Point-of-care ultrasound (POCUS) is a focused examination, which is performed and interpreted at the bedside by the treating physician answering a specific clinical question. It is currently utilized as an essential adjunct to physical examination in many medical specialties. Recent advances in technology have made POCUS machines portable, affordable, and could be used with minimal training even by nonradiologists. This review aims to cover the fundamental physics of POCUS and its applications for diagnosing the acute abdomen in the primary health care including the most common causes encountered by family physicians. These are acute appendicitis, acute cholecystitis, renal colic, ectopic pregnancy, acute diverticulitis, bowel obstruction, and abdominal aortic aneurysm. We hope to encourage primary care physicians to incorporate POCUS in their routine clinical practice. We also highlight challenges encountered when using POCUS in the primary health care including limited availability and the need for proper training. Furthermore, we review the POCUS results when performed by primary health-care physicians. Integrating POCUS in primary health care empowers primary health-care physicians to provide high-quality, safe, and cost-effective care to the patients.

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BACKGROUND: The first cases of the coronavirus disease 2019 (COVID-19) were reported in Wuhan, China. No antiviral treatment options are currently available with proven clinical efficacy. However, preliminary findings from phase III trials suggest that remdesivir is an effective and safe treatment option for COVID-19 patients with both moderate and severe disease. OBJECTIVE: The aim of the present meta-analysis was to investigate whether remdesivir was effective for treating COVID-19 including reduced in-hospital adverse events, oxygen support, and mortality rates. METHODS: According to the PRISMA reporting guidelines, a review was conducted from January 1, 2020, until August 25, 2020, with MeSH terms including COVID-19, COVID, coronavirus, SARS-CoV-2, remdesivir, adenosine nucleoside triphosphate analog, and Veklury using MEDLINE, Scopus, and CINAHL Plus. A modified Delphi process was utilized to include the studies and ensure that the objectives were addressed. Using dichotomous data for select values, the unadjusted odds ratios (ORs) were calculated applying Mantel–Haenszel random-effects method in Review Manager 5.4. RESULTS: Randomized controlled trials pooled in 3013 participants with 46.3% (n = 1395) in the remdesivir group and 53.7% (n = 1618) in the placebo group. The placebo group had a higher risk of mortality as compared to the intervention group with significant OR (0.61) (95% confidence interval of 0.45–0.82; P = 0.001). There was minimal heterogeneity among the studies (I² = 0%). CONCLUSIONS: Our findings suggest that remdesivir extends clinical benefits by reducing mortality, adverse events, and oxygen support in moderate to severely ill COVID-19 patients. Concerted efforts and further randomized placebo-controlled trials are warranted to examine the potency of antiviral drugs and immunopathological host responses contributing to the severity of COVID-19.

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OBJECTIVES: Prevention and reduction of pain, anxiety, and fear during medical procedures is one of the most important factors that should be considered in pediatric emergencies. The aim of this study was to compare the efficacy of oral versus intranasal midazolam in sedation during radiologic imaging in the largest province of Iran, Kerman. MATERIALS AND METHODS: Eighty children were enrolled in this single-blind clinical trial based on convenience sampling and were divided into two groups receiving 0.5 mg/kg midazolam in oral route administration and 0.2 mg/kg midazolam in intranasal route administration. Finally, 75 patients remained for evaluating medication acceptability, sedation level, onset time of sedation, additional sedative dose, adverse effects of sedation, and provider satisfaction. RESULTS: Children in the intranasal group accepted medication more easily (89.8% vs. 36.9%; P≤ 0.001), while these children received a lower sedation dose, but the sedation level in both methods was similar (P = 0.72). Our findings showed that children in the intranasal sedation group had a faster onset of sedation compared to the oral group (17.94 ± 8.99 vs. 34.50 ± 11.45; P≤ 0.001). The frequency of midazolam side effects had no difference between the groups (29.7% vs. 15.8%; P = 0.15). CONCLUSION: Intranasal midazolam with a lower sedation dose induces a faster onset and better acceptance. Intranasal midazolam can be used as an effective sedative method for pediatric patients, especially in emergency wards.

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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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The world is facing one of its worst public health crises in modern history. Coronavirus 2019 (COVID-19) has shown how fragile our global preparedness for infectious diseases is. The world is a small-connected globe with short travel time between its remote parts. COVID-19 has spread globally and swiftly with major impacts on health, economy, and quality of life of communities. At this point in the time, April 9, 2020, >1,500,000 patients have been infected and >88,000 patients have died worldwide within the last 3 months. The status is evolving and the costly lessons learned over time are increasing. These lessons are global as this virus is. They involve different domains of health sciences including virology, public health, clinical, critical care, and disaster management. This review addresses our current knowledge of COVID-19 pandemic from the basic virology and transmission, through prevention, infection control, clinical management, and finally disaster management including the recovery period. This review has a multidisciplinary approach, which is needed at this time. After this difficult period passes, we have to carry the lessons we learned for the future so that we can be better prepared. One thing that has clearly emerged from this ongoing crisis is that infectious diseases have no borders and we have to work together, using the one world, one health approach, if we are to minimize the enormous impact such pandemics can cause.

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OBJECTIVES: Endotracheal tube (ETT) displacement occurs by improper fixation. To fix an ETT, many types of fixation tools are employed. Thomas tube holder is one of the fixation tools widely used in many countries. This study aims to compare the ETT fixation using the Thomas tube holder with the conventional method (adhesive tape) in a mannequin model. METHODS: The fixation tools were random, using the box of six randomizes to Thomas tube holder and conventional method. After fixation, the mannequin model was being logged roll, chest compression by automated chest compression machine, and transported by the paramedic. The time to ETT fixation and displacements were recorded. RESULTS: The mean time (standard deviation) to fixate an ETT was shorter (33.0 s [7.3]) with a Thomas tube holder compared to adhesive tape (52.6 s [7.3], P < 0.001). The number and proportion of the ETT displacements were significantly less with Thomas tube holder compared to adhesive tape during log roll (16, 35.6% vs. 29, 64.4%, P = 0.011), chest compression with automated machine (23, 51.1% vs. 37, 82.2%, P = 0.003), and transport (26, 57.8% vs. 40, 88.9%, P = 0.002). CONCLUSION: The Thomas tube holder is more effective than adhesive tape in preventing ETT displacement in a mannequin subjected to log roll, chest compressions, and transportation.

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OBJECTIVES: In this study, we aimed to investigate the accuracy of recognition of stroke in the Emergency Room (ROSIER) Scale in the diagnosis of patients with acute ischemic stroke (AIS) transferred to the emergency department (ED). METHODS: The present study was a multicenter study. Records from patients suspected of stroke, who referred to the ED were reviewed. Demographic, clinical, and diagnostic data were extracted and then entered in checklists. ROSIER Scale was used to evaluate the possible diagnosis in this study. The definitive diagnosis of a stroke was made based on neurologist's assessment and clinical and neuroimaging findings, mainly brain magnetic resonance imaging (MRI). Receiver operating characteristic (ROC) curve analysis was conducted for assessing the accuracy of ROSIER in discrimination of stroke. RESULTS: The data of 356 suspected stroke patients were analyzed. Of all, 186 patients (52.2%) were male, and the mean age was 65.2 (standard deviation = 14.0) years ranging from 26 to 95 years. One hundred and fifty-one patients (42.4%) had AIS based on the final diagnosis. The area under the ROC curve was 0.85. The best cutoff point for ROSIER scale was ≥1 with a sensitivity of 85.4% (95% confidence interval [CI]: 78.8, 90.6%) and specificity of 65.8% (95% CI: 58.9, 72.3%). CONCLUSION: Based on the findings, although the best cutoff point was the same as the original (derivation) study, its sensitivity (85.4% vs. 92%) and specificity (65.8% vs. 86%) were considerably lower.

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OBJECTIVES: Because the benefits of bicarbonate therapy remain unclear, it is not routinely recommended for the cardiopulmonary resuscitation (CPR) given to individuals with cardiac arrest (CA). This study aims to evaluate the clinical benefits of bicarbonate therapy in adults with CA. METHODS: Without any language restriction, we searched PubMed/MEDLINE, Scopus, Web of Science, and Cochrane CENTRAL from the inception until April 30, 2020. We performed hand-search to identify the relevant trials included in previous meta-analyses. Included studies were randomized controlled trials (RCTs) comparing bicarbonate and placebo treatment in adults with CA. Two authors independently assessed the trial risk of bias. The primary outcome was the survival to hospital admission. The secondary outcomes included the return of spontaneous circulation, the survival to hospital discharge, and the neurological outcome at discharge. We calculated the odds ratios of those outcomes using the Mantel-Haenszel model and assessed the heterogeneity using the I² statistic. RESULTS: Our searches found 649 unduplicated studies. Of these, three RCTs involving 1344 patients were included in the meta-analysis. The trial risk of bias ranged between fair and poor, mainly due to no blindness of outcome assessment and the selective reports of outcomes. Bicarbonate therapy showed no significant improvement in the survival to hospital admission (odds ratio [OR] 0.96; 95% confidence interval [CI] 0.73–1.25). Subgroup analysis in those receiving prolonged CPR showed a similar result (OR 0.88; 95% CI 0.10–8.01). No study reported the predefined secondary outcomes. CONCLUSION: For both acute and prolonged CPR, bicarbonate therapy might not show benefit to improve the rate of survival to hospital admission in adults with cardiac arrest.

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OBJECTIVES: The accuracy and duration of triage is vital in emergency departments. However, patient density, diversity of cases, and time pressure make triage difficult. Triage performed properly and at the right time prevents patients from experiencing any untoward incidents that may occur because of waiting. Therefore, the study aimed to share the data obtained from the Hospital Information Management System (HIMS) regarding the accuracy and duration of nurse triage in an adult emergency department. METHODS: This descriptive and cross-sectional study evaluated the accuracy and duration of triage decisions made by nurses for patients admitted to an adult emergency department between June 15 and July 15, 2019. Statistical analysis was performed using Statistical analysis was performed using SPSS software version 23.00. RESULTS: The study included the data of 7705 adult patients. The accuracy rate of nurse triage was 59.3% (n = 4566), and the average duration of triage was 1.52 ± 2.10 min. It was observed that the average duration of accurate triage decisions was longer in patients with triage category 3. A statistically significant relationship was determined between the accuracy of nurse triage and the duration of triage, years of seniority of the nurse, and shifts (P < 0.05). CONCLUSIONS: The accuracy and duration of nurse triage in the hospital where the study was conducted can be evaluated via the HIMS. In order to increase the accuracy of nurse triage in the emergency department, it is necessary to employ experienced and trained nurses, develop computer-based support systems, and increase the number of nurses working in shifts providing care to a large number of patients.

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Out-of-hospital cardiac arrest remains a major challenge worldwide, with survival to discharge rates of <20% in the great majority of countries. Advancements in prehospital care, including increasing deployment of automated external defibrillators and improvements in bystander cardiopulmonary resuscitation, have led to more victims achieving return of spontaneous circulation (ROSC), yet the majority of patients with ROSC suffer in-hospital mortality or significant neurologic injuries that persist after discharge. This postarrest morbidity and mortality is largely due to a complex syndrome of mitochondrial dysfunction, inflammatory cascades and cellular injuries known as the postcardiac arrest syndrome (PCAS). The management of PCAS represents a formidable task for emergency and critical care providers. A cornerstone of PCAS treatment is the use of aggressive core body temperature control using thermostatically controlled devices, known as targeted temperature management (TTM). This therapy, demonstrated to be effective in improving both survival and neurologic recovery by several randomized controlled trials nearly 20 years ago, remains a major topic of clinical investigation. Important practical questions about TTM remain: How soon must providers initiate the therapy? What TTM goal temperature maximizes benefit while limiting potential adverse effects? How long should TTM therapy be continued in patients following resuscitation? In this review, we will address these issues and summarize clinical research over the past decade that has added to our fund of knowledge surrounding this important treatment of patients following cardiac arrest.

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OBJECTIVES: Intensive care unit (ICU) patients are at an increased risk of many catastrophic events during intrahospital transport (IHT) for various procedures. This study was planned to determine the incidence and types of adverse events occurring during the transport of critically ill patients in a tertiary care hospital. METHODS: This prospective observational study was conducted in the ICU of a tertiary care hospital for 8 months after ethical clearance from the institute ethics committee. All patients transported out of the ICU during the audit period for diagnostic or therapeutic procedures were included in the study. Vitals and several study parameters were recorded before, during, and after shifting patients to and from the ICU. Various critical events were noted during transport and classified into major and minor critical events based on the presence and absence of potential consequences that lead to a change of therapy during transport. RESULTS: One hundred and sixty patients were studied for consecutive IHT to and from the ICU. The patients were transported for imaging studies (58.1%), minor surgery (31.8%), major surgery (2.5%), and other procedures (7.5%). A total of 248 critical events were observed in 104 IHTs (65%; 95% confidence interval [95% CI]: 57.4%–72.1%). Hence, an average of 2.38 critical events occurred per IHT. There were 31 major events among the 248 critical events (12.5%; 95% CI: 8.8%–17.1%). CONCLUSIONS: Standard guidelines about the accompanying personnel and monitoring need to be followed during IHT. Conduct of minor surgical procedures in the ICU and better bedside diagnostic procedures may be considered for the future.

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OBJECTIVES: The sooner the primary percutaneous coronary intervention (PPCI) is performed, the better prognosis is expected in patients with acute myocardial infarction. The objective is to evaluate the effect of prehospital triage based on electrocardiogram (ECG) and telecardiology on the mortality and morbidity of ST-segment elevated myocardial infarction (STEMI) patients undergoing PPCI. METHODS: This cross-sectional study was conducted based on the data extracted from the hospital information system (HIS) of one general hospital, which had the capability of performing PPCI 24 h a day, 7 days a week. All patients with STEMI who undergone PPCI during 1 year, transferred by emergency medical service (EMS) and their data were registered in the HIS were eligible. Besides the baseline characteristics, first medical contact (FMC)-to-balloon time was recorded. Morbidity based on predischarge left ventricular ejection fraction (LVEF) and mortality based on Global Registry of Acute Cardiac Events (GRACE) score were also recorded. Patients who were referred to the hospital by EMS with prehospital ECG and telecardiology were compared with those without prehospital ECG. RESULTS: Totally, 298 patients with STEMI were enrolled, of whom 183 patients (61.4%) had prehospital ECG (telecardiology), and 115 patients (38.6%) had not. The means of predischarge LVEF of the patients in the first and the second groups were 40.7 ± 10.4 and 40.6 ± 11.2, respectively (P = 0.946). The mean of the probability of 6-month mortality based on GRACE score in the first group was significantly less than that of the second group (P = 0.004). Analyses of multivariable ordinal logistic regression showed that 6-month mortality severity risk in the second group was 1.5 times more than the first group (95% confidence interval 0.8–2.6), although this difference was not statistically significant (P = 0.199). CONCLUSIONS: It is likely that prehospital telecardiology, with shortening FMC to balloon time result in reducing probability 6-month mortality in STEMI patients who undergone PPCI. However, the process of telecardiology had no effect on predischarge LVEF in the current study.

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OBJECTIVE: Intubation is a skill that must be mastered by the emergency physician (EP). Today, we have a host of video laryngoscopes which have been developed to make intubations easier and faster. It may seem that in a busy emergency department (ED), a video laryngoscope (VL) in the hands of an EP would help him intubate patients faster compared to the traditional direct laryngoscope (DL). Our goal was to compare the time taken to successfully intubate patients coming in ED using King Vision VL (KVVL) and DL. MATERIALS AND METHODS: This was a prospective observational study on patients coming to the ED requiring emergent intubation. They were allocated one to one alternatively into two groups – KVVL and DL. Accordingly, KVVL or DL intubations were carried out by the EPs. Time taken to intubate, first-pass success, and crossover between laryngoscopes were recorded. RESULTS: A total of 350 patients were enrolled in the study. Overall, mean time to intubate patients using the DL was 15.85 s (95% confidence interval [CI] 14.05–17.65), while the meantime with KVVL was 13.75 s (95% CI 12.32–15.18) (P = 0.084). The overall first-pass success rates with DL and KVVL were 89.94% and 85.16%, respectively (P = 0.076). A total of 7.43% (95% CI 5.12–10.66) patients had crossover between laryngoscopes. CONCLUSION: We found the KVVL to have a similar performance to the DL in terms of time for intubations and ease in difficult airways. We consider the KVVL a useful device for EDs to equip themselves with.

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Peripartum cardiomyopathy (PPCM) is a rare disease of unknown cause that affects women of childbearing age. A high index of suspicion should be maintained in the pregnant and peripartum woman who presents with sudden cardiac decompensation without any prior history of cardiac disease. The diagnosis can be confirmed with echocardiographic evidence of global left ventricular dysfunction. Timely diagnosis and institution of therapy for heart failure can avoid adverse outcomes in a parturient with PPCM. In this case report, we describe the management of primigravida presenting to the hospital's emergency department with acute cardiac failure and respiratory distress due to PPCM. The case also highlights that though preeclampsia and PPCM are two separate entities, these can coexist in the same parturient due to the common pathophysiological mechanism. In the review, the recommended medical management of heart failure in PPCM with the “BOARD” (Bromocriptine, Oral heart failure drugs, Anticoagulants, Vasorelaxing agents, and Diuretics) scheme is discussed.

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Circulatory shock is a common condition that carries high morbidity and mortality. This review aims to update the critical steps in managing common types of shock in adult patients admitted to medical emergency and intensive care units. A literature review was performed by searching PubMed, EMBASE Ovid, and Cochrane Library, using the following search items: ("shock" OR "circulatory shock" OR "septic shock" OR "cardiogenic shock") AND ("management" OR "treatment" OR "resuscitation"). The review emphasizes prompt shock identification with tissue hypoperfusion, knowledge of the underlying pathophysiological mechanism, initial fluid resuscitation with balanced crystalloids, norepinephrine as the preferred vasopressor in septic and profound cardiogenic shock, and tailored intervention addressing specific etiologies. Point-of-care ultrasound may help evaluate an undifferentiated shock and determine fluid responsiveness. The approach to septic shock is improving; however, confirmatory studies are required for many existing (e.g., amount of initial fluids and steroids) and emerging (e.g., angiotensin II) therapies. Knowledge gaps and wide variations persist in managing cardiogenic shock that needs urgent addressing to improve outcomes.

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OBJECTIVES: Sutures require follow-up visits for favorable evolution. To improve postemergency wound care, we decided to include a standardized advice sheet for patients based on current recommendations. The objective is to assess its effectiveness on outpatients' compliance after being discharged from the emergency department (ED). METHODS: We performed a prospective, pre–post design trial in an ED of a teaching hospital. We included for two consecutive months all patients aged ≥16 years old and consulting for wounds that needed suturing, and we excluded chronic wounds, burns, and hand wounds since they all need special care. During the 1^st month, all patients received during ED visit usual verbal instructions concerning the postemergency care (Group A). During the 2^nd month, all patients received usual verbal instructions and a standardized written advice sheet that detailed postemergency wound care (Group B). We organized telephone follow-up after the suture removal date and asked about dressing changes, appearance of infection signs, and respect of suture removal date. We compared patients;' characteristics in the two groups and performed a multivariable logistic regression using compliance to discharge instructions as our endpoint. RESULTS: For 2 months, 509 patients consulted for wounds. 119 (23.4%) patients were included in the study and followed. Baseline characteristics of patients did not differ between the two groups. Patients who received the advice sheet (Group B) had a better compliance in postemergency care (91.7% vs. 72.9%;P= 0.01). Moreover, there were significantly less dressing changes in Group B than in Group A (5.3 [2.2] vs. 12.9 [7.7];P< 0.01) and suture removal date was more in agreement with recommendations in Group B (83.9% vs. 66.7%;P= 0.03). Occurrence of infection was not significantly different between groups (9.7% vs. 13.7%;P= 0.37). CONCLUSION: For the management of wound care, discharge hospital process including a written advice sheet improves outpatients' compliance and postemergency care.

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OBJECTIVES: This study aimed to determine the effect of adding intravenous midazolam to paracetamol in the treatment of patients with primary headache referring to the emergency department. METHODS: In a randomized clinical trial, 120 patients (18–65 years old) with primary headache referring to the emergency department were enrolled. Patients were divided into two groups (case: paracetamol + midazolam and control: paracetamol + placebo), and the treatment was administered based on the treatment group. The severity of pain (according to the initial Visual Analog Scale) and at different times after the treatment onset (15, 30, and 60 min) and the degree of satisfaction with the treatment were compared in two groups of patients. RESULTS: There were no statistically difference between the two groups about the median of pain severity at the time of 0 min (case: 8 vs. control: 8), 15 min (case: 6 vs. control: 6), and 30 min (case: 4 vs. control: 4) with P > 0.05. Headache severity at 60 min after the treatment onset in the case group (median: 1) was less than that of the control group (median: 3). There was also a statistically significant difference in the median of patient satisfaction in the case group (case: 9 and control: 7 with P < 0.001) and satisfaction in the case group was higher. CONCLUSIONS: Based on our primary and secondary outcomes and the results of the study, we conclude that adding intravenous midazolam to paracetamol do not improve the therapeutic response ratio over time, but the effect of this intervention appeared after 1 h.

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Aspiration of barium sulfate is a well-known complication, occurring accidentally during contrast-enhanced examinations of the upper gastrointestinal system. Massive aspiration of contrast material causes mechanical obstruction that increases alveolar dead space leading to altered ventilation/perfusion (V/Q) ratio with secondary respiratory failure and death. The potential treatment strategies include early recognition of predisposing factors, pretreatment with antireflux medications, such as domperidone, correct choice of contrast media, and use of retroesophageal suction catheter during barium swallow study. We report a case of barium swallow aspiration, which was successfully managed by early institution of bronchioalveolar lavage (BAL) and positive pressure mechanical ventilation. Till date, BAL has not been recommended for the same, with studies showing it can worsen the clinical scenario.

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OBJECTIVES: Pediatric trauma patients presenting to general emergency departments (EDs) may be transferred to pediatric EDs for further management. Unnecessary transfers increase health-care costs, add to workload, and decrease satisfaction. We, therefore, aimed to evaluate the proportion of unnecessary pediatric trauma transfers and describe patient characteristics of these transfers at the pediatric ED. METHODS: A retrospective chart review of cases with trauma-related diagnoses was carried out from January to April 2017. Information regarding patient demographics, diagnosis, and clinical progress was collected. A transfer was defined as unnecessary if the patient was discharged from the pediatric ED without any therapeutic procedure performed. RESULTS: There were 117 cases of trauma transfers. The mean age was 8.3 ± 4.9 years, and 77 (65.8%) patients were male. Ninety-five (81.2%) transfers were from restructured hospitals. Thirty-one (26.5%) cases were admitted to the hospital. Thirty-four (29.1%) cases were unnecessary transfers. The length of stay in the ED for these transferred cases was 118.4 ± 87.1 min. Referring ED was not significantly associated with discharge (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 0.43–3.83, P = 0.792), discharge without any therapeutic procedure performed (OR: 1.47, 95% CI: 0.50–4.31, P = 0.591), or length of stay (mean difference: 22.3 min, 95% CI: 84.5–39.9, P = 0.471). CONCLUSION: About a third of trauma transfers were unnecessary. Further collaborative efforts would be necessary to further define the situation in different health-care settings and exact reasons elucidated so that targeted interventions could be implemented to improve pediatric trauma care.

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OBJECTIVES: Although the reliability of e-point septal separation (EPSS) and caval index (CI) is proven in the diagnosis of acute heart failure (AHF), how much they contribute to the initial clinical impression is unclear. This study aimed to determine the diagnostic contribution of EPSS and CI to the initial clinical impression of AHF. METHODS: This is a prospective observational study conducted in an academic emergency department (ED). The patients admitted to the ED with acute undifferentiated dyspnea were included. Primary diagnosis was made after an initial clinical evaluation, and a secondary diagnosis was made after EPSS and CI measurements. Independent cardiologists made the final diagnosis. The primary outcome was the diagnostic contribution of EPSS and CI to the primary diagnosis. RESULTS: A total of 182 patients were included in the study. The primary diagnosis was found with a sensitivity of 0.55 and specificity of 0.84 and the secondary diagnosis was determined with a sensitivity of 0.78 and specificity of 0.83 in predicting the final diagnosis. The agreement coefficient between the primary and final diagnosis was 0.44 and between the secondary diagnosis and the final diagnosis was 0.61. When the primary diagnosis was coherent with secondary diagnosis, sensitivity and specificity were found to be 0.74 and 0.90, respectively. CONCLUSION: Although a detailed history and physical examination are the essential factors in shaping clinical perception, CI and EPSS combined significantly contribute to the initial clinical impression.

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Little is known about liraglutide overdose and in particular its association with hypoglycemia. The aim of this study was to report on an accidental case of liraglutide overdose and to review similar cases in the literature. Here, we report a case of a young female presented with an accidental injection of 18 mg of liraglutide subcutaneously. She presented with relative hypoglycemia with gastrointestinal symptoms that resembled pancreatitis. We concluded with several implications and policies targeting accidental injections from the use of such medication and similar subcutaneous medications in clinical practice.

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OBJECTIVES: The aim of the present study was to perform a demographic analysis of complications and to determine the factors affecting in-hospital mortality in geriatric patients with warfarin overdose. MATERIALS AND METHODS: All patients aged 65 years or older using warfarin with an international normalized ratio (INR) level above 3.5 IU between 01.01.2014 and 01.01.2018 were included in the study. Characteristics of patients with in-hospital mortality and surviving patients were compared. Multivariate regression analysis was used to assess the predictors for in-hospital mortality. RESULTS: A total of 302 geriatric patients included in the study for statistical analyses. Bleeding rate was 14.2%. A comparison of patient characteristics for in-hospital mortality (survivor vs. nonsurvivor) revealed significant differences for age, gender, chronic renal failure history, creatinine, aspartate aminotransferase (AST), and alanine aminotransferase levels (P < 0.05). A multivariate logistic regression analysis was performed. It was found that elevated AST (P = 0.029, odds ratio [OR]: 1.004, 95% confidence intervals [CIs]; 1.001–1.007) and creatinine (P = 0.045, OR: 2.36, 95% CIs; 1.02–5.48) levels as well as advanced age (P = 0.031, OR: 1.11, 95% CIs; 1.01–1.22) and male gender (P = 0.017, OR: 5.48, 95% CIs; 1.35–22.1) had a negative impact on survival. CONCLUSION: Our study results revealed that male gender, advanced age, and hepatic and renal dysfunctions were the predictors of in-hospital mortality in the elderly with warfarin overdose. In order to avoid serious warfarin-related complications in the older age groups, particularly when there is renal or hepatic dysfunction, patients should be informed about minor warning side effects of warfarin, INR levels should be more frequently checked, and patients should have more strict follow-up schedules.

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INTRODUCTION: Because of the subjectivity and ambiguity of the noninvasive measurements and limited use of invasive ones, there is an impending need for a real-time, fast, inexpensive, and reproducible noninvasive measurement method in acute upper gastrointestinal (GI) bleeding with active bleeding in emergency services. AIMS: In this study, we aimed to evaluate the effect of bedside carotid artery flow time (CFT) measurement before and after the passive leg raising (PLR) maneuver on the determination of active bleeding in patients admitted to the emergency department (ED) with upper GI bleeding. MATERIALS AND METHODS: This prospective case–control study was conducted in the ED of a training and research hospital with upper GI bleeding. Patients were placed in the supine position to perform bedside carotid Doppler ultrasonography before starting treatment. CFT, corrected CFT (CFTc), and carotid artery Doppler flow velocity were measured. After then performed PLR, the same parameters were measured again. RESULTS: A total of 94 patients, including 50 patients with GI bleeding and 44 healthy volunteers as control group were included in the study. CFT and CFTc were shorter in the patient group than the control group (P < 0.001, P = 0.004, respectively). After PLR, there were statistically significant differences in change in the CFT (ΔCFT) and change in the corrected CFT (ΔCFTc) between the groups (P = 0.001, P < 0.001). There were also statistically significant differences in ΔCFT and ΔCFT between the patients with active bleeding and the nonbleeding ones (P = 0.01, P = 0.005, respectively). Area under curve to detect active bleeding for ΔCFT and ΔCFTc were calculated as 0.801 (95% confidence interval [CI]: 0.65–0.95) and 0.778 (95% CI: 0.63–0.91), respectively. CONCLUSION: The corrected carotid Doppler flow time measurements in patients with GI bleeding at the time of presenting to the emergency department can be helpful to interpret the active bleeding.

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OBJECTIVES: Sternal fractures (SFs) are rare pathologies that mainly occur as a result of traffic accidents, which can cause mortality due to concomitant complications. In this study, we aimed to evaluate clinical processes and termination status of patients diagnosed with a SF in the emergency department. METHODOLOGY: Patients diagnosed with a SF in the emergency department during 8 years were retrospectively reviewed. The demographic and clinical characteristics of the patients were recorded, and standard data forms were created. RESULTS: In total, 128 patients were included in the study; 81 (63.3%) patients were male, and the mean age was 49.4 years. When the fracture mechanism was examined, car traffic accidents were the most common type and the cause of fracture in 85 (66.4%) patients. The most common thoracic pathology accompanying SFs was rib fractures (35.9%), and the most common extrathoracic pathology was cranial pathology (27.3%). Pericardial effusion was detected in 12 (9.4%) patients. Of the participating patients, one died and the others were hospitalized. CONCLUSION: Since SFs and associated complications can be life-threatening, emergency room physicians should consider it in the diagnosis. In particular, the necessary examinations and follow-up should be done to assess cardiac damage.

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OBJECTIVE: This study aimed to determine additional predictors of cardiopulmonary resuscitation success using a national emergency medical services (EMS) database. METHODS: This retrospective study was conducted by retrieving data from the Information Technology of Emergency Medical Service, a national EMS database. The inclusion criteria were adult patients (18 years old or over) who suffered from out-of-hospital cardiac arrest and received emergency life support. The outcome was a return of spontaneous circulation (ROSC). Predictors for ROSC were determined using multivariate logistic regression analysis. RESULTS: During the study period, 1070 patients met the study criteria, among whom 199 (18.60%) belonged to the ROSC group. Five factors were eligible for multivariate logistic regression analysis for predicting ROSC. Accordingly, only adrenaline administration was independently and negatively associated with ROSC with an adjusted odds ratio of 0.722 (95% confidence interval: 0.522, 0.997) and a Hosmer–Lemeshow Chi-square of 5.84 (P = 0.665). CONCLUSIONS: Adrenaline use may be a poor predictor for ROSC during out-of-hospital cardiac arrest.

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