OBJECTIVE:In this study, we aimed to evaluate the performance of emergency department intubations for 1 year. METHODS:This was a retrospective analysis of prospectively collected data. The collected variables were patient demographics, indication for intubation, preintubation hemodynamics, preoxygenation methods, medications used for premedication, induction and paralysis, type of laryngoscope used, Cormack-Lehane (C-L) grades, number of intubation attempts, and peri-intubation adverse events. RESULTS:A total of 194 patients were included. The median age of the population was 66.5 years (53.75-79); 61.9% of the patients were male. The majority of the patients were intubated due to medical conditions. The main indication for endotracheal intubation was respiratory failure in 38.6% of the patients. Preoxygenation before intubation was performed in 87.2% of the patients. Fifty-eight percent of the population were hemodynamically stable before the intubation. Fentanyl was the agent used for premedication, induction agents of choice were ketamine and midazolam, and rocuronium was the neuromuscular blocking agent. The C-L grades 1 and 2 were detected in 87.6% of the patients. The first-pass success rate was 72.8%. The peri-intubation adverse events were mainly hypotension and desaturation observed in 82 (42%) patients. The patients with higher C-L grades needed more intubation attempts (P < 0.001). Peri-intubation adverse events were associated with the increased number of intubation attempts (P < 0.001). CONCLUSION:This and similar studies or an airway registry on a national level may help improve the quality of service given and delineate the deficiencies of the airway-related procedures in the emergency department.

Abstract: Objective: This study investigated the role of the reference value of ultra-sensitive troponin kits used in daily practice in determining mortality. Material-methods: This study was conducted in the emergency department (ED) of Akdeniz University Hospital between January 1, 2018, and June 30, 2019. All patients admitted to the emergency department within a period of eighteen months and who had the result of the ultra-sensitive troponin level in the range of 0.06-0.1 ng/mL were included in the study. The recurrent admissions of the patients to the ED were included, and only the first troponin values of the patients were taken as s reference for the study. Result: It was determined that 1029 troponin values of 591 patients with initial troponin I value in the range 0.06-0.1 ng/mL were measured. It was found that 332 of these patients were discharged from the emergency department, and the others were hospitalized. It was found that 168 (28.43%) of the patients died. Considering the gender distribution of the patients who died, it was observed that 101 (60.11%) patients were male, and 67 (39.89%) patients were female. A statistically significant difference was found between the ages of the patients who died (mean 71.38±12.25) and the age of patients alive (mean 61.78 ± 15.89) (p

OBJECTIVE:The aim of this randomized, cross-over trial is to reveal the effect of smartphone cardio-pulmonary resuscitation (CPR) feedback applications (App) on a group of lay rescuers' chest compression-only CPR quality metrics. Quality metrics is measured initially and after 3 months.METHODS:A floor-based Resusci Anne mannequin (Laerdal Medical, Stavanger, Norway) was used. Three scenarios (CPR with device App-on [scenario-a], CPR with device App-off [scenario-b], and hands-only CPR [scenario-c]) were randomly allocated to all participants. All the participants performed 2 min of hands only-CPR for each scenario. Data of mean chest compression rate, mean chest compression depth, and recoil were recorded and compared for each scenario.RESULTS:One hundred and thirty-seven first-year students from the Vocational School of Health Services in Turkey participated in this study to mimic lay rescuers. Difference in the initial mean rate of chest compressions was statistically significant when CPR was performed with device App-on (scenario-a) compared to scenarios b and c (P < 0.001, P < 0.001). Furthermore, difference in the mean chest compression rate at the 3rd month was statistically significant among the scenarios when CPR was performed with device App-on (scenario-a) (P = 0.002, P = 0.001). The difference in initial and 3rd month mean compression depth and the percentage of recoil was not statistically significant among the scenarios.CONCLUSION:This study shows that the mean chest compression rate and percentage of compressions with adequate rate improved with smartphone App-on, and these results were persistent up to 3 months.

OBJECTIVE The aim of this study was to determine the diagnostic value of Doppler ultrasound (DU) in predicting arterial injuries following the penetrating trauma of the forearm, by comparing preoperative diagnosis made by DU and that made by physical examination (PE) with the intraoperative diagnosis. METHODS In this retrospective study, 48 patients (44 men, 3 women; mean age = 30 ± 12.5 years) who underwent surgical treatment due to a suspected arterial injury following a penetrating trauma in the forearm from 2016 to 2018 were included. The DU examination was frequently done before an orthopedic examination. In the orthopedic PE, the knowledge as to whether an arterial injury occurred or (if present) which artery was injured was noted. Preoperative diagnoses by PE and DU were first compared with each other, and then with the intraoperative diagnoses. The specificity, sensitivity, negative and positive predictive values were calculated. RESULTS While the DU findings from 24 patients (50%) matched their intraoperative results, the result from the remaining 24 patients (50%) did not. Nine (18.75%) were considered false-positive and 15 (31.25%) were false-negative. Whereas the PE findings from 30 patients (62.5%) matched their intraoperative results, the remaining 18 patients (37.5%) did not. Six (12.5%) were considered false-positive and 12 (25%) were false- negative. No significant difference was found between the diagnoses of DU and PE, and there was good agreement between the DU and PE findings (P = 0,065, κ = 0,504). While the DU findings were significantly different from the intraoperative findings (P = 0.004), the PE findings were not significantly different from the intraoperative findings (P = 0.302). Sensitivities of DU and PE were both 75% for the diagnosis of radial artery injury as well as 63.3% and 70% for the ulnar artery injury, respectively. Specificities of DU and PE were 83.3% and 91.66% for the diagnosis of radial artery injury as well as 77.77% and 72.22% for the ulnar artery injury, respectively. CONCLUSION The PE seems more sensitive and useful than the DU in predicting arterial injuries following the penetrating trauma of the forearm. LEVEL OF EVIDENCE Level IV.

Hanoglu, Didem Nazife; Goksu, Erkan; Kazanir, Seyfettin; Chebl, Ralphe Bou Author Information

Nizâmu’l-mulk, devlet teskilatinda yaptigi duzenlemeler ve onculuk ettigi muesseselerle Selcuklu tarihinde onemli bir role sahiptir. Siyeru’l-muluk ya da Siyâsetnâme isimli onemli bir esere imza atan Nizâmu’l-mulk, uzun yillar Selcuklularin vezirligini yapmis, bu bakimdan eserinde ortaya koydugu devlet yonetim esaslarinin sadece teorisyeni degil, ayni zamanda da icracisi olmustur. Bir yandan eski Iran devlet gelenegine, bir yandan da Islam kultur ve medeniyetine son derece vakif olan Nizamulmulk’un, Selcuklu hanedani ve devleti teskilati icerisinde yer aldigi uzun hizmet hayati boyunca Turk devlet gelenegini, kultur ve medeniyetini de ogrenmis oldugu muhakkaktir. Bu bilgi ve tecrubesiyle onculuk ettigi duzenlemelerden biri iktâ‘ sistemidir. Selcuklulardan onceki donemlerde de uygulanan iktâ‘ nizaminin aksayan yonlerini tadil etmis, onceki donemlerde pek fazla uygulanmayan askeri iktâ‘yi yayginlastirarak iktâ‘nin idari ve iktisadi fonksiyonlari yaninda askeri bir islev kazanmasini saglamistir. Boylece kendine hâs ozelliklerle dikkat ceken bir Selcuklu iktâ‘i ortaya cikmis ve Buyuk Selcuklulardan sonra kurulan butun Musluman Turk devletleri bu Selcuklu iktâ‘’ini kendilerine model almislardir.

A 45-year-old woman presented to the emergency department for the evaluation of shortness of breath, orthopnea, and cough when she was in the supine position. The intensity of her symptoms had increased over the last 20 days. Her physical examination was normal other than a 2/6 systolic murmur in the apex. Her vital signs at presentation were blood pressure of 134/96 mm Hg, a heart rate of 113 beats/min, a respiratory rate of 20 breaths/min, and oxygen saturation of 97% on room air. Bedside cardiac ultrasonography was performed (Figure 1, Video 1 [available online at www.jem-journal.com]).

As emergency physicians, we encounter patients suffering from either hypoxemic and/or hypercarbic respiratory problems on a daily basis. A stepwise approach to solving this problem seems logical from an emergency medicine perspective. Current literature supports the notion that NIV decreases endotracheal intubation rates and, mortality in select patient populations. The key to the success of NIV is patient cooperation and support for the care givers. In this narrative review, non-invasive ventilation (NIV) is discussed in terms of modes of delivery, interface and patient selection, as well as practical considerations.

Ortaçağ devletler hukukuna göre savaş veya sulh yoluyla bir devletin hâkimiyetini kabul eden hükümdar veya emîrler, klasik tâbiiyet (vasallık) şartlarını ve bu şartlardan doğan mükellefiyetleri yerine getirirlerdi. Avrupa, Uzak Doğu ve sair bölgelerde kurulmuş muhtelif devletlerde de mevcut olduğu görülen tâbiiyet hukukunun, Ortaçağ İslâm devletlerinde tezahür eden en önemli şart ve mükellefiyetleri, yıllık haraç vermek, metbû' hükümdar adına hutbe okutmak ve metbû' hükümdar asına sikke darp ettirmekti. Bunların dışında, metbû' hükümdar "sultan" unvanını taşırken, tâbi hükümdarın "melik" unvanını kullanması, metbû' hükümdarın sarayının kapısında günde beş nevbet çalınırken, tâbi hükümdarın üç nevbetle yetinmesi, metbû' hükümdar nezdinde hükümdar soyundan ve ekseriya tâbi hükümdarın oğullarından rehineler bulundurulması ve tâbi hükümdarın, her lüzum gösterdiği anda yardımcı kuvvetlerin başında metbû' hükümdarın hizmetine koşması gibi hususlar da klasik tabiiyet alâmetlerinden kabul edilmişti. Buna mukabil her tâbi hükümdar, metbû' hükümdarın menfaatlerini haleldar etmemek kayıt ve şartıyla iç ve dış işlerinde tamamıyla müstakil olup, üçüncü bir devletle harp veya sulh yapmakta, elçiler gönderip kabul etmekte serbest idi. Tâbiiyet hukukunun genel çerçevesi bu şekilde olmakla birlikte zaman zaman farklı uygulamalara da tesadüf edilmektedir. Bunun yanı sıra oldukça basit görünen metbû-tâbi ilişkileri, bazen oldukça karmaşık bir hale gelebilmiştir. Bu durumun yaşandığı devletlerden biri de Türkiye Selçuklu Devleti'dir. Bu dönemde çoğu zaman klasik tâbiiyet hukukunun cari olduğu görülse de gerek şekil gerekse mahiyet itibarıyla farklı uygulamalara da rastlanmaktadır.

The validity of a diagnostic test can be demonstrated by comparing it to a gold standard test. Sensitivity, specificity, positive and negative predictive values (PPV, NPV), positive and negative likelihood ratios, diagnostic odds ratio, and the area under the ROC curve are the parameters that reflect the discriminative ability of a diagnostic study. Diagnostic accuracy is very sensitive to the characteristics of the study population and it is affected by the prevalence or the spectrum of the disease studied. Therefore, it is important to know how to interpret the diagnostic parameters of the tests studied (3). This article is protected by copyright. All rights reserved.

According to the Medieval laws of states; obligations of being a vassal state and duties resulting from those obligations were carried out by kings, princes or emirs who submitted to the sovereignty of another state by way of war or peace. The vassalage law is seen to have existed in the states founded in Europe, the Far East and in the other regions and the most important obligations and requirements of the vassalage law seen in Medieval Islamic states were paying annual tribute, reading khutba in the name of the suzerain state, minting coins (sikka) in the name of the suzerain king. In addition to these, those had been accepted as the signs of being vassal: that the suzerain king bears the title "sultan" and the vassal king bears the title "malik", that the suzerain king has five nawbats (the ceremony of military band as a sign of sovereignty) a day in front of his palace and the vassal king has three nawbats a day, that the suzerain king keeps someone descending from a king family and usually one of sons of the vassal king and that the vassal king runs -as a leader of the auxiliary troops- to the service of the suzerain king in any necessary time. However every vassal king was independent in his domestic and foreign relations on condition that he not spoil the interests of the suzerain king, the vassal king was free for fighting or making peace with another state, sending or accepting envoys. Though the general outline of the vassalage law was in that way, occasionally different practices were seen. Additionally, even if it is seemed very simple, sometimes suzerain-vassal relations could be very complicated. One of the states where this case could be seen was Seljuk Sultanate of Rum. During the age of that state, even if classical vassalage law usually was seen having been in effect, different practices can be seen in terms of nature and form.

OBJECTIVE:The aim of this randomized cross-over study was to compare one-minute and two-minute continuous chest compressions in terms of chest compression only CPR quality metrics on a mannequin model in the ED. MATERIALS AND METHODS:Thirty-six emergency medicine residents participated in this study. In the 1-minute group, there was no statistically significant difference in the mean compression rate (p=0.83), mean compression depth (p=0.61), good compressions (p=0.31), the percentage of complete release (p=0.07), adequate compression depth (p=0.11) or the percentage of good rate (p=51) over the four-minute time period. Only flow time was statistically significant among the 1-minute intervals (p<0.001). In the 2-minute group, the mean compression depth (p=0.19), good compression (p=0.92), the percentage of complete release (p=0.28), adequate compression depth (p=0.96), and the percentage of good rate (p=0.09) were not statistically significant over time. In this group, the number of compressions (248±31 vs 253±33, p=0.01) and mean compression rates (123±15 vs 126±17, p=0.01) and flow time (p=0.001) were statistically significant along the two-minute intervals. There was no statistically significant difference in the mean number of chest compressions per minute, mean chest compression depth, the percentage of good compressions, complete release, adequate chest compression depth and percentage of good compression between the 1-minute and 2-minute groups. CONCLUSION:There was no statistically significant difference in the quality metrics of chest compressions between 1- and 2-minute chest compression only groups.

Introduction: Despite advances in therapeutic and diagnostic options, acute pulmonary embolism (PE) is associated with high morbidity and mortality. Risk classification is important in deciding how and where to treat patients This study aimed to investigate simplified pulmonary embolism severity index (sPESI) scores and highly sensitive troponin levels to predict 30-day clinical outcomes. Methods: Patients with the symptoms of dyspnoea, chest pain, and haemoptysis were included in the study. Multiple detector computed tomography (CT) examinations were performed. If the patients' glomerular filtration rate levels were less than 60 ml/min/1.73 m(2), then the ventilation/perfusion (V/Q) scan was the preferred imaging modality. Venous blood samples were collected to test for highly sensitive troponin T levels (Elecsys troponin T high sensitive, Roche diagnostics). All patients were examined by two-dimensional bedside echocardiography for detection of right ventricular dilatation. Patients' baseline characteristics (sex, ages, etc.) were recorded along with co-morbidities, symptoms, haemodynamic conditions, all-cause mortality rates during hospitalisation, the duration of hospital stay, radiographic test results, and laboratory findings, and electrocardiography were also obtained during emergency department admission. Primary outcome measure was defined as death in a month. Logistic regression model was created to reveal the associated parameters related to mortality within a month of the emergency department visit. Results: One hundred and seventy patients suspected of PE underwent either a CT angiogram or pulmonary V/Q scan. In total 70 patients were diagnosed with PE and included in the study. The logistic regression model was created in order to assess poor prognosis markers. In addition to the troponin levels and sPESI scores commonly used for pulmonary embolism prognosis, right ventricular dilatation, heart rate, systolic blood pressure and oxygen saturation using logistic regression models were created. Positive troponin level (odds ratio: 5.23 and 95% confidence interval [CI] 1.03 to 26.51) and negative sPESI score (odds ratio 2.14 and 95% CI 1.00 to 4.60) were found to be significant. Conclusions: Some scoring systems, including PESI and sPESI score, can be used for predicting mortality in patients with pulmonary embolism. If sPESI score is zero, and troponin levels are negative, the patient can be discharged safely.

A 27-year-old man presented to the emergency department for evaluation of a tender, painful, swollen mass on the distal ulnar aspect of the palm. Two weeks before his presentation, the patient accidentally lacerated the palmar crease of the left hand with broken glass, and his ulnar artery was repaired (Figure 1). The ulnar aspect of the palm was swollen and tender. The distal neurovascular examination result was normal. A thrill could be appreciated on palpation. Bedside ultrasonography was performed (Video 1). Ulnar artery pseudoaneurysm. In this case, bedside Doppler ultrasonography revealed a pseudoaneurysm of the ulnar artery. Unlike true aneurysms, pseudoaneurysms do not contain all the layers of a vessel, and they are limited by a fibrin wall that communicates (neck) with the lumen of the affected artery.1Levis J.T. Garmel G.M. Radial artery pseudoaneurysm formation after cat bite to the wrist.Ann Emerg Med. 2008; 51: 668-670Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar The diagnosis of a pseudoaneurysm may be confirmed with various imaging modalities, such as color Doppler ultrasonography, computed tomography, or angiography.2Mann G.S. Heran M.K. Percutaneous thrombin embolization of a post-traumatic superficial temporal artery pseudoaneurysm.Pediatr Radiol. 2007; 37: 578-580Crossref PubMed Scopus (39) Google Scholar There are 3 classic signs of a pseudoaneurysm in sonography3Goksu E. Yuruktumen A. Kaya H. Traumatic pseudoaneurysm and arteriovenous fistula detected by bedside ultrasound.J Emerg Med. 2014; 46: 667-669Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar: (1) the neck communicating with the pseudoaneurysm (Figure 2, Video 1); (2) a yin-yang sign, which indicates bidirectional flow because of the swirling of blood within the pseudoaneurysm cavity (Video 1); and (3) a “to-and-fro” spectral waveform within the neck, which indicates reversal of flow in the neck during diastole because of changes in pressure gradients. Bedside ultrasonography should be the first imaging modality (with a sensitivity and specificity of 94% and 94% to 97%, respectively) in the evaluation of possible vascular injury causing pseudoaneurysm.4Gullo J. Singletary E.M. Larese S. Emergency bedside sonographic diagnosis of subclavian artery pseudoaneurysm with brachial plexopathy after clavicle fracture.Ann Emerg Med. 2013; 61: 204-206Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI0MWYyMGU3ODFkMjE2MTZmODc4MjRiMzdmNDBhYTBlYSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc5NjUzMjkzfQ.GH2EBafO5LMcs99-M5DIPoykiGzummryDa_PP7QtaLAaEGb7B6OYnrKUHhdYxHXSWRXoh1BDLI8t_YxDVUw2yxpOCvZkoY5KaY6QY4X3z6hYhGIxMGDyUy9nPMMBfPwjfpzx8VLxvC4An0Xs1qt5u1Q7JfxStmc7GhsOcMRURXJBZ7xsQ9ncoKcIiLlYeWL3xVnBk2walFWw79FZJT4B5l8ToV6acLWSumVjr0C6r8-CmAY6QW1Dgvjl5bT7VrhW0k442shnUeN7y6MoypfAabGKsnDaXxJDsuRCTrJ9DdIwQAjAXL0lEpI8Mu-zro-LzdbaNOMnqIj9zFfaUwaAMg Download .mp4 (7.98 MB) Help with .mp4 files Video 1The video clip demonstrates the neck and a red and blue flow pattern (ying-yang) sign within the pseudoaneursym.

Objective: The aim of the study was to compare ultrasonography (US) and surface landmark techniques for detecting the cricothyroid membrane (CTM) to perform a cricothyroidotomy on healthy volunteers.Methods: In this prospective observational study, 5 operators and 24 models were included. The borders of the CTM were marked with an invisible pen. The operators were asked to point the CTM either with the palpation method or the US-guided fashion.Results: The CTM was detected accurately in 80 (66.7%) attempts with palpation and 83 (69.2%) attempts with US. There was no statistically significant difference in the accuracy of detection of the CTM with palpation and US. The mean time for detecting the CTM with palpation was 8.25 +/- 4.8 seconds (95% confidence interval, 7.3-9.1). The mean time for detecting CTM with US was 17 +/- 9.2 seconds (95% confidence interval, 15.3-18.7). The duration for detecting the localization of the CTM was longer with US.Conclusion: According to the results of this study, the accuracy of US and palpation was similar in detecting the localization of the CTM. However, the duration for detecting the CTM was longer with US when compared with the palpation technique. (C) 2015 Elsevier Inc. All rights reserved.

Patients with headache constitute up to 4.5% of emergency department (ED) visits.[1] Cerebral venous thrombosis (CVT) is an important cause of the headache that is more common than once suspected. The diagnosis of CVT is often missed or delayed because of non-specific clinical manifestations, and brain computerized tomography (CT) may easily be misinterpreted.[2] Herein we report a patient with CVT who presented with headache only and was misdiagnosed with subarachnoid hemorrhage (SAH).

The Effects of Classic Two-Minute Pressing and Commercial Adhesive Bandages on Ecchymosis Development Following Removal of Intravenous Catheters. Emerg Med Inves 2016: 34-37. Abstract Introduction: Peripheral intravenous catheter insertion in emergency department has become a routine process. After removing intravenous catheter general approach is to apply pressure with cotton or tampon to entrance area for a few minutes. However, patients are demanding for commercial adhesive bandages instead of applying pressure to the area. The purpose of our study was to investigate the effects of compression and commercial adhesive bandages on development and size of ecchymosis following removal of intravenous catheter in the antecubital region. Material-Methods: This prospective observational study was conducted in emergency department of a Training and Research Hospital with an average of 300.000 annual admissions. Patients were randomized to receive compression in odd days of the month and commercial adhesive bandages in even days of the month. A total of 221 patients were included in the study. There were 115 patients in the compression group and 106 patients in the commercial adhesive bandage group. Results: Ecchymosis was found to occur in 22 (22%) patients in compression group and 30 (30%) in bandage group. No statistically significant difference was found between two groups in terms of ecchymosis development (p = 0.197). There was no correlation between the diameter of ecchymosis and compression or bandage application (p = 0.144). Independent from the application type, ecchymosis was found to occur in 16 (18.7%) male patients and 36 (33.3%) female patients. Significant difference was found between genders in terms of ecchymosis development.