Turk J Emegr Med 2014 / 2

ISSN 1304-7361

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Citation Abbreviation: Turk J Emerg Med

@TrJEmergMed

www.trjemergmed.com

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.

VOLUME 14 NUMBER 2 YEAR 2014

Turkish Journal ofEmergency MedicineTürkiye Acil Tıp Dergisi

Visual Diagnosis

Headache, Blurred Vision and Seizure in Hemodialysis PatientDuman Atilla O, Yesilaras M

Chronic Ankle Pain After An Initial ‘Twisting’ Injury To The AnkleAykanat F, Kose O

ORIGINAL ARTICLES

Comparing Finger-stick β-Hydroxybutyrate with Dipstick Urine Tests in the Detection of Ketone BodiesKuru B, Sever M, Aksay E, Dogan T, Yalcin N, Seker Eren E, Ustuner F

An Evaluation of Complications in Ultrasound-Guided Central Venous Catheter Insertion in the Emergency DepartmentOzakin E, Can R, Acar N, Baloglu Kaya F, Cevik AA

Reasons for Overcrowding in the Emergency Department: Experiences and Suggestions of an Education and Research HospitalErenler AK, Akbulut S, Guzel M, Cetinkaya H, Karaca A, Turkoz B, Baydin A

A New Model in Reducing Emergency Department Crowding: The Electronic Blockage SystemColak Oray N, Yanturali S, Atilla R, Ersoy G, Topacoglu H

Success Rate of Pre-hospital Emergency Medical Service Personnel in Implementing Pre Hospital Trauma Life Support Guidelines on Traffic Accident VictimsGholipour C, Shams Vahdati S, Notash M, Miri SH, Ghafouri RR

Characteristics of Patients Presenting to the Academic Emergency Department in Central AnatoliaZeytin AT, Cevik AA, Acar N, Kaya S, Ozcelik H

CASE REPORTS

Successful Outcome of Mediastinitis After 26 Days Delay in DiagnosisMilani FE, Shams Vahdati S, Paknejad P

Subarachnoid Pleural Fistula Due to Gunshot Wound Gullupinar B, Topacoglu H

Lower Extremity Tissue Defect Caused by Mobile Phone Charger Explosion: A Case Report Duran A, Ocak T, Tekelioglu UY, Karabekmez FE, Cetin A

Pancreatic Injury Caused By A Fall From Height: Transection at the Tail Oktay C, Durmaz D, Karadeniz OO, Isik S

Turkish Journal ofEmergency MedicineTürkiye Acil Tıp Dergisi

VOLUME 14

Citation Abbreviation: Turk J Emerg Med

NUMBER 2 YEAR 2014

ISSN 1304-7361

Visual Diagnosis

Headache, Blurred Vision and Seizure in Hemodialysis PatientDuman Atilla O, Yesilaras M


ORIGINAL ARTICLES

Comparing Finger-stick β-Hydroxybutyrate with Dipstick Urine Tests in the Detection of Ketone BodiesKuru B, Sever M, Aksay E, Dogan T, Yalcin N, Seker Eren E, Ustuner F






CASE REPORTS

Successful Outcome of Mediastinitis After 26 Days Delay in DiagnosisMilani FE, Shams Vahdati S, Paknejad P


Lower Extremity Tissue Defect Caused by Mobile Phone Charger Explosion: A Case Report Duran A, Ocak T, Tekelioglu UY, Karabekmez FE, Cetin A

Pancreatic Injury Caused By A Fall From Height: Transection at the Tail Oktay C, Durmaz D, Karadeniz OO, Isik S

www.trjemergmed.com



@TrJEmergMed

1 De Luca G. et al. (2004). Circulation, 109(10), 1223-5.2 Hamm, C.W. et al. (2011). Eur Heart J. 32(23), 2999-3054.3 Wu, A.H. et al. (1999). Clin Chem. 45(7), 1104-21.

Her dakika değerlidirAKS’de erken teşhis hayat kurtarır

Test early.Treat right.Save lives.

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

Erken test et

Akut miyokard infarktüs (AMİ)1 hastalarında semptomlar

ile tedavi arasındaki her 30 dakikalık gecikme, 1 yıllık bağıl

mortalite riskini %7.5 arttırmaktadır.

Doğru tedavi et

Kardiyak Troponinler, ST segment yüksekliği olmayan AMİ

tanısında önemli bir rol oynar. Artmış Troponin seviyeleri,

erken invazif ya da invazif olmayan tedavi startejisi

ihtiyacının belirlenmesine yardımcı olur.2

Hayat kurtar

Kardiyak Troponin T testleri AMİ tanısını büyük ölçüde

iyileştirir ve hayat kurtarıcı erken tedavi

implementasyonuna yardımcı olur.

Elecsys® Troponin T hs (yüksek duyarlılıklı) ve cobas®

h232 Troponin T (hasta başı sistemi) testleri 18 dakika ya

da daha kısa sürede hızlı ve standardize kardiyak Troponin

sonuçları sağlar. Hasta başı sistemleri, sağlık kuruluşlarının

NACB* önerisine uygun olarak 60 dakika içinde sonuç

verebilmelerine yardımcı olur.3

* National Academy of Clinical Biochemistry

ASSOCIATE EDITORS

Haldun AKOGLU, M.D.Marmara University, Faculty of Medicine, Department of Emergency Medicine

Seyran BOZKURT, M.D.Mersin University Faculty of Medicine, Department of Emergency Medicine

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

Nurettin Ozgur DOGAN, M.D.Kocaeli University, Faculty of Medicine, Department of Emergency Medicine

Nese COLAK ORAY, M.D.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. Acıbadem University, Faculty of Medicine, Department of Emergency Medicine

Ibrahim TURKCUER, M.D.Pamukkale University, Faculty of Medicine, Department of Emergency Medicine

EDITORS

Suleyman TUREDI, M.D.Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine

Orhan CINAR, M.D.Gulhane Military Medical Academy (GMMA), Department of Emergency Medicine

Arzu DENIZBASI, M.D.Marmara University, Faculty of Medicine, Department of Emergency Medicine

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)

CONSULTING EDITORS (2014, Number 2)

Gokhan AKSEL, M.D.Yusuf Ali ALTUNCI, M.D.Basak BAYRAM, M.D.Ahmet DEMIRCAN, M.D.Murat DURUSU, M.D.Bulent ERBIL, M.D.Serkan Emre EROGLU, M.D.Betul GULALP, M.D.Ahmet IMERCI, M.D.

Turkish Journal ofEmergency Medicine

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.

RESEARCH MEDHODOLOGY EDITOR

Levent DONMEZ, M.D.Akdeniz University, Faculty of Medicine, Department of Public Health

Funda KARBEK AKARCA, M.D.Mutlu KARTAL, M.D.Ataman KOSE, M.D.Isa KILICASLAN, M.D.Mehmet Mahir KUNT, M.D.Ayhan OZHASENEKLER, M.D.Gul PAMUKCU GUNAYDIN, M.D.Murat YESILARAS, M.D.Serjad Saddam Al ZAIDAWI, M.D.

www.trjemergmed.com



CORRESPONDENCE

Turkiye Acil Tip Dernegi, Cankaya Mah., Cinnah Cad., No: 51/10Cankaya, Ankara, TurkeyTel: +90 - 312 - 438 12 66 • Fax: +90 - 312 - 438 12 68e-mail: [email protected], [email protected]

PUBLISHER KARE YAYINCILIK | karepublishingSogutlucesme Cad., No: 76/103, 34730 Kadikoy, İstanbul, TurkeyTel: +90 - 216 - 550 61 11 Fax: +90 - 216 - 550 61 12

DESIGN Edibe COMAKTEKİNPRESS YILDIRIM Printing House PRESS DATE June 2014CIRCULATION 1500

ISSN 1304-7361

VOLUME 14NUMBER 2JUNE 2014

Published four times a year.

Printed on acid-free paper.

Periodical

This publication is printed on paper that meets the international standard ISO 9706: 1994.

Free full-text articles in Turkish and English are available at www.trjemergmed.com.

English correction service by makaletercume.

@TrJEmergMed


KARE

ISSUED BY THE EMERGENCY MEDICINE ASSOCIATION OF TURKEY

OWNER

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

Emergency MedicinePublishing with the Turk J Emerg Med Instructions for Authors

Visual Diagnosis Headache, Blurred Vision and Seizure in Hemodialysis PatientDuman Atilla O, Yesilaras M


ORIGINAL ARTICLES Comparing Finger-stick β-Hydroxybutyrate with Dipstick Urine Tests in the Detection of Ketone BodiesKuru B, Sever M, Aksay E, Dogan T, Yalcin N, Seker Eren E, Ustuner F






CASE REPORTSSuccessful Outcome of Mediastinitis After 26 Days Delay in Diagnosis Milani FE, Shams Vahdati S, Paknejad P


Lower Extremity Tissue Defect Caused by Mobile Phone Charger Explosion: A Case ReportDuran A, Ocak T, Tekelioglu UY, Karabekmez FE, Cetin A

Pancreatic Injury Caused By A Fall From Height: Transection at the TailOktay C, Durmaz D, Karadeniz OO, Isik S

Contents

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Turkish Journal ofEmergency MedicineJUNE 2014

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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 stud-ies, 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 emer-gency 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 manu-script deserves further evaluation or not. For submis-sions 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 origi-nal 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 au-thors 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 revi-sions. 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 method-ology editor to clarify any problems in the statistical design and evaluation of the study during the peer re-view 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 ac-ceptance 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 jour-nals.

8. Articles are listed on the content page and are pub-lished 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 cita-tion nor may it be copied in any format. Authors are responsible for all statements made in their articles.

Editors of the Turk J Emerg MedAssoc. Prof. Dr. Suleyman TUREDIAssoc. Prof. Dr. Orhan CINAR Prof. Dr. Arzu DENIZBASI


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 emer-gency medicine articles, opinions and relevant scientific announcements. The main sections of the journal include emergency medicine systems, ac-ademic emergency medicine, emergency medicine education, emergency department management, disaster medicine, environmental emergencies, trauma, resuscitation, analgesia, pediatric emergencies, medical emergen-cies, 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 bio-medical journals. Further information can be found in the following article: “Uniform requirements for manuscripts submitted to biomedical jour-nals 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 ap-pointed by the Board of the Emergency Medicine Association of Turkey once a year in December.

CATEGORIESResearch 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, limi-tations 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 edu-cational value. Consideration will be given to articles presenting clinical con-ditions, 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 re-search on the topic. Turkish and English abstracts are required. Case reports must include introduction, case presentation and discussion sections. They must be limited to 1,500 words, contain 15 references or less and two tables or figures. A maximum of five authors for a case study will be permitted.

Case Series: Brief descriptions of clinical cases or the complications that are seldom encountered in emergency medicine practice and have edu-cational value. Case series must include introduction, case presentation and discussion sections. They must be limited to 2,500 words, contain 15 references or less and three tables or figures. A maximum of six authors for a case series will be permitted.

Brief Reports: Reports involving a small number of cases that require fur-ther investigation. Preliminary data and results are shared. Turkish and Eng-lish 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 ap-proval from the Regional Ethics Board approval prior to publication.

Concepts: Clinical or non-clinical articles related to the field of emergency medicine and detailing improvements to emergency medicine practice. Turkish and English abstracts are required. The manuscripts must not ex-ceed 4,000 words and limited three authors per article.

Review Articles: Comprehensive articles reviewing national and interna-tional 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 discus-sion 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 concern-ing 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 MANUSCRIPTSTurk 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 DOCUMENTSCover Letter: The author(s) should present the title, type and category of the article, and whether the submitted work had previously been present-ed in a scientific meeting. In addition, the full name of the corresponding author and his/her contact information including the address, phone num-ber, fax number and email address should be provided at the bottom of the cover letter.

Title Page: On the title page, the title of the article, and the names of the authors’, including their academic titles and institutions should be listed in order. In addition, the running title and the name of the corresponding author along with his/her contact information should be provided.

For the Blind Initial Review: The names of the authors’, and any identify-ing information including the academic titles, institutions and addresses must be omitted. Manuscripts submitted with any information pertaining to the author(s) will be rejected.

MANUSCRIPT PREPARATIONTurkish 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.


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 con-tain the following sections:

Introduction: A three-paragraph structure should be used. Background in-formation 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. Comment-ing on the results and discussing the literature findings should be avoided in this section. The results should be presented with graphs, mean, me-dian 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 sepa-rate 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 present-ing 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” sec-tion 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 dif-ferences 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 medi-cine thrombolytic therapy. In: Tintinalli JE, Ruiz E, Krome RL, eds. Emergen-cy Medicine: A Comprehensive Study Guide. 4th ed. New York, NY: McGraw-Hill;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 pre-sented 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 POLICYOriginal 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 ob-tained from the patients refered to in case reports, images and case series.

REVIEW AND PUBLICATION PROCESSInitial Review: A blind initial review is performed for all submitted mate-rial. The editor will review all the manuscripts for completeness and con-tent. 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 re-sponsible 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 bet-ter assess the manuscripts. It is, therefore, vital to submit a full address and other contact information on the title page of the manuscript.


VISUAL DIAGNOSIS

Turk J Emerg Med 2014;14(2):45 [82] doi: 10.5505/1304.7361.2014.98624

Submitted: November 22, 2013 Accepted: December 12, 2013 Published online: January 07, 2014

Correspondence: Dr. Ozge Duman Atilla. Tepecik Egitim ve Araştırma Hastanesi, Acil Tıp Klinigi,Yenişehir, Izmir, Turkey.

e-mail: [email protected]

Department of Emergency Medicine, Tepecik Training and Research Hospital, Izmir

Ozge DUMAN ATILLA, Murat YESILARAS

Headache, Blurred Vision and Seizurein Hemodialysis Patient

A 53-year-old man with severe headache, blurred vision, and single generalized tonic-clonic seizure du-ring hemodialysis presented to the emergency department (ED). On admission to the ED, the patient was in postictal state and measured at the following levels: blood pressure 203/113 mmHg, pulse rate 80/min, respiratory rate of 17/min, body temperature of 36,5 °C, peripheral O2 saturation of 96%, and GCS of 9. Neurologic examination revealed no focal deficit. Bedside finger-stick glucose test was detected at 59 mg/dl. ECG of the patient was in normal sinus rhythm and revealed no ischemic sign. Intravenous 25 g glucose was administered to the patient and control of finger stick glucose test was detected at 281 mg/dl. However, the mental status of the patient did not improve. The patient had complaints of headache and blurred vision for at least one day according to family members. The patient had chronic renal failure and hemodialysis for 1.5 years and was on eye drops for glaucoma. On fundoscopic examination, acute pathology was not detected. Noncontrast enhanced cranial computerized tomography (CT) was perfor-med and CT revealed no acute pathology. Laboratory tests of the patient showed creatinin 5.8 and urea 79 mg/dl and no electrolyte imbalance, leucositosis, or thrombocytopenia. GCS of the patient was detected at 14 without focal deficits at two hours after admission to the ED. Contrast enhanced magnetic resonance imaging (MRI) of cranial and diffusion MRI was also performed (Figure 1).

Figure 1. The patient’s flair (a) and T2-weighted (b, c) cranial MRI images.

(a) (b) (c)

45

[see page 82 for diagnosis]

VISUAL DIAGNOSIS


Submitted: July 26, 2013 Accepted: September 04, 2013 Published online: September 13, 2013

Correspondence: Dr. Faruk Aykanat. Çamlıca Mahallesi, Garnizon Caddesi, No: 1, İslahiye Merkez,27800 Gaziantep, Turkey.


1Department of Orthoapedics and Traumatology, Islahiye State Hospital, Gaziantep;2Department of Orthoapedics and Traumatology, Antalya Education and Research Hospital, Antalya

Faruk AYKANAT,1 Ozkan KOSE2

Chronic Ankle Pain After An Initial ‘Twisting’Injury To The Ankle

A 42-year-old woman was admitted to our outpatient clinic with chronic left ankle pain that began after having a twisting ankle injury fifteen days prior. Immediately after the injury, she was admitted to the nearest emergency department and foot radiographs were taken. Lateral and oblique foot radiographs revealed no abnormal findings, and the patient was diagnosed as simple ankle sprain and was treated with anti-inflammatory medications, elastic bandage, rest, and ice. Although the soft

tissue swelling subsided gradually, the patient suffered from chronic ankle pain and persistent antalgic gait. On physical examination, there was tenderness over the foot distal and inferior to the anterior talofibular ligament (ATFL). The range of ankle movements was slightly painful and inversion of the ankle produced considerable pain. Neurovascular examina-tion was normal. The initial foot radiographs were available and re-evaluated (Figure 1).

Figure 1. (a) Lateral and (b) oblique foot radiographs of the patient.

(a)

(b)

[see page 83 for diagnosis]

46

Turk J Emerg Med 2014;14(2):47-52 doi: 10.5505/1304.7361.2014.14880

Submitted: February 06, 2014 Accepted: March 13, 2014 Published online: June 04, 2014

Correspondence: Dr. Mustafa Sever. Manavkuyu Mahallesi, 275/10 Sokak,No: 12 Platinium Sitesi, C Blok., D: 4, 35330 Izmir, Turkey.


ORIGINAL ARTICLE

1Department of Emergency Medicine, Tepecik Training and Research Hospital, Izmir;2Department of Biochemistry, Tepecik Training and Research Hospital, Izmir

Baris KURU,1 Mustafa SEVER,1 Ersin AKSAY,1 Tarik DOGAN,1

Necmiye YALCIN,1 Ezgi SEKER EREN,1 Fusun USTUNER2

Comparing Finger-stick β-Hydroxybutyrate with Dipstick Urine Tests in the Detection of Ketone Bodies

Keton Cisimciklerinin Tespitinde Parmakucu β-Hidroksibütirat ileİdrar Daldırma Testlerinin Karşılaştırılması

SUMMARYObjectivesBlood ketone (beta-hydroxybutyrate) measurements are suggested instead of urine ketone (acetoacetate) measurements in the diagnosis of diabetic ketoacidosis. Urine ketone examination is difficult and time consuming, and may result in an incorrect interpretation. Studies per-formed in emergency departments on blood ketones are limited. Our objective is to compare urine ketones and capillary blood ketones in patients whose serum glucose levels were ≥150 mg/dl.

MethodsIn our cross-sectional prospective study, finger-stick blood beta-hy-droxybutyrate, arterial blood gas and urine ketone measurements of patients whose serum glucose levels were 150 mg/dL and higher were performed in the emergency department.

ResultsA total of 265 patients were included in the study. The mean age of the patients was 62.4±14.9 years, and 65.7% of them were female. The mean of the capillary blood ketone levels of the patients was deter-mined to be 0.524±0.9 mmol/L (min: 0 mmol/L, max: 6.7 mmol/L). In 29 (13.1%) of the 221 patients whose urine ketone levels were nega-tive, the finger-stick blood ketone levels were positive. Three of these patients were severely ketonemic, six were moderately ketonemic, and 20 were mildly ketonemic.

ConclusionsIn patients admitted to the emergency department with a blood glu-cose level of 150 mg/dL or higher, performing a capillary blood ketone measurement instead of a urine ketone measurement was a better pre-dictor of ketonemia.

Key words: Diabetic ketoacidosis; hydroxybutyrates; ketosis.

ÖZETAmaçDiyabetik keto asidoz tanısında idrar ketonu (asetoasetat) yerine kan ketonu (beta-hidroksibütirat) ölçümü önerilmektedir. İdrar ketonu bakılması zahmetli, zaman alıcı ve yanlış yorumlara yol açabilen bir testtir. Acil servislerde kan ketonu ile ilgili yapılan çalışmalar sınırlıdır. Bu çalışmadaki amacımız serum glikoz düzeyi ≥150 mg/dl tespit edilen hastalarda idrar ketonu ile kapiller kanda keton varlığını karşılaştır-maktır.

Gereç ve Yöntemİleriye yönelik kesitsel çalışmada, acil serviste serum glikoz düzeyi 150 mg/dL ve üzerinde olan hastaların parmak ucu kan beta-hidroksibütirat, venöz kan gazı ve idrar ketonu ölçümü yapıldı.

BulgularBu çalışmaya toplam 265 hasta dâhil edildi. Hastaların yaş ortalama-sı 62.4±14.9 yıl, %65.7’si kadındı. İdrar ketonu negatif olan 221 hastanın 29’unda (%13.1) parmak ucundan kan ketonu pozitif olarak saptandı. Bu hastaların üçü ağır, altısı orta düzeyli, 20’si hafif düzeyli ketonemikti. Ol-guların kapiller kan keton düzeyleri ortalaması 0.524±0.9 mmol/L (min.: 0 mmol/L, maks.: 6.7 mmol/L) tespit edildi.

SonuçAcil servise başvuran ve kan glikoz değeri 150 mg/dL üzerindeki hastalar içinde, idrar keton ölçümü yerine kapiller kan keton ölçümünün kullanıl-ması hastaların yönetiminde önemli değişikliğe yol açabilir.

Anahtar sözcükler: Diyabetik ketoasidoz; hidroksibütirat; ketozis.

47

IntroductionIt has been reported that 25% of patients who are admitted to the emergency department (ED) are diabetic, and the rou-tine glycemic control results of nearly half of these patients were negative. In emergency medicine practice, diabetic ketoacidosis (DKA) should be considered in patients whose blood glucose level is ≥250 mg/dL, regardless of symptoms.[1] DKA is a severe complication of diabetes that is character-ized by hyperglycemia, ketone body production and meta-bolic acidosis.[2-4] Early diagnosis of DKA patients is critical because of the high mortality rate (2-5%).[5]

In current emergency medicine practice, ketonemia is fre-quently tested using a urine dipstick that measures ace-toacetate (AA) concentrations.[1] A urine dipstick does not measure the concentration of β-hydroxybutyrate (β-OHB), a major ketone body that plays an important role in DKA pathogenesis.[2-4]

Studies of blood ketone concentrations in ED patients are limited.[1,6-9] Detection of ketone bodies in capillary blood provides analytical, technical, and clinical advantages com-pared to a urine dipstick test.[3] The objective of our study was to compare urine ketone (AA) and capillary blood ke-tone (β-OHB) levels in ED patients whose serum glucose lev-els were ≥150 mg/dl.

Materials and Methods Our cross-sectional prospective study was performed over a period of three months in the Department of Emergency Medicine of Izmir Tepecik Training and Research Hospital, a tertiary training clinic. Ethics committee approval was obtained before the study. All the patients included in the study gave consent.

Patient Selection

All the patients admitted to our ED who were older than 14 years and whose serum glucose level was 150 mg/dL or

higher were consecutively enrolled in the study. The criteria of the American Diabetes Association (ADA) were used for the definition of DKA as follows: blood glucose levels higher than 250 mg/dl, the existence of an anion gap greater than 10, bicarbonate levels lower than 18 mEq/L, and 3 mmol/L ketonemia or significant ketonuria (“≥3+” by standard urine dipstick) with blood pH lower than 7.3.[1,4,10,11]

Patients who declined to participate in the study as well as any patients whose blood biochemical tests, blood gas anal-ysis, or urine or capillary ketone measurements could not be performed for any reason were excluded from the study.

Study Protocol

Patients whose finger-stick blood glucose level was mea-sured to be 150 mg/dL and higher for any reason were iden-tified. Serum glucose levels, serum electrolyte (Na+1, K+1, Cl-1; to calculate the anion gap) measurements, complete urine tests, arterial blood gases (pH, lactate, HCO3-, base ex-cess), and capillary blood ketone measurements were per-formed.

Serum electrolytes and glucose levels were measured with an Olympus AU640 auto-analyzer. Arterial blood gas param-eters were evaluated with a GEM Premier 3000 S/N 17839 blood gas analyzer®. To avoid observer bias, complete urine tests were evaluated using DIRUI H10–800 urine dipsticks with a DIRUI H800 Urine Analyzer® device with a spectro-photometric measurement technique. Urine ketone levels were grouped as no ketonemia, “trace quantity”, “1+”, “2+”, or “3+”.

Capillary blood glucose levels were measured with a Glu-cometer® (HMD Biomedical Inc., Hsinchu, Taiwan) in mg/dL at the bedside using a finger-stick test. Measurement of capillary blood ketone levels was performed at the bedside using β-ketone test strips (Optium-meter, Optium TM Xceed TM/Abbott®). Capillary blood ketone levels were grouped as follows: no ketonemia (0–0.5 mmol/L), mild ketonemia (0.6–

Turk J Emerg Med 2014;14(2):47-52

Table 1. Comparison of capillary blood ketone levels with dipstick urine ketone levels

Blood ketone Urine ketone levels Total

– Trace 1+ 2+ 3+

n % n % n % n % n % n %

No 192 72.4 18 6.8 1 0.4 0 0 0 0 211 79.6

Mild 20 7.5 7 2.6 5 1.9 0 0 2 0.8 34 12.8

Moderate 6 2.3 1 0.4 5 1.9 0 0 0 0 12 4.5

Severe 3 1.1 2 0.8 1 0.4 1 0.4 1 0.4 8 3

Total 221 83.4 28 10.6 12 4.5 1 0.4 3 1.1 265 100

levels

48

1.5 mmol/L), moderate ketonemia (1.6–3.1 mmol/L) and severe ketonemia (3.2 mmol/L and higher). Patients whose blood ketone levels were determined to be higher than 0.5 mmol/L were classified as “ketonemia positive“.

The socio-demographic (age, gender) and clinical properties (biochemical laboratory test results, finger-stick ketone lev-els) required for the study were transferred from the patient medical records onto data collection forms for evaluation.

Statistical Analysis

Statistical analyses were performed using SPSS for Windows Ver. 17.0, (SPSS Inc., IL, USA). Non-parametric (qualitative) variables were shown as a number and percentage (%), and Mann-Whitney U and chi-square tests were used for evalu-ation. In the crosstab values, when the expected value in at least one cell was less than five, Fisher’s Exact Test was used. Parametric (quantitative) data were shown as the mean ± standard deviation (SD). For parametric data, analysis of variance (ANOVA), correlation, and regression analyses were used. In the statistical analysis, p<0.05 was accepted as sig-nificant.

ResultsThe serum glucose levels of 408 patients who were admitted to ED in the course of our study were higher than 150 mg/dl. A total of 143 patients were excluded from the study for the following reasons: 43 patients’ the urine ketones could not be studied; 56 patients’ blood gas analysis could not be studied; 27 patients’ blood biochemistry parameters could not be studied; and 17 patients refused to participate in the

study. A total of 265 patients were included in the study, and 174 (65.7%) of the patients were female. The mean age of the patients was 62.4±14.9 years (range: 15-96 years).

In 221 of the cases (83.4%), no ketones were found in the urine. In 29 (13.1%) of the patients who did not have ketonu-ria, the capillary blood ketone (ketonemia) was determined to be positive (>0.5 mmol/L). Three (1.3%) of these patients were severely ketonemic, six (2.6%) were moderately keto-nemic, and 20 (9.2%) were mildly ketonemic (Table 1). The mean capillary blood ketone level was determined to be 0.524±0.9 mmol/L (range: 0-6.7 mmol/L). The relationship between the patients’ biochemical test results and capillary blood ketone levels is shown in Table 2. The comparisons of the capillary blood ketone levels and serum glucose, pH, lac-tate and bicarbonate levels are shown in Table 3.

In 211 (79.6%) patients, no ketones were found in the cap-illary blood. Twenty-nine (53.7%) of the 54 patients whose capillary blood ketone levels were positive had no ketonuria. Of these patients, 34 (12.8%) had mild ketonemia, 12 (4.1%) had moderate ketonemia, and 8 (3%) had severe ketonemia (Table 1).

Ten patients (3.8%) were identified who were positive for ke-tonemia by capillary blood and who had a blood pH value of <7.3. Four (1.5%) of these patients were diagnosed as DKA according to the ADA criteria; one had a urine ketone level of “3+”, two had trace quantities, and one had a nega-tive urine ketone test. These patients’ capillary blood ketone levels were determined as 6.7, 5.2, 3.5 and 6.3 mmol/L, re-spectively.

Kuru B et al. Comparing Finger-stick β-Hydroxybutyrate with Dipstick Urine Tests

Table 2. Relationship between capillary ketone levels and laboratory results

Ketone levels (mmol/L)

Variables All patients 0–0.5 0.6–1.5 1.6–3.1 ≥3.2 p (no) (mild) (moderate) (severe)

Capillary glucose (mg/dL) 282.1±107.4 273.3±98.6 279.6±118.6 362.1±144.6 404.7±114.7 =0.402

Serum glucose (mg/dL) 309.7±131.1 301.6±121.7 292.5±138.5 398.3±156.1 463.5±174 =0.878

Serum base excess -1.7±6.4 -1.1±5.4 -3.8±8.9 -1.6±5.7 -10.4±12.4 =0.001

Serum bicarbonate (mmol/L) 22.8±5.5 23.7±4.7 20.7±6.2 22.5±4.8 10.2±5.5 =0.594

Serum pH 7.38±09 7.38±.1 7.37±.1 7.41±.1 7.32±0.1 =0.017

Anion gap 12.9±5.7 11.8±4.7 15.6±5.4 17.3±9.3 25.4±5.5 =0.011

Serum Lactate (mmol/L) 2.2±2.1 2.1±1.8 2.5±2.8 2.8±2.9 3.6±4.4 =0.064

Serum Sodium (Na+) (mEq/L) 136.2±5.9 136.5±5.2 136.1±7.8 133.6±10 133.9±8.9 =0.07

Serum Potassium (K+) (mEq/L) 4.4±0.7 4.5±.6 4.6±.8 4.1±.6 4.5±.8 =0.209

Serum Chlorine (Cl-) (mEq/L) 100.5±7.2 101.1±6 99.8±8.7 93.7±13.5 98.2±9.6 =0.01

Data are given as mean±standard deviation. p values are results of Fisher’s exact test.

49

Although six patients’ pH values were <7.3, they were not considered to be DKA according to the ADA criteria, as three had blood glucose levels lower than 250 mg/dL; two had bi-carbonate levels higher than 18 mmol/L; and one had capil-lary blood ketone levels lower than 3 mmol/dL. Two of those patients had ketonuria (one patient had a trace quantity and the other “1+”), whereas no ketonuria was identified in the other four patients. All six patients had mild ketonemia (0.6, 0.6, 1.2, 1.1, 0.9, 0.8 mmol/L, respectively).

Four (1.5%) patients who met the ADA DKA criteria except for having an arterial blood gas pH value greater than 7.3 were considered to have compensated metabolic acidosis. The capillary blood ketone levels of these patients were 3.2, 3.9, 5.6, and 5.2 mmol/L. No ketonuria was found in the urine tests of two of these patients, whereas one had “1+”, and the other had a trace quantity of ketonuria.

One hundred and eighty-one (68.3%) of the patients were discharged from the hospital. Four (1.5%) patients died, sev-en (2.6%) refused treatment and fifteen (5.7%) were referred. Additionally, 17 (6.4%) patients were admitted to the inten-sive care unit and 41 patients (15.5%) to other departments.

DiscussionThe main objective of our study was to compare blood ke-tone levels with the presence of urine ketones in hyperglyce-mic ED patients. We found that capillary ketone levels were

high in 13% of the patients who had no ketonuria. Severe ketonemia was identified in 10% of these patients. In DKA, the β-OHB/AA ratio can increase from 1/1 to 5/1. With treat-ment, β-OHB will be oxidized to AA. As a result, the measur-able blood ketone levels (β-OHB) will decrease, whereas the measurable urine ketone levels (AA) will increase.[2] In our study, there were four patients who were diagnosed with DKA according to the ADA criteria. In spite of the fact that significant ketonemia was determined in these patients, the urine dipsticks only identified significant ketonuria (‘‘3+’’) in one of these patients. In the early stages of DKA, some cases might be missed if urine dipsticks for ketone detection are used instead of capillary blood ketone measurement.

It was determined that only four (1.5%) of the ten patients who had ketones in the capillary blood and whose pH value was <7.3 met the ADA DKA criteria. In our study, the capillary blood ketone levels of the four adults who were diagnosed with DKA were determined to be 3.5, 5.2, 6.3 and 6.7 mmol/L.

Additionally, in six patients who did not meet the ADA cri-teria, acidosis was determined with mild (0.6-1.5 mmol/L) ketonemia. Charles et al. reported a blood β-OHB threshold level of 3.5 mmol/L for the diagnosis of DKA,[8] whereas Sav-age et al. reported this value to be ≥3 mmol/L.[11] Laffel et al. reported that all capillary blood ketone body values higher than 0.5 mmol/L are abnormal. In the populations that are a specific risk group for DKA (e.g. those who use insulin pumps), this value decreases to the lower limit value of 0.3

Table 3. Comparison of capillary blood ketone levels and serum glucose, pH, lactate and bicarbonate levels

Variable Ketone levels

Ketosis (-) Ketosis (+)

Serum glucose level 0–0.5 0.6–1.5 1.6–3.1 ≥3.2 Total p(mg/dL) (No) (mild) (moderate) (severe)

n % n % n % n % n %

150–249 92 34.7 17 6.4 1 0.4 0 0 110 41.5 =0.03

≥250 119 44.9 17 6.4 11 4.2 8 3 155 58.5

Acidosis

Yes (pH<7.3) 18 6.8 6 2.3 0 0 4 1.5 28 10.6 =0.001

No (pH≥7.3) 193 72.8 28 10.6 12 4.5 4 1.5 237 89.4

Bicarbonate level (mEq/L)

<18 11 4.2 6 2.3 1 0.4 6 2.3 24 9.1 <0.001

≥18 200 75.5 28 10.6 11 4.2 2 0.8 241 90.9

Lactate level (mmol/L)

≥4 197 74.3 28 10.6 11 4.2 6 2.3 242 91.3 =0.042

<4 14 5.3 6 2.3 1 0.4 2 0.8 23 8.7

p values are results of Fisher’s exact test.

50 Turk J Emerg Med 2014;14(2):47-52

mmol/L.[12] Thus, although the aforementioned six patients are not considered as DKA according to ADA criteria, they might be diagnosed as being in the early stages of DKA. We hypothesize that, even at low levels, early stage DKA cases can be diagnosed with capillary blood ketone measure-ment. Otherwise, these patients, whose blood ketone levels are less than 3 mmol/L, might be discharged from the hos-pital without being adequately treated because they do not meet ADA criteria and are not diagnosed as DKA.

In current clinical practice, urine dipsticks are frequently used for ketone detection in patients presenting with hyperglyce-mia in the ED. Urine dipsticks measure AA via a semi-quan-titative method dependent on a sodium-nitroprusside reac-tion. This test gives a weak reaction with acetone, whereas it has no reaction with β-OHB. When the spectrophotomet-ric method is not used, the accuracy of the urine dipstick is user-dependent in the manner of sensing the color change on the dipstick.[2] The literature and the ADA encourage serum ketone measurement instead of urine dipstick tests because the specificity of urine dipsticks is low (<50%), and urine dipsticks frequently give false positive results, which cause an increased workload and inappropriate treatment.[1-8,11,13-15] Umperriez et al. reported that, in more than half of patients, even after the ketoacidosis attack was eliminated, ketones were detected in the urine.[16] Urine dipstick tests can create an incorrect impression that ketosis has not been eliminated. The delay in urine sample collection in seriously dehydrated patients can cause delays in diagnosis. In anuric patients with end-stage renal failure, a urine dipstick cannot be used.[2] False negatives in urine ketone measurements might result from faulty urine dipsticks, urinary tract infec-tions, and medications such as acetylcysteine, captopril and vitamin C.[1,3,6,8-10,13,14]

Blood ketones (β-OHB) can be measured in less than 30 minutes with bedside finger-stick tests. Bedside finger-stick tests have several advantages over urine dipstick measure-ments, including quick and quantitative results, ease of use, and repeatability in the ED.[1,3,6,8-10,13,14]

It has been reported that capillary ketone measurements are highly accurate, sensitive (98.1%) and specific (78.5%) for de-tection of DKA.[1] Bektas et al. found the sensitivity and spec-ificity of urine ketone dipstick testing and capillary blood ketone testing in determining DKA were 66% and 78%, and 72% and 82%, respectively.[6]

In our study, the urine ketone level was determined to be negative in more than half of the patients whose capillary blood ketone level was positive. It should be considered that, in the management of hyperglycemic ED patients, 53% of the patients might be inappropriately treated if a urine dipstick is used. In cases in which the incidence and prog-

nosis of hyperglycemic patients admitted to the ED is based on an inappropriate diagnosis, the treatment administered might adversely affect the quality of patient care. Inad-equate treatment could result in the re-admission of some patients to the ED.

Limitations

Because pregnant women and children were not included in our study, our data must not be generalized to these pop-ulations. We did not compare urine AA or capillary β-OHB ketone levels to serum β-OHB ketone levels, which is the gold standard in ketonemia diagnosis. There are studies re-porting that the bedside capillary β-OHB ketone level test is as accurate and reliable as the serum β-OHB ketone level.[1,6-10,13,14]

Conclusion

Capillary blood ketone measurement should be considered for use instead of urine ketone measurement in hyperglyce-mic ED patients.

Acknowledgments

The authors thank Abbott Laboratories for their donation of the β-OHB test strips.

Conflict of Interest

The authors declare that there is no potential conflicts of in-terest.

References

1. Arora S, Henderson SO, Long T, Menchine M. Diagnostic ac-curacy of point-of-care testing for diabetic ketoacidosis at emergency-department triage: {beta}-hydroxybutyrate ver-sus the urine dipstick. Diabetes Care 2011;34:852-4.

2. Wallace TM, Matthews DR. Recent advances in the monitoring and management of diabetic ketoacidosis. QJM 2004;97:773-80.

3. Guerci B, Tubiana-Rufi N, Bauduceau B, Bresson R, Cuperlier A, Delcroix C, et al. Advantages to using capillary blood beta-hydroxybutyrate determination for the detection and treat-ment of diabetic ketosis. Diabetes Metab 2005;31:401-6.

4. Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, et al. Hyperglycemic crises in diabetes. Diabe-tes Care 2004;27 Suppl 1:S94-102.

5. Umpierrez GE, Murphy MB, Kitabchi AE. Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome. Diabetes Spec-trum 2002;15:28-36.

6. Bektas F, Eray O, Sari R, Akbas H. Point of care blood ketone testing of diabetic patients in the emergency department. Endocr Res 2004;30:395-402.

7. Taboulet P, Haas L, Porcher R, Manamani J, Fontaine JP, Feu-

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geas JP, et al. Urinary acetoacetate or capillary beta-hydroxy-butyrate for the diagnosis of ketoacidosis in the Emergency Department setting. Eur J Emerg Med 2004;11:251-8.

8. Charles RA, Bee YM, Eng PH, Goh SY. Point-of-care blood ke-tone testing: screening for diabetic ketoacidosis at the emer-gency department. Singapore Med J 2007;48:986-9.

9. Naunheim R, Jang TJ, Banet G, Richmond A, McGill J. Point-of-care test identifies diabetic ketoacidosis at triage. Acad Emerg Med 2006;13:683-5.

10. Kitabchi AE, Umpierrez GE, Murphy MB, Kreisberg RA. Hyper-glycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care 2006;29:2739-48.

11. Savage MW, Hammersley MS, Rayman G, et al. The Manage-ment of Diabetic Ketoacidosis in Adults. Joint British Diabe-tes Societies Inpatient Care Group. March 2010. Available in: http://www.bsped.org.uk/clinical/docs/DKAManage-

mentOfDKAinAdultsMarch20101.pdf. Accessed 28 May 2012.12. Laffel L. Sick-day management in type 1 diabetes. Endocrinol

Metab Clin North Am 2000;29:707-23.13. Byrne HA, Tieszen KL, Hollis S, Dornan TL, New JP. Evaluation

of an electrochemical sensor for measuring blood ketones. Diabetes Care 2000;23:500-3.

14. Wallace TM, Meston NM, Gardner SG, Matthews DR. The hospital and home use of a 30-second hand-held blood ketone meter: guidelines for clinical practice. Diabet Med 2001;18:640-5.

15. Sheikh-Ali M, Karon BS, Basu A, Kudva YC, Muller LA, Xu J, et al. Can serum beta-hydroxybutyrate be used to diagnose dia-betic ketoacidosis? Diabetes Care 2008;31:643-7.

16. Umpierrez GE, Watts NB, Phillips LS. Clinical utility of beta-hy-droxybutyrate determined by reflectance meter in the man-agement of diabetic ketoacidosis. Diabetes Care 1995;18:137-8.

52 Turk J Emerg Med 2014;14(2):47-52



Correspondence: Dr. Engin Ozakin. Eskisehir Osmangazi Universitesi Tıp Fakultesi,Acil Tıp Anabilim Dalı, 26240 Eskisehir, Turkey.


ORIGINAL ARTICLE

Department of Emergency Medicine, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir

Engin OZAKIN, Rumeysa CAN, Nurdan ACAR, Filiz BALOGLU KAYA, Arif Alper CEVİK

An Evaluation of Complications in Ultrasound-GuidedCentral Venous Catheter Insertion in the

Emergency DepartmentAcil Serviste Ultrasonografi Eşliğinde Takılan Santral

Venöz Kataterlerin Komplikasyon Açısından Değerlendirilmesi

SUMMARYObjectivesIn emergency departments, emergency physicians frequently have to perform central venous access. In cases where peripheral venous access is not possible, central venous access is required for dialysis, fulfillment of urgent fluid need, or central venous pressure mea-surement. This study was carried out to evaluate the emergence of complications in the process of and in the 15 days following the insertion of central venous catheter under ultrasound guidance in the emergency department.

MethodsFor this study, patients who presented to the emergency depart-ment over a period of eight months with an urgent need for central catheter were examined prospectively. Age, gender, and accompa-nying diseases of patients as well as the type, time, duration, and indication of the venous access were recorded. Furthermore, the amount of experience of the physician was taken into consideration.

ResultsIn the emergency department, physicians performed ultrasound-guided central venous catheter insertion for 74 patients (40 men and 34 women). For access, internal jugular vein was used in 65 (87.8%) patients, and femoral vein was used in 9 (12.2%) patients. The reason for access was urgent dialysis need in 55 (74.3%), CVP measurement in 3 (4.1%), fluid support due to severe hypovolemia in 6 (8.1%), and difficulty of peripheral venous access in 10 (13.5%) patients. None of the patients developed complications in the pro-cess of or after the insertion. Patients did not have infections re-lated to the catheter in 15 days following the insertion.

ConclusionsCentral venous access is frequently required in emergency depart-ments. The risk of complication is little if any in ultrasonography-guided access carried out under appropriate conditions.

Key words: Central venous catheter; emergency department; ultrasound-guided.

ÖZETAmaçAcil servislerde acil tıp hekimlerince santral damar yolu işlemi sık uygulanır. Periferik damar yolu açılamadığı hallerde, diyaliz, acil sıvı ihtiyacı veya santral venöz basınç ölçümü gereken durumlar-da hastalar için santral damar yolu gerekmektedir. Acil serviste, ultrasonografi (USG) kılavuzluğunda uygulanan acil santral venöz katater girişimi sürecinde ve uygulamayı takip eden 15 gün içeri-sinde komplikasyon varlığını değerlendirmek amacı ile bu çalışma yapıldı.

Gereç ve YöntemSekiz aylık sürede acil servise başvuran ve acil santral katater gerek-sinimi olan hastalar ileriye dönük olarak incelendi. Hastaların yaşı, cinsiyeti, eşlik eden hastalıkları ile tercih edilen girişimin yolu, saati, süresi ve endikasyonu kaydedildi. Ayrıca girişimi yapan hekimin ça-lışma yılı da değerlendirmeye dahil edildi.

BulgularUltrasonografi eşliğinde santral venöz katater takılan 74 (40 erkek, 34 kadın) hastanın 65’inde (%87.8) internal juguler ven, dokuzun-da (%12.2) femoral ven girişim için kullanıldı. Uygulama olguların 55’inde (%74.3) acil diyaliz ihtiyacı, üçünde (%4.1) CVP ölçümü, al-tısında (%8.1) ciddi hipovolemi için sıvı desteği, 10’unda (%13.5) pe-riferik damar yolu güçlüğü nedeniyle yapıldı. Hastaların hiçbirinde işlem esnasında ve sonrasında komplikasyon izlenmedi. Yatırıldıkları bölümde takiplerinde 15 günlük süre içerisinde katater ile ilişkili en-feksiyon da saptanmadı.

SonuçAcil servislerde santral damar yolu gereksinimi sıktır. Kılavuzların öne-risi doğrultusunda USG eşliğinde uygun şartlar altında yapılan girişim-lerde komplikasyon riski yok denecek kadar azdır.

Anahtar sözcükler: Santral venöz katater; acil servis; ultrason kılavuzluğu.

53

IntroductionThe insertion of central venous catheters (CVC) has increased in emergency departments particularly with the spread in usage of ultrasonography (US). While internal jugular vein is commonly preferred for placement under ultrasound guid-ance, subclavian and femoral vein access has decreased due to higher complication risks. Emergency physicians apply CVC primarily in cases of hemodialysis, difficulty of periph-eral venous access, measurement of central venous pressure (CVP), and need for rapid fluid resuscitation.[1]

Following the insertion of CVC in the emergency depart-ment, complications such as infection, pneumothorax, hemothorax, subcutaneous hemorrhage, or puncture of vertebral and cervical arteries, catheter breakage, cath-eter malposition, thrombus formation, and infection may emerge.[1-3]

In order to reduce CVC complications, the healthcare per-sonnel placing the CVC is required to work under sterile con-ditions, be experienced, and use the appropriate technique for each unique patient. The quality of material used is also important.[4] This study focuses on the complications that may develop in the process of and in the 15 days following the insertion of CVC under ultrasound guidance in our clinic.

Materials and Methods This study was carried out prospectively in the emergency department of a university between January 2011 and Au-gust 2011 after the approval of the local board of ethics was obtained. The study involved patients aged over 18 in urgent need of CVC, who agreed to take part in the study or whose relatives gave consent. Patients with trauma, who were pregnant at the time of admittance, and patients who has two or more septic inflammatory response syndrome criteria[5] (fever of more than 38°C (100.4°F) or less than 36°C (96.8°F), heart rate of more than 90 beats per minute, respi-ratory rate of more than 20 breaths per minute or arterial carbon dioxide tension (PaCO2) of less than 32 mmHg, white blood cell count >12,000/μL or <4,000/μL or >10% imma-ture forms) were excluded. All interventions were performed by emergency physicians under US guidance, who previous-ly received training on US. For the purpose of the study, age, gender, and accompanying diseases of patients as well as the type, time, duration, and indication of the venous access were recorded. Furthermore, the physician’s level of experi-ence was taken into consideration. All patients were taken to a unit where vital and cardiac findings were monitored. The patients or their relatives were informed and their consent was received. In supine position, the patients were evalu-ated for an appropriate vein for US-guided intervention. For this purpose, the anatomic characteristics of the patients as

well as the proximity of vein to the skin, lumen diameters, and the proximity of vein to vital organs were checked. After the location of access was determined, local skin cleaning was performed with 10% povidone-iodine. The probe was covered with sterile glove (Figure 1) and area of access was covered with sterile drape. Once sterility was assured, sedo-analgesia and/or local anesthesia were administered with the agents appropriate for the clinical situation of each pa-tient. 7.5 MHz linear probe, used in US scan (Sonosite, Titan) was covered appropriately. The vascular structures in the rel-evant area were displayed on the transverse axis (Figure 2). The intervention was performed on the location where the vein is most proximate to the skin, the lumen is largest, and the adjacent artery is most protected. During the interven-tion, the needle movements were followed on the US screen dynamically. When the blood flow into the injector in the vein became clear, the catheter (double lumen hemodialysis catheter, 12F, 15 cm, Sentia) was placed using the Seldinger method. Blood and fluid flow were checked using heparin-containing fluid (50 U/ml), administered through the cathe-ter. Following the intervention, all patients were checked for subcutaneous emphysema, local hematoma, and bleeding by physical examination, for pneumothorax and hemotho-rax by US, and for the position of catheters and again pneu-mothorax and hemothorax by chest radiography. Then, in the intensive care unit or other departments where patients were transferred, they were observed for 15 days to detect any CVC-induced infections or other complications due to catheter placement by emergency physicians. Rash, temper-

Turk J Emerg Med 2014;14(2):53-58

Table 1. Patient characteristics

Properties n %

Sex

Male 40 54.1

Female 34 45.9

Past medical history

Diabetes mellitus 15 20.3

Renal insufficiency 15 20.3

Hypertension 13 17.6

Malignancy 6 8.1

None 23 31.1

Catheter location

Internal jugular vein 65 87.8

Femoral vein 9 12.2

İndications

Dialysis 55 74.4

CVP 3 4.1

Hypovolemia 6 8.1

Difficult peripheral venous access 10 13.5

54

ature rise, and swelling on the location where the catheter was inserted were considered local symptoms of infection and systemic inflammatory response syndrome criteria were considered the systemic symptoms. SPSS 20 was used for data analysis.

ResultsOf 74 patients that had central venous catheter insertion, 40 (54.1%) were male and 34 (45.9%) were female. The mean age was 63.7±12.42 (range: 32-85). The medical histories of the patients showed that 15 (20.3%) patients had diabetes mellitus, 15 (20.3%) had chronic renal failure, 13 (17.6%) had hypertension, 6 (8.1%) had malignity, and 2 (2.7%) had chronic liver disease. In 23 (31.1%) patients, there were no

comorbid diseases in past medical history. Internal jugular vein catheterization was preferred in 65 (87.8%) patients, and femoral vein catheterization was preferred in 9 (12.2%) patients. 29 (39.2%) interventions were performed between 8 am and 4 pm, 31 (41.9%) between 4 pm and 12 am, and 14 (18.9%) between 12 am and 8 am. CVC indicated urgent dialysis need in 55 (74.3%), need for CVP measurement in 3 (4.1%), urgent fluid need due to severe hypovolemia in 6 (8.1%), and difficulty of peripheral venous access in 10 (13.5%) patients. The average duration of the intervention was 12.34±6.54 (range: 6-37) minutes in internal jugular vein access, 14.56±6.3 (range: 6-29) minutes in femoral vein ac-cess, and 12.61± 6.51 (range: 6-37) minutes in total. The in-tervention was successful in the first attempt in 52 (70.3%) patients, in the second attempt in 18 (24.3%) patients, and in

Özakın E et al. Complications in Ultrasound-Guided Central Venous Catheter Insertion in ED

Figure 1. Ultrasound-guided central venous catheter insertion.

55

three or more attempts in 4 (5.5%) patients. 17 (23%) cathe-ters were placed by emergency medical physicians with one year of experience, 25 (33.8%) catheters by physicians with two years of experience, 23 (%31.1) catheters by physicians with three years of experience, 6 (8.1%) catheters by physi-cians with four years of experience, and 3 (4.1%) catheters by physicians with five years of experience.

In the case of one patient, because blood and fluid flow could not be assured through the catheter inserted in the right internal jugular vein, the intervention was completed successfully from the left. No complication was found in examinations, US, or additional tests performed after the interventions. There was no anomaly in catheter positions, but five patients suffered from temporary dysrhythmia be-cause the catheter was inserted overmuch. In consideration of their clinical indications, 61 (82.4%) patients were trans-ferred to the intensive care unit and 13 (17.6%) patients to other units. Six (8.1%) of these patients died in one week due to causes independent of catheter complications. The 6 patients that died and other patients observed in relevant units for 15 days did not develop local or systemic infections or mechanic complication due to catheter insertion.

DiscussionCVC is a common practice in emergency and intensive care units. The major cases that require CVC are CVP measure-ment, long-term parenteral treatment, high-concentration fluid and drug administration, recurring blood and blood products administration, hyperalimentation, hemodialysis, and plasmapheresis.

Today, internal jugular veins are frequently preferred for

CVC. Furthermore, external jugular, subclavian, femoral, basilic-cephalic, and rarely portal, inferior vena cava and hepatic veins may be used for this purpose. The Seldinger technique is commonly preferred because it is easy, fast, and reliable. For the patients in our study, the Seldinger method was used, and internal jugular and femoral veins were pre-ferred for insertion.

CVC, which is a vital and life-saving intervention for critical patients, may cause high-cost complications, and the mor-tality rate of this intervention was reported as 20%.[6] The literature lists 35 types of complications.[7] Among the com-plications that may arise are infection, sepsis, hemorrhage, pneumothorax, air embolism, arterial or nerve laceration, cardiac perforation, arrhythmia, loss of guidewire, catheter malposition, extravasation, infiltration, edema, refractory bleeding, catheter breakage, catheter blockage, and throm-bophlebitis.[7] That is why it is important to control complica-tions by clinical and radiological means after the interven-tion.

The success of intervention depends on the characteristics of the anatomic location and the experience of the practitio-ner.[8,9] The majority of mechanic complications emerge dur-ing or right after the intervention. Thrombosis is seen more frequently in cases where the intervention is difficult and the practitioner is inexperienced. The incidence of thrombotic complications ranges between 5 and 50%.[6] The rate of mor-tality is high when thrombus breaks up in the catheter and mixes with blood. Additionally, thrombus formation in the catheter is associated with increased infection. Embolism is also a fatal complication of catheter insertion.[10]

Ventricular dysrhythmia and bundle branch blocks may emerge if the catheter reaches the right atrium during the intervention. Inserting a catheter shorter than 16 cm may prevent these complications.[11,12] Because of the patients’ movements, catheter migration of up to 3 cm is frequent, which shows up in the form of delayed arrhythmia. In our study, 5 patients suffered from temporary dysrhythmia be-cause the catheter was inserted overmuch. The dysrhythmia disappeared when the catheter was brought back to the ap-propriate location.

Pneumothorax and hemothorax may develop when the practitioner is inexperienced or the patient is in a wrong position. These complications develop more commonly in access through the subclavian vein. That is why, after the invention, the patient should be observed using physical ex-amination as well as chest radiography and US.

Infection is one of the most frequent complications associ-ated with CVC insertion. Hospital-acquired infection is the most common third infection following ventilator-related

Figure 2. The vascular structures in the relevant area were displa-yed on the transverse axis.

56 Turk J Emerg Med 2014;14(2):53-58

pneumonia and urinary tract infection associated with uri-nary catheterization.[13] The Center for Disease Control (CDC) reported that 250,000 catheter-related infections occur annu-ally and that the relevant annual mortality rate is 20%.[14] Ap-proximately 90% of the bacteremia develops due to CVC.[15]

With the spread of the use of US in emergency departments, the rate of success in ultrasound-guided interventions has increased, and the risk of complication reduced in the last 5-10 years.[16,17] The Agency for Healthcare Research and Quality, the Institute of Medicine, and the National Institute for Health and Clinical Excellence recommend that such in-terventions should be performed under ultrasound guid-ance.

In internal jugular venous catheterizations, the use of real-time two-dimensional US was reported to yield fewer com-plications compared to landmark guide techniques.[17-19] A meta-analysis study, involving 18 researchers and 1646 patients, compared the groups for which US was used and not used, and reported that the use of US reduced complica-tions considerably among both children and adults.[6] There is no adequate research on subclavian and femoral vein ac-cess. In internal jugular vein catheterization, performed in non-emergency cases and without the use of US, carotid ar-tery puncture of 5.9% in average was reported.[20] In another research, the rate was reported as 3-5%.[9] The rate increases when catheterization is performed under emergency and by inexperienced physicians.[21] In cases where there is a delay in diagnosis, hemorrhagic and neurological complications may develop.[22,23] It is reported in the literature that the rate of carotid artery puncture in US-guided internal jugular vein catheterization ranges between 2 and 9%.[24] In our study, there was no artery puncture in US-guided catheterization.

It is not recommended to perform catheterization without US on patients with coagulopathy; however, it is also re-ported that experienced physicians may perform it safely.[25] In our study, although two patients had coagulopathy (liver failure) (INR of the first patient: 2.1, and INR of the second patient: 1.94), the interventions were completed without any complications. Furthermore, it is reported that the risk of bleeding is highest in patients with thrombocytopenia; however, no bleeding was detected in two patients that were diagnosed with thrombocytopenia in the present study.

In our study, as mentioned above, six patients died in one week after the intervention. The cause of death was respi-ratory insufficiency in three patients, electrolyte abnormal-ity in two patients, and liver failure in one patient. In the remaining 68 patients, no findings of local infection or SIRS criteria were detected.

In a comparison of our study and literature, we determined fewer complications in our study. Reasons for these results may include careful applications using sterile techniques, accordance with procedural rules, and experienced emer-gency physicians for US-guided catheterization (minimum 50 procedures per physician).

Conclusion

CVC interventions may cause severe complications when not performed under appropriate conditions. The present study shows that emergency physicians perform CVC inter-ventions under emergency conditions without any compli-cations, provided that the environment is sterile, the appro-priate method is selected, and US is used. We believe that the use of US should be more widespread, and emergency physicians should enhance their experience in order to per-form these interventions successfully.

Limitations

There were some limitations of our study. There may not be enough patients included in the study to observe complica-tions. Physicians who performed procedures were well ex-perienced. Observing time duration was 15 days.



References1. Ruesch S, Walder B, Tramèr MR. Complications of central ve-

nous catheters: internal jugular versus subclavian access--a systematic review. Crit Care Med 2002;30:454-60.

2. Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization. Failure and complication rates by three percutaneous approaches. Arch Intern Med 1986;146:259-61.

3. Bona RD. Thrombotic complications of central venous cathe-ters in cancer patients. Semin Thromb Hemost 1999;25:147-55.

4. Batra RK, Guleria S, Mandal S. Unusual complication of in-ternal jugular vein cannulation. Indian J Chest Dis Allied Sci 2002;44:137-9.

5. Bone RC, Balk RA, Cerra FB. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 1992;101:1644-55.

6. Polderman KH, Girbes AJ. Central venous catheter use. Part 1: mechanical complications. Intensive Care Med 2002;28:1-17.

7. Silberzweig JE, Sacks D, Khorsandi AS, Bakal CW; Society of In-terventional Radiology Technology Assessment Committee. Reporting standards for central venous access. J Vasc Interv

57Özakın E et al. Complications in Ultrasound-Guided Central Venous Catheter Insertion in ED

Radiol 2003;14:443-52.8. Eisen LA, Narasimhan M, Berger JS, Mayo PH, Rosen MJ,

Schneider RF. Mechanical complications of central venous catheters. J Intensive Care Med 2006;21:40-6.

9. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33.

10. Brown S. Complications with the use of venous access devic-es. U.S. Pharmacist, 2002.

11. Boyd R, Saxe A, Phillips E. Effect of patient position upon success in placing central venous catheters. Am J Surg 1996;172:380-2.

12. Lefrant JY, Muller L, De La Coussaye JE, Prudhomme M, Ripart J, Gouzes C, et al. Risk factors of failure and immediate com-plication of subclavian vein catheterization in critically ill pa-tients. Intensive Care Med 2002;28:1036-41.

13. Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosoco-mial infections in combined medical-surgical intensive care units in the United States. Infect Control Hosp Epidemiol 2000;21:510-5.

14. O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, et al. Guidelines for the prevention of intravas-cular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002;51:1-29.

15. Sherertz RJ, Ely EW, Westbrook DM, Gledhill KS, Streed SA, Kiger B, et al. Education of physicians-in-training can de-crease the risk for vascular catheter infection. Ann Intern Med 2000;132:641-8.

16. Leung J, Duffy M, Finckh A. Real-time ultrasonographically-guided internal jugular vein catheterization in the emergen-cy department increases success rates and reduces compli-cations: a randomized, prospective study. Ann Emerg Med 2006;48:540-7.

17. Hilty WM, Hudson PA, Levitt MA, Hall JB. Real-time ultrasound-guided femoral vein catheterization during cardiopulmonary resuscitation. Ann Emerg Med 1997;29:331-7.

18. Calvert N, Hind D, McWilliams R, Davidson A, Beverley CA, Thomas SM. Ultrasound for central venous cannulation: economic evaluation of cost-effectiveness. Anaesthesia 2004;59:1116-20.

19. Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med 1996;24:2053-8.

20. el-Shahawy MA, Khilnani H. Carotid-jugular arteriovenous fis-tula: a complication of temporary hemodialysis catheter. Am J Nephrol 1995;15:332-6.

21. Garutti I, Olmedilla L, Pérez-Peña JM, Jiménez C, Sanz FJ, Ber-mejo L, et al. Internal jugular vein catheterization performed by resident and staff physicians. Rev Esp Anestesiol Reanim 1993;40:360-2.

22. Jobes DR, Schwartz AJ, Greenhow DE, Stephenson LW, Elli-son N. Safer jugular vein cannulation: recognition of arterial puncture and preferential use of the external jugular route. Anesthesiology 1983;59:353-5.

23. Oliver WC Jr, Nuttall GA, Beynen FM, Raimundo HS, Abenstein JP, Arnold JJ. The incidence of artery puncture with central venous cannulation using a modified technique for detection and prevention of arterial cannulation. J Cardiothorac Vasc Anesth 1997;11:851-5.

24. Droll KP, Lossing AG. Carotid-jugular arteriovenous fistula: case report of an iatrogenic complication following internal jugular vein catheterization. J Clin Anesth 2004;16:127-9.

25. Doerfler ME, Kaufman B, Goldenberg AS. Central venous catheter placement in patients with disorders of hemostasis. Chest 1996;110:185-8.

58 Turk J Emerg Med 2014;14(2):53-58



Correspondence: Dr. Ahmet Baydın. Ondokuz Mayıs Üniversitesi Tıp Fakültesi,Acil Tıp Anabilim Dalı, 55139 Samsun, Turkey.


ORIGINAL ARTICLE

1Department of Emergency, Samsun Training and Research Hospital, Samsun;2Department of Emergency, Ondokuz Mayis University Faculty of Medicine, Samsun

Ali Kemal ERENLER,1 Sinan AKBULUT,1 Murat GUZEL,1 Halil CETINKAYA,1

Alev KARACA,1 Burcu TURKOZ,1 Ahmet BAYDIN2

Reasons for Overcrowding in the Emergency Department: Experiences and Suggestions of anEducation and Research Hospital

Acil Serviste Aşırı Kalabalığın Nedenleri:Bir Eğitim Araştırma Hastanesinin Deneyimleri ve Önerileri

SUMMARYObjectivesIn this study, we aimed to determine the causes of overcrowding in the Emergency Department (ED) and make recommendations to help reduce length of stay (LOS) of patients in the ED.

MethodsWe analyzed the medical data of patients admitted to our ER in a one-year period. Demographic characteristics, LOS, revisit frequen-cy, and consultation status of the patients were determined.

ResultsA total of 163,951 patients were admitted to our ED between Janu-ary 1, 2013, and December 31, 2013. In this period 1,210 patients revisited the ED within 24 hours. A total of 38,579 patients had their treatment in the observation room (OR) of the ED and mean LOS was found to be 164.1 minutes. Cardiology was the most frequently consulted specialty. Mean arrival time of the consultants in ED was 64 minutes.

ConclusionsSimilar to EDs in other parts of the world, prolonged length of stay in the ED, delayed laboratory and imaging tests, delay of consul-tants, and lack of sufficient inpatient beds are the most important causes of overcrowding in the ED. Some drastic measures must be taken to minimize errors and increase satisfaction ratio.

Key words: Consultation; emergency department; overcrowding.

ÖZETAmaçBu çalışmada, acil serviste aşırı yoğunluğun nedenlerini belirlemeyi ve hastaların acil serviste kalış sürelerini azaltmaya yönelik önerilerimizi sunmayı hedefledik.

Gereç ve YöntemBir yıllık sürede acil servise başvuran hastaların tıbbi bilgileri incelendi. Hastaların demografik özellikleri, kalış süreleri, tekrar başvuru sayıları ve konsültasyon durumları belirlendi.

Bulgular1 Ocak 2013 ile 31 Aralık 2013 tarihleri arasında toplam 163951 has-ta acil servise başvurdu. Bu süre içinde, 1210 hasta 24 saat içerisinde tekrar acile başvurdu. Toplam 38579 hasta tedavisini acil servisin göz-lem odasında aldı ve ortalama kalış süresi 164.1 dakikaydı. En fazla konsültasyon istenen bölüm kardiyoloji idi. Konsültanların acil servise varış süresi ortalama 64 dakikaydı.

SonuçDünyanın diğer bölgelerindeki acil servislere benzer şekilde, acilde aşı-rı yoğunluğun en önemli nedenleri acil serviste uzun kalış süresi, gecik-miş laboratuvar ve görüntüleme testleri, konsültanların gecikmesi ve yeterli hastane yatağı olmamasıdır. Hataları en aza indirmek ve mem-nuniyet oranını artırmak için, ilgili farklı birimlerle temas halinde, bazı sert önlemler alınmalıdır.

Anahtar sözcükler: Konsültasyon; acil servis; aşırı yoğunluk.

59

IntroductionThe Emergency Department (ED) is one of the most over-crowded units in the inpatient service delivery system. De-lays in services in the ED may have unpleasant consequenc-es for patients.[1] Crowding in the ED is defined as having more patients than treatment rooms or more patients than staff should ideally care for, and overcrowding was defined as dangerously crowded, with an extreme volume of pa-tients in ED treatment areas which forces the ED to operate beyond its capacity.[2,3]

In the Emergency Medicine literature, overcrowding in EDs is described as a major public health problem due to degrada-tion of the quality of care (prolonged waiting times, delays to diagnosis and treatment, delays in treating seriously ill patients), increased costs (leading to unnecessary diagnos-tic investigations), and patients’ dissatisfaction.[4,5] Although the most important cause of bottleneck in the ED seems to be a growing population with non-urgent complaints. Over-crowding in EDs is a multi-factorial problem worldwide, oc-curring as a result of prolonged length of stay (LOS) in the ED, inadequate healthcare personnel appointment, delayed response to ED consultations, repeated ED visits (including inappropriate use), and hospital-specific factors (size and location, lack of available inpatient beds). In this article, we investigated ED systems of different countries and aimed to find a solution to overcrowding in the ED in the light of statistical data of Samsun Education and Research Hospital (SERH) Emergency Department. We also presented our rec-ommendations to prevent overcrowding in the ED.

Materials and Methods We retrospectively collected the medical data of the pa-

tients admitted to SERH Department of Emergency Medi-cine in a one-year period between January 1, 2013, and December 31, 2013. Data was collected using analysis of electronic medical records from the ED over a 12-month period. Besides demographical findings, annual ED admis-sion count, seasonal distribution, number of repeated visits within 24 hours, LOS of the patients in the ED observation rooms, and period of arrival of consultants were investigat-ed. Demographical findings of the patients were collected by reviewing the medical reports. Other information, such as consultation call time, start and finish time of the consul-tations, and LOS of the patients, was collected. Status was determined and compared with other facilities from the per-spective of preventing overcrowding in the ED. Medical data was recorded on Statistical Package for the Social Sciences (SPSS) 15.0 programme. Data were presented as frequency. After statistical analysis, graphics were obtained using Mi-crosoft® Office Excel Programme. Study was conducted with the permission of SERH Administration.

ResultsA total of 163,951 patients were admitted to our ED in a one-year period. Of these patients, 87,549 (53.3%) were male and 76,402 (46.7%) were female. The proportion of those under the age of 18 was 16,743 (10.2%). Consultation with at least one department was required in 18.1% of the pa-tients. Among all patients admitted to the ED, 1.3% did not have health insurance. In this period 1,210 (0.7%) patients revisited the ED within 24 hours. With 16,095 patients and 139 revisits, the month of August was the most crowded in the ED. Table 1 demonstrates the number of monthly visits, revisits, and frequencies. A total of 38,579 patients had their treatment in the observation room (OR) of the ED and mean

Turk J Emerg Med 2014;14(2):59-63

Table 1. Number of patients admitted to the ED and revisits monthly

Month Number of revisits Number of patients admitted Ratio (%)

January 71 11688 0.61

February 106 12991 0.82

March 101 13745 0.73

April 95 12972 0.73

May 128 13508 0.95

June 85 13724 0.62

July 107 13721 0.78

August 139 16095 0.86

September 78 13454 0.58

October 85 15640 0.54

November 124 12973 0.96

December 91 13458 0.68

60

LOS was 164.1 minutes. Table 2 represents the monthly ad-missions to OR and mean LOS of patients. The number of patients with an LOS of 12 hours was 432 (mean value was 36 per month). Cardiology was the leading department ac-cording to consultation ratios (16.4%), followed by general surgery (12.6%), neurology (8.6%), and internal medicine (8.4%). In one year, the mean period between call for consul-tation and arrival of the consultant was 64 minutes. Seasonal distribution of consultation periods and mean value is dem-onstrated in Figure 1.

DiscussionSamsun, with its population of 593,260 in the city center ac-cording to 2012 census data, is the largest city in the Karad-eniz Region located in the North of Turkey. In the city, there are three main hospitals: University Hospital, Education and Research Hospital, and State Hospital. Besides. Other health-

care service providers include one obstetrics hospital, one hospital for lung disease, and a few private hospitals. Sam-sun Education and Research Hospital gives emergency ser-vice to 600 patients daily and 163,951 patients annually with 3 doctors per shift (a specialist, resident, and practitioner) in the ED. For comparison, in a study in Switzerland, it was re-ported that 57,645 patients were admitted to the ED of an urban teaching hospital in the year 2008.[6]

The largest proportion of patients in our study was admitted in summer months, particularly in August. The reason of this human density in summertime may be associated with sum-mer vacation, increasing number of outdoor activities and touristic travels, and heat strokes and suffocations related to season of sea. July of 2013 was an exception to this trend because it was the holy month of Ramadan and the number of activities tended to decrease during the day.

As in other EDs worldwide, in our country, the most com-mon problem is overcrowding of the ED which results in dis-satisfaction of both ED personnel and patients. In our opin-ion, people in Turkey tend to use ED frequently because of financial concerns, lack of medical insurance, and expecta-tion of rapid service.

In fact, patients requiring vital interventions represent less than 3% of those using EDs.

Non-urgent patients’ use of EDs, rather than primary care settings, allows them to be treated without an appointment in a setting with modern and high-quality technologies.

Erenler AK et al. Reasons for Overcrowding in the Emergency Department

Table 2. Number of patients admitted to the observation room of the ED, sum and mean values of length of stay

Month Sum of LOS of Number of patients Mean LOS of patients patients in the OR admitted to the OR in the OR (min) (min)

January 498049 3095 161.3

February 533510 3117 171.1

March 534309 3268 163.5

April 538887 3183 169.3

May 529759 3259 162.5

June 547410 3234 169.2

July 481559 3240 149.03

August 574824 3640 158.3

September 480047 3173 151.05

October 485056 3235 150.3

November 433373 3025 143.2

December 471949 3110 152.1

OR: Observation room; min: Minute.

Figure 1. Seasonal distribution of periods of consultations and an-nual mean value.

90.0080.0070.0060.0050.0040.0030.0020.0010.00

0.00

min

Spring

55.71

79.06

Period between call for consultation and arrival of the consultant

65.3054.51

64.1

Summer Autumn Winter Mean

61

The French government implemented several measures to improve the coordination of health care services and EDs and to control the flow of ED visits.[7] Alternative health care structures, such as primary care units located near the hospitals that can take care of non-urgent patients who go by themselves to an ED or have been wrongly directed to one, were constructed. These structures helped solve the ED overcrowding problem.[8] “Inappropriate” use of emer-gency departments (ED) is a term used for over use of EDs in western society.[9] Inappropriate use results in not only compromised efficiency of healthcare personnel, infrastruc-ture, and financial resources of the ED, but also in delay of treatment of serious medical conditions.[10-12] In our study, we determined that people not only over-use the ED but also contribute to overcrowding by repetitive admissions. Prolonged LOS may occur as a result of overcrowding, de-lay of radiological and laboratory test results, delayed and inappropriate consultations, and inadequate inpatient bed counts. Despite a relatively short LOS, it was reported in the Netherlands that almost half of the crowded EDs experi-enced overcrowding two or more times per week. Delays in consultations and laboratory and radiology services contrib-uted to the problem. Admitted patients had a longer LOS because of delays in obtaining inpatient beds.[13] Another factor that affects LOS in the ED is inpatient LOS. A study in Canada revealed that prolonged LOS in the ED was associ-ated with prolonged inpatient LOS. In that study, patient age, comorbid factor level, and sex were found to influence LOS.[14] Our study revealed that prolonged LOS, as in the EDs of other hospitals in the world, is the main cause of loss of resources and manpower in our hospital.

Consultation is an important component of ED patient care. Consultations are common and often lead to hospital ad-mission in academic tertiary EDs. It is the process by which emergency physicians request other specialists (consultants) to participate in the care of the ED patient. By the end of this process, the consultant should provide one of the following recommendations: admit, discharge with or without consul-tant follow-up, or consult another specialty.[15] In our study, mean annual consultation time was found to be 64.1 min-utes which is an unacceptable period, particularly in the ED. In a study, frequency and outcomes of consultations were in-vestigated and it was reported that at least one consultation was requested in 38% of patients. More than one-half of the patients (54.3%) who received a consultation were admitted to the hospital.[16] In another study, Cortazzo et al. reported that the frequency of consultation was approximately 40% at a U.S. Army base hospital ED with 60,000 annual visits.[17] These results reveal the importance of urgent response to consultations in order to reduce overcrowding. Specialty consultation was also associated with prolonged LOS, and this effect was highly variable depending on the service con-

sulted.[18] In our study, frequency of the consultations was found to be 18.1%, which is a relatively low proportion when compared to other studies. This may be related to a higher ratio of non-urgent patients admitted to our ED, resulting in overcrowding. We agree with Woods et al. that interventions to streamline the consultation process and rules regarding consultation times appear warranted when the current sta-tus of many hospitals are considered.[16] EDs must also be organized to transport the patients from ED to the related ward as soon as possible.

In a study from Turkey, it was determined that the most im-portant factor for the effectiveness of consultation was the definition of the urgency of the patients by residents in the ED. It was observed that as the level of urgency of the pa-tient increased, time of arrival of the consultant decreased.[19] These results reveal that standardization for the consulta-tion system is essential. In a multicenter study, Cooke et al. reported that 20.5-37.9% of patients visiting four different EDs did not actually use any departmental resources except for examination and advice.

They recommended using staff with little experience or re-stricted in their decision by protocols to reduce the number of patients requiring only examination and advice. They also reported that 13.3-18% of patients arrived by ambulance and some of these patients may avoid attendance at hos-pital if paramedics were trained to deal with these cases.[20] They concluded that a large percentage of patients seen in EDs may not require the extra facilities of that department. There is potential for a large number to be discharged within a few minutes of arrival if appropriate assessment skills are available at first contact. A similar system may be applied to our ED and contribute to prevention of overcrowding and misdiagnosis of critical patients in the ED.

Conclusion

Overcrowding is a common problem in EDs worldwide. It has undesired consequences such as loss of resources, ineffec-tive use of time, and dissatisfaction of both ED personnel and applicants. Policy makers and hospital managers must focus on measures to reduce non-urgent presentations to the ED in order to minimize possible medical inaccuracies. We believe that emphasizing PCUs, increasing the number of personnel, ensuring compliance of the consultants, and educating the public about receiving appropriate healthcare may reduce overcrowding in the ED. Collaboration between ED physi-cians and consultants must be constituted and maintained. A systematic approach for ambulance systems and EDs must be developed to refer patients to optimal centers where they can receive the appropriate therapy. In the future, govern-ments must focus on and develop the family physician sys-tem to keep non-urgent patients out of EDs.

Turk J Emerg Med 2014;14(2):59-6362



References

1. Alavi-Moghaddam M, Forouzanfar R, Alamdari S, Shahrami A, Kariman H, Amini A, et al. Application of Queuing Analytic Theory to Decrease Waiting Times in Emergency Depart-ment: Does it Make Sense? Arch Trauma Res 2012;1:101-7.

2. Schneider SM, Gallery ME, Schafermeyer R, Zwemer FL. Emer-gency department crowding: a point in time. Ann Emerg Med 2003;42:167-72.

3. Gordon JA, Billings J, Asplin BR, Rhodes KV. Safety net re-search in emergency medicine: proceedings of the Academic Emergency Medicine Consensus Conference on “The Unrav-eling Safety Net”. Acad Emerg Med 2001;8:1024-9.

4. Agence Régionale de l’Hospitalisation Provence Alpes Côtes d’Azur: Schéma Régional d’Organisation Sanitaire 2006-2011. Thématique: Prise en charge des urgences et articulation avec la permanence des soins. Avril 2006, 191-227.

5. Journal Officiel de la République Française: Arrêté du 22 sep-tembre 2004 fixant la liste et la réglementation des diplômes d’études spécialisés complémentaires de médecine. 2004, NOR: SANP0423091A.

6. Grosgurin O, Cramer B, Schaller M, Sarasin FP, Rutschmann OT. Patients leaving the emergency department without be-ing seen by a physician: a retrospective database analysis. Swiss Med Wkly 2013;143:w13889.

7. Unions Régionales des Médecins en Exercice Libéral: Livre blanc sur l’organisation de la permanence des soins en mé-decine libérale. Rapport pour la Conférence des Présidents des Unions Régionales de Médecins en Exercice Libéral. Juil-let 2001.

8. Gentile S, Vignally P, Durand AC, Gainotti S, Sambuc R, Ger-beaux P. Nonurgent patients in the emergency department? A French formula to prevent misuse. BMC Health Serv Res 2010;10:66.

9. Philips H, Remmen R, De Paepe P, Buylaert W, Van Royen P.

Out of hours care: a profile analysis of patients attending the emergency department and the general practitioner on call. BMC Fam Pract 2010;11:88.

10. Carret ML, Fassa AG, Kawachi I. Demand for emergency health service: factors associated with inappropriate use. BMC Health Serv Res 2007;7:131.

11. Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U, et al. The effect of emergency department crowd-ing on clinically oriented outcomes. Acad Emerg Med 2009;16:1-10.

12. Vieth TL, Rhodes KV. The effect of crowding on access and quality in an academic ED. Am J Emerg Med 2006;24:787-94.

13. van der Linden C, Reijnen R, Derlet RW, Lindeboom R, van der Linden N, Lucas C, et al. Emergency department crowding in The Netherlands: managers’ experiences. Int J Emerg Med 2013;6:41.

14. Nippak PM, Isaac WW, Ikeda-Douglas CJ, Marion AM, Vanden-Broek M. Is there a relation between emergency department and inpatient lengths of stay? Can J Rural Med 2014;19:12-20.

15. Office of Health and the Information Highway. Information technologies serving health: consultation workshop with emergency room staff in Quebec region. Ottawa (ON): Health Canada; 1998.

16. Woods RA, Lee R, Ospina MB, Blitz S, Lari H, Bullard MJ, et al. Consultation outcomes in the emergency department: ex-ploring rates and complexity. CJEM 2008;10:25-31.

17. Cortazzo JM, Guertler AT, Rice MM. Consultation and referral patterns from a teaching hospital emergency department. Am J Emerg Med 1993;11:456-9.

18. Yoon P, Steiner I, Reinhardt G. Analysis of factors influenc-ing length of stay in the emergency department. CJEM 2003;5:155-61.

19. Karakaya Z, Gökel Y, Açikalin A, Karakaya O. Evaluation of the process and effectiveness of consultation system in the De-partment of Emergency Medicine. Ulus Travma Acil Cerrahi Derg 2009;15:210-6.

20. Cooke MW, Arora P, Mason S. Discharge from triage: model-ling the potential in different types of emergency depart-ment. Emerg Med J 2003;20:131-3.

Erenler AK et al. Reasons for Overcrowding in the Emergency Department 63


Submitted: January 31, 2014 Accepted: March 20, 2014 Published online: June 04, 2014

Correspondence: Dr. Neşe Çolak Oray. Dokuz Eylül Üniversitesi Tıp Fakültesi,Acil Tıp Anabilim Dalı, 35320 Izmir, Turkey.


64 ORIGINAL ARTICLE

1Department of Emergency Medicine, Dokuz Eylul University Faculty of Medicine, Izmir;2Department of Clinic of Emergency, İstanbul Training and Research Hospital, Istanbul

Nese COLAK ORAY,1 Sedat YANTURALI,1 Ridvan ATILLA,1

Gurkan ERSOY,1 Hakan TOPACOGLU2

A New Model in Reducing Emergency DepartmentCrowding: The Electronic Blockage System

Acil Servis Kalabalığını Azaltmada Yeni Bir Model:Elektronik Blokaj Sistemi

SUMMARYObjectivesEmergency department (ED) crowding is a growing problem across the world. Hospitals need to identify the situation using emergency department crowding scoring systems and to produce appropriate solutions.

MethodsA new program (Electronic Blockage System, EBS) was written supple-mentary to the Hospital Information System. It was planned that the number of empty beds in the hospital should primarily be used for pa-tients awaiting admission to a hospital bed at the ED. In the presence of patients awaiting admission at the ED, non-urgent admissions to other departments were blocked. ED overcrowded was measured in the period before initiation of EBS, the early post-EBS period and the late post-EBS period, of one-week’s duration each, using NEDOCS scoring.

ResultsNEDOCS values were significantly lower in the early post-EBS pe-riod compared to the other periods (p<0.0001). Although outpatient numbers applying to the ED and existing patient numbers at time of measurement remained unchanged in all three periods, the number of patients awaiting admission in the early post-EBS period was signifi-cantly lower than in the pre-EBS and late post-EBS periods (p=0.0001, p=0.001).

ConclusionsEBS is a form of triage system aimed at preventing crowding and ensur-ing the priority admission of emergency patients over that of polyclinic patients. In hospitals with an insufficient number of total beds it can be used to reduce ED crowding and accelerate admissions to hospital from the ED.

Key words: Emergency department; National Emergency Department Overcrowding Study; NEDOCS; overcrowding.

ÖZETAmaçAcil servis kalabalığı tüm dünyada giderek yaygınlaşan bir sorundur. Has-tanelerin acil servis kalabalık ölçütlerini kullanarak durum tespiti yapması ve uygun çözüm önerileri üretmeleri gereklidir.

Gereç ve YöntemÇalışmamızda Hastane Bilgi Yönetim Sistemine ek bir program (Elektro-nik Blokaj Sistemi, EBS) yazıldı. Buna göre hastanede bulunan boş ya-takların öncelikli olarak acil serviste yatış bekleyen hastalar için kullanıl-ması planlandı. Acil serviste yatış bekleyen hasta varken, ilgili servislere yapılacak acil olmayan poliklinik yatışları bloke edildi. EBS başlamadan önceki dönem, EBS sonrası erken dönem ve EBS sonrası geç dönemde birer hafta boyunca NEDOCS skorlaması ile acil servis kalabalıklığı öl-çüldü.

BulgularElektronik blokaj sistemi sonrası erken dönemde diğer dönemlere göre NEDOCS değeri anlamlı olarak daha düşük bulundu (p<0.0001). Her üç dönemde de acil servise başvuran günlük hasta sayısı ve ölçüm anında mevcut olan hasta sayısı değişmediği halde, acil servis içinde yatış bekle-yen hasta sayısı EBS sonrası erken dönemde, EBS öncesi ve EBS sonrası geç döneme göre anlamlı olarak daha azdı (p=0.0001, p=0.001).

SonuçElektronik blokaj sistemi, acil hastaların poliklinik hastalarına göre ön-celikli olarak hastaneye yatışını sağlayan, kalabalığı önlemeye yönelik bir çeşit yatış triajı sistemidir. Hastanedeki toplam yatak sayısının yeterli olmadığı hastanelerde, acil servis kalabalığını azaltmak için acil servisten hastaneye olan yatışları hızlandırmak amacıyla kullanılabilir.

Anahtar sözcükler: Acil servis; National Emergency Department Overcrow-ding Study; NEDOCS; kalabalık.

IntroductionOvercrowding occurs when no inpatient beds are available in hospital as a result of too many patients with non-urgent medical conditions seeking emergency care.[1] Emergency department (ED) overcrowding is an increasing problem worldwide. Overcrowding is correlated with several nega-tive outcomes, such as increased in-hospital death rates, prolonged treatment times, a rise in preventable medical errors, patients leaving without receiving medical advice from a physician or without being examined in the ED, and repeated applications to hospital.[2,3]

Among the reasons for ED overcrowding are an insufficient number of hospital beds, a rise in ED applications, excessive critical patient numbers, an insufficient numbers of nurse, delayed consultations, delayed radiological examinations, and a shortage of ED physical space.[4]

There are no globally accepted standard criteria for measur-ing ED overcrowding. However, five main scoring systems have been employed in studies regarding ED overcrowding.[5-9]

1. Emergency Department Crowding Score, EDCS

2. Real Time Emergency Analysis of Demand Indicators Score, READI

3. Emergency Department Work Index, EDWIN

4. National Emergency Department Overcrowding Study, NEDOCS

5. Work Score

Hoot et al. compared overcrowding scoring systems and re-ported that EDWIN, NEDOCS and Work Score provided pow-erful prediction of emergency service overcrowding, with negative predictive values of approximately 94%.[10]

A new strategy has been introduced with an aim to reduce

the overcrowding in the our ED and accelerate turnover called the Electronic Blockage System (EBS). The main princi-ple of the EBS is to prioritize, patients awaiting admission to the ED. For example, patients that are waiting clinical admis-sion within the ED are registered and all other admissions outside the ED are blocked in the electronic system.

In order to evaluate the success of the EBS based on the principle of priority being given to patients in the ED in ad-mission and reduce ED overcrowding, our study evaluated ED overcrowding in the pre-EBS and early and late post-EBS periods.

Materials and Methods Study environment

The Dokuz Eylül University Hospital (DEUH) is one of two universities and four ministry of health training and re-search hospitals providing tertiary casualty department service in the Izmir with a metropolitan population of ap-proximately 4 million. With its 925-bed capacity, it is the third-largest hospital in the province of Izmir. The DEUH ED served 85,813 patients in 2011. Despite a rise in numbers of patients applying to our hospital ED in recent years, the admission rates from the ED to hospital have declined in relative terms since there has been no change in depart-ment/intensive care admission rates (Table 1). The mean age of patients applying was determined to be 46. Eight percent of the patients were able to be admitted, while 4% transferred to another institution or left the ED of their own volition. The majority (87%) were able to be seen at the ED and discharged. The ED harbors 42 beds, consisting of: 1 resuscitation room, 11 monitored observation, 10 ob-servation units, 5 for the trauma, 5 in other areas (ear-nose-and-throat, eye, gynecology, psychiatry) and 10 additional beds. Sixteen beds are monitored and 6 have mechanical ventilators. There are two work shifts in the ED from 08:00 to18:00 and 18:00 to 08:00. Each shift includes one emer-

Çolak Oray N et al. A New Model in Reducing Emergency Department Crowding 65

Table 1. Five-year emergency department admission numbers

Year Patient numbers Rise in patient Percentage of admissions numbers (%) from the emergency department to hospital (%)

2011 85.813 8 8.0

2010 79.438 18 8.0

2009 67.476 22 8.1

2008 55.438 22 8.4

2007 45.326 16 9.6

2006 35.808 26 11.8

gency physician, 5 or 6 emergency residents (ER), 5 nurses, 5 medical students in their final year of school, 4 patient care assistants, and 2 paramedics.

Intervention technique: Electronic Blockage System

Before implementation, a meeting of the Emergency Medi-cine Coordination Board was held at the DEUH Chief Medical Office with representatives of all the clinical units in the hos-pital and members of the ED teaching staff. The following decisions were made:

• Empty beds in the hospital “should always and without ex-ception” be used for patients awaiting admission at the ED.

• In the presence of patients awaiting admission at the ED, other admissions to relevant wards (polyclinics, for example) should be stopped by the Hospital Information System (HIS), although admissions are to be permitted once patients wait-ing at the ED have been admitted.

• At transfers between institutions: if a request for a transfer to a clinical department has come from an external institu-tion, the patient is only to be admitted if there are no pa-tients awaiting admission in the ED.

An additional program to the HIS was written for the imple-mentation of this system. In the program, if there are pa-tients in the ED awaiting admission to the relevant ward, then other non-urgent polyclinic admissions are blocked, and admissions are only permitted once patients in the ED have been admitted.

Study protocol

Once approval had been granted by the Dokuz Eylül Univer-sity Faculty of Medicine Clinical Research Ethical Committee, the study was performed at the DEUH Adult ED where pa-tients aged 18 and over are accepted. Three different one-week periods were selected for data collection: the pre-EBS period (one week immediately before EBS), the early post-EBS period (one week after EBS) and the late post-EBS period, the first week in the second month after EBS). A question-naire was given out that consisted of questions evaluating ED overcrowding every day throughout the course of the study (NEDOCS scoring) and questions regarding ED person-nel (senior ER and senior nurse and paramedic) perceptions related to overcrowding. The questionnaire was completed every day at 07:00 (time of fewest applications to the ED), 17:00 (time of average ED density) and 22:00 (time of most applications to the ED) and the mean of the values obtained taken. In order to evaluate perceptions of overcrowding, the following scoring system was used; 1- calm, 2- normal, 3- crowded or 4- Severely crowded. Additionally, a senior ER personnel was asked about the ED turnaround and the re-plies scored 1- fast, 2- normal, 3- slowed or 4- stopped.

Crowding measurement technique

NEDOCS scoring was used for overcrowding measurement.[1]

1. Patient index: Number of existing patients in the ED to ED bed numbers.

2. Admission index: Number of patients in the ED waiting

66 Turk J Emerg Med 2014;14(2):64-70

Table 2. Pre-EBS, early post-EBS and late post-EBS results

Pre-EBS period* Early post-EBS period* Late post-EBS periods* P**

Number of existing patients 32.0±8.4 26.8±7.8 31.7±8.4 0.074

(range 17-47) (range 15-42) (range 14-44)

Number of patients admitted to the 8.0±5.9 7.9±4.6 7.7±4.6 0.969

emergency department in the (range 1-21) (range 1-16) (range 0-15)

previous hour

Number of patients awaiting 11.6±3.4 7.2±3.3 10.9±2.5 0.0001

admission (range 37-19) (range 2-13) (range 6-16)

Longest admit time 196.3±49.6 72.1±24.7 160.9±30.8 0.0001


Number of patients using 2.4±0.9 2.7±1.1 5.8±1.0 0.0001

mechanical ventilator (range 1-4) (range 1-4) (range 4-8)

NEDOCS value 196.8±10.3 131.0±29.9 196.3±10.2 0.0001


Mean daily patient number 177 159 162

*: Mean of 07:00-17:00-22:00 time intervals. **: One-Way ANOVA.

for hospital beds to become available to number of hospital beds.

3. Number of ED patients using mechanical ventilators.

4. Admission time: Longest waiting time among patients awaiting admission to the ED.

5. Registration time: Time spent in the waiting room by the last patient taken for admission to an ED bed.

NEDOCS values were calculated on the basis of our hospital standard emergency bed number of 42 and a total hospi-tal bed number of 925 on the http://www.nedocs.org/ web site. At analysis of scores between 0 and 200 at NEDOCS scoring, 100 points was taken as the cut-off value. Accord-ingly,

• 0-50 points; calm,

• 51-100 points; busy,

• 101-140 points: crowded,

• 141- 180 points: seriously crowded,

• 181 and above: dangerously crowded.

Statistical analysis

The data collected were recorded onto Statistical Package for Social Sciences (SPSS) 15.0. One-way ANOVA and the Kruskal Wallis test were used to compare means, and signifi-cance was set at p<0.05.

ResultsA number of patients, including those in the ED, awaiting admission to hospital, using mechanical ventilators, wait-ing the longest time, admitted to the ED in the previous one hour, and mean NEDOCS values at time of measurement in all three periods are given in Table 2.

No significant difference was determined between the groups in terms of existing numbers of patients in the ED and number of patients admitted to the ED in the last hour (p=0.074 and p=0.969). Examination of numbers of patients awaiting admission at the ED revealed a significantly lower number of patients awaiting admission in the early post-EBS period compared to the pre-EBS and late post-EBS periods (p=0.0001 and p=0.00, respectively). There was no signifi-cant difference between the pre-EBS and late post-EBS pe-riods (p=0.713).

67

Table 3. Mean NEDOCS values by Emergency Department Staff Crowing Perceptions

Mean NEDOCS Values by Crowding Perceptions

Calm Normal Crowded Severely overcrowded p*

n 12 18 24 9

Doctors 152.1±42.6 164.3±43.9 189.3±19.9 186.8±27.8 0.009

n 8 17 22 16

Nurses 155.9±39.5 175.0±39.8 178.2±38.4 178.9±27.6 0.474

n 16 15 21 11

Paramedics 162.9±43.5 169.7±41.3 184.8±29.5 179.4±27.7 0.293

*: One-Way ANOVA.

Table 4. Emergency Department Personnel Perceptions of Crowding and Work Turnaround

Pre-EBS Early post-EBS Late post-EBS p

Personnel perception* Mean Median Mean Median Mean Median

Doctors 2.7 3 2.1 2 2.6 3 0.080

Nurses 2.9 3 2.8 3 2.6 3 0.641

Paramedics 2.5 3 2.4 2 2.4 3 0.960

Perception of Work Turnaround¥ 2.8 3 1.8 2 2.4 2 0.000

*: Personnel crowding perception: 1- calm, 2- normal, 3- crowded, 4- severely crowded¥: Work turnaround perception: 1- fast, 2- normal, 3- slow, 4- stopped

Çolak Oray N et al. A New Model in Reducing Emergency Department Crowding

Comparison of mean waiting for admission times of those patients waiting for longest at the ED revealed a statistically significant difference between all three periods (p=0.0001, p=0.0001 and p=0.007, respectively). The period with the shortest waiting time was the early post-EBS period.

Comparison of numbers of patients using mechanical ven-tilators in the ED revealed no significant difference between the pre-EBS and early post-EBS periods, while the number of patients using mechanical ventilators in the late post-EBS period was significantly higher than in the other periods (p=0.449, p=0.0001 and p=0.0001, respectively).

Comparison of mean NEDOCS values by periods revealed a significantly lower NEDOCS value in the early post-EBS period compared to the other periods (Kruskal Wallis test, p<0.0001, Figure 1).

Comparing mean NEDOCS values by perceptions of crowd-ing of each personnel group in the ED, perceptions of crowd-ing increase as NEDOCS values rise. However, no correlation was determined between NEDOCS values and perceptions of crowding of nurses and paramedics (Table 3).

Comparing ED personnel perceptions of crowding in the pre- and post-EBS periods, no significant internal difference was determined in the doctor, nurse or paramedic groups (Table 4).

Comparing NEDOCS values with work turnaround evalu-ations of senior ED physicians, as NEDOCS values rose they considered there was a deceleration in turnaround (p=0.0001, Table 5).

DiscussionOvercrowding is a common problem in many EDs. There have been several previous studies on the subject. However, there are still no effective and standard recommendations aimed at resolving the problem of overcrowding.[11] Hospi-tals produce their own solutions supplementary to nation-wide health policies in order to prevent overcrowding.[12] EBS was implemented in our hospital for the purpose of re-ducing the overcrowding problem.

Although there was no significant variation in numbers of patients applying to the emergency service and existing pa-

68 Turk J Emerg Med 2014;14(2):64-70

Table 5. Mean NEDOCS Values by Senior Emergency Department Physician Work Turnaround Evaluation

Mean NEDOCS Values by Work Turnaround Perception

Fast Normal Slow Stopped Total

n 8 30 22 3 63

Doctors 122.5±29.6 171.6±37.3 194.6±12.6 199.0±1.7 174.7±36.5

250

NED

OC

NEDOC DURING PERIODS

PERIODS

200

150

100

50

0

PreD

EBS-

07:0

0h

PreD

EBS-

17:0

0h

PreD

EBS-

22:0

0h

Post

DEB

S-07

:00h

Post

DEB

S-17

:00h

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DEB

S-22

:00h

Late

DEB

S-07

:00h

Late

DEB

S-17

:00h

Late

DEB

S-22

:00h

NEDOC

Figure 1. NEDOCS Values by Periods.

tient numbers measured at that time in the department in the early period when EBS was implemented, NEDOCS val-ues declined from dangerously overcrowded to overcrowd-ed (196 and 131, respectively). We ascribe this to patients being admitted to the relevant departments more quickly and the number of patients awaiting admission in the ED decreasing to a lower number of patients using mechanical ventilators in the ED at that time and to a shortening in wait-ing times among patients awaiting admission in the ED.

Due to the lack of sufficient intensive care beds, the EBS system planned for all admissions from the ED could only be applied to ED admissions. This in turn led to elevated NEDOCS values at times when there were large numbers of patients awaiting intensive care admission. There was no significant variation in numbers of patients applying to the ED and momentarily measured existing patient numbers in the department in the late post-EBS period compared to the pre-EBS and early post-EBS period. This was quite possible due to an increase in the numbers of patients using me-chanical ventilators and awaiting intensive care admission. In addition, there was also a rise in existing patient numbers in the ED and patients awaiting admission. This in turn led to NEDOCS values again reaching overcrowded levels in the late post-EBS period. A rise in the number of patients using mechanical ventilators in the ED and in the number of pa-tients awaiting admission to intensive care, even if not using mechanical ventilators, will mean EDs turning into chronic care centers. A solution needs to be found to this, since it will mean a decline in the quality of care given to other patients applying to the ED and requiring first aid. We think that this basic aim of the EBS system can be achieved by increasing the number of intensive care beds and initiating the mea-sure for intensive care.

Crowding perceptions of doctors working in the ED rose in line with NEDOCS values. However, no such relationship was determined for nurses and paramedics. Examination of the effect of the EBS system on ED personnel perceptions of crowding revealed no significant differences within the doc-tor, nurse and paramedic groups in the pre- and post-EBS periods. Duration of care in the ED is reported to be associ-ated with numbers of ED doctors and nurses and hospital capacity.[13] The reason for the difference in crowding per-ceptions between doctors and nurses may be that the num-ber of patients per doctor in our ED is sufficient and meets standards, while nurse numbers are inadequate. In addition, despite a partial improvement in NEDOCS values in the post-EBS period, persisting measurement at the ‘crowded’ level may also affect perceptions of crowding.

Senior ER in our study thought that as NEDOCS values rose there was a slow-down in work turnaround. As crowding in

the ED rises, personnel perceptions of crowding worsen and work turnaround decelerates in parallel with this. Increased ED crowding and a slowdown in work turnaround may have led to fatigue, or personnel fatigue may affect perceptions of crowding as a vicious circle, in a vicious circle. However, fatigue levels were not measured in our study.

Limitations

The effectiveness of EBS was measured using only NEDOCS scoring. Other parameters that can measure effectiveness, such as mean durations of hospitalization and hospitaliza-tion levels, were not investigated. In addition, EBS was not applied to intensive care admissions. We therefore think that the number of patients awaiting intensive care admission in the post-EBS period may have resulted in the NEDOCS scor-ing system to overestimate the measurements.

Conclusion

EBS is a form of admission triage system that ensures that ED patients have admission priority over polyclinic patients and is intended to prevent overcrowding. In a hospital where to-tal bed numbers are inadequate, the EBS can be used for the purpose of accelerating admission to hospital from the ED in order to reduce ED overcrowding. Further investigation into the EBS and its practicality and application in different hospitals is need.



References1. Crowding (policy statement) Approved January 2006. Ameri-

can College of Emergency Physicians. Access to: http://www.acep.org/content.aspx?id=29156. Accessed February 06, 2014.

2. Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U, et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med 2009;16:1-10.

3. Richardson DB. Increase in patient mortality at 10 days as-sociated with emergency department overcrowding. Med J Aust 2006;184:213-6.

4. Derlet RW, Richards JR. Emergency department overcrowd-ing in Florida, New York, and Texas. South Med J 2002;95:846-9.

5. Jones SS, Allen TL, Flottemesch TJ, Welch SJ. An indepen-dent evaluation of four quantitative emergency department crowding scales. Acad Emerg Med 2006;13:1204-11.

6. Bernstein SL, Verghese V, Leung W, Lunney AT, Perez I. Devel-opment and validation of a new index to measure emergen-cy department crowding. Acad Emerg Med 2003;10:938-42.

69Çolak Oray N et al. A New Model in Reducing Emergency Department Crowding

7. Asplin BR, Rhodes KV, Flottemesch TJ, Wears R, Camargo CA, Hwang U, et al. Is this emergency department crowded? A multicenter derivation and evaluation of an emergen-cy department crowding scale (EDCS). Acad Emerg Med 2004;11:484-5.

8. Weiss SJ, Derlet R, Arndahl J, Ernst AA, Richards J, Fernández-Frackelton M, et al. Estimating the degree of emergency de-partment overcrowding in academic medical centers: results of the National ED Overcrowding Study (NEDOCS). Acad Emerg Med 2004;11:38-50.

9. Reeder TJ, Burleson DL, Garrison HG. The overcrowded emer-gency department: a comparison of staff perceptions. Acad

Emerg Med 2003;10:1059-64.10. Hoot NR, Zhou C, Jones I, Aronsky D. Measuring and fore-

casting emergency department crowding in real time. Ann Emerg Med 2007;49:747-55.

11. Feferman I, Cornell C. How we solved the overcrowding prob-lem in our emergency department. CMAJ 1989;140:273-6.

12. Hoot NR, Aronsky D. Systematic review of emergency depart-ment crowding: causes, effects, and solutions. Ann Emerg Med 2008;52:126-36.

13. Harris A, Sharma A. Access block and overcrowding in emer-gency departments: an empirical analysis. Emerg Med J 2010;27:508-11.

70 Turk J Emerg Med 2014;14(2):64-70


Submitted: September 04, 2013 Accepted: January 27, 2014 Published online: June 03, 2014

Correspondence: Dr. Samad Shams Vahdati. No 1, Gholestan 2, Pezeshkan Alley,Abrasani Street Tabriz, Iran.


ORIGINAL ARTICLE

1Department of General Surgery, Sina Hospital, Tabriz University of Medical Sciences Tabriz, Iran;2Department of Emergency Medicine, Tabriz University of Medical Sciences, Tabriz, Iran;

3School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran

Changiz GHOLIPOUR,1 Samad SHAMS VAHDATI,2 Mehdi NOTASH,3

Seyed Hassan MIRI,2 Rouzbeh Rajaei GHAFOURI2

Success Rate of Pre-hospital Emergency Medical Service Personnel in Implementing Pre Hospital Trauma Life

Support Guidelines on Traffic Accident Victims

Trafik Kazası Kurbanlarında Hastaneye Gelmeden Önce Travma Yaşam Desteği Uygulayan Acil Tıp Personelinin Medikal Hizmetlerdeki Başarı Oranı

SUMMARYObjectivesRoad traffic injuries are responsible for a vast number of trauma-related deaths in middle- and low-income countries. Pre-hospital emergency medical service (PHEMS) provides care and transports the injured pa-tients from the scene of accident to the destined hospital. The PHEMS providers and paramedics were recently trained in the Pre Hospital Trauma Life Support (PHTLS) guidelines to improve the outcome of trauma patients in developing countries. We decided to carry out a study on the success rate of PHEMS personnel in implementing PHTLS guidelines at the scene of trauma.

MethodsSevere trauma patients who had been transferred to the emergency department were included in the study. Evaluations included transfer time, airway management, spinal immobilization, external bleeding management, intravenous (IV) line access, and fluid therapy. All evalu-ations were performed by an expert emergency physician in the emer-gency department.

ResultsThe mean response time was 17.87±9.1 minutes. The PHEMS personnel immobilized cervical spine in 60.4% of patients, out of whom 16.7% were not properly immobilized. Out of 99 (98%) cases of established IV line access by the PHEMS providers, 57% were satisfactory. Fluid thera-py, which was carried out in 99 (98%) patients by the PHEMS personnel, was appropriate in 92% of the cases.

ConclusionsPHEMS personnel need more education and supervising to provide services according to PHTLS guidelines.

Key words: Pre-hospital emergency medical service, pre hospital trauma life support, trauma.

ÖZETAmaçOrta ve düşük gelirli ülkelerde travmayla ilişkili ölümlerin büyük bir bölü-münden karayollarındaki trafik kazalarındaki yaralanmalar sorumludur. Hastane öncesi acil tıp ekibi (PHEMS) yaralı kişilere kaza yerinden gidilecek hastaneye kadar nakleder ve bu arada onlara tıbbi bakım sunar. Son za-manlarda gelişmekte olan ülkelerde acil tıbbi bakım ve tedaviyi üstlenen-lerle tıp teknisyenleri travma hastalarından alınan sonuçları iyileştirme amacıyla Hastane Öncesi Travma Yaşam Desteği (PHTLS) kılavuz ilkeleri konusunda eğitilmektedir. Yaralanma mahallinde bu personele verilen eğitimin başarı oranına ilişkin bir çalışma yapmaya karar verdik.

Gereç ve YöntemÇalışmaya acil servise aktarılan ağır travma hastaları alındı. Hasta nakli sırasında geçen süre, hava yolu açılması, omurganın stabilize edilmesi, dış kanama tedavisi, intravenöz (IV) giriş yolu açılması ve sıvı tedavisi değer-lendirildi. Değerlendirmelerin tümü acil servisteki acil tıp uzmanı tarafın-dan gerçekleştirildi.

BulgularOrtalama yanıt verme süresi 17.87±9.1 dakika idi. Acil tıp ekibi, hastaların %60.4‘ünün boyun omurlarını stabilize etmiş olup bunların %16.7’si usu-lüne uygun biçimde gerçekleştirilmemişti. Acil tıp ekibi tarafından %57’si tatminkâr olmak üzere 99 (%98) yaralıya IV damar yolu açılmıştı. Yine 99 (%98) yaralıya verilen sıvı tedavisinin %92’si usulüne uygundu.

SonuçAcil tıp ekibi, hastane öncesi acil bakım ilkelerine uygun hizmet vermesi için daha fazla eğitim ve denetimden geçmelidir.

Anahtar sözcükler: Hastane öncesi acil tıbbi hizmet, hastane öncesi travma-da yaşam desteği, travma.

71

IntroductionRoad traffic injuries are responsible for a vast number of trauma-related deaths in middle- and low-income countries where 90% of total mortality occurs due to such injuries.[1,2] Pre-hospital emergency medical service (PHEMS) is a vital part of the health system and emergency safety net which provides care and transports injured patients from the scene of the accident to the appropriate hospital.[3] In developing countries, the majority of road injury mortality takes place in the pre-hospital setting.[4] Improvement in the PHEMS can thus reduce the related mortality and morbidity. At the scene of accident, PHEMS providers and paramedics should quickly recognize critically-injured patients, take the neces-sary measures, and transport the patients to an appropriate hospital.[5]

Numerous studies have evaluated the time intervals in which PHEMS providers offer services to injured patients. The first 60 minutes after trauma has been referred to as the “golden hour” by trauma experts.[6] Previous studies sug-gested that increased pre-hospital time intervals are associ-ated with increased mortality and morbidity rates in severe trauma patients.[7,8]

PHEMS providers and paramedics in low- and middle-in-come countries have recently been trained in the Pre Hos-pital Trauma Life Support (PHTLS) guidelines to improve the outcome of trauma patients. However, there is little infor-mation on the success rate of PHEMS providers in achiev-ing the international standards.[9] A German study has lately suggested that PHEMS providers make many mistakes and unsafe actions in PHEMS scenarios.[10]

Considering the abovementioned facts, we decided to carry out a study on the success rate of PHEMS personnel in im-plementing PHTLS guidelines at the scene of trauma.

Materials and Methods In a prospective cross-sectional study completed during March-September 2011, 101 severe trauma patients who had been transferred to the emergency department (ED) of Imam Reza Hospital (Tabriz, Iran) by PHEMS agencies, all nurses or paramedics, were included. Severe trauma was defined as an injury severity score (ISS) of over 15.[11,12] The study was undertaken in Tabriz, the capital city of East Azer-baijan Province, Iran with a population of 1,400,000.

Trauma management and care during transportation of the patients by PHEMS providers were evaluated against the 6th edition PHTLS. Evaluations included response time, air-way management, spinal immobilization, external bleeding management, intravenous (IV) line access, and fluid therapy.

All evaluations were carried out by an expert emergency physician in the ED. The data related to response time, de-fined as the time from alarm activation at the agency to arrival of the first responding ambulance at the scene, was obtained from the ambulance dispatch center. The data was assessed and mean response time was calculated. Airway management was defined as the implementation of maneu-ver, airway device, and intubation.

Due to the double-blind design of the study, the PHEMS pro-viders were not aware of the study protocol. Likewise, the emergency physician who evaluated the PHEMS providers was not informed about their names and identification.

Ethical Consideration

Ethical approval was obtained from the Medical Ethics Com-mittee of Tabriz University of Medical Sciences. Furthermore, due to the lack of any interventions on the patients, no written informed consents were obtained from the studied population. This research was accepted by the Deputy of Re-search of the Faculty of Medicine, Tabriz University of Medi-cal Science.

Data Analysis

Data was presented as mean±standard deviation (SD) or percentage. Statistical analyses were performed in SPSS16 for Windows (SPSS Inc., Chicago, IL, USA) using chi-square, Fisher’s exact, and independent samples-t tests wherever appropriate. P values less than 0.05 were considered statisti-cally significant.

ResultsOverall, 100 subjects with a mean age of 33.19±21.18 years were studied. While 43.9% of the injuries occurred in urban areas, 56.1% took place in interurban roads and semi-urban regions. The most frequent cause of trauma was motor vehi-cle collision (Table 1). There was a significant association be-tween the location and type of trauma. While motor vehicle collisions were more frequent in urban areas, motor vehicle roll-overs were more common in interurban roads (p<0.001).

The mean response time for the arrival of PHEMS at the scene

Turk J Emerg Med 2014;14(2):71-74

Table 1. The frequencies of trauma causes

Trauma cause Frequency

Car-car accident 57

Pedestrian accident 21

Motorcycle–car accident 12

Motorcycle roll over 11

72

of accident was 17.87±9.1 (95% confidence intervals) minutes (range: 1-60 minutes) (Figure 1). The mean response time was 13.35±8.9 minutes for urban accidents and 21.51±7.77 (95% confidence intervals) minutes for interurban and semi-urban regions. The response time for interurban road injuries was significantly longer than urban areas (p<0.001).

Indication of airway management was evaluated by an ex-pert emergency physician according to the PHTLS guide-lines. Among patients being transported to the ED, 21% had indications of airway maneuver, 19% had indications of air-way device placement, and 12.1% had indications of intuba-tion. However, the three airway management methods had been carried out by the PHEMS personnel only in 20.8% of all cases.

The PHEMS personnel immobilized cervical spine in 60.4% of patients, out of whom 16.7% were not correctly immobilized. There were no significant associations between the location of trauma and quality of neck immobilization (p=0.39). More-over, in 31.7% of patients thoracolumbar spine was immobi-lized using a long back board.

All patients had external bleeding (i.e. every kind of bleeding in the head, trunk, and limbs), of which 60% were correctly managed by the PHEMS personnel. There was no significant relationship between the location of trauma and the quality of bleeding management (p=0.228).

The PHEMS providers established 99 cases (98%) of IV line access out of which 57% were satisfactory. The rest of the IV lines were not inserted correctly or in the proper limb. The quality of IV line access was not significantly different be-tween urban and interurban road injuries (p=0.627).

Fluid therapy, which was carried out in 99 (98%) patients by the PHEMS personnel, was appropriate in 92% of the cases. In

8% of the cases, the fluid was chosen incorrectly and admin-istered more or less than expected. There was no significant difference in the quality of fluid therapy between urban and interurban road injuries (p=0.275).

DiscussionPHTLS guidelines have been commonly used in training PHEMS providers in low- and middle-income countries. In the present study, we tried to evaluate the efforts of PHEMS providers in trauma patient care based on PHTLS guidelines. To the best of our knowledge, no similar studies have been carried out in developing countries such as Iran.

In a study carried out in northwest Iran, most cases of se-vere trauma (Injury Severity Score >15) were in interurban roads;[13] however, in our study most severe trauma injuries occurred in urban areas.

Our “dispatch-beginning-to-scene-arrival interval” was longer than previous studies. In an American study, the re-sponse time was 4.28 minutes.[14] An Iranian study reported a response time of 10.6 minutes,[13] while another study in Teh-ran (the capital city of Iran) found the mean response time to be 10 minutes.[15] Furthermore, in our study, the mean measured time on interurban road injuries was significantly longer than urban areas. Taking this into consideration, the response time of PHEMS is not acceptable.

The most frequent accidents in urban areas were motor ve-hicle roll-overs. Speed control can therefore decrease the number of trauma events.

According to the PHTLS guidelines, in a severe trauma case for which the time to the hospital is more than 30 minutes, patients should be intubated at the scene. In the presented study, according to PHTLS, although 52% of patients had in-dications of airway management (maneuver, airway device management, and intubation), only 20.8% were appropri-ately managed by PHEMS providers. This finding indicates that the PHEMS providers failed in airway management of severe trauma patients.

PHTLS guidelines suggest that spinal immobilization should be performed in all severe trauma patients. In our study, however, immobilization was only partially applied.

According to PHTLS, IV lines should be established for all se-vere trauma patients in interurban areas. In our study, nearly all patients, even those who had been injured in urban re-gions, had IV line access. While Gonzalez et al. reported a 79% success rate in IV line access,[16] the success rate of IV line was not satisfactory (57%) in this study. However, any delay in IV line access may increase the “on-scene” time.[17]

Gholipour C et al. Success Rate of Pre-hospital Emergency Medical Service Personnel

Figure 1. The mean response time for the arrival of PHEMS.

-5

30

Freq

uenc

y

Response time

25

20

15

5

0

0 20 40 60 80

10

73

Some studies suggested the fluid therapy en route for trauma patients is ineffective. In contrast, based on PHTLS guidelines, fluid therapy is essential for severe trauma pa-tients in interurban road injuries.[17,18] The PHEMS providers performed fluid therapy for almost all patients. Nearly all flu-ids were selected properly and the amounts of fluids were administered exactly.

Limitation

Research would be more effective if completed over the course of an entire year so topographic and climate interfer-ence can be taken into consideration.

This research was done only for EMS of one provience. It may be more effective to complete this study in multiple prov-inces and then compare results.

Conclusion

The PHEMS providers failed to perform PHTLS guidelines at the scene of accident.



References1. Hofman K, Primack A, Keusch G, Hrynkow S. Addressing the

growing burden of trauma and injury in low- and middle-income countries. Am J Public Health 2005;95:13-7.

2. Haghparast-Bidgoli H, Hasselberg M, Khankeh H, Khorasani-Zavareh D, Johansson E. Barriers and facilitators to provide effective pre-hospital trauma care for road traffic injury vic-tims in Iran: a grounded theory approach. BMC Emerg Med 2010;10:20.

3. Delbridge TR, Bailey B, Chew JL Jr, Conn AK, Krakeel JJ, Manz D, et al. EMS Agenda for the Future: where we are...where we want to be. Prehosp Emerg Care 1998;2:1-12.

4. Mock C, Arreola-Risa C, Quansah R. Strengthening care for injured persons in less developed countries: a case study of Ghana and Mexico. Inj Control Saf Promot 2003;10:45-51.

5. Mackersie RC. History of trauma field triage development and the American College of Surgeons criteria. Prehosp Emerg Care 2006;10:287-94.

6. Carr BG, Caplan JM, Pryor JP, Branas CC. A meta-analysis of

prehospital care times for trauma. Prehosp Emerg Care 2006;10:198-206.

7. Stiell IG, Nesbitt LP, Pickett W, Munkley D, Spaite DW, Banek J, et al. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity. CMAJ 2008;178:1141-52.

8. Osterwalder JJ. Can the “golden hour of shock” safely be ex-tended in blunt polytrauma patients? Prospective cohort study at a level I hospital in eastern Switzerland. Prehosp Di-saster Med 2002;17:75-80.

9. Jayaraman S, Sethi D. Advanced trauma life support train-ing for ambulance crews. Cochrane Database Syst Rev 2010;1:CD003109.

10. Zimmer M, Wassmer R, Latasch L, Oberndörfer D, Wilken V, Ackermann H, et al. Initiation of risk management: incidence of failures in simulated Emergency Medical Service scenarios. Resuscitation 2010;81:882-6.

11. Demetriades D, Martin M, Salim A, Rhee P, Brown C, Doucet J, et al. Relationship between American College of Surgeons trauma center designation and mortality in patients with severe trauma (injury severity score > 15). J Am Coll Surg 2006;202:212-5.

12. Di Bartolomeo S, Valent F, Rosolen V, Sanson G, Nardi G, Can-cellieri F, et al. Are pre-hospital time and emergency depart-ment disposition time useful process indicators for trauma care in Italy? Injury 2007;38:305-11.

13. Bigdeli M, Khorasani-Zavareh D, Mohammadi R. Pre-hospital care time intervals among victims of road traffic injuries in Iran. A cross-sectional study. BMC Public Health 2010;10:406.

14. Newgard CD, Schmicker RH, Hedges JR, Trickett JP, Davis DP, Bulger EM, et al. Emergency medical services intervals and survival in trauma: assessment of the “golden hour” in a North American prospective cohort. Ann Emerg Med 2010;55:235-246.

15. Modaghegh MH, Roudsari BS, Sajadehchi A. Prehospital trau-ma care in Tehran: potential areas for improvement. Prehosp Emerg Care 2002;6:218-23.

16. Gonzalez RP, Cummings GR, Rodning CB. Rural EMS en route IV insertion improves IV insertion success rates and EMS scene time. Am J Surg 2011;201:344-7.

17. Spaite DW, Tse DJ, Valenzuela TD, Criss EA, Meislin HW, Ma-honey M, et al. The impact of injury severity and prehospital procedures on scene time in victims of major trauma. Ann Emerg Med 1991;20:1299-305.

18. Kaweski SM, Sise MJ, Virgilio RW. The effect of prehospital flu-ids on survival in trauma patients. J Trauma 1990;30:1215-9.

Turk J Emerg Med 2014;14(2):71-7474


Submitted: October 13, 2013 Accepted: February 21, 2014 Published online: June 04, 2014

Correspondence: Dr. Ahmet Tugrul Zeytin. SB Dumlupınar Üniversitesi,Kütahya Evliya Celebi Egitim ve Arastirma Hastanesi, Kutahya, Turkey.


ORIGINAL ARTICLE

1 Department of Emergency Medicine, Turkish Republic Ministry of Health Dumlupinar UniversityKutahya Evliya Celebi Training and Research Hospital, Kutahya;

2Department of Emergency Medicine, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir;3Department of Emergency, Turkish Republic Ministry of Health Eskisehir State Hospital, Eskisehir;

4Department of Emergency Medicine, Turkish Republic Ministry of Health Canakkale State Hospital, Canakkale

Ahmet Tugrul ZEYTIN,1 Arif Alper CEVIK,2 Nurdan ACAR,2 Seyhmus KAYA,3 Hamit OZCELIK4

Characteristics of Patients Presenting to the Academic Emergency Department in Central Anatolia

Orta Anadolu’da Akademik Bir Acil Servise BaşvuranHastaların Özellikleri

SUMMARYObjectivesDetermining the properties of patients admitted to the emergency de-partment (ED) is important to plan for future and quality assurance. In this study, we aimed to evaluate the properties of patients admitted to our ED to improve the quality of care within our hospital.

MethodsIn the study period, the patients: (i) who have their full information in hospital information and management system (HIMS) and (ii) older than 17 years of age were included into the study. Demographic infor-mation, admission and discharge rates, mean staying time in the ED, triage categories, International Classification of Diseases – 10 (ICD-10) diagnoses were evaluated.

ResultsDuring the study period, 32,117 cases were seen by the ED. However, 22,955 patients (71.4%) had complete information in the HIMS. The mean age was 44.92±19.50 and female gender was found 52.2%. The patients who were located in 18-29 age group was the major group of all cases (30.8%). Emergent and urgent cases were 26.1% and 14.8%, respectively. Non-urgent cases were also found (59.1%). The mean age of patients located in the emergent group (55.19±18.59) were signifi-cantly higher than urgent and non-urgent group (p<0.01). The highest patient volume was seen on Sunday, between 20:00 and 22:00 o’clock. The mean staying time in the ED was 183.6 minutes and the admission rate was 17.6%. The three most noted ICD-10 codes were respiratory (16.6%), gastrointestinal (11.3%), musculoskeletal (11.2%) codes.

ConclusionsThe data that was correctly uploaded into the system did not reach our expectation. Data can be more appropriately uploaded by medical sec-retaries. Registering patient information in a digital atmosphere while performing analyses will undoubtedly have an effect on future focused studies.

Key words: Data base management systems; demography; emergency de-partment.

ÖZETAmaçAcil servise başvuran hastaların özelliklerinin bilinmesi, acil servis (AS) hizmetlerinin planlanması ve kalitesinin artırılması için önem taşımak-tadır. Bu çalışmada, AS hastalarımızı bu perspektifte değerlendirmeyi amaçladık.

Gereç ve YöntemÇalışma periyodunda 17 yaş üstü ve hastane bilgi ve yönetim sistemine (HBYS) kaydı olan hastalar çalışmaya dahil edildi. Demografik bilgiler, yatış ve taburculuk oranları, AS’de ortalama kalış süresi, triyaj kategori-leri, International Classification of Diseases – 10 (ICD-10) tanıları değer-lendirildi.

BulgularÇalışma süresi boyunca 32117 olgu AS’de görüldü. Verileri eksiksiz olan 22955 hasta (%71.4) HBYS’den alındı. Hastaların yaş ortalaması 44.92±19.50 ve kadın cinsiyet %52.2 olarak bulundu. 18-29 yaş grubun-daki hastalar tüm olguların majör grubunu oluşturmaktaydı (%30.8). Acil olamayan olgular %59.1, çok acil ve acil olanlar ise sırasıyla %26.1 ve %14.8 olarak bulundu. Çok acil kategorisindeki hastaların yaş ortala-ması (55.19±18.59) acil ve acil olmayan gruptan anlamlı olarak yüksek bulundu (p<0.01). En çok başvurunun yapıldığı gün Pazar ve gün içinde saat 20:00 ile 22:00 arasıydı. Hastaların AS’de ortalama kalış süresi 183.6 dakikaydı. Hastalarda %17.6 yatış oranı saptandı. En çok not edilen ICD-10 kodları, solunumsal (%16.6), gastrointestinal sistem (%11.3), kas iske-let sistemi (%11.2) olarak saptandı.

SonuçSistemden yüklenen veriler bizim beklentilerimizi karşılamamaktaydı (%71.4). Verilerin tıbbi sekreterler tarafından yüklenmesi daha uygun olabilir. Hastaların bilgilerini dijital atmosferde kayıt altına alınması ve analizlerinin yapılması gelecekte yapılacak çalışmalar üzerine etkili ola-caktır.

Anahtar sözcükler: Acil servis; demografik; veritabanı yönetim sistemi.

75

IntroductionThe emergency service department requires a high level of public relations within the hospital. That is why public opin-ion regarding a hospital is mostly based on the healthcare service that people receive and the quality of time they ex-perience within the ED.

Throughout the world, emergency medicine has been a ‘medical specialty’ of clinical medicine in its own right for thirty years. In particular, countries such as the United States, Canada, Japan, and the United Kingdom have pioneered this field.[1] In our country, academic emergency medical services have been established for twenty years and continue to de-velop and become increasingly structured.[2,3] According to the latest data, there are 1,350 hospitals and hospital affili-ated EDs operating in Turkey.[4] However, there is no up-to-date and accurate patient data information in the majority of these units due to the lack of sufficient personnel and the appropriate registration systems.

In recent years, advances in computer-aided data recording programs have been used particularly in EDs offering devel-oped medical services. Nevertheless, the development of a data registration system eligible for use in all emergency departments has not been implemented due to financial dif-ficulties.[5]

There is a need to evaluate and review the services presently offered in order to improve the future healthcare and pa-tient service quality of EDs. In particular, a need to store and retrieve patient data quickly, practically, and accurately is warranted.[6] Characteristics of patients of the ED are impor-tant in order to plan for the future and improve quality as-surance. In this study, we aimed to evaluate our ED patients from this perspective. Current developments in data storage technologies may not only reduce data loss but also contrib-ute to the planning of future services.

Materials and Methods This is a retrospective descriptive study based on computer-based records of all adult patients that were admitted to the ED between February 17, 2009 and February 16, 2010.The ED was associated with a medical faculty training and re-search hospital offering tertiary health services and approx-imately 900 beds in a central Anatolian city in Turkey. The study began after having received approval from the Ethics Committee (Eskisehir Osmangazi University Ethical Commit-tee-21.05.2010/107).

The Hospital Information and Management System (HIMS), used by the computer center to record information on pa-tients presenting to the emergency department, was em-ployed to gather data required for this study.

Recordings of HIMS were used to access information on pa-tients’ age and gender, date on which they presented to the emergency department, admission and discharge time, pa-tients’ triage categories and diagnoses, the clinics where pa-tients stayed in the hospital, and medical results when they were discharged from the emergency department. A three level system of triage categories were used in classification: emergent (triage 1), urgent (triage 2) and non-urgent (tri-age 3).

The data obtained from HIMS allowed us to study the follow-ing: (i) demographic information on patients (distribution by age and gender, distribution of patients’ gender by age groups), (ii) triage categories, (iii) triage categories by age groups, (iv) triage categories by gender, (v) date and hour of presenting to the hospital, (vi) average period of stay in the emergency department, (vii) average period of stay in the emergency department by triage categories, (viii) distribu-tion of patients by residents offering treatment, (ix) medical results of patients, (x) referral to other clinics for inpatient hospitalization from the emergency department, (xi) and distribution of diagnoses by body systems defined accord-ing to ICD-10 diagnosis coding system.

The Statistical Package for Social Sciences (SPSS) for Win-dows 17.0 was used for the statistical analyses of data col-lected for this study. In addition to descriptive statistical methods (i.e. frequency distribution, percentile distribution, standard deviation), Pearson’s Chi-square test was used to compare qualitative data. For the analysis of quantitative data, independent samples t-test was used to compare pa-rameters between groups in cases where there were two groups. One-way ANOVA was used to compare the groups’ parameters, which showed a normal distribution, and the Tukey test was used to specify the group that caused dif-ference in cases where there was more than one group. The results were evaluated bidirectionally at the confidence in-terval of 95% with a significance level of p<0.05.

ResultsBetween February 17, 2009 and February 16, 2010, 32,117 patients were admitted to the adult emergency department of the hospital. Out of this number, 9,262 patients (28.5%) whose data were incomplete or inaccurate in HIMS were ex-cluded from the study and 22,955 patients were included in the study.

The average age of the patients was 44.92±19.50. The major-ity of patients were in the young group (age 18 to 29, 30.8%). In the distribution of patients’ age groups, the patients aged from 20 to 23 constituted the largest group in the distribu-tion (Table 1).

Turk J Emerg Med 2014;14(2):75-8176

The gender distribution of patients presenting in the emer-gency department was as follows: 11,270 (48.8%) patients were male (average age 45.96±19.37) and 11,748 (51.2%) were female (average age 43.93±19.56).

The number of female patients was greater in age groups 18 to 29, 30 to 39, and 40 to 49 whereas, the number of male patients was greater in age groups 50 to 59, 60 to 69, and 70 to 79 (Chi-square=90.22; p<0.01). There was no difference in the number of female and male patients in the age groups 80 to 89 and 90 to 99.

In the group of participants, 5,981 patients (26.1%) were in Triage 1 (emergent), 3,400 (14.8%) in Triage 2 (urgent) and 13,574 (59.1%) in Triage 3 (non-urgent) category (Figure 1).

The average age of patients by triage category was as fol-lows: 55.19±18.59 in Triage 1, 48.74±19.09 in Triage 2, and 39.44±17.87 in Triage 3. The relationship between the triage category and the average age of patients was significant (Chi-square=1635; p<0.01). The average age of patients in the emergent group was significantly higher compared to that of patients in the urgent and non-urgent groups (p<0.01). Furthermore, the average age of patients in the urgent group was significantly higher compared to that of patients in the non-urgent group (p<0.01).

Given the relationship between the age and the triage cat-egory, the study showed that the triage category of patients worsened as their age increased. This relationship is statisti-cally significant (Chi-square=2823; p<0.01) (Figure 2).

Given the distribution of triage categories by gender, the study revealed that triage 1, 2 and 3 were seen at a rate of respectively 55.8%, 49.0%, and 45.7% among male patients, and respectively 44.2%, 51.0%, and 54.3% among female pa-tients.

The comparison of female and male groups with regard to tri-

age categories determined that the rate of male patients was higher in Triage 1 and that the rate of female patients was higher in Triage 3. Chi-square test revealed that this relation-ship was statistically significant (Chi-square=167; p<0.01).

Patients were admitted to the ED most frequently on Sun-days (15.3%) and least frequently on Fridays (13.3%). The

Zeytin AT et al. Characteristics of Patients Presenting to the Academic ED in Central Anatolia

Table 1. The distribution of patients by age group

Age group Number of patients Percentage

18-29 7.069 30.8

30-39 3.245 14.1

40-49 3.151 13.7

50-59 3.322 14.5

60-69 2.954 12.9

70-79 2.360 10.3

80-89 812 3.5

90-99 42 0.2

Total 22.955 100.0

Figure 1. Triage categories of patients presenting to the emer-gency department.

14000

12000

10000

8000

6000

4000

2000

0N

umbe

r of p

atie

nts

Emergent Urgent Non-urgent

Figure 2. Distribution of triage categories of patients presenting to the emergency department by age group.

6000

4000

3000

2000

5000

1000

0

Num

ber o

f pat

ient

s

18-29Age groups

30-39 40-49 50-59 60-69 70-79 80-89 90-99

Non-urgentUrgentEmergent

Figure 3. Distribution of emergency department patients by hours of the day.

40

35

25

15

5

0

10

20

30

Num

ber o

f pat

ient

s

00:00 02:30 07:3205:00 10:02 12:32 15:02 17:32 20:02 22:32

Hours of visit

77

rate of frequency on Sundays was significantly higher than the rates of weekdays (p<0.05).

The number of patients presenting to the ED decreased from 12 pm to 8 am, and increased gradually after 8 am. The emergency department visits peaked between 8 pm and 10 pm (Figure 3).

The patients’ average length of stay in the emergency de-partment was 183.6 minutes (~three hours).

With respect to the relationship between triage categories and average length of stay, this study demonstrated that the average length of stay in Triage 1, 2, and 3 was 258.3 minutes (4.3 hours), 215.4 minutes (4 hours) and 142.6 minutes (2.4 hours), respectively. The groups were significantly different from each other with respect to the average length of stay by triage categories. The length of stay of patients in the emergent category was significantly higher than that of the urgent and non-urgent patients. Furthermore, the length of stay of urgent patients was significantly higher than that of non-urgent patients.

Of the subjects of this study, 17,988 patients (78.4%) were discharged from the hospital after medical examination, and 4,045 patients (17.6%) were hospitalized. In the latter group, 2,156 patients (9.3%) were hospitalized in various departments and 1,889 patients (8.2%) placed in intensive care units of the hospital. The total number of patients that died was 73 (0.3%). The number of patients that registered but then left the emergency department without examina-tion or at any stage of the examination was 792 (3.5%). Of these patients, 729 (3.2%) rejected treatment by their own will, and 63 (0.3%) left the department without permission. The rate of patients referred to other healthcare institutions was 0.2%.

Given the distribution of patients discharged by triage cat-egories, the following results were obtained: 53.4% of emer-gent patients, 72.0% of urgent patients, and 91.0% of non-urgent patients were discharged from the hospital. On the other hand, 39.4% of emergent patients, 23.7% of urgent patients, and 6.5% of non-urgent patients were hospitalized in intensive care units and various departments.

Table 2. The distribution of diagnoses, defined according to ICD-10 coding system, by triage categories

Immediate Urgent Non-urgent

Code Category n % n % n %

A Certain infectious and parasitic diseases 18 0.3 15 0.5 35 0.2

B Viral infections 11 0.2 10 0.3 75 0.6

C Tumors 495 8.3 338 10.0 497 3.7

D Diseases of the blood and the immune system 123 2.0 80 2.4 150 1.1

E Endocrine, nutritional and metabolic diseases 267 4.5 74 2.2 176 1.3

F Mental and behavioral disorders 262 4.4 153 4.5 510 3.8

G Diseases of the nervous system 490 8.2 205 6.1 694 5.1

H Eye and otorhinolaryngology diseases 86 1.4 168 4.9 949 7.0

I Diseases of the circulatory system 1717 29.0 302 8.9 442 3.3

J Diseases of the respiratory system 683 11.5 295 8.6 3041 22.4

K Diseases of the digestive system 362 6.1 464 13.6 1795 13.2

L Diseases of the skin and subcutaneous tissue 39 0.6 69 2.0 561 4.1

M Diseases of the musculoskeletal system and connective tissue 439 7.4 306 9.0 1755 12.9

N Diseases of the genitourinary system 171 2.8 301 8.8 1341 9.9

O Pregnancy, childbirth and the puerperium 14 0.2 41 1.2 39 0.3

P Certain conditions originating in the perinatal period 5 0.1 17 0.5 9 0.1

Q Congenital malformations, deformations 6 0.1 1 0.0 6 0.0

S Injury of external causes 381 6.4 428 12.6 958 7.1

T Poisoning and poisoning and certain other consequences of external causes 245 4.1 67 1.9 304 2.2

V Transport accidents 48 0.8 5 0.1 2 0.0

W Falls 34 0.5 16 0.5 113 0.8

X, Y, Z Other (Poisoning, Assault, Other medical problems) 81 1.3 45 1.4 122 0.9

Total 5.981 100 3.400 100 13.574 100

Turk J Emerg Med 2014;14(2):75-8178

The medical units that ED patients were referred to for hos-pitalization were internal medicine with 641 patients [119 (3.0%) patients in medical oncology, 5 (0.1%) patients in rheumatology, 103 (2.5%) patients in hematology, 42 (1.0%) patients in gastroenterology, 37 (0.9%) patients in gen-eral internal medicine, 79 (2.0%) patients in nephrology, 22 (0.5%) patients in endocrinology, and 234 (5.8%) patients in the intensive care unit], cardiology with 636 patients [66 (1.6%) in the department and 570 (14.2%) patients in the intensive care unit], and neurology with 530 patients [429 (10.7%) in the department and 101 (2.5%) patients in the in-tensive care unit].

The diagnoses defined according to ICD-10 diagnosis coding system were recorded by HIMS. A total of 28,806 diagnoses were established for 22,955 patients because some patients were diagnosed with more than one disorder. Given the dis-tribution of ICD-10 codes, the first four most frequently en-countered codes were J (16.6%), K (11.3%), M (11.2%) and I (11.1%).

Given the distribution of diagnosis codes by triage catego-ries, the following results were obtained: the most frequent-ly encountered diagnosis in emergent category was “I” code representing diseases of the circulatory system, in urgent category was “K” code representing diseases of the digestive system, and in non-urgent category was “J” code represent-ing diseases of the respiratory system (Table 2).

DiscussionThe ED of a hospital is the first place to which patients have recourse in case of urgent medical needs. Emergency medi-cine is the field of specialty in which physicians provide diag-nosis and treatment in case of an acute disease or injury, re-fer patients to other units for further support, and treatment when required, and also strive to prevent urgent cases.[7,8]

There is a need to measure and assess the healthcare service provided in order to promote the quality of emergency med-ical services. This is possible only with a better documenta-tion and data collection system. Better medical recording is important for, not only clinical purposes but, also medico-legal purposes.[9] Today, there is a need for computer-based data collection and thus, specific software for the dynamic analysis of data. The next step is national and international integration of all data collected.[5]

The rate of patients whose data were incomplete in the system for our study was higher than expected. Previous studies showed that data loss was reduced to 10% in similar cases.[10] The loss of data in the present study mainly stems from the entry of incomplete data, due to lack of experience most likely because the HIMS was launched in January 2009

(just one and a half months before the start of this study). Furthermore, the number of residents in emergency medi-cine was limited. Thus, the data related to triage were not entered by paramedics who have received training on data entry, but by nurses and intern physicians. Schootman et al. showed that the loss of data decreased from 22.6% to 8.1% in a period of one year after a two-month training was is-sued, which is an indicator of the importance of personnel training in the success of recording systems.[10]

In their study related to the use of computers in emergency departments, Hu et al. emphasized the need to use comput-er-based programs in medical data collection in emergency departments and highlighted the importance of the person-nel’s efforts in this process.[11]

This study has also revealed that the health personnel, in-cluding physicians, are required to be competent in comput-er use to ensure accurate and complete entry of data. Adirim et al. stated that, in order to minimize data loss, at least one secretary should be responsible for data entry at any hour of the day in emergency departments.[12]

The number of patients in the emergent triage category was higher compared to similar data in the US. This may be because the hospital where this study was conducted was a tertiary healthcare institution. As there are not suf-ficient healthcare institutions that may offer this service in surrounding cities, the number of patients in the emergent category may be higher compared to similar studies in the literature.

The average age of Triage 1 patients was 55.19, and the ma-jority of these patients were over 50. The relationship be-tween triage categories and age groups revealed that the triage category worsened as the age of patients increased. Singal et al. studied geriatric recourse to the emergency de-partment. They found that geriatric patients that suffered more from comorbid diseases stayed for longer periods of time in the emergency department and, had higher rate of hospitalization and emergency compared to younger pa-tients.[13] Bozkurt et al. also stated that aged patients came to the emergency department more frequently.[14]

Given the distribution of triage categories by gender, our study showed that the rate of male patients was higher in emergent category and that of female patients was higher in non-urgent category. According to similar findings, the rate of inappropriate emergency department visits is higher among women.[3,15] The studies in the US did not show any significant difference in emergency status between men and women presenting to the ED.[16,17] The fact that female patients tend to present to the ED in non-urgent cases may result from certain cultural characteristics of the Turkish so-

Zeytin AT et al. Characteristics of Patients Presenting to the Academic ED in Central Anatolia 79

ciety. Many women are reluctant to go to policlinics without being accompanied by their spouse or another acquain-tance. As male family members are at work, they typically have to come to the ED after working hours. Because men are more engaged in work life, they have recourse to hospi-tals in case of higher emergency. There is a need for further research on policlinic and hospital use to explain the differ-ence between male and female behaviors more clearly.

The highest volume of emergency department visits oc-curred on Sundays and the lowest on Fridays. Some other studies have also reached similar findings related to the most frequently visited day, as other healthcare units are closed at weekends.[18,19] Ersel et al. found that the busiest day of the emergency department was Saturday, and con-sidered that people tend to more easily admit themselves to the ED for the solution of any health problem, whether it be urgent or not, because they could not access healthcare services during working hours on weekdays.[20]

The number of patients was relatively low between 8 and 10 am and increased between 10 and 12 am. This may mean that patients with less severe complaints prefer coming to the ED for medical examination on the hours that are more appropriate for them. The number of patients visiting the department was stable between 12 am and 6 pm. The num-ber peaked between 8 and 10 pm, which may mean that pa-tients visited easily accessible, always-open EDs after com-pleting their daily activities. The number of patients reduced considerably after 12 am. In the study of Ersel et al.,[20] the same time interval was the busiest hours of the ED. Guter-man et al. found that the number of patients decreased dur-ing the night hours, but that the rate of hospitalization at nights was two-fold higher compared to daytime.[21] Given that the majority of emergency visits was between 11 am and 10 pm, the distribution of visit hours is similar to the 2007 CDC data (64.7% of emergency visits in the US were between 5 pm and 8 pm).[22]

In the emergency department, the respiratory system with J code accounted for the highest rate of visits (16.6%) and respiratory system diseases were the leading cause of visits (10.3%). The high rate of emergency visits in case of upper respiratory track diseases leads us to consider that primary healthcare services do not function properly in Turkey. Fur-thermore, patients prefer presenting to the ED of university hospitals rather than primary healthcare centers. This may be related to the patients’ expectations of receiving better service in tertiary healthcare institutions.

Given the distribution of diagnosis codes defined according to the ICD-10 coding system by triage categories, the follow-ing results were obtained. The most frequently encountered diagnosis in the emergent category was “I” code represent-

ing diseases of the circulatory system. The urgent category was “K” code representing diseases of the digestive system and the non-urgent category was “J” code representing dis-eases of the respiratory system. The cardiology department received the highest number of emergency department visits resulting in inpatient hospitalization. This supports the high rate of circulatory system diseases among Triage 1 patients.

In order to improve emergency departments, it is of par-ticular importance to determine the appropriate number of beds in service and intensive care units of hospitals. In addi-tion, it is important to determine the number of beds in the ED in proportion to the number of beds in the hospital, and optimize occupancy rates of beds. Some of the basic rec-ommendations to improve the functioning of emergency departments are to increase the number of personnel, to modernize the equipment to facilitate and accelerate the functioning, to arrange working hours in consideration of patient volume, and to employ qualified and experienced healthcare professional in these departments.[20]

Limitations

The limitations of our study can be summarized. Our study is single-centered and retrospective. Additionally, there was a 28.5% data loss. This can be explained by the following reasons: collection of the data was started after a month of the begining of HIMS system, lack of experience in collect-ing the data, and lack of emergency medicine residents. In our emergency department, we do not have paramedics or physicians in the triage. Instead, there are nurses and intern doctors, which also contributes to the limitation. In sum-mary, the data of our department may be different from the other EDs in Turkey. After all, further prospective multi-cen-ter studies must be done.

Conclusion

Gathering patient data through a well-designed data re-cording system in EDs contributes, not only to the statistical analyses and the evaluation of service quality but also, to the improvement of future EDs. Diagnosis codes used in the in-ternational area and computer-assisted recording programs, allowing integrated and easy data entry and analysis, may contribute considerably to the appropriate and regular col-lection of data. Particularly with advanced technologies, all medical procedures and results related to a patient may be recorded in addition to their demographic data. Data entry in the system is as important as a well-designed recording system. We had data loss of 28.5% implicating the need for well-trained medical secretaries to provide uninterrupted service in addition to healthcare professionals in EDs.

Turk J Emerg Med 2014;14(2):75-8180

Annual data should be taken into consideration to deter-mine the number and quality of staff to be employed in EDs. There is also need to update job definitions and qualifica-tions of specialists, research assistants, general practitioners, nurses, sanitarians, paramedics, emergency medical techni-cians, and medical secretaries. Furthermore, the workload of hospitals in the city and in surrounding cities should be determined with a view for identifying the source of high patient volume during certain days and hours.



References

1. Arnold JL. International emergency medicine and the recent development of emergency medicine worldwide. Ann Emerg Med 1999;33:97-103.

2. Bresnahan KA, Fowler J. Emergency medical care in Tur-key: current status and future directions. Ann Emerg Med 1995;26:357-60.

3. Kilicslan I, Bozan H, Oktay C, Goksu E. Demographic proper-ties of patients presenting to the emergency department. [Article in Turkish] Turk J Emerg Med 2005;5:5-13.

4. Basara BB, Guler C, Eryılmaz Z, Yentur GK, Pulgat E. T.C. Sağlık Bakanlığı Sağlık İstatistikleri Yıllığı, 2011. Sağlık Araştırmaları Genel Müdürlüğü, Ankara, 2012.

5. Barthell EN, Cordell WH, Moorhead JC, Handler J, Feied C, Smith MS, et al. The Frontlines of Medicine Project: a proposal for the standardized communication of emergency depart-ment data for public health uses including syndromic surveil-lance for biological and chemical terrorism. Ann Emerg Med 2002;39:422-9.

6. Smith MS, Feied CF. The next-generation emergency depart-ment. Ann Emerg Med 1998;32:65-74.

7. Definition of emergency medicine and the emergency physi-cian. American College of Emergency Physicians. Ann Emerg Med 1986;15:1240-1.

8. Schneider SM, Hamilton GC, Moyer P, Stapczynski JS. Defini-tion of emergency medicine. Acad Emerg Med 1998;5:348-51.

9. Hoyte P. Can I see the records? Access to clinical notes. Hosp

Med 1998;59:411-2.10. Schootman M, Zwerling C, Miller ER, Torner JC, Fuortes L,

Lynch CF, et al. Method to electronically collect emergency department data. Ann Emerg Med 1996;28:213-9.

11. Hu SC, Yen DH, Kao WF. The feasibility of full computerization in the ED. Am J Emerg Med 2002;20:118-21.

12. Adirim TA, Wright JL, Lee E, Lomax TA, Chamberlain JM. In-jury surveillance in a pediatric emergency department. Am J Emerg Med 1999;17:499-503.

13. Singal BM, Hedges JR, Rousseau EW, Sanders AB, Berstein E, McNamara RM, et al. Geriatric patient emergency visits. Part I: Comparison of visits by geriatric and younger patients. Ann Emerg Med 1992;21:802-7.

14. Bozkurt S, Atilla R, Turkçuer I, Eritmen UT, Oray NC, Arslan ED. Differences in management between young and elderly pa-tients in the emergency department. [Article in Turkish] Turk J Emerg Med 2006;6:16-24.

15. Oktay C, Cete Y, Eray O, Pekdemir M, Gunerli A. Appropriate-ness of emergency department visits in a Turkish university hospital. Croat Med J 2003;44:585-91.

16. Horwitz LI, Green J, Bradley EH. US emergency department performance on wait time and length of visit. Ann Emerg Med 2010;55:133-41.

17. Young GP, Wagner MB, Kellermann AL, Ellis J, Bouley D. Am-bulatory visits to hospital emergency departments. Patterns and reasons for use. 24 Hours in the ED Study Group. JAMA 1996;276:460-5.

18. Afilalo M, Guttman A, Colacone A, Dankoff J, Tselios C, Beau-det M, et al. Emergency department use and misuse. J Emerg Med 1995;13:259-64.

19. Gill JM. Nonurgent use of the emergency department: appro-priate or not? Ann Emerg Med 1994;24:953-7.

20. Ersel M, Karcioglu O, Yanturali S, Yuruktumen A, Sever M, Tunc MA. Emergency department utilization characteristics and evaluation for patient visit appropriateness from the patients’ and physicians’ point of view. [Article in Turkish] Turk J Emerg Med 2006;6:25-35.

21. Guterman JJ, Franaszek JB, Murdy D, Gifford M. The 1980 pa-tient urgency study: further analysis of the data. Ann Emerg Med 1985;14:1191-8.

22. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medi-cal Care Survey: 2007 emergency department summary. Natl Health Stat Report 2010;26:1-31.

Zeytin AT et al. Characteristics of Patients Presenting to the Academic ED in Central Anatolia 81

VISUAL DIAGNOSIS


DIAGNOSIS: Posterior ReversibleEncephalopathy Syndrome

MRI revealed hyperintensity compatible with vaso-genic edema on FLAIR and t2 weighted sequences in the bilateral occipital, parietal, and frontal region (Figure 2). After magnetic resonance imaging, the pa-tient had generalized tonic-clonic seizures. Reduction of the patient’s blood pressure from 203/113 mmHg to 179/95 mmHg did not cause any clinical improve-ment. Loading dose of valproic acid was given intra-venously to the patient. The patient was intubated due to uncontrolled seizures and shallow breathing and was admitted to intensive care unit. The patient died after 6 days due to intracranial hemorrhage.

Posterior reversible encephalopathy syndrome (PRES), initially described in 1996 by Hinchey et al., is a clinical-neuroradiological entity characterized by headache, vomiting, altered mental status, blurred vi-sion, and seizures.[1] This syndrome is most commonly encountered in association with acute hypertensi-on, preeclampsia or eclampsia, autoimmune disea-ses, renal failure, post-transplantation, sepsis, shock, and exposure to immunosuppressants.[2-4] Although the lesions in PRES are due to vasogenic edema, the mechanism responsible for the imaging appearance remains unclear and controversial.[1,2] There are two main hypotheses: 1) Cerebral hypoperfusion related to disruption of the blood-brain barrier results in va-sogenic edema (e.g. eclampsia/preeclampsia, cyclos-porine toxicity, and infection/sepsis/septic shock), and 2) Cerebral hyperperfusion results in vasogenic edema by exceeding the capacity for autoregulation of perfusion pressure (e.g. acute hypertension).[5] In our patient, we considered that hypertension indu-ced by renal failure led to regional dysautoregulation, consequently causing hypoperfusion.

Radiologic findings of PRES are best seen on MRI of the brain. The typical imaging findings of PRES are most ap-parent as hyperintensity on FLAIR and t2 weighted sequences of cranial MRI in the parietooccipital and posterior, fron-tal, cortical, and subcortical white mat-ter and are reversible with appropriate management.[4,5]

The treatment is based in the manage-

ment or withdrawal of the triggering factor. Hypogl-ycemia should be looked for routinely and corrected. Antiepileptic treatment should be initiated at the emergency department. Control of hypertensive emergency is an important part of the symptomatic management.[1,5] Mortality has been reported in 15% of patients. Cause of death in PRES may be due to the underlying disease, increased cerebral edema, and intracerebral hemorrhage.[6]

The early recognition and treatment of PRES is im-portant to prevent permanent neurological sequelae. Awareness of the clinical and radiographic findings of acute PRES is essential to avoid misdiagnosis and treatment delay.

References1. Pedraza R, Marik PE, Varon J. Posterior reversible en-

cephalopathy syndrome: A review. Crit Care Shock 2009;12:135-43.

2. Fugate JE, Claassen DO, Cloft HJ, Kallmes DF, Kozak OS, Rabinstein AA. Posterior reversible encephalopa-thy syndrome: associated clinical and radiologic find-ings. Mayo Clin Proc 2010;85:427-32.

3. Naqi R, Ahsan H, Azeemuddin M. Posterior reversible encephalopathy syndrome: a case series in patients with eclampsia. J Pak Med Assoc 2010;60:394-7.

4. Bartynski WS. Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features. AJNR Am J Neuroradiol 2008;29:1036-42.

5. Legriel S, Pico F, Azoulay E. Understanding posterior reversible encephalopathy syndrome. An update in-tens. Care Emerg Med 2011;1:631-53.

6. Coskun EY, Koc E, Akoğlu H, Piskinpasa SV, Ozturk R, Ozkayar N, et al. Son dönem böbrek yetmezlikli hasta-da posterior reversibl ensefalopati sendromu (PRES): Nefrologlar olarak ne kadar farkındayız? Turk Neph Dial Transpl 2012;21:178-80.

82

VISUAL DIAGNOSIS


83

DIAGNOSIS: Fracture of Anterior Superior Process of Calcaneus: A Commonly Missed Fracture

A careful examination of the initial lateral foot radiograph raised the suspicion of fracture of the ante-rior superior process of calcaneus (ASPC) (Figure 2a). Further imaging with computerized tomography (CT) and multiplanar reconstruction confirmed our preliminary diagno-sis (Figure 2b, c). Below-knee plaster cast was applied and continued for four weeks, after which a gradual re-turn to full activities was allowed. At the final follow-up six months after the initial injury, the patient was free of pain and was able to return to his previous level of activity.

Fracture of ASPC is a rare fracture that constitutes 3% of all calcaneal fractures.[1,2] The mechanism of the in-jury is often an inversion injury with the foot in plantar flexion, similar to simple ankle sprain.[1-3] Because of its infrequency, the similarity between typical history and clinical presentation of an ankle sprain and difficulties in direct radiographic evaluationof the fractures of the ASPC is usually misdiagnosed as ankle sprain at initial emergency visits. On the other hand, early identifica-tion and prompt treatment of these moderately seem-ing fractures may prevent chronic ankle problems as observed in our patient. Therefore, emergency physi-cians should be aware of this fracture.

In order to prevent misdiagnosis, a high level of sus-picion and investigation is necessary. Furthermore, the physical examination the tenderest point on pal-pation should be correctly identified. In the fracture of the ASPC, the tender point is 3-4 cm distal to the lateral malleolar tip over the bifurcate ligament.[2,3] Whereas in ankle sprain of the ATFL is usually tender.[4] In addition to a careful physical examination, a care-ful examination of the foot radiographs is important. Anteroposterior and lateral foot radiographs should be obtained as the first line imaging work-up. How-ever, complex anatomic structure of the foot and superimposition on direct radiography makes the evaluation difficult causing these fractures may easily be missed. In case of suspicion, computed tomogra-

phy (CT) is the most useful imaging method to detect and define the extent of the fracture.[4] Sagittal recon-struction best demonstrates the fracture.[3]

The os calcaneus secundarius is an uncommon acces-sory ossicle of the midfoot which is present in the 5% of the normal population.[3-5] However, in the context of foot trauma, this normal anatomic variant may be misdiagnosed as a fracture of the ASPC. Thus, os calca-neus secundarius should be considered in the differen-tial diagnosis of acute fractures of the ASPC. The most important radiographic clue to differentiate an os cal-caneus secundarius from an acute fracture is the oval configuration and well-corticated margins.[3,4] Conser-vative treatment in the form of plaster cast immobiliza-tion that last 4 weeks is sufficient for the treatment.[1,4]

References1. Trnka HJ, Zettl R, Ritschl P. Fracture of the anterior supe-

rior process of the calcaneus: an often misdiagnosed fracture. Arch Orthop Trauma Surg 1998;117:300-2.

2. Petrover D, Schweitzer ME, Laredo JD. Anterior pro-cess calcaneal fractures: a systematic evaluation of as-sociated conditions. Skeletal Radiol 2007;36:627-32.

3. Ouellette H, Salamipour H, Thomas BJ, Kassarjian A, Torriani M. Incidence and MR imaging features of fractures of the anterior process of calcaneus in a consecutive patient population with ankle and foot symptoms. Skeletal Radiol 2006;35:833-7.

4. Hodge JC. Anterior process fracture or calcaneus se-cundarius: a case report. J Emerg Med 1999;17:305-9.

5. Golder WA. Anterior process of the calcaneus: a clin-ical-radiological contribution to anatomical vocabu-lary. Surg Radiol Anat 2004;26:163-6.

Successful Outcome of MediastinitisAfter 26 Days Delay in Diagnosis Başarıyla Sonuçlanan 26 Gün Geç Tanı Almış

Mediastinit Olgusu

CASE REPORT


Submitted: May 17, 2013 Accepted: July 25, 2013 Published online: September 24, 2013

Correspondence: Dr. Pouya Paknejad. Emergency Department, Imam Reza Hospital, Tabriz, Iran.


Department of Emergency Medicine, Imam Reza Hospital, Tabriz, Iran

Farid Eftekhari MILANI, Samad SHAMS VAHDATI, Pouya PAKNEJAD

IntroductionMediastinitis is a severe, life-threatening condition and a surgical emergency that arises as a complication of thoracic surgery, oropharyngeal infection, or after neck and chest trauma. Mediastinitis has a mortality rate between 14% and 42%.[1] Early diagnosis and treatment can minimize mortal-ity,[2] while delays in treatment increase rates of mortality.[3] We report and discuss a 38-year-old male patient with medi-astinitis, which occurred due to trauma.

Case ReportA 38-year-old man presented to the emergency department

(ED) of Imam Reza hospital with neck and back pain after a trauma due to falling down 3 meters. Physical exams and neck and chest X-rays (CXR) were normal and chest magnet-ic resonance imaging (MRI) did not show any neurological damage. Patient was discharged from ED with stable vital signs and analgesic drugs.

Two weeks later he was admitted again in ED with a com-plaint of pain in sternum. Due to normal chest X-Ray (Figure 1a) and electrocardiogram (ECG), physicians came to the conclusion that the pain had been caused by heavy physical activity. Patient was discharged with analgesics.

Twenty-six days later, the patient was brought to the ED with

SUMMARYAcute mediastinitis, which is characterized by inflammation of tho-racic tissues, is a life-threatening infection and a surgical emergen-cy. The mortality rate for this ailment is reported between 14-42%, which makes it important to diagnose and treat as soon as possible. We presented and discussed a case of a 38-year-old male patient with blunt trauma to the chest and back from falling who reported to the emergency department after 26 days with severe chest pain and a toxic condition. He underwent an anterolateral thoracotomy and several rounds of pleural flushing; ultimately, he survived.

Key words: Infection; mediastinitis; trauma.

ÖZETAkut mediastinit, torasik dokuların iltihabı olarak, hayatı tehdit eden bir enfeksiyon ve cerrahi acildir. Ölüm oranı %14 ile 42 arasında bil-dirilmektedir. Akut mediastinitin en kısa zamanda tanınması ve te-davi edilmesi önemlidir. Bu yazıda, düşmeye bağlı künt göğüs ve sırt travması olan ve 26 gün sonra acil servise ciddi göğüs ağrısı ve toksik durumda başvuran 38 yaşında erkek olguyu sunduk ve tartıştık. Has-taya anterolateral torakotomi ve birkaç kez plevral yıkama yapıldı ve sonuçta hasta hayatta kalabildi.

Anahtar sözcükler: Enfeksiyon; mediastinit; travma.

84

severe sternal pain and swelling on xiphoid. He was toxic and had high fever (39.1 °C) and tachycardia (135 beats per minute). Initial laboratory findings of significance showed 27,000/mm3 leukocytes, 12.5 mg/dl hemoglobin, and 127 mEq/lit Na. CXR was performed and showed mediastinal widening and an osteomyelitis on sternum. A thoracic com-puterized tomography (CT) revealed air and fluid collection in mediastinum, bilateral pleural effusion, and pericardial ef-fusion (Figure 1b). A chest tube was placed on the right side, which had more effusion, and purulent fluid was drained. The patient’s symptoms improved partially after drainage of effusion. Esophagus was normal in barium swallow.

Patient admitted to thoracic surgery ward and underwent an anterolateral thoracotomy and debridement of ne-crotic tissues of mediastinum. A pericardial window was performed and intravenous administration of antibiotics was started. Daily flushing of mediastinum continued until the discharge day. A week after discharge, the patient was again admitted in thoracic surgery ward due to the continu-ation of his symptoms. Daily pleural flushing and drainage of pleural fluid continued until a negative pleural effusion culture.

Ten days later, in his last follow up, the patient was pain free, not febrile, and ambulatory. Drains were removed. Right side chest tube had a small amount of bloody fluid. Laboratory results showed 5900 (cell/mm3) leukocytes and 10.1 (mg/dl) hemoglobin.

DiscussionAcute mediastinitis is a surgical emergency that has a high rate of mortality, ranging from 14% to 42%.[1] In most cases acute infection of mediastinum occurs because of esopha-geal rupture caused by neoplasm, trauma, or medical ex-amination or treatment.[4] Macrí et al. studied 26 cases of mediastinaitis and showed that in 64% of patients, infection originated from esophagus, and in 23% of cases it originated from oropharyngeal infection or dental or peritonsillar ab-scess named as descending necrotizing mediastinitis (DNM).[1] Estrera et al. published diagnostic criteria for DNM in 1983.[5] Symptoms and signs of mediastinitis such as fever, chest pain, leukocytosis, and high erythrocyte sedimentation rate are not specific but can give a clue for diagnosis in patients with a risk factor for mediastinitis.[6] Because of low sensitiv-ity and specificity, conventional X-ray is not diagnostic for mediastinitis and may delay diagnosis and treatment, in-creasing mortality.[1,6] In any patient with high susceptibility of mediastinitis, computerized tomography should be per-formed.[1,6] Aggressive treatment should be started as soon as possible. Standard treatment for mediastinitis is surgical debridement of necrotic mediastinal tissue and adequate drainage of pleura and pericardia, followed by an appro-priate antibiotic therapy and supportive medical care in an intensive care unit.[1,6] Although esophageal rupture is the main cause of mediastinitis, in our case the esophagus was normal and intact in both barium swallow and MRI. There was no evidence of oropharyngeal and dental infection and Estrera criteria for DNM were not fulfilled. There was a delay

Figure 1. (a) Normal chest X-Ray. (b) Thoracic computerized tomography images. Air and fluid collection in the mediastinum, bilateral pleural effusion and pericardial effusion as seen.

(a) (b)

85Milani FE et al. Successful Outcome of Mediastinitis After 26 Days Delay in Diagnosis

in diagnosis because of mismanagement of patient’s chest pain, showing the low sensitivity of plain chest radiography for mediastinitis. Despite the delayed treatment, the patient survived the condition, which shows the importance of ag-gressive treatment with adequate debridement and early antibiotic therapy. Patient’s healthy condition before medi-astinitis and no existence of comorbidities were positive fac-tors in his survival.



References1. Macrí P, Jiménez MF, Novoa N, Varela G. A descriptive analy-

sis of a series of patients diagnosed with acute mediastinitis.

[Article in Spanish] Arch Bronconeumol 2003;39:428-30. [Ab-stract]

2. De Feo M, Gregorio R, Della Corte A, Marra C, Amarelli C, Ren-zulli A, et al. Deep sternal wound infection: the role of early debridement surgery. Eur J Cardiothorac Surg 2001;19:811-6.

3. Dwivedi MK, Pal RK, Gupta R, Rizvi SJ, Singh RP, Borkar PB. CT finding of descending necrotizing mediastinitis. Ind J Radiol Imag 2001;11:131-4.

4. Kurowski K, Matuszek I, Nunez CF. Successful outcome of de-scending necrotizing mediastinitis due to neck trauma. Pol J Radiol 2011;76:65-7.

5. Estrera AS, Landay MJ, Grisham JM, Sinn DP, Platt MR. De-scending necrotizing mediastinitis. Surg Gynecol Obstet 1983;157:545-52.

6. Kilic D, Findikcioglu A, Ates U, Hekimoglu K, Hatipoglu A. Management of descending mediastinal infections with an unusual cause: a report of 3 cases. Ann Thorac Cardiovasc Surg 2010;16:198-202.

86 Turk J Emerg Med 2014;14(2):84-86

1Department of Emergency Medicine, Toros Training and Research Hospital, Mersin;2Department of Emergency Medicine, Istanbul Training and Research Hospital, Istanbul

Birdal GULLUPINAR,1 Hakan TOPACOGLU2

Subarachnoid Pleural Fistula Due to Gunshot Wound Ateşli Silah Yaralanması Sonrası Subaraknoid Plevral Fistül

ÖZETSubaraknoid plevral fistül (SPF) son derece nadir bir komplikasyondur. Dural aralık ve vertebral kolonların hasarı sonrası oluşur. SPF pnö-mosefali ve pnömorachis yokluğu ve varlığı şeklinde iki gruba ayrılır. Pnömosefali, kraniyal kavite içerisinde hava bulunması olarak tanım-lanırken spinal kanala hava girmesine ise pnömorachis denir. Genelde pnömosefali ve pnömorachis ile SPF birlikteliği nadirdir ve künt trav-ma sonrası gelişir. Ancak bizim hastamızda pnömosefali ve pnömo-rachis ile SPF birlikteliği ateşli silah yaralanması sonrası gelişmiştir. Bu yazıda, ateşli silah yaralanması sonrası torakal omurga yaralanması-nın neden olduğu pnömorachis ve pnömosefalisi bulunan SPF olgusu sunuldu.

Anahtar sözcükler: Ateşli silah yaralanması; pnömosefali; subaraknoid plev-ral fistül.

SUMMARYSubarachnoid pleural fistula (SPF) is an extremely rare complication that occurs after dural space and vertebral columns injuries. SPF is divided into two diagnoses based on the absence or presence of pneumocephalus and pneumorrachis. While pneumocephalus is defined as the presence of air the cranial cavity, if there is air in the spinal canal, this is defined as pneumorrhachis. In general, the asso-ciation of SPF with pneumocephalus and pneumorrachis is rare but can occur after blunt trauma. In our patient, pneumorrhachis and pneumocephalus with SBF developed after the patient suffered a gunshot wound. This paper reports an SPF case accompanied by pneumorrachis and pneumocephalus, which occurred after tho-racic spine injury due to a gunshot wound.

Key words: Gunshot; pneumocephalus, pneumorrachis; subarachnoid pleural fistula.

CASE REPORT

IntroductionSubarachnoid pleural fistula (SPF) is an extremely rare comp-lication that occurs after injury of dural space and vertebral columns.[1] In SPF, both pneumocephalus and pneumorrac-his may be seen. Pneumocephalus is defined as the presence of air in cranial cavity[2] and is most commonly caused by tra-uma. It has been reported that the incidence of the pneumo-cephalus due to trauma is 5.6%.[3] A rare condition in which air enters the spinal canal after trauma is called pneumorrac-his. Occurence of pneumorrhachis is frequently asymptoma-tic and does not require any specific treatment because air is reabsorbed spontaneously without leaving any neurological sequelae.[4] This paper reports an SPF case accompanied by

pneumorrachis and pneumocephalus, which occurred after thoracic spine injury due to a gunshot wound.

Case ReportA 20-year-old male patient with a gunshot wound was bro-ught to the emergency room by air ambulance. His medical history was normal. In the emergency department, he had a poor general condition: he was unconscious, non-oriented, and non-cooperative. Glasgow Coma Scale was evaluated as E1M5Vt. The patient was brought in intubated with bilate-ral chest tube. His blood pressure was 86/43 mmHg, cardi-ac pulse 86 beat/min, respiration rate 24 breaths/min, axilla temperature 36.7 °C, and oxygen saturation 96%.


Submitted: August 06, 2013 Accepted: October 22, 2013 Published online: January 07, 2014

Correspondence: Dr. Birdal Gullupinar. Toros Devlet Hastanesi, Acil Servis,

Akdeniz, 33330 Mersin, Turkey.


87

Turk J Emerg Med 2014;14(2):87-89

While examining the patient’s head and neck, it was ob-served that there was a laceration on the right parietal and frontal area and also a subcutaneous emphysema spanning from the right side of neck to inguinal region. In respiratory system examination, the bullet entry hole on the posterior region of left shoulder and bullet exit hole on anterior of right shoulder were detected. Examination of other systems yielded normal findings.

Computed tomography (CT) of the brain and maxillofacial area exhibited bilateral putamen, cerebellar haemorrhage, and pneumocephalus without any bone fracture (Figure 1). In CT of cervical vertebrae and thorax, a fracture in T2 ver-

tebra along with pneumorrachis, haemopneumothorax, and pneumomediastinium were detected (Figure 2a, b). In other tomographic examinations no acute pathologies were ob-served. The pateint was transferred to ICU after consultation with anesthesia and reanimation clinics. The pateint died on the seventh day in anesthesia ICU.

DiscussionSPF can be caused by blunt or penetrating trauma. The main cause of blunt and penetrating traumas are motor vehicle accidents and gunshot injuries.[5] SPF is divided into two gro-ups: the first group consists of absence of radiological pne-umorrhachis and pneumocephalus, and the second group is defined as the presence of pneumocephalus and pneu-morrachis. The second group is rare and the most common feature of this group is its secondary occurence after blunt trauma.[6] However, in this case, pneumorrhachis and pne-umocephalus developed after a gunshot wound not due to a blunt trauma. Pneumocephalus and pneumorrachis are important radiological findings that may indicate serious pathologies.

Pneumocephalus develops after a trauma if there is a dural membrane tear, leading to contact with air and greater air pressure in this area compared to the cerebrospinal fluid (CSF) pressure. This is rare if no tension pneumothorax is present as the pressure of pleural space is under atmosphe-ric pressure.[6] In this case, the patient did not have tension pneumothorax. For this reason, it is thought that high air pressure may also cause secondary pneumocephalus and SPF without tension pneumothorax.

Pressure can change depending on the patient’s position. Intratechal pressure at thoracic vertebra level injuries is pro-

Figure 1. Bilateral pneumocephalus in brain CT.

Figure 2. The fracture of T2 vertebra with pneumorrachis (a), haemopneumothorax and pneumomedi-astinium (b).

(a) (b)

88

bably low in supine position and under the state of shock.[7] In addition, CSF production decreases about 30% after stimulation of the sympathetic nervous system. In this case, a decrease in CSF production resulting in decrease in CSF pressure can lead to formation of SPF easily as observed in our patient. Wide dural defect due to gunshot wound can lead to the loss of a large amount CSF, a condition that cau-ses CSF pressure to be reduced to zero. In addition, high int-rathoracic pressure caused by gunshot shock wave may be higher than that of cerebrospinal fluid pressure. In our case, it is thought that the pateint developed pneumocephalus and SPF due to pressure changes at high altitudes during patient transfer to ER by air ambulance.

There is no definitive method in the treatment of SPF. Ver-tebral column injury, dural and pleural tears are all develo-ped after high-energy trauma mechanisms. This may explain why this condition results in high mortality rates.

Conclusion

SPF is a rare complication that occurs following an injury to the vertebral column and is usually reported after a blunt trauma. Here we are reporting a case of a victim with pne-umorrhachis and pneumocephalus after a gunshot wound, leading to SPF as a secondary defect after trauma. Airborne transfer of patients with vertebral injuries may lead to SPF due to air pressure changes at high elevations; thus cauti-

on must be exercised for the air ambulance transfer of such patients.



References1. Liang MK, Moore EE, Williams AM, Marks JL. Traumatic sub-

arachnoid pleural fistula. J Trauma 2008;65:1155-61.

2. Kozikowski GP, Cohen SP. Lumbar puncture associated with pneumocephalus: report of a case. Anesth Analg 2004;98:524-6.

3. Iwama T, Andoh H, Murase S, Miwa Y, Ohkuma A. Diffuse cere-bral air embolism following trauma: striking postmortem CT findings. Neuroradiology 1994;36:33-4.

4. Oertel MF, Korinth MC, Reinges MH, Krings T, Terbeck S, Gils-bach JM. Pathogenesis, diagnosis and management of pneu-morrhachis. Eur Spine J 2006;15 Suppl 5:636-43.

5. Kairinos N, Nicol A, Navsaria P. Pneumocephalus following gunshot injury to the thoracic vertebral column: a case re-port. Ulus Travma Acil Cerrahi Derg 2009;15:614-6.

6. Cole JD. Assessment. In: Illis LS, editor. Spinal cord dysfunc-tion. Chapter 9. Oxford University Press; 1988. p. 216-31.

7. Kuczkowski KM. Post-dural puncture headache, intracranial air and obstetric anesthesia. Anaesthesist 2003;52:798-800.

Gullupinar B et al. Subarachnoid Pleural Fistula Due to Gunshot Wound 89

1Department of Emergency Medicine, Abant Izzet Baysal University Faculty of Medicine, Bolu;2Department of Anesthesiology and Reanimation, Abant Izzet Baysal University Faculty of Medicine, Bolu;

3Department of Plastic Reconstructive and Aesthetic Surgery, Abant Izzet Baysal University Faculty of Medicine, Bolu

Arif DURAN,1 Tarık OCAK,1 Umit Yasar TEKELIOGLU,2 Furkan Erol KARABEKMEZ,3 Ayse CETIN1

Lower Extremity Tissue Defect Caused byMobile Phone Charger Explosion: A Case Report

Cep Telofonu Şarj Aleti Patlamasının Neden OlduğuAlt Ekstremite Doku Defekti: Olgu Sunumu

CASE REPORT


Submitted: March 05, 2013 Accepted: April 29, 2013 Published online: July 29, 2013

Correspondence: Dr. Arif Duran. Abant İzzet Baysal Üniversitesi Tıp Fakültesi,Acil Tıp Anabilim Dalı, 14280 Gölköy, Bolu, Turkey.


IntroductionThe use of electronic devices is ever increasing due to our heightened reliance on technology for daily routines. As electronic devices such as cell phones, tablet computers, and notebooks take a significant part of our life, the risks re-lated to chemicals in the batteries and cables carrying high current are an issue and present possible danger to ordinary life.[1-4] Improper manufacturing of such devices may put ones life in a potential threatening situation.

In the this case report, we present a 9-year old patient with a burn injury and tissue defect as a consequence of a cell phone charger explosion.

Case ReportA 9-year-old female applied to our emergency service due to a cell phone charger explosion. The patient stated that she plugged in her battery charger and pressed the “yes” key on the cell phone as it was ringing causing the charger to explode. Initial examination revealed a 5-6 cm uneven burn with a tissue defect involving skin and underlying subcuta-neous tissue in the right anterolateral field above the knee. There were also several small areas of full thickness skin glow on both lower limbs (Figures 1a and b). The patient could not produce the battery charger as evidence since the charger broke into many pieces (Figure 1c). There was no other problem with her systemic examinations. The patient

SUMMARYAs the usage of cell phones is markedly increasing worldwide, ac-cidental injuries and even lethal damages caused by cellular phone explosions have been reported lately. Although, cell phone char-ger explosion related scalding and tissue loss is extremely rare, they generally cause severe damage to tissues and cause severe complications, ending up in hospitalization. We are presenting a case of 9-year old female patient who was admitted to our emer-gency service due to a phone charger explosion that resulted in a lower extremity tissue defect.

Key words: Charger; explosion; tissue defect.

ÖZET

Cep telefonu kullanımı dünya çapında belirgin bir şekilde arttık-ça, yaralanmaların, hatta ölümcül hasarların olduğu kazalar son zamanlarda bildirilmiştir. Her ne kadar cep telefonu şarj aleti pat-laması ile ilgili yanık ve doku kaybı oldukça nadir olsa da, komşu dokularda ciddi hasar yapıp problem oluşturabilirler. Bu yazıda, cep telefonu şarj aleti patlamasına bağlı alt ekstremitede doku defekti ile acil servise başvuran dokuz yaşında bir kız çocuğu olgusu sunul-du.

Anahtar sözcükler: Şarj aleti; patlama; doku defekti.

90

was consultated with a plastic surgery office and underwent rapid debridement and corruption preparation. There was no postoperative problem, and she was discharged with antibiotherapy (cephazoline). Dressing change on every other day was also suggested to the patient. There were no complications during the follow-up time as well. Figure 1d showed the final appearance of the right anterolateral area with a skin graft.

DiscussionMobil phones usage is increasing daily, not only for specta-tors but also, for healthcare professionals especially during work hours in the hospitals.[5] As we increasingly use these

devices in all aspect of the life, we also should be aware of the potential dangers of cell phones. There are some anec-dotal studies for mobile phone battery explosion.[4,6-8] How-ever, we have not had many injuries associated with the use of phone chargers or any literature on this topic.

Karabağlı et al. reported a case of a 16-year-old female that was burned by a sudden exploding mobile phone.[4] In their case study, the patient was speaking on the phone while it is charging. In our case study, the phone and the battery of the phone were intact after the explosion but not the charging device. Ben et al. reported a 24-year old man who was admit-ted to the hospital with multiple injuries, including severe burns in the left cheek and cervical area, perforation of left

Figure 1. (a) Right anterolateral area above the knee and left upper leg injury. (b) The main injury on right upper leg shorly after mobile phone charger explosion. (c) Mobile phone charge adapter. (d) The final postoperative appearance of the injured region after immediate debridement and graft operation.

(a)

(c)

(b)

(d)

91Duran A et al. Lower Extremity Tissue Defect Caused by Mobile Phone Charger Explosion

tympanic membrane, cracking on scull base with paralysis of left facial nerve, and left clavicle fracture.[2] These injuries were triggered by a spontaneously exploding mobile phone, which may have heated up during a prolonged (over half an hour) discussion. Contrary to our case, there was warning signal for the patient before the explosion occcurred most likely due to lengthy phone conversation. There was no sign or evidence in our case that the explosion occurred just after plugging in the phone charger.

Fadeyibi et al. reported a case of a 1.5 volt conventional bat-tery explosion and death which offered an extreme example about the danger of small batteries. The patient had 53% second degree burn and inhalation injuries, and subsequent death was reported in that case.[3] The dangers of batteries are reported as precautionary statements, which are written on them and are indiciative of the risk we take each day that we use any portable device.

Yigit et al. presented a case of the abdominal wall hemato-ma caused by an exploded phone.[8] The victim just finished his conversation and there was no ringing or talking at the time of explosion, which is opposite of other reported cases including our study.

Using mobile phones has an inherent risk for various de-vices, including equipment and petroleum products. It was reported that there was no serious danger from using the cellular phone as long as they were 1 m away from suscep-tible equipment. With the most recent equipment, the se-curity margin is much greater with a distance of 30 m away from the equipment.[6] There was one record of an adult who was burned by detonation while employed on a petrol tank without any factors triggering this explosion apart from for his mobile phone ringing.[7] In our case, when the patient wanted to answer the ringing cell phone, the charger ex-ploded while pressing “yes” key.

In general, people do not believe a charger to be hazardous, so they frequently leave the phone turn on while it is charg-ing. The cellular phone should be turn off before being left to charge and unblocked before answering an external call or

making a call.[4] People need more formal education regard-ing the inherent dangers of the use of dry-cell batteries.[3]

In conclusion, we recommend that cell phones and battery chargers, which are important links to the devices of our age, should be used carefully. In addition, people should be more educated about taking the necessary safety precau-tions during handling of these devices. Even though cellular phone explosion is a rare and extraordinary event, the inevi-tability of cellular phones is associated with well-being risk. Increasing awareness of the potential hazards and taking ex-tra precautions can decrease cellular phone-related hazards.



References1. Moore AT, Cheng H, Boase DL. Eye injuries from car battery

explosions. Br J Ophthalmol 1982;66:141-4.

2. Ben D, Ma B, Liu L, Xia Z, Zhang W, Liu F. Unusual burns with combined injuries caused by mobile phone explosion: watch out for the “mini-bomb”! J Burn Care Res 2009;30:1048.

3. Fadeyibi IO, Izegbu MC, Benebo AS. Fatal domestic accident from a 1.5 volt dry-cell battery explosion as seen in lagos state university teaching hospital, ikeja, lagos, Nigeria. Ann Burns Fire Disasters 2008;21:219-20.

4. Karabagli Y, Köse AA, Cetin C. Partial thickness burns caused by a spontaneously exploding mobile phone. Burns 2006;32:922-4.

5. Soto RG, Chu LF, Goldman JM, Rampil IJ, Ruskin KJ. Commu-nication in critical care environments: mobile telephones im-prove patient care. Anesth Analg 2006;102:535-41.

6. Ettelt S, Nolte E, McKee M, Haugen OA, Karlberg I, Klazinga N, et al. Evidence-based policy? The use of mobile phones in hospital. J Public Health (Oxf ) 2006;28:299-303.

7. Potokar T, Ross AD, Clewer G, Dickson WA. Mobile phones-a potential fire hazard? Burns 2003;29:493-4.

8. Yigit Ö, Bektaş F, Güngör F. Abdominal wall hematoma caused by an exploded phone and a review of mobile phone-related hazards. Erciyes Med J 2012;34:158-9.

92 Turk J Emerg Med 2014;14(2):90-92

Pancreatic Injury Caused By A Fall From Height: Transection at the Tail

Yüksekten Düşme Nedeniyle Oluşan Pankreas Yaralanması: Kuyrukta Kopma

CASE REPORT


Submitted: July 01, 2013 Accepted: July 24, 2013 Published online: September 13, 2013

Correspondence: Dr. Cem Oktay. Akdeniz Üniversitesi Tıp Fakültesi,Acil Tıp Anabilim Dalı, 07059 Antalya, Turkey.


1Department of Emergency Medicine, Akdeniz University Faculty of Medicine, Antalya;2Department of Emergency Medicine, Sevket Yılmaz Training and Research Hospital, Bursa;

3Department of Emergency, Balikesir State Hospital, Baliskesir;4Department of Emergency, Antalya Life Hospital, Antalya

Cem OKTAY,1 Dilek DURMAZ,2 Ozgur Onder KARADENIZ,3 Soner ISIK4

IntroductionIsolated pancreatic injury due to the blunt abdominal trau-ma is rare and accounts for less than 1% of all trauma ad-missions.[1] Most pancreatic injuries occur in young men.[1,2] Pancreatic injuries often accompany rapid decelerating in-jury and result from a direct epigastric blow that compress-es the organ against the vertebral column.[2,3] Blunt trauma

to the pancreas may be clinically difficult to diagnose and the injuries may not be recognized during initial evalua-tion or even surgery. Unfortunately, the rate of pancreatic complications was higher in the blunt trauma patients with a delayed diagnosis when compared with those patients diagnosed within 24 hours.[4] We present a case with an atypical location of pancreatic injury a fall from heigth and

SUMMARYIsolated pancreatic injury due to blunt abdominal trauma is rare and may be clinically difficult to diagnose. Parenchymal injuries may not be recognized during initial evaluation. We report the case of a 30-year-old male presented to the Emergency Department (ED) with the complaint of persistent abdominal pain, nausea, and vomiting. His medical history revealed that he fell from a height of approximately 1.5 meters 1 day ago and hit an iron block. He was presented and discharged from another hospital ED. Contrast enhanced computerized tomography (CECT) of the abdomen was ordered during his second presentation and revealed pancreatic parenchymal contusion, laceration, and transection at the tail of pancreas. Our findings suggest that, when there is high index of suspicion for pancreatic injury, a CECT should always be ordered.

Key words: Abdominal trauma; computed tomography; pancreatic injury.

ÖZETKünt abdominal travmaya bağlı izole pankreas yaralanması na-dirdir ve klinik olarak tanı konulması zordur. Parankimal yaralan-malar ilk değerlendirme sırasında ayırt edilemeyebilinir. Bu yazıda, devam eden karın ağrısı, bulantı ve kusma yakınması ile acil servise başvuran 30 yaşındaki bir hasta sunuldu. Hastanın öyküsünde bir gün önce 1.5 metre yükseklikten demir bir blok üzerine düştüğü ve başvurduğu başka bir hastanenin acil servisinden taburcu edildiği öğrenildi. İkinci başvurusu sırasında kontrastlı batın tomografisi çe-kildi ve pankreas parankiminde kontüzyon, laserasyon ve pankreas kuyruk kesiminde kopma tespit edildi. Pankreas yaralanmasına ait yüksek şüphe mevcut ise kontrastlı batın tomografisi her zaman is-tenmelidir.

Anahtar sözcükler: Karın travması; bilgisayarlı tomografi; pankreas yaralan-ması.

93

Turk J Emerg Med 2014;14(2):93-95

late presentation. In addition, we review the importance of ordering contrast enhanced computerized tomography (CECT) for patients with persistent nonspecific symptoms following abdominal trauma.

Case ReportA 30-year-old male was presented to the emergency depart-ment (ED) of Akdeniz University Hospital with complaints of abdominal pain, nausea and vomiting. History revealed that he fell from a height of approximately 1.5 meters and hit an iron block 10 hours ago. He presented to another hospital ED soon after the event and his medical history revealed that repeated hemoglobin levels, abdominal ultrasonogra-phy (US), and abdominal computed tomography (CT) were normal. He was discharged with a diagnosis of abdominal trauma with no organ injury after a few hours of follow-up.

He presented to our ED with persistent nausea and vomit-ing. Initial vital signs were normal; blood pressure: 143/93 mmHg; heart rate: 84/min.; respiratory rate: 24/min.; tem-perature: 37.0 °C. There was an abrasion on the left upper quadrant on abdominal examination and he had tender-ness at the same abdominal region, however; guarding or rebound tenderness were not noted. Initial leukocyte count and serum lipase levels were elevated (23,590/mm3 and 1419 U/L, respectively) where as his hemoglobin level was 16.3 g/dL.

US revealed free fluid accumulation of maximally 60 mm in the perihepatic, perisplenic, pelvic, and left perirenal area of the abdominal cavity. CECT of the abdomen was ordered and uncovered pancreatic parenchymal contusion, lacera-tion, and transection at the tail of pancreas (Figure 1). The patient was admitted to the general surgery and under-

went to emergency laparotomy. Distal pancreatectomy with splenectomy was performed. His body temperature was elevated a day after the surgery and antibiotherapy was changed to imipenem/cilastatin sodium. Pleural effusion of 80 mm was noted on the left pleural space on the third day post-surgery. Respiratory disease consultation was offered to monitor the amount of fluid, since the accumulation was thought to be caused by transdiaphragmatic transition. He was discharged on the 13th day post-surgery with complete recovery.

DiscussionBlunt trauma to the pancreas usually results from road traf-fic accidents. For example, when an unrestrained driver is thrown onto the steering wheel or a motorcyclists or chil-dren on bicycles fall onto the handlebars. Mainly, transec-tion occurrs at the neck of the pancreas over the vertebral bodies due to the deceleration injury during blunt trauma to the epigastric region.[2,4-7]

Patients usually present late and have minimal symptoms and signs.[8] An early normal serum amylase does not ex-clude major pancreatic trauma.[2,3,9] On the other hand, amy-lase levels may be elevated from nonpancreatic sources. However, persistently elevated or rising serum amylase lev-els should prompt further evaluation of the pancreas and other abdominal viscera.[3]

Although abdominal US has the ability to detect small amounts of fluid in the abdomen, it misses the diaphragm, bowel, pancreatic, and solid organ injuries.

CECT is the best investigation on diagnosing pancreatic inju-ries and should be done in all cases with clinically suspected

Figure 1. Axial contrast enhanced CT image of the abdomen demonstrating pancreatic parenchymal contusion, laceration and transection at the tail of pancreas (arrows).

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Oktay C et al. Pancreatic Injury Caused By A Fall From Height

isolated pancreatic trauma.[2] Despite all, CT scanning may be initially normal with acute blunt pancreatic injuries. The ability of CT scanning to facilitate accurate diagnosis of pan-creatic injury depends on the quality of the CT scanner, the imaging technique, the experience of the observer, and the timing of the examination.[10] Within the first 12 h after the injury, CT scans may appear normal in a significant fraction of injuries.[11-13] This is due to the obscuration of the fracture plane, hemorrhage, and close apposition of the pancreatic fragments.[11,13] CT scan diagnoses of the pancreatic injuries revealed variable sensitivity and specificity because many findings are subtle, absent or, at times, slow to develop. The sensitivity and specificity of a CT scan in detecting pancre-atic trauma of all grades has been reported to be around 80%.[12-15]

Direct signs of pancreatic injury on CT include pancreatic lac-eration, transection, and comminution. At the site of injury or transection, fluid collections, such as hematomas, pseu-docysts, and abscesses, are often seen communicating with the pancreas. Peripancreatic fluid and focal enlargement of the pancreatic tissue also suggest pancreatic injury. Useful secondary signs are peripancreatic fat stranding, hemor-rhage, and fluid between the splenic vein and pancreas.[6,9,16]

In conclusion, a high index of suspicion for isolated pancre-atic injury is necessary in patients with specific upper ab-dominal injuries during initial ED evaluation and contrast enhanced CT should always be ordered. Repeat scanning at 12 to 24 hours should also be considered to detect an abnor-mality which may be initially ambiguous or subtle.



References1. Akhrass R, Yaffe MB, Brandt CP, Reigle M, Fallon WF Jr, Malan-

goni MA. Pancreatic trauma: a ten-year multi-institutional ex-

perience. Am Surg 1997;63:598-604.2. Beckingham IJ, Krige JE. ABC of diseases of liver, pancre-

as, and biliary system: Liver and pancreatic trauma. BMJ 2001;322:783-5.

3. American College of Surgeons Committee on Trauma. Ad-vanced Trauma Life Support for Doctors. 8th ed. Chicago: American College of Surgeons; 2008. p. 111-26.

4. Kao LS, Bulger EM, Parks DL, Byrd GF, Jurkovich GJ. Predic-tors of morbidity after traumatic pancreatic injury. J Trauma 2003;55:898-905.

5. Krige JE, Kotze UK, Hameed M, Nicol AJ, Navsaria PH. Pan-creatic injuries after blunt abdominal trauma: an analysis of 110 patients treated at a level 1 trauma centre. S Afr J Surg 2011;49:58-64.

6. Visrutaratna P, Na-Chiangmai W. Computed tomography of blunt abdominal trauma in children. Singapore Med J 2008;49:352-9.

7. Mittal GS, Kumar S. Isolated pancreatic injury in case of blunt trauma abdomen. JK Science 2007;9:148-50.

8. Klin B, Abu-Kishk I, Jeroukhimov I, Efrati Y, Kozer E, Broide E, et al. Blunt pancreatic trauma in children. Surg Today 2011;41:946-54.

9. Tan KK, Chan DX, Vijayan A, Chiu MT. Management of pan-creatic injuries after blunt abdominal trauma. Experience at a single institution. JOP 2009;10:657-63.

10. Jurkovich GJ. The duodenum and pancreas. In: Mattox KL, Feliciano DV, Moore EE, editors. Trauma. 4th ed. New York: McGraw-Hill; 2000. p. 735-62.

11. Akhrass R, Kim K, Brandt C. Computed tomography: an unreli-able indicator of pancreatic trauma. Am Surg 1996;62:647-51.

12. Cirillo RL Jr, Koniaris LG. Detecting blunt pancreatic injuries. J Gastrointest Surg 2002;6:587-98.

13. Jeffrey RB Jr, Federle MP, Crass RA. Computed tomography of pancreatic trauma. Radiology 1983;147:491-4.

14. Almaramhy HH, Guraya SY. Computed tomography for pan-creatic injuries in pediatric blunt abdominal trauma. World J Gastrointest Surg 2012;4:166-70.

15. Leppäniemi AK, Haapiainen RK. Risk factors of delayed diag-nosis of pancreatic trauma. Eur J Surg 1999;165:1134-7.

16. Milia DJ, Brasel K. Current use of CT in the evaluation and management of injured patients. Surg Clin North Am 2011;91:233-48.

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