Turk J Emerg Med 2014 / 4

ORIGINAL ARTICLES

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

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

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

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

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

CASE REPORTS

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

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

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

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

REVIEW

Some Ethical Issues in Prehospital Emergency MedicineErbay H

ISSN 1304-7361

Turkish Journ

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e Türkiye Acil Tıp Dergisi V

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Citation Abbreviation: Turk J Emerg Med

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 4 YEAR 2014

Turkish Journal ofEmergency MedicineTürkiye Acil Tıp Dergisi

@TrJEmergMed

Turkish Journal ofEmergency MedicineTürkiye Acil Tıp Dergisi

VOLUME 14

Citation Abbreviation: Turk J Emerg Med

NUMBER 4 YEAR 2014

ISSN 1304-7361

ORIGINAL ARTICLES

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





CASE REPORTS

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

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

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

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

REVIEW

Some Ethical Issues in Prehospital Emergency MedicineErbay H

www.trjemergmed.com



@TrJEmergMed

1 Januzzi et al. (2005). Am J Cardiol. 95(8), 948-542 Moe et al. (2007). Circulation. 115(24), 3103-103 Januzzi et al. (2006). Eur Heart J. 27(22), 2619-20

Her testin arkasında kurtarılacak bir yaşam vardır Dispne ile başvuran hastalarda erken ve doğru tanı sonuçları iyileştirir ve 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

NT-proBNP testi akut kalp yetersizliğinin tanısında/ihtimal dışı bırakılmasında ve prognozunda güçlü bir belirteçtir.1,2,3

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 4)

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

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

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

www.trjemergmed.com



1 Januzzi et al. (2005). Am J Cardiol. 95(8), 948-542 Moe et al. (2007). Circulation. 115(24), 3103-103 Januzzi et al. (2006). Eur Heart J. 27(22), 2619-20

Her testin arkasında kurtarılacak bir yaşam vardır Dispne ile başvuran hastalarda erken ve doğru tanı sonuçları iyileştirir ve 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

NT-proBNP testi akut kalp yetersizliğinin tanısında/ihtimal dışı bırakılmasında ve prognozunda güçlü bir belirteçtir.1,2,3

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

COORDINATION Ali CANGULDESIGN Edibe COMAKTEKINPRESS YILDIRIM Printing House PRESS DATE December 2014CIRCULATION 1500

ISSN 1304-7361

VOLUME 14NUMBER 4DECEMBER 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

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





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

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

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

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

REVIEWSome Ethical Issues in Prehospital Emergency Medicine Erbay H

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Contents

Turkish Journal ofEmergency MedicineDECEMBER 2014

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.


Turk J Emerg Med 2014;14(4):147-152 doi: 10.5505/1304.7361.2014.74317

Submitted: June 08, 2014 Accepted: October 10, 2014 Published online: November 30, 2014

Correspondence: Dr. Marzieh Fathi. Emergency Department, Rasoul-e-akram Hospital, Niyayesh St, Sattarkhan Ave, Tehran, Iran.

e-mail: [email protected]

ORIGINAL ARTICLE

1Iran University of Medical Sciences, 2Shiraz University of Medical Sciences, Iran

Mohsen ABBASI,1 Mahmoudreza SAJJADI,1 Marzieh FATHI,2 Mohammadreza MAGHSOUDI1

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

Travmatik Beyin Hasarı olan Acil Servis Hastalarında Sonucu Öngörme Aracı Olarak Serum S100B Protein

SUMMARYObjectivesTraumatic brain injury is a common cause of death and disability world-wide. Early recognition of patients with brain cellular damage allows for early rehabilitation and patient outcome improvement.

MethodsIn this prospective study, the clinical conditions of patients with mild to moderate traumatic brain injury (TBI) were assessed, and patient serum S100B levels were measured. Patients were followed up one month later and evaluated for level of consciousness, presence or absence of post-traumatic headache, and daily activity performance (using the Barthel scale). Student’s t-test and the chi-square test were used for data analysis, which was performed using SPSS software.

ResultsThe mean serum S100B value was significantly lower for patients with minor TBI than for patients with moderate TBI (23.1±14.2 ng/dl and 134.0±245.0 ng/dl, respectively). Patients with normal CT scans also had statistically significantly lower serum S100B levels than patients with abnormal CT findings. The mean S100B value was statistically significantly higher for patients with suspected diffused axonal injury (632.18±516.1 ng/dl) than for patients with other abnormal CT find-ings (p=0.000): 24.97±22.9 ng/dl in patients with normal CT results; 41.56±25.7 ng/dl in patients with skull bone fracture; 57.38 ±28.9 ng/dl in patients with intracranial hemorrhage; and 76.23±38.3 ng/dl in patients with fracture plus intracranial hemorrhage).

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

Key words: Biomarker; head trauma; S100B protein; traumatic brain in-jury.

ÖZETAmaçTravmatik beyin travması dünya ölçeğinde olağan bir ölüm ve özürlülük nedenidir. Beyin hücre hasarı olan hastaların erkenden tanınması erkend-sen rehabilitasyon ve hasta sonuçlarında iyileşmeye olanak tanır.

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

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

SonuçHafif ve orta derecede TBH özellikle yaygın akson travması olanlarda se-rum S100B düzeyleri yükselmektedir. Ancak serum S100B değerleri 1 ay sonrasının nöropsikolojik sonuçları ve performansını doğru biçimde ön-görememektedir.

Anahtar sözcükler: Biyobelirteç; kafa travması; S100B proteini; travmatik be-yin hasarı.

147

IntroductionTraumatic brain injury (TBI) is a common cause of death and disability worldwide. TBI is a public health priority because it is associated with extensive physical, psychological and social impacts and a high economic burden.[1] Some studies have demonstrated that more than 10-40% of patients with TBI are still disabled 6-12 months after trauma, including those with mild TBI and unremarkable neuroimaging findings. Although early recognition and proper management of patients with TBI may result in better rehabilitation and substantial out-come improvement, assessing different cellular and clinical aspects and effects of TBI is still less than optimal.[2-4]

S100B, a calcium binding protein highly expressed in as-troglial cells of the brain and released in cerebrospinal fluid (CSF) and blood, can be measured by available immunoas-say kits. Different studies have evaluated S100B as a bio-marker for different brain injuries, such as stroke[5,6], bacte-rial meningitis[7], carbon monoxide poisoning[8] and TBI[9-12]. Some recent studies have also highlighted the complex re-lease pattern of S100B and its potential role in brain tissue repair processes[13-17]

This prospective study evaluates the diagnostic and prog-nostic roles of serum S100B protein in emergency depart-ment (ED) patients with minor to moderate TBI.

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

Participants

Patients at least 18 years old with a clinical diagnosis of acute mild to moderate TBI were enrolled. Patients with a history of isolated head trauma and Glasgow Coma Scale (GCS) score between 9 and 15 who presented in the ED within the first six hours of their head injury were considered to have mild to moderate TBI. All clinical assessments, including GCS calculations, were performed by a research assistant who was a physician. The research assistant was blinded to other assessments results.

Patients with the following were excluded: severe TBI (GCS≤8); hemodynamic instability; body temperature great-er than 38.5°C; concurrent trauma to any other organs; con-current primary and secondary brain injury, including refrac-tory severe hypoxia (arterial oxygen saturation <92% while receiving 100% oxygen), post-traumatic seizure, and skull

bone fracture; and any other identified or suspected dif-ferential diagnosis for the patient’s decreased level of con-sciousness, including alcohol abuse, drug abuse, substance abuse, drug toxicity, hypo/hyperglycemia, hypo/hypernatre-mia, endocrine disorder, or infection. Patients who did not undergo a head CT scan were also excluded.

Intervention

S100B assay: A blood sample was drawn from the peripheral veins within the first six hours of ED admission. The time of blood sample collection was recorded. Samples were centri-fuged, and the serum was refrigerated at -20°C until analyzed.

Neuroimaging: Ten millimeter thick slices obtained using a GE VCT Lightspeed 64 multi-slice detector were interpreted by a board certified radiologist and confirmed by another consultant radiologist who was blinded to the first inter-pretation. Both radiologists were blinded to the clinical conditions and S100B results of the patients. All pathologic findings, including skull bone fracture and any type of intra-cranial hemorrhage (e.g. brain contusion, subdural/epidural intracranial hematoma), were reported as positive comput-ed tomography findings.

Follow up: The patients were called by two blinded research assistant one month later. During follow-up, patients were evaluated for level of consciousness, presence or absence of post-traumatic headaches, and daily activity performance (using the Barthel scale) to determine if any significant in-tracranial complications had occurred (.i.e. complications requiring further neuroimaging).

Turk J Emerg Med 2014;14(4):147-152148

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

Subjects Assessed for Eligibility (n=187)

Included patients (n=109)

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

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

Measurements

Initial TBI severity was assessed using the GCS. Patients with GCS scores between 9 and 15 were considered to have mild to moderate TBI. To measure S100B serum levels, the human S100 ELISA kit (BioVendor - laboratorni medicina a.s., Brno, Czech Republic) was used. The lowest detection limit of the test is about 15 pg/ml. Serum S100B levels were measured in ng/dl.

The Barthel scale is an ordinal 10-variable scale used to mea-sure patient performance on daily activities and to predict the likelihood a patient will be able to live at home indepen-dently. The Barthel scale has high inter-rater and test re-test reliability, as well as, high correlations with other measures of physical disability. The ten Barthel scale variables are: presence/absence of fecal incontinence; presence/absence of urinary incontinence; and help needed with grooming, toilet use, feeding, transfers, walking, dressing, climbing stairs, and bathing. Each variable is given a score (between 0 and 3). These scores are summed to determine the total score (out of 20). The higher the Barthel score, the less as-sistance the patient is likely to need with daily activities after discharge from the hospital. For example, when a person can

perform about 50% of their daily tasks and activities inde-pendently, then their Barthel score will be 10 out of 20.[18-20] Patient outcome measures were level of consciousness, re-sidual headache, and Barthel score one month after trauma.

Data Analysis

The Student’s t-test was used to compare the mean values of quantitative variables, and the Chi square test was used to compare qualitative variables. All data analyses were per-formed with SPSS version 13.5 (SPSS, Inc., Chicago, IL).

ResultsOne hundred eighty-seven patients were assessed for eli-gibility, and 78 patients were excluded from the study: six patients had hemodynamic instability; 18 patients had concurrent trauma to other organs; 34 patients had concur-rent brain injuries; and 20 patients had other causes of de-creased level of consciousness. Venous blood samples were obtained from 109 patients with minor to moderate TBI who had undergone CT as a part of their routine diagnostic eval-uations. Eleven samples were wasted due to various errors between initial preparation and analysis. A total of 98 pa-tients with mild to moderate TBI and available serum S100B results were followed. During the telephone follow-up one month post-trauma, six patients refused to continue partici-pating in the study, and two additional cases were unreach-able by telephone. Follow-up interviews were performed for 90 patients, all of whom completed the study. No patients had died in the month between injury and follow-up, and all patients had GCS scores of 15.

The mean age of the study participants was 33.1±10.3 years (95% CI: 29.99-34.28) and ranged from 18 to 50 years old. Other basic characteristics of the patients are shown in Ta-ble1. In the present study, 38 (80.9%) of the minor TBI pa-tients and 6 (14.0%) of the moderate TBI patients had normal CT results. Suspected diffused axonal injury (DAI) was not seen in the minor TBI patients, but 5 (11.6%) of the moder-ate TBI patients had suspected DAI. GCS scores were signifi-cantly different between the patients with normal CT results and the patients with abnormal CT findings (p=0.000). The mean serum S100B value was 23.1±14.2 ng/dl (95% CI: 17.4-27.3) in patients with minor TBI and 134.0±245.0 ng/dl (95% CI 51.1-179.6) in patients with moderate TBI. Student’s t-test demonstrated that the difference was statistically significant (p=0.003). The mean serum S100B value was statistically sig-nificantly higher in patients with suspected DAI compared to patients with other abnormal CT findings (p=0.000). Se-rum S100B results are summarized in Table 2.

Initial GCS scores, CT findings, headache, and Barthel scores of patients with Barthel scores ≤18 and with the highest

Fathi M et al. Serum S100B Protein as an Outcome Prediction Tool in ED Patients with Traumatic Brain Injury 149

Table 1. Basic characteristics of study participants

Variable n %Sex

Male 80 88.9

Female 10 11.1

Initial GCS

15 40 44.4

14 7 7.8

13 13 14.4

12 19 21.1

11 6 6.7

10 5 5.6

Mechanism of injury

Auto-Pedestrian 36 40.0

MVC 23 25.6

Falling 16 17.8

Direct trauma 9 10.0

Others 6 6.7

CT findings

Normal 44 48.9

DAI 5 5.6

ICH 10 11.1

Fx 10 11.1

Fx+ICH 21 23.3

S100B levels are shown in Table 3. At one-month follow-up, 3 (3.3%) patients had Barthel scores less than 18, 12 (13.4%) had Barthel scores of 18 or 19, and 75 (83.3%) had Barthel scores of 20. The mean serum S100B value was 206.43±316.0 ng/dl (95% CI: 49.3-163.4) in patients with Barthel scores less than 18 (range: 68-1047 ng/dl). Patients with Barthel scores of 18 and 19 had a mean serum S100B level of 88.20±46.5 ng/dl (95% CI: 24.8-407.8, range: 48-175 ng/dl). The mean serum S100B level was 59.51±156.9 ng/dl (95% CI: 18.6-99.6) for patients with Barthel scores of 20 (range: 68-1047 ng/dl). Serum S100B levels were higher in patients with lower Bar-thel scores, but the difference was not statistically significant (p=0.06).

Thirty-eight (42.2%) patients had residual headaches one month after TBI. The mean serum S100B level was 87.03±163.2 ng/dl (95% CI: 26.5-150.6) in patients with residual headaches, and 68.13±188.5 ng/dl (95% CI: 11.3-127.8) in patients without headaches; the difference was not statistically significant (p=0.59).

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

The present study found that although serum S100B increas-

es in minor to moderate traumatic brain injuries (especially in cases of DAI), it cannot accurately predict one-month out-comes. These results are compatible with some other stud-ies which have emphasized the complicated release pattern of S100B. These past studies have highlighted the role of blood-brain barrier integrity and disruption in S100B release into the serum, the poor correlation between serum and CSF S100B levels, and the possible reparative roles of S100B that may improve outcomes in patients with acute brain injuries. These studies also mention that the relationship between S100B values and likely outcomes in patients with TBI is not necessarily a causative relationship.[27]

A study of a large cohort of patients showed some associa-tion between high serum S100B level and poor outcome in patients with brain injury, but not significant enough to support use as an outcome prediction tool.[28] Similarly, a re-view by Townend showed that, although patients with high serum S100B levels at initial evaluation may be at higher risk for disability after TBI, no association between serum S100B levels and the neuro-psychological performance of injured patients has been established.[2] Metting et al. studied 94 pa-tients with mild TBI and demonstrated that S100B is not re-lated to outcome or imaging results.[29] Some newer studies have proposed that serum S100B level might be used for pre-dicting the probability of brain death in patients with TBI.[30]

Conclusion

The current study showed that serum S100B levels increase with minor to moderate TBIs, especially in patients with sus-pected DAI. However, serum S100B cannot accurately pre-dict one-month neuropsychological outcomes and perfor-mance.

Limitations

The present study has some limitations. The study was con-ducted at two teaching hospitals, and the human S-100 ELISA kits may not be available at other smaller hospitals. Only patients who had undergone brain CT were enrolled;

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

Table 2. Serum S100B levels in patients with different CT results

CT Findings Mean±SD* (ng/dl) 95% Confidence Interval Skull Fracture 41.56±25.7 22.1-58.9

ICH† 5.38±28.9 28.9

Skull Fracture plus ICH 76.23±38.3 57.7-92.7

DAI†† 632.18±516.1 -9.7-1272.0

Abnormal 125.0±238.5 53.1-194.8

Normal 24.9±22.9 16.9-30.9

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

patients who had not undergone CT or who refused to un-dergo neuroimaging were not included. The sample size was small, and similar studies with larger sample sizes would be preferable. The study did not focus on any cutoff S100B level to categorize at-risk patients, though it might be helpful to determine a cutoff diagnostic serum S100B value.

Conflict of Interest

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

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4. Pickering A, Grundy K, Clarke A, Townend W. A cohort study of outcomes following head injury among children and young adults in full-time education. Emerg Med J 2012;29:451-4.

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7. Hamed SA, Hamed EA, Abdella MM. Septic encephalopathy: relationship to serum and cerebrospinal fluid levels of adhe-sion molecules, lipid peroxides and S-100B protein. Neurope-diatrics 2009;40:66-72.

8. Ide T, Kamijo Y, Ide A, Yoshimura K, Nishikawa T, Soma K, Mo-chizuki H. Elevated S100B level in cerebrospinal fluid could predict poor outcome of carbon monoxide poisoning. Am J Emerg Med 2012;30:222-5.

9. Nylén K, Ost M, Csajbok LZ, Nilsson I, Hall C, Blennow K, Nell-gård B, et al. Serum levels of S100B, S100A1B and S100BB are all related to outcome after severe traumatic brain injury. Acta Neurochir (Wien) 2008;150:221-7.

10. Savola O, Pyhtinen J, Leino TK, Siitonen S, Niemelä O, Hillbom M. Effects of head and extracranial injuries on serum protein S100B levels in trauma patients. J Trauma 2004;56:1229-34.

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12. Wiesmann M, Steinmeier E, Magerkurth O, Linn J, Gottmann D, Missler U. Outcome prediction in traumatic brain injury: comparison of neurological status, CT findings, and blood levels of S100B and GFAP. Acta Neurol Scand 2010;121:178-85.

13. Kleindienst A, Ross Bullock M. A critical analysis of the role of the neurotrophic protein S100B in acute brain injury. J Neu-rotrauma 2006;23:1185-200.

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Submitted: April 11, 2014 Accepted: September 23, 2014 Published online: November 30, 2014

Correspondence: Dr. Sonay Goktas. Maltepe Universitesi Marmara Egitim Koyu Hemsirelik Yuksek Okulu, İstanbul, Turkey.


ORIGINAL ARTICLE

1Maltepe University School of Nursing, Istanbul;2Halic University School of Nursing, Istanbul;

3Istanbul Sisli Vocational School, Istanbul

Sonay GOKTAS,1 Gulay YILDIRIM,2 Selmin KOSE,2 Senay YILDIRIM,3 Fatma OZHAN,2 Leman SENTURAN2

First Aid Knowledge of University Students in Poisoning Cases

Üniversite Öğrencilerinin Zehirlenme Vakalarındaki İlkyardım Bilgileri

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

Methods

The research was conducted between the dates of May 2013 -June 2013 with the permission gained from the University Rectorship. The cohort of the research contained 4,560 students who received education in Is-tanbul. The sample of the study included 936 students who accepted to participate in the research and attended the school during the research. The data were collected by using a questionnaire form, which had 21 questions prepared by researchers. Analysis of the data was carried out with a percentage evaluation method and chi square tests in a computer environment.

Results

In our study, 92.6% of students (n=867) knew the phone number of the ambulance in case of emergency. In addition, 57.3% of students (n=536) knew the phone number of the poison hotline, and it was seen that they answered correctly the questions regarding the relation be-tween body system and indications of poisoning. It was determined that the students who received education in medical departments an-swered the questions correctly more than the students who had edu-cation in other departments. (p<0.001, p<0.01).

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

Key words: First aid; poisoning; university student.

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

Gereç ve YöntemAraştırma Mayıs 2013–Haziran 2013 tarihleri arasında, özel bir vakıf üni-versitesinde, üniversite rektörlüğünden gerekli izin alınarak gerçekleştiril-di. Evrenini üniversitede okuyan 4560 öğrenci, örneklemi ise çalışmanın yapıldığı günlerde okula devam eden ve araştırmaya katılmayı kabul eden 936 öğrenci oluşturdu. Veriler araştırmacılar tarafından hazırlanan 21 so-ruluk anket formu kullanılarak toplandı. Verilerin analizi bilgisayar orta-mında yüzdelik değerlendirme yöntemi ve ki-kare testi kullanılarak yapıldı.

BulgularÇalışmamızda öğrencilerin %92.6’sının (n=867) acil durumda aranması gereken ambulans numarasını ve %57.3’ünün (n=536) zehir danışma hat-tı numarasını bildikleri ve zehirlenmelerde ortaya çıkan belirtiler ile vücut sistemleri arasındaki ilişkiyi soran sorulara doğru olarak cevap verdikleri belirlendi. Sağlık bölümlerinde okuyan öğrencilerin zehirlenme belirtileri ve sindirim ile solunum yolu zehirlenmelerinde yapılacak olan ilkyardım girişimleri ile ilgili bilgi sorularına diğer bölümlerde okuyan öğrencilere göre daha fazla doğru cevap verdikleri saptandı (p<0.001, p<0.01).

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

Anahtar sözcükler: İlkyardım; üniversite öğrencisi; zehirlenme.

153

IntroductionPoisoning is a clinical state that occurs as a result of the hu-man body being exposed to toxic substance(s). Exposure can include respiration, circulation, ingestion, or skin con-tact. Poisoning is defined with various indicators that arise in the digestive, respiration, and nervous systems and adhere to the factor causing it.[1] It is possible that poisoning occurs as a result of different factors. Acute poisoning which is of-ten seen in the emergency services generally develops from consuming spoiled foods, animal bites, and in attempts of suicide. In addition, chronic poisoning can come from the accumulation of chemicals within air, water, and foods with-in human body in the course of time.[2]

The factors that contribute to poisoning differ in regard to geographical region, seasons, level of development, age group, and level of socio-cultural status.[3] In developing countries where agricultural activities are dominant, poi-soning caused by insects and pesticides is more common. However, in developed countries poisoning from suicide is observed at a higher rate.[2,4,5,6] By carrying out the general evaluation, pathogens that cause poisoning predominantly get into the body through the digestive system. Chemical substances that are used at home or in the garden, such as toadstools, spoiled foods, medicine, and excessive alcohol use can cause the poisoning to occur through the digestive system.[2,7]

Early intervention is crucial for an effective treatment of

acute poisoning. As in all emergency cases, every lost mo-ment would be a disadvantage for the patient according to poisoning facts. To prevent the delays, the support can be received from “The National Poisoning Information Center,” which provides service 7 days and 24 hours. Detrimental ef-fects can be prevented by the use early decontamination attempts and proper antidotes.[8] Therefore, community-re-siding persons should have basic information about first-aid to the prevent and minimize unnecessary deaths. First-aid courses are provided at schools and driving courses in our country. However, there are not enough studies to reveal whether proper first-aid awareness has been developed in the society.

This study was conducted to evaluate the information of university students regarding poisoning cases. The students’ knowledge was determined based on first-aid applications in which the university students were involved in the poi-soning cases. This study helped to determine which sub-jects were needed to increase student awareness on first aid and proper poison training.

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

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

Turk J Emerg Med 2014;14(4):153-159154

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

Characteristic n %

Gender

Female 634 67.7

Male 302 32.3

Department

Medical department 481 51.4

Other departments of the university 455 48.6

Grade

1st Grade 269 28.7

2nd Grade 265 28.3

3rd Grade 255 27.2

4th Grade 147 15.7

With family 585 62.5

Living in where/with whom

Alone 77 8.2

In dorm 132 14.1

With friend 142 15.2

training period, etc.), the research was conducted with 936 students receiving education and who were accepted to participate in the study at that time. Introductory characte-ristics of students who participated into the study were dec-lared in Table 1. Moreover, the distribution of given answers to the questions regarding poisoning was shown in Table 2.

Students who were receiving education at health depart-ments had more correct answers than the students who were studying at other departments (respectively p<0.001, p<0.01) for the questions which analyzed the relations-hip between indications and ways of poisoning and body systems. Of the students who answered correctly about

first-aid attempt in the case of digestive and respiration po-isoning, it was determined that the number of the students who were studying at medical departments were more than the number of students at other departments (p<0.001). Furthermore, it was observed that students who knew the phone number of the poison hotline were mostly studying at health departments (p<0.001) (Table 3).

When the number of students who knew digestive system indications and the first–aid attempts required for poisoning through the digestive system were compared, it was shown that the number of students that received first-aid educati-on was significantly different than number of students who

Goktas S et al. First Aid Knowledge of University Students in Poisoning Cases 155

Table 2. Distribution of number to call in case of poisoning, poisoning indication, and first aid attempts (n=936)

Questions about poisoning Answer n %

Status of Having First aid Education Yes 394 42.1

Knowing Related Phone Numbers

In case of emergency,

what is the phone number for ambulance? Correct 867 92.6

What is the phone number of poisoning hotline? Correct 536 57.3

Poisoning Indications

Which system disfunction do the

indications such as Loss of

consciousness, convulsion, sense of

sickness, inconsistency of motion seen

on poisoning cases show? Correct 507 54.2

Which ways do toxic substances such

as insect sting and animal bites poison? Correct 869 92.8

Which way was the patient who has complaints

of nausea, vomitting, diarrhea poisoned? Correct 804 85.9

What kind of poisoning has indications such

as empurpling of lips and labored breathing? Correct 698 74.6

Do you have information regarding

first aid provided in poisoning? Yes 457 48.8

First-aid Attempts

How should first aid in poisoning

by the way of digestive system be? Correct 223 23.8


by the way of respiratory tract be? Correct 735 78.5

How should first aid in necton stinging be? Correct 340 36.3

How should first aid in scorpion and snake stinging be? Correct 159 17.0

Status of encountering poisoning before Yes 269 28.7

Season when poisoning occured* (n=269) Summer 110 40.9

Which way did poisoning occur?* (n=269) Digestive 224 83.6

* Answers of people answered “Yes” only

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

DiscussionPoisoning is an important community health problem, which constitutes an important portion of emergency ser-vice applications. It requires a serious approach with truth-ful answers to first-aid applications which are done properly and on time. At the present time, the success of the treat-ment can be increased by enhancing awareness and protec-tive measures regarding the issue. In the case of poisoning, proper first-aid is lifesaving, and it is an application which should be provided by all individuals regardless of medical studies. [7,9,10]

In our research, it was observed that 92.6% of the students answered correctly to the phone number for the ambulance

service in case of emergency. This pleasing result showed that the Ministry of Health 112 ambulance service was well-known and adopted in our country. Ministry of Health may be the reason that the number of 112 ambulance stations was increased, easily reachable, more satisfactory, and well-known in our country. It can also be said that the number of individuals who received first-aid education may play a role.[11] It is a known reality that the press has the power of influ-ence regarding that.[12] Another reason of this result can be that 112 ambulances were seen on the news of accident and injury events by the participants.

It was determined that most of the students answered cor-rectly to the question of the relation between indications observed for poisoning and the body system (Table 2). It is crucial to know indications that give clues about of the kind of poisoning and convey the information to the medical per-

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

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

Poisoning indications and first-aid attempts Medical department Other departments p (n=481) (n=455) Correct Correct of universities

Poisoning indications

Which system dysfunction do the

indications such as Loss of consciousness

convulsion, sense of sickness, inconsistency

of motion seen on poisoning cases show? 306 201 <0.001

Which ways do toxic substances such as

insect sting and animal bites poison? 457 412 <0.01

Which way was the patient who has complaints

of nausea, vomiting, diarrhea poisoned? 434 370 <0.001

What kind of poisoning has indications such as

empurpling of lips and labored breathing? 392 306 <0.001

First-aid attempts

How should the first-aid on poisoning

via digestive system be provided? 161 62 <0.001


by the way of respiratory tract be? 405 330 <0.001

How should first aid for insect

stinging be administered? 188 152 p>0.05

How should first aid in scorpion

and snake stinging be administered? 83 76 p>0.05

Which is the phone number

of poisoning hotline? 385 209 <0.001

sonnel for the success of the first-aid and treatment at the hospital.

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

that the least known first-aid subject was animal bites and insect stings.[16] In addition, Dinçer et al. drew attention to the study on pre-school educators, which showed that most of the educators performed the application wrongly for the first-aid for insect bites and stings.[17] It can be reasoned that animal bites and insect stings are rarely seen in our country.

In our study, it was determined that poisoning cases were seen by students in the summer time (40.9 %), and most of them occurred through ingestion (Table 2). In the litera-ture, there are studies conducted in Turkey that show poi-soning cases mostly occurred in summer time and most of them were caused by ingestion.[18-23] The finding of poison

157Goktas S et al. First Aid Knowledge of University Students in Poisoning Cases

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

Poisoning indications Students who received Students who did not receive pand first-aid attempts first-aid education* first-aid education (n=394) (n=542) Correct Correct

Poisoning indications

Which system dysfunction does

the indications such as

Loss of consciousness,

convulsion, sense of sickness,

inconsistency of motion seen

on poisoning cases show? 216 291 >0.05

Which ways do toxic substances

such as insect sting and

animal bites poison? 369 500 >0.05

Which way was the patient who

has complaints of nausea,

vomiting, diarrhea poisoned? 352 452 <0.05

What kind of poisoning has

indications such as empurpling

of lips and labored breathing? 301 397 >0.05

First-aid Attempts

How should the first-aid

on poisoning via digestive

system be provided? 108 115 <0.05

How should first aid in

poisoning by the way of

respiratory tract be? 318 417 >0.05

How should first aid in insect stinging be? 149 191 >0.05

How should first aid in scorpion

and snake stinging be? 70 89 >0.05

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

rates are higher in the summer time seems related to the increased temperatures and foods that are easily spoiled in those temperatures. However, a lot of poisoning cases caused ingestion were seen by students, and they could not answer correctly regarding the first-aid applications.

In the study, it was observed that the students who were receiving education at medical departments partially knew, and the students who were studying at other departments did not have sufficient knowledge regarding poisoning indi-cations and first-aid efforts (Table 3). This result is dependent on medical departments and medical units that have a first-aid course. Özçelikay and colleagues determined that stu-dents who did not take the first-aid course at the university did not have enough knowledge about first-aid in the study conducted.[24] The study which was conducted by Savaşer determined that first aid information points of medical per-sonnel except doctors were higher than high school teach-ers had and it shows parallelism with our study.[25] In our study, 80% of medical students knew the phone number of the Poison Hotline. However, only 46% of students at other departments knew the number (Table3).

The significant difference for first-aid knowledge regarding only the digestive system was determined between stu-dents who received first-aid education and students did not receive the education. However, although it is not statistical-ly meaningful, the right answers of students who received education were above the expectation. On the other hand, the answers of students who did not receive education were under the expectation (Table 4). The reason for this state is believed to be associated with students who took first-aid courses from some institutes and foundations. However, it often falls short because these courses have not been con-tinuous and updated.[26] Adding first-aid courses into cur-riculum of all university departments as an elective course, and inclining students to choose this course, would provide increased awareness about first-aid knowledge and skills.

Limitations

The results of the study are limited with the students of the university where the research was conducted. It cannot be generalized to all university students.

Conclusion

As a result of the study, it was determined that university students who were studying at medical departments had more knowledge regarding first-aid as compared to the stu-dents who were studying at other departments. We propose that adding first-aid courses to curriculum at universities can increase the students’ knowledge on both poisoning and subjects that require first-aid.

Conflict Interest

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

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15. Duman NB, Koçak C, Sözen C. Üniversite öğrencilerinin ilk yardım bilgidüzeylerive bunu etkileyen faktörler. Hitit Üni-versitesi Sosyal Bilimler Enstitüsü Dergisi 2013;6:57-70.

16. Dereli F, Turasay N, Özçelik H. Muğla iki no’lu sağlık ocağı böl-gesinde yaşayan 0-6 yaş çocuğu olan annelerin ilkyardım ko-nusundaki bilgi düzeylerinin belirlenmesi. TAF Prev Med Bull

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18. Sunay YM, Faruk Oİ. Okul öncesi dönem zehirlenme olgularının değerlendirilmesi. Adli Tıp Dergisi 2003;17:22-7.

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21. Sönmez E, Karakuş A, Çavuş UY, Civelek C, İpek G, Zeren C. Bir üniversite hastanesi acil servisine başvuran zehirlenme olgularının değerlendirilmesi. Dicle Tıp Dergisi 2012;39:21-6.

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24. Özçelikay G, Şimşek I, Asil E. Üniversite öğrencilerinin ilkyardım konusundaki bilgi düzeyleri üzerine bir çalışma. A. Ü. Eczacılık Fak Der 1996;25:43-8

25. Savaşer, F. Çankırı ilinde görev yapan hekim dışı sağlık per-soneli ile lise öğretmenlerinin ilk yardım konusunda bilgi düzeylerinin karşılaştırılması Ankara Üniversitesi, Sağlık Bil-imleri Enstitüsü, Ankara 2001.

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159Goktas S et al. First Aid Knowledge of University Students in Poisoning Cases


Submitted: January 15, 2014 Accepted: March 20, 2014 Published online: November 30, 2014

Correspondence: Dr. Fatma Sarı Doğan. İstanbul Goztepe Egitim ve Arastirma Hastanesi,Fahrettin Kerim Gokay Cad., Kadikoy, İstanbul, Turkey.


160 ORIGINAL ARTICLE

1Department of Emergency Clinic, Medeniyet University Goztepe Training and Research Hospital, Istanbul;2Department of Emergency Servicis, Van Training and Research Hospital, Van

Fatma SARI DOGAN,1 Vehbi OZAYDIN,1 Behcet VARISLI,2 Onur INCEALTIN,1 Zeynep OZKOK1

The Analysis of Poisoning Cases Presented tothe Emergency Department within a One-Year Period

Acil Servise Başvuran Bir Yıllık Zehirlenme Olgularının Analizi

SUMMARYObjectivesIntoxication is the emergence of unwanted signs and symptoms in an organism after exposure to potentially harmful chemical, physi-cal or organic materials. In our study, we evaluated demographic and etiological factors of adult patients admitted to the emergency depart-ment with suicidal or accidental poisoning.

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

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

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

Key words: Emergency services; poisoning; suicide.

ÖZETAmaçZehirlenme potansiyel olarak zarar verebilen herhangi bir kimyasal, fizik-sel veya organik maddeye maruziyet sonrası organizmada bazı istenme-yen belirti ve bulguların ortaya çıkmasıdır. Biz bu çalışmamızda intihar amaçlı veya kazara zehirlenme nedeniyle acil servisimize başvuran erişkin hastaların demografik ve etiyolojik faktörlerini araştırdık.

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

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

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

Anahtar sözcükler: Acil servis; zehirlenme, intihar.

IntroductionIntoxication is the emergence of unwanted signs and symp-toms in an organism after exposure to potentially harmful chemical, physical or organic materials.[1,2] The poisoning can be unintentional (accidental) or intentional (suicide). Early diagnosis, identification of substance that caused intoxica-tion and early treatment are important for good prognosis.

Poisoning cases can vary according to type of exposed poi-sonous substances, method of poisoning, demographic characteristics of the country and even regions within the same country. In this study we aimed to contribute to the literature by determining the demographic and etiologic features of patients admitted to our emergency department with poisoning in a 1-year period.

Materials and Methods All patients over the age of 14 years that were admitted to Goztepe Training and Research Hospital Adult Emergency Department due to acute poisoning within a one-year pe-riod (between 01.09.2011 and 01.09.2012) were included in the study. Children under the age of 14 are not assessed in the adult emergency department and therefore were ex-cluded from the study. The data was obtained and recorded by retrospectively analyzing protocol and forensic books.

Goztepe Training and Research Hospital Research Assess-ment Commission approved our study (decree # 22/e from 17/05/2012). Patients’ age, gender, chronic diseases, diag-nosed psychiatric conditions, previous suicide attempts, causes of poisoning, the time of admission after the medi-cation intake, the reason for medication intake, examina-tion findings, follow-up time, admission time (in terms of months), discharge from emergency department or hospi-talization status were investigated.

The SPSS (Statistical Package for Social Science) 17.0 pro-gram was used for statistical analyses. Descriptive statistical methods (mean, standard deviation, frequency, percentage) were used for evaluation of the data. The 95% confidence interval and p-value <0.05 were considered statistically sig-nificant.

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

patients was 25.15±9.56 years, while that of male patients was 31.39±4.14 years. The mean age of poisoned patients was 27.4±11.75 years (minimum 14, maximum 90). The age and gender distribution of poisoned patients is given in Table 1.

The causes of poisoning included the following: 348 pa-tients (80.93%) due to medication, 39 patients (9.06%) from alcohol and medication, 37 patients (8.6%) ingested roden-ticides, 4 patients (0.93%) took a caustic substance and 2 patients (0.46%) consumed organophosphates (Figure 1). Among the patients that were poisoned due to medication intake, 106 patients (24.7%) took multiple medications, 102 patients (23.7%) took antidepressants, 66 patients (15.3%) took non-steroidal analgesics, 24 patients (5.6%) took ace-tylsalicylic medicine, 19 patients (4.4%) took antibiotics, 8 patients (1.9%) took antiepileptics and 23 patients (5.34%) used other medications.

According to the statistical evaluation of poisoning causes, medication related poisoning was significantly more com-mon than any other reason (p<0.05). There was no signifi-cant difference in terms of causes of poisoning between male and female patients (p=0.062).

We also determined that among our patients, 293 (91.2%) did not have continuous medication use, while 38 patients (8.8%) used at least one medication continuously. In addi-tion, 36 out of 430 patients (8.4%) had a chronic disease,

Sari Dogan F et al. The Analysis of Poisoning Cases Presented to the Emergency Department within a One-Year Period 161

Table 1. Distribution according to age and gender

n (%)

Gender

Women 278 (64.7)

Men 152 (35.3)

Age (Mean±SD) 27.4±11.75 Min./Max.: 14/90

Figure 1. Distribution according to the reason for poisoning.

90.00

0

Drug Alcohol Rodenticide Caustic substance Organophosphate

80.93

9.06 8.6

0.93 0.46

while 394 patients (91.6%) did not have any chronic disease.

When we investigated whether poisoning cases in our study were diagnosed with psychiatric illnesses we determined that 372 patients (86.5%) did not have any psychiatric illness, while 58 patients (13.5%) were diagnosed with a psychiat-ric illness. We also determined that 115 out of 430 patients (26.7%) had previously attempted suicide.

Investigation of the time passed between poison intake and emergency department application showed that 237 pa-tients (55.1%) applied to the hospital within the first three hours after intake of the poisoning substance, while for 41 patients (9.5%) it took 3-6 hours, and for 55 patients (12.8%) it took more than 6 hours. We could not obtain information about the time passed between poison intake and emer-gency department application for 97 patients (22.6%).

Three hundred and seventy nine of the acute poisoning pa-tients (88.1%) poisoned themselves as an attempt of suicide, while 51 patients (11.9%) were poisoned accidentally.

The admission examinations of poisoning cases deter-mined that physical examination was normal in 373 patients (86.7%) and neurological examination was normal in 371 patients (86.1%). Moreover, the requested laboratory tests were normal for 390 patients (90.7%).

Nine out of 430 patients (2.09%) were intubated in the emer-gency department. Six of the intubated patients were poi-soned as a result of multiple medication intake, while 3 of them were poisoned due to antidepressant intake. The time between the poison intake and hospital admission was over 6 hours.

While 204 out of 430 patients (47.4%) were discharged from the emergency department, 226 patients (52.6%) were hos-pitalized for treatment and follow up. Evaluation of the fol-low-up time at the emergency room showed that 81 out of 430 patients (18%) were followed for 0-6 hours, 32 patients (7.4%) for 6-12 hours, 22 patients (5.1%) for 12-24 hours and 187 patients (43.5%) for followed for more than 24 hours. We

couldn’t reach the information regarding the follow-up time of 108 patients (25.1%).

The distribution of emergency department admittance due to poisoning in terms of months is shown in Figure 2. The highest admittance rate was detected in July followed by August and September. When the admittance frequency was evaluated in terms of seasons, summer had the high-est frequency of emergency department admittance due to poisoning with 35.6%, followed by autumn (29.1%), spring (19.8%) and winter (15.6%). The frequency of emergency department admittance due to poisoning was significantly higher in summer (p=0.000).

There was no significant difference in terms of causes of poi-soning between the seasons (p=0.310).

DiscussionAlthough poisoning cases constitute only 1-2% of all emer-gency cases, such cases are important because they require early intervention and respond well to treatment. According to data from poison control centers 2.3 million cases of poi-soning were recorded in the United States in 2011. Among those cases 26.4% had to be treated in a health care institu-tion, while 7.1% required hospitalization. The mortality rate among all cases was 5%.[3]

In Turkey, the number of poisoning cases constitute 0.46-1.78% of all cases admitted to the emergency department.[4-7] However, Yağan et al. reported this rate to be higher, at 2.43%.[8] The percentage of poisoning cases among all emer-gency department cases varies form 1 to 3% in different countries.[4,5] In our study, this percentage was found to be 0.77% and therefore was consistent with the literature.

The poisoning can be accidental or intentional (suicide). Ac-cidental poisoning is more common in children and usually involves corrosive substances,[4,9] while suicidal poisoning is more common in the adult group and is usually associated with medication intake.[4,7,9-11] In our study, the most com-mon cause of poisoning was also medication poisoning, fol-lowed by intoxication due to alcohol, and rodenticides, re-spectively. Zeren et al. also found similar results and reported that medication related poisoning and multiple medication intake were the most common causes of poisoning.[10] When we compared the types of medications taken the most com-mon was multiple medication intake, followed by antide-pressants, non-steroidal analgesics and acetylsalicylic acid, respectively. Similar results are available in the literature.[6,7,9] The easy access to analgesic drugs in some cases may lead to misuse of these drugs. In addition, the psychological status of patients using antidepressants may not be stable, making it easier for them to attempt suicide by means of these drugs.

Turk J Emerg Med 2014;14(4):160-164162

Figure 2. Distribution according to months.

0000000000

January

February

March AprilMay

June

July

August

September

October

November

December

According to the protocol of our hospital, patients over the age of 14 who are admitted to the hospital with poisoning are treated in the adult emergency department. Among 430 patients evaluated in our study 63 patients (14.65%) were between the ages of 14 (included) and 18 years. When these patients were evaluated in terms of causes of poisoning, 52 had been poisoned due to multiple medication intake, 5 due to intake of a caustic substance, 3 due to alcohol and 3 due to rodenticide intake. The assessment of patients over the age of 18 showed that the poisoning causes did not change and the most common cause of poisoning was multiple medication intake followed by caustic substance, alcohol and rodenticide intake.

The female/male ratio of poisoning cases has been reported to range from 1.12 - 3 and therefore, poisoning was reported to be more common in females.[5,7,9-13] In our study we deter-mined the female/male ratio to be 1.82/1 and women had a significantly higher poisoning rate (p<0.05).

The mean age of female patients was 25.15±9.56 years, while that of males was 31.39±4.14 years. These results were consistent with previous studies conducted in our country.[5,8,10-12] According to these results, young age and female gender can be considered as risk factors for accidental and or intentional poisoning.

In the literature, the rate of hospitalization ranges from 5.1% to 84%.[4,5,7,10,11,13] We think that this percentage shows varia-tion due to multiple factors such as the hospital in which the study was carried out being a reference hospital in that area, hospitalization of patients with bad symptoms or the patient being transferred from a different institution. In our study the hospitalization rate was 52.6% and we suggest that it might be because of our hospital being a level-three hospital and the presence of intensive care unit as well as dialysis facilities in our institution.

Karcıoğlu et al. reported that 50% of their cases were ad-mitted to the emergency room within first 2 hours of the poisoning,[5] while Akın et al. reported this rate as 57.6%.[11] Similarly, in our study 55.1% of patients were admitted to the hospital within the first 3 hours after the poisoning incident. In 9 patients that required intubation during their treatment process the time elapsed between the poisoning and hospital admission was found to be over 6 hours. The initial step in the general approach in cases with intoxication is stabilization of unstable patients (as it is for all unstable patients). Then, the support therapy specific for the poison-ing case is initiated. The decontamination process can be used to reduce the local and systemic effects of the poison-ous material.[14] Delayed application to the hospital after poisoning causes delayed decontamination and treatment and therefore we think that this delay might be the one of

the reasons for requirement of intubation to ensure patient stabilization.

In earlier studies the mortality rate was reported to range from 0-2.5%.[6,8-10,12] During the period of our study there were no deaths due to poisoning. After the poisoning took place the patients were rushed to the hospital and were treated at an early stage. Therefore, we suggest that early diagno-sis and treatment may have prevented mortality. However, since the majority of mortality cases are usually recorded as having suffered from cardiopulmonary arrest and because our study was retrospective we were not able to obtain the patients’ long-term survival information and therefore might not have detected cases of mortality.

Poisoning cases were admitted at various times. Zeren et al. reported that December was the month with the most frequent admissions due to poisoning,[10] whereas Sonmez et al reported that admittance due to poisoning was most frequently observed in winter and least frequently observed in fall.[12] On the other hand, Köse et al. indicated that March, April and October were the months with the highest num-ber of suicide attempts.[15] In our study, the most frequent admission to the hospital due to poisoning was seen in sum-mer and in the month of July. Carbon monoxide poisoning is more common during the winter months because of intense usage of stoves for heating.[16] Deniz et al. reported that fun-gi poisoning was more frequent in October and during the winter months,[7] which was similar to the report by Ecevit et al., who also determined winter months to be the most frequent time for fungi poisoning.[17] Our study does not contain carbon monoxide and fungi poisoning, which might be the reason for why in our study the poisoning rates were lower in winter months.

Limitations of the study: Since our study was conducted retrospectively we collected data from forensic notes and protocols and patient files and patients whose data was missing was excluded from the study. Moreover, carbon monoxide and fungi poisoning data were also missing and therefore such cases were not included in the study. In ad-dition, the patients who were admitted to the emergency room with cardiopulmonary arrest, but whose medication intake was uncertain were also excluded from the study.

Conclusion

The results of our study were similar to previous studies con-ducted in Turkey. The poisoning cases were more common in women and medication intake was the most common cause of poisoning. By making it more difficult to acquire non-prescription medications and carrying out social inves-tigations to raise awareness of intoxication, especially for the indicated risk groups can contribute to a reduction in poi-

Sari Dogan F et al. The Analysis of Poisoning Cases Presented to the Emergency Department within a One-Year Period 163

soning cases. The first place where these cases are admitted is the emergency room and the patients’ early diagnosis and treatment can lead to recovery without any consequences. We believed that emergency department physicians that are performing a differential diagnosis on patients should keep the possibility of poisoning in their mind. Unlike previ-ously reported studies, in our study we found that summer is the most common time for poisonings. Poisoning cases vary by region and we believe that conducting multicenter studies in order to develop national policies would be useful to combat poisoning.



References

1. Salihoğlu G. Zehirlenme epidemiyolojisi. In: Satar S, editor. Acilde klinik toksikoloji. Adana: Nobel; 2009. p. 19-38.

2. Beers MH, Berkow R, editors. The Merck manual of diagnosis and therapy. 17th ed. Merck Research Laboratories, New Jer-sey 1999. p. 2619.

3. Rhyee SH. General approach to drug poisoning in adults. Available at: http://www.uptodate.com Accessed October 5, 2013.

4. Çetin NG, Beydilli H, Tomruk O. Retrospective evaluation poi-soning patients in emergency department. [Article in Turk-ish] SDÜ Tıp Fakültesi Dergisi 2004;11:7-9.

5. Karcıoğlu Ö, Ayrık C, Tomruk Ö, Topaçoğlu H, Keleş A. Acil serviste yetişkin zehirlenme olgularının geriye dönük analizi. O.M.Ü. Tıp Dergisi 2000;17:156-62.

6. Kurt İ, Erpek G, Kurt MN, Gürel A. Adnan Menderes Üniversi-tesinde izlenen zehirlenme olguları. ADÜ Tıp Fakültesi Dergisi 2004;5:37-40.

7. Deniz T, Kandiş H, Saygun M, Büyükkoçak Ü, Ülger H, Karakuş A. Evaluation of intoxication cases applied to Emergency De-partment of Kirikkale University Hospital. [Article in Turkish] Düzce Tıp Fakültesi Dergisi 2009;11:15-20.

8. Yagan O, Akan B, Erdem D, Albayrak D, Bilal B, Gogus N. The retrospective analysis of the acute poisoning cases applying to the emergency unit in one year. [Article in Turkish] Sisli Et-fal Hastanesi Tıp Bulteni 2009;43:60-4.

9. Mert E, Bilgin NG, Erdoğan K, Bilgin TE. Acil servise başvuran akut zehirlenme olgularının değerlendirilmesi. Akademik Acil Tıp Dergisi 2006;4:14-9.

10. Zeren C, Karakuş A, Çelik MM, Arıca V, Tutanç M, Arslan MM. Evaluation of intoxication cases applying to the emergency department of medical school hospital. JAEM 2012;11:31-4.

11. Akın D, Tüzün Y, Çil T. Türkiye’ nin Güneydoğusundaki akut Ze-hirlenme olgularının profili. Dicle Tıp Dergisi 2007;34:195-8.

12. Sönmez E, Karakuş A, Çavuş UY, Cemil Civelek C, İpek G, Zeren C. Bir üniversite hastanesi acil servisine başvuran zehirlenme olgularının değerlendirilmesi. Dicle Tıp Dergisi 2012;39:21-6.

13. Yeşil O, Akoğlu H, Onur Ö, Güneysel Ö. Acil servise başvuran zehirlenme olgularının geriye dönük analizi. Marmara Medi-cal Journal 2008;21:26-32.

14. Prosser JM, Goldfrank LR. Zehirlenen hastaya yaklaşım. In: Sa-tar Z, editor. Acilde klinik toksikoloji. Adana: Nobel; 2009. p. 67-74.

15. Köse A, Eraybar S, Köse B, Köksal Ö, Aydın ŞA ve ark. Patients over the age of 15 years admitted for attempted suicide to the emergency department and the psychosocial support unit. JAEM 2012;11:193-6.

16. Arıcı AA, Demir Ö, Özdemir D, Ünverir P, Tunçok Y. Acil ser-vise başvuran karbonmonoksit maruz kalımları: On dört yıllık analiz. DEÜ Tıp Fakültesi Dergisi 2010;24:25-32.

17. Ecevit Ç, Hızarcıoğlu M, Gerçek PA, Gerçek H, Kayserili E, Gülez P ve ark. Evaluation of musroom intoxications presenting at the emercency department of Dr. Behçet Uz Children’s Hospi-tal. [Article in Turkish] ADÜ Tıp Fakültesi Dergisi 2004;5:11-4.

Turk J Emerg Med 2014;14(4):160-164164


Submitted: July 02, 2014 Accepted: July 31, 2014 Published online: November 30, 2014

Correspondence: Dr. Seda Dagar. Kars Devlet Hastanesi, Acil Servis, Kars, Turkey.


ORIGINAL ARTICLE

1 Department of Emergency Medicine, Kars State Hospital, Kars;2Department of Emergency Medicine, Artvin State Hospital, Artvin;

3Department of Pediatric Service, Kars State Hospital, Kars

Seda DAGAR,1 Sibel SAHIN,2 Yunus YILMAZ,3 Ugur DURAK1

Emergency Department During Long Public Holidays

Uzun Resmi Tatil Dönemlerinde Acil Servis

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

MethodsThe study groups included all of the patients who visited the emer-gency department during the nine-day public holiday (Eid al-Adha, a religious festival of sacrifice) celebrations and a nine-day non-holiday “normal” period. The patients’ demographic information, reasons for their visits, comorbid diseases, whether or not they had undergone laboratory and screening tests, consultations, length of stay, and the way their visits ended were compared statistically.

ResultsOf the 6353 patients enrolled in the study, 3523 (55.5%) were seen in the emergency department during the holiday period, while 2830 (45.5%) were seen during the non-holiday period (p<0.001). During the holiday period, there was a 1.9% decrease in laboratory test requests (p=0.108), a 7.7% increase in radiology examination requests (p<0.001), and a 1.2% increase in consultation requests (p=0.063). The patients’ length of stay during the holiday period was 55.9±75.3 minutes and was 56.3±71.9 minutes during the non-holiday period (p=0.819). The length of time for the patients who underwent tests or consultations was 88.6±92.8 minutes during the holiday period and 92.6±87.5 min-utes during the non-holiday period (p=0.224).

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

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

ÖZETAmaçÇalışmamızda uzun tatillerde acil servis başvurularında artış beklentisi-nin, hekimlerin inceleme ya da konsültasyon isteme yönelimine ve acil serviste hastaların kalış süresine etkisi olup olmadığını ortaya çıkarmayı amaçladık.

Gereç ve YöntemÇalışmamızda tatil dönemi olarak dokuz günlük Kurban Bayramı tatili ka-bul edilirken, karşılaştırma grubu ise dokuz günlük tatil dışı bir dönemde acil servise başvuran tüm hastalardan oluşturuldu. Her iki dönemde acil servise başvuran hastalar demografik bilgileri, başvuru nedenleri, komor-bid hastalıkları, laboratuvar ve görüntüleme incelemesi yapılıp yapılmadı-ğı, konsültasyon istemleri, acil serviste kalış süreleri ve sonuçlanma şekilleri bakımından karşılaştırıldı.

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

SonuçUzun süreli tatillerde acil servislerde beklendiği gibi hasta yoğunluğu art-maktadır. Bu yoğunluk, hekimlerin laboratuvar incelemesi ve konsültas-yon istemlerinde artışa yol açmazken, radyolojik inceleme istemlerinde artış gözlenmiştir. Ayrıca acil serviste ortalama kalış süresi başvuru sayı-sındaki artıştan etkilenmemektedir.

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

165

IntroductionHospitals are among the vital institutions that face interrup-tion of services during weekends and public holidays. It has been reported that the volume of patients at emergency de-partments, which are always open, increases during week-ends and public holidays due to the interruption of services in other departments.[1,2] Several studies have stated that the disruption at emergency departments during afterhours or holidays is due to the lack of personnel and experienced medical staff as well as limited access to laboratory and radi-ology services.[3-8]

Religious festivals in Turkey are usually celebrated as long public holidays by including both the previous and follow-ing weekends. Several reports have shown that there is an increase in the volume of non-emergency patient visits to emergency departments during times where regular clinical services are not offered or limited.[9-11] Regulations passed by the Turkish Ministry of Health regarding “Health servic-es during public holidays” point out the expected increase in workload and volume of patients at emergency depart-ments during public holidays, and recommends precaution-ary measures be taken in order to avoid serious disruption in health services.[12] However, to our knowledge, there has been no study in the literature reporting whether this in-crease during the holidays affects physicians’ tendencies to request tests or consultations or the length of stay for pa-tients at emergency departments.

Therefore, the purpose of this study is to determine the dis-ruptions of health services during a nine day religious public holiday, and how these disruptions affect patients and phy-sicians at emergency services.

Materials and Methods Kars State Hospital, as a district hospital, provides health care to around 550,000 people, including referrals it receives from neighboring cities. The hospital is home to a second-ary emergency department, which serves to around 600 pa-tients a day and approximately 210,000 patients a year.

After receiving approval from the local ethics committee, this study was conducted to compare emergency depart-ments during a holiday period and a non-holiday period. All emergency department visits during both periods were in-cluded in our study. Consent was obtained from all patients enrolled in the study. Those who did not consent were ex-cluded from the study. The first study group is composed of all patients who visited the emergency department during a nine-day public holiday (Eid al-Adha, a religious festival of sacrifice) between October 12th and October 20th, 2013. Because there is often a temporary increase in the volume of patients visiting the emergency department after the

holiday period, the control group is composed of all patients who visited the emergency department during a nine-day non-holiday “regular” period between September 28th and October 6th of the same year. All patients visiting the emer-gency department between midnight Friday and midnight of the Sunday on the next weekend were prospectively in-corporated into the study.

The patients’ demographic information, reasons for their vis-its, the way they were transported to the hospital, comorbid diseases, whether or not laboratory and screening tests were performed, consultations, length of stay, and how their vis-its ended were recorded. Both traumatic and non-traumatic cases and reasons for visiting the emergency department were categorized. The data obtained from the both the study and the control groups were compared statistically.

Statistical analyses were performed using “Statistical Pack-age for Social Sciences (SPSS) for Windows version 21.0” soft-ware (SPSS Inc., IL. USA). Quantitative data and the number of observations are expressed as percentages (%), and the qualitative data are expressed as mean±standard deviation (SD) or median (minimum-maximum). The T test and the chi-square test were used for comparing the data gathered from both groups. A p value <0.05 was considered significant.

ResultsOf the 6353 emergency department visits included in the study, 3523 (55.5%) were during the holiday period and 2830 (45.5%) were during the non-holiday period, which in-dicated a 10% increase in the volume of emergency depart-ment visits during the holiday period. The difference in visits between the groups was statistically significant (p<0.001).

Of the patients visiting during the holiday period, 2051 (58.2%) were male, as were 1550 (54.8%) who visited during the non-holiday period (p=0.007). The mean age of patients who visited during the holiday period was 39.6±19.4 years (range, 1-110 years), and was 39.6±19.9 (range, 1-93 years) for the non-holiday period (p=0.965). During business hours (08:00-16:00), 1828 (51.9%) patients visited the emergency department during the holiday period compared to 1368 (48.3%) patients during the non-holiday period. There was a significant difference in terms of the rate of visits during both periods (p=0.004). The frequency of patients’ comorbid diseases during both periods are listed in Table 1.

There were 660 (18.7%) patients admitted due to trauma during the holiday period and 484 (17.1%) during the non-holiday period (p=0.105). The reasons for traumatic and non-traumatic cases visiting the emergency department during both periods are listed in Tables 2 and 3, respectively.

The frequencies of physicians’ laboratory and radiology re-

Turk J Emerg Med 2014;14(4):165-171166

quests during both periods are listed in Table 4. The frequen-cies of physicians’ consultation requests during the holiday and non-holiday periods are listed in Table 5.

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

Dagar S et al. Emergency Department During Long Public Holidays 167

Table 1. The frequency of patients’ comorbid diseases

Holiday period Non-holiday period

n % n %

Hypertension 505 14.3 375 13.3

Chronic obstructive pulmonary disease 203 5.8 117 4.1

Malignancy 78 2.2 81 2.9

Diabetes mellitus 70 2.0 39 1.4

Coronary artery disease 61 1.7 48 1.7

Heart failure 17 0.5 9 0.3

Table 2. The reasons traumatic cases visited the emergency department


n % n %

Slip and fall 335 9.5 203 7.2

Sharp object injuries 79 2.2 27 1.0

Car accidents 40 1.1 32 1.1

Assault 37 1.1 42 1.5

Fall from height 21 0.6 10 0.4

Burns 12 0.3 11 0.4

Workplace accidents 9 0.3 7 0.2

Animal related injuries 8 0.2 2 0.1

Others 119 3.4 150 5.3

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


n % n %

Upper respiratory infection 698 19.8 567 20.0

Abdominal pain 279 7.9 171 6.0

Headache 228 6.5 183 6.5

Chest pain 156 4.4 121 4.3

Hypertensive crisis 133 3.8 154 5.4

Diarrhea 115 3.3 64 2.3

Asthma-COPD attack 99 2.8 84 3.0

Psychiatric disorders 37 1.1 18 0.6

Poisoning 11 0.3 5 0.2

Gastrointestinal bleeding 0 0.0 1 0.2

Others 1107 31.4 978 34.6

emergency department data, some of the patients who were not discharged were hospitalized (holiday period: n=31, 0.9%; non-holiday period: n=36, 1.3%; p=0.157), some were referred to another hospital (holiday period: n=10, 0.3%; non-holiday period: n=9; 0.3%, p=0.817), and some were ad-mitted to the intensive care unit (holiday period: n=8, 0.2%; non-holiday period: n=5, 0.2%; p=0.777). While none of the patients in the study died in the emergency department, some of them refused treatment or left the hospital without notice before their examination and treatment were com-pleted (holiday period: n=6, 0.2%; non-holiday period: n=18, 0.6%; p=0.017).

The average length of stay for the patients who visited the emergency department during the holiday period was 55.9±75.3 minutes and was 56.3±71.9 minutes for those vis-iting during the non-holiday period (p=0.819). The lengths

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

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

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

Table 4. Physicians’ use of laboratory and radiology tests


n % n % p

Laboratory test Requested 1051 29.8 897 31.7 0.108

Not requested 2472 70.2 1933 68.3 0.108

Radiology test Requested 1338 38.0 857 30.3 <0.001

Not requested 2185 62.0 1973 69.7 <0.001

Laboratory test or Requested 1763 50.0 1366 48.3 0.186

radiology test Not requested 1760 50.0 1464 51.7 0.186

Table 5. Physicians’ consultation requests


n % n % p

Consultation Requested 255 7.2 169 6.0 0.063

Not requested 3268 92.8 2661 94.0 0.063

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

Duration/minutes p

Mean±SD

Laboratory test, radiology Requested Holiday period (n=1769, 56.3%) 88.6±92.8 0.224

test or consultation Non-holiday period (n=1370, 43.7%) 92.6±87.5

Not requested Holiday period (n=1748, 54.8%) 22.8±22.7 0.585

Non-holiday period (n=1442, 45.2%) 22.4±21.5

question the quality of medical care in emergency depart-ments during these times.[3-11]

The purpose of this study was to examine the impact of increased patient volumes during public holidays on phy-sicians’ tendencies regarding the use of laboratory tests, radiology examinations, and consultation requests, and in addition, how all these factors would affect the length of stay for patients in the emergency department. Similar to previ-ous research, we also found a 10% increase in the volume of patient visits to emergency departments during the long public holiday when compared to a regular, non-holiday period, which was statistically significant. Similarly, Zeng et al. reported a 9% increase in patient visits to the emergency department during holidays, while Yıldırım et al. reported a 32% increase during holidays.[2,9] These increases were due to the closure of most private institutions during holidays, the high volume of referrals received from surrounding hos-pitals, and the increase in non-emergency patients due the limited health services offered by departments during the holiday. In addition, the revival and mobility in society dur-ing free times also can cause increases in visits to the emer-gency department.[9] The current study highlights the limita-tions in regular clinical services as the main reason for the increased volume of patient visits to the emergency depart-ment. We also found that there were several referrals from other hospitals that do not increase staff during the holiday period and that many patients visited our emergency de-partment because there is no other private hospital in the district. Pekdemir et al. reported that 440 patients visited the emergency department during the nine-day public holiday compared to 407 during non-holiday period. They explained that there was not much difference between holiday and non-holiday periods because most people spent their holi-days away from the city.[13] People who live in bigger cities often prefer to spend their holidays outside of their cities. However, in our case, most of the people prefer to go to local villages rather than leave the city. This may be one of the rea-sons that explain the difference between our findings and the results of Pekdemir et al’s research.

In our study, there was a decrease in the physicians’ tenden-cies to request laboratory tests. Meanwhile, there was a 7.7% increase in requests for radiology examinations during the holiday period. This may be because laboratory tests take more time than do radiology examinations and consulta-tions. The increase in requests for radiology examinations may also be due to the celebrations of Eid al-Adha, which include the slaughtering of livestock, which may cause an increase in injuries due to falls, sharp objects, and animals. While there was a 10% increase in the volume of patient vis-its during the holiday period, there was just a 1.2% increase in physicians’ consultation requests. This disparity may be

because patients visiting the emergency department during the holiday do not require consultation. In addition, even if required, it is often difficult to reach physicians for consulta-tion during the holidays, which might be another reason for the low increase in consultations. Patients who received lab-oratory tests and consultation stayed in the emergency de-partment three times longer than those who did not. Again, the 1.6% increase in tests consultation requests during the holiday period, which is not statistically significant, consid-ered together with the 10% increase in patient volume can be explained by physicians’ tendencies to limit the number of tests and consultations to avoid long wait times during holiday periods.

Pekdemir et al found that the length of stay for patients in emergency services during the holiday period was 60.3±53.1 minutes and 75.2±60.6 minutes during the non-holiday pe-riod, which was statistically significant.[13] Similarly, in our study, the length of stay during holidays (55.9±75.3 min-utes) was shorter than the length of stay during non-holiday periods (56.3±71.9 minutes), but this difference was not sig-nificant. Moreover, the length of stay for patients receiving tests or consultation was shorter during the holiday periods (88.6 ± 92.8 minutes) than during the non-holiday periods (92.6±87.5 minutes), which was not significant statistically. In conclusion, we found that the increase in the volume of patient visits to emergency departments during holiday pe-riods does not affect their length of stay in emergency de-partments. This is mostly due to the physicians’ tendencies to limit test and consultation requests to avoid long wait times.

Mohammed et al. found that the majority of patients visiting emergency departments and those who were hospitalized during holiday periods were elderly and male.[14] Pekdemir et al. did not report any significant differences between the age of patients visiting during holiday and non-holiday pe-riods.[13] In our study, there was no significant difference be-tween the ages of the patients visiting during either period. However, we did observe that the number of male patients visiting the emergency department during the holiday pe-riod was 3.4% higher than those visits during the non-holi-day period. We believe that this is because many of the local business are closed during the public holiday.

In our study, we observed a 1.6% increase in trauma cases during the holiday period, which was not statistically signifi-cant. Yıldırım et al. observed a 5.3% increase in the volume of patient visits due to traumatic reasons during the holiday period, and a 5.3% decrease in the volume of patient visits due to non-traumatic reasons.[9] Pekdemir et al. found that 19.1% of visits were due to traumatic reasons during the hol-idays and 19.7% during the non-holiday period, which was

169Dagar S et al. Emergency Department During Long Public Holidays

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

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

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

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

Limitations

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

Another important limitation of our study is that the hos-pital that hosted our study is a secondary health institution located in a rural area. Therefore, our findings may not be ap-plicable to many of the other hospitals around the country.

Conclusion

As expected, we observed that the number of patient visits to emergency services increased during the holiday period. However, this increase did not lead to a similar increase in physicians’ requests for tests and consultations, except for radiology examination requests. In addition, the length of stay for the patients in emergency services was not affected by the increase in the volume of patient visits during the holiday period.



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

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2. Zheng W, Muscatello DJ, Chan AC. Deck the halls with rows of trolleys...emergency departments are busiest over the Christ-mas holiday period. Med J Aust 2007;187:630-3.

3. Keatinge WR, Donaldson GC. Changes in mortalities and hospital admissions associated with holidays and respira-tory illness: implications for medical services. J Eval Clin Pract 2005;11:275-81.

4. Sachs L. Firm but fair policies for staff vacations and holidays. J Med Pract Manage 2002;18:42-4.

5. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med 2002;346:1715-22.

6. Schmulewitz L, Proudfoot A, Bell D. The impact of weekends on outcome for emergency patients. Clin Med 2005;5:621-5.

7. Lamn H. The lost weekend in hospitals. N Engl J Med 1973;289:923.

8. DeCoster C, Roos NP, Carrière KC, Peterson S. Inappropriate hospital use by patients receiving care for medical condi-tions: targeting utilization review. CMAJ 1997;157:889-96.

9. Yildırım C, Sozuer EM, Yurumez Y, İkizceli İ. Emergency de-partment services during long-term holidays. Ulus Travma Acil Cerrahi Derg 2000;6:106-9.

10. Hoot NR, Aronsky D. Systematic review of emergency depart-ment crowding: causes, effects, and solutions. Ann Emerg

Med 2008;52:126-36. 11. Trzeciak S, Rivers EP. Emergency department overcrowding in

the United States: an emerging threat to patient safety and public health. Emerg Med J 2003;20:402-5.

12. http://www.saglik.gov.tr/TR/dosya/1-86291/h/sh3.pdf.13. Pekdemir M, Durukan P, Yıldız M, Kavalcı C. Satisfaction and de-

mographic analysis of patients addmitting to emergency de-partment on long holiday periods. Fırat Med J 2003;8:149-52.

14. Mohammed MA, Khesh SS, Rudge G, Stevens AJ. Weekend admission to hospital has a higher risk of death in the elective setting than in the emergency setting: a retrospective data-base study of national health service hospitals in England. BMC Health Services Research 2012;12:87-96.

15. Mäkelä P, Martikainen P, Nihtilä E. Temporal variation in deaths related to alcohol intoxication and drinking. Int J Epi-demiol 2005;34:765-71.

16. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med 2001;345:663-8.

17. Freemantle N, Richardson M, Wood J, Ray D, Khosla S, Shahian D, et al. Weekend hospitalization and additional risk of death: an analysis of inpatient data. J R Soc Med 2012;105:74-84.

18. Cram P, Hillis SL, Barnett M, Rosenthal GE. Effects of weekend admission and hospital teaching status on in-hospital mor-tality. Am J Med 2004;117:151-7.

19. Seward E, Greig E, Preston S, Harris RA, Borrill Z, Wardle TD, et al. A confidential study of deaths after emergency medi-cal admission: issues relating to quality of care. Clin Med 2003;3:425-34.

20. Phillips D, Barker GE, Brewer KM. Christmas and New Year as risk factors for death. Soc Sci Med 2010;71:1463-71.

171Dagar S et al. Emergency Department During Long Public Holidays


Submitted: December 05, 2013 Accepted: February 25, 2014 Published online: November 30, 2014

Correspondence: Dr. Vesile Senol. Saglik Hizmetleri Meslek Yuksek Okulu, Ilk ve Acil Yardım Tek. Bol.,Erciyes Universitesi, 38039 Kayseri, Turkey.


ORIGINAL ARTICLE

1Department of First and Emergency Aid Technician, Vocational School of Health, Erciyes University, Kayseri;2Department of Surgial Nursing, School of Health Sciences, Erciyes University, Kayseri;

3Department of Orthopaedics and Traumatology, Erciyes University Faculty of Medicine, Kayseri;4Department of Emergency Medicine, Erciyes University Faculty of Medicine, Kayseri

Vesile SENOL,1 Ferhan SOYUER,1 Gulsum Nihal GULESER,2 Mahmut ARGUN,3 Levent AVSAROGULLARI4

The Effects of the Sleep Quality of 112 Emergency Health Workers in Kayseri, Turkey on Their Professional Life

Kayseri 112 Acil Sağlık Çalışanlarında Uyku Kalitesinin Mesleki Yaşam Üzerine Etkisi

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

MethodsThe study was carried out on 121 voluntary emergency health workers in 112 Emergency Aid Stations in Kayseri, Turkey, in 2011. The data was col-lected through the Socio-Demographics Form and the Pittsburgh Sleep Quality Index (PSQI) and analyzed via SPSS 18.00. The statistical analysis involved percentage and frequency distributions, mean±standard de-viations, a chi-square test, correlations, and logistic regression analysis.

ResultsThe mean score of the participants according to the Pittsburgh Sleep Quality Index was 4.14±3.09, and 28.9% of participants had poor sleep quality. Being single and being a woman accounted for 11% (p=0.009, 95% CI: 0.111-0.726) and 7% (p=0.003, 95% CI: 0.065-0.564) of poor sleep quality respectively. There was a positive correlation between sleep quality scores and negative effects on professional and social life activities. Negative effects on professional activities included increased loss of attention and concentration (40.0%, p=0,016), increased fail-ure to take emergency actions (57.9%, p=0.001), reduced motivation (46.2%, p=0.004), reduced performance (41.4%, p=0.024), and low work efficiency (48.1%, p=0.008). Poor sleep quality generally nega-tively affected the daily life of the workers (51.6%, p=0.004), restricted their social life activities (45.7%, p=0.034), and caused them to experi-ence communication difficulties (34.7%, p=0.229).

ConclusionsOne third of the emergency health workers had poor sleep quality and experienced high levels of sleep deficiency. Being a woman and being single were the most important factors in low sleep quality. Poor sleep quality continuously affected daily life and professional life negatively by leading to a serious level of fatigue, loss of attention-concentration, and low levels of motivation, performance and efficiency.

Key words: 112 Emergency Health Workers, professional life; sleep quality.

ÖZETAmaçUyku yeterliliği başarılı iş yaşamının temel belirleyicilerindendir. Bu çalış-manın amacı acil sağlık çalışanlarında uyku kalitesini belirlemek, mesleki ve sosyal yaşam üzerine etkisini araştırmaktır.

Gereç ve YöntemAraştırma 2011 yılında Kayseri ilinde aktif hizmet veren 112 Acil Yardım İs-tasyonunda görev yapan gönüllü 121 Acil Sağlık Çalışanı üzerinde yürütül-dü. Araştırmada, Sosyo-demografik Veri Formu ve Pittsburgh Uyku Kalitesi Ölçeği (PSQI) kullanıldı. Veriler SPSS 18.00 versiyonu ile değerlendirildi, is-tatiksel analizde yüzde ve frekans dağılımları, ortalama±standart sapma, ki kare testi, korelasyon ve lojistik regresyon analizi kullanıldı.

BulgularPittsburgh Uyku Kalitesi puan ortalaması 4.14±3.09 olan grubun %28.9’unun uyku kalitesi kötü idi. Kötü uyku kalitesinin %11’inden (p=0.009, %95 GA: 0.111-0.726) bekar olmak, %7’sinden (p=0.003, %95 GA: 0.065-0.564) ise kadın olmak sorumlu idi. Uyku kalitesi puanları ile mesleki ve sosyal yaşam etkinliklerinin olumsuz etkilenimi pozitif korelas-yon gösterdi, uyku kalitesi kötü olan acil sağlık çalışanlarında, genellikle dikkat ve konsantrasyon kaybı (%40.0, p=0.016), acil müdahalelerde ba-şarısızlık (%57.9, p=0.001), motivasyon (%46.2, p=0.004), performans (%41.4, p=0.024) ve iş verimi (%48.1, p=0.008) düşüklüğü yaşayanların oranı anlamlı düzeyde daha yüksekti. Düşük uyku kalitesi çalışanların günlük yaşam düzenini (%51.6, p=0.004) genellikle olumsuz etkiledi, sosyal yaşam sınırlılıkları (%45.7, p=0.034) ve iletişim güçlüğüne (%34.7, p=0.229) neden oldu.

SonuçAcil sağlık çalışanlarının üçte birinin uyku kalitesi kötü olup, grup düşük düzeyde uyku yeterliliği sorunu yaşamaktadır. Kadın ve bekar olmak uyku kalitesini düşüren en önemli faktörlerdir. Kötü uyku kalitesi hem günlük ya-şam düzenini hem de ciddi düzeyde yorgunluk, dikkat-konsantrasyon kay-bı, motivasyon, performans ve verim düşüklüğü yaratarak mesleki yaşamı sürekli olumsuz etkilemektedir.

Anahtar sözcükler: 112 Acil Sağlık Çalışanları; mesleki yaşam; uyku kalitesi.

172

IntroductionHuman beings have biological, psychological, social, and cultural needs that must be satisfied to maintain their ex-istence. Sleep is one of such basic requirements.[1,2] Sleep is linked to and compatible with the body’s circadian rhythm.[3] One of the main functions of the circadian rhythm is to prepare one for sleep, which is the rest period for the night. A disturbance to the circadian rhythm leads to a correspond-ing malfunction in one’s sleep pattern. In fact, sleep quality, as well as its duration, is diminished by working at night, in shifts, or for irregular hours.[4] Prolonged sleeplessness has adverse impacts on human life. Therefore, it is inevitable that a health worker suffering from prolonged sleeplessness ow-ing to the shift system will experience negative influences on his/her mental and physical health.[5]

Emergency care service delivery is a profession that requires the shift system. Working during the night influences the ex-tent to which one is ready for and adapted to the next day. Subsequent outcomes may include work accidents and trau-mas. For example, nurses working in the night shift are com-monly observed to experience work accidents associated with scalpel cuts and pricks with injector needles later in the day.[6] Emergency health workers have to work beyond ordi-nary working hours or days, have duties and responsibilities that potentially pose fatal threats, compete with time, use different technologies, and cause a great deal of stress and pressure. Currently, most work on a 24-hour basis, meaning they are continuously working for 24 hours. They have to cope not only with occupational risks caused by the nature of the night shift but also with the risk of making mistakes brought about by overworking. It is a known fact that long hours and overworking puts one at greater the risk of mak-ing mistakes is at work. In fact, it is reported in the literature that nurses who work in 12.5-hour shifts are three times as likely to make mistakes as those who work for 8.5 hours, and that the former group is more susceptible to medication-related mistakes and injuries associated with needles.[7]

To sum up, research suggests that working in shifts has an adverse impact on one’s physiological and psychological health, thus negatively affecting the security of both work-ers and patients.[8] There is compelling evidence that work-ing in shifts has a permanent influence on sleep quality. Ac-cording to the findings of a study on nurses, daytime sleep following the night shift is of rather low quality.[9] Those working during the night sleep two to four hours less than daytime workers and suffer from sleep deficiency, functional disturbances and fatigue.

All this information suggests that emergency health workers likely have impaired sleep quality as a result of working in a way not compatible with their natural biological rhythms.

Additionally, impaired sleep of emergency health workers may possibly be reflected in their professional and social life.

The purpose of the present study is to identify the sleep quality of emergency health workers and to determine its effects on professional and social life.

Materials and Methods The study was conducted on a total of 121 voluntary emer-gency health workers who worked for 112 Emergency Aid Stations that actively operated in Kayseri in 2011. The data were collected through face-to-face interviews and two in-struments, namely the Socio-Demographics Form and the Pittsburgh Sleep Quality Index (PSQI).

The PSQI is comprised of 24 questions. 19 questions are based on self-report and the remaining five are answered by the spouse or roommate. The scored 18 questions con-tain 7 domains (subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction). Each com-ponent is assigned a score ranging from zero to three. The sum of the scores in the seven domains yields the score for the whole scale. Thus, the overall score varies between zero and 21, with higher scores representing poorer sleep quality. A score of ≤5 in the overall PSQI suggests high sleep qual-ity whereas a score of >5 stands for poor sleep quality. For the present study, the effect of sleep quality on professional and social life was measured on a four-point scale (0=Never, 1=Rarely, 2=Often, 3=Always); however, the options often and always were merged into generally in the discussion section.[10]

Statistical analysisThe continuous variables were represented in mean scores and standard deviation values whereas the discrete vari-ables were expressed in terms of percentage and frequency distribution. The correlation among the categorical variables was studied via a chi-square test.

The correlation between the scores in sleep quality and variables in professional and social life was tested through a Pearson correlation analysis, while a logistic regression anal-ysis was performed in order to identify the factors account-ing for poor sleep quality. Sleep quality was identified as a dependent variable. Participants with a PSQI score of zero to five was assigned good=0 as a reference value whereas par-ticipants with a PSQI score of six to 20 was assigned poor=1 as a reference value. In addition, such variables as age, gen-der, educational status, marital status, length of service, and weekly working hours were accepted into the model as in-dependent variables. The level of significance was p<0.05.

Senol V et al. The Effects of the Sleep Quality of 112 Emergency Health Workers in Kayseri 173

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

ResultsMore than half of the participants (56.2%) were women, and 76% of them were 18 to 27 years old. In addition, 59.5% of the workers were single. As for their educational status, 68.6% were high school graduates whereas 31.4% had ei-ther an associate degree or bachelor’s degree. Slightly more than half of the participants (52.9%) smoked, and 62% con-sumed large quantities of tea or coffee (Table 1).

Participant demographics were varied. 61.2% of the partici-pants were emergency medical technicians and 20.7% were paramedics. For employment location, 69.4% of the partici-pants worked for Emergency Aid Stations and the remain-ing 30.6% worked for Command and Control Centers. Nearly two-thirds of participants (64.5%) had been serving for one to five years. 70.2% of the participants worked on a 24-hour basis and 71.7% worked for 48 hours a week. Only 20% of participants functioned as ambulance drivers permanently twice a week. Out of these ambulance drivers, 7.4% were in-volved in a traffic accident when on duty.

Out of all the participants, 86% reported experiencing sleep deficiency at varying percentages (rarely-generally). The mean score of the participants in the Pittsburgh Sleep Quali-ty Index was 4.14±3.09 (min: 0, max: 14), and 28.9% had poor sleep quality (scores of 6 to 14). The prevalence of poor sleep quality was 39.7% (p=0.004) among women, 41.7% (p<0.001) among single participants, 31.6% (p=0.005) among univer-sity graduates, 33.4% (p=0.003) among those with a length of service less than five years, 36.5% (p=0.014) among emer-gency medical technicians, and 64.3% (p=0.002) among those who permanently worked in the night shift (Table 2).

The participants with poor sleep quality suffered from loss of attention or concentration (40%, p=0.016), failure to take emergency actions (57.9%, p=0.001), reduced motivation (46.2%, p=0.004), reduced performance (41.4%, p=0.024), and low work efficiency (48.1%, p=0.008). Poor sleep quality led the sufferers to experience negative influences on their daily life (51.6%, p=0.004), restrictions on their social life activities (45.7%, p=0.034), and communication difficulties (34.7%, p=0.229) (Table 3).

According to the correlation analysis, poorer sleep qual-ity (higher PSQI scores) led to disturbances in daily life ac-tivities (r=0.462, p<0.001) and social life (r=0.375, p<0.001), excessive fatigue (r=0.429, p<0.001), reduced motivation (r=0.318, p<0.001), low work efficiency (r=0.306, p=0.001), reduced performance (0.275, p=0.002), failure to take emer-gency actions (r=0.300, p=0.001), and loss of attention and

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

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

Turk J Emerg Med 2014;14(4):172-178174

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

Descriptive characteristics n %

Gender

Man 53 43.8

Woman 68 56.2

Total 121 100.0

Age groups

18-27 92 76.0

28-37 26 21.5

38-46 3 2.5

Total 121 100.0

Marital status

Married 49 40.5

Single 72 59.5

Total 121 100.0

Educational status

High school 83 68.6

Associate degree 33 27.3

Bachelor’s degree 5 4.1

Total 121 100.0

Length of service (Years)

≤1-5 96 79.4

6-10 20 16.5

16-20 5 4.1

Total 121 100.0

Weekly work schedule

Day shift (8.00 am-5.00 pm) 5 4.3

Night shift (5.00 pm-8.00 am) 14 11.5

Evening shift (5.00 pm-11.59 pm) 17 14.0

24-hour basis (8.00 am-8.00 am) 85 70.2

Total 121 100.0

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

According to the findings of the present study, one crucial factor in low sleep quality was gender. Similar to other stud-ies, this study indicated that women had poorer sleep qual-

ity. Likewise, research on nurses indicates that women have lower sleep quality than men.[13,14] According to Ruggiero,[15] women health workers who work in shifts tend to have poorer sleep quality. In the present study, the women partic-ipants were more inclined to fatigue. Similarly, one finding of a study on the general public in Sweden is that women have more sleep-related problems although they sleep for longer than men.[16] Difficulty falling asleep, uneasy sleep and fatigue cause women health workers to have increased stress and to experience physiological disturbances.[16]

The other significant factor in poor sleep quality was being single. Similarly, Watanabe et al.[14] conducted a study in a Japanese hospital on female nurses who work shifts, and observed that the effects of shift changes on sleep patterns were less strong among the married women than the sin-

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

Demographics and Sleep quality pprofessional variables

Good Poor Total (PSQI: 0 to 5 p) (PSQI: 6 to 14 p) n=86 n=35

n % n % n %*

Gender

Man 45 84.9 8 15.1 53 43.8 0.004

Woman 41 60.3 27 39.7 68 56.2

Marital status

Married 44 89.8 5 10.2 49 40.5 <0.001

Single 42 58.3 30 41.7 72 59.5

Educational status

High school 60 72.3 23 27.7 83 68.6 0.005

Associate degree or bachelor’s degree 26 68.4 12 31.6 38 31.4

Length of service

0-5 years 64 66.6 32 33.4 96 79.3 0.003

6-20 years 22 88.0 3 12.0 25 20.7

Professional status

Emergency medical technician (EMT) 47 63.5 27 36.5 74 61.1 0.014

Emergency medical technician (Paramedic) 18 72.0 7 28.0 25 20.7

Physician-nurse-health officer 21 95.5 1 4.5 22 18.2

Work Schedule

8.00 am-5.00 pm (Day shift) 4 80.0 1 20.0 5 4.1 0.002

5.00 pm-8.00 am (Night shift) 5 35.7 9 64.3 14 11.6

5.00 pm-11.59 pm (Evening shift) 12 70.6 5 29.4 17 14.0

24-hour basis (8.00 am-8.00 am) 65 76.5 20 23.5 85 70.3

* Column percentage.


gle women. According to Vidacek et al.,[17] however, women who are married sleep for significantly shorter following the night shift when compared to those who are not married.

Such conflicting findings in the literature might result from the possibility that participants will have different familial/domestic responsibilities and life styles. To further compli-

cate this issue, Caliyurt[4] reports that marital status has no influences whatsoever on sleep quality.

In the present study, poor sleep quality had negative im-pacts on the participants’ professional and social life. It led to fatigue, loss of attention and concentration, failure to take emergency actions, and reduced job motivation and work

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

Variables in professional and social life Sleep quality p

Good Poor Total*

(PSQI: 0 to 5 p) (PSQI: 6 to 14 p)

n % n % n %

Sleep deficiency prior to the 24-hour duty Never 13 76.5 4 23.5 17 14.0 0.285 Sometimes 43 65.2 23 34.8 66 54.5 Generally 30 78.9 8 21.1 38 31.4 Fatigue Never 14 100.0 0 0.0 14 11.6 <0.001 Sometimes 65 77.4 19 22.6 84 69.4 Generally 7 30.4 16 69.6 23 19.0 Loss of attention and concentration Never 29 90.6 3 9.4 32 26.4 0.016 Sometimes 48 64.9 26 35.1 74 61.2 Generally 9 60.0 6 40.0 15 12.4 Failure to take emergency actions Never 35 87.5 5 12.5 40 33.1 0.001 Sometimes 43 69.4 19 30.6 62 51.2 Generally 8 42.1 11 57.9 19 15.7 Reduced job motivation Never 22 91.7 2 8.3 24 19.8 0.004 Sometimes 43 74.1 15 25.9 58 47.9 Generally 21 53.8 18 46.2 39 32.2 Reduced job performance Never 26 86.7 4 13.3 30 24.8 0.024 Sometimes 43 69.4 19 30.6 62 51.2 Generally 17 58.6 12 41.4 29 24.0 Low work efficiency Never 26 89.7 3 10.3 29 24.0 0.008 Sometimes 46 70.8 19 29.2 65 53.7 Generally 14 51.9 13 48.1 27 22.3 Communication difficulty Never 25 80.6 6 19.4 31 25.6 0.229 Sometimes 47 65.3 25 34.7 72 59.5 Generally 14 77.8 4 22.2 18 14.9 Negative effects on social life Never 25 78.1 7 21.9 32 26.4 0.034 Sometimes 42 77.8 12 22.2 54 44,6 Generally 19 54.3 6 45.7 25 28.9 Negative effects on daily life Never 27 84.4 5 15.6 32 26.4 0.004 Sometimes 44 75.9 14 24.1 58 47.9 Generally 15 48.3 16 51.6 31 25.6

* Column percentage.

Turk J Emerg Med 2014;14(4):172-178176

efficiency. Sleep quality, as well as its duration, is diminished by working at night, in shifts, or for irregular hours.[18] Emer-gency health workers represent one of the few professional groups that have to work during the night shift for varying hours for the extent of their career. Working during the night means that one will sleep during the day, which affects sleep both qualitatively and quantitatively. Working for varying hours has two influences on health, namely inability of the body to satisfy its biological rhythm, especially in terms of sleep and digestion, and disruptions in one’s familial and so-cial life. It is reported in the literature that a reduction of a night’s sleep by 1.3 to 1.5 hours diminishes alertness in the following day by 32%.[19] A disturbance in sleep quality as a consequence of working in shifts also influences job perfor-mance, as was demonstrated in the present study. From their study looking at the effects of working at night on the circa-dian rhythm and sleep quality among nurses, Brugne et al.[20] concluded that working at night is not advisable. This study demonstrated that those who work at night generally lack attention between 02.00 and 04.00 am, and recommended that periodical periods of sleep and rest (e.g. at noon) could reduce the negative impacts of working at night.

Sleep deprivation among health workers and the negative impacts of fatigue is an interesting and relevant field of study. These subjects have significant impacts on patient safety and the local economy. The influence of sleep on cognitive function and performance are revealed through prospective and retrospective studies.[20-22] Sleep is an important part of human life, and it is necessary for efficient performance. Ex-perimental studies on sleep have demonstrated that sleep deprivation leads to disorders in cognitive functions such as attention-related problems,[23] disturbances in practical functions, memory disorders, perception-related disorders, and affective disorders.[23,24]

Ratcliff et al.[25] reported that sleep deprivation has common but reversible influences on brain functions, especially cog-nitive functions. They stressed that sleep deprivation results in disturbances in decision-making mechanisms and infor-mation quality. Sleep deprivation is also reported to increase the risk of injuries and accidents. Sleeplessness, which results from working in shifts or on a 24-hour basis, is accompanied by mental and physical fatigue owing to irregular sleep pat-terns, frustration, distractibility, and irritation. Sleeplessness diminishes one’s ability to self-maintain, affecting his or her preparedness for and adaptation to the next day as well as his or her quality of life.[8,26] Human metabolism cannot ad-just to working at night, and negative impacts on the body can persist even ten years after this type of working is aban-doned.[8]

In the present study, it was observed that emergency health workers with poor sleep quality were generally tired. Fatigue is a reaction to insufficient satisfaction of physical and psy-chological needs. It is also an indicator of the existence of a disease. Fatigue usually prevents one from performing activities that he or she would be able to carry out under normal conditions. It gradually and cumulatively reduces ef-fective performance. Despite this, one can overcome with a period of good sleep. Even so, it is known that the effects of sleeplessness make it hard for one to handle various activi-ties when he or she is awake.[27,28]

Our study has some limitations. First, the data was collected through a survey based on subjective reporting. Second, the study did not include a control group comprised of indi-viduals who did not work in night shifts. Finally, our popula-tion consisted of emergency health workers in Kayseri, and thus we cannot generalize our results to other occupational groups.

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

Variables in professional and social life Rho p

Negative effects on daily life 0.462 <0.001

Excessive fatigue 0.429 <0.001

Negative effects on social life 0.375 <0.001

Reduced motivation 0.318 <0.001

Low job efficiency 0.306 0.001

Failure to take emergency actions 0.300 0.001

Reduced performance 0.275 0.002

Loss of attention and concentration 0.235 0.009

Communication difficulty 0.151 0.098


Conclusion

It is necessary for the working conditions at 112 Emergency Aid Stations, along with the length of shifts, to be reorga-nized. Areas allocated for rest during shifts should be im-proved and appropriate rest conditions should be estab-lished for the period following shifts. This will possibly better the currently poor sleep quality among emergency health workers, thus increasing work efficiency and performance and to enabling health workers to thrive in their profession.



References

1. Öztürk MO. Uyku bozuklukları, ruh sağlığı ve bozuklukları, Yenilenmiş 10. Basım. Ankara: Nobel Tıp Kitabevleri; 2004. p. 479-86.

2. Papilla İ, Acıoglu E. Obstrüktif uyku apne sendromu. Hipokrat Dergisi 2004;13:387–91.

3. Ertekin S. Hastanede yatan hastalarda uyku kalitesinin değerlendirilmesi. Cumhuriyet Üniversitesi Sağlık Bilimleri Enstitüsü Yayımlanmamış Yüksek Lisans Tezi, Sivas, 1998.

4. Çalıyurt O. Sirkadiyen uyku uyanıklık düzenini etkileyen ve çalışma gruplarında uyku kalitesinin değerlendirilmesi. Trakya Üniversitesi Tıp Fakültesi Psikiyatri Anabilim Dalı Yayımlanmamış Uzmanlık Tezi, Edirne, 1998.

5. Demir M. Vardiya sistemi ile çalışan hemşirelerin vardiya siste-minden kaynaklanan sorunlar hakkındaki görüşleri. Hacette-pe Üniversitesi Sağlık Bilimleri Enstitüsü Yayınlanmamış Bilim Uzmanlığı Tezi, Ankara, 1990.

6. Sarquis LM, Felli VE. Occupational accidents with sharp in-struments in nursing workers. [Article in Portuguese] Rev Esc Enferm USP 2002;36:222-30. [Abstract]

7. Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. The working hours of hospital staff nurses and patient safety. Health Aff (Millwood) 2004;23:202-12.

8. Bilazer FN, Konca GE, Uğur S, Uçak H, Erdemir F, Çıtak E. Türkiye’de hemşirelerin çalışma koşulları. Türk Hemşireler Derneği 2008;12-5.

9. Fischer FM, Bruni Ade C, Berwerth A, Moreno CR, Fernan-dez Rde L, Riviello C. Do weekly and fast-rotating shiftwork schedules differentially affect duration and quality of sleep? Int Arch Occup Environ Health 1997;69:354-60.

10. Ağargün MY, Kara H, Anlar Ö. Pittsburgh uyku kalitesi in-deksinin geçerliliği ve güvenirliği. Türk Psikiyatri Dergisi 1996;2:107-15.

11. Machi MS, Staum M, Callaway CW, Moore C, Jeong K, Suyama J, et al. The relationship between shift work, sleep, and cog-nition in career emergency physicians. Acad Emerg Med

2012;19:85-91. 12. Shao MF, Chou YC, Yeh MY, Tzeng WC. Sleep quality and

quality of life in female shift-working nurses. J Adv Nurs 2010;66:1565-72.

13. Fischer FM, Teixeira LR, Borges FN, Goncalves MB, Ferreira RM. How nursing staff perceive the duration and quality of sleep and levels of alertness. [Article in Portuguese] Cad Saude Pu-blica 2002;18:1261-9. [Abstract]

14. Watanabe M, Akamatsu Y, Furui H, Tomita T, Watanabe T, Ko-bayashi F. Effects of changing shift schedules from a full-day to a half-day shift before a night shift on physical activities and sleep patterns of single nurses and married nurses with children. Ind Health 2004;42:34-40.

15. Ruggiero JS. Correlates of fatigue in critical care nurses. Res Nurs Health 2003;26:434-44.

16. Edéll-Gustafsson UM. Sleep quality and responses to insuf-ficient sleep in women on different work shifts. J Clin Nurs 2002;11:280-8.

17. Vidacek S, Radosević-Vidacek B, Kaliterna L, Prizmić Z. The productivity of female shift workers. [Article in Croatian] Arh Hig Rada Toksikol 1990;41:339-45. [Abstract]

18. Ertekin Ş, Doğan O. Hastanede yatan hastalarda uyku kalite-sinin değerlendirilmesi. Erzurum, VII. Ulusal Hemşirelik Kon-gresi Kitabı; 1999. p. 222-7.

19. Karagozoglu S, Bingöl N. Sleep quality and job satisfaction of Turkish nurses. Nurs Outlook 2008;56:298-307.

20. Brugne JF. Effects of night work on circadian rhythms and sleep. Prof Nurse 1994;10:25-8.

21. Drummond SP, Gillin JC, Brown GG. Increased cerebral re-sponse during a divided attention task following sleep depri-vation. J Sleep Res 2001;10:85-92.

22. Bortoletto M, Tona Gde M, Scozzari S, Sarasso S, Stegagno L. Effects of sleep deprivation on auditory change detec-tion: a N1-mismatch negativity study. Int J Psychophysiol 2011;81:312-6.

23. Killgore WD. Effects of sleep deprivation on cognition. Prog Brain Res 2010;185:105-29.

24. McCoy JG, Strecker RE. The cognitive cost of sleep lost. Neuro-biol Learn Mem 2011;96:564-82.

25. Ratcliff R, Van Dongen HP. Sleep deprivation affects multiple distinct cognitive processes. Psychon Bull Rev 2009;16:742-51.

26. Karagözoğlu Ş, Çabuk S, Tahta Y, Temel F. Hastanede yatan yetişkin hastaların uykusunu etkileyen bazı faktörler. Toraks Dergisi 2007;8:234-40.

27. Dement WC, Carskadon MA. Current perspectives on daytime sleepiness: the issues. Sleep 1982;5 Suppl 2:56-66.

28. Haire JC, Ferguson SA, Tilleard JD, Negus P, Dorrian J, Thom-as MJ. Effect of working consecutive night shifts on sleep time, prior wakefulness, perceived levels of fatigue and per-formance on a psychometric test in emergency registrars. Emerg Med Australas 2012;24:251-9.

Turk J Emerg Med 2014;14(4):172-178178

An Adult Patient who Presented to Emergency Service with a Papular Purpuric Gloves and Socks Syndrome:

A Case ReportPapüler Purpurik Eldiven ve Çorap Sendromu ile

Acil Servise Başvuran Yetişkin Bir Hasta: Olgu Sunumu

CASE REPORT

Department of Emergency Medicine, Medeniyet Universty Göztepe Training and Research Hospital, Istanbul

Vehbi OZAYDIN, Alev ECEVIZ, Fatma SARI DOGAN, Arzu DOGAN

ÖZETMakül, papül, vezikül ve püstüllerle seyreden hastalıklara dö-küntülü hastalıklar denir. Pek çok viral enfeksiyon, jeneralize morbiliform deri döküntüleri ile ilişkilidir. Papüler purpurik el-diven ve çorap sendromu (PPGSS), insan parvovirus B19 virüsü-nün sebep olduğu klinik bir durumdur. El ve ayaklarda simetrik eldiven ve çorap tarzı lezyonlar ile beraberinde ağızda lezyon-lar ve ateş vardır. Otuz beş yaşında kadın hasta el ve ayaklarda papüler simetrik döküntü, aftöz orofarengeal lezyonlar ve ateş ile başvurdu. Fizik muayenesinde el-ayaklarda simetrik dökün-tüler ve ağızda aftöz lezyonlar mevcuttu. Parvovirus Ig M po-zitif saptanan hasta semptomatik tedavi uygulanarak taburcu edildi.

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

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

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

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

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

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


Submitted: March 27, 2013 Accepted: July 11, 2014 Published online: July 18, 2014

Correspondence: Dr. Vehbi Ozaydın. Medeniyet Universitesi Goztepe Egitim veArastirma Hastanesi, Acil Tip Klinigi, 34720 Istanbul, Turkey.


179

Turk J Emerg Med 2014;14(4):179-181

Case ReportA 35-year-old female patient had the complaints of rashes on her hands and feet, sore throat, high fever, and a burn/sting during urination when she was admitted to the emergency service. The patient, who did not have any known history of disease, had itchy hands and feet about five days before admittance, which sparked a high fever. The patient was conscious, oriented, and cooperative during her physical ex-amination and her physical findings were TA: 120/80 mmHg, pulse 102/min, and fever 39.5°C. The patient’s neck stiffness and lymphadenomegaly could not be measured. There were aphthous lesions in her oropharyx hyperemic and oral mu-cosa. She had petechial rashes of the gloves and socks type, and a macular appearance that did not go pale when pressed (Figure 1). Her other system findings were ordinary. Before presenting to the emergency service, she used antibiotics prescribed to her (gentamicin and cefditoren 200 mg) for two days. But when her complaints did not regress, she came to the service. In her tests, the white blood cell count was 6.5 (4.0-10.0 10^3/mm^3), Hemoglobin: 12.1 (11.5-16.0 g/dl), hematocrit: 37.1 (37-43%), serum reactive protein: 6.38 (0.00-0.800 mg/dL), and TIT: leukocyte esterase (LE) +++ and her biochemical tests were considered normal. She had a normal sinus rhythm in her electrocardiograph with a speed of 102 and there was not any ST-T change. Her troponin I level was also normal. After the initial diagnosis of gloves and socks syndrome, a consultation was requested from the infectious diseases department. The patient was then bedded in the infectious diseases department. When the B19 lgM Posi-tive: 1.219 (<0.572) and parvovirus B19 lgG Negative: 0.419 (<0.402) was observed, the etiology determined to be a acute parvovirus infection. The patient was diagnosed with parvovirus B19-related papular purpuric gloves and socks

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

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

180

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

mas and erythemas on hands and feet that exhibit a gloves and socks distribution, which is accompanied by fever and oral lesions. However, its relationship with parvovirus B19 was not known until 1991.[7] Systemic symptoms including exanthema, mucosal lesions, lymphadenopathy, mild fever, loss of appetite, and arthralgia are seen in PPGSS. Papular-purpuric lesions on hands and feet accompanied by painful and itchy symmetrical erythema and edema are its charac-teristics. Mucosal findings include petechia, pharyngeal ery-thema, swollen lips, and painful oral aphthous lesions.[8] Vul-var edema and erythema as well as dysuria have also been described.[9] Often lymphopenia and temporary anemia are seen in laboratory tests, with a less than often elevation in liver enzymes.[8] We did not find any anemia, lymphopenia, or biochemical abnormality in our patient. This syndrome limits itself to a period of 7-14 days.

Although our patient did not have any chest pain, she had slight myocarditis, so we took her electrocardiograph. Sinus tachycardia was detected and Troponin I was requested and found to be negative. Patients with rashes and a toxic ap-pearance should be questioned for chest pain, and their electrocardiographs should be taken with follow up ap-pointments.

The specific laboratory diagnosis of parvovirus B19 can be made by using a B19 antibody, viral antigen, or viral DNA. However, B19 specific DNA count results can still turn out positive. It will be useful to test DNA amounts with a Real-Time PCR in patients with immune deficiency due to insuf-ficient antibody response.[10] In our case, a final diagnosis could be established based on the findings parvovirus B19 lgM Positive: 1.219 (<0.572) and parvovirus B19 lgG Nega-tive: 0.419 (<0.402).

A specific antiviral treatment is not available for B19 infec-tion. A symptomatic treatment is hardly required for ery-thema infectiosum. Most of the time, the disease cures itself without leaving any sequels. The use of aspirin or ibuprofen may be necessary in patients who complain from arthralgia

or arthritis.[1,2] There is no vaccine to treat parvovirus B19, but research ongoing to find a treatment.[1]

In conclusion, we presented a case to remind that childhood diseases can, although rarely, be seen in adults who present to emergency services with high fever and rashes.



References1. Topcu Willke A, Söyletir G, Doganay M. Enfeksiyon hastalıkları

ve mikrobiyoloji. 3. baskı. İstanbul: Nobel Tıp Kitap Evi; 2008. p. 1710-7.

2. Brown KE. Human parvoviruses. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and practice of infectious diseases. 7th ed. New York: Churchill Livingstone; 2010. p. 2087-93.

3. Thomas JJ, Perron AD, Brady WJ. Ağır jeneralize deri hastalıkları. In: Judith E, editor. Tintinalli Acil Tıp. İstanbul: No-bel Kitap evi; 2013. p. 1619.

4. Cherry JD. Human parvovirus B19. In: Feigin RD, Cherry JD, Demler GJ, Kaplan SL, editors. Textbook of pediatric infec-tious diseases. 5th ed. Saunders; 2004. p.1796-809.

5. Bonfante G, Rosenau AM. İnfant ve çocuklarda döküntülü hastalıklar. In: Judith E, editor. Tintinalli Acil Tıp. İstanbul: No-bel Kitap evi; 2013. p. 912.

6. Woolf AD, Campion GV, Chishick A, Wise S, Cohen BJ, Klouda PT, et al. Clinical manifestations of human parvovirus B19 in adults. Arch Intern Med 1989;149:1153-6.

7. Harms M, Feldmann R, Saurat JH. Papular-purpuric “gloves and socks” syndrome. J Am Acad Dermatol 1990;23:850-4.

8. Katta R. Parvovirus B19: a review. Dermatol Clin 2002;20:333-42.

9. Harel L, Straussberg I, Zeharia A, Praiss D, Amir J. Papular pur-puric rash due to parvovirus B19 with distribution on the dis-tal extremities and the face. Clin Infect Dis 2002;35:1558-61.

10. Işık N, Sabahoglu E, Işık DM, Anak S, Ağafidan A, Bozkaya E. Klinik olarak parvovirus B19 infeksiyonu ön tanılı olguların vi-rolojik takibi. Turk Mikrobiyol Cem Derg 2004;34:62-6.

Ozaydin V et al. An Adult Patient Who Presented to Emergency Service with a Papular 181

Retropharyngeal Hematoma due to Oral Warfarin Usage

Oral Varfarin Kullanımına Bağlı Gelişen Retrofarengeal Hematom

CASE REPORT182

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

Ibrahim TOKER, Ozge DUMAN ATILLA, Murat YESILARAS, Burcu URSAVAS

ÖZETAntikoagülan kullanımına bağlı retrofaringeal hematom nadir görü-len, hızlı tanı ve tedavi edilmesi gereken hayatı tehdit edici bir durum-dur. Hava yolu ve koagülopatinin acil kontrolü tedavi yönetiminin esa-sını oluşturur. Olgular çoğunlukla konservatif tedaviye cevap verirken bazen endotrakeal entübasyon ve acil trakeotomi gerekebilir. Bu ya-zıda, varfarin kullanımına sekonder retrofaringeal hematom gelişmiş 49 yaşındaki erkek olguyu sunduk.

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

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

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

IntroductionWarfarin and other vitamin K antagonists are used in a vari-ety of clinical situations.[1] By inhibiting vitamin K sycloepo-xide reductase and vitamin K reductase enzymes that play a role in α (alpha) carboxylation of factor 2, factor 7, factor 9, factor 10 and other vitamin K related proteins, warfarin pre-vents the activation of coagulation factors and thus reduces coagulation or inhibits it entirely.[2] Its most frequent side-ef-fect is hemorrhage. Spontaneous hemorrhage as a result of anticoagulation with warfarin is rare, potentially life-threate-ning and requires individual care for each patient.[3,4]

In this article, we present a case with retropharyngeal hema-toma due to warfarin overdose.

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

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


Submitted: January 13, 2013 Accepted: February 21, 2014 Published online: November 30, 2014

Correspondence: Dr. Ibrahim Toker. Izmir Tepecik Egitim ve Arastirma Hastanesi, Acil Tip Klinigi, Gaziler Caddesi, No: 468, Yenisehir, 35170 İzmir, Turkey.


and 9.59 g/dl, respectively. In the lateral cervical graphy, pre-vertebral soft tissue thickness at level C2 was measured at 33.5 mm (Figure 2). Noncontrast enhanced computerized tomography (CT) of the neck was performed and revealed retropharyngeal hematoma spread through to subglottic area from nasopharynx (Figure 2).

The patient consulted with internal medicine specialist and otorhinolaryngologist and was admitted to the otorhino-laryngology clinic for follow-up. The patient was discharged following the regression of pharyngeal hematoma and ab-sence of additional problems during his hospital stay.

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

Toker I et al. Retropharyngeal Hematoma due to Oral Warfarin Usage 183

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

(a) (b)

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

Turk J Emerg Med 2014;14(4):182-184

speed. Although tenderness and swelling in the neck directly points to this diagnosis, symptoms such as sore throat, short-ness of breath, dysphagia, or odinophagia may also point to the same diagnosis.[7] Some cases have reported warfarin-as-sociated upper airway hemorrhage following a severe coug-hing episode or straining6. Risk of warfarin-associated major hemorrhage significantly increases when INR value becomes >5.08. Anticoagulation must be inhibited with fresh frozen plasma (FFP) or 2.5-5.0 mg intravenous vitamin K in hemorr-hages which are thought to be more serious than the risk of thrombosis and cannot be controlled locally.[8] There is no in-formation that indicates thromboembolism risk due to tem-porary reversion of anticoagulation is more dominant than the results of severe hemorrhage in patients with mechanical prosthesis.[9] Treatment involves providing a secure airway, controlling hemorrhage and correcting coagulopathy. En-dotracheal intubation, cricothyroidotomy or tracheostomy may be required depending on the patient’s condition.[10] Most patients with retropharyngeal hematoma can be trea-ted conservatively. Hematoma is mostly cured with conser-vative treatment, but it might take a few weeks.[11]

Retropharyngeal hematoma is a life-threatening complicati-on of anticoagulant treatment. Patients might be admitted with complains such as a sore throat, as in our case. These symptoms might be related to common causes such as up-per airway infections, so hematoma might be overlooked. Therefore, hematoma in the pharyngeal area should be con-sidered in admitted patients administered anticoagulants and in whom symptoms such as odinophagia, dysphagia, cough and hoarseness are observed.



References

1. http://www.uptodate.com/contents/therapeutic-use-of-warfarin-and-other-vitamin-k-antagonists, last access: De-cember 18, 2013.

2. Horton JD, Bushwick BM. Warfarin therapy: evolving strate-gies in anticoagulation. Am Fam Physician 1999;59:635-46.

3. Howard MR, Hamilton PJ. Anticoagulation and thrombolytic therapy. In: Howard MR, Hamilton PJ, editors. Haematology & An Illustrated Colour Text. 4th ed. UK: Churchill Livingstone; 2013. p. 80-1.

4. Koch CA, Olsen SM, Saleh AM, Orvidas LJ. Spontaneous epi-glottic hematoma secondary to supratherapeutic anticoagu-lation. Int J Otolaryngol 2010;2010:201806.

5. Warkentin TE, Crowther MA. Anticoagulant and thrombolyt-ic therapy. In: Young NS, Gerson SL, High KA, editors. Clinical hematology. 1st ed. St. Louis; Mosby-Elsevier; 2006. p. 1114-33.

6. Kaya M, Ceylan M, Nesteren S, Yıldırım Ö, Eskiçırak HE, Kadıoğulları AN. Pharynx hematoma due to anticoagulant treatment: case report. Turk J Anesth Reanim 2012;40:287-9.

7. Aslan S, Keşkek Ö, Kesici A. Spontaneous, retro- and parapha-ryngeal hematoma due to anticouagulant treatment: case Report. Turkish Otolaryngology Archive 2009;47:53-7.

8. http://www.uptodate.com/contents/antithrombotic-thera-py-in-patients-with-prosthetic-heart-valves, last access: De-cember 12, 2013.

9. Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquiv-ias G, Baumgartner H, et al. European Society of Cardiology (ESC) cardiac valve diseases treatment guide, 2012 version, Turkish Cardiology Association 2012:83-128.

10. Yaman H, Guven DG, Kandis H, Subasi B, Alkan N, Yilmaz S. Sublingual and supraglottic haemorrhage as a complication of warfarin therapy warfarin: case report. Hong Kong J Emerg Med 2011;18:177-81.

184

Cost of Beauty; Prilocaine Induced Methemoglobinemia

Güzelliğin Bedeli; Prilokaine Bağlı Gelişen Methemoglobinemi Olgusu

CASE REPORT

Department of Emergency Medicine, Baskent University Faculty of Medicine, Ankara

Elif KILICLI, Gokhan AKSEL, Betul AKBUGA OZEL, Cemil KAVALCI, Dilek SUVEREN ARTUK

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

Anahtar sözcükler: Methemoblobinemi; prilokain; siyanoz.

SUMMARY

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

Key words: Methemoglobinemia; prilocaine; cyanosis.

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

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

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


Submitted: August 20, 2013 Accepted: November 11, 2013 Published online: January 17, 2014

Correspondence: Dr. Gökhan Aksel. Başkent Üniversitesi Tıp Fakültesi Ankara Hastanesi,Mareşal Fevzi Çakmak Mah., 10. Sokak, No: 45, Bahçelievler, Ankara, Turkey.


185

Turk J Emerg Med 2014;14(4):185-187

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

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

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

In methemoglobinemia resulting from chemical substances,

the first step of treatment is to avoid further exposure. If methemoglobinemia is under 20%, spontaneous recovery is usually observed after drug avoidance, but treatment may be necessary in newborns and infants.[8] Methylene blue, ascorbic acid, and riboflavin have been suggested as treat-ment modalities.[9] Methylene blue should be administered 1-2 mg/kg intravenously in five minutes, and repeated one hour later if adequate improvement is not observed.[10] It is contraindicated in patients with glucose 6 phosphate dehy-drogenase deficiency because administration of methylene blue can cause aggravation of methemoglobinemia, chest pain, cyanosis and hemolytic anemia.[3] In such cases, ascor-bic acid can be considered as an antidote.[11,12] Hyperbaric oxygen therapy and exchange transfusion is another option if MetHb level is over 70%.

Ascorbic acid reduces MetHb by a non-enzymatic processes in animal and human erythrocytes in vitro, which makes ascorbic acid a candidate for treatment of methemoglo-binemia.[13,14] It is most commonly used orally in long term treatment of patients with hereditary methemoglobinemia.[1] Although, methylene blue can be a first choice treatment of methemoglobinemia, if there is limited experience in the use of ascorbic acid in toxic methemoglobinemia.[15] Al-though MetHb was measured relatively less (14.1%) in the present case, there was an indication of antidote therapy due to the patient being symptomatic. In addition, ascorbic acid was chosen because a limited supply of methylene blue in the hospital. After administration of ascorbic acid, MetHb was measured as 2.4% and she was asymptomatic. Aydogan et al. reported that two patients with methemoglobinemia recovered after ascorbic acid administration.[13] Tekbas et al. also reported an improvement in a patient with combined treatment of methylene blue and ascorbic acid caused by methemoglobinemia due to prilocaine given before intra-vascular laser therapy.[16]

Conclusion

Methemoglobinemia resulting from the usage of prilocaine within and out of hospital is a major concern. Methemoglo-binemia should be considered in patients who had cyanosis after local anesthetic administration. In cases which methy-lene blue could not be used as an antidote, ascorbic acid can be a safe alternative.



References1. Honig GR. Hemoglobin disorder. In: Behrman RE, Kleigman

186

RM, Jenson HB, editors. Nelson textbook of pediatrics. Phila-delpiha: Saunders; 2004. p. 1478-88.

2. Aygencel SG, Akinci E, Pamukcu G. Prilocaine induced methe-moglobinemia. Saudi Med J 2006;27:111-3.

3. Tabel Y, Sandikkaya A, Gungor S, Ozgen U. Methemoglobin-emia after injection of prilocaine for pre-medication of cir-cumcision. [Article in Turkish] J Dicle Med School 2009:36:53-5.

4. Coleman MD, Coleman NA. Drug-induced methaemoglobi-naemia. Treatment issues. Drug Saf 1996;14:394-405.

5. Kreutz RW, Kinni ME. Life-threatening toxic methemoglobin-emia induced by prilocaine. Oral Surg Oral Med Oral Pathol 1983;56:480-2.

6. Warren RE, Van de Mark TB, Weinberg S. Methemoglobinemia induced by high doses of prilocaine. Oral Surg Oral Med Oral Pathol 1974;37:866-71.

7. Guay J. Methemoglobinemia related to local anesthetics: a summary of 242 episodes. Anesth Analg 2009;108:837-45.

8. Mansouri A, Lurie AA. Concise review: methemoglobinemia. Am J Hematol 1993;42:7-12.

9. Akıncı E, Yüzbaşıoğlu E, Aslay S, Coşkun F. Incidence of meto-clopramide-induced methemoglobinemia. Turk J Emerg Med 2011;11:49-53.

10. Ryoo S, Sohn Ch, Oh B, Kim W, Lim K. A case of severe methe-moglobinemia caused by hair dye poisoning. Hum Exp Toxi-col 2014;33:103-5.

11. Gülgün M, Kul M, Sarıcı S. Prilocaine-induced methemoglo-binemia: report of two cases and review of literature. Erciyes Tıp Dergisi (Erciyes Medical Journal) 2007;29:322-5.

12. Öztürk E, Aktaş BT, Öztarhan K, Adal E. Lokal anestezik uygulaması sonrası gelişen methemoglobinemi. Jopp Rerg 2010;2:46-8.

13. Aydogan M, Toprak DG, Turker G, Zengin E, Arisoy ES, Go-kalp AS. Intravenous ascorbic acid treatment in prilocaine-induced methemoglobinemia: report of two cases. [Article in Turkish] Cocuk Sagligi ve Hastaliklari Dergisi 2005;48:65-8.

14. den Boer PJ, Bleeker WK, Rigter G, Agterberg J, Stekkinger P, Kannegieter LM, et al. Intravascular reduction of methemo-globin in plasma of the rat in vivo. Biomater Artif Cells Immo-bilization Biotechnol 1992;20:647-50.

15. Ballin A, Brown EJ, Koren G, Zipursky A. Vitamin C-in-duced erythrocyte damage in premature infants. J Pediatr 1988;113:114-20.

16. Tekbas G, Oguzkurt L, Ozkan U, Gurel K. Prilocain-induced methemoglobinemia after endovenous laser ablation. J Vasc Interv Radiol 2010;21:758-9.

Kilicli E et al. Cost of Beauty 187

Spinal Trauma is Never without Sin: A TetraplegiaPatient Presented Without any Symptoms

Spinal Travma Masum Değildir: Asemptomatik Başvuran Tetrapleji Olgusu

CASE REPORT188

1Department of Emergency Medicine, Marmara University Faculty of Medicine, Istanbul;2Department of Radiology, Tirebolu State Hospital, Giresun

Melis EFEOGLU,1 Haldun AKOGLU,1 Tayfun AKOGLU,2 Serkan Emre EROGLU,1

Ozge Ecmel ONUR,1 Arzu DENIZBASI1

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

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

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

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

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

Thoracic and cervical segments are affected most and para-plegia secondary to autonomic dysfunction, respiratory or cardiovascular disorders or tetraplegia can be seen.

While SCI patients can rarely present asymptomatically, pro-gressive neurological disorders and death can be seen due to edema and secondary injury. For this reason, all SCI cases


Submitted: August 21, 2013 Accepted: January 05, 2014 Published online: January 07, 2014

Correspondence: Dr. Melis Efeoglu. Marmara Universitesi Pendik Egitim ve Arastirma Hastanesi,Acil Tıp Anabilim Dali, Ustkaynarca, Pendik, 34347 Istanbul, Turkey.


should be thoroughly examined and accompanying pathol-ogies must be excluded.

In this case report, the progressive nature of the neurologi-cal disorders in an asymptomatic SCI case, its diagnostic processes and treatment are discussed, with an attempt to emphasize the importance of the approach to injuries with dangerous mechanisms.

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

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

Efeoglu M et al. A Tetraplegia Patient Presented Without any Symptoms 189

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

(a) (b)

Turk J Emerg Med 2014;14(4):188-192

2a, b); there were compression fractures of the T1-T2-T3-T5-T11 vertebral corpus, along with left paracentral protrusions causing compression of the anterior subarachnoid space of the intervertebral discs at the T7-T8 level (Figure 2c, d). The patient was consulted to the Neurology and Neurosurgery Departments, and was admitted by the Neurosurgery De-partment. Upon no pathology being detected in the Digital Subtraction Angiography (DSA), the patient was operated and C3-to-C6 laminectomy surgery was performed on the same day. The patient, who developed respiratory failure

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

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

190

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

(a)

(c)

(b)

(d)

(34.9%). Complete SCI is more common than incomplete SCI (56.5% to 43%), and paraplegia is more common than tetraplegia (58.7% to 40.6%).[2] Firearm injuries, sports inju-ries, and diving accidents can also be included among other etiological factors.[3]

The cervical level (C5) is the most commonly affected area.[4] The pathophysiology of spinal injury generally consists of direct damage to the medulla spinalis by trauma, compres-sion due to bone fragments, hematomas and disc material, ischemia as a result of spinal artery injuries and the accom-panying tissue edema.[5]

In studies carried out to evaluate the blood flow in the dor-solateral cord in severe spinal trauma, it has been shown that for 60 to 90 minutes following cord damage autoregu-lation mechanisms remain intact; however, simultaneously with the onset of ischemia this continuity begins to be dis-rupted. As a response to SCI, both disruption of autoregula-tion and vasoconstriction of resistance blood vessels devel-ops. In the early post-traumatic period, intervention aimed at ensuring perfusion can be valuable in terms of reverting or limiting loss of function due to secondary damage caused by ischemia.[6]

In a study by Morais DF et al. it was shown that MRI was dis-tinctly superior to CT in terms of evaluating bone structure, in posterior ligament injuries, spinal cord compression and disc herniation.[7] In our case, the 1st Radiologist reported no osseous pathologies from the CT scan, however the 2nd and 3rd Radiologists reported a fracture of the left C1 lamina. The two Radiologists evaluating the MRI (2nd and 3rd Ra-diologists) identified cervical and thoracic fractures which were unapparent on the CT. The 2nd Radiologist was an ex-perienced faculty member tasked with routine reporting at the hospital where the case presented, and the 3rd Radiolo-gist was a physician with 10 years of academic experience working in a different city (TA), who was invited to review images blindly upon the preparation of this article. Both ra-diologists had the same opinion that central protrusions of the intervertebral discs exerting pressure on the spinal cord along C2-C7, edema/bleeding was prominent at C2-C3, C3-C4 levels secondary to contusion, and apparent compres-sion fractures of T3 and T11 along with the degeneration of T1, T2 and T5 (Figure 2a-d). Additionally, in the evaluation carried out by the 3rd Radiologist, minimally displaced flex-ion-distraction type fracture from the frontal section of the lower plateau of the C3 vertebra corpus towards the upper-mid section, with a tear drop fracture, a minimal retrolisthe-sis of the C3 according to C4, along with Modic type 2 bone marrow signal intensity changes consistent with degen-eration of the T1, T3 and T5 vertebra corpuses and Schmorl nodule indentations were noted. During surgery, loss of the

complete integrity of the C3 vertebra was determined and laminectomy surgery was performed on adjacent vertebrae. Thus, the C3 vertebra extension-distraction and tear-drop fractures were responsible for the spinal cord bleeding, which could not be determined by three separate radiolo-gists and the emergency medicine physicians on the CT, and which was only determined by one of two radiologists re-porting the MRI, was clinically diagnosed.

The bilateral sensory-motor loss is accepted as an indication of complete SCI. The lack of neuromotor loss upon admis-sion in our case, followed by motor and sensation loss start-ing from the shoulder level leading to tetraplegia shows that the edema/bleeding due to contusions at the C2-C3-C4 levels were increased and led to a complete SCI. Since up-dated SCI treatment guidelines (2013) do not recommend high-dose methylprednisolone anymore, immediate surgi-cal treatment of the patient was planned.[8]

Vertebral artery injuries (VAI) may accompany cervical in-juries, their mortality is high and they can lead to ischemic stroke.[9] Upper level vertebral fractures (such as C1-C3) - in-cluding transverse foramen fractures - are particular risk fac-tors for vertebral artery injury.[10] Today, CT angiography is the diagnostic method of choice for VAI. DSA is also one of the commonly used imaging methods. It has been reported that despite all anticoagulant therapy, fatal complications such as cerebrovascular insufficiency or embolus may de-velop in 5.8% of patients, while 2.9% of patients die due to cerebrovascular ischemia.[11] In VAI, treatment options are anticoagulants, antiplatelets, thrombolysis, endovascular or surgical treatment.[12-14] In our case, VAI was excluded by the lack of thrombus or dissection of the vertebral artery from CT angiography, which was ordered upon the presence of the stable C1 lamina fracture (one of the risk factors) and worsening findings upon neurological examination. This data suggests that the acute ischemic lesion in the left pa-rieto-temporo-occipital region detected in the diffusion MRI of our patient may have not been developed due to VAI, but may have developed due to hypoperfusion leading to loss of consciousness.

Neurogenic shock may develop in a portion of patients with spinal trauma[15] and can cause neurological disorders to progress to levels which may threaten the patient’s life. Spinal stabilization of the patients, vasopressor treatment with fluid support and early surgical decompression of the spinal cord are accepted treatments.[16] In a study by Tuli et al. delayed surgical treatment has been shown to be associated with the development of neurogenic shock.[17] Our patient had a blood pressure of 90/65 upon presenta-tion, and the absence of a source of bleeding to explain the hypotension suggests that the patient may actually have

Efeoglu M et al. A Tetraplegia Patient Presented Without any Symptoms 191

been developing neurogenic shock.

The acute cerebral infarct which appeared in the diffusion MRI of the patient may have developed secondary to hypo-tension due to neurogenic shock. Additionally, the loss of consciousness for a period of three to four minutes upon the accident and the SPO2 being 90% upon presentation may have contributed to the development of the cerebral infarct. In this context, we believe that our patient, where cerebral infarct and complete high spinal injury developed due to progressive edema, highlights the importance of a skeptical approach to patients presenting with asymptomatic spinal trauma, and not delaying advanced examination by putting forward the indications on radiological imaging.

Respiratory failure, multiple organ failure and gastroin-testinal bleeding are the leading causes of death in these patients.[18] In the light of this information, it is of vital im-portance that emergency physicians predict the possible complications that can develop and take the necessary pre-cautions.

Conclusion

Spinal trauma is likely to cause neurological disorders. In asymptomatic patients in whom no fractures were diag-nosed in CTs, neurological examination should be repeated several times to exclude if any neurological injuries were en-sued. Even though it is not a frequent diagnostic modality, especially in patients without any fractures on CT but who have neurological signs, MRI should be ordered in emergen-cy department.



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7. Morais DF, de Melo Neto JS, Meguins LC, Mussi SE, Filho JR, Tognola WA. Clinical applicability of magnetic resonance im-aging in acute spinal cord trauma. Eur Spine J 2014;23:1457-63.

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9. DeVivo MJ, Chen Y, Mennemeyer ST, Deutsch A. Costs of care following spinal cord injury. Top Spinal Cord Inj Rehabil 2011;16:1-9.

10. Savitz SI, Caplan LR. Vertebrobasilar disease. N Engl J Med 2005;352:2618-26.

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12. Vaccaro AR, Klein GR, Flanders AE, Albert TJ, Balderston RA, Cotler JM. Long-term evaluation of vertebral artery injuries following cervical spine trauma using magnetic resonance angiography. Spine 1998;23:789-95.

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16. Maurin O, de Régloix S, Caballé D, Arvis AM, Perrochon JC, Tourtier JP. Traumatic neurogenic shock. [Article in French] Ann Fr Anesth Reanim 2013;32:361-3. [Abstract]

17. Tuli S, Tuli J, Coleman WP, Geisler FH, Krassioukov A. Hemo-dynamic parameters and timing of surgical decompres-sion in acute cervical spinal cord injury. J Spinal Cord Med 2007;30:482-90.

18. Leng YX, Nie CY, Yao ZY, Zhu X. Analysis of the risk factors for early death in acute severe traumatic cervical spinal cord in-jury. [Article in Chinese] Zhonghua Wei Zhong Bing Ji Jiu Yi Xue 2013;25:294-7. [Abstract]

Turk J Emerg Med 2014;14(4):188-192192

Department of History of Medicine and Ethics, Afyon Kocatepe University Faculty of Medicine, Afyonkarahisar

Hasan ERBAY

Some Ethical Issues in Prehospital Emergency Medicine Hastane Öncesi Acil Tıpta Bazı Etik Konular

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

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

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

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

REVIEW

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

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


Submitted: June 27, 2014 Accepted: August 27, 2014 Published online: November 30, 2014

Correspondence: Dr. Hasan Erbay. Afyon Kocatepe Universitesi Tip Fakultesi, Dekanlık Binasi, B Blok,Tip Tarihi ve Etik Anabilim Dalı, Afyonkarahisar, Turkey.


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emergency medical care has many different characteristics, including unpredictable patient profiles, emergency condi-tions, and administration of care in a non-medical area. Ad-ditionally, it is a team-based process.

This article addresses general ethical issues, especially conf-licts that occur in prehospital emergency medicine that are not situations that might differ by country. Prehospital care is delivered by emergency physicians in some countries and by emergency medical technicians or nurses in others. It should be stated that the term “prehospital emergency ca-regivers” (PECs) is used in this article to refer to any physi-cians, emergency technicians, nurses, or paramedics. Many of the conflicts occur in the same way across countries and require an ethical decision to be made. It is high time to turn attention to the ethical issues in prehospital medicine. The following overview describes the range of ethical conflicts that occur in prehospital emergency care settings; however, it avoids attempting to try to solve the conflicts. In the con-text of operation of the ambulance dispatch system, ethical issues can be classified into four categories:

1- Process before medical interventions

2- Treatment process

3- End of life and care

4- Perceptions of using/misusing the ambulance.

1. Ethical issues related to the process beforemedical interventions:

a. Justice: Justice is a primary ethical principle that expects caregivers to try to be as fair as possible to the patients.[1] It comes into conflict particularly when there are many emer-gency calls and not enough ambulances. Justice may not be straightforward in the situations such as scarce medical resources. Justice is primarily an issue related to the emer-gency dispatch call center. The cases in which a preference is involved also raise ethical concerns.

b. Problems associated with finding an address: Finding an address in a short period of time requires a strong and ef-fective technical support infrastructure. Indeed, there is no point in having the best medical knowledge, skills, or ambu-lances if a patient cannot be reached in time. The prognosis of the emergency case can be affected by this delay. Thus, it is important to have a strong and effective technical support for prehospital emergency care so as not to delay treatment of emergency patients. It might appear to be simply a basic technical issue, but it is truly an important ethical issue re-lated to the basic principle of beneficence/nonmaleficence as well.

c. Stigmatization: Stigmatization in prehospital settings oc-curs in relation to individuals’ diseases, locations, and the social or cultural criticism that may accompany them. Stig-matization occurs socially and culturally in PECs’ minds befo-re any medical inventions. Examples include administering care to alcoholics, drug addicts, sex workers, and terminal cancer patients. Before first contact is made, stigmas and prejudices held by PECs can affect the care administered in prehospital emergency medical care. It is an ethical conflict for PECs whether or not to act in accordance with a percei-ved stigma.

d. Interventions in dangerous situations: Some prehospital settings pose dangerous conditions for emergency teams. These settings include war zones, traffic accidents, and areas at risk of fire or explosions. These situations, which put an ambulance crew at personal risk, raise ethical conflicts. The crucial question is whether or not PECs should risk their own lives for injured individuals.[4] One ethical dilemma is whet-her or not the duty of emergency care includes placing one-self at risk. It is a crucial question for prehospital emergency settings, and whatever the answer, it could include very im-portant ethical issues /conflicts.

e. Safe driving: It is important to drive an ambulance in ac-cordance with general traffic rules. In the class of a mid-size car, an ambulance must be driven within the speed limits in a safe manner. There are many studies about the effects of siren and light usage in relation to the time of arrival to the hospital.[5] Someone who is speeding while driving to act on behalf of the patient risks their own safety and health as well as the patient’s. Such a situation is much more related to altruism, which is an ethical term. It is not easy to justify because the PECs should ensure their own safety.[4,6]

2. Ethical issues which are related to thetreatment process:

a. Beneficence/nonmaleficence: As a basic principle for all me-dical practice, beneficence/nonmaleficence is also clinical in medical emergencies. The arising ethical conflict is the issue of what is better for the patient. PECs are supposed to act for the benefit of the patient.[7] But what about (or to whom) the beneficence of the patient? What is the beneficence? Is it just a medical beneficence? It is the value of professionalism and responsibility of PECs to be aware of individuals’ psycho-logical and emotional state.

b. Triage: Triage is one of the most important ethical issues of emergency medicine.[7,8] In this article, two basic appro-aches on this issue have been mentioned, and extensive evaluations have been referred to in other studies. The main issue is the evaluation and selection criteria. Most educati-on systems emphasize maximum benefit. However, it is very

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difficult to standardize the meaning of “maximum benefit”. Does maximum benefit prioritize the age of the patients, calculated life expectancy, or contribution to society? Is it just the sheer number of patients saved? As demonstrated, the selection and evaluation process during triage contains many ethical conflicts.

Thus, this area needs more information and discussion; ma-ximum beneficence is one of two approaches, while the ot-her is to give each patient an equal chance in emergency situations.[9] The first approach focuses on result while the second puts an emphasis on intention.

c. Refusal of treatment: In a case of refusal of treatment, PECs face ethical conflicts addressing two basic principles: bene-ficence and respect for patient autonomy.[10] The main point of this conflict is assessing the patient’s decision-making ca-pacity. However, there is no point in assessing the patient’s capacity if you do not administer care. It is the critical zone in emergency medicine, but PECs are not required to assess the decision-making capacity of the patient. It is difficult to properly assess this capacity in a short period of time.

However, the presence of advance directives might make conflicts easier to resolve, but it should be remembered that the status of advance directives is not described clearly in many countries.

d. Refusal of transport to hospital: When patients do not want to go to the hospital, it creates an ethical conflict between the patient’s desire and the duty of PECs. The patient may believe that it is probably not necessary to go to the hos-pital. The patient perceives an easy solution with medical interventions at home; however, the emergency crew might not agree with that solution.

e. Irrational requests of relatives (or bystanders): The ethical responsibility of a health professional is not only in regards to him- or herself and his or her patients, but also the profes-sional value. For example, a relative might irrationally requ-est an unnecessary ambulance ride or refuse treatment for their relative. It is a conflict that arises between the patient’s best interest and PECs’ professional roles.[11]

f. Dealing with difficult patients: The term “difficult patient” refers to two meanings here: those who are intoxicated (by alcohol or drugs), or those who are terrified, obstinate, or agitated. These two main reasons may cause difficult patient cases: the patient is aware of being in a non-hospital envi-ronment and therefore acts override of the formal pressure of health care systems; or the patient is anxious/nervous as a result of his/her illness. Effective communication skills are necessary to deal with these patients. Being aware of the patient’s point of view is important in this instance.

g. Relationships within the crew: Prehospital care personnel are expected to work together, ignoring real or imagined dif-ferentiations and egos.[6] Some differences in opinion abo-ut the emergency patient or the process can lead to ethical conflicts in the crew. Additionally, some cases with structu-re of personality of health care professionals can cause the similar conflicts. It is about the best interest of the emer-gency patient, and it could be affected by many individual or professional factors. For example, ambulance nurses act according to how they would want to be treated in the same situation.[12]

h. Relationship between other care professionals: Different care professionals could be in conflict about what it is in the best interest of the patient.[13] PECs might think it is best for the patient to be transported. However, somebody in the hospital care system may not agree with them. Prehospital emergency needs and hospital needs could be in conflict. It is worth mentioning that sharing the responsibilities and identifying a novice or experienced actor are the main deter-minants of conflicts.

i. Informed consent: Informed consent is one of the most common ethical issues and conflicts encountered by PECs.[14] It is a valuable professional practice when the patient can make his/her own health care decision. But in some prehos-pital settings, the patient is not in a situation that facilitates this decision. Therefore, two questions arise:[4] “When do pa-tients lack capacity?” and “Who makes the decision?”

The competency of the patient is important with regards to informed consent. A patient not only needs to be com-petent to make a decision, but also to have enough time to be informed properly. Unfortunately, as is the case in many prehospital settings, there is insufficient time or unsuitable conditions for informed consent. A medical emergency is an exception to the requirements of informed consent.[1] This is based on the presumption that a reasonable patient would consent to such kind of treatment. The conflict arises over whether the case should be an exception, and whether or not the patient is a reasonable person.

j. Decision-making capacity: This is also related to informed consent. After some emergencies, the patient is unable to make his own decision, and PECs must be aware that the pa-tient has an impaired decision-making capacity. Assessing the decision-making capacity is quite difficult and compli-cated in prehospital settings.[15] Physicians are frequently unaware of a patient’s incapacity for decision making.[16] This difficulty further complicates the situation for non-physician emergency health care professionals.

k. Patient privacy and confidentiality: Prehospital emergency settings may involve a patient’s home or place of work. In

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Turk J Emerg Med 2014;14(4):193-198

these cases, PECs need to pay more attention to the privacy and confidentiality of the patient. PECs need to maintain privacy with regards to the individual’s health information, privacy, physical condition, private life, and lifestyle.[17] This principle also applies to the rights of a person who died (or is newly dead). Due to variations in perception changing from person to person about privacy and confidentiality, ethical challenges result in ethical conflicts in prehospital emer-gency medicine when considering patient privacy.

l. Telling the truth: Like other health professinals, PECs are expected to be honest with patients. However, they face a conflict between the implication of the truth and the patient’s best interest. When time is of the essence and the patient is critically ill, it is more important to administer me-dical care than to explain the procedure to the patient, even if the PEC is unsure of whether the patient will look upon the procedure favorably. it is a slippery slope. It is rationalized that a reasonable person would consent to treatment, and a delay (because of being told about the procedure) in treat-ment would lead to death or serious harm.[18] This is not just an ethical issue but a legal one as well; thus, PECs should be aware of the legislation in their countries.

3. Ethical issues related to the end of life and care:

a. Terminal stage patients: The word “terminal stage” is com-monly used for patients with cancer; however, this article uses this term for all patients who are near death or severely ill. Therefore, it is also a difficult period for patients, caregi-vers, and relatives. Prehospital emergency care is sometimes necessary for terminal stage patients. In these cases, effective communication skills are as important as medical care. The difference between the expectations of the patient (as well as relatives) and provided health care may be greater than expected. Obviously, this is a very difficult ethical issue, and the conflicts should be regarded as usual when there are lots of expectations and people but fewer things to do. However, rich and sensitive dialogue is needed so that all dying pati-ents and their families receive quality end-of-life care.[19]

b. Life-sustaining treatments: In terminal care, physicians’ ex-perience and training, as well as personal life-values and at-titudes, markedly influence their decision making processes.[20] It depends on the perception of the duty of life-sustaining care in prehospital emergency medicine. However, further discussion is needed on the role of medicine-especially emergency-at the end of life.

c. Initiation of prehospital cardiopulmonary resuscitation (CPR): These are the patients with the potential for long-term survival; however, it is infrequently determined at an early stage. The medical decision in such situations must be made within seconds. If patients are to benefit from resuscitation,

they could regain consciousness and their life activities.[21] Although there are standardized signs of death, appropria-teness of resuscitation is important. There are also characte-ristics of both patients and the attending ambulance crew that affect the likelihood of resuscitation attempts.[22]

Making the initiation of prehospital CPR more ethically complex is a Do-Not-Resuscitate (DNR) order. DNR has no basis towards making decisions about the current treatment but only avoids resuscitation.[23] DNR conflicts are one of the most frequent dilemmas reported by emergency medical technicians.[24]

When confronting these challenges, the majority of the pa-ramedics relied heavily on the advice of medical experts, but some had to make more autonomous decisions.[25] In gene-ral, if there is any doubt about the appropriateness of with-holding resuscitative attempts, CPR should be initiated.[26]

d. Withholding or withdrawal of CPR: In a prehospital setting, the decision to withhold or withdraw CPR is principally ba-sed on reliable criteria that include obvious clinical signs of death, evidence of cardiac death, or fatal trauma. However, in some ambulance services there are no doctors in the crew, and evaluating the signs of death is a duty of parame-dics. This poses the first conflict in prehospital CPR.

The second is the termination of CPR. Generally, CPR is ter-minated after 30 to 45 minutes if it has been unsuccessful.[27] However, is it appropriate to make any suggestions about the end-of-life process which are not only medical, but also social and cultural? Families are comfortable accepting ter-mination of unsuccessful out-of hospital cardiac resuscitati-on.[28] An individual situation is affected by many things, inc-luding the age of the patient, ongoing or coexisting disease, the reason for the CPR, resource and continuity CPR efforts, and response to CPR.

e. Futile CPR: Futile CPR is defined as a failure to save a life by means of CPR. PECs rarely terminate resuscitative efforts, and most continue to perform it in situations they consider futile.[29] PECs do not always act in accordance with their ethical convictions. The main reason is that their personal beliefs do not always match internal or external procedures.[25] However, the determination of futility should be based on physiological outcome criteria, not on value-based cri-teria. In some cases, expectations and pressures from the prehospital environment in which PECs are working while being observed by other people (especially someone close to the patient) could direct the PECs to perform futile CPR.[12] It has been argued that it is an acceptable moral practi-ce to signal that everything possible has been done, which helps to enable the grief of significant others to be properly addressed.[30]

196

f. Family presence during resuscitation: Family presence has become a part of everyday life in emergency departments of hospitals. Patients’ families have reported benefits from being present during resuscitation and invasive procedures.[31] It is accepted as an important necessity in some cultures.[32] In prehospital settings, family presence during resuscita-tion is one of the ethical conflicts.

4. Ethical issues related to some perceptionsof using/misusing the ambulance:

There are some perceptions related to the ambulance that are not just about prehospital emergency settings. PECs face ethical issues that include misuse of ambulances, care of mi-nors, telling “the bad news”, death and the newly dead, child and elder abuse, etc. One of the most challenging situati-ons is the transport for patients without emergency medical conditions.[33] Emergency medical conditions might chan-ge public and PECs. There needs to be a clear definition of emergency medical conditions for general public.

Conclusion

In summary, prehospital settings are much more challen-ging to health caregivers than the controlled environment of medical departments over emergency rooms. In prehos-pital emergency medicine, all patients and situations are unique, and the ethical implications are unique to each pati-ent encounter as well. Therefore, there are no quick formulas for the right action and emotion. It is important to recogni-ze ethical conflicts and then act to provide the appropriate care. PECs are expected to have adequate ethical knowledge to make the best a priori decision in difficult cases.

Prehospital emergency medicine is quite different from the emergency medicine in hospitals. Furthermore, the ethical issues of this field are more important, so conflicts are much difficult. In prehospital settings, the more complicated the ethical problem is, the harder finding a solution is. Therefo-re, it is highly important to establish protocols that address these ethical challenges.


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

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199INDEX

Turkish Journal of Emergency Medicine, Index of Vol. 14

Abdominal mass see 2014;14(3):99-103Abdominal pain see 2014;14(3):99-103Abdominal trauma see 2014;14(2):93-95Acute appendicitis see 2014;14(1):20-24Arrest see 2014;14(1):37-40Autopsy see 2014;14(3):115-120

Biomarker see 2014;14(4):147-152Bladder cancer see 2014;14(3):139-141Bladder rupture see 2014;14(3):139-141

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

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

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

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

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

Gastroenteritis see 2014;14(3):111-114General surgery see 2014;14(1):20-24Granulocyte colony-stimulating factor see 2014;14(1):41-43 Gunshot see 2014;14(2):87-89

Head trauma see 2014;14(4):147-152Headache see 2014;14(3):132-134Hemlock see 2014;14(1):34-36 Holiday see 2014;14(4):165-171Hydroxybutyrates see 2014;14(2):47-52Hypothermia see 2014;14(1):37-40

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

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

Length of stay see 2014;14(4):165-171Low back pain see 2014;14(3):125-129

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

200 Turk J Emerg Med 2014;14(4)

National Emergency Department Overcrowding Study see 2014;14(2):64-70Necrotizing see 2014;14(1):15-19NEDOCS see 2014;14(2):64-70

Osborn wave see 2014;14(1):37-40Overcrowding see 2014;14(2):59-63 see 2014;14(2):64-70

Pancreatic injury see 2014;14(2):93-95Papular purpuric gloves and socks syndrome (PPGSS) see 2014;14(4):179-181Parvovirus B19 see 2014;14(4):179-181Pediatric see 2014;14(3):132-134Pelvic fracture see 2014;14(3):139-141Pneumocephalus see 2014;14(2):87-89 Pneumorrachis see 2014;14(2):87-89 Poisoning see 2014;14(1):34-36 see 2014;14(3):104-110 see 2014;14(4):153-159 see 2014;14(4):160-164 see 2014;14(3):125-129Pre hospital trauma life support see 2014;14(2):71-74Pre-hospital emergency medical service see 2014;14(2):71-74Pregnancy see 2014;14(3):135-138Prehospital emergency medicine see 2014;14(4):193-198Prilocaine see 2014;14(4):185-187Professional life see 2014;14(4):172-178Prognosis see 2014;14(1):15-19

Ramsay Hunt syndrome see 2014;14(3):142-145Rehydration see 2014;14(3):111-114

Resident see 2014;14(3):125-129Resuscitation see 2014;14(1):25-31Retropharyngeal hematoma see 2014;14(4):182-184

S100B protein see 2014;14(4):147-152Sleep quality see 2014;14(4):172-178Spinal injury see 2014;14(4):188-192Spinal radiology see 2014;14(4):188-192Subarachnoid pleural fistula see 2014;14(2):87-89 Sudden death see 2014;14(3):115-120Suicide see 2014;14(4):160-164Summer season see 2014;14(3):104-110

Test see 2014;14(4):165-171 Tetraplegia see 2014;14(4):188-192Tissue defect see 2014;14(2):90-92Tomography see 2014;14(1):9-14Trauma see 2014;14(1):37-40 see 2014;14(2):71-74 see 2014;14(2):84-86Traumatic brain injury see 2014;14(4):147-152

Ultrasound-guided see 2014;14(2):53-5University student see 2014;14(4):153-159Urine see 2014;14(3):121-124

Varicella-zoster virus see 2014;14(3):142-145Vomiting see 2014;14(3):111-114

Warfarin overdose see 2014;14(4):182-184

112 Emergency Health Workers see 2014;14(4):172-178

Author Index

Abbasi H,, see 2014;14(4):147-152Acar N,, see 2014;14(2):53-5Acar N,, see 2014;14(2):75-81Adimi İ, see 2014;14(3):125-129Akay S, see 2014;14(1):25-31Akay S, see 2014;14(1):3-8Akbuga OZEL B, see 2014;14(4):185-187Akbulut S, see 2014;14(2):59-63Akdemir R, see 2014;14(3):135-138Akelma AZ, see 2014;14(3):132-134Akkisi Kumsar N, see 2014;14(1):41-43Akoglu H, see 2014;14(4):188-192Akoglu T, see 2014;14(4):188-192Akoz A, see 2014;14(3):97 [130]Aksay E, see 2014;14(2):47-52 Aksel G, see 2014;14(4):185-187Aktimur R, see 2014;14(1):15-19Alatas OD, see 2014;14(3):115-120Argun M, see 2014;14(4):172-178Atescelik M, see 2014;14(3):115-120Atilla Duman O, see 2014;14(2):45Atilla R, see 2014;14(2):64-70Avsarogullari L, see 2014;14(4):172-178Ayhan H, see 2014;14(1):9-14Ayhan H, see 2014;14(3):121-124Azarfar A, see 2014;14(3):111-114

Bagheri S, see 2014;14(3):111-114Baloglu Kaya F, see 2014;14(2):53-5Baydin A, see 2014;14(2):59-63Bayramoglu A, see 2014;14(3):97 [130]Bilir O, see 2014;14(1):2 [33]Bilir O, see 2014;14(3):142-145Bork T, see 2014;14(3):115-120Bosnak M, see 2014;14(1):34-36

Cakar MA, see 2014;14(1):37-40Calmasur A, see 2014;14(3):97 [130]Can R, see 2014;14(2):53-5Cetin A, see 2014;14(2):90-92Cetinkaya H, see 2014;14(2):59-63Cevik AA, see 2014;14(2):53-5Cevik AA, see 2014;14(2):75-81Cevik AA, see 2014;14(3):104-110Cizmeci MN, see 2014;14(3):132-134

Colak E, see 2014;14(1):15-19Colak Oray N, see 2014;14(2):64-70

Dagar S, see 2014;14(4):165-171Demirtas Y, see 2014;14(1):20-24Demirtas Y, see 2014;14(1):3-8Denizbasi A, see 2014;14(4):188-192Dogan A, see 2014;14(4):179-181Dogan T, see 2014;14(2):47-52 Duman Atilla O, see 2014;14(4):182-184 Durak U, see 2014;14(4):165-171Duran A, see 2014;14(2):90-92Durmaz D, see 2014;14(2):93-95

Eceviz A, see 2014;14(4):179-181Efeoglu M, see 2014;14(4):188-192Ekingen E, see 2014;14(3):115-120Erbay H, see 2014;14(4):193-198Erdur B, see 2014;14(1):25-31Erenler AK, see 2014;14(2):59-63Eroglu SE, see 2014;14(4):188-192Ersoy G, see 2014;14(2):64-70Ersunan G, see 2014;14(3):142-145Ertan C, see 2014;14(3):139-141Eryigit U, see 2014;14(3):99-103Eryigit V, see 2014;14(1):20-24Eryigit V, see 2014;14(1):3-8Esmaeeli M, see 2014;14(3):111-114

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

Gencer EG, see 2014;14(3):121-124Ghafouri RR, see 2014;14(2):71-74Gharashi Z, see 2014;14(3):111-114Gholipour C, see 2014;14(2):71-74Giakoup B, see 2014;14(3):142-145Goktas S, see 2014;14(4):153-159Guclu E, see 2014;14(1):41-43Guleser GN, see 2014;14(4):172-178Gullupinar B, see 2014;14(2):87-89 Gunaydin YK, see 2014;14(3):121-124Gunduz A, see 2014;14(3):99-103Gunduz H, see 2014;14(3):135-138Gurger M, see 2014;14(3):115-120Guzel M, see 2014;14(2):59-63

201Turkish Journal of Emergency Medicine, Index of Vol. 14

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

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

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

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

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

Kanburoglu MK, see 2014;14(3):132-134

Karabay O, see 2014;14(1):41-43

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

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

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

Karahan SC, see 2014;14(3):99-103

Karakayali O, see 2014;14(3):121-124

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

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

Kayayurt K, see 2014;14(3):142-145

Keser N, see 2014;14(1):37-40

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Mahsanlar Y, see 2014;14(1):3-8

Mentese A, see 2014;14(3):99-103

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

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

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

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

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

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

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

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

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

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

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

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

Ozhan F, see 2014;14(4):153-159

Ozkok Z, see 2014;14(4):160-164

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

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

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

Palak İ, see 2014;14(1):25-31

Parlak İ, see 2014;14(1):20-24

Parlak İ, see 2014;14(1):3-8

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Shams Vahtadi S, see 2014;14(1):1 [32]

Shams Vahdati S, see 2014;14(2):71-74



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

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

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

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

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

Tokdemir M, see 2014;14(3):115-120

Toker I, see 2014;14(4):182-184

Tomruk O, see 2014;14(1):25-31

Topacoglu H, see 2014;14(2):64-70

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

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

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

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

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

202 Turk J Emerg Med 2014;14(4)

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

Ugurhan A, see 2014;14(3):139-141Unluoglu I, see 2014;14(3):104-110Ursavas B, see 2014;14(4):182-184Ustuner F, see 2014;14(2):47-52 Uzun O, see 2014;14(3):99-103

Varisli B, see 2014;14(4):160-164 Vatan MB, see 2014;14(1):37-40

Yalcin N, see 2014;14(2):47-52 Yanturali S, see 2014;14(2):64-70Yavasi O, see 2014;14(3):142-145Yaylaci S, see 2014;14(1):41-43

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

Zeytin AT, see 2014;14(2):75-81

203Turkish Journal of Emergency Medicine, Index of Vol. 14

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