. The institutional ethics committee (Faculty of Medicine, Iran University of Medical Sciences) approved this prospective study, and informed consent was obtained from all patients.

bone fracture; and any other identified or suspected differential diagnosis for the patient’s decreased level of consciousness, including alcohol abuse, drug abuse, substance abuse, drug toxicity, hypo/hyperglycemia, hypo/hypernatremia, endocrine disorder, or infection. Patients who did not undergo a head CT scan were also excluded. Intervention S100B assay: A blood sample was drawn from the peripheral veins within the first six hours of ED admission. The time of blood sample collection was recorded. Samples were centrifuged, and the serum was refrigerated at -20°C until analyzed. Neuroimaging: Ten millimeter thick slices obtained using a GE VCT Lightspeed 64 multi-slice detector were interpreted by a board certified radiologist and confirmed by another consultant radiologist who was blinded to the first interpretation. Both radiologists were blinded to the clinical conditions and S100B results of the patients. All pathologic findings, including skull bone fracture and any type of intracranial hemorrhage (e.g. brain contusion, subdural/epidural intracranial hematoma), were reported as positive computed tomography findings. Follow up: The patients were called by two blinded research assistant one month later. During follow-up, patients were evaluated for level of consciousness, presence or absence of post-traumatic headaches, and daily activity performance (using the Barthel scale) to determine if any significant intracranial complications had occurred (.i.e. complications requiring further neuroimaging).

Participants Patients at least 18 years old with a clinical diagnosis of acute mild to moderate TBI were enrolled. Patients with a history of isolated head trauma and Glasgow Coma Scale (GCS) score between 9 and 15 who presented in the ED within the first six hours of their head injury were considered to have mild to moderate TBI. All clinical assessments, including GCS calculations, were performed by a research assistant who was a physician. The research assistant was blinded to other assessments results. Patients with the following were excluded: severe TBI (GCS≤8); hemodynamic instability; body temperature greater than 38.5°C; concurrent trauma to any other organs; concurrent primary and secondary brain injury, including refractory severe hypoxia (arterial oxygen saturation <92% while receiving 100% oxygen), post-traumatic seizure, and skull

Subjects Assessed for Eligibility (n=187) Excluded Patients (n=78): - Inclusion criteria not met (n=21) - hemodynamic instability (6) - concurrent trauma to other organs (18) - concurrent brain injuries (34) - other causes of decreased level of consciousness (20) Included patients (n=109)

Lost to follow-up (n=19) - Wasted blood samples (11) - Refused to participate (6) - Failed to reach by telephone (2)

Figure 1. Participant flow over the course of the study.

Fathi M et al.

Serum S100B Protein as an Outcome Prediction Tool in ED Patients with Traumatic Brain Injury

Table 1. Basic characteristics of study participants Variable Sex Male Female Initial GCS 15 14 13 12 11 10 Mechanism of injury Auto-Pedestrian MVC Falling Direct trauma Others CT findings Normal DAI ICH Fx Fx+ICH

n % 80

88.9

11.1

44.4

7.8

14.4

21.1

6.7

5.6

40.0

25.6

17.8

10.0

6.7

48.9

5.6

11.1

23.3

Measurements Initial TBI severity was assessed using the GCS. Patients with GCS scores between 9 and 15 were considered to have mild to moderate TBI. To measure S100B serum levels, the human S100 ELISA kit (BioVendor - laboratorni medicina a.s., Brno, Czech Republic) was used. The lowest detection limit of the test is about 15 pg/ml. Serum S100B levels were measured in ng/dl. The Barthel scale is an ordinal 10-variable scale used to measure patient performance on daily activities and to predict the likelihood a patient will be able to live at home independently. The Barthel scale has high inter-rater and test re-test reliability, as well as, high correlations with other measures of physical disability. The ten Barthel scale variables are: presence/absence of fecal incontinence; presence/absence of urinary incontinence; and help needed with grooming, toilet use, feeding, transfers, walking, dressing, climbing stairs, and bathing. Each variable is given a score (between 0 and 3). These scores are summed to determine the total score (out of 20). The higher the Barthel score, the less assistance the patient is likely to need with daily activities after discharge from the hospital. For example, when a person can

perform about 50% of their daily tasks and activities independently, then their Barthel score will be 10 out of 20.[18-20] Patient outcome measures were level of consciousness, residual headache, and Barthel score one month after trauma. Data Analysis The Student’s t-test was used to compare the mean values of quantitative variables, and the Chi square test was used to compare qualitative variables. All data analyses were performed with SPSS version 13.5 (SPSS, Inc., Chicago, IL).

Results One hundred eighty-seven patients were assessed for eligibility, and 78 patients were excluded from the study: six patients had hemodynamic instability; 18 patients had concurrent trauma to other organs; 34 patients had concurrent brain injuries; and 20 patients had other causes of decreased level of consciousness. Venous blood samples were obtained from 109 patients with minor to moderate TBI who had undergone CT as a part of their routine diagnostic evaluations. Eleven samples were wasted due to various errors between initial preparation and analysis. A total of 98 patients with mild to moderate TBI and available serum S100B results were followed. During the telephone follow-up one month post-trauma, six patients refused to continue participating in the study, and two additional cases were unreachable by telephone. Follow-up interviews were performed for 90 patients, all of whom completed the study. No patients had died in the month between injury and follow-up, and all patients had GCS scores of 15. The mean age of the study participants was 33.1±10.3 years (95% CI: 29.99-34.28) and ranged from 18 to 50 years old. Other basic characteristics of the patients are shown in Table1. In the present study, 38 (80.9%) of the minor TBI patients and 6 (14.0%) of the moderate TBI patients had normal CT results. Suspected diffused axonal injury (DAI) was not seen in the minor TBI patients, but 5 (11.6%) of the moderate TBI patients had suspected DAI. GCS scores were significantly different between the patients with normal CT results and the patients with abnormal CT findings (p=0.000). The mean serum S100B value was 23.1±14.2 ng/dl (95% CI: 17.427.3) in patients with minor TBI and 134.0±245.0 ng/dl (95% CI 51.1-179.6) in patients with moderate TBI. Student’s t-test demonstrated that the difference was statistically significant (p=0.003). The mean serum S100B value was statistically significantly higher in patients with suspected DAI compared to patients with other abnormal CT findings (p=0.000). Serum S100B results are summarized in Table 2. Initial GCS scores, CT findings, headache, and Barthel scores of patients with Barthel scores ≤18 and with the highest

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Table 2. Serum S100B levels in patients with different CT results CT Findings Mean±SD* (ng/dl) 95% Confidence Interval Skull Fracture 41.56±25.7 22.1-58.9 ICH† 5.38±28.9 28.9 Skull Fracture plus ICH 76.23±38.3 57.7-92.7 DAI†† 632.18±516.1 -9.7-1272.0 Abnormal 125.0±238.5 53.1-194.8 Normal 24.9±22.9 16.9-30.9 †

: Intracranial hemorrhage; ††: Diffused axonal injury; *: Standard deviation.

S100B levels are shown in Table 3. At one-month follow-up, 3 (3.3%) patients had Barthel scores less than 18, 12 (13.4%) had Barthel scores of 18 or 19, and 75 (83.3%) had Barthel scores of 20. The mean serum S100B value was 206.43±316.0 ng/dl (95% CI: 49.3-163.4) in patients with Barthel scores less than 18 (range: 68-1047 ng/dl). Patients with Barthel scores of 18 and 19 had a mean serum S100B level of 88.20±46.5 ng/dl (95% CI: 24.8-407.8, range: 48-175 ng/dl). The mean serum S100B level was 59.51±156.9 ng/dl (95% CI: 18.6-99.6) for patients with Barthel scores of 20 (range: 68-1047 ng/dl). Serum S100B levels were higher in patients with lower Barthel scores, but the difference was not statistically significant (p=0.06). Thirty-eight (42.2%) patients had residual headaches one month after TBI. The mean serum S100B level was 87.03±163.2 ng/dl (95% CI: 26.5-150.6) in patients with residual headaches, and 68.13±188.5 ng/dl (95% CI: 11.3127.8) in patients without headaches; the difference was not statistically significant (p=0.59).

Discussion The S100B protein has a half-life of two hours and can be measured both in CSF and in the blood. Although some studies have shown that S100B protein levels increase after extra-cranial injuries in the absence of brain injury,[21] many other studies have introduced S100B protein as a highly sensitive and speciﬁc biomarker of CNS injuries.[13-17] S100B has been suggested as a triage tool for identifying patients who need neuroimaging and as a diagnostic tool for early recognition of patients with possible brain tissue injury and timely administration of medication (e.g. benzodiazepines to reduce post-concussion syndrome risk after mild TBI). S100B has also been suggested as a prognostic tool to identify atrisk patients and to begin rehabilitation activities as soon as possible, especially for patients who do not need neurosurgical interventions.[22-26] The present study found that although serum S100B increas-

es in minor to moderate traumatic brain injuries (especially in cases of DAI), it cannot accurately predict one-month outcomes. These results are compatible with some other studies which have emphasized the complicated release pattern of S100B. These past studies have highlighted the role of blood-brain barrier integrity and disruption in S100B release into the serum, the poor correlation between serum and CSF S100B levels, and the possible reparative roles of S100B that may improve outcomes in patients with acute brain injuries. These studies also mention that the relationship between S100B values and likely outcomes in patients with TBI is not necessarily a causative relationship.[27] A study of a large cohort of patients showed some association between high serum S100B level and poor outcome in patients with brain injury, but not significant enough to support use as an outcome prediction tool.[28] Similarly, a review by Townend showed that, although patients with high serum S100B levels at initial evaluation may be at higher risk for disability after TBI, no association between serum S100B levels and the neuro-psychological performance of injured patients has been established.[2] Metting et al. studied 94 patients with mild TBI and demonstrated that S100B is not related to outcome or imaging results.[29] Some newer studies have proposed that serum S100B level might be used for predicting the probability of brain death in patients with TBI.[30] Conclusion The current study showed that serum S100B levels increase with minor to moderate TBIs, especially in patients with suspected DAI. However, serum S100B cannot accurately predict one-month neuropsychological outcomes and performance. Limitations The present study has some limitations. The study was conducted at two teaching hospitals, and the human S-100 ELISA kits may not be available at other smaller hospitals. Only patients who had undergone brain CT were enrolled;

Fathi M et al.

Serum S100B Protein as an Outcome Prediction Tool in ED Patients with Traumatic Brain Injury

patients who had not undergone CT or who refused to undergo neuroimaging were not included. The sample size was small, and similar studies with larger sample sizes would be preferable. The study did not focus on any cutoff S100B level to categorize at-risk patients, though it might be helpful to determine a cutoff diagnostic serum S100B value. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. von Holst H, Cassidy JD. Mandate of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. J Rehabil Med 2004;(43 Suppl):8-10. 2. Townend W, Ingebrigtsen T. Head injury outcome prediction: a role for protein S-100B? Injury 2006;37:1098-108. 3. Thornhill S, Teasdale GM, Murray GD, McEwen J, Roy CW, Penny KI. Disability in young people and adults one year after head injury: prospective cohort study. BMJ 2000;320:1631-5. 4. Pickering A, Grundy K, Clarke A, Townend W. A cohort study of outcomes following head injury among children and young adults in full-time education. Emerg Med J 2012;29:451-4. 5. Dassan P, Keir G, Brown MM. Criteria for a clinically informative serum biomarker in acute ischaemic stroke: a review of S100B. Cerebrovasc Dis 2009;27:295-302. 6. Brouns R, De Vil B, Cras P, De Surgeloose D, Mariën P, De Deyn PP. Neurobiochemical markers of brain damage in cerebrospinal fluid of acute ischemic stroke patients. Clin Chem 2010;56:451-8. 7. Hamed SA, Hamed EA, Abdella MM. Septic encephalopathy: relationship to serum and cerebrospinal fluid levels of adhesion molecules, lipid peroxides and S-100B protein. Neuropediatrics 2009;40:66-72. 8. Ide T, Kamijo Y, Ide A, Yoshimura K, Nishikawa T, Soma K, Mochizuki H. Elevated S100B level in cerebrospinal fluid could predict poor outcome of carbon monoxide poisoning. Am J Emerg Med 2012;30:222-5. 9. Nylén K, Ost M, Csajbok LZ, Nilsson I, Hall C, Blennow K, Nellgård B, et al. Serum levels of S100B, S100A1B and S100BB are all related to outcome after severe traumatic brain injury. Acta Neurochir (Wien) 2008;150:221-7. 10. Savola O, Pyhtinen J, Leino TK, Siitonen S, Niemelä O, Hillbom M. Effects of head and extracranial injuries on serum protein S100B levels in trauma patients. J Trauma 2004;56:1229-34. 11. Raabe A, Kopetsch O, Woszczyk A, Lang J, Gerlach R, Zimmermann M, et al. Serum S-100B protein as a molecular marker in severe traumatic brain injury. Restor Neurol Neurosci 2003;21:159-69. 12. Wiesmann M, Steinmeier E, Magerkurth O, Linn J, Gottmann D, Missler U. Outcome prediction in traumatic brain injury: comparison of neurological status, CT findings, and blood levels of S100B and GFAP. Acta Neurol Scand 2010;121:17885.

13. Kleindienst A, Ross Bullock M. A critical analysis of the role of the neurotrophic protein S100B in acute brain injury. J Neurotrauma 2006;23:1185-200. 14. Anderson RE, Hansson LO, Nilsson O, Dijlai-Merzoug R, Settergren G. High serum S100B levels for trauma patients without head injuries. Neurosurgery 2001;48:1255-60. 15. Willoughby KA, Kleindienst A, Müller C, Chen T, Muir JK, Ellis EF. S100B protein is released by in vitro trauma and reduces delayed neuronal injury. J Neurochem 2004;91:1284-91. 16. Jackson RG, Samra GS, Radcliffe J, Clark GH, Price CP. The early fall in levels of S-100 beta in traumatic brain injury. Clin Chem Lab Med 2000;38:1165-7. 17. Shinozaki K1, Oda S, Sadahiro T, Nakamura M, Hirayama Y, Abe R, et al. S100B and neuron-specific enolase as predictors of neurological outcome in patients after cardiac arrest and return of spontaneous circulation: a systematic review. Crit Care 2009;13:R121. 18. Mahoney Fi, Barthel DW. Functional Evaluation: The barthel index. Md State Med J 1965;14:61-5. 19. Shah S, Vanclay F, Cooper B. Improving the sensitivity of the Barthel Index for stroke rehabilitation. J Clin Epidemiol 1989;42:703-9. 20. Sulter G, Steen C, De Keyser J. Use of the Barthel index and modified Rankin scale in acute stroke trials. Stroke 1999;30:1538-41. 21. Bloomfield SM, McKinney J, Smith L, Brisman J. Reliability of S100B in predicting severity of central nervous system injury. Neurocrit Care 2007;6:121-38. 22. Müller B, Evangelopoulos DS, Bias K, Wildisen A, Zimmermann H, Exadaktylos AK. Can S-100B serum protein help to save cranial CT resources in a peripheral trauma centre? A study and consensus paper. Emerg Med J 2011;28:938-40. 23. Undén J, Romner B. Can low serum levels of S100B predict normal CT findings after minor head injury in adults?: an evidence-based review and meta-analysis. J Head Trauma Rehabil 2010;25:228-40. 24. Bazarian JJ, McClung J, Cheng YT, Flesher W, Schneider SM. Emergency department management of mild traumatic brain injury in the USA. Emerg Med J 2005;22:473-7. 25. Winter CD, Clough GF,Pringle AK, Church MK. Outcome following severe traumatic brain injury TBI correlates with serum S100B but not brain extracellular fluid S100B: An intracerebral microdialysis study. World Journal of Neuroscience. 2013;3:93-99. 26. Goyal A, Failla MD, Niyonkuru C, Amin K, Fabio A, Berger RP, et al. S100b as a prognostic biomarker in outcome prediction for patients with severe traumatic brain injury. J Neurotrauma 2013;30:946-57. 27. Kleindienst A, Ross Bullock M. A critical analysis of the role of the neurotrophic protein S100B in acute brain injury. J Neurotrauma 2006;23:1185-200. 28. Kleindienst A, Schmidt C, Parsch H, Emtmann I, Xu Y, Buchfelder M. The Passage of S100B from Brain to Blood Is Not Specifically Related to the Blood-Brain Barrier Integrity. Cardiovasc Psychiatry Neurol 2010;2010:801295.

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29. Metting Z, Wilczak N, Rodiger LA, Schaaf JM, van der Naalt J. GFAP and S100B in the acute phase of mild traumatic brain injury. Neurology 2012;78:1428-33. 30. Egea-Guerrero JJ, Murillo-Cabezas F, Gordillo-Escobar E,

RodrĂguez-RodrĂguez A, Enamorado-Enamorado J, Revuelto-Rey J, et al. S100B protein may detect brain death development after severe traumatic brain injury. J Neurotrauma 2013;30:1762-9.

ORIGINAL ARTICLE

153

First Aid Knowledge of University Students in Poisoning Cases Üniversite Öğrencilerinin Zehirlenme Vakalarındaki İlkyardım Bilgileri Sonay GOKTAS,1 Gulay YILDIRIM,2 Selmin KOSE,2 Senay YILDIRIM,3 Fatma OZHAN,2 Leman SENTURAN2 Maltepe University School of Nursing, Istanbul; 2 Halic University School of Nursing, Istanbul; 3 Istanbul Sisli Vocational School, Istanbul

SUMMARY

ÖZET

Objectives Poisoning is a crucial public health problem which needs serious approach and response to treatment. In case of poisoning, proper first aid is lifesaving and application should be applied in every condition. This research was conducted in order to evaluate first aid knowledge of university students for poisoning.

Amaç Zehirlenmeler ciddi yaklaşım gerektiren ve tedaviye iyi yanıt veren önemli bir halk sağlığı problemidir. Zehirlenme durumlarında uygun ilk yardım hayat kurtarıcı olup, toplumun bütün bireylerinin, her türlü koşulda yapması gereken bir uygulamalar bütünüdür. Bu araştırma, üniversite öğrencilerinin zehirlenme vakalarındaki ilkyardım bilgilerini incelemek amacı ile yapıldı.

Methods The research was conducted between the dates of May 2013 -June 2013 with the permission gained from the University Rectorship. The cohort of the research contained 4,560 students who received education in Istanbul. The sample of the study included 936 students who accepted to participate in the research and attended the school during the research. The data were collected by using a questionnaire form, which had 21 questions prepared by researchers. Analysis of the data was carried out with a percentage evaluation method and chi square tests in a computer environment. Results In our study, 92.6% of students (n=867) knew the phone number of the ambulance in case of emergency. In addition, 57.3% of students (n=536) knew the phone number of the poison hotline, and it was seen that they answered correctly the questions regarding the relation between body system and indications of poisoning. It was determined that the students who received education in medical departments answered the questions correctly more than the students who had education in other departments. (p<0.001, p<0.01).

Gereç ve Yöntem Araştırma Mayıs 2013–Haziran 2013 tarihleri arasında, özel bir vakıf üniversitesinde, üniversite rektörlüğünden gerekli izin alınarak gerçekleştirildi. Evrenini üniversitede okuyan 4560 öğrenci, örneklemi ise çalışmanın yapıldığı günlerde okula devam eden ve araştırmaya katılmayı kabul eden 936 öğrenci oluşturdu. Veriler araştırmacılar tarafından hazırlanan 21 soruluk anket formu kullanılarak toplandı. Verilerin analizi bilgisayar ortamında yüzdelik değerlendirme yöntemi ve ki-kare testi kullanılarak yapıldı. Bulgular Çalışmamızda öğrencilerin %92.6’sının (n=867) acil durumda aranması gereken ambulans numarasını ve %57.3’ünün (n=536) zehir danışma hattı numarasını bildikleri ve zehirlenmelerde ortaya çıkan belirtiler ile vücut sistemleri arasındaki ilişkiyi soran sorulara doğru olarak cevap verdikleri belirlendi. Sağlık bölümlerinde okuyan öğrencilerin zehirlenme belirtileri ve sindirim ile solunum yolu zehirlenmelerinde yapılacak olan ilkyardım girişimleri ile ilgili bilgi sorularına diğer bölümlerde okuyan öğrencilere göre daha fazla doğru cevap verdikleri saptandı (p<0.001, p<0.01).

Conclusions It was observed that the university students in medical departments had more first aid knowledge on poisoning cases compared to the students in other departments who did not have sufficient information regarding these issues. It is thought that first aid education in all departments of universities, both poisoning and other first aid issues, should be conveyed to all students.

Sonuç Sağlıkla ilgili bölümlerde okuyan üniversite öğrencilerinin zehirlenmelerle ilgili ilkyardım konusunda daha bilgili oldukları, diğer bölümlerde okuyan öğrencilerin ise bu konularla ilgili bilgilerinin yetersiz olduğu görülmektedir. Üniversitelerin tüm bölümlerinde ilk yardım derslerinin okutulmaya başlanması ile gerek zehirlenmeler gerekse diğer ilkyardım bilgilerinin bireylere doğru bir şekilde aktarılacağı ve toplumdaki ilkyardım bilgisinin artacağı düşünülmektedir.

Key words: First aid; poisoning; university student.

Anahtar sözcükler: İlkyardım; üniversite öğrencisi; zehirlenme.

Submitted: April 11, 2014 Accepted: September 23, 2014 Published online: November 30, 2014 Correspondence: Dr. Sonay Goktas. Maltepe Universitesi Marmara Egitim Koyu Hemsirelik Yuksek Okulu, İstanbul, Turkey. e-mail: sonaygoktas@maltepe.edu.tr

Turk J Emerg Med 2014;14(4):153-159

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Introduction Poisoning is a clinical state that occurs as a result of the human body being exposed to toxic substance(s). Exposure can include respiration, circulation, ingestion, or skin contact. Poisoning is defined with various indicators that arise in the digestive, respiration, and nervous systems and adhere to the factor causing it.[1] It is possible that poisoning occurs as a result of different factors. Acute poisoning which is often seen in the emergency services generally develops from consuming spoiled foods, animal bites, and in attempts of suicide. In addition, chronic poisoning can come from the accumulation of chemicals within air, water, and foods within human body in the course of time.[2] The factors that contribute to poisoning differ in regard to geographical region, seasons, level of development, age group, and level of socio-cultural status.[3] In developing countries where agricultural activities are dominant, poisoning caused by insects and pesticides is more common. However, in developed countries poisoning from suicide is observed at a higher rate.[2,4,5,6] By carrying out the general evaluation, pathogens that cause poisoning predominantly get into the body through the digestive system. Chemical substances that are used at home or in the garden, such as toadstools, spoiled foods, medicine, and excessive alcohol use can cause the poisoning to occur through the digestive system.[2,7] Early intervention is crucial for an effective treatment of

Table 1. Introductory characteristic of students (n=936) Characteristic

n %

Gender Female

634

67.7

Male

302

32.3

Department

Medical department

481

51.4

Other departments of the university

455

48.6

1st Grade

269

28.7

2nd Grade

265

28.3

Grade

3 Grade

255

27.2

4th Grade

147

15.7

585

62.5

Alone

8.2

In dorm

132

14.1

With friend

142

15.2

With family

acute poisoning. As in all emergency cases, every lost moment would be a disadvantage for the patient according to poisoning facts. To prevent the delays, the support can be received from “The National Poisoning Information Center,” which provides service 7 days and 24 hours. Detrimental effects can be prevented by the use early decontamination attempts and proper antidotes.[8] Therefore, community-residing persons should have basic information about first-aid to the prevent and minimize unnecessary deaths. First-aid courses are provided at schools and driving courses in our country. However, there are not enough studies to reveal whether proper first-aid awareness has been developed in the society. This study was conducted to evaluate the information of university students regarding poisoning cases. The students’ knowledge was determined based on first-aid applications in which the university students were involved in the poisoning cases. This study helped to determine which subjects were needed to increase student awareness on first aid and proper poison training.

Materials and Methods The research was conducted between the dates of May 2013 – June 2013 at a private university. The permission was received through a related institution before the research. All undergraduate students who received education in the 2012-2013 academic year were consented for the research. The data were collected by using a questionnaire form that included 21 questions prepared by researchers with the help of related literature. The first part of the questionnaire form included questions about demographical characteristics (age, gender, department, grade, and environment). The second part of the questionnarie form focused on the subject of first-aid. In this department, questions related to first-aid education before encountering poisoning cases, the number of poisoning hotline, information regarding poisoning indications, and knowledge of the right first-aid attempts in case of poisoning were highlighted. The questions about first-aid knowledge were prepared as multiple choice and included 4 options. The questionnaire form was given to students at a date that was previously determined by the researchers. Analysis of the data was performed with a percentage evaluation method and chi-square tests using “SPSS for Windows 10.0” program.

Results

Living in where/with whom

It was determined that 4,560 undergraduate students received education within the time period when the research was conducted. However, owing to the fact that the students did not stay at the school due to different reasons (application,

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Table 2. Distribution of number to call in case of poisoning, poisoning indication, and first aid attempts (n=936) Questions about poisoning Status of Having First aid Education

Answer

Yes

394

42.1

Knowing Related Phone Numbers

In case of emergency,

what is the phone number for ambulance?

Correct

867

92.6

What is the phone number of poisoning hotline?

Correct

536

57.3

Poisoning Indications

Which system disfunction do the

indications such as Loss of

consciousness, convulsion, sense of

sickness, inconsistency of motion seen

on poisoning cases show?

Which ways do toxic substances such

as insect sting and animal bites poison?

Which way was the patient who has complaints

of nausea, vomitting, diarrhea poisoned?

What kind of poisoning has indications such

as empurpling of lips and labored breathing?

Do you have information regarding

first aid provided in poisoning?

Correct Correct Correct Correct Yes

507 869 804 698 457

54.2 92.8 85.9 74.6 48.8

First-aid Attempts

How should first aid in poisoning

by the way of digestive system be?

How should first aid in poisoning

by the way of respiratory tract be?

Correct

735

78.5

How should first aid in necton stinging be?

Correct

340

36.3

How should first aid in scorpion and snake stinging be?

Correct

159

17.0

Status of encountering poisoning before

Yes

269

28.7

Season when poisoning occured* (n=269)

Summer

110

40.9

Which way did poisoning occur?* (n=269)

Digestive

224

83.6

Correct

223

23.8

* Answers of people answered “Yes” only

training period, etc.), the research was conducted with 936 students receiving education and who were accepted to participate in the study at that time. Introductory characteristics of students who participated into the study were declared in Table 1. Moreover, the distribution of given answers to the questions regarding poisoning was shown in Table 2. Students who were receiving education at health departments had more correct answers than the students who were studying at other departments (respectively p<0.001, p<0.01) for the questions which analyzed the relationship between indications and ways of poisoning and body systems. Of the students who answered correctly about

first-aid attempt in the case of digestive and respiration poisoning, it was determined that the number of the students who were studying at medical departments were more than the number of students at other departments (p<0.001). Furthermore, it was observed that students who knew the phone number of the poison hotline were mostly studying at health departments (p<0.001) (Table 3). When the number of students who knew digestive system indications and the first–aid attempts required for poisoning through the digestive system were compared, it was shown that the number of students that received first-aid education was significantly different than number of students who

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Table 3. Comparison of answers to poisoning indications and first-aid attempts according to university departments (n=936) Poisoning indications and first-aid attempts

Medical department (n=481) Correct

Other departments (n=455) Correct

of universities

Poisoning indications

Which system dysfunction do the

indications such as Loss of consciousness

convulsion, sense of sickness, inconsistency

of motion seen on poisoning cases show?

Which ways do toxic substances such as

insect sting and animal bites poison?

Which way was the patient who has complaints

of nausea, vomiting, diarrhea poisoned?

What kind of poisoning has indications such as

empurpling of lips and labored breathing?

306 457 434 392

201 412 370 306

<0.001 <0.01 <0.001 <0.001

First-aid attempts

How should the first-aid on poisoning

via digestive system be provided?

How should first aid in poisoning

by the way of respiratory tract be?

How should first aid for insect

stinging be administered?

How should first aid in scorpion

and snake stinging be administered?

Which is the phone number

of poisoning hotline?

did not receive first-aid education (p<0.05) (Table 4).

Discussion Poisoning is an important community health problem, which constitutes an important portion of emergency service applications. It requires a serious approach with truthful answers to first-aid applications which are done properly and on time. At the present time, the success of the treatment can be increased by enhancing awareness and protective measures regarding the issue. In the case of poisoning, proper first-aid is lifesaving, and it is an application which should be provided by all individuals regardless of medical studies. [7,9,10] In our research, it was observed that 92.6% of the students answered correctly to the phone number for the ambulance

161 405 188 83 385

62 330 152 76 209

<0.001 <0.001 p>0.05 p>0.05 <0.001

service in case of emergency. This pleasing result showed that the Ministry of Health 112 ambulance service was wellknown and adopted in our country. Ministry of Health may be the reason that the number of 112 ambulance stations was increased, easily reachable, more satisfactory, and wellknown in our country. It can also be said that the number of individuals who received first-aid education may play a role. [11] It is a known reality that the press has the power of influence regarding that.[12] Another reason of this result can be that 112 ambulances were seen on the news of accident and injury events by the participants. It was determined that most of the students answered correctly to the question of the relation between indications observed for poisoning and the body system (Table 2). It is crucial to know indications that give clues about of the kind of poisoning and convey the information to the medical per-

Goktas S et al.

First Aid Knowledge of University Students in Poisoning Cases

157

Table 4. Poisoning Indications and comparison of first-aid attempts answers with status of receiving education (n=936) Poisoning indications and first-aid attempts

Students who received first-aid education* (n=394) Correct

Students who did not receive first-aid education (n=542) Correct

Poisoning indications

Which system dysfunction does

the indications such as

Loss of consciousness,

convulsion, sense of sickness,

inconsistency of motion seen

on poisoning cases show?

Which ways do toxic substances

such as insect sting and

animal bites poison?

Which way was the patient who

has complaints of nausea,

vomiting, diarrhea poisoned?

What kind of poisoning has

indications such as empurpling

of lips and labored breathing?

216

369

352

301

291

500

452

397

>0.05

<0.05

>0.05

First-aid Attempts

How should the first-aid

on poisoning via digestive

system be provided?

How should first aid in

poisoning by the way of

respiratory tract be?

318

417

>0.05

How should first aid in insect stinging be?

149

191

>0.05

How should first aid in scorpion

and snake stinging be?

108

115

<0.05

>0.05

*First-aid education was received as course, driving-course and lesson

sonnel for the success of the first-aid and treatment at the hospital. It was determined that the students did not know the firstaid attempts regarding poisoning via digestive system (Table 2), and it was also demonstrated that they chose vomiting as an initial method of choice. In the literature, the vomiting method for poisoning via digestive system is debatable, and our research showed parallelism with other researchers in regard to this important issue.[13,14,15] In our study, we determined that most of the students did not know the proper first-aid efforts for treating poisoning caused by an animal sting (Table 2). Dereli and colleagues determined

that the least known first-aid subject was animal bites and insect stings.[16] In addition, Dinรงer et al. drew attention to the study on pre-school educators, which showed that most of the educators performed the application wrongly for the first-aid for insect bites and stings.[17] It can be reasoned that animal bites and insect stings are rarely seen in our country. In our study, it was determined that poisoning cases were seen by students in the summer time (40.9 %), and most of them occurred through ingestion (Table 2). In the literature, there are studies conducted in Turkey that show poisoning cases mostly occurred in summer time and most of them were caused by ingestion.[18-23] The finding of poison

Turk J Emerg Med 2014;14(4):153-159

158

rates are higher in the summer time seems related to the increased temperatures and foods that are easily spoiled in those temperatures. However, a lot of poisoning cases caused ingestion were seen by students, and they could not answer correctly regarding the first-aid applications. In the study, it was observed that the students who were receiving education at medical departments partially knew, and the students who were studying at other departments did not have sufficient knowledge regarding poisoning indications and first-aid efforts (Table 3). This result is dependent on medical departments and medical units that have a firstaid course. Özçelikay and colleagues determined that students who did not take the first-aid course at the university did not have enough knowledge about first-aid in the study conducted.[24] The study which was conducted by Savaşer determined that first aid information points of medical personnel except doctors were higher than high school teachers had and it shows parallelism with our study.[25] In our study, 80% of medical students knew the phone number of the Poison Hotline. However, only 46% of students at other departments knew the number (Table3). The significant difference for first-aid knowledge regarding only the digestive system was determined between students who received first-aid education and students did not receive the education. However, although it is not statistically meaningful, the right answers of students who received education were above the expectation. On the other hand, the answers of students who did not receive education were under the expectation (Table 4). The reason for this state is believed to be associated with students who took first-aid courses from some institutes and foundations. However, it often falls short because these courses have not been continuous and updated.[26] Adding first-aid courses into curriculum of all university departments as an elective course, and inclining students to choose this course, would provide increased awareness about first-aid knowledge and skills. Limitations The results of the study are limited with the students of the university where the research was conducted. It cannot be generalized to all university students. Conclusion As a result of the study, it was determined that university students who were studying at medical departments had more knowledge regarding first-aid as compared to the students who were studying at other departments. We propose that adding first-aid courses to curriculum at universities can increase the students’ knowledge on both poisoning and subjects that require first-aid.

Conflict Interest The author(s) stated that there was no conflict of interest.

References 1. Meyer S, Eddleston M, Bailey B, Desel H, Gottschling S, Gortner L. Unintentional household poisoning in children. Klin Padiatr 2007;219:254-70. 2. Batemen N. The epidemiology of poisoning. Medicine 2007;35:537-9. 3. Zhang J, Xiang P, Zhuo X, Shen M. Acute poisoning types and prevalence in Shanghai, China, from January 2010 to August 2011. J Forensic Sci 2014;59:441-6. 4. Kapur N, Clements C, Bateman N, Foëx B, Mackway-Jones K, Hawton K, et al. Self-poisoning suicide deaths in England: could improved medical management contribute to suicide prevention? QJM 2010;103:765-75. 5. McMahon A, Brohan J, Donnelly M, Fitzpatrick GJ. Characteristics of patients admitted to the intensive care unit following self-poisoning and their impact on resource utilisation. Ir J Med Sci 2014;183:391-5. 6. Patrick Walker J, Morrison R, Stewart R, Gore D. Venomous bites and stings. Curr Probl Surg 2013;50:9-44. 7. Deniz T, Kandiş H, Saygun M, Büyükkoçak Ü, Ülger H, Karakuş A. Kırıkkale Üniversitesi Tıp Fakültesi acil servisine başvuran zehirlenme olgularının analizi. Düzce Tıp Fakültesi Dergisi 2009;11:15-20. 8. Biçer S, Sezer S, Çetindağ F, Kesikminare M, Tombulca N, Aydoğan G ve ark. Çocuk acil kliniği 2005 yılı akut zehirlenme olgularının değerlendirilmesi. Marmara Medical Journal 2007;20:12-20. 9. Kondolot M, Akyıldız B, Görözen F, Kurtoğlu S, Patıroğlu T. Çocuk acil servisine getirilen zehirlenme olgularının değerlendirilmesi. Çocuk Sağlığı ve Hastalıkları Dergisi 2009;52:68-74. 10. Karaoğlu N, Pekcan S, Soner BC, Şeker M, Ors R. Probleme dayalı öğrenim senaryosunun üçüncü sınıf öğrencilerinin çocukluk çağı zehirlenmeleri ile ilgili bilgisine etkisi. Güncel Pediatri 2011;9:68-74. 11. Kose S, Yıldırım G, Sabuncu N, Ozhan F, Yorulmaz H. The knowledge level of students at Halic University on spinal cord injuries. Turk J Emerg Med 2010;10:15-9. 12. ‘Emergency Service’ from press media perspective: content analysis of the news about emergency service in the national newspapers of Turkey. Turk J Emerg Med 2013;13:166-70. 13. Polat SA, Turacı G. Bir polis okulundaki öğrencilerin ilkyardım konusundaki bilgi ve tutumları. AÜTD 2003;35:27-32. 14. Tekin D, Suskan E. Aileler arasında pediatrik ilk yardım bilgi düzeyinin değerlendirilmesi. 3. Uludağ Pediatri Kış Kongresi Poster Özetleri. Güncel Pediatri 2007; s. 203. 15. Duman NB, Koçak C, Sözen C. Üniversite öğrencilerinin ilk yardım bilgidüzeylerive bunu etkileyen faktörler. Hitit Üniversitesi Sosyal Bilimler Enstitüsü Dergisi 2013;6:57-70. 16. Dereli F, Turasay N, Özçelik H. Muğla iki no’lu sağlık ocağı bölgesinde yaşayan 0-6 yaş çocuğu olan annelerin ilkyardım konusundaki bilgi düzeylerinin belirlenmesi. TAF Prev Med Bull

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First Aid Knowledge of University Students in Poisoning Cases

2010;9:217-24. 17. Dinçer Ç, Atakurt Y, Şimşek I. Okul öncesi eğitimcilerinin ilkyardım bilgi düzeyleri üzerine bir araştırma. Ankara Üniversitesi Tıp Fakültesi Mecmuası 2000;53:31-8. 18. Sunay YM, Faruk Oİ. Okul öncesi dönem zehirlenme olgularının değerlendirilmesi. Adli Tıp Dergisi 2003;17:22-7. 19. Genç G, Saraç A, Ertan Ü. Çocuk hastanesi acil servisine başvuran zehirlenme olgularının değerlendirilmesi. Nobel Med 2007;3:18-22. 20. Akbay ÖY, Uçar B. Eskişehir bölgesinde çocukluk çağı zehirlenmelerinin retrospektif değerlendirilmesi. Çocuk Sağ Hast Derg 2003;46:103-13. 21. Sönmez E, Karakuş A, Çavuş UY, Civelek C, İpek G, Zeren C. Bir üniversite hastanesi acil servisine başvuran zehirlenme olgularının değerlendirilmesi. Dicle Tıp Dergisi 2012;39:21-6. 22. Polat S, Özyazıcıoğlu N, Tüfekci Güdücü F, Yazar F. Çocuk acil kliniğine başvuran 0-18 yaş grubu olguların incelen-

mesi. Atatürk Üniversitesi Hemşirelik Yüksekokulu Dergisi 2005;8:55-2. 23. Mohseni Saravi B, Kabirzadeh A, Asghari Z, Reza Zadeh I, Bagherian Farahabbadi E, Siamian H. Prevalence of Non-drug Poisoning in Patients Admitted to Hospitals of Mazandaran University of Medical Sciences, 2010-2011. Acta Inform Med 2013;21:192-5. 24. Özçelikay G, Şimşek I, Asil E. Üniversite öğrencilerinin ilkyardım konusundaki bilgi düzeyleri üzerine bir çalışma. A. Ü. Eczacılık Fak Der 1996;25:43-8 25. Savaşer, F. Çankırı ilinde görev yapan hekim dışı sağlık personeli ile lise öğretmenlerinin ilk yardım konusunda bilgi düzeylerinin karşılaştırılması Ankara Üniversitesi, Sağlık Bilimleri Enstitüsü, Ankara 2001. 26. Erkan M, Göz F. Öğretmenlerin ilk yardım konusundaki bilgi düzeylerinin belirlenmesi. Atatürk Üniversitesi Hemşirelik Yüksekokulu Dergisi 2006;9:63-8.

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ORIGINAL ARTICLE

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The Analysis of Poisoning Cases Presented to the Emergency Department within a One-Year Period Acil Servise Başvuran Bir Yıllık Zehirlenme Olgularının Analizi Fatma SARI DOGAN,1 Vehbi OZAYDIN,1 Behcet VARISLI,2 Onur INCEALTIN,1 Zeynep OZKOK1 Department of Emergency Clinic, Medeniyet University Goztepe Training and Research Hospital, Istanbul; 2 Department of Emergency Servicis, Van Training and Research Hospital, Van

SUMMARY

ÖZET

Objectives Intoxication is the emergence of unwanted signs and symptoms in an organism after exposure to potentially harmful chemical, physical or organic materials. In our study, we evaluated demographic and etiological factors of adult patients admitted to the emergency department with suicidal or accidental poisoning.

Amaç Zehirlenme potansiyel olarak zarar verebilen herhangi bir kimyasal, fiziksel veya organik maddeye maruziyet sonrası organizmada bazı istenmeyen belirti ve bulguların ortaya çıkmasıdır. Biz bu çalışmamızda intihar amaçlı veya kazara zehirlenme nedeniyle acil servisimize başvuran erişkin hastaların demografik ve etiyolojik faktörlerini araştırdık.

Methods This study was conducted retrospectively by using data from the forensics books, protocol notebooks and patient files. Patients over the age of 14 years that were admitted to the Goztepe Training and Research Hospital during a 1-year period (September 2011-September 2012) with poisoning were included in the study.

Gereç ve Yöntem Çalışma geriye dönük bir çalışma olup veriler adli defter, protokol defteri ve hasta dosyalarından elde edilmiştir. Bir yıllık süre içerisinde (Eylül 2011Eylül 2012) Göztepe Eğitim ve Araştırma Hastanesi’ne zehirlenme ile başvuran 14 yaş üstü hastalar çalışmaya dahil edildi.

Results A total of 430 patients were included in the study and 278 of those patients were females (64.7%). The male/female (F/M) ratio was 1.82/1 and the mean age of the patients was 27.4±11.75 years. The analyses showed that in 348 patients (80.93%) the cause of poisoning was medicine, in 39 patients (9.06%) alcohol and drugs, in 37 patients (8.6%) rat poison, in 4 patients (0.93%) a caustic substance and organophosphates in 2 patients (0.46%). The highest rate of admittance due to poisoning was seen in July, followed by August and September. When the frequency of admittance was evaluated in terms of seasons: summer had the highest frequency with 35.6%, then autumn with 29.1%, spring with 19.8% and winter with 15.6%.

Bulgular Çalışmaya toplam 430 hasta dahil edildi. Olguların 278’i kadın (%64.7), 152’si erkekti (%35.3). Kadın/erkek (K/E) oranı 1.82/1, yaş ortalaması 27.4±11.75 idi. Zehirlenme nedeni incelendiğinde; 348’inin (%80.93) ilaç, 39’unun (%9.06) alkol ve ilaç, 37’sinin (%8.6) fare zehiri, dördünün (%0.93) kostik madde, ikisinin (%0.46) organofosfat olduğu görüldü. En yüksek başvurunun sırasıyla temmuz, ağustos, eylül aylarında olduğu görüldü. Mevsimlere göre başvuru sıklığına bakıldığında %35.6 yaz, %29.1 sonbahar, %19.8 ilkbahar ve %15.6 kışın başvuru olduğu tespit edildi.

Conclusions The results of our studies are similar to previously reported studies in Turkey. Poisoning cases are more common in women and the most common way of poisoning is by medication. Unlike previous reports from the literature, we found that poisoning was most frequent in the summer.

Sonuç Çalışmamızın sonuçları literatürde Türkiye’de daha önce yapılan çalışmalarla benzerlik göstermektedir. Zehirlenme olguları kadınlarda daha sık olup en sık ilaç alımı yolu ile olmaktadır. Literatürden farklı olarak en sık yaz mevsiminde zehirlenme tespit edildi.

Key words: Emergency services; poisoning; suicide.

Anahtar sözcükler: Acil servis; zehirlenme, intihar.

Submitted: January 15, 2014 Accepted: March 20, 2014 Published online: November 30, 2014 Correspondence: Dr. Fatma Sarı Doğan. İstanbul Goztepe Egitim ve Arastirma Hastanesi, Fahrettin Kerim Gokay Cad., Kadikoy, İstanbul, Turkey. e-mail: fatmasdogan@gmail.com

Turk J Emerg Med 2014;14(4):160-164

doi: 10.5505/1304.7361.2014.87360

Sari Dogan F et al. The Analysis of Poisoning Cases Presented to the Emergency Department within a One-Year Period

Introduction Intoxication is the emergence of unwanted signs and symptoms in an organism after exposure to potentially harmful chemical, physical or organic materials.[1,2] The poisoning can be unintentional (accidental) or intentional (suicide). Early diagnosis, identification of substance that caused intoxication and early treatment are important for good prognosis. Poisoning cases can vary according to type of exposed poisonous substances, method of poisoning, demographic characteristics of the country and even regions within the same country. In this study we aimed to contribute to the literature by determining the demographic and etiologic features of patients admitted to our emergency department with poisoning in a 1-year period.

Materials and Methods All patients over the age of 14 years that were admitted to Goztepe Training and Research Hospital Adult Emergency Department due to acute poisoning within a one-year period (between 01.09.2011 and 01.09.2012) were included in the study. Children under the age of 14 are not assessed in the adult emergency department and therefore were excluded from the study. The data was obtained and recorded by retrospectively analyzing protocol and forensic books. Goztepe Training and Research Hospital Research Assessment Commission approved our study (decree # 22/e from 17/05/2012). Patients’ age, gender, chronic diseases, diagnosed psychiatric conditions, previous suicide attempts, causes of poisoning, the time of admission after the medication intake, the reason for medication intake, examination findings, follow-up time, admission time (in terms of months), discharge from emergency department or hospitalization status were investigated. The SPSS (Statistical Package for Social Science) 17.0 program was used for statistical analyses. Descriptive statistical methods (mean, standard deviation, frequency, percentage) were used for evaluation of the data. The 95% confidence interval and p-value <0.05 were considered statistically significant.

patients was 25.15±9.56 years, while that of male patients was 31.39±4.14 years. The mean age of poisoned patients was 27.4±11.75 years (minimum 14, maximum 90). The age and gender distribution of poisoned patients is given in Table 1. The causes of poisoning included the following: 348 patients (80.93%) due to medication, 39 patients (9.06%) from alcohol and medication, 37 patients (8.6%) ingested rodenticides, 4 patients (0.93%) took a caustic substance and 2 patients (0.46%) consumed organophosphates (Figure 1). Among the patients that were poisoned due to medication intake, 106 patients (24.7%) took multiple medications, 102 patients (23.7%) took antidepressants, 66 patients (15.3%) took non-steroidal analgesics, 24 patients (5.6%) took acetylsalicylic medicine, 19 patients (4.4%) took antibiotics, 8 patients (1.9%) took antiepileptics and 23 patients (5.34%) used other medications. According to the statistical evaluation of poisoning causes, medication related poisoning was significantly more common than any other reason (p<0.05). There was no significant difference in terms of causes of poisoning between male and female patients (p=0.062). We also determined that among our patients, 293 (91.2%) did not have continuous medication use, while 38 patients (8.8%) used at least one medication continuously. In addition, 36 out of 430 patients (8.4%) had a chronic disease, Table 1. Distribution according to age and gender

n (%)

Gender

Women

Men

Age (Mean±SD)

90.00

278 (64.7) 152 (35.3)

27.4±11.75

Min./Max.: 14/90

80.93

Results A total of 55,752 patients applied to the emergency department within a 1-year period. Four-hundred thirty (0.77%) patients presented to the emergency department with acute poisoning. Among those patients, 278 were females (64.7%). The female/male (F/M) ratio was 1.82/1. According to this ratio, poisoning was significantly more common in females than males (p<0.05) in this study. The average age of female

9.06

8.6

Alcohol

Rodenticide

0.93 Drug

0.46

Caustic substance Organophosphate

Figure 1. Distribution according to the reason for poisoning.

161

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while 394 patients (91.6%) did not have any chronic disease. When we investigated whether poisoning cases in our study were diagnosed with psychiatric illnesses we determined that 372 patients (86.5%) did not have any psychiatric illness, while 58 patients (13.5%) were diagnosed with a psychiatric illness. We also determined that 115 out of 430 patients (26.7%) had previously attempted suicide. Investigation of the time passed between poison intake and emergency department application showed that 237 patients (55.1%) applied to the hospital within the first three hours after intake of the poisoning substance, while for 41 patients (9.5%) it took 3-6 hours, and for 55 patients (12.8%) it took more than 6 hours. We could not obtain information about the time passed between poison intake and emergency department application for 97 patients (22.6%). Three hundred and seventy nine of the acute poisoning patients (88.1%) poisoned themselves as an attempt of suicide, while 51 patients (11.9%) were poisoned accidentally. The admission examinations of poisoning cases determined that physical examination was normal in 373 patients (86.7%) and neurological examination was normal in 371 patients (86.1%). Moreover, the requested laboratory tests were normal for 390 patients (90.7%). Nine out of 430 patients (2.09%) were intubated in the emergency department. Six of the intubated patients were poisoned as a result of multiple medication intake, while 3 of them were poisoned due to antidepressant intake. The time between the poison intake and hospital admission was over 6 hours. While 204 out of 430 patients (47.4%) were discharged from the emergency department, 226 patients (52.6%) were hospitalized for treatment and follow up. Evaluation of the follow-up time at the emergency room showed that 81 out of 430 patients (18%) were followed for 0-6 hours, 32 patients (7.4%) for 6-12 hours, 22 patients (5.1%) for 12-24 hours and 187 patients (43.5%) for followed for more than 24 hours. We

ly Au gu Se pt st em be Oc r to No be ve r m be De r ce m be r

Ja nu Fe ary br ua ry M ar ch Ap r il M ay

0 0 0 0 0 0 0 0 0 0

Figure 2. Distribution according to months.

couldnâ&#x20AC;&#x2122;t reach the information regarding the follow-up time of 108 patients (25.1%). The distribution of emergency department admittance due to poisoning in terms of months is shown in Figure 2. The highest admittance rate was detected in July followed by August and September. When the admittance frequency was evaluated in terms of seasons, summer had the highest frequency of emergency department admittance due to poisoning with 35.6%, followed by autumn (29.1%), spring (19.8%) and winter (15.6%). The frequency of emergency department admittance due to poisoning was significantly higher in summer (p=0.000). There was no significant difference in terms of causes of poisoning between the seasons (p=0.310).

Discussion Although poisoning cases constitute only 1-2% of all emergency cases, such cases are important because they require early intervention and respond well to treatment. According to data from poison control centers 2.3 million cases of poisoning were recorded in the United States in 2011. Among those cases 26.4% had to be treated in a health care institution, while 7.1% required hospitalization. The mortality rate among all cases was 5%.[3] In Turkey, the number of poisoning cases constitute 0.461.78% of all cases admitted to the emergency department. [4-7] However, YaÄ&#x;an et al. reported this rate to be higher, at 2.43%.[8] The percentage of poisoning cases among all emergency department cases varies form 1 to 3% in different countries.[4,5] In our study, this percentage was found to be 0.77% and therefore was consistent with the literature. The poisoning can be accidental or intentional (suicide). Accidental poisoning is more common in children and usually involves corrosive substances,[4,9] while suicidal poisoning is more common in the adult group and is usually associated with medication intake.[4,7,9-11] In our study, the most common cause of poisoning was also medication poisoning, followed by intoxication due to alcohol, and rodenticides, respectively. Zeren et al. also found similar results and reported that medication related poisoning and multiple medication intake were the most common causes of poisoning.[10] When we compared the types of medications taken the most common was multiple medication intake, followed by antidepressants, non-steroidal analgesics and acetylsalicylic acid, respectively. Similar results are available in the literature.[6,7,9] The easy access to analgesic drugs in some cases may lead to misuse of these drugs. In addition, the psychological status of patients using antidepressants may not be stable, making it easier for them to attempt suicide by means of these drugs.

Sari Dogan F et al. The Analysis of Poisoning Cases Presented to the Emergency Department within a One-Year Period

According to the protocol of our hospital, patients over the age of 14 who are admitted to the hospital with poisoning are treated in the adult emergency department. Among 430 patients evaluated in our study 63 patients (14.65%) were between the ages of 14 (included) and 18 years. When these patients were evaluated in terms of causes of poisoning, 52 had been poisoned due to multiple medication intake, 5 due to intake of a caustic substance, 3 due to alcohol and 3 due to rodenticide intake. The assessment of patients over the age of 18 showed that the poisoning causes did not change and the most common cause of poisoning was multiple medication intake followed by caustic substance, alcohol and rodenticide intake. The female/male ratio of poisoning cases has been reported to range from 1.12 - 3 and therefore, poisoning was reported to be more common in females.[5,7,9-13] In our study we determined the female/male ratio to be 1.82/1 and women had a significantly higher poisoning rate (p<0.05). The mean age of female patients was 25.15±9.56 years, while that of males was 31.39±4.14 years. These results were consistent with previous studies conducted in our country. [5,8,10-12] According to these results, young age and female gender can be considered as risk factors for accidental and or intentional poisoning. In the literature, the rate of hospitalization ranges from 5.1% to 84%.[4,5,7,10,11,13] We think that this percentage shows variation due to multiple factors such as the hospital in which the study was carried out being a reference hospital in that area, hospitalization of patients with bad symptoms or the patient being transferred from a different institution. In our study the hospitalization rate was 52.6% and we suggest that it might be because of our hospital being a level-three hospital and the presence of intensive care unit as well as dialysis facilities in our institution. Karcıoğlu et al. reported that 50% of their cases were admitted to the emergency room within first 2 hours of the poisoning,[5] while Akın et al. reported this rate as 57.6%. [11] Similarly, in our study 55.1% of patients were admitted to the hospital within the first 3 hours after the poisoning incident. In 9 patients that required intubation during their treatment process the time elapsed between the poisoning and hospital admission was found to be over 6 hours. The initial step in the general approach in cases with intoxication is stabilization of unstable patients (as it is for all unstable patients). Then, the support therapy specific for the poisoning case is initiated. The decontamination process can be used to reduce the local and systemic effects of the poisonous material.[14] Delayed application to the hospital after poisoning causes delayed decontamination and treatment and therefore we think that this delay might be the one of

the reasons for requirement of intubation to ensure patient stabilization. In earlier studies the mortality rate was reported to range from 0-2.5%.[6,8-10,12] During the period of our study there were no deaths due to poisoning. After the poisoning took place the patients were rushed to the hospital and were treated at an early stage. Therefore, we suggest that early diagnosis and treatment may have prevented mortality. However, since the majority of mortality cases are usually recorded as having suffered from cardiopulmonary arrest and because our study was retrospective we were not able to obtain the patients’ long-term survival information and therefore might not have detected cases of mortality. Poisoning cases were admitted at various times. Zeren et al. reported that December was the month with the most frequent admissions due to poisoning,[10] whereas Sonmez et al reported that admittance due to poisoning was most frequently observed in winter and least frequently observed in fall.[12] On the other hand, Köse et al. indicated that March, April and October were the months with the highest number of suicide attempts.[15] In our study, the most frequent admission to the hospital due to poisoning was seen in summer and in the month of July. Carbon monoxide poisoning is more common during the winter months because of intense usage of stoves for heating.[16] Deniz et al. reported that fungi poisoning was more frequent in October and during the winter months,[7] which was similar to the report by Ecevit et al., who also determined winter months to be the most frequent time for fungi poisoning.[17] Our study does not contain carbon monoxide and fungi poisoning, which might be the reason for why in our study the poisoning rates were lower in winter months. Limitations of the study: Since our study was conducted retrospectively we collected data from forensic notes and protocols and patient files and patients whose data was missing was excluded from the study. Moreover, carbon monoxide and fungi poisoning data were also missing and therefore such cases were not included in the study. In addition, the patients who were admitted to the emergency room with cardiopulmonary arrest, but whose medication intake was uncertain were also excluded from the study. Conclusion The results of our study were similar to previous studies conducted in Turkey. The poisoning cases were more common in women and medication intake was the most common cause of poisoning. By making it more difficult to acquire non-prescription medications and carrying out social investigations to raise awareness of intoxication, especially for the indicated risk groups can contribute to a reduction in poi-

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soning cases. The first place where these cases are admitted is the emergency room and the patients’ early diagnosis and treatment can lead to recovery without any consequences. We believed that emergency department physicians that are performing a differential diagnosis on patients should keep the possibility of poisoning in their mind. Unlike previously reported studies, in our study we found that summer is the most common time for poisonings. Poisoning cases vary by region and we believe that conducting multicenter studies in order to develop national policies would be useful to combat poisoning. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. Salihoğlu G. Zehirlenme epidemiyolojisi. In: Satar S, editor. Acilde klinik toksikoloji. Adana: Nobel; 2009. p. 19-38. 2. Beers MH, Berkow R, editors. The Merck manual of diagnosis and therapy. 17th ed. Merck Research Laboratories, New Jersey 1999. p. 2619. 3. Rhyee SH. General approach to drug poisoning in adults. Available at: http://www.uptodate.com Accessed October 5, 2013. 4. Çetin NG, Beydilli H, Tomruk O. Retrospective evaluation poisoning patients in emergency department. [Article in Turkish] SDÜ Tıp Fakültesi Dergisi 2004;11:7-9. 5. Karcıoğlu Ö, Ayrık C, Tomruk Ö, Topaçoğlu H, Keleş A. Acil serviste yetişkin zehirlenme olgularının geriye dönük analizi. O.M.Ü. Tıp Dergisi 2000;17:156-62. 6. Kurt İ, Erpek G, Kurt MN, Gürel A. Adnan Menderes Üniversitesinde izlenen zehirlenme olguları. ADÜ Tıp Fakültesi Dergisi 2004;5:37-40.

7. Deniz T, Kandiş H, Saygun M, Büyükkoçak Ü, Ülger H, Karakuş A. Evaluation of intoxication cases applied to Emergency Department of Kirikkale University Hospital. [Article in Turkish] Düzce Tıp Fakültesi Dergisi 2009;11:15-20. 8. Yagan O, Akan B, Erdem D, Albayrak D, Bilal B, Gogus N. The retrospective analysis of the acute poisoning cases applying to the emergency unit in one year. [Article in Turkish] Sisli Etfal Hastanesi Tıp Bulteni 2009;43:60-4. 9. Mert E, Bilgin NG, Erdoğan K, Bilgin TE. Acil servise başvuran akut zehirlenme olgularının değerlendirilmesi. Akademik Acil Tıp Dergisi 2006;4:14-9. 10. Zeren C, Karakuş A, Çelik MM, Arıca V, Tutanç M, Arslan MM. Evaluation of intoxication cases applying to the emergency department of medical school hospital. JAEM 2012;11:31-4. 11. Akın D, Tüzün Y, Çil T. Türkiye’ nin Güneydoğusundaki akut Zehirlenme olgularının profili. Dicle Tıp Dergisi 2007;34:195-8. 12. Sönmez E, Karakuş A, Çavuş UY, Cemil Civelek C, İpek G, Zeren C. Bir üniversite hastanesi acil servisine başvuran zehirlenme olgularının değerlendirilmesi. Dicle Tıp Dergisi 2012;39:21-6. 13. Yeşil O, Akoğlu H, Onur Ö, Güneysel Ö. Acil servise başvuran zehirlenme olgularının geriye dönük analizi. Marmara Medical Journal 2008;21:26-32. 14. Prosser JM, Goldfrank LR. Zehirlenen hastaya yaklaşım. In: Satar Z, editor. Acilde klinik toksikoloji. Adana: Nobel; 2009. p. 67-74. 15. Köse A, Eraybar S, Köse B, Köksal Ö, Aydın ŞA ve ark. Patients over the age of 15 years admitted for attempted suicide to the emergency department and the psychosocial support unit. JAEM 2012;11:193-6. 16. Arıcı AA, Demir Ö, Özdemir D, Ünverir P, Tunçok Y. Acil servise başvuran karbonmonoksit maruz kalımları: On dört yıllık analiz. DEÜ Tıp Fakültesi Dergisi 2010;24:25-32. 17. Ecevit Ç, Hızarcıoğlu M, Gerçek PA, Gerçek H, Kayserili E, Gülez P ve ark. Evaluation of musroom intoxications presenting at the emercency department of Dr. Behçet Uz Children’s Hospital. [Article in Turkish] ADÜ Tıp Fakültesi Dergisi 2004;5:11-4.

ORIGINAL ARTICLE

165

Emergency Department During Long Public Holidays Uzun Resmi Tatil Dönemlerinde Acil Servis Seda DAGAR,1 Sibel SAHIN,2 Yunus YILMAZ,3 Ugur DURAK1 Department of Emergency Medicine, Kars State Hospital, Kars; Department of Emergency Medicine, Artvin State Hospital, Artvin; 3 Department of Pediatric Service, Kars State Hospital, Kars 1

SUMMARY

ÖZET

Objectives The purpose of this study is to determine the impact of the expected increase in the volume of patient visits in the emergency department during holiday periods on physicians’ tendencies regarding test and consultation requests as well as on the length of time patients stay in the emergency department.

Amaç Çalışmamızda uzun tatillerde acil servis başvurularında artış beklentisinin, hekimlerin inceleme ya da konsültasyon isteme yönelimine ve acil serviste hastaların kalış süresine etkisi olup olmadığını ortaya çıkarmayı amaçladık.

Methods

Gereç ve Yöntem Çalışmamızda tatil dönemi olarak dokuz günlük Kurban Bayramı tatili kabul edilirken, karşılaştırma grubu ise dokuz günlük tatil dışı bir dönemde acil servise başvuran tüm hastalardan oluşturuldu. Her iki dönemde acil servise başvuran hastalar demografik bilgileri, başvuru nedenleri, komorbid hastalıkları, laboratuvar ve görüntüleme incelemesi yapılıp yapılmadığı, konsültasyon istemleri, acil serviste kalış süreleri ve sonuçlanma şekilleri bakımından karşılaştırıldı.

The study groups included all of the patients who visited the emergency department during the nine-day public holiday (Eid al-Adha, a religious festival of sacrifice) celebrations and a nine-day non-holiday “normal” period. The patients’ demographic information, reasons for their visits, comorbid diseases, whether or not they had undergone laboratory and screening tests, consultations, length of stay, and the way their visits ended were compared statistically. Results Of the 6353 patients enrolled in the study, 3523 (55.5%) were seen in the emergency department during the holiday period, while 2830 (45.5%) were seen during the non-holiday period (p<0.001). During the holiday period, there was a 1.9% decrease in laboratory test requests (p=0.108), a 7.7% increase in radiology examination requests (p<0.001), and a 1.2% increase in consultation requests (p=0.063). The patients’ length of stay during the holiday period was 55.9±75.3 minutes and was 56.3±71.9 minutes during the non-holiday period (p=0.819). The length of time for the patients who underwent tests or consultations was 88.6±92.8 minutes during the holiday period and 92.6±87.5 minutes during the non-holiday period (p=0.224).

Bulgular Tatil döneminde 3523 (%55.5), tatil dışı dönemde 2830 (%45.5) olmak üzere toplam 6353 acil servis başvurusu kaydedildi (p<0.001). Tatil dışı döneme göre tatil döneminde laboratuvar inceleme istemlerinde %1.9 oranında azalma (p=0.108), radyolojik inceleme kullanımında %7.7 oranında artış (p<0.001), konsültasyon istemlerinde %1.2 oranında artış (p=0.063) saptadık. Acil serviste ortalama kalış süreleri tatil döneminde 55.9±75.3 dakika, tatil dışı dönemde 56.3±71.9 dakika olarak bulundu (p=0.819). İnceleme veya konsültasyon yapılan hastaların ortalama kalış süresini tatil döneminde (88.6±92.8 dakika) tatil dışı döneme (92.6±87.5 dakika) göre daha kısa saptadık (p=0.224).

Conclusions As expected, the number of patient visits to the emergency department increased during the holiday period, but this increase did not lead to a similar increase in test and consultation requests by the physicians, except for radiology examination requests. In addition, the length of time that patients stayed in the emergency department was not affected by the increase in the volume of patient visits during the holiday period.

Sonuç Uzun süreli tatillerde acil servislerde beklendiği gibi hasta yoğunluğu artmaktadır. Bu yoğunluk, hekimlerin laboratuvar incelemesi ve konsültasyon istemlerinde artışa yol açmazken, radyolojik inceleme istemlerinde artış gözlenmiştir. Ayrıca acil serviste ortalama kalış süresi başvuru sayısındaki artıştan etkilenmemektedir.

Key words: Consultation; emergency; holiday; length of stay; test.

Anahtar sözcükler: Konsültasyon; acil; tatil; kalış süresi; inceleme.

Submitted: July 02, 2014 Accepted: July 31, 2014 Published online: November 30, 2014 Correspondence: Dr. Seda Dagar. Kars Devlet Hastanesi, Acil Servis, Kars, Turkey. e-mail: sddagar@msn.com

Turk J Emerg Med 2014;14(4):165-171

doi: 10.5505/1304.7361.2014.20438

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Introduction Hospitals are among the vital institutions that face interruption of services during weekends and public holidays. It has been reported that the volume of patients at emergency departments, which are always open, increases during weekends and public holidays due to the interruption of services in other departments.[1,2] Several studies have stated that the disruption at emergency departments during afterhours or holidays is due to the lack of personnel and experienced medical staff as well as limited access to laboratory and radiology services.[3-8] Religious festivals in Turkey are usually celebrated as long public holidays by including both the previous and following weekends. Several reports have shown that there is an increase in the volume of non-emergency patient visits to emergency departments during times where regular clinical services are not offered or limited.[9-11] Regulations passed by the Turkish Ministry of Health regarding “Health services during public holidays” point out the expected increase in workload and volume of patients at emergency departments during public holidays, and recommends precautionary measures be taken in order to avoid serious disruption in health services.[12] However, to our knowledge, there has been no study in the literature reporting whether this increase during the holidays affects physicians’ tendencies to request tests or consultations or the length of stay for patients at emergency departments. Therefore, the purpose of this study is to determine the disruptions of health services during a nine day religious public holiday, and how these disruptions affect patients and physicians at emergency services.

Materials and Methods Kars State Hospital, as a district hospital, provides health care to around 550,000 people, including referrals it receives from neighboring cities. The hospital is home to a secondary emergency department, which serves to around 600 patients a day and approximately 210,000 patients a year. After receiving approval from the local ethics committee, this study was conducted to compare emergency departments during a holiday period and a non-holiday period. All emergency department visits during both periods were included in our study. Consent was obtained from all patients enrolled in the study. Those who did not consent were excluded from the study. The first study group is composed of all patients who visited the emergency department during a nine-day public holiday (Eid al-Adha, a religious festival of sacrifice) between October 12th and October 20th, 2013. Because there is often a temporary increase in the volume of patients visiting the emergency department after the

holiday period, the control group is composed of all patients who visited the emergency department during a nine-day non-holiday “regular” period between September 28th and October 6th of the same year. All patients visiting the emergency department between midnight Friday and midnight of the Sunday on the next weekend were prospectively incorporated into the study. The patients’ demographic information, reasons for their visits, the way they were transported to the hospital, comorbid diseases, whether or not laboratory and screening tests were performed, consultations, length of stay, and how their visits ended were recorded. Both traumatic and non-traumatic cases and reasons for visiting the emergency department were categorized. The data obtained from the both the study and the control groups were compared statistically. Statistical analyses were performed using “Statistical Package for Social Sciences (SPSS) for Windows version 21.0” software (SPSS Inc., IL. USA). Quantitative data and the number of observations are expressed as percentages (%), and the qualitative data are expressed as mean±standard deviation (SD) or median (minimum-maximum). The T test and the chisquare test were used for comparing the data gathered from both groups. A p value <0.05 was considered significant.

Results Of the 6353 emergency department visits included in the study, 3523 (55.5%) were during the holiday period and 2830 (45.5%) were during the non-holiday period, which indicated a 10% increase in the volume of emergency department visits during the holiday period. The difference in visits between the groups was statistically significant (p<0.001). Of the patients visiting during the holiday period, 2051 (58.2%) were male, as were 1550 (54.8%) who visited during the non-holiday period (p=0.007). The mean age of patients who visited during the holiday period was 39.6±19.4 years (range, 1-110 years), and was 39.6±19.9 (range, 1-93 years) for the non-holiday period (p=0.965). During business hours (08:00-16:00), 1828 (51.9%) patients visited the emergency department during the holiday period compared to 1368 (48.3%) patients during the non-holiday period. There was a significant difference in terms of the rate of visits during both periods (p=0.004). The frequency of patients’ comorbid diseases during both periods are listed in Table 1. There were 660 (18.7%) patients admitted due to trauma during the holiday period and 484 (17.1%) during the nonholiday period (p=0.105). The reasons for traumatic and non-traumatic cases visiting the emergency department during both periods are listed in Tables 2 and 3, respectively. The frequencies of physicians’ laboratory and radiology re-

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Table 1. The frequency of patientsâ&#x20AC;&#x2122; comorbid diseases

Holiday period Non-holiday period n %

n %

Hypertension

505 14.3

375 13.3

Chronic obstructive pulmonary disease

203

117

Malignancy

78 2.2

81 2.9

Diabetes mellitus

70 2.0

39 1.4

Coronary artery disease

1.7

Heart failure

0.5

0.3

5.8

4.1

Table 2. The reasons traumatic cases visited the emergency department

Holiday period Non-holiday period n %

n %

Slip and fall

335

9.5

203

7.2

Sharp object injuries

2.2

1.0

Car accidents

1.1

Assault

37 1.1

42 1.5

Fall from height

Burns

12 0.3

11 0.4

Workplace accidents

9 0.3

7 0.2

Animal related injuries Others

0.6

0.2

119 3.4

0.4

0.1

150 5.3

Table 3. The reasons non-traumatic cases visited the emergency department

Holiday period Non-holiday period n %

Upper respiratory infection

698

Abdominal pain

279 7.9

171 6.0

Headache

228 6.5

183 6.5

Chest pain

156 4.4

121 4.3

Hypertensive crisis

133

154

Diarrhea

115 3.3

64 2.3

Asthma-COPD attack

99 2.8

84 3.0

Psychiatric disorders

37 1.1

18 0.6

Poisoning

11 0.3

5 0.2

Gastrointestinal bleeding

0 0.0

1 0.2

Others

quests during both periods are listed in Table 4. The frequencies of physiciansâ&#x20AC;&#x2122; consultation requests during the holiday and non-holiday periods are listed in Table 5.

19.8

n %

3.8

1107 31.4

567

20.0

5.4

978 34.6

There were 3468 (98.4%) patients discharged from the emergency department during the holiday period and 2762 (97.6%) during the non-holiday period (p=0.028). Based on

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Table 4. Physicians’ use of laboratory and radiology tests

Holiday period Non-holiday period

n %

Laboratory test

Requested

1051

Not requested

Radiology test Laboratory test or radiology test

29.8

n % 897

31.7

p 0.108

2472 70.2

1933 68.3

0.108

Requested

1338

38.0

857

30.3

<0.001

Not requested

2185

62.0

1973

69.7

<0.001

Requested

1763

50.0

1366

48.3

0.186

Not requested

1760

50.0

1464

51.7

0.186

Table 5. Physicians’ consultation requests

Holiday period Non-holiday period

n %

Consultation

n %

Requested

255 7.2

169 6.0

0.063

Not requested

3268 92.8

2661 94.0

0.063

emergency department data, some of the patients who were not discharged were hospitalized (holiday period: n=31, 0.9%; non-holiday period: n=36, 1.3%; p=0.157), some were referred to another hospital (holiday period: n=10, 0.3%; non-holiday period: n=9; 0.3%, p=0.817), and some were admitted to the intensive care unit (holiday period: n=8, 0.2%; non-holiday period: n=5, 0.2%; p=0.777). While none of the patients in the study died in the emergency department, some of them refused treatment or left the hospital without notice before their examination and treatment were completed (holiday period: n=6, 0.2%; non-holiday period: n=18, 0.6%; p=0.017). The average length of stay for the patients who visited the emergency department during the holiday period was 55.9±75.3 minutes and was 56.3±71.9 minutes for those visiting during the non-holiday period (p=0.819). The lengths

of stay for the patients visiting emergency services during both periods are listed in Table 6.

Discussion Health services must be provided whenever needed within reasonable wait times. This requires sacrifice by physicians and all other medical staff in order to avoid disruptions in health services during long public holidays. Although official announcements and recommendations are regularly made by the Turkish Ministry of Health before every public holiday indicating the need to take required precautionary measures to manage the expected work overload, disruptions are still common.[12] During holiday periods, the increase in the number of patients visiting the emergency department and the lack of staff and medical equipment cause one to

Table 6. Impact of tests or consultations on the average length of stay inthe emergency department

Duration/minutes p

Mean±SD Laboratory test, radiology

Holiday period (n=1769, 56.3%)

88.6±92.8

test or consultation

Requested

Non-holiday period (n=1370, 43.7%)

92.6±87.5

Holiday period (n=1748, 54.8%)

22.8±22.7

Non-holiday period (n=1442, 45.2%)

22.4±21.5

Not requested

0.224 0.585

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question the quality of medical care in emergency departments during these times.[3-11] The purpose of this study was to examine the impact of increased patient volumes during public holidays on physicians’ tendencies regarding the use of laboratory tests, radiology examinations, and consultation requests, and in addition, how all these factors would affect the length of stay for patients in the emergency department. Similar to previous research, we also found a 10% increase in the volume of patient visits to emergency departments during the long public holiday when compared to a regular, non-holiday period, which was statistically significant. Similarly, Zeng et al. reported a 9% increase in patient visits to the emergency department during holidays, while Yıldırım et al. reported a 32% increase during holidays.[2,9] These increases were due to the closure of most private institutions during holidays, the high volume of referrals received from surrounding hospitals, and the increase in non-emergency patients due the limited health services offered by departments during the holiday. In addition, the revival and mobility in society during free times also can cause increases in visits to the emergency department.[9] The current study highlights the limitations in regular clinical services as the main reason for the increased volume of patient visits to the emergency department. We also found that there were several referrals from other hospitals that do not increase staff during the holiday period and that many patients visited our emergency department because there is no other private hospital in the district. Pekdemir et al. reported that 440 patients visited the emergency department during the nine-day public holiday compared to 407 during non-holiday period. They explained that there was not much difference between holiday and non-holiday periods because most people spent their holidays away from the city.[13] People who live in bigger cities often prefer to spend their holidays outside of their cities. However, in our case, most of the people prefer to go to local villages rather than leave the city. This may be one of the reasons that explain the difference between our findings and the results of Pekdemir et al’s research. In our study, there was a decrease in the physicians’ tendencies to request laboratory tests. Meanwhile, there was a 7.7% increase in requests for radiology examinations during the holiday period. This may be because laboratory tests take more time than do radiology examinations and consultations. The increase in requests for radiology examinations may also be due to the celebrations of Eid al-Adha, which include the slaughtering of livestock, which may cause an increase in injuries due to falls, sharp objects, and animals. While there was a 10% increase in the volume of patient visits during the holiday period, there was just a 1.2% increase in physicians’ consultation requests. This disparity may be

because patients visiting the emergency department during the holiday do not require consultation. In addition, even if required, it is often difficult to reach physicians for consultation during the holidays, which might be another reason for the low increase in consultations. Patients who received laboratory tests and consultation stayed in the emergency department three times longer than those who did not. Again, the 1.6% increase in tests consultation requests during the holiday period, which is not statistically significant, considered together with the 10% increase in patient volume can be explained by physicians’ tendencies to limit the number of tests and consultations to avoid long wait times during holiday periods. Pekdemir et al found that the length of stay for patients in emergency services during the holiday period was 60.3±53.1 minutes and 75.2±60.6 minutes during the non-holiday period, which was statistically significant.[13] Similarly, in our study, the length of stay during holidays (55.9±75.3 minutes) was shorter than the length of stay during non-holiday periods (56.3±71.9 minutes), but this difference was not significant. Moreover, the length of stay for patients receiving tests or consultation was shorter during the holiday periods (88.6 ± 92.8 minutes) than during the non-holiday periods (92.6±87.5 minutes), which was not significant statistically. In conclusion, we found that the increase in the volume of patient visits to emergency departments during holiday periods does not affect their length of stay in emergency departments. This is mostly due to the physicians’ tendencies to limit test and consultation requests to avoid long wait times. Mohammed et al. found that the majority of patients visiting emergency departments and those who were hospitalized during holiday periods were elderly and male.[14] Pekdemir et al. did not report any significant differences between the age of patients visiting during holiday and non-holiday periods.[13] In our study, there was no significant difference between the ages of the patients visiting during either period. However, we did observe that the number of male patients visiting the emergency department during the holiday period was 3.4% higher than those visits during the non-holiday period. We believe that this is because many of the local business are closed during the public holiday. In our study, we observed a 1.6% increase in trauma cases during the holiday period, which was not statistically significant. Yıldırım et al. observed a 5.3% increase in the volume of patient visits due to traumatic reasons during the holiday period, and a 5.3% decrease in the volume of patient visits due to non-traumatic reasons.[9] Pekdemir et al. found that 19.1% of visits were due to traumatic reasons during the holidays and 19.7% during the non-holiday period, which was

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not statistically significant.[13] Yıldırım et al. hypothesized that the 15% increase in car accidents during holiday periods is due to increased travelling and increased consumption of alcohol, while Pekdemir et al. did not observe such a difference in their studies.[9,13] Makela et al. reported that the increase in assault and car accidents during the weekends is due to the increased consumption of alcohol. They also emphasized that the risk of related injuries increases during the holidays and during the following three days, other than weekends.[15] In our study, we observed a 1.6% increase in traumatic cases during the holiday, although this was not statistically significant. In addition, we did not notice any increase in patient visits due to car accidents during the holiday or non-holiday period. This may be because there is no highway around the city, and because the city itself is not at the crossroads of major highways connecting other cities. While there was no significant difference in patient visits due to assault, there was a significant increase in the number of sharp object injuries during the holiday period, which coincided with the religious festival of sacrifice. Yıldırım et al. reported a 5% decrease in workplace accidents during the holidays,[9] while in our study, we noted a 0.1% increase. Although most of the local businesses were closed during the holiday period, patient visits due to workplace accidents were generally low in our study, even during non-holiday period.

reported high mortality rates during weekends, and they addressed the lack of personnel, the impact of shifts, limitations in diagnosis methods, and limited experienced medical staff as the main reasons behind the disorientation in emergency departments.[16,17] Schmulevitz et al. and Cram et al. reported similar results, and referred to this phenomenon as “lost hospital phenomenon during weekend” and “weekend phenomenon,” respectively.[6,18] Seward et al. indicated that the main reasons for the weekend phenomenon include difficulties in finding physicians to work and longer wait times for diagnoses and treatments.[19] Phillips et al. observed that experienced medical staff often refrains from weekend duties and discourages patients from visiting the hospitals during the weekends.[20] As previously mentioned, religious festivals coinciding with weekdays extend the duration of public holidays in our country, and therefore, their impact becomes more significant due to their extended length. We emphasize that although there is an increase in the volume of patients visiting the emergency department during the holiday period, this increase is not reflected in physicians’ requests for laboratory tests and consultations. This is most likely done in order to avoid longer wait times during work overload periods, such as holidays.

We did not observe and significant differences in hospitalizations to regular departments or intensive care units with regards to how patient stay ended in the emergency department. Similarly, Yıldırım et al. and Pekdemir et al. did not find any significant difference regarding the rate of patients being hospitalized.[7,9] Keatinge et al. found that there was a 22% decrease in the number of patients hospitalized during the holiday period. They explained that this was due to physicians’ tendencies to reserve that option only for patients whose health conditions were really critical.[3] In our study, we observed a statistically significant increase in discharge of patients during the holiday period. This result supports previous explanations regarding physicians making their decisions based on the increased workloads and long wait times during the holidays. There was also a statistically significant decrease in the number of patients refusing treatment or leaving the hospital without notice or permission during the holiday period. The possible reason might be the decrease in laboratory test requests or consultations, which extends the wait time of patients. Therefore, the length of stay at the emergency department during the holiday period was not increased.

The holiday period designated for the study is known as Eid al-Adha, which is the feast of sacrifice. Therefore, the reasons for the increased numbers of visits due to traumatic cases and the increase in radiology examinations are most likely due to the way this festival is celebrated, and that is why these findings may not be applicable to other holiday periods.

Turkey is one of the exceptional countries in terms of celebrating such long public holidays. The impacts of short holidays, such as weekends, on patients in different countries have been well studied. Bell et al. and Freemantle et al.

Conflict of Interest

Limitations

Another important limitation of our study is that the hospital that hosted our study is a secondary health institution located in a rural area. Therefore, our findings may not be applicable to many of the other hospitals around the country. Conclusion As expected, we observed that the number of patient visits to emergency services increased during the holiday period. However, this increase did not lead to a similar increase in physicians’ requests for tests and consultations, except for radiology examination requests. In addition, the length of stay for the patients in emergency services was not affected by the increase in the volume of patient visits during the holiday period.

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

Dagar S et al.

Emergency Department During Long Public Holidays

References 1. Salazar A, Corbella X, Sánchez JL, Argimón JM, Escarrabill J. How to manage the ED crisis when hospital and/or ED capacity is reaching its limits. Report about the implementation of particular interventions during the Christmas crisis. Eur J Emerg Med 2002;9:79-80. 2. Zheng W, Muscatello DJ, Chan AC. Deck the halls with rows of trolleys...emergency departments are busiest over the Christmas holiday period. Med J Aust 2007;187:630-3. 3. Keatinge WR, Donaldson GC. Changes in mortalities and hospital admissions associated with holidays and respiratory illness: implications for medical services. J Eval Clin Pract 2005;11:275-81. 4. Sachs L. Firm but fair policies for staff vacations and holidays. J Med Pract Manage 2002;18:42-4. 5. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med 2002;346:1715-22. 6. Schmulewitz L, Proudfoot A, Bell D. The impact of weekends on outcome for emergency patients. Clin Med 2005;5:621-5. 7. Lamn H. The lost weekend in hospitals. N Engl J Med 1973;289:923. 8. DeCoster C, Roos NP, Carrière KC, Peterson S. Inappropriate hospital use by patients receiving care for medical conditions: targeting utilization review. CMAJ 1997;157:889-96. 9. Yildırım C, Sozuer EM, Yurumez Y, İkizceli İ. Emergency department services during long-term holidays. Ulus Travma Acil Cerrahi Derg 2000;6:106-9. 10. Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg

Med 2008;52:126-36. 11. Trzeciak S, Rivers EP. Emergency department overcrowding in the United States: an emerging threat to patient safety and public health. Emerg Med J 2003;20:402-5. 12. http://www.saglik.gov.tr/TR/dosya/1-86291/h/sh3.pdf. 13. Pekdemir M, Durukan P, Yıldız M, Kavalcı C. Satisfaction and demographic analysis of patients addmitting to emergency department on long holiday periods. Fırat Med J 2003;8:149-52. 14. Mohammed MA, Khesh SS, Rudge G, Stevens AJ. Weekend admission to hospital has a higher risk of death in the elective setting than in the emergency setting: a retrospective database study of national health service hospitals in England. BMC Health Services Research 2012;12:87-96. 15. Mäkelä P, Martikainen P, Nihtilä E. Temporal variation in deaths related to alcohol intoxication and drinking. Int J Epidemiol 2005;34:765-71. 16. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med 2001;345:663-8. 17. Freemantle N, Richardson M, Wood J, Ray D, Khosla S, Shahian D, et al. Weekend hospitalization and additional risk of death: an analysis of inpatient data. J R Soc Med 2012;105:74-84. 18. Cram P, Hillis SL, Barnett M, Rosenthal GE. Effects of weekend admission and hospital teaching status on in-hospital mortality. Am J Med 2004;117:151-7. 19. Seward E, Greig E, Preston S, Harris RA, Borrill Z, Wardle TD, et al. A confidential study of deaths after emergency medical admission: issues relating to quality of care. Clin Med 2003;3:425-34. 20. Phillips D, Barker GE, Brewer KM. Christmas and New Year as risk factors for death. Soc Sci Med 2010;71:1463-71.

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ORIGINAL ARTICLE

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The Effects of the Sleep Quality of 112 Emergency Health Workers in Kayseri, Turkey on Their Professional Life Kayseri 112 Acil Sağlık Çalışanlarında Uyku Kalitesinin Mesleki Yaşam Üzerine Etkisi Vesile SENOL,1 Ferhan SOYUER,1 Gulsum Nihal GULESER,2 Mahmut ARGUN,3 Levent AVSAROGULLARI4 Department of First and Emergency Aid Technician, Vocational School of Health, Erciyes University, Kayseri; 2 Department of Surgial Nursing, School of Health Sciences, Erciyes University, Kayseri; 3 Department of Orthopaedics and Traumatology, Erciyes University Faculty of Medicine, Kayseri; 4 Department of Emergency Medicine, Erciyes University Faculty of Medicine, Kayseri

SUMMARY

ÖZET

Objectives Sleep adequacy is one of the major determinants of a successful professional life. The aim of this study is to determine the sleep quality of emergency health workers and analyze its effects on their professional and social lives.

Amaç Uyku yeterliliği başarılı iş yaşamının temel belirleyicilerindendir. Bu çalışmanın amacı acil sağlık çalışanlarında uyku kalitesini belirlemek, mesleki ve sosyal yaşam üzerine etkisini araştırmaktır.

Methods The study was carried out on 121 voluntary emergency health workers in 112 Emergency Aid Stations in Kayseri, Turkey, in 2011. The data was collected through the Socio-Demographics Form and the Pittsburgh Sleep Quality Index (PSQI) and analyzed via SPSS 18.00. The statistical analysis involved percentage and frequency distributions, mean±standard deviations, a chi-square test, correlations, and logistic regression analysis. Results The mean score of the participants according to the Pittsburgh Sleep Quality Index was 4.14±3.09, and 28.9% of participants had poor sleep quality. Being single and being a woman accounted for 11% (p=0.009, 95% CI: 0.111-0.726) and 7% (p=0.003, 95% CI: 0.065-0.564) of poor sleep quality respectively. There was a positive correlation between sleep quality scores and negative effects on professional and social life activities. Negative effects on professional activities included increased loss of attention and concentration (40.0%, p=0,016), increased failure to take emergency actions (57.9%, p=0.001), reduced motivation (46.2%, p=0.004), reduced performance (41.4%, p=0.024), and low work efficiency (48.1%, p=0.008). Poor sleep quality generally negatively affected the daily life of the workers (51.6%, p=0.004), restricted their social life activities (45.7%, p=0.034), and caused them to experience communication difficulties (34.7%, p=0.229). Conclusions One third of the emergency health workers had poor sleep quality and experienced high levels of sleep deficiency. Being a woman and being single were the most important factors in low sleep quality. Poor sleep quality continuously affected daily life and professional life negatively by leading to a serious level of fatigue, loss of attention-concentration, and low levels of motivation, performance and efficiency. Key words: 112 Emergency Health Workers, professional life; sleep quality.

Gereç ve Yöntem Araştırma 2011 yılında Kayseri ilinde aktif hizmet veren 112 Acil Yardım İstasyonunda görev yapan gönüllü 121 Acil Sağlık Çalışanı üzerinde yürütüldü. Araştırmada, Sosyo-demografik Veri Formu ve Pittsburgh Uyku Kalitesi Ölçeği (PSQI) kullanıldı. Veriler SPSS 18.00 versiyonu ile değerlendirildi, istatiksel analizde yüzde ve frekans dağılımları, ortalama±standart sapma, ki kare testi, korelasyon ve lojistik regresyon analizi kullanıldı. Bulgular Pittsburgh Uyku Kalitesi puan ortalaması 4.14±3.09 olan grubun %28.9’unun uyku kalitesi kötü idi. Kötü uyku kalitesinin %11’inden (p=0.009, %95 GA: 0.111-0.726) bekar olmak, %7’sinden (p=0.003, %95 GA: 0.065-0.564) ise kadın olmak sorumlu idi. Uyku kalitesi puanları ile mesleki ve sosyal yaşam etkinliklerinin olumsuz etkilenimi pozitif korelasyon gösterdi, uyku kalitesi kötü olan acil sağlık çalışanlarında, genellikle dikkat ve konsantrasyon kaybı (%40.0, p=0.016), acil müdahalelerde başarısızlık (%57.9, p=0.001), motivasyon (%46.2, p=0.004), performans (%41.4, p=0.024) ve iş verimi (%48.1, p=0.008) düşüklüğü yaşayanların oranı anlamlı düzeyde daha yüksekti. Düşük uyku kalitesi çalışanların günlük yaşam düzenini (%51.6, p=0.004) genellikle olumsuz etkiledi, sosyal yaşam sınırlılıkları (%45.7, p=0.034) ve iletişim güçlüğüne (%34.7, p=0.229) neden oldu. Sonuç Acil sağlık çalışanlarının üçte birinin uyku kalitesi kötü olup, grup düşük düzeyde uyku yeterliliği sorunu yaşamaktadır. Kadın ve bekar olmak uyku kalitesini düşüren en önemli faktörlerdir. Kötü uyku kalitesi hem günlük yaşam düzenini hem de ciddi düzeyde yorgunluk, dikkat-konsantrasyon kaybı, motivasyon, performans ve verim düşüklüğü yaratarak mesleki yaşamı sürekli olumsuz etkilemektedir. Anahtar sözcükler: 112 Acil Sağlık Çalışanları; mesleki yaşam; uyku kalitesi.

Submitted: December 05, 2013 Accepted: February 25, 2014 Published online: November 30, 2014 Correspondence: Dr. Vesile Senol. Saglik Hizmetleri Meslek Yuksek Okulu, Ilk ve Acil Yardım Tek. Bol., Erciyes Universitesi, 38039 Kayseri, Turkey. e-mail: vsenol@erciyes.edu.tr

Turk J Emerg Med 2014;14(4):172-178

doi: 10.5505/1304.7361.2014.60437

Senol V et al.

The Effects of the Sleep Quality of 112 Emergency Health Workers in Kayseri

Introduction Human beings have biological, psychological, social, and cultural needs that must be satisfied to maintain their existence. Sleep is one of such basic requirements.[1,2] Sleep is linked to and compatible with the body’s circadian rhythm. [3] One of the main functions of the circadian rhythm is to prepare one for sleep, which is the rest period for the night. A disturbance to the circadian rhythm leads to a corresponding malfunction in one’s sleep pattern. In fact, sleep quality, as well as its duration, is diminished by working at night, in shifts, or for irregular hours.[4] Prolonged sleeplessness has adverse impacts on human life. Therefore, it is inevitable that a health worker suffering from prolonged sleeplessness owing to the shift system will experience negative influences on his/her mental and physical health.[5] Emergency care service delivery is a profession that requires the shift system. Working during the night influences the extent to which one is ready for and adapted to the next day. Subsequent outcomes may include work accidents and traumas. For example, nurses working in the night shift are commonly observed to experience work accidents associated with scalpel cuts and pricks with injector needles later in the day.[6] Emergency health workers have to work beyond ordinary working hours or days, have duties and responsibilities that potentially pose fatal threats, compete with time, use different technologies, and cause a great deal of stress and pressure. Currently, most work on a 24-hour basis, meaning they are continuously working for 24 hours. They have to cope not only with occupational risks caused by the nature of the night shift but also with the risk of making mistakes brought about by overworking. It is a known fact that long hours and overworking puts one at greater the risk of making mistakes is at work. In fact, it is reported in the literature that nurses who work in 12.5-hour shifts are three times as likely to make mistakes as those who work for 8.5 hours, and that the former group is more susceptible to medicationrelated mistakes and injuries associated with needles.[7] To sum up, research suggests that working in shifts has an adverse impact on one’s physiological and psychological health, thus negatively affecting the security of both workers and patients.[8] There is compelling evidence that working in shifts has a permanent influence on sleep quality. According to the findings of a study on nurses, daytime sleep following the night shift is of rather low quality.[9] Those working during the night sleep two to four hours less than daytime workers and suffer from sleep deficiency, functional disturbances and fatigue. All this information suggests that emergency health workers likely have impaired sleep quality as a result of working in a way not compatible with their natural biological rhythms.

Additionally, impaired sleep of emergency health workers may possibly be reflected in their professional and social life. The purpose of the present study is to identify the sleep quality of emergency health workers and to determine its effects on professional and social life.

Materials and Methods The study was conducted on a total of 121 voluntary emergency health workers who worked for 112 Emergency Aid Stations that actively operated in Kayseri in 2011. The data were collected through face-to-face interviews and two instruments, namely the Socio-Demographics Form and the Pittsburgh Sleep Quality Index (PSQI). The PSQI is comprised of 24 questions. 19 questions are based on self-report and the remaining five are answered by the spouse or roommate. The scored 18 questions contain 7 domains (subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction). Each component is assigned a score ranging from zero to three. The sum of the scores in the seven domains yields the score for the whole scale. Thus, the overall score varies between zero and 21, with higher scores representing poorer sleep quality. A score of ≤5 in the overall PSQI suggests high sleep quality whereas a score of >5 stands for poor sleep quality. For the present study, the effect of sleep quality on professional and social life was measured on a four-point scale (0=Never, 1=Rarely, 2=Often, 3=Always); however, the options often and always were merged into generally in the discussion section.[10]

Statistical analysis The continuous variables were represented in mean scores and standard deviation values whereas the discrete variables were expressed in terms of percentage and frequency distribution. The correlation among the categorical variables was studied via a chi-square test. The correlation between the scores in sleep quality and variables in professional and social life was tested through a Pearson correlation analysis, while a logistic regression analysis was performed in order to identify the factors accounting for poor sleep quality. Sleep quality was identified as a dependent variable. Participants with a PSQI score of zero to five was assigned good=0 as a reference value whereas participants with a PSQI score of six to 20 was assigned poor=1 as a reference value. In addition, such variables as age, gender, educational status, marital status, length of service, and weekly working hours were accepted into the model as independent variables. The level of significance was p<0.05.

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The study was designed in accordance with the Helsinki principles of research.

Results More than half of the participants (56.2%) were women, and 76% of them were 18 to 27 years old. In addition, 59.5% of the workers were single. As for their educational status, 68.6% were high school graduates whereas 31.4% had either an associate degree or bachelor’s degree. Slightly more than half of the participants (52.9%) smoked, and 62% consumed large quantities of tea or coffee (Table 1). Participant demographics were varied. 61.2% of the participants were emergency medical technicians and 20.7% were paramedics. For employment location, 69.4% of the participants worked for Emergency Aid Stations and the remaining 30.6% worked for Command and Control Centers. Nearly two-thirds of participants (64.5%) had been serving for one to five years. 70.2% of the participants worked on a 24-hour basis and 71.7% worked for 48 hours a week. Only 20% of participants functioned as ambulance drivers permanently twice a week. Out of these ambulance drivers, 7.4% were involved in a traffic accident when on duty. Out of all the participants, 86% reported experiencing sleep deficiency at varying percentages (rarely-generally). The mean score of the participants in the Pittsburgh Sleep Quality Index was 4.14±3.09 (min: 0, max: 14), and 28.9% had poor sleep quality (scores of 6 to 14). The prevalence of poor sleep quality was 39.7% (p=0.004) among women, 41.7% (p<0.001) among single participants, 31.6% (p=0.005) among university graduates, 33.4% (p=0.003) among those with a length of service less than five years, 36.5% (p=0.014) among emergency medical technicians, and 64.3% (p=0.002) among those who permanently worked in the night shift (Table 2). The participants with poor sleep quality suffered from loss of attention or concentration (40%, p=0.016), failure to take emergency actions (57.9%, p=0.001), reduced motivation (46.2%, p=0.004), reduced performance (41.4%, p=0.024), and low work efficiency (48.1%, p=0.008). Poor sleep quality led the sufferers to experience negative influences on their daily life (51.6%, p=0.004), restrictions on their social life activities (45.7%, p=0.034), and communication difficulties (34.7%, p=0.229) (Table 3). According to the correlation analysis, poorer sleep quality (higher PSQI scores) led to disturbances in daily life activities (r=0.462, p<0.001) and social life (r=0.375, p<0.001), excessive fatigue (r=0.429, p<0.001), reduced motivation (r=0.318, p<0.001), low work efficiency (r=0.306, p=0.001), reduced performance (0.275, p=0.002), failure to take emergency actions (r=0.300, p=0.001), and loss of attention and

concentration (p=0.237, p=0.009) (Table 4). The regression analysis indicated that two main predictors of poor sleep quality were being a woman (wald: 6.91, p=0.09, 95% Confidence Interval: 0.111-0.726) and being single (wald: 11.07, p=0.001, 95% Confidence Interval: 0.057-0.477).

Discussion Nearly one-third of the participants reported that their sleep quality was poor. Among the main factors in low sleep quality were being a woman and single. In addition to disrupting one’s daily life, low sleep quality also led sufferers to experience excessive fatigue, loss of attention/concentration, lack of motivation, and reduced performance, thereby having negative impacts on their professional life.

Table 1. The distribution of the emergency health workers by their descriptive characteristics Descriptive characteristics

Gender Man

43.8

Woman

56.2

Total

121 100.0

Age groups 18-27

76.0

28-37

21.5

38-46

2.5

Total

121 100.0

Marital status Married

40.5

Single

59.5

Total

121 100.0

Educational status

High school

68.6

Associate degree

27.3

Bachelor’s degree

4.1

Total

121 100.0

Length of service (Years)

≤1-5

79.4

6-10

16.5

16-20

4.1

Total

121 100.0

Weekly work schedule

Day shift (8.00 am-5.00 pm)

4.3

Night shift (5.00 pm-8.00 am)

11.5

Evening shift (5.00 pm-11.59 pm)

14.0

24-hour basis (8.00 am-8.00 am)

70.2

Total

121 100.0

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Table 2. The scores of the emergency health workers in the pittsburgh sleep quality Index in reference to certain characteristics Demographics and professional variables

Sleep quality

Good (PSQI: 0 to 5 p) n=86

Poor (PSQI: 6 to 14 p) n=35

Total

n % n % n %*

Gender Man

45 84.9 8 15.1 53 43.8 0.004

Woman

41 60.3 27 39.7 68 56.2

Marital status

Married

Single

89.8

10.2

40.5

<0.001

42 58.3 30 41.7 72 59.5

Educational status High school

60 72.3 23 27.7 83 68.6 0.005

Associate degree or bachelorâ&#x20AC;&#x2122;s degree

68.4

31.6

31.4

Length of service 0-5 years

64 66.6 32 33.4 96 79.3 0.003

6-20 years

22 88.0 3 12.0 25 20.7

Professional status

Emergency medical technician (EMT)

63.5

36.5

61.1

Emergency medical technician (Paramedic)

72.0

28.0

20.7

Physician-nurse-health officer

95.5

4.5

18.2

0.014

Work Schedule

8.00 am-5.00 pm (Day shift)

80.0

20.0

4.1

5.00 pm-8.00 am (Night shift)

35.7

64.3

11.6

5.00 pm-11.59 pm (Evening shift)

70.6

29.4

14.0

24-hour basis (8.00 am-8.00 am)

76.5

23.5

70.3

0.002

* Column percentage.

Approximately one-third of the participants had low levels of sleep deficiency. Similarly, Machi et al.[11] reported that the prevalence of sleep deficiency was 31% among emergency health workers. Shao et al.[12] found a more profound prevalence of 57% among nurses who worked in shifts. The slight but frequent problems with sleep quality among the participants in our study could be attributed to the fact that the sample was mainly comprised of individuals that were young and within first years of their career, and thus they had not experienced shift intolerance yet. Another reason for the poor sleep quality might be that the great majority of the participants worked on a 24-hour basis. According to the findings of the present study, one crucial factor in low sleep quality was gender. Similar to other studies, this study indicated that women had poorer sleep qual-

ity. Likewise, research on nurses indicates that women have lower sleep quality than men.[13,14] According to Ruggiero,[15] women health workers who work in shifts tend to have poorer sleep quality. In the present study, the women participants were more inclined to fatigue. Similarly, one finding of a study on the general public in Sweden is that women have more sleep-related problems although they sleep for longer than men.[16] Difficulty falling asleep, uneasy sleep and fatigue cause women health workers to have increased stress and to experience physiological disturbances.[16] The other significant factor in poor sleep quality was being single. Similarly, Watanabe et al.[14] conducted a study in a Japanese hospital on female nurses who work shifts, and observed that the effects of shift changes on sleep patterns were less strong among the married women than the sin-

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Table 3. The effect of the sleep quality of the emergency health workers on their professional and social life Variables in professional and social life

Sleep quality

Good (PSQI: 0 to 5 p)

n % n % n %

Sleep deficiency prior to the 24-hour duty Never Sometimes Generally Fatigue Never Sometimes Generally Loss of attention and concentration Never Sometimes Generally Failure to take emergency actions Never Sometimes Generally Reduced job motivation Never Sometimes Generally Reduced job performance Never Sometimes Generally Low work efficiency Never Sometimes Generally Communication difficulty Never Sometimes Generally Negative effects on social life Never Sometimes Generally Negative effects on daily life Never Sometimes Generally

Poor (PSQI: 6 to 14 p)

p Total*

13 76.5 4 23.5 17 14.0 0.285 43 65.2 23 34.8 66 54.5 30 78.9 8 21.1 38 31.4 14 100.0 0 0.0 14 11.6 <0.001 65 77.4 19 22.6 84 69.4 7 30.4 16 69.6 23 19.0 29 90.6 3 9.4 32 26.4 0.016 48 64.9 26 35.1 74 61.2 9 60.0 6 40.0 15 12.4 35 87.5 5 12.5 40 33.1 0.001 43 69.4 19 30.6 62 51.2 8 42.1 11 57.9 19 15.7 22 91.7 2 8.3 24 19.8 0.004 43 74.1 15 25.9 58 47.9 21 53.8 18 46.2 39 32.2 26 86.7 4 13.3 30 24.8 0.024 43 69.4 19 30.6 62 51.2 17 58.6 12 41.4 29 24.0 26 89.7 3 10.3 29 24.0 0.008 46 70.8 19 29.2 65 53.7 14 51.9 13 48.1 27 22.3 25 80.6 6 19.4 31 25.6 0.229 47 65.3 25 34.7 72 59.5 14 77.8 4 22.2 18 14.9 25 78.1 7 21.9 32 26.4 0.034 42 77.8 12 22.2 54 44,6 19 54.3 6 45.7 25 28.9 27 84.4 5 15.6 32 26.4 0.004 44 75.9 14 24.1 58 47.9 15 48.3 16 51.6 31 25.6

* Column percentage.

gle women. According to Vidacek et al.,[17] however, women who are married sleep for significantly shorter following the night shift when compared to those who are not married. Such conflicting findings in the literature might result from the possibility that participants will have different familial/ domestic responsibilities and life styles. To further compli-

cate this issue, Caliyurt[4] reports that marital status has no influences whatsoever on sleep quality. In the present study, poor sleep quality had negative impacts on the participantsâ&#x20AC;&#x2122; professional and social life. It led to fatigue, loss of attention and concentration, failure to take emergency actions, and reduced job motivation and work

Senol V et al.

The Effects of the Sleep Quality of 112 Emergency Health Workers in Kayseri

Table 4. The correlation between the scores of the emergency health workers in the Pittsburgh Sleep Quality Index and the variables in professional/social life Variables in professional and social life

Rho

Negative effects on daily life

0.462

<0.001

Excessive fatigue

0.429

<0.001

Negative effects on social life

0.375

<0.001

Reduced motivation

0.318

<0.001

Low job efficiency

0.306

0.001

Failure to take emergency actions

0.300

0.001

Reduced performance

0.275

0.002

Loss of attention and concentration

0.235

0.009

Communication difficulty

0.151

0.098

efficiency. Sleep quality, as well as its duration, is diminished by working at night, in shifts, or for irregular hours.[18] Emergency health workers represent one of the few professional groups that have to work during the night shift for varying hours for the extent of their career. Working during the night means that one will sleep during the day, which affects sleep both qualitatively and quantitatively. Working for varying hours has two influences on health, namely inability of the body to satisfy its biological rhythm, especially in terms of sleep and digestion, and disruptions in one’s familial and social life. It is reported in the literature that a reduction of a night’s sleep by 1.3 to 1.5 hours diminishes alertness in the following day by 32%.[19] A disturbance in sleep quality as a consequence of working in shifts also influences job performance, as was demonstrated in the present study. From their study looking at the effects of working at night on the circadian rhythm and sleep quality among nurses, Brugne et al.[20] concluded that working at night is not advisable. This study demonstrated that those who work at night generally lack attention between 02.00 and 04.00 am, and recommended that periodical periods of sleep and rest (e.g. at noon) could reduce the negative impacts of working at night. Sleep deprivation among health workers and the negative impacts of fatigue is an interesting and relevant field of study. These subjects have significant impacts on patient safety and the local economy. The influence of sleep on cognitive function and performance are revealed through prospective and retrospective studies.[20-22] Sleep is an important part of human life, and it is necessary for efficient performance. Experimental studies on sleep have demonstrated that sleep deprivation leads to disorders in cognitive functions such as attention-related problems,[23] disturbances in practical functions, memory disorders, perception-related disorders, and affective disorders.[23,24]

Ratcliff et al.[25] reported that sleep deprivation has common but reversible influences on brain functions, especially cognitive functions. They stressed that sleep deprivation results in disturbances in decision-making mechanisms and information quality. Sleep deprivation is also reported to increase the risk of injuries and accidents. Sleeplessness, which results from working in shifts or on a 24-hour basis, is accompanied by mental and physical fatigue owing to irregular sleep patterns, frustration, distractibility, and irritation. Sleeplessness diminishes one’s ability to self-maintain, affecting his or her preparedness for and adaptation to the next day as well as his or her quality of life.[8,26] Human metabolism cannot adjust to working at night, and negative impacts on the body can persist even ten years after this type of working is abandoned.[8] In the present study, it was observed that emergency health workers with poor sleep quality were generally tired. Fatigue is a reaction to insufficient satisfaction of physical and psychological needs. It is also an indicator of the existence of a disease. Fatigue usually prevents one from performing activities that he or she would be able to carry out under normal conditions. It gradually and cumulatively reduces effective performance. Despite this, one can overcome with a period of good sleep. Even so, it is known that the effects of sleeplessness make it hard for one to handle various activities when he or she is awake.[27,28] Our study has some limitations. First, the data was collected through a survey based on subjective reporting. Second, the study did not include a control group comprised of individuals who did not work in night shifts. Finally, our population consisted of emergency health workers in Kayseri, and thus we cannot generalize our results to other occupational groups.

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Conclusion It is necessary for the working conditions at 112 Emergency Aid Stations, along with the length of shifts, to be reorganized. Areas allocated for rest during shifts should be improved and appropriate rest conditions should be established for the period following shifts. This will possibly better the currently poor sleep quality among emergency health workers, thus increasing work efficiency and performance and to enabling health workers to thrive in their profession. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. Öztürk MO. Uyku bozuklukları, ruh sağlığı ve bozuklukları, Yenilenmiş 10. Basım. Ankara: Nobel Tıp Kitabevleri; 2004. p. 479-86. 2. Papilla İ, Acıoglu E. Obstrüktif uyku apne sendromu. Hipokrat Dergisi 2004;13:387–91. 3. Ertekin S. Hastanede yatan hastalarda uyku kalitesinin değerlendirilmesi. Cumhuriyet Üniversitesi Sağlık Bilimleri Enstitüsü Yayımlanmamış Yüksek Lisans Tezi, Sivas, 1998. 4. Çalıyurt O. Sirkadiyen uyku uyanıklık düzenini etkileyen ve çalışma gruplarında uyku kalitesinin değerlendirilmesi. Trakya Üniversitesi Tıp Fakültesi Psikiyatri Anabilim Dalı Yayımlanmamış Uzmanlık Tezi, Edirne, 1998. 5. Demir M. Vardiya sistemi ile çalışan hemşirelerin vardiya sisteminden kaynaklanan sorunlar hakkındaki görüşleri. Hacettepe Üniversitesi Sağlık Bilimleri Enstitüsü Yayınlanmamış Bilim Uzmanlığı Tezi, Ankara, 1990. 6. Sarquis LM, Felli VE. Occupational accidents with sharp instruments in nursing workers. [Article in Portuguese] Rev Esc Enferm USP 2002;36:222-30. [Abstract] 7. Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. The working hours of hospital staff nurses and patient safety. Health Aff (Millwood) 2004;23:202-12. 8. Bilazer FN, Konca GE, Uğur S, Uçak H, Erdemir F, Çıtak E. Türkiye’de hemşirelerin çalışma koşulları. Türk Hemşireler Derneği 2008;12-5. 9. Fischer FM, Bruni Ade C, Berwerth A, Moreno CR, Fernandez Rde L, Riviello C. Do weekly and fast-rotating shiftwork schedules differentially affect duration and quality of sleep? Int Arch Occup Environ Health 1997;69:354-60. 10. Ağargün MY, Kara H, Anlar Ö. Pittsburgh uyku kalitesi indeksinin geçerliliği ve güvenirliği. Türk Psikiyatri Dergisi 1996;2:107-15. 11. Machi MS, Staum M, Callaway CW, Moore C, Jeong K, Suyama J, et al. The relationship between shift work, sleep, and cognition in career emergency physicians. Acad Emerg Med

2012;19:85-91. 12. Shao MF, Chou YC, Yeh MY, Tzeng WC. Sleep quality and quality of life in female shift-working nurses. J Adv Nurs 2010;66:1565-72. 13. Fischer FM, Teixeira LR, Borges FN, Goncalves MB, Ferreira RM. How nursing staff perceive the duration and quality of sleep and levels of alertness. [Article in Portuguese] Cad Saude Publica 2002;18:1261-9. [Abstract] 14. Watanabe M, Akamatsu Y, Furui H, Tomita T, Watanabe T, Kobayashi F. Effects of changing shift schedules from a full-day to a half-day shift before a night shift on physical activities and sleep patterns of single nurses and married nurses with children. Ind Health 2004;42:34-40. 15. Ruggiero JS. Correlates of fatigue in critical care nurses. Res Nurs Health 2003;26:434-44. 16. Edéll-Gustafsson UM. Sleep quality and responses to insufficient sleep in women on different work shifts. J Clin Nurs 2002;11:280-8. 17. Vidacek S, Radosević-Vidacek B, Kaliterna L, Prizmić Z. The productivity of female shift workers. [Article in Croatian] Arh Hig Rada Toksikol 1990;41:339-45. [Abstract] 18. Ertekin Ş, Doğan O. Hastanede yatan hastalarda uyku kalitesinin değerlendirilmesi. Erzurum, VII. Ulusal Hemşirelik Kongresi Kitabı; 1999. p. 222-7. 19. Karagozoglu S, Bingöl N. Sleep quality and job satisfaction of Turkish nurses. Nurs Outlook 2008;56:298-307. 20. Brugne JF. Effects of night work on circadian rhythms and sleep. Prof Nurse 1994;10:25-8. 21. Drummond SP, Gillin JC, Brown GG. Increased cerebral response during a divided attention task following sleep deprivation. J Sleep Res 2001;10:85-92. 22. Bortoletto M, Tona Gde M, Scozzari S, Sarasso S, Stegagno L. Effects of sleep deprivation on auditory change detection: a N1-mismatch negativity study. Int J Psychophysiol 2011;81:312-6. 23. Killgore WD. Effects of sleep deprivation on cognition. Prog Brain Res 2010;185:105-29. 24. McCoy JG, Strecker RE. The cognitive cost of sleep lost. Neurobiol Learn Mem 2011;96:564-82. 25. Ratcliff R, Van Dongen HP. Sleep deprivation affects multiple distinct cognitive processes. Psychon Bull Rev 2009;16:74251. 26. Karagözoğlu Ş, Çabuk S, Tahta Y, Temel F. Hastanede yatan yetişkin hastaların uykusunu etkileyen bazı faktörler. Toraks Dergisi 2007;8:234-40. 27. Dement WC, Carskadon MA. Current perspectives on daytime sleepiness: the issues. Sleep 1982;5 Suppl 2:56-66. 28. Haire JC, Ferguson SA, Tilleard JD, Negus P, Dorrian J, Thomas MJ. Effect of working consecutive night shifts on sleep time, prior wakefulness, perceived levels of fatigue and performance on a psychometric test in emergency registrars. Emerg Med Australas 2012;24:251-9.

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An Adult Patient who Presented to Emergency Service with a Papular Purpuric Gloves and Socks Syndrome: A Case Report Papüler Purpurik Eldiven ve Çorap Sendromu ile Acil Servise Başvuran Yetişkin Bir Hasta: Olgu Sunumu Vehbi OZAYDIN, Alev ECEVIZ, Fatma SARI DOGAN, Arzu DOGAN Department of Emergency Medicine, Medeniyet Universty Göztepe Training and Research Hospital, Istanbul

SUMMARY Rash diseases characterized macules, papules, vesicles and pustules. Many viral infection associated with generalized morbilliform skin rash. Papular purpuric gloves and socks syndrome (PPGSS) is a clinical situation caused by human parvovirus B19. PPGSS occurs at hands and foot through lesions exhibiting symmetrical gloves and socks-like erythematous dispersion. Concomitantly, there are lesions and fever at mouth. A 35 years old woman applied with papular symmetrical eruption at hands and foot, oral lesions and fever. There existed symmetrical rashes at hands and foot and lesions in mouth during her physical examination. Parvovirus İg M positive were determined.The patient who was administered symptomatic treatment was externalized.

ÖZET Makül, papül, vezikül ve püstüllerle seyreden hastalıklara döküntülü hastalıklar denir. Pek çok viral enfeksiyon, jeneralize morbiliform deri döküntüleri ile ilişkilidir. Papüler purpurik eldiven ve çorap sendromu (PPGSS), insan parvovirus B19 virüsünün sebep olduğu klinik bir durumdur. El ve ayaklarda simetrik eldiven ve çorap tarzı lezyonlar ile beraberinde ağızda lezyonlar ve ateş vardır. Otuz beş yaşında kadın hasta el ve ayaklarda papüler simetrik döküntü, aftöz orofarengeal lezyonlar ve ateş ile başvurdu. Fizik muayenesinde el-ayaklarda simetrik döküntüler ve ağızda aftöz lezyonlar mevcuttu. Parvovirus Ig M pozitif saptanan hasta semptomatik tedavi uygulanarak taburcu edildi.

Key words: Emergency service; erythema infectiosum; papular purpuric gloves and socks syndrome (PPGSS); parvovirus B19.

Anahtar sözcükler: Acil servis; eritema infeksiyozum; papüler purpurik eldiven ve çorap sendromu (PPGSS); parvovirus B19.

Introduction

tiosum is the most frequently seen symptom of Parvovirus B19 infection. It occurs most frequently in children between 4 and 11 years of age. Joint ailments such as arthritis and arthralgia are seen more in adults.[1,2] Fetal infection results in hydrops fetalis.

Parvovirus B19 is a single-stranded DNA virus.[1,2] It causes acute infection erythema infectiosum in non-immunocompromised individuals, temporary aplastic crisis in patients with chronic hemolysis, and acquired pure red cell aplasia in those who have immune deficiency. Rash diseases are characterized by macules, papules, vesicles, and pustules. Many viral infections are associated with generalized morbilli-form skin rashes. Erythematous macules and papules, or less often vesicles and petechiae, are usually centrally localized and leave palms and soles free of disease.[3] Erythema infec-

Gloves and socks syndrome, and less often hemophagocytosis, acute hepatitis, and cardiomyopathy can be seen due to this virus. We presented in this case report a gloves and socks syndrome associated with parvovirus B19 in a 35-yearold female patient who was admitted to the emergency service with skin rashes, oral lesions, and fever.

Submitted: March 27, 2013 Accepted: July 11, 2014 Published online: July 18, 2014 Correspondence: Dr. Vehbi Ozaydın. Medeniyet Universitesi Goztepe Egitim ve Arastirma Hastanesi, Acil Tip Klinigi, 34720 Istanbul, Turkey. e-mail: vozaydin@hotmail.com

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Case Report A 35-year-old female patient had the complaints of rashes on her hands and feet, sore throat, high fever, and a burn/sting during urination when she was admitted to the emergency service. The patient, who did not have any known history of disease, had itchy hands and feet about five days before admittance, which sparked a high fever. The patient was conscious, oriented, and cooperative during her physical examination and her physical findings were TA: 120/80 mmHg, pulse 102/min, and fever 39.5Â°C. The patientâ&#x20AC;&#x2122;s neck stiffness and lymphadenomegaly could not be measured. There were aphthous lesions in her oropharyx hyperemic and oral mucosa. She had petechial rashes of the gloves and socks type, and a macular appearance that did not go pale when pressed (Figure 1). Her other system findings were ordinary. Before presenting to the emergency service, she used antibiotics prescribed to her (gentamicin and cefditoren 200 mg) for two days. But when her complaints did not regress, she came to the service. In her tests, the white blood cell count was 6.5 (4.0-10.0 10^3/mm^3), Hemoglobin: 12.1 (11.5-16.0 g/dl), hematocrit: 37.1 (37-43%), serum reactive protein: 6.38 (0.000.800 mg/dL), and TIT: leukocyte esterase (LE) +++ and her biochemical tests were considered normal. She had a normal sinus rhythm in her electrocardiograph with a speed of 102 and there was not any ST-T change. Her troponin I level was also normal. After the initial diagnosis of gloves and socks syndrome, a consultation was requested from the infectious diseases department. The patient was then bedded in the infectious diseases department. When the B19 lgM Positive: 1.219 (<0.572) and parvovirus B19 lgG Negative: 0.419 (<0.402) was observed, the etiology determined to be a acute parvovirus infection. The patient was diagnosed with parvovirus B19-related papular purpuric gloves and socks

Figure 1. In view of the hands and feet macular petechial rash seen.

syndrome and she was discharged when her complaints were gone and after a symptomatic treatment.

Discussion There is a spectrum of clinical conditions caused by parvovirus B19. The most apparent clinical signs are erythema infectiosum, arthritis and arthralgia, intrauterine infection, and hydrops fetalis. It is a persistent infection involving temporary aplastic crises in patients with hemolytic disease and chronic anemia in patients with immune deficiency. Myocarditis, vasculitis, glomerulonephritis, and neurologic involvement are less frequently seen conditions.[1,2,4] Parvovirus B19 infection has been observed as common in worldwide studies carried out in various countries.[2] Erythema infectiosum is the most widely seen clinical symptom of B19 infection. It is seen more in children between 4 and 11 years of age. Suddenly emerging rashes is the first clinical symptom of erythema infectiosum. The rash is a diffuse erythema that occurs in thin papules grouped on the erythematous surface.[5] Joint ailments such as arthritis and arthralgia are seen more in adults.[1,2] Anthony D. et al. found that rashes were seen together with acute arthropathy accompanied by flulike symptoms in females during a parvovirus B19 infection. They also found that arthritis symptoms were seen less in males than in females, and males had flu-like symptoms more often. Arthritis is mostly in the form of synovitis with a sudden onset, pain and rash. It is usually of a transient and self-limited character.[6] Although our patient described pain in her joint regions, we did not find any sign of arthritis. However, fatigue, high fever, and gloves and socks type rashes on her hands and feet indicated that our patient had gloves and socks syndrome. This syndrome, which was first defined by Harms et al. in 1990, is characterized by symmetrical ede-

Ozaydin V et al.

An Adult Patient Who Presented to Emergency Service with a Papular

mas and erythemas on hands and feet that exhibit a gloves and socks distribution, which is accompanied by fever and oral lesions. However, its relationship with parvovirus B19 was not known until 1991.[7] Systemic symptoms including exanthema, mucosal lesions, lymphadenopathy, mild fever, loss of appetite, and arthralgia are seen in PPGSS. Papularpurpuric lesions on hands and feet accompanied by painful and itchy symmetrical erythema and edema are its characteristics. Mucosal findings include petechia, pharyngeal erythema, swollen lips, and painful oral aphthous lesions.[8] Vulvar edema and erythema as well as dysuria have also been described.[9] Often lymphopenia and temporary anemia are seen in laboratory tests, with a less than often elevation in liver enzymes.[8] We did not find any anemia, lymphopenia, or biochemical abnormality in our patient. This syndrome limits itself to a period of 7-14 days. Although our patient did not have any chest pain, she had slight myocarditis, so we took her electrocardiograph. Sinus tachycardia was detected and Troponin I was requested and found to be negative. Patients with rashes and a toxic appearance should be questioned for chest pain, and their electrocardiographs should be taken with follow up appointments. The specific laboratory diagnosis of parvovirus B19 can be made by using a B19 antibody, viral antigen, or viral DNA. However, B19 specific DNA count results can still turn out positive. It will be useful to test DNA amounts with a RealTime PCR in patients with immune deficiency due to insufficient antibody response.[10] In our case, a final diagnosis could be established based on the findings parvovirus B19 lgM Positive: 1.219 (<0.572) and parvovirus B19 lgG Negative: 0.419 (<0.402). A specific antiviral treatment is not available for B19 infection. A symptomatic treatment is hardly required for erythema infectiosum. Most of the time, the disease cures itself without leaving any sequels. The use of aspirin or ibuprofen may be necessary in patients who complain from arthralgia

or arthritis.[1,2] There is no vaccine to treat parvovirus B19, but research ongoing to find a treatment.[1] In conclusion, we presented a case to remind that childhood diseases can, although rarely, be seen in adults who present to emergency services with high fever and rashes. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. Topcu Willke A, Söyletir G, Doganay M. Enfeksiyon hastalıkları ve mikrobiyoloji. 3. baskı. İstanbul: Nobel Tıp Kitap Evi; 2008. p. 1710-7. 2. Brown KE. Human parvoviruses. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and practice of infectious diseases. 7th ed. New York: Churchill Livingstone; 2010. p. 2087-93. 3. Thomas JJ, Perron AD, Brady WJ. Ağır jeneralize deri hastalıkları. In: Judith E, editor. Tintinalli Acil Tıp. İstanbul: Nobel Kitap evi; 2013. p. 1619. 4. Cherry JD. Human parvovirus B19. In: Feigin RD, Cherry JD, Demler GJ, Kaplan SL, editors. Textbook of pediatric infectious diseases. 5th ed. Saunders; 2004. p.1796-809. 5. Bonfante G, Rosenau AM. İnfant ve çocuklarda döküntülü hastalıklar. In: Judith E, editor. Tintinalli Acil Tıp. İstanbul: Nobel Kitap evi; 2013. p. 912. 6. Woolf AD, Campion GV, Chishick A, Wise S, Cohen BJ, Klouda PT, et al. Clinical manifestations of human parvovirus B19 in adults. Arch Intern Med 1989;149:1153-6. 7. Harms M, Feldmann R, Saurat JH. Papular-purpuric “gloves and socks” syndrome. J Am Acad Dermatol 1990;23:850-4. 8. Katta R. Parvovirus B19: a review. Dermatol Clin 2002;20:33342. 9. Harel L, Straussberg I, Zeharia A, Praiss D, Amir J. Papular purpuric rash due to parvovirus B19 with distribution on the distal extremities and the face. Clin Infect Dis 2002;35:1558-61. 10. Işık N, Sabahoglu E, Işık DM, Anak S, Ağafidan A, Bozkaya E. Klinik olarak parvovirus B19 infeksiyonu ön tanılı olguların virolojik takibi. Turk Mikrobiyol Cem Derg 2004;34:62-6.

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CASE REPORT

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Retropharyngeal Hematoma due to Oral Warfarin Usage Oral Varfarin Kullanımına Bağlı Gelişen Retrofarengeal Hematom Ibrahim TOKER, Ozge DUMAN ATILLA, Murat YESILARAS, Burcu URSAVAS Department of Emergency Medicine, Tepecik Training and Research Hospital, Izmir

SUMMARY

ÖZET

Retropharyngeal hematoma due to anticoagulant usage is a rare, life-threatening situation which must be immediately diagnosed and treated. Immediate control of the airway and coagulopathy are the bases of treatment management. Patients often respond to conservative treatment but occasionally urgent tracheostomy and endotracheal intubation may be necessary. We presented a case of retropharyngeal hematoma secondary to warfarin usage in a 49-year-old male.

Antikoagülan kullanımına bağlı retrofaringeal hematom nadir görülen, hızlı tanı ve tedavi edilmesi gereken hayatı tehdit edici bir durumdur. Hava yolu ve koagülopatinin acil kontrolü tedavi yönetiminin esasını oluşturur. Olgular çoğunlukla konservatif tedaviye cevap verirken bazen endotrakeal entübasyon ve acil trakeotomi gerekebilir. Bu yazıda, varfarin kullanımına sekonder retrofaringeal hematom gelişmiş 49 yaşındaki erkek olguyu sunduk.

Key words: Emergency department; retropharyngeal hematoma; warfarin overdose.

Anahtar sözcükler: Acil servis; retrofaringeal hematom; varfarin aşırı dozu.

Introduction

who had had a previous history of mitral valve replacement and oral warfarin usage, was complaining of swallowing difficulty, hoarseness and oral intake disorder. On admission, the patient had a blood pressure of 116/67 mmHg, heart rate of 106/min, temperature of 36.6 °C, peripheral O2 saturation of 97% and respiratory rate of 22/min. Bilateral neck swelling, a few petechia in soft palate and common ecchymosis and edema in pharynx were detected in the physical examination (Figure 1). Except for metallic valve sound, cardiovascular system examination was normal. The patient’s laboratory tests showed activate Partial Thromboplastin Time (aPTT) 81.1 secs, Prothrombin Time (PT) 183 secs, International Normalized Ratio (INR) 15.9, hemoglobin (Hb) 4.9 gr/dL, creatinine 1.6 mg/dL and no electrolyte imbalance, leucositosis or thrombocytopenia. After administration of 10 mg intravenous vitamin K, 3 units of fresh frozen plasma and 5 units of packed red blood cells to the patient in the emergency department, INR and Hb were detected at 1.23

Warfarin and other vitamin K antagonists are used in a variety of clinical situations.[1] By inhibiting vitamin K sycloepoxide reductase and vitamin K reductase enzymes that play a role in α (alpha) carboxylation of factor 2, factor 7, factor 9, factor 10 and other vitamin K related proteins, warfarin prevents the activation of coagulation factors and thus reduces coagulation or inhibits it entirely.[2] Its most frequent side-effect is hemorrhage. Spontaneous hemorrhage as a result of anticoagulation with warfarin is rare, potentially life-threatening and requires individual care for each patient.[3,4] In this article, we present a case with retropharyngeal hematoma due to warfarin overdose.

Case Report

A 49-year-old male with ongoing sore throat for two days presented to our emergency department (ED). The patient,

Submitted: January 13, 2013 Accepted: February 21, 2014 Published online: November 30, 2014 Correspondence: Dr. Ibrahim Toker. Izmir Tepecik Egitim ve Arastirma Hastanesi, Acil Tip Klinigi, Gaziler Caddesi, No: 468, Yenisehir, 35170 İzmir, Turkey. e-mail: ibrahimtoker9@gmail.com

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Toker I et al.

Retropharyngeal Hematoma due to Oral Warfarin Usage

Figure 1. Bilateral neck swelling, a few petechia in soft palate and widespread ecchymosis and edema in pharynx.

and 9.59 g/dl, respectively. In the lateral cervical graphy, prevertebral soft tissue thickness at level C2 was measured at 33.5 mm (Figure 2). Noncontrast enhanced computerized tomography (CT) of the neck was performed and revealed retropharyngeal hematoma spread through to subglottic area from nasopharynx (Figure 2). The patient consulted with internal medicine specialist and otorhinolaryngologist and was admitted to the otorhinolaryngology clinic for follow-up. The patient was discharged following the regression of pharyngeal hematoma and absence of additional problems during his hospital stay.

(a)

Discussion Anticoagulants are commonly used for the treatment and inhibition of arterial and venous thrombosis and thrombosis due to heart valve prostheses.[5] Their usage is troublesome because of the narrowness of therapeutic range and changes in metabolism due to genetic factors, drug interaction and nutrition.[1] Most of the hemorrhage cases that cause obstruction in upper airways due to anticoagulant treatment are retropharyngeal, sublingual or, rarely laryngeal hematomas. [6] Hematomas in the pharynx area may constitute different clinical cases depending upon their mass and development

(b)

Figure 2. (a) Lateral cervical radiography image. (b) Noncontrast enhanced computerized tomography images of the patient.

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speed. Although tenderness and swelling in the neck directly points to this diagnosis, symptoms such as sore throat, shortness of breath, dysphagia, or odinophagia may also point to the same diagnosis.[7] Some cases have reported warfarin-associated upper airway hemorrhage following a severe coughing episode or straining6. Risk of warfarin-associated major hemorrhage significantly increases when INR value becomes >5.08. Anticoagulation must be inhibited with fresh frozen plasma (FFP) or 2.5-5.0 mg intravenous vitamin K in hemorrhages which are thought to be more serious than the risk of thrombosis and cannot be controlled locally.[8] There is no information that indicates thromboembolism risk due to temporary reversion of anticoagulation is more dominant than the results of severe hemorrhage in patients with mechanical prosthesis.[9] Treatment involves providing a secure airway, controlling hemorrhage and correcting coagulopathy. Endotracheal intubation, cricothyroidotomy or tracheostomy may be required depending on the patient’s condition.[10] Most patients with retropharyngeal hematoma can be treated conservatively. Hematoma is mostly cured with conservative treatment, but it might take a few weeks.[11] Retropharyngeal hematoma is a life-threatening complication of anticoagulant treatment. Patients might be admitted with complains such as a sore throat, as in our case. These symptoms might be related to common causes such as upper airway infections, so hematoma might be overlooked. Therefore, hematoma in the pharyngeal area should be considered in admitted patients administered anticoagulants and in whom symptoms such as odinophagia, dysphagia, cough and hoarseness are observed. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. http://www.uptodate.com/contents/therapeutic-use-ofwarfarin-and-other-vitamin-k-antagonists, last access: December 18, 2013. 2. Horton JD, Bushwick BM. Warfarin therapy: evolving strategies in anticoagulation. Am Fam Physician 1999;59:635-46. 3. Howard MR, Hamilton PJ. Anticoagulation and thrombolytic therapy. In: Howard MR, Hamilton PJ, editors. Haematology & An Illustrated Colour Text. 4th ed. UK: Churchill Livingstone; 2013. p. 80-1. 4. Koch CA, Olsen SM, Saleh AM, Orvidas LJ. Spontaneous epiglottic hematoma secondary to supratherapeutic anticoagulation. Int J Otolaryngol 2010;2010:201806. 5. Warkentin TE, Crowther MA. Anticoagulant and thrombolytic therapy. In: Young NS, Gerson SL, High KA, editors. Clinical hematology. 1st ed. St. Louis; Mosby-Elsevier; 2006. p. 111433. 6. Kaya M, Ceylan M, Nesteren S, Yıldırım Ö, Eskiçırak HE, Kadıoğulları AN. Pharynx hematoma due to anticoagulant treatment: case report. Turk J Anesth Reanim 2012;40:287-9. 7. Aslan S, Keşkek Ö, Kesici A. Spontaneous, retro- and parapharyngeal hematoma due to anticouagulant treatment: case Report. Turkish Otolaryngology Archive 2009;47:53-7. 8. http://www.uptodate.com/contents/antithrombotic-therapy-in-patients-with-prosthetic-heart-valves, last access: December 12, 2013. 9. Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G, Baumgartner H, et al. European Society of Cardiology (ESC) cardiac valve diseases treatment guide, 2012 version, Turkish Cardiology Association 2012:83-128. 10. Yaman H, Guven DG, Kandis H, Subasi B, Alkan N, Yilmaz S. Sublingual and supraglottic haemorrhage as a complication of warfarin therapy warfarin: case report. Hong Kong J Emerg Med 2011;18:177-81.

CASE REPORT

185

Cost of Beauty; Prilocaine Induced Methemoglobinemia Güzelliğin Bedeli; Prilokaine Bağlı Gelişen Methemoglobinemi Olgusu Elif KILICLI, Gokhan AKSEL, Betul AKBUGA OZEL, Cemil KAVALCI, Dilek SUVEREN ARTUK Department of Emergency Medicine, Baskent University Faculty of Medicine, Ankara

SUMMARY

ÖZET

Prilocaine induced methemoglobinemia is a rare entity. In the present paper, the authors aim to draw attention to the importance of this rare condition by reporting this case. A 30-year-old female presented to Emergency Department with headache, dispnea and cyanosis. The patient has a history of 1000-1200 mg of prilocaine subcutaneous injection for hair removal at a beauty center, 5 hours ago. Tension arterial: 130/73 mmHg, pulse: 103/minute, body temperature: 37 °C and respiratory rate: 20/minute. The patient had acral and perioral cyanosis. Methemoglobin was measured 14.1% in venous blood gas test. The patient treated with 3 gr ascorbic acid intravenously. The patient was discharged free of symptoms after 48 hours of observation. Emergency physician should consider methemoglobinemia in presentation of dispnea and cyanosis after injection of prilocaine.

Prilokaine bağlı gelişen methemoglobinemi nadir görülen bir durumdur. Bu yazıda epilasyon öncesi kullanılan prilokaine sekonder gelişen methemoglobinemi olgusunu sunarak nadir görülen bu durumun önemine işaret etmek istiyoruz. Otuz yaşında kadın acil servise baş ağrısı, dispne ve siyanoz şikayetleri ile başvurdu. Hastaya beş saat öncesinde bir güzellik merkezinde epilasyon öncesinde yaklaşık 1000-1200 mg prilokain subkutan enjeksiyonu yapıldığı öğrenildi. Başvuruda kan basıncı 130/73 mmHg, nabız 103/dk, vücut ısısı 37 °C ve solunum sayısı 20/dk olarak kaydedilmişti. Hastanın akral siyanozu belirgindi. Venöz kan gazında methemoglobin düzeyi %14.1 olarak ölçüldü. Hastaya 3 g intravenöz askorbik asit uygulandı. Tedavi sonrası semptomları gerileyen ve komplikasyon geliştirmeyen hasta 48 saat sonra taburcu edildi. Acil servis doktorları, prilokain enjeksiyonu sonrası gelişen dispne ve siyanoz ayırıcı tanısında mutlaka methemoglobinemiyi akla getirmelidirler.

Key words: Methemoglobinemia; prilocaine; cyanosis.

Anahtar sözcükler: Methemoblobinemi; prilokain; siyanoz.

Introduction

tachycardia, hypotension, confusion, and even death can be seen in the more severe cases.[1] There are three common causes of methemoglobinemia, including hemoglobinopathies, hereditary enzyme deficiencies (NADH MetHb reductase), and exposure to drugs. Interestingly, hemoglobinopathies and hereditary enzyme deficiencies (NADH MetHb reductase) are the least common causes, whereas exposure to drugs is the most common.[2]

Hemoglobin (Hb) is a molecule which carries oxygen from respiratory organs to the rest of the body. Hb binds to iron in a ferrous (Fe2+) oxidation state under normal conditions. However, the existence of oxidative stress is known to transform iron to ferric iron (Fe3+). Upon oxidation, hemoglobin or methemoglobin (MetHb) cannot bind to oxygen molecules. In methemoglobinemia, the Hb is unable to release oxygen effectively to body tissues. While mild forms of methemoglobinemia can be asymptomatic, cyanosis, tachypnea,

Many chemicals and drugs had been reported to cause toxic methemoglobinemia, including nitrite, nitrate, chlorate, qui-

Submitted: August 20, 2013 Accepted: November 11, 2013 Published online: January 17, 2014 Correspondence: Dr. Gökhan Aksel. Başkent Üniversitesi Tıp Fakültesi Ankara Hastanesi, Mareşal Fevzi Çakmak Mah., 10. Sokak, No: 45, Bahçelievler, Ankara, Turkey. e-mail: gokhanaksel@gmail.com

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nine, aminobenzene, nitrobenzene, nitrotoluenes, phenacetin, chloroquine, dapson, phenytoin, sulphonamides, and local anesthetics.[3] Methemoglobinemia, caused by prilocaine a local anesthesia is rare.[4] Prilocaine, a derivative of toluidine, is an amide local anesthetic and has been shown to produce high MetHb levels.[2,5] Because of its rarity, our knowledge about treatment use is limited. In this paper, we discuss a treatment strategy using ascorbic acid for a patient diagnosed with methemoglobinemia by prilocaine. Research targets and strategies to understand best treatment strategies will be discussed.

Case Report A 30-year-old woman was admitted to emergency department (ED) with complaints of tachycardia, headache, dyspnea, and cyanosis. It was learned from her history that she was anesthetized with 2.5-3 vials (1000-1200 mg?) of prilocaine (citanest®) subcutaneously before a laser hair removal procedure. Although the severity of the symptoms decreased at the time of ED admission compared to the initial time point, her symptoms were still ongoing. The patient’s medical history was unremarkable. The tension arterial rate was 130/73 mmHg, pulse rate was 103/minute, body temperature was 37 °C, and respiratory rate was 20/minute. The pulse oximeter measured O2 saturation as 90%, and she had acral cyanosis. Electrocardiography revealed sinus tachycardia with a rate of 103/minute. Chest radiograph, complete blood counting, renal function tests and electrolytes were all in the normal range. Venous blood gas analyses revealed MetHb as 14.1%. Despite treatment with 4 L/minute O2, her symptoms were still continual. She was admitted to the intensive care unit and 3 grams of ascorbic acid was given intravenously. Two hours after treatment, control MetHb was measured as 2.4%, and the patient was free of symptoms and with no complications. She was discharged as healthy upon a 48 hour of follow up period.

Discussion Prilocaine at therapeutic doses (1-2 mg/kg) can cause limited methemoglobinemia without cyanosis.[6] The maximum safe dose of prilocaine is 8 mg/kg (maximum of 600 mg) as a single injection.[2] In this case, 1000-1200 mg of prilocaine was administered, in which the limits were highly exceeded. The effects of local anesthetic induced methemoglobinemia are known and include seizures, respiratory compromise, myocardial infarction, shock state, coma, hypoxic encephalopathy, and death. In a retrospective study it was reported that most patients with a methemoglobin (≥8%) were symptomatic.[7] In methemoglobinemia resulting from chemical substances,

the first step of treatment is to avoid further exposure. If methemoglobinemia is under 20%, spontaneous recovery is usually observed after drug avoidance, but treatment may be necessary in newborns and infants.[8] Methylene blue, ascorbic acid, and riboflavin have been suggested as treatment modalities.[9] Methylene blue should be administered 1-2 mg/kg intravenously in five minutes, and repeated one hour later if adequate improvement is not observed.[10] It is contraindicated in patients with glucose 6 phosphate dehydrogenase deficiency because administration of methylene blue can cause aggravation of methemoglobinemia, chest pain, cyanosis and hemolytic anemia.[3] In such cases, ascorbic acid can be considered as an antidote.[11,12] Hyperbaric oxygen therapy and exchange transfusion is another option if MetHb level is over 70%. Ascorbic acid reduces MetHb by a non-enzymatic processes in animal and human erythrocytes in vitro, which makes ascorbic acid a candidate for treatment of methemoglobinemia.[13,14] It is most commonly used orally in long term treatment of patients with hereditary methemoglobinemia. [1] Although, methylene blue can be a first choice treatment of methemoglobinemia, if there is limited experience in the use of ascorbic acid in toxic methemoglobinemia.[15] Although MetHb was measured relatively less (14.1%) in the present case, there was an indication of antidote therapy due to the patient being symptomatic. In addition, ascorbic acid was chosen because a limited supply of methylene blue in the hospital. After administration of ascorbic acid, MetHb was measured as 2.4% and she was asymptomatic. Aydogan et al. reported that two patients with methemoglobinemia recovered after ascorbic acid administration.[13] Tekbas et al. also reported an improvement in a patient with combined treatment of methylene blue and ascorbic acid caused by methemoglobinemia due to prilocaine given before intravascular laser therapy.[16] Conclusion Methemoglobinemia resulting from the usage of prilocaine within and out of hospital is a major concern. Methemoglobinemia should be considered in patients who had cyanosis after local anesthetic administration. In cases which methylene blue could not be used as an antidote, ascorbic acid can be a safe alternative. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. Honig GR. Hemoglobin disorder. In: Behrman RE, Kleigman

Kilicli E et al.

2. 3.

4. 5.

7. 8. 9.

Cost of Beauty

RM, Jenson HB, editors. Nelson textbook of pediatrics. Philadelpiha: Saunders; 2004. p. 1478-88. Aygencel SG, Akinci E, Pamukcu G. Prilocaine induced methemoglobinemia. Saudi Med J 2006;27:111-3. Tabel Y, Sandikkaya A, Gungor S, Ozgen U. Methemoglobinemia after injection of prilocaine for pre-medication of circumcision. [Article in Turkish] J Dicle Med School 2009:36:535. Coleman MD, Coleman NA. Drug-induced methaemoglobinaemia. Treatment issues. Drug Saf 1996;14:394-405. Kreutz RW, Kinni ME. Life-threatening toxic methemoglobinemia induced by prilocaine. Oral Surg Oral Med Oral Pathol 1983;56:480-2. Warren RE, Van de Mark TB, Weinberg S. Methemoglobinemia induced by high doses of prilocaine. Oral Surg Oral Med Oral Pathol 1974;37:866-71. Guay J. Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesth Analg 2009;108:837-45. Mansouri A, Lurie AA. Concise review: methemoglobinemia. Am J Hematol 1993;42:7-12. Akıncı E, Yüzbaşıoğlu E, Aslay S, Coşkun F. Incidence of metoclopramide-induced methemoglobinemia. Turk J Emerg Med 2011;11:49-53.

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10. Ryoo S, Sohn Ch, Oh B, Kim W, Lim K. A case of severe methemoglobinemia caused by hair dye poisoning. Hum Exp Toxicol 2014;33:103-5. 11. Gülgün M, Kul M, Sarıcı S. Prilocaine-induced methemoglobinemia: report of two cases and review of literature. Erciyes Tıp Dergisi (Erciyes Medical Journal) 2007;29:322-5. 12. Öztürk E, Aktaş BT, Öztarhan K, Adal E. Lokal anestezik uygulaması sonrası gelişen methemoglobinemi. Jopp Rerg 2010;2:46-8. 13. Aydogan M, Toprak DG, Turker G, Zengin E, Arisoy ES, Gokalp AS. Intravenous ascorbic acid treatment in prilocaineinduced methemoglobinemia: report of two cases. [Article in Turkish] Cocuk Sagligi ve Hastaliklari Dergisi 2005;48:65-8. 14. den Boer PJ, Bleeker WK, Rigter G, Agterberg J, Stekkinger P, Kannegieter LM, et al. Intravascular reduction of methemoglobin in plasma of the rat in vivo. Biomater Artif Cells Immobilization Biotechnol 1992;20:647-50. 15. Ballin A, Brown EJ, Koren G, Zipursky A. Vitamin C-induced erythrocyte damage in premature infants. J Pediatr 1988;113:114-20. 16. Tekbas G, Oguzkurt L, Ozkan U, Gurel K. Prilocain-induced methemoglobinemia after endovenous laser ablation. J Vasc Interv Radiol 2010;21:758-9.

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Spinal Trauma is Never without Sin: A Tetraplegia Patient Presented Without any Symptoms Spinal Travma Masum Değildir: Asemptomatik Başvuran Tetrapleji Olgusu Melis EFEOGLU,1 Haldun AKOGLU,1 Tayfun AKOGLU,2 Serkan Emre EROGLU,1 Ozge Ecmel ONUR,1 Arzu DENIZBASI1 Department of Emergency Medicine, Marmara University Faculty of Medicine, Istanbul; 2 Department of Radiology, Tirebolu State Hospital, Giresun

SUMMARY

ÖZET

Spinal cord injuries are amongst the most dangerous injuries, leading to high mortality and morbidity. Injured patients are occasionally faced with life-threatening complications and qualityof-life changing neurological deficits. Thoracic and cervical spinal segments are the most effected sites of injury and a wide range of complications including paraplegia, respiratory and cardiovascular compromise secondary to autonomic dysfunction or tetraplegia may ensue. We aim to draw attention to the progressive nature of the neurological deficits in a patient admitted asymptomatically. Also, we would like to discuss the importance of swift diagnosis and management in such patients. In asymptomatic patients in whom no fractures are diagnosed with CT scans, a neurological examination should be repeated several times to exclude any neurological injuries that were missed. MRI should be ordered in an emergency setting even though it is not frequently used as a diagnostic modality. This should be done especially in patients without any fractures on CT but with neurological signs.

Spinal kord yaralanmaları yüksek mortalite ve sakatlanma oranlarına neden olan en tehlikeli yaralanmalar arasında sayılmaktadır. Etkilenen hastalarda sıklıkla yaşamı tehdit edici komplikasyonlar ve hastanın hayat kalitesini etkileyen nörolojik bozukluklar gelişebilmektedir. Torakal ve servikal segmentler en sık etkilenen yaralanma yerleri olup, hastalarda otonom disfonksiyona ikincil parapleji, solunumsal ve kardiyovasküler bozukluklar gelişebilir ya da tetrapleji görülebilir. Bu olgu sunumuyla, semptomsuz olarak başvuran bir hastanın nörolojik bozukluklarının ilerleyici doğasına dikkat çekmek istiyoruz. Ayrıca, bu tip hastalarda hızlı tanı ve yönetimin önemini tartışmak istemekteyiz. Semptomsuz olarak başvuran ve bilgisayarlı tomografilerinde kırık saptanmayan hastalarda nörolojik muayene sık aralıklarla tekrarlanarak herhangi bir nörolojik hasarın gelişip gelişmediği izlenmelidir. Acil servislerde manyetik rezonans görüntüleme sık kullanılan tanı testlerinden biri olmamasına rağmen özellikle bilgisayarlı tomografisinde herhangi bir patoloji tespit edilmeyen ancak nörolojik bulguları mevcut olan hastalarda mutlaka istenmelidir.

Key words: Motor vehicle accident; MRI myelography; spinal injury; spinal radiology; tetraplegia.

Anahtar sözcükler: Motorlu taşıt kazası; MR miyelografi; spinal yaralanma; spinal görüntüleme; tetrapleji.

Introduction Spinal cord injury (SCI) is an injury causing temporary or permanent damage to the motor, sensory and autonomic function of the spinal cord. Generally, permanent and progressive neurological disorders are seen.[1] Life threatening complications and neurological disorders affecting quality of life can develop in these patients.

Thoracic and cervical segments are affected most and paraplegia secondary to autonomic dysfunction, respiratory or cardiovascular disorders or tetraplegia can be seen. While SCI patients can rarely present asymptomatically, progressive neurological disorders and death can be seen due to edema and secondary injury. For this reason, all SCI cases

Submitted: August 21, 2013 Accepted: January 05, 2014 Published online: January 07, 2014 Correspondence: Dr. Melis Efeoglu. Marmara Universitesi Pendik Egitim ve Arastirma Hastanesi, Acil Tıp Anabilim Dali, Ustkaynarca, Pendik, 34347 Istanbul, Turkey. e-mail: drhaldun@gmail.com

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should be thoroughly examined and accompanying pathologies must be excluded. In this case report, the progressive nature of the neurological disorders in an asymptomatic SCI case, its diagnostic processes and treatment are discussed, with an attempt to emphasize the importance of the approach to injuries with dangerous mechanisms.

Case Report A 59-year-old male patient with known cervical stenosis was brought to the emergency department by provincial ambulance after being involved in a traffic accident as a pedestrian. The patient was on a trauma board with a cervical collar upon arrival. His general condition was good; he was conscious, cooperative and oriented. His Glasgow Coma Scale score (GCS) was calculated as 15 (E4, V5, M6). The patient’s vital signs were unremarkable except borderline hypotension (blood pressure 90/65 mmHg, pulse 74/min, PSO2 90%, temperature 36.2°C). According to the information obtained from the patient himself, the vehicle struck him on the diagonal directly in the back area and he experienced a temporary loss of consciousness and vision for three to four minutes afterwards. Upon physical examination, other than a 3 cm cutaneous-subcutaneous laceration on the left parietal area, there were no visible injuries. The neurological examination displayed that motor strength was full on all extremities; however, there was decreased rectal tone upon digital rectal examination. The patient was given 1000 cc of saline through a 16 gauge intravenous catheter in both antecubital areas, and tetanus prophylaxis was given. Labora(a)

tory findings were unremarkable (white blood cell: 12.700/ mm3, hemoglobin: 14.3 g/dL, MCV: 81 fL, platelets: 235000/ dl, glucose: 115 mg/dL, urea: 45 mg/dL, creatinine: 1.2, AST: 15 U/L, ALT: 23 U/L, Na: 143 meq/L, K: 3.4 meq/L, INR: 0.98). Transverse, sagittal and axial slice computed tomography (CT) scans (cranial, spinal, thoracic and IV contrast abdominal and pelvic) examinations were evaluated by the on duty radiologist (1st Radiologist), and a verbal and written report was given stating there were no pathological features. However, evaluation of the CT images by Emergency Medicine physicians revealed a stable fracture of the left lamina on C1 vertebrae. Vital sign evaluation repeated approximately one hour later during the follow up of the patient was as follows: blood pressure: 105/70 mmHg, Pulse: 80 pm, PSO2: 98%, temperature: 36.5°C. Repeat physical examination revealed a motor weakness in the lower extremities, followed by loss of touch and motor weakness in the upper extremities. With the patient rapidly progressing to tetraplegia, a full spinal magnetic resonance imaging (MRI) scan, along with a thoraco-abdominal CT angiography to rule out vertebral artery dissection due to the suspected C1 fracture and an aortic dissection if the progressive tetraplegia was caused by a vascular pathology was carried out. In the diffusion MRI of the patient, whose CT had been unremarkable and vascular pathologies were ruled out according to radiology reports (1st and 2nd Radiologists), an acute cerebral infarct (Figure 1) in the parieto-tempero-occipital region was prominent. In the spinal MRI (2nd Radiologist) central protrusions of the intervertebral discs along C2-C7 were exerting pressure on the spinal cord and a narrowing of the antero-posterior diameter of the spinal canal was present; there was edema secondary to contusions on the C2-C3, C3-C4 levels (Figure (b)

Figure 1. (a) Acute infarction in the left parietal-tempero-occipital region in diffusion magnetic resonance imaging. (b) Its ADC diffusion magnetic resonance imaging.

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2a, b); there were compression fractures of the T1-T2-T3-T5T11 vertebral corpus, along with left paracentral protrusions causing compression of the anterior subarachnoid space of the intervertebral discs at the T7-T8 level (Figure 2c, d). The patient was consulted to the Neurology and Neurosurgery Departments, and was admitted by the Neurosurgery Department. Upon no pathology being detected in the Digital Subtraction Angiography (DSA), the patient was operated and C3-to-C6 laminectomy surgery was performed on the same day. The patient, who developed respiratory failure (a)

(c)

two to three hours following the surgery, was intubated and admitted to the intensive care unit. However, the patient died due to cardiac arrest on the same day.

Discussion The average incidence of SCI in developing countries is 25.5 million/year (2.1 and 130.7 million/year). 82.8% of all SCI cases are male with an average age of 32.4 years. The leading causes of SCI are motor vehicle accidents (41.4%) and falls (b)

(d)

Figure 2. Central protrusions of the intervertebral discs at the C2-C7 level exerting pressure on the spinal cord and narrowing the spinal canal in the anterior-posterior diameter. (a) Lysthesis at C2 and C3 on the cervical magnetic resonance imaging, intensity changes due to flexion-distraction type opened and closed fracture of the C3 and a teardrop fracture, (b) CT images of the same levels. (c) Compression fractures of the vertebral corpus of T3 and T11, and possible degenerative changes on T1, T2 and T5 on MRI, (d) CT image of the same level.

Efeoglu M et al.

A Tetraplegia Patient Presented Without any Symptoms

(34.9%). Complete SCI is more common than incomplete SCI (56.5% to 43%), and paraplegia is more common than tetraplegia (58.7% to 40.6%).[2] Firearm injuries, sports injuries, and diving accidents can also be included among other etiological factors.[3] The cervical level (C5) is the most commonly affected area. [4] The pathophysiology of spinal injury generally consists of direct damage to the medulla spinalis by trauma, compression due to bone fragments, hematomas and disc material, ischemia as a result of spinal artery injuries and the accompanying tissue edema.[5] In studies carried out to evaluate the blood flow in the dorsolateral cord in severe spinal trauma, it has been shown that for 60 to 90 minutes following cord damage autoregulation mechanisms remain intact; however, simultaneously with the onset of ischemia this continuity begins to be disrupted. As a response to SCI, both disruption of autoregulation and vasoconstriction of resistance blood vessels develops. In the early post-traumatic period, intervention aimed at ensuring perfusion can be valuable in terms of reverting or limiting loss of function due to secondary damage caused by ischemia.[6] In a study by Morais DF et al. it was shown that MRI was distinctly superior to CT in terms of evaluating bone structure, in posterior ligament injuries, spinal cord compression and disc herniation.[7] In our case, the 1st Radiologist reported no osseous pathologies from the CT scan, however the 2nd and 3rd Radiologists reported a fracture of the left C1 lamina. The two Radiologists evaluating the MRI (2nd and 3rd Radiologists) identified cervical and thoracic fractures which were unapparent on the CT. The 2nd Radiologist was an experienced faculty member tasked with routine reporting at the hospital where the case presented, and the 3rd Radiologist was a physician with 10 years of academic experience working in a different city (TA), who was invited to review images blindly upon the preparation of this article. Both radiologists had the same opinion that central protrusions of the intervertebral discs exerting pressure on the spinal cord along C2-C7, edema/bleeding was prominent at C2-C3, C3C4 levels secondary to contusion, and apparent compression fractures of T3 and T11 along with the degeneration of T1, T2 and T5 (Figure 2a-d). Additionally, in the evaluation carried out by the 3rd Radiologist, minimally displaced flexion-distraction type fracture from the frontal section of the lower plateau of the C3 vertebra corpus towards the uppermid section, with a tear drop fracture, a minimal retrolisthesis of the C3 according to C4, along with Modic type 2 bone marrow signal intensity changes consistent with degeneration of the T1, T3 and T5 vertebra corpuses and Schmorl nodule indentations were noted. During surgery, loss of the

complete integrity of the C3 vertebra was determined and laminectomy surgery was performed on adjacent vertebrae. Thus, the C3 vertebra extension-distraction and tear-drop fractures were responsible for the spinal cord bleeding, which could not be determined by three separate radiologists and the emergency medicine physicians on the CT, and which was only determined by one of two radiologists reporting the MRI, was clinically diagnosed. The bilateral sensory-motor loss is accepted as an indication of complete SCI. The lack of neuromotor loss upon admission in our case, followed by motor and sensation loss starting from the shoulder level leading to tetraplegia shows that the edema/bleeding due to contusions at the C2-C3-C4 levels were increased and led to a complete SCI. Since updated SCI treatment guidelines (2013) do not recommend high-dose methylprednisolone anymore, immediate surgical treatment of the patient was planned.[8] Vertebral artery injuries (VAI) may accompany cervical injuries, their mortality is high and they can lead to ischemic stroke.[9] Upper level vertebral fractures (such as C1-C3) - including transverse foramen fractures - are particular risk factors for vertebral artery injury.[10] Today, CT angiography is the diagnostic method of choice for VAI. DSA is also one of the commonly used imaging methods. It has been reported that despite all anticoagulant therapy, fatal complications such as cerebrovascular insufficiency or embolus may develop in 5.8% of patients, while 2.9% of patients die due to cerebrovascular ischemia.[11] In VAI, treatment options are anticoagulants, antiplatelets, thrombolysis, endovascular or surgical treatment.[12-14] In our case, VAI was excluded by the lack of thrombus or dissection of the vertebral artery from CT angiography, which was ordered upon the presence of the stable C1 lamina fracture (one of the risk factors) and worsening findings upon neurological examination. This data suggests that the acute ischemic lesion in the left parieto-temporo-occipital region detected in the diffusion MRI of our patient may have not been developed due to VAI, but may have developed due to hypoperfusion leading to loss of consciousness. Neurogenic shock may develop in a portion of patients with spinal trauma[15] and can cause neurological disorders to progress to levels which may threaten the patientâ&#x20AC;&#x2122;s life. Spinal stabilization of the patients, vasopressor treatment with fluid support and early surgical decompression of the spinal cord are accepted treatments.[16] In a study by Tuli et al. delayed surgical treatment has been shown to be associated with the development of neurogenic shock.[17] Our patient had a blood pressure of 90/65 upon presentation, and the absence of a source of bleeding to explain the hypotension suggests that the patient may actually have

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been developing neurogenic shock. The acute cerebral infarct which appeared in the diffusion MRI of the patient may have developed secondary to hypotension due to neurogenic shock. Additionally, the loss of consciousness for a period of three to four minutes upon the accident and the SPO2 being 90% upon presentation may have contributed to the development of the cerebral infarct. In this context, we believe that our patient, where cerebral infarct and complete high spinal injury developed due to progressive edema, highlights the importance of a skeptical approach to patients presenting with asymptomatic spinal trauma, and not delaying advanced examination by putting forward the indications on radiological imaging. Respiratory failure, multiple organ failure and gastrointestinal bleeding are the leading causes of death in these patients.[18] In the light of this information, it is of vital importance that emergency physicians predict the possible complications that can develop and take the necessary precautions. Conclusion Spinal trauma is likely to cause neurological disorders. In asymptomatic patients in whom no fractures were diagnosed in CTs, neurological examination should be repeated several times to exclude if any neurological injuries were ensued. Even though it is not a frequent diagnostic modality, especially in patients without any fractures on CT but who have neurological signs, MRI should be ordered in emergency department. Conflict of Interest The authors declare that there is no potential conflicts of interest.

References 1. Dincer F, Oflazer A, Beyazova M, Celiker R, Basgöze O, Altioklar K. Traumatic spinal cord injuries in Turkey. Paraplegia 1992;30:641-6. 2. Rahimi-Movaghar V, Sayyah MK, Akbari H, Khorramirouz R, Rasouli MR, Moradi-Lakeh M, et al. Epidemiology of traumatic spinal cord injury in developing countries: a systematic review. Neuroepidemiology 2013;41:65-85. 3. Bellon K, Kolakowsky-Hayner SA, Chen D, McDowell S, Bitterman B, Klaas SJ. Evidence-based practice in primary prevention of spinal cord injury. Top Spinal Cord Inj Rehabil

2013;19:25-30. 4. James G. Adams MD FACEP. Clinical Essentials of Emergency Medicine, September 19, 2012 | ISBN-10: 1437735487. 5. Wilson JR, Fehlings MG. Emerging approaches to the surgical management of acute traumatic spinal cord injury. Neurotherapeutics 2011;8:187-94. 6. Senter HJ, Venes JL. Loss of autoregulation and posttraumatic ischemia following experimental spinal cord trauma. J Neurosurg 1979;50:198-206. 7. Morais DF, de Melo Neto JS, Meguins LC, Mussi SE, Filho JR, Tognola WA. Clinical applicability of magnetic resonance imaging in acute spinal cord trauma. Eur Spine J 2014;23:145763. 8. Hadley MN, Walters BC. Introduction to the Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries. Neurosurgery 2013;72 Suppl 2:5-16. 9. DeVivo MJ, Chen Y, Mennemeyer ST, Deutsch A. Costs of care following spinal cord injury. Top Spinal Cord Inj Rehabil 2011;16:1-9. 10. Savitz SI, Caplan LR. Vertebrobasilar disease. N Engl J Med 2005;352:2618-26. 11. Mueller CA, Peters I, Podlogar M, Kovacs A, Urbach H, Schaller K, et al. Vertebral artery injuries following cervical spine trauma: a prospective observational study. Eur Spine J 2011;20:2202-9. 12. Vaccaro AR, Klein GR, Flanders AE, Albert TJ, Balderston RA, Cotler JM. Long-term evaluation of vertebral artery injuries following cervical spine trauma using magnetic resonance angiography. Spine 1998;23:789-95. 13. Dziewas R, Konrad C, Dräger B, Evers S, Besselmann M, Lüdemann P, et al. Cervical artery dissection-clinical features, risk factors, therapy and outcome in 126 patients. J Neurol 2003;250:1179-84. 14. Keilani ZM, Berne JD, Agko M. Bilateral internal carotid and vertebral artery dissection after a horse-riding injury. J Vasc Surg 2010;52:1052-7. 15. Popa C, Popa F, Grigorean VT, Onose G, Sandu AM, Popescu M, et al. Vascular dysfunctions following spinal cord injury. J Med Life 2010;3:275-85. 16. Maurin O, de Régloix S, Caballé D, Arvis AM, Perrochon JC, Tourtier JP. Traumatic neurogenic shock. [Article in French] Ann Fr Anesth Reanim 2013;32:361-3. [Abstract] 17. Tuli S, Tuli J, Coleman WP, Geisler FH, Krassioukov A. Hemodynamic parameters and timing of surgical decompression in acute cervical spinal cord injury. J Spinal Cord Med 2007;30:482-90. 18. Leng YX, Nie CY, Yao ZY, Zhu X. Analysis of the risk factors for early death in acute severe traumatic cervical spinal cord injury. [Article in Chinese] Zhonghua Wei Zhong Bing Ji Jiu Yi Xue 2013;25:294-7. [Abstract]

REVIEW

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Some Ethical Issues in Prehospital Emergency Medicine Hastane Öncesi Acil Tıpta Bazı Etik Konular Hasan ERBAY Department of History of Medicine and Ethics, Afyon Kocatepe University Faculty of Medicine, Afyonkarahisar

SUMMARY

ÖZET

Prehospital emergency medical care has many challenges including unpredictable patient profiles, emergency conditions, and administration of care in a non-medical area. Many conflicts occur in a prehospital setting that require ethical decisions to be made. An overview of the some of ethical issues in prehospital emergency care settings is given in this article. Ethical aspects of prehospital emergency medicine are classified into four groups: the process before medical interventions, including justice, stigmatization, dangerous situations, and safe driving; the treatment process, including triage, refusal of treatment or transport, and informed consent; the end of life and care, including life-sustaining treatments, prehospital cardiopulmonary resuscitation (CPR), withholding or withdrawal of CPR, and family presence during resuscitation; and some ambulance perception issues, including ambulance misuse, care of minors, and telling of bad news. Prehospital emergency medicine is quite different from emergency medicine in hospitals, and all patients and situations are unique. Consequently, there are no quick formulas for the right action and emotion. It is important to recognize the ethical conflicts that occur in prehospital emergency medicine and then act to provide the appropriate care that is of optimal value.

Hastane öncesi acil tıp, öngörülemeyen hasta profili, acil durumlar ve tıbbi olmayan bir alanda sağlık hizmeti veriliyor olmasından ötürü çeşitli sorunlar içermektedir. Pek çok ikilem ortay çıkmakta ve bu türden ikilemlere etiği ilgilendiren kararlar vermek gerekmektedir. Bu çalışmada genel bir çerçeve dahilinde, hastane öncesi acil tıp alanında ortaya çıkan bazı etik konulardan bahsedilmektedir. Bu bağlamda konu dört ana başlık halinde ele alınmıştır: (1) Tıbbi müdahale başlamadan önceki süreçle ilişkili etik konular; acil sağlık hizmetinin adil dağıtımı, damgalanma, tehlikeli durumlara müdahale ve güvenli sürüş, (2) tedavi sürecindeki etik konular; triaj, tedavi ya da nakil reddi, aydınlatma ve onam alma, (3) yaşam sonu ve yaşam sonu bakımla ilgili etik konular; yaşam destek/sürdürme tedavileri, kardiyo-pulmoner resüsitasyon (CPR), resüsitasyona başlamak ya da onu sürdürmemekle ilgili konular ve (aile) tanıklı resüsitasyon, (4) ambulans hizmetleriyle ilgili sosyal algı ile ilgili konular; ambulans (kötüye) yanlış kullanımı, çocukların acil tıbbi tedavisi ve kötü haberi verme. Hastane öncesi acil tıpta; her bir hasta ve onunla bağlantılı süreçler kendine has olduğundan dolayı, tıp etiğini ilgilendiren konularla ilgili daha iyi bir eylem ve duruş için, önceden hazırlanmış bir takım davranış formülleri vermek olanaksızdır. Hastane öncesi acil tıpta önemli olan, etik sorunun farkına varmak ve etik açıdan en az değer harcayan eylemi tercih edebilmektir.

Key words: Ethical conflicts; ethics; prehospital emergency medicine.

Anahtar sözcükler: Etik sorunlar; etik, hastane öncesi acil tıp.

Introduction Medical care is based on many applications and occurs between health care providers and patients. In this process, many value choices, including ethical ones, can be made instinctively based on individual beliefs, commitments, and habits.[1] However, in some cases, patients and physicians may disagree on certain values, and ethical problems arise.[2]

Emergency medical care is a crucial part of hospital-based care. The things that make it different from other areas of medical care include the necessity to react quickly, restricted time to consider medical and ethical aspects of the case or situation, and an absence of prior knowledge about the patients.[3] Obviously, it is very difficult to think through every aspect of the situation in a short period of time. Prehospital

Submitted: June 27, 2014 Accepted: August 27, 2014 Published online: November 30, 2014 Correspondence: Dr. Hasan Erbay. Afyon Kocatepe Universitesi Tip Fakultesi, Dekanlık Binasi, B Blok, Tip Tarihi ve Etik Anabilim Dalı, Afyonkarahisar, Turkey. e-mail: hasanerbay@yahoo.com

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emergency medical care has many different characteristics, including unpredictable patient profiles, emergency conditions, and administration of care in a non-medical area. Additionally, it is a team-based process. This article addresses general ethical issues, especially conflicts that occur in prehospital emergency medicine that are not situations that might differ by country. Prehospital care is delivered by emergency physicians in some countries and by emergency medical technicians or nurses in others. It should be stated that the term “prehospital emergency caregivers” (PECs) is used in this article to refer to any physicians, emergency technicians, nurses, or paramedics. Many of the conflicts occur in the same way across countries and require an ethical decision to be made. It is high time to turn attention to the ethical issues in prehospital medicine. The following overview describes the range of ethical conflicts that occur in prehospital emergency care settings; however, it avoids attempting to try to solve the conflicts. In the context of operation of the ambulance dispatch system, ethical issues can be classified into four categories: 1- Process before medical interventions 2- Treatment process 3- End of life and care 4- Perceptions of using/misusing the ambulance. 1. Ethical issues related to the process before medical interventions: a. Justice: Justice is a primary ethical principle that expects caregivers to try to be as fair as possible to the patients.[1] It comes into conflict particularly when there are many emergency calls and not enough ambulances. Justice may not be straightforward in the situations such as scarce medical resources. Justice is primarily an issue related to the emergency dispatch call center. The cases in which a preference is involved also raise ethical concerns. b. Problems associated with finding an address: Finding an address in a short period of time requires a strong and effective technical support infrastructure. Indeed, there is no point in having the best medical knowledge, skills, or ambulances if a patient cannot be reached in time. The prognosis of the emergency case can be affected by this delay. Thus, it is important to have a strong and effective technical support for prehospital emergency care so as not to delay treatment of emergency patients. It might appear to be simply a basic technical issue, but it is truly an important ethical issue related to the basic principle of beneficence/nonmaleficence as well.

c. Stigmatization: Stigmatization in prehospital settings occurs in relation to individuals’ diseases, locations, and the social or cultural criticism that may accompany them. Stigmatization occurs socially and culturally in PECs’ minds before any medical inventions. Examples include administering care to alcoholics, drug addicts, sex workers, and terminal cancer patients. Before first contact is made, stigmas and prejudices held by PECs can affect the care administered in prehospital emergency medical care. It is an ethical conflict for PECs whether or not to act in accordance with a perceived stigma. d. Interventions in dangerous situations: Some prehospital settings pose dangerous conditions for emergency teams. These settings include war zones, traffic accidents, and areas at risk of fire or explosions. These situations, which put an ambulance crew at personal risk, raise ethical conflicts. The crucial question is whether or not PECs should risk their own lives for injured individuals.[4] One ethical dilemma is whether or not the duty of emergency care includes placing oneself at risk. It is a crucial question for prehospital emergency settings, and whatever the answer, it could include very important ethical issues /conflicts. e. Safe driving: It is important to drive an ambulance in accordance with general traffic rules. In the class of a mid-size car, an ambulance must be driven within the speed limits in a safe manner. There are many studies about the effects of siren and light usage in relation to the time of arrival to the hospital.[5] Someone who is speeding while driving to act on behalf of the patient risks their own safety and health as well as the patient’s. Such a situation is much more related to altruism, which is an ethical term. It is not easy to justify because the PECs should ensure their own safety.[4,6] 2. Ethical issues which are related to the treatment process: a. Beneficence/nonmaleficence: As a basic principle for all medical practice, beneficence/nonmaleficence is also clinical in medical emergencies. The arising ethical conflict is the issue of what is better for the patient. PECs are supposed to act for the benefit of the patient.[7] But what about (or to whom) the beneficence of the patient? What is the beneficence? Is it just a medical beneficence? It is the value of professionalism and responsibility of PECs to be aware of individuals’ psychological and emotional state. b. Triage: Triage is one of the most important ethical issues of emergency medicine.[7,8] In this article, two basic approaches on this issue have been mentioned, and extensive evaluations have been referred to in other studies. The main issue is the evaluation and selection criteria. Most education systems emphasize maximum benefit. However, it is very

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difficult to standardize the meaning of “maximum benefit”. Does maximum benefit prioritize the age of the patients, calculated life expectancy, or contribution to society? Is it just the sheer number of patients saved? As demonstrated, the selection and evaluation process during triage contains many ethical conflicts. Thus, this area needs more information and discussion; maximum beneficence is one of two approaches, while the other is to give each patient an equal chance in emergency situations.[9] The first approach focuses on result while the second puts an emphasis on intention. c. Refusal of treatment: In a case of refusal of treatment, PECs face ethical conflicts addressing two basic principles: beneficence and respect for patient autonomy.[10] The main point of this conflict is assessing the patient’s decision-making capacity. However, there is no point in assessing the patient’s capacity if you do not administer care. It is the critical zone in emergency medicine, but PECs are not required to assess the decision-making capacity of the patient. It is difficult to properly assess this capacity in a short period of time. However, the presence of advance directives might make conflicts easier to resolve, but it should be remembered that the status of advance directives is not described clearly in many countries. d. Refusal of transport to hospital: When patients do not want to go to the hospital, it creates an ethical conflict between the patient’s desire and the duty of PECs. The patient may believe that it is probably not necessary to go to the hospital. The patient perceives an easy solution with medical interventions at home; however, the emergency crew might not agree with that solution. e. Irrational requests of relatives (or bystanders): The ethical responsibility of a health professional is not only in regards to him- or herself and his or her patients, but also the professional value. For example, a relative might irrationally request an unnecessary ambulance ride or refuse treatment for their relative. It is a conflict that arises between the patient’s best interest and PECs’ professional roles.[11] f. Dealing with difficult patients: The term “difficult patient” refers to two meanings here: those who are intoxicated (by alcohol or drugs), or those who are terrified, obstinate, or agitated. These two main reasons may cause difficult patient cases: the patient is aware of being in a non-hospital environment and therefore acts override of the formal pressure of health care systems; or the patient is anxious/nervous as a result of his/her illness. Effective communication skills are necessary to deal with these patients. Being aware of the patient’s point of view is important in this instance.

g. Relationships within the crew: Prehospital care personnel are expected to work together, ignoring real or imagined differentiations and egos.[6] Some differences in opinion about the emergency patient or the process can lead to ethical conflicts in the crew. Additionally, some cases with structure of personality of health care professionals can cause the similar conflicts. It is about the best interest of the emergency patient, and it could be affected by many individual or professional factors. For example, ambulance nurses act according to how they would want to be treated in the same situation.[12] h. Relationship between other care professionals: Different care professionals could be in conflict about what it is in the best interest of the patient.[13] PECs might think it is best for the patient to be transported. However, somebody in the hospital care system may not agree with them. Prehospital emergency needs and hospital needs could be in conflict. It is worth mentioning that sharing the responsibilities and identifying a novice or experienced actor are the main determinants of conflicts. i. Informed consent: Informed consent is one of the most common ethical issues and conflicts encountered by PECs. [14] It is a valuable professional practice when the patient can make his/her own health care decision. But in some prehospital settings, the patient is not in a situation that facilitates this decision. Therefore, two questions arise:[4] “When do patients lack capacity?” and “Who makes the decision?” The competency of the patient is important with regards to informed consent. A patient not only needs to be competent to make a decision, but also to have enough time to be informed properly. Unfortunately, as is the case in many prehospital settings, there is insufficient time or unsuitable conditions for informed consent. A medical emergency is an exception to the requirements of informed consent.[1] This is based on the presumption that a reasonable patient would consent to such kind of treatment. The conflict arises over whether the case should be an exception, and whether or not the patient is a reasonable person. j. Decision-making capacity: This is also related to informed consent. After some emergencies, the patient is unable to make his own decision, and PECs must be aware that the patient has an impaired decision-making capacity. Assessing the decision-making capacity is quite difficult and complicated in prehospital settings.[15] Physicians are frequently unaware of a patient’s incapacity for decision making.[16] This difficulty further complicates the situation for non-physician emergency health care professionals. k. Patient privacy and confidentiality: Prehospital emergency settings may involve a patient’s home or place of work. In

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these cases, PECs need to pay more attention to the privacy and confidentiality of the patient. PECs need to maintain privacy with regards to the individual’s health information, privacy, physical condition, private life, and lifestyle.[17] This principle also applies to the rights of a person who died (or is newly dead). Due to variations in perception changing from person to person about privacy and confidentiality, ethical challenges result in ethical conflicts in prehospital emergency medicine when considering patient privacy. l. Telling the truth: Like other health professinals, PECs are expected to be honest with patients. However, they face a conflict between the implication of the truth and the patient’s best interest. When time is of the essence and the patient is critically ill, it is more important to administer medical care than to explain the procedure to the patient, even if the PEC is unsure of whether the patient will look upon the procedure favorably. it is a slippery slope. It is rationalized that a reasonable person would consent to treatment, and a delay (because of being told about the procedure) in treatment would lead to death or serious harm.[18] This is not just an ethical issue but a legal one as well; thus, PECs should be aware of the legislation in their countries. 3. Ethical issues related to the end of life and care: a. Terminal stage patients: The word “terminal stage” is commonly used for patients with cancer; however, this article uses this term for all patients who are near death or severely ill. Therefore, it is also a difficult period for patients, caregivers, and relatives. Prehospital emergency care is sometimes necessary for terminal stage patients. In these cases, effective communication skills are as important as medical care. The difference between the expectations of the patient (as well as relatives) and provided health care may be greater than expected. Obviously, this is a very difficult ethical issue, and the conflicts should be regarded as usual when there are lots of expectations and people but fewer things to do. However, rich and sensitive dialogue is needed so that all dying patients and their families receive quality end-of-life care.[19] b. Life-sustaining treatments: In terminal care, physicians’ experience and training, as well as personal life-values and attitudes, markedly influence their decision making processes. [20] It depends on the perception of the duty of life-sustaining care in prehospital emergency medicine. However, further discussion is needed on the role of medicine-especially emergency-at the end of life. c. Initiation of prehospital cardiopulmonary resuscitation (CPR): These are the patients with the potential for long-term survival; however, it is infrequently determined at an early stage. The medical decision in such situations must be made within seconds. If patients are to benefit from resuscitation,

they could regain consciousness and their life activities.[21] Although there are standardized signs of death, appropriateness of resuscitation is important. There are also characteristics of both patients and the attending ambulance crew that affect the likelihood of resuscitation attempts.[22] Making the initiation of prehospital CPR more ethically complex is a Do-Not-Resuscitate (DNR) order. DNR has no basis towards making decisions about the current treatment but only avoids resuscitation.[23] DNR conflicts are one of the most frequent dilemmas reported by emergency medical technicians.[24] When confronting these challenges, the majority of the paramedics relied heavily on the advice of medical experts, but some had to make more autonomous decisions.[25] In general, if there is any doubt about the appropriateness of withholding resuscitative attempts, CPR should be initiated.[26] d. Withholding or withdrawal of CPR: In a prehospital setting, the decision to withhold or withdraw CPR is principally based on reliable criteria that include obvious clinical signs of death, evidence of cardiac death, or fatal trauma. However, in some ambulance services there are no doctors in the crew, and evaluating the signs of death is a duty of paramedics. This poses the first conflict in prehospital CPR. The second is the termination of CPR. Generally, CPR is terminated after 30 to 45 minutes if it has been unsuccessful. [27] However, is it appropriate to make any suggestions about the end-of-life process which are not only medical, but also social and cultural? Families are comfortable accepting termination of unsuccessful out-of hospital cardiac resuscitation.[28] An individual situation is affected by many things, including the age of the patient, ongoing or coexisting disease, the reason for the CPR, resource and continuity CPR efforts, and response to CPR. e. Futile CPR: Futile CPR is defined as a failure to save a life by means of CPR. PECs rarely terminate resuscitative efforts, and most continue to perform it in situations they consider futile.[29] PECs do not always act in accordance with their ethical convictions. The main reason is that their personal beliefs do not always match internal or external procedures. [25] However, the determination of futility should be based on physiological outcome criteria, not on value-based criteria. In some cases, expectations and pressures from the prehospital environment in which PECs are working while being observed by other people (especially someone close to the patient) could direct the PECs to perform futile CPR. [12] It has been argued that it is an acceptable moral practice to signal that everything possible has been done, which helps to enable the grief of significant others to be properly addressed.[30]

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f. Family presence during resuscitation: Family presence has become a part of everyday life in emergency departments of hospitals. Patients’ families have reported benefits from being present during resuscitation and invasive procedures. [31] It is accepted as an important necessity in some cultures. [32] In prehospital settings, family presence during resuscitation is one of the ethical conflicts. 4. Ethical issues related to some perceptions of using/misusing the ambulance: There are some perceptions related to the ambulance that are not just about prehospital emergency settings. PECs face ethical issues that include misuse of ambulances, care of minors, telling “the bad news”, death and the newly dead, child and elder abuse, etc. One of the most challenging situations is the transport for patients without emergency medical conditions.[33] Emergency medical conditions might change public and PECs. There needs to be a clear definition of emergency medical conditions for general public. Conclusion In summary, prehospital settings are much more challenging to health caregivers than the controlled environment of medical departments over emergency rooms. In prehospital emergency medicine, all patients and situations are unique, and the ethical implications are unique to each patient encounter as well. Therefore, there are no quick formulas for the right action and emotion. It is important to recognize ethical conflicts and then act to provide the appropriate care. PECs are expected to have adequate ethical knowledge to make the best a priori decision in difficult cases. Prehospital emergency medicine is quite different from the emergency medicine in hospitals. Furthermore, the ethical issues of this field are more important, so conflicts are much difficult. In prehospital settings, the more complicated the ethical problem is, the harder finding a solution is. Therefore, it is highly important to establish protocols that address these ethical challenges. Conflict of Interest The author declare that there is no potential conflicts of interest.

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gency care professionals toward refusal of treatment: A regional survey in Turkey. Nurs Ethics 2013;21:530-539. 4. Iserson KV. Ethical principles-emergency medicine. Emerg Med Clin North Am 2006;24:513-45. 5. Brown LH, Whitney CL, Hunt RC, Addario M, Hogue T. Do warning lights and sirens reduce ambulance response times? Prehosp Emerg Care 2000;4:70-4. 6. Larkin GL, Fowler RL. Essential ethics for EMS: cardinal virtues and core principles. Emerg Med Clin North Am 2002;20:887911. 7. Iserson KV, Sanders AB, Mathieu DR, Buchanan AE. Ethics in emergency medicine. Baltimore: Williams & Wilkins; 1987. 8. Aacharya RP, Gastmans C, Denier Y. Emergency department triage: an ethical analysis. BMC Emerg Med 2011;11:16. 9. Moskop JC, Iserson KV. Triage in medicine, part II: Underlying values and principles. Ann Emerg Med 2007;49:282-7. 10. Erbay H, Alan S, Kadıoğlu S. A case study from the perspective of medical ethics: refusal of treatment in an ambulance. J Med Ethics 2010;36:652-5. 11. Brown JF. Ethics, emergency medical services, and patient rights: system and patient considerations. Top Emerg Med 1999;21:45-57. 12. Gunnarsson BM, Warrén Stomberg M. Factors influencing decision making among ambulance nurses in emergency care situations. Int Emerg Nurs 2009;17:83-9. 13. Sandman L, Nordmark A. Ethical conflicts in prehospital emergency care. Nurs Ethics 2006;13:592-607. 14. Adams JG, Arnold R, Siminoff L, Wolfson AB. Ethical conflicts in the prehospital setting. Ann Emerg Med 1992;21:1259-65. 15. Erbay H. What if the patient says ‘No!’ in the ambulance: An ethical perspective for assessment of capacity in the prehospital emergency setting. El Mednifico J 2014;4:2-4. 16. Appelbaum PS. Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med 2007;357:1834-40. 17. Alan S, Erbay H. Patient privacy and confidentiality in the ambulance services from the perspective of medical ethics. J Acad Emerg Med 2011;10:33-8. 18. Etchells E, Sharpe G, Walsh P, Williams JR, Singer PA. Bioethics for clinicians: 1. Consent. CMAJ 1996;155:177-80. 19. Jacobs LM, Burns K, Bennett Jacobs B. Trauma death: views of the public and trauma professionals on death and dying from injuries. Arch Surg 2008;143:730-5. 20. Hinkka H, Kosunen E, Metsänoja R, Lammi UK, KellokumpuLehtinen P. Factors affecting physicians’ decisions to forgo life-sustaining treatments in terminal care. J Med Ethics 2002;28:109-14. 21. Holm S, Jørgensen EO. Ethical issues in cardiopulmonary resuscitation. Resuscitation 2001;50:135-9. 22. Weston CF, Burrell CC, Jones SD. Failure of ambulance crew to initiate cardiopulmonary resuscitation. Resuscitation 1995;29:41-6. 23. Jones JW, McCullough LB. Just how far goes DNR? J Vasc Surg 2008;48:1630-2. 24. Heilicser B, Stocking C, Siegler M. Ethical dilemmas in emer-

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gency medical services: the perspective of the emergency medical technician. Ann Emerg Med 1996;27:239-43. 25. Nordby H, Nøhr Ø. The ethics of resuscitation: how do paramedics experience ethical dilemmas when faced with cancer patients with cardiac arrest? Prehosp Disaster Med 2012;27:64-70. 26. Mohr M, Kettler D. Ethical aspects of resuscitation. Br J Anaesth 1997;79:253-9. 27. Mohr M, Kettler D. Ethical aspects of prehospital CPR. Acta Anaesthesiol Scand Suppl 1997;111:298-301. 28. Delbridge TR, Fosnocht DE, Garrison HG, Auble TE. Field termination of unsuccessful out-of-hospital cardiac arrest resuscitation: acceptance by family members. Ann Emerg Med 1996;27:649-54. 29. Marco CA, Schears RM. Prehospital resuscitation practices: a

survey of prehospital providers. J Emerg Med 2003;24:101-6. 30. Bremer A, Sandman L. Futile cardiopulmonary resuscitation for the benefit of others: an ethical analysis. Nurs Ethics 2011;18:495-504. 31. Mian P, Warchal S, Whitney S, Fitzmaurice J, Tancredi D. Impact of a multifaceted intervention on nurses’ and physicians’ attitudes and behaviors toward family presence during resuscitation. Crit Care Nurse 2007;27:52-61. 32. Bae H, Lee S, Jang HY. The ethical attitude of emergency physicians toward resuscitation in Korea. J Emerg Med 2008;34:485-90. 33. Becker TK, Gausche-Hill M, Aswegan AL, Baker EF, Bookman KJ, Bradley RN, et al. Ethical challenges in Emergency Medical Services: controversies and recommendations. Prehosp Disaster Med 2013;28:488-97.

INDEX

Turkish Journal of Emergency Medicine, Index of Vol. 14 Abdominal mass see 2014;14(3):99-103 Abdominal pain see 2014;14(3):99-103 Abdominal trauma see 2014;14(2):93-95 Acute appendicitis see 2014;14(1):20-24 Arrest see 2014;14(1):37-40 Autopsy see 2014;14(3):115-120 Biomarker see 2014;14(4):147-152 Bladder cancer see 2014;14(3):139-141 Bladder rupture see 2014;14(3):139-141

Emergency room see 2014;14(1):9-14 Emergency service see 2014;14(1):3-8 see 2014;14(3):115-120 see 2014;14(4):179-181 see 2014;14(4):160-164 Erythema infectiosum see 2014;14(4):179-181 Ethical conflicts see 2014;14(4):193-198 Ethics see 2014;14(4):193-198 Explosion see 2014;14(2):90-92

Capnography see 2014;14(1):25-31 Capnometry see 2014;14(1):25-31 Carbon monoxide see 2014;14(3):132-134 Cardiopulmonary arrest see 2014;14(1):25-31 Cellulitis see 2014;14(1):41-43 Central venous catheter see 2014;14(2):53-5 Charger see 2014;14(2):90-92 Childhood see 2014;14(1):34-36 Clozapine see 2014;14(1):41-43 Computed tomography see 2014;14(2):93-95 Conium maculatum see 2014;14(1):34-36 Consultation see 2014;14(2):59-63 Consultation see 2014;14(4):165-171 Coronary thrombosis see 2014;14(3):135-138 Culture see 2014;14(3):121-124 Cyanosis see 2014;14(4):185-187

Facial palsy see 2014;14(3):142-145 Fasciitis see 2014;14(1):15-19 Febrile neutropenia see 2014;14(1):41-43 First aid see 2014;14(4):153-159

Data base management systems see 2014;14(2):75-81 Demography see 2014;14(2):75-81 Diabetic ketoacidosis see 2014;14(2):47-52 Drowning see 2014;14(1):37-40

I-FABP see 2014;14(3):99-103 İncidental findings see 2014;14(1):9-14 Infection see 2014;14(2):84-86 Intensive care unit see 2014;14(1):3-8

E. coli see 2014;14(3):121-124 Elderly see 2014;14(3):104-110 Emergency see 2014;14(3):121-124 see 2014;14(3):132-134 see 2014;14(4):165-171 Emergency department see 2014;14(1):20-24 see 2014;14(2):53-5 see 2014;14(2):59-63 see 2014;14(2):64-70 see 2014;14(2):75-81 see 2014;14(3):104-110 ee 2014;14(3):111-114 see 2014;14(3):139-141 see 2014;14(4):182-184

Ketosis see 2014;14(2):47-52

Gastroenteritis see 2014;14(3):111-114 General surgery see 2014;14(1):20-24 Granulocyte colony-stimulating factor see 2014;14(1):41-43 Gunshot see 2014;14(2):87-89 Head trauma see 2014;14(4):147-152 Headache see 2014;14(3):132-134 Hemlock see 2014;14(1):34-36 Holiday see 2014;14(4):165-171 Hydroxybutyrates see 2014;14(2):47-52 Hypothermia see 2014;14(1):37-40

Length of stay see 2014;14(4):165-171 Low back pain see 2014;14(3):125-129 Mediastinitis see 2014;14(2):84-86 Mesenteric ischemia see 2014;14(3):99-103 Methemoglobinemia see 2014;14(4):185-187 Migraine see 2014;14(3):132-134 Monitorized observation unit see 2014;14(1):3-8 Mortality see 2014;14(1):15-19 Motor vehicle accident see 2014;14(4):188-192 MRI myelography see 2014;14(4):188-192 Mushroom see 2014;14(3):104-110 Myocardial infarction see 2014;14(3):135-138

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National Emergency Department Overcrowding Study see 2014;14(2):64-70 Necrotizing see 2014;14(1):15-19 NEDOCS see 2014;14(2):64-70 Osborn wave see 2014;14(1):37-40 Overcrowding see 2014;14(2):59-63 see 2014;14(2):64-70 Pancreatic injury see 2014;14(2):93-95 Papular purpuric gloves and socks syndrome (PPGSS) see 2014;14(4):179-181 Parvovirus B19 see 2014;14(4):179-181 Pediatric see 2014;14(3):132-134 Pelvic fracture see 2014;14(3):139-141 Pneumocephalus see 2014;14(2):87-89 Pneumorrachis see 2014;14(2):87-89 Poisoning see 2014;14(1):34-36 see 2014;14(3):104-110 see 2014;14(4):153-159 see 2014;14(4):160-164 see 2014;14(3):125-129 Pre hospital trauma life support see 2014;14(2):71-74 Pre-hospital emergency medical service see 2014;14(2):71-74 Pregnancy see 2014;14(3):135-138 Prehospital emergency medicine see 2014;14(4):193-198 Prilocaine see 2014;14(4):185-187 Professional life see 2014;14(4):172-178 Prognosis see 2014;14(1):15-19 Ramsay Hunt syndrome see 2014;14(3):142-145 Rehydration see 2014;14(3):111-114

Resident see 2014;14(3):125-129 Resuscitation see 2014;14(1):25-31 Retropharyngeal hematoma see 2014;14(4):182-184 S100B protein see 2014;14(4):147-152 Sleep quality see 2014;14(4):172-178 Spinal injury see 2014;14(4):188-192 Spinal radiology see 2014;14(4):188-192 Subarachnoid pleural fistula see 2014;14(2):87-89 Sudden death see 2014;14(3):115-120 Suicide see 2014;14(4):160-164 Summer season see 2014;14(3):104-110 Test see 2014;14(4):165-171 Tetraplegia see 2014;14(4):188-192 Tissue defect see 2014;14(2):90-92 Tomography see 2014;14(1):9-14 Trauma see 2014;14(1):37-40 see 2014;14(2):71-74 see 2014;14(2):84-86 Traumatic brain injury see 2014;14(4):147-152 Ultrasound-guided see 2014;14(2):53-5 University student see 2014;14(4):153-159 Urine see 2014;14(3):121-124 Varicella-zoster virus see 2014;14(3):142-145 Vomiting see 2014;14(3):111-114 Warfarin overdose see 2014;14(4):182-184 112 Emergency Health Workers see 2014;14(4):172-178

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Author Index Abbasi H,, see 2014;14(4):147-152 Acar N,, see 2014;14(2):53-5 Acar N,, see 2014;14(2):75-81 Adimi İ, see 2014;14(3):125-129 Akay S, see 2014;14(1):25-31 Akay S, see 2014;14(1):3-8 Akbuga OZEL B, see 2014;14(4):185-187 Akbulut S, see 2014;14(2):59-63 Akdemir R, see 2014;14(3):135-138 Akelma AZ, see 2014;14(3):132-134 Akkisi Kumsar N, see 2014;14(1):41-43 Akoglu H, see 2014;14(4):188-192 Akoglu T, see 2014;14(4):188-192 Akoz A, see 2014;14(3):97 [130] Aksay E, see 2014;14(2):47-52 Aksel G, see 2014;14(4):185-187 Aktimur R, see 2014;14(1):15-19 Alatas OD, see 2014;14(3):115-120 Argun M, see 2014;14(4):172-178 Atescelik M, see 2014;14(3):115-120 Atilla Duman O, see 2014;14(2):45 Atilla R, see 2014;14(2):64-70 Avsarogullari L, see 2014;14(4):172-178 Ayhan H, see 2014;14(1):9-14 Ayhan H, see 2014;14(3):121-124 Azarfar A, see 2014;14(3):111-114 Bagheri S, see 2014;14(3):111-114 Baloglu Kaya F, see 2014;14(2):53-5 Baydin A, see 2014;14(2):59-63 Bayramoglu A, see 2014;14(3):97 [130] Bilir O, see 2014;14(1):2 [33] Bilir O, see 2014;14(3):142-145 Bork T, see 2014;14(3):115-120 Bosnak M, see 2014;14(1):34-36 Cakar MA, see 2014;14(1):37-40 Calmasur A, see 2014;14(3):97 [130] Can R, see 2014;14(2):53-5 Cetin A, see 2014;14(2):90-92 Cetinkaya H, see 2014;14(2):59-63 Cevik AA, see 2014;14(2):53-5 Cevik AA, see 2014;14(2):75-81 Cevik AA, see 2014;14(3):104-110 Cizmeci MN, see 2014;14(3):132-134

Colak E, see 2014;14(1):15-19 Colak Oray N, see 2014;14(2):64-70 Dagar S, see 2014;14(4):165-171 Demirtas Y, see 2014;14(1):20-24 Demirtas Y, see 2014;14(1):3-8 Denizbasi A, see 2014;14(4):188-192 Dogan A, see 2014;14(4):179-181 Dogan T, see 2014;14(2):47-52 Duman Atilla O, see 2014;14(4):182-184 Durak U, see 2014;14(4):165-171 Duran A, see 2014;14(2):90-92 Durmaz D, see 2014;14(2):93-95 Eceviz A, see 2014;14(4):179-181 Efeoglu M, see 2014;14(4):188-192 Ekingen E, see 2014;14(3):115-120 Erbay H, see 2014;14(4):193-198 Erdur B, see 2014;14(1):25-31 Erenler AK, see 2014;14(2):59-63 Eroglu SE, see 2014;14(4):188-192 Ersoy G, see 2014;14(2):64-70 Ersunan G, see 2014;14(3):142-145 Ertan C, see 2014;14(3):139-141 Eryigit U, see 2014;14(3):99-103 Eryigit V, see 2014;14(1):20-24 Eryigit V, see 2014;14(1):3-8 Esmaeeli M, see 2014;14(3):111-114 Fathi M, see 2014;14(4):147-152 Gencer EG, see 2014;14(3):121-124 Ghafouri RR, see 2014;14(2):71-74 Gharashi Z, see 2014;14(3):111-114 Gholipour C, see 2014;14(2):71-74 Giakoup B, see 2014;14(3):142-145 Goktas S, see 2014;14(4):153-159 Guclu E, see 2014;14(1):41-43 Guleser GN, see 2014;14(4):172-178 Gullupinar B, see 2014;14(2):87-89 Gunaydin YK, see 2014;14(3):121-124 Gunduz A, see 2014;14(3):99-103 Gunduz H, see 2014;14(3):135-138 Gurger M, see 2014;14(3):115-120 Guzel M, see 2014;14(2):59-63

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202

Halhalli HC, see 2014;14(3):121-124

Ozaydin V, see 2014;14(4):160-164 Ozaydin V, see 2014;14(4):179-181

Incealtin O, see 2014;14(4):160-164

Ozcelik H, see 2014;14(2):75-81

Isik S, see 2014;14(2):93-95

Ozhan F, see 2014;14(4):153-159 Ozkok Z, see 2014;14(4):160-164

Kahramaner Z, see 2014;14(1):34-36

Ozlem N, see 2014;14(1):15-19

Kalkan A, see 2014;14(1):2 [33]

Ozturk F, see 2014;14(1):25-31

Kanburoglu MK, see 2014;14(3):132-134 Karabay O, see 2014;14(1):41-43

Paknejad P, see 2014;14(2):84-86

Karabekmez FE, see 2014;14(2):90-92

Palak İ, see 2014;14(1):25-31

Karaca A, see 2014;14(2):59-63

Parlak İ, see 2014;14(1):20-24

Karadeniz OO, see 2014;14(2):93-95

Parlak İ, see 2014;14(1):3-8

Karahan SC, see 2014;14(3):99-103 Karakayali O, see 2014;14(3):121-124

Rajaei Ghafouri R, see 2014;14(3):125-129

Kavalci C, see 2014;14(4):185-187

Ravanshad Y, see 2014;14(3):111-114

Kaya S, see 2014;14(2):75-81

Riazi A, see 2014;14(1):1 [32]

Kayayurt K, see 2014;14(3):142-145 Keser N, see 2014;14(1):37-40

Sahinkus S, see 2014;14(3):135-138

Kesmer S, see 2014;14(1):15-19

Sahin S, see 2014;14(4):165-171

Keykhosravi A, see 2014;14(3):111-114

Sajjadi M, see 2014;14(4):147-152

Kilic H, see 2014;14(1):37-40

Sari Dogan F, see 2014;14(4):160-164

Kilic H, see 2014;14(3):135-138

Sari Dogan F, see 2014;14(4):179-181

Kilicaslan R, see 2014;14(1):25-31

Saritemur M, see 2014;14(3):97 [130]

Kilicli E, see 2014;14(4):185-187

Sarkhosh Khiavi R, see 2014;14(3):125-129

Kocamaz H, see 2014;14(1):34-36

Seker Eren E, see 2014;14(2):47-52

Konca C, see 2014;14(1):34-36

Senol V, see 2014;14(4):172-178

Kose S, see 2014;14(4):153-159

Senturan L, see 2014;14(4):153-159

Kucuk GO, see 2014;14(1):15-19

Sever M, see 2014;14(2):47-52

Kuru B, see 2014;14(2):47-52

Shams Vahtadi S, see 2014;14(1):1 [32] Shams Vahdati S, see 2014;14(2):71-74

Limon O, see 2014;14(3):139-141

Shams Vahdati S, see 2014;14(2):84-86 Shams Vahdati S, see 2014;14(3):125-129

Maghsoudi M, see 2014;14(4):147-152

Soyuer F, see 2014;14(4):172-178

Mahsanlar Y, see 2014;14(1):20-24

Suveren Artuk D, see 2014;14(4):185-187

Mahsanlar Y, see 2014;14(1):3-8 Mentese A, see 2014;14(3):99-103

Tajlil A, see 2014;14(1):1 [32]

Milani FE, see 2014;14(2):84-86

Tamer A, see 2014;14(1):41-43

Miran AS, see 2014;14(1):25-31

Tekelioglu UY, see 2014;14(2):90-92

Miri SH, see 2014;14(2):71-74

Tokdemir M, see 2014;14(3):115-120 Toker I, see 2014;14(4):182-184

Notash M, see 2014;14(2):71-74

Tomruk O, see 2014;14(1):25-31 Topacoglu H, see 2014;14(2):64-70

Ocak T, see 2014;14(2):90-92

Topacoglu H, see 2014;14(2):87-89

Oktay C, see 2014;14(2):93-95

Turedi S, see 2014;14(3):99-103

Onur OE, see 2014;14(4):188-192

Turkmen S, see 2014;14(3):99-103

Oray D, see 2014;14(3):139-141

Turkoglu A, see 2014;14(3):115-120

Ozakin E, see 2014;14(2):53-58

Turkoz B, see 2014;14(2):59-63

203

Turkish Journal of Emergency Medicine, Index of Vol. 14

Turkyilmaz S, see 2014;14(3):99-103 Ugurhan A, see 2014;14(3):139-141 Unluoglu I, see 2014;14(3):104-110 Ursavas B, see 2014;14(4):182-184 Ustuner F, see 2014;14(2):47-52 Uzun O, see 2014;14(3):99-103 Varisli B, see 2014;14(4):160-164 Vatan MB, see 2014;14(1):37-40 Yalcin N, see 2014;14(2):47-52 Yanturali S, see 2014;14(2):64-70 Yavasi O, see 2014;14(3):142-145 Yaylaci S, see 2014;14(1):41-43

Yazici V, see 2014;14(3):121-124 Yesilaras M, see 2014;14(2):45 Yesilaras M, see 2014;14(4):182-184 Yigit Y, see 2014;14(1):9-14 Yigit Y, see 2014;14(3):121-124 Yildirim G, see 2014;14(4):153-159 Yildirim S, see 2014;14(4):153-159 Yilmaz EU, see 2014;14(1):41-43 Yilmaz S, see 2014;14(1):37-40 Yilmaz S, see 2014;14(3):135-138 Yilmaz Y, see 2014;14(4):165-171 Yolcu S, see 2014;14(1):25-31 Yolcu S, see 2014;14(1):3-8 Zeytin AT, see 2014;14(2):75-81

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