Nerve blocks are frequently used in emergency department for pain management in patients with fractures. Their utility in medical conditions with severe intactable pain is largely unknown. We report a series of seven patients with pancreatitis who presented with severe abdominal pain (defense and veteran pain rating scale > 7) and had no relief on regular analgesia. They were subjected to erector spinae plane block (ESPB), and reduction in pain score at different time intervals, side effects, and additional analgesic dose requirements were noted. The objective of this case series is to explore the utility of ESPB in patients with pancreatitis.

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Bullet embolism (BE) is a rare and misdiagnosed phenomenon that can significantly affect the cardiovascular system. It occurs when a bullet enters and migrates through the body vessels in gunshot victims. We report in this article a case of a 25-year-old male patient, victim of penetrating trauma caused by a firearm projectile that presented two embolism destinations with acute ischemic repercussions: the right brachial artery and the branches of the superior mesenteric artery. We quickly performed surgical exploration to assess the level of ischemia and resect the foreign body. To the best of the authors' knowledge, this is the only case of acute vascular abdomen due to BE in the literature. There is no standard treatment for BE, and each case should be studied according to signs and symptoms while considering the risks of the destination vessel for the victim. Imaging is necessary for early diagnosis, and the medical team must be aware of multiple and extraordinary critical ischemia presentations when bullet trajectory suggests embolism.

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OBJECTIVES: Despite the acute and life-threatening repercussions that tuberculosis (TB) may have on the burgeoning older population in endemic countries like India, the spectrum of geriatric TB emergencies is not adequately understood. METHODS: We performed a prospective observational study at the emergency department of an academic hospital in north India between January 2019 and June 2020, investigating the clinical and laboratory features and outcomes of active TB in older patients aged 60 years and above. RESULTS: Out of 71 geriatric TB emergencies, central nervous system disease predominated (n = 41, 57.7%), followed by pulmonary (n = 16, 22.5%), pleural TB (n = 8, 11.3%), and multisite involvement (n = 6, 8.4%). Nearly 71.8% were male, and 77.4% belonged to low socioeconomic status (lower-middle or lower class). Usual predisposing factors were tobacco smoking (38.0%), chronic alcohol use (27.0%), and diabetes mellitus (23.9%). Atypical features were more frequent with extrapulmonary TB. Only 28.2% were microbiologically confirmed cases, and rifampicin resistance was seen in only one case. The mortality rate was considerably high (24.0%), highest with pulmonary TB (37.0%). CONCLUSION: Older patients with TB emergencies have atypical presentations, diagnostic difficulties, and high mortality.

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OBJECTIVES: Acute decompensated heart failure (ADHF) is a clinical condition that requires urgent diagnosis and treatment. Patients present with pulmonary capillary wedge pressure, pulmonary arterial pressure, and venous pressure elevation. Along with the progressive deterioration observed in the clinical picture, impairment or deterioration of kidney function may also occur. In this study, we evaluated the B-type natriuretic peptide (BNP)/ferritin ratio as a predictor of the risk of developing acute renal injury (ARI) in ADHF. METHODS: A total of 157 patients with a diagnosis of ischemic dilated cardiomyopathy for more than 6 months that presented to our clinic with ADHF were included in this cohort study. After the treatment protocol was applied, the sample was divided into two groups as patients with and without ARI. The BNP and ferritin levels were examined along with the routine blood parameters (BNP), and the BNP, ferritin, and BNP/ferritin values were compared between the groups. RESULTS: ARI was present in 34.3% (n = 54) of the patients, who were also found to have higher BNP (892.76 vs. 817.54), lower ferritin (86.78 ± 57.2 vs. 105.46 ± 38.3), and higher BNP/ferritin (10.48 ± 2.14 vs. 7.89 ± 1.89). The multivariate logistic regression analysis revealed the BNP/ferritin ratio as an independent risk factor for ARI (odds ratio = 3.19; 95% CI, 1.92-6.54; P = 0.001). Using the receiver operating characteristic curve, a cutoff value of 9.32 for BNP/ferritin ratio had a sensitivity of 81.8% and a specificity of 93.5% (area under the curve 0.842, P < 0.001) for the prediction of ARI. CONCLUSION: The BNP/ferritin ratio is a new parameter that can be used to draw attention to the severity of the treatment and renal function in ADHF cases in emergency situations.

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Here, we reported a 32-year-old male presenting to the emergency department with respiratory symptoms and coronavirus disease 2019 (COVID-19) diagnosis. Multiple thrombi were detected in his heart and inferior vena cava, probably due to former deep-vein thrombosis. The presence of patent foramen ovale and high pressure of the right heart caused the clots to enter the heart's left side. He received fibrinolytics, and his condition improved with no need for surgery. Hence, patients with impending paradoxical embolism may take advantage of medical treatment, such as fibrinolytics. Moreover, COVID-19 appears to be associated with a strong thrombotic tendency, and anticoagulants might be helpful.

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Acute abdomen is always a challenging case presentation in an emergency department. A thorough clinical examination and prompt differential diagnosis and required investigations can save patients from potentially life-threatening conditions. We report the case of a 49-year-old gentleman who presented with a rare presentation of acute lower abdominal pain which initially mimicked renal colic (flank pain and dysuria), later as an upper gastrointestinal bleed manifested by massive hematemesis due to the stomach being pulled down into a giant inguinoscrotal hernia resulting in a gastric perforation. The patient underwent life-saving emergency midline open laparotomy. To our knowledge and as per the literature reviewed, this is an uncommon presentation of an acute lower abdomen pain wherein the gastric perforation due to a giant inguinoscrotal hernia masquerade as renal colic and posed a diagnostic challenge to the treating emergency physician.

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OBJECTIVES: We aimed to compare the demographic and clinical characteristics between pediatric cardiac arrest patients treated in Gaziantep at South-eastern Anatolian region and Izmir at Aegean Shore. MATERIALS And METHODS: We retrospectively reviewed sociodemographic characteristics, laboratory parameters, and clinical outcomes of pediatric patients that underwent cardiopulmonary resuscitation due to prehospital cardiac arrest at two pediatric emergency departments in Izmir Hospital of Health Sciences University and Gaziantep Cengiz Gökçek Kadın Doğum ve Çocuk Hospital of Health Ministry between August 2017 and August 2018. RESULTS: The present study included 188 patients (112 patients from Gaziantep and 76 patients from Izmir). All patients arrived at the hospital through emergency medical services. The median age was lower (14 days vs. 15 months; P < 0.001), and the proportion of Syrian refugees was higher in patients from Gaziantep (78.6% vs. 7.9%; P < 0,001). In both centers, respiratory failure was the most common etiology. In patients from Gaziantep, pH levels were lower (median: 7.10 vs. 7.24), and lactate levels were higher (median: 6 mmol/L vs. 3.6 mmol/L; P < 0.001). The mortality rate was higher among patients from Gaziantep (27.7% vs. 7.9%; P = 0.001). CONCLUSIONS: The rate of Syrian refugees among children who were brought to emergency department due to pre-hospital cardiac arrest was much higher in Gaziantep compared to Izmir. Syrian children were significantly younger and had more severe tissue hypoxia, resulting in a higher mortality rate.

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OBJECTIVES: Pleth variability index (PVI) has been studied mostly in mechanically ventilated patients, and the role of PVI in predicting volume status and volume changes among spontaneously breathing patients is not clear in the literature. We hypothesized that hemodialysis (HD) can be a valid model for a simulation that can be evaluated the correlation of PVI with fluid changes in various volume states. The aim of this study was to investigate the utility of PVI for assessing volume changes in HD patients who are breathing spontaneously. METHODS: This prospective, observational study included patients aged 18 years or older who had end-stage renal failure and presented for routine HD between December 2019 and January 2020. PVI values were measured before and after HD session. Changes in PVI levels were compared according to the amount of ultrafiltration. RESULTS: A total of sixty patients were included. Mean PVI level before HD (20.7% ± 5%) showed a statistically significant increase to 27.7% ± 6% after HD session (P < 0.001). According to the amount of fluid removed during HD, the changes in PVI were statistically significant (P = 0.015). There was a strong correlation between ΔPVI and ultrafiltrated volume (r = 0.744, P < 0.001). CONCLUSION: The fluid removed by HD caused increase in PVI, and the increase was strongly correlated with the amount of volume change. Bedside monitoring of PVI may provide the clinicians with useful information for monitoring the volume status in critically ill patients with spontaneous breathing.

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OBJECTIVES: Many studies have recently been conducted on measuring optic nerve sheath diameter (ONSD) with computed tomography (CT). However, no studies focused on the interrater reliability in ONSD measurements with CT yet. Our first aim was to investigate the interrater reliability of the emergency medicine residents in the measurement of the ONSD with CT. Our secondary aim was to evaluate the interrater reliability and agreement of the emergency medicine residents and neuroradiologist measurements, which is the gold standard. METHODS: Twelve residents (six seniors and six juniors) and a neuroradiologist measured ONSD in twenty different CTs in axial and sagittal planes. The interrater reliability was calculated by the intraclass correlation coefficient (ICC), and the level of agreement in categorical variables was calculated by kappa (κ) analysis. RESULTS: We found that the interrater reliability level of all residents was “good” (ICC: 0.824), for seniors was “good” (ICC: 0.824), and for juniors was “moderate” (ICC: 0.748) in the measurement of ONSD. ICC was 0.812 for axial, and 0.783 for sagittal plane measurements. The interrater reliability between residents and the neuroradiologist measurements was “good” (ICC 0.891), and the agreement was found to be “good” (κ: 0.688; P < 0.001). The sensitivity of residents in detecting increased ONSD was 78%, and specificity was 90.8%. CONCLUSION: The ONSD measurements with CT performed by the residents are reliable in themselves, and they are compatible with the gold standard measurements.

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