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   Table of Contents - Current issue
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October-December 2021
Volume 21 | Issue 4
Page Nos. 137-224

Online since Friday, October 29, 2021

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CLINICAL GUIDELINE  

2021 Guideline for the Management of COPD Exacerbations: Emergency Medicine Association of Turkey (EMAT) / Turkish Thoracic Society (TTS) Clinical Practice Guideline Task Force p. 137
Nurettin Özgür Dogan, Yelda Varol, Nurdan Köktürk, Ersin Aksay, Aylin Özgen Alpaydin, Şeref Kerem Çorbacıoğlu, Gökhan Aksel, Ayşe Baha, Haldun Akoğlu, Sevilay Karahan, Elif Şen, Begüm Ergan, Başak Bayram, Serkan Yılmaz, Alev Gürgün, Mehmet Polatlı
DOI:10.4103/2452-2473.329630  
Chronic obstructive pulmonary disease (COPD) is an important public health problem that manifests with exacerbations and causes serious mortality and morbidity in both developed and developing countries. COPD exacerbations usually present to emergency departments, where these patients are diagnosed and treated. Therefore, the Emergency Medicine Association of Turkey and the Turkish Thoracic Society jointly wanted to implement a guideline that evaluates the management of COPD exacerbations according to the current literature and provides evidence-based recommendations. In the management of COPD exacerbations, we aim to support the decision-making process of clinicians dealing with these patients in the emergency setting.
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ORIGINAL ARTICLES Top

Comparative evaluation of the efficacy of intravenous paracetamol and ibuprofen on the treatment of tonsillopharyngitis with fever: A prospective, randomized controlled, double-blind clinical trial p. 177
Gizem Oncel, Atakan Yilmaz, Ramazan Sabirli, Yesim Kinaci Cimen, Mert Ozen, Murat Seyit, Ibrahim Turkcuer, Uzeyir Cimen
DOI:10.4103/2452-2473.329629  
OBJECTIVE: Tonsillopharyngitis is one of the constituents of upper respiratory tract infection (URTI). Fever is a URTI symptom requiring treatment due to the occurrence of discomfort and high fever-based complications. This study primarily sets out to observe and compare the efficacy of intravenous administration of paracetamol and ibuprofen drugs on fever in adult patients with tonsillopharyngitis. METHODS: This study was performed in a prospective, randomized controlled, double-blind design. The study population was divided as Group 1 (treated with paracetamol) and as Group 2 (treated with ibuprofen). While the first group was treated with paracetamol as 1000 mg in 150 ml normal saline, the second group was treated with ibuprofen as 400 mg in 150 ml normal saline. The primary outcome was the decrease in fever at 15, 30, and 60 min, while the secondary outcome was the need for additional treatment after 60 min. RESULTS: One hundred and eighty-five patients were included in the final analysis. The mean age of the paracetamol group (57.4% male) was 28.36 ± 9.6, whereas that of the ibuprofen group (54.9% male) was 27.45 ± 7.98. Fever was reduced significantly between 0 and 60 min in both groups (P ≤ 0.001 and P ≤ 0.001, respectively). Although the antipyretic effect of ibuprofen was more pronounced in the early period than that of paracetamol, no significant difference was noted between the two groups in terms of fever drop between 0 and 60 min (P = 0.350). CONCLUSION: Although both drugs prove effective in controlling fever at the 60 min, stronger efficacy of ibuprofen in the first 15 min may enable rapid discharge from the emergency department.
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May the first-line treatment for foreign body aspiration in childhood be flexible bronchoscopy? p. 184
Hasan Yuksel, Adem Yaşar, Arzu Açıkel, İsmet Topçu, Özge Yılmaz
DOI:10.4103/2452-2473.329631  
INTRODUCTION: Rigid bronchoscopy (RB) is the traditional treatment in foreign body (FB) aspiration in childhood but is a traumatic and invasive procedure. However, flexible optic bronchoscopy (FoB) is a noninvasive and nontraumatic respiratory intervention. The aim of this study was to evaluate FoB as a first-line treatment modality in pediatric cases presenting with a preliminary diagnosis of FB aspiration. METHODS: Subjects who underwent FoB under general anesthesia with the preliminary diagnosis of FB aspiration were enrolled in this cross-sectional study. Two cases were inherited from pediatric surgery because they were not removed with FoB. The demographic, clinical, and radiological findings at the presentation were recorded. Results of success rate and complications were recorded. RESULTS: Among the FB aspiration cases age range of 7 months to 16 years. FoB demonstrated a FB in the airways of 31 (62.2%) subjects. The duration of the symptoms in the subjects was 9.1 ± 8.8 days. Three of the cases were taken over from pediatric surgery because they were not removed with RB. Most commonly encountered FB's were organic materials (n = 20, 64%). FoB was successful in removing the FB from the proximal and also distal airways in 93% of the subjects. No significant complications and side effects were observed except post-FoB cough. CONCLUSION: This result has shown that FoB for the treatment of FB aspiration is successful in removing FB aspiration from both the proximal and distal airway that the RB cannot remove. Furthermore, FoB did not have any significant airway complication. FoB may be used as the first-line treatment modality for FB aspiration instead of RB in childhood the fact that noninvasive and nontraumatic respiratory intervention.
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Pain management practices in the emergency departments in Turkey p. 189
Murat Cetin, Bora Kaya, Turgay Yilmaz Kilic, Nazife Didem Hanoğlu, Şervan Gökhan, Serkan Emre Eroğlu, Sakine Neval Akar, Ozgen Gonenc Cekic, Dicle Polat, Emre Üstsoy, Orhan Çınar, Serkan Yilmaz
DOI:10.4103/2452-2473.329633  
OBJECTIVES: This study aimed to evaluate pain management practices in the emergency departments (EDs) in Turkey and to evaluate the prevalence and etiologies of oligoanalgesia to identify possible improvement strategies. METHODS: This multicenter cross-sectional observational study was conducted in 10 tertiary care hospitals in Turkey. Patients who were admitted to the ED with pain chief complaints were included in the study. Both patients and physicians were surveyed with two separate forms by the research associates, respectively. The patient survey collected data about the pain and the interventions from the patients' perspective. The pain was evaluated using the Numerical Rating Scale. The physician survey collected data to assess the differences between study centers on pain management strategies and physician attitudes in pain management. RESULTS: Ten emergency physicians and 740 patients (male/female: 365/375) enrolled in the study. The median pain score at admission at both triage and ED was 7 (interquartile range: 5–8). The most frequent type of pain at admission was headache (n = 184, 24.7%). The most common analgesics ordered by physicians were nonsteroidal anti-inflammatory drugs (n = 505, 67.9%), and the most frequent route of administration was intramuscular injection (n = 396, 53.2%). About half of the patients (n = 366, 49.2%) received analgesics 10–30 min from ED admission. The posttreatment median pain score decreased to 3 (P < 0.001). About 79.2% of patients did not need a second analgesic administration (n = 589), and opioid analgesics were the most frequently administered analgesic if the second application was required. Physicians prescribed an analgesic at discharge from the ED in 55.6% of the patients (n = 414) and acute pain was present in 7.5% (n = 56) of the patients. CONCLUSION: Our study on the pain management practices in the EDs in Turkey suggested that high rate of intramuscular analgesic use and long emergency room stay durations are issues that should constitute the focus of our quality improvement efforts in pain management.
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The effects of synthetic cannabinoids on the cardiovascular system: A case–control study p. 198
Selman Yeniocak, Asım Kalkan, Adnan Yamanoğlu, Semi Öztürk, Özgür Söğüt, Merve Metiner
DOI:10.4103/2452-2473.329634  
OBJECTIVES: Limited clinical studies have investigated the effects of synthetic cannabinoids (SCs) on the cardiovascular system (CVS). The aim of this study was to evaluate the effects of SCs on the CVS. METHODS: The patient group of this single-center, prospective, case–control study consisted of adult patients presenting to the emergency department (ED) with symptoms of SC use. Vital signs and electrocardiogram (ECG) after use of SC of patients were followed. A control group with a similar number of patients and patient demographics were formed following the patient admission process. Pulse rate, arterial blood pressure (ABP), and ECG of patient and control groups were compared using Mann–Whitney U and Chi-squared tests. RESULTS: A total of 148 people were included in the study, 74 in the patient group and 74 in the control group. Systolic and diastolic ABPs of patient group were statistically significantly lower than those of the control group (P < 0.001). P-wave width and amplitude in the patient group were significantly higher compared to the control group (P: 0.027 and P: 0.004, respectively). QRS width on patient group ECGs was significantly higher than in the control group, while T-wave amplitude was significantly lower (P: 0.045 and P < 0.001, respectively). ST elevation was seen in 12 (16.2%) subjects in the patient group, while no ST elevation was seen in the control group (P < 0.001). CONCLUSION: SCs can reduce systemic tension and SCs may cause changes in ECG, especially P wave, ST segment, T wave, and QRS. Further large-scale studies are needed to show whether these changes are associated with fatal arrhythmias or myocardial infarction.
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Selective intubation with endotracheal tube introducer in difficult airway: A randomized, prospective, cross-over study p. 205
Hakan Ozerol, Emre Şancı, Onur Karakayalı, Erdem Aydın, Hüseyin Cahit Halhallı
DOI:10.4103/2452-2473.329632  
BACKGROUND: Selective lung intubation is a life-saving procedure in emergency departments. While various equipment can be used in selective lung intubation, most of this equipment is not readily available; therefore, single-lumen endotracheal intubations are performed for rapid interventions. MATERIALS AND METHODS: This study was designed as a randomized, prospective, cross-over study using the 90° rotation technique for selective intubation on a manikin model with and without endotracheal tube introducer (ETI) in difficult airway settings. Forty-six emergency physicians were included in the study. The primary outcome was evaluating time to selective intubations, and secondary outcomes were first and second attempt success rates and the self-perceived difficulty level of each method according to the participants. RESULTS: The mean time to the first successful endotracheal intubation was significantly longer for both right selective and left selective intubations with ETI utilization than without ([39.71 ± 9.83 vs. 21.86 ± 5.94 s], [P < 0.001]), ([42.2 ± 10.81 vs. 26.23 ± 7.97 s], [P < 0.001], respectively). The first-pass success rate did not differ for right selective intubation with or without an ETI (45/46 [97.8%] and 45/46 [97.8%], respectively). However, the first-pass success rate for left selective intubation was significantly higher with ETI as compared to without an ETI (30/46 [65.2%] and 13/46 [28.3%], respectively) (P < 0.001). CONCLUSIONS: While the success rates of right selective intubation were the same, the left selective intubation success rates with ETI are higher than the styletted endotracheal tube, which can be strong evidence for this method's applicability in practice. Expanding the use of ETI and increasing the experience of the practitioners can contribute to further success.
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CASE REPORTS Top

Salmonella paratyphi-induced splenic vein thrombosis: A case report on infrequent cause of acute abdomen p. 210
Ruchika Saini, Gautam Jesrani, Monica Gupta, Samiksha Gupta, Ankit Chhabra
DOI:10.4103/2452-2473.329625  
Splenic vein thrombosis and splenic infarction are complications beyond the usual clinical spectrum of paratyphoid fever, and the presentation is rarely described. We report the case of a young female, who presented with high-grade fever and severe left upper quadrant pain. Her blood culture was positive for Salmonella paratyphi A, with Widal test suggesting 4-fold rise in titers. Computed tomography revealed splenic vein thrombosis and multiple splenic infarcts, for which antibiotic and anticoagulation were instituted simultaneously. She had a complete resolution with this management, and anticoagulation was tapered off on subsequent visits.
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Splenic infarction and pulmonary embolism as a rare manifestation of COVID-19 p. 214
Egemen Yildiz, Dilay Satilmis, Erdem Cevik
DOI:10.4103/2452-2473.329627  
Coronavirus disease 2019 (COVID-19) disease leads to a hypercoagulable state and associated with thrombotic events that can cause mortality and morbidity. Thrombotic events include both venous and arterial thrombosis. In this case report, we present a 68-year-old COVID-19 patient with multisystemic infarction who was admitted to the hospital by splenic infarction and later pulmonary embolism diagnosed during the stay in hospital despite anticoagulant use. It is important for emergency physicians to know that patients who had COVID-19 infection but not confirmed or not tested can visit the emergency department due to complications of COVID-19 infection such as thromboembolic events primarily.
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A successful treatment with intravenous lipid emulsion therapy in a child with verapamil poisoning p. 217
Merve Havan, Tanıl Kendirli, Serhan Özcan, Melih Timuçin Doğan, Ahmet Onur Yiğit, Tayfun Uçar
DOI:10.4103/2452-2473.329626  
In recent years, intravenous lipid emulsion therapy (ILE) was used for lipophilic drug intoxications, and successful results were obtained. In the literature, there is a small number of reported cases about verapamil intoxication and ILE therapy in the pediatric age group. We used ILE therapy in a 14-year-old girl with verapamil intoxication in the 2nd h of the pediatric intensive care unit stay, before using traditional treatments such as glucagon and hyperinsulinemic euglycemia. She had resistant bradycardia and hypotension which was unresponsive to inotropic agents and a successful result was obtained after using ILE treatment. We believe our report may contribute to the early use of ILE therapy for toxicity with calcium channel blockers such as verapamil in pediatric patients.
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Complicated spontaneous intercostal lung hernia - A rare clinical case p. 221
Ivan Petkov Novakov, Velizar Dafinov Hadzhiminev, Pavel Todorov Timonov
DOI:10.4103/2452-2473.329628  
Spontaneous lung herniation is a rare pathological entity. We present a case of intercostal type of spontaneous lung hernia after heavy lifting complicated with huge soft tissue hematoma, single rib fracture, hemothorax, diaphragmatic laceration, and great omentum pleural cavity herniation in a 46-year-old man. His comorbidities were arterial hypertension, congestive heart failure, and type II diabetes mellitus and had no history of trauma, surgical procedures in his thoracic wall, or chronic obstructive pulmonary disease. Physical examination revealed a huge left-sided flank hematoma. Chest X-ray determined stable intercostal lung hernia confirmed by chest computed tomography. Conventional approach by left mid-lateral thoracotomy was used for surgical repair of the lung hernia and stabilization of the intercostal space. The patient was discharged on the 9th postoperative day in a good condition. Control examination 2 years after the operation found no deformation of the thorax or recurrence of the lung hernia. This is a case of interest of spontaneous intercostal lung hernia because of the number and type of associated injuries. This case demonstrates low morbidity and good postoperative result by conventional surgery in intercostal lung hernias.
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