Evaluation of erythrocyte membrane fatty-acid compositions in association with interleukin-6 levels in patients with COVID-19.

OBJECTIVE: The cytokine storm presented in the hyperimmune response is related to poor prognosis in people with COVID-19. Interleukin-6 (IL-6) is one of the most prominent cytokines, especially on mucosal surfaces during infection, causing the cytokine storm. Polyunsaturated fatty acids (PUFAs) are the precursors of eicosanoids, which play critical roles in immune regulation and inflammation. The balance between ω-3 and ω-6 levels in the cell membrane has a critical role in regulating the equilibrium between proinflammatory and antiinflammatory processes and inducing IL-6 production. The present study focused on inflammatory and antiinflammatory mechanisms in COVID-19 over PUFAs and on relating their levels with disease prognosis and severity. METHODS: A total of 106 participants were included in the study. They were divided into three groups according to IL-6 level- 1: <35 pg/mL, 2: between 35 and 300 pg/mL, and 3: >300 pg/mL. Erythrocyte membrane PUFA compositions were analyzed by group. RESULTS: Levels of γ-linolenic acid and ω-6/ω-3 ratios were significantly increased in all comparison groups (P < 0.05). Total ω-6 and the ratio of arachidonic acid to eicosopentaenoic acid showed a statistically significant difference only between groups 1 and 3 (P < 0.05). There was a moderately negative correlation between total ω-3 and IL-6 and procalcitonin. There were positive correlations with ω-6/ω-3 ratio inflammatory markers, and the total ω-6 index also showed a moderately positive correlation with IL-6, procalcitonin, and D-dimer levels. CONCLUSIONS: The ratio of arachidonic acid to eicosopentaenoic acid, and ω-3 PUFAs, can be systemic signs of poor prognosis, increased lung damage, and high mortality in COVID-19, together with IL-6.

Do carboxyhaemoglobin and methaemoglobin levels predict the return of spontaneous circulation and prognosis of cardiac arrest patients?

BACKGROUND: Early prediction of return of spontaneous circulation (ROSC) for cardiac arrest (CA) patients is a major challenge. Different biomarkers have been studied as an early predictor for ROSC, but a consensus has not been achieved in this regard. This study's goal was to investigate the value of the carboxyhaemoglobin (COHb) and methaemoglobin (MetHb) levels as a predictive marker for ROSC and prognostic marker for patients who achieve ROSC. METHODS: A total of 241 adult patients (109 female, 132 male) diagnosed as non-traumatic CA were included in the study. The patients were divided into two groups based on whether they achieved ROSC. The ROSC group was divided into two sub-groups: survivors and non-survivors. Complete blood count parameters, routine biochemistry measurements, coagulation parameters, and blood gas analysis, and cardiac markers values were compared between the groups. RESULTS: COHb levels were significantly lower in the non-ROSC group than in the ROSC group (P = .002). Urea, creatinine, potassium and cTn (cardiac troponin) levels in the non-ROSC group were significantly higher than in the ROSC group (P < .001, .001, .014, and .005, respectively). COHb levels were significantly lower in the non-survivor group than in the survivor group (P = .022). Urea, creatinine, potassium, lactate dehydrogenase, and cTn levels were significantly higher in the non-survivor group than the survivor group (P = .001, .005, .001, .010 and .008, respectively). There was no significant difference between the ROSC and non-ROSC groups and survivor group and non-survivor groups in terms of MetHb levels (P = .769 and .668, respectively). Moreover, CPR duration is significantly shorter in the survivor group than the non-survivor group (P Ë‚ .001). CONCLUSION: COHb levels in the blood gas analysis at the time of admission could be used as a predictive marker for ROSC and prognostic marker for the patients who achieved ROSC.

The boundaries between survival and nonsurvival at COVID-19: Experience of tertiary care pandemic hospital.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) is an emerging, fast-spreading, highly mortal and worldwide infectious disease. The pulmonary system was defined as the main target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), but the mortality concept of this disease presented with more severe and systemic disease. The present study investigated the relationship between the patient characteristics at the initial hospital administration and fatality in COVID-19 patients. METHODS: In this retrospective and comparative cohort study, all the 767 hospitalised COVID-19 patients, treated between 18 March and 15 May 2020 in the Covid Clinics of Gulhane Training and Research Hospital in Ankara, Turkey, were evaluated. RESULTS: The fatality rate was significantly increased in patients with any comorbid disease except asthma. The initial laboratory test results indicated highly significant differences according to the patient's outcome. A multifactor logistic regression analysis was performed to calculate the adjusted odds ratios for predicting patient outcomes. Being older than 60 years increased the death risk with an adjusted OR of 7.2 (95% CI: 2.23-23.51; P = .001). The presence of a cancer and the extended duration of intensive care unit treatment were other significant risk factors for nonsurvival. Azithromycin treatment was determined as significantly reduced the death ratio in these patients (P = .002). CONCLUSION: It was revealed that being older than 60 years, presence of a cancer and extended duration of ICU treatment were the major risk factors for predicting fatality rate in hospitalised COVID-19 patients.

Cardiopulmonary resuscitation is more effective for in-hospital cardiac arrest when performed on a stretcher. A manikin study.

OBJECTIVES: To compare the efficacies of various chest compression procedures performed on a stretcher during dynamic transport of patients with in-hospital cardiac arrest. Methods: This prospective and randomized cross-over study used manikins. Practitioners were asked to perform chest compressions on a manikin placed on a moving stretcher for 2 minutes. Cardiopulmonary resuscitation (CPR)  procedures were included the following 3 types: i) CPR-walking (CPR-W) ii) CPR-straddling (CPR-S), and iii) CPR-mechanical chest compression device (CPR-MCCD). Demographic data of the participants, CPR quality indicators, the time between the start command and first compression, level of difficulty, and the distance covered by the stretcher for the duration of each application were recorded. RESULTS: Thirty-two physicians (9 female, 23 male), participated in this study. The CPR-MCCD procedure was the most effective for all parameters, except the time between the start command and first compression. On the other hand, the compression rate at optimal depth, CPR success score, distance covered, and level of difficulty parameters were significantly favored in the CPR-S group, when compared to the CPR-W group (p less than 0.001, all comparisons). CONCLUSIONS: It is possible to perform high-quality chest compressions during patient transport using the CPR-MCCD method. The CPR-S method allowed practitioners to perform higher-quality chest compressions compared to CPR-W.

Assessment of endotracheal intubation procedures following inadvertent esophageal intubation. A randomized crossover manikin trial.

OBJECTIVE: To evaluate the success, degree of difficulty and completion time of endotracheal intubation without removing the endotracheal tube in the event of an oesophageal intubation.. METHODS: The prospective, randomised crossover study was conducted at Gulhane Training and Research Hospital, Ankara, Turkey, from July 1, 2018, to August 31, 2018, and used a manikin model. Endotracheal intubation was performed using Miller, Macintosh blades and a video laryngoscope. The procedures were randomised into two groups, with group E+ being subjected to it while an endotracheal tube ETT was placed in the oesophagus (E+) simulating the oesophageal intubation, and control group E- getting the standard procedure without the endotracheal tube in the oesophagus. All methods were evaluated for their success, completion time, and degree of difficulty. Data was analysed using SPSS 22. RESULTS: There were 120 manikins, with 60(50%) in each of the two groups. The mean completion time with Miller in E+ group was 19.05±9.65 and for E- it was 17.55±11.95 seconds. With Macintosh, E+ had a mean completion time of 19.85±12.66 seconds and E- had 16.75±8.66. With video laryngoscope, E+ group had a mean completion time of 16.75±8.66 seconds, while E- had it 14.60±8.17. No significant difference was found in the paired group comparisons in terms of the degree of task difficulty (p>0.05). CONCLUSIONS: In case of inadvertent oesophageal intubation condition, leaving the tube in the oesophagus and performing subsequent endotracheal intubation attempts was not found to decrease the rate of success regardless of the laryngoscope type.

Investigation of the Value of T peak to T end and QTc Intervals as Electrocardiographic Arrhythmia Susceptibility Markers in Acute Ischemic Stroke.

INTRODUCTION: Arrhythmias are one of the most common causes of mortality in patients with acute ischemic stroke (AIS). This study aimed to investigate the relationships of arrhythmia susceptibility markers (QT, QTc, Tpe, Tpe-D, Tpe/QT, and Tpe/QTc) with the localization and volume of the ischemic area, the National Institutes of Health Stroke Scale (NIHSS) scores, and troponin levels in AIS. METHODS: Patients diagnosed with AIS in the emergency department in the period from 01 November 2016 to 31 March 2019 were retrospectively reviewed. Patients admitted to the emergency department with no pathological ECG findings were included. The measurements of QT, QTc, Tpe, Tpe-D, Tpe/QTc, and Tpe/QT were performed under a digital microscope. The NIHSS scores, troponin values, and the ischemic area volume based on the diffusion-weighted magnetic resonance imaging findings at the time of admission were found. RESULTS: A total of 135 patients, comprising 70 AIS patients and 65 individuals as controls, were included in the study. The male/female ratio was 73/62 and the mean age was 68.51±10.80 years. All of the ECG parameters in the AIS group and the control group were statistically significantly different between the groups except Tpe-D (p=0.454) (For QT, QTc, Tpe, Tpe/QTc, and Tpe/QT; p=0.003, 0.022, <0.001, 0.001, 0.001; respectively). QT, QTc, Tpe, Tpe/QTc, and Tpe/QT values were not significantly different between the groups with a NIHSS score of ≤5 and >5 (p=0.480, 0.688, 0.663, 0.512, 0.333, respectively). CONCLUSIONS: Arrhythmia susceptibility markers including QT, QTc, Tpe, the values of Tpe-D, Tpe/QT, and Tpe/QTc are different in AIS patients compared to the individuals in the control group; therefore, these parameters can be included among the other parameters of close cardiac monitoring.

Concomitant hypertriglyceridemia-induced pancreatitis in pregnant monozygotic twin siblings.

Hypertriglyceridemia-induced pancreatitis (HTIP) is the third most common cause of pancreatitis. Hypertriglyceridemia shows familial transition and pregnancy increases the risk of HTIP. The treatment of HTIP is initiated with supportive treatment and continues with specific treatments including plasmapheresis, insulin, heparin infusion, and hemofiltration. The current study reports monozygotic twins who are pregnant at the same time having concurrent HTIP attack.

Myocardial Repolarization Parameters and Neutrophil-to-Lymphocyte Ratio are Associated with Cardiotoxicity in Carbon Monoxide Poisoning.

The present study aims to examine the clinical values of complete blood count (CBC) bioindicators and corrected QT (QTc), Tpeak - Tend interval (Tp-e), Tpeak dispersion (Tp disp), and Tp-e/QT ratio that are the parameters of myocardial repolarization (M-rep) for cardiotoxicity, which develops due to acute carbon monoxide (CO) intoxication in patients admitted to the emergency service. This retrospective, cross-sectional, observational, and single-center study was conducted between April and June 2019. Statistical analysis was performed using the SPSS 23.0 software. Data of 234 participants were analyzed. Of these, 54.9% (n = 129) were female. Neutrophil-to-lymphocyte ratio (NLR), QTc, Tp-e values were significantly high in the CO intoxication group (p < 0.001, p < 0.001, and p < 0.001, respectively), whereas Tp-e/QTc ratio was significantly lower in the CO intoxication group than that in the control group (p < 0.001). NLR, Tp-e, Tp disp values were significantly high in the myocardial injury (M-inj) group (p < 0.001, p = 0.003, and p = 0.018, respectively). Furthermore, Tp-e/QTc ratio was significantly low in the M-inj group (p = 0.002). M-rep parameters and NLR are associated with CO intoxication and the development of M-inj. Moreover, these bioindicators and can provide clinicians an early indication of M-inj.

Comparative evaluation of the efficacy of using monocular, binocular and panoramic night vision goggles in successful venous access in darkness.

INTRODUCTION: The use of night vision goggles (NVGs) by medical staff operating in active combat areas may present a tactical advantage in maintaining unit concealment. This study seeks to assess the degree to which NVG use improves speed and ease of intravenous access in comparison to no NVG use, and which NVG system (monocular, binocular or panoramic) provides the best conditions for the clinician. METHODS: Cannulation was carried out using both eyes open (BEO) and one eye open (OEO) in well-lit conditions to establish a baseline measurement. The same procedure was then performed with a variety of NVGs, with and without infrared (IR) light sources in a dark room, and the degree of difficulty, time to procedural completion and success rate were compared. RESULTS: NVG use improved procedure speed in comparison to the BEO method in the dark. Among the NVG methods trialled, binocular NVG (BNVG) methods outperformed panoramic NVG (PNVG) and monocular NVG in terms of success rate. CONCLUSIONS: Use of BNVG resulted with a better success rate in our study. We would like to emphasise that although combatant units prefer PNVGs for the wider temporal vision they provide, it must be kept in mind that this may pose a disadvantage in peripheral vascular access procedures while providing first aid to the casualty at close distances.

Endotracheal Intubation by Paramedics Using Neodymium Magnet and Modified Stylet in Simulated Difficult Airway: A Prospective, Randomized, Crossover Manikin Study.

BACKGROUND: The present study evaluates the success and efficacy of endotracheal intubation (ETI) using a modified intubation stylet and a magnet system to direct the stylet into the trachea. The system was developed by the researchers in an attempt to increase the success and efficacy of ETI. METHODS: ETI procedures were performed on an airway management manikin by emergency medical technicians with at least four years of experience in ETI. The technicians used a stylet modified with an iron ball affixed to the tip and a neodymium magnet, designed specifically for the study. The intention was to guide the endotracheal tube into the trachea at the level of the thyroid and cricoid cartilages on the manikin with the aid of the modified stylet and the magnetic force of the neodymium magnet. The success rate, completion time, and degree of difficulty of two procedures were compared: magnetic endotracheal intubation (METI) and classic ETI (CETI). RESULTS: The success rate was 100% in both groups. The mean completion times for the METI and CETI procedures were 18.31 ± 2.46 s and 20.01 ± 1.95 s, respectively. There were significant differences in completion time and degree of difficulty between the METI and CETI procedures (both p=0.001). CONCLUSIONS: We found the use of a neodymium magnet and modified stylet to be an effective method to guide the endotracheal tube into the trachea. The present study may provide a basis for future studies.

Lansoprazole as an uncommon cause of anaphylaxis: What to give next?

Proton pump inhibitors (PPIs) are one of the most prescribed drugs worldwide. Anaphylactic reactions of PPIs are rare; however, several cases have been reported. Here, we report a rare case of anaphylaxis that occurred immediately following lansoprazole intake. Following the successful management in the emergency department, skin prick and oral controlled challenge tests were performed to evaluate cross-reactivity. Thereafter, lansoprazole was switched to pantoprazole, which was well tolerated. Skin prick and oral controlled challenge tests can be performed for determining the cross-reactivity of PPIs to prevent adverse reactions.

Comparison of the efficacy of ShotBlocker and cold spray in reducing intramuscular injection-related pain in adults. A prospective, randomized, controlled trial.

OBJECTIVES: To compare the efficacy of ShotBlocker and cold spray in reducing intramuscular (IM) injection-related pain in adults. Methos: A prospective, randomized, controlled study carried out between January 2018 and March 2018 at the Department of Emergency Medicine, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey. Adult patients receiving IM injection of diclofenac sodium (75 mg/3 ml) were included. The patients were randomized into 3 groups: ShotBlocker, cold spray, and control. Each group comprised 40 patients. Patients were instructed to rate the intensity of IM injection-related pain using a 100-mm visual analog scale (VAS). Visual analog scale scores of the patients were statistically analyzed. Results: Visual analog scale scores were lower in the ShotBlocker (11 mm) and cold spray (10 mm) groups than in the control group (31 mm) (p=0.001). There were no significant differences in VAS scores between the ShotBlocker and cold spray groups. The operators' responses revealed that ShotBlocker was more difficult to administer than cold spray. Conclusion: ShotBlocker is an effective non-pharmacological method that reduces IM injection-related pain and is similar in efficacy, to cold spray.

Comparison of the non-mortal gunshot and handmade explosive blast traumas during a low-intensity conflict on urban terrain.

OBJECTIVES: We aimed to conduct a cross-sectional data analysis involving 60 patients wounded during a low-intensity conflict on urban terrain. MATERIAL AND METHODS: Data of the 60 patients wounded during a low-intensity conflict on urban terrain between September 1st, 2016, and January 15th, 2017, and transferred to our hospital after the initial medical interventions conducted in the regional hospitals were probed retrospectively. Group A consisted of 25 (41.67%) patients suffering gunshot wounds, and Group B consisted of 35 (58.33%) patients with blast trauma injuries. Their Abbreviated Injury Scale scores were compared according to the injured body compartment. RESULTS: In both groups, extremities were the most common site of injury (17 [50%] for Group A, 18 [33.33%] for Group B). The difference between the two groups was statistically significant for only head and neck injuries and facial injuries (p<0.05). In each group, only one body compartment was affected in 19 patients, which represented 55.88% of patients in Group A and 35.18% of patients in Group B. Injuries of three compartments concurrently occurred in 3 (8.82%) patients in Group A and 4 (7.4%) patients in Group B. None of our patients died because of their injuries. CONCLUSION: Contrary to the expected, gunshot casualties were found to be more likely to suffer from extremity injuries than blast casualties did, and it should be noted that blast trauma casualties tend to have multiple compartment injuries that should not be missed. Ocular ruptures are also common, especially with blast injuries, warranting equipping the personnel with protective goggles.

The success of endotracheal intubation with a modified laryngoscope using night vision goggles.

BACKGROUND: Endotracheal intubation (ETI) procedure in the combat area differs from prehospital trauma life support procedures because of the danger of gunfire and the dark environment. We aimed to determine the success, difficulty degree, and duration of ETI procedures with a classical laryngoscope (CL) in a bright room and with a modified laryngoscope (ML) model in a dark room. METHODS: All interventions were performed by a combatant medical staff of 10 members. We developed an ML model to obtain a tool that can be used in combination with night vision goggles (NVGs) to perform ETI at night. The procedures were performed using a CL with the naked eye in a bright room and using a ML with NVGs in a dark room. The ETI procedure that used the ML was performed by engaging and locking the blade on the handle either in the mouth (ML-IM) or outside of the mouth (ML-OM). RESULTS: The mean completion times for the ETI procedures, namely Day-CL, ML-OM+NVG, and ML-IM+NVG, performed by the operators were 14.46, 26.9, and 32.38 s, respectively. The ML-OM+NVG and ML-IM+NVG procedures were significantly longer than the Day-CL procedure (p<0.05). The ML-IM+NVG procedure was significantly longer than the ML-OM+NVG procedure (p<0.05). All ETI procedures were found to be 100% successful. The Day-CL procedure was easier than the ML-OM+NVG and ML-IM+NVG procedures (p>0.05). CONCLUSION: The ETI procedure is applicable using NVGs in dark conditions on the battlefield. Medical interventions performed using NVGs in the dark should be a part of the basic training provided in tactical emergency medicine.

A new perspective on life-saving procedures in a battlefield setting: Emergency cricothyroidotomy, needle thoracostomy, and chest tube thoracostomy with night vision goggles.

BACKGROUND: In the patients with multiple and serious trauma, early applications of life-saving procedures are related to improved survival. We tried to experimentally determine the feasibility of life-saving interventions that are performed with the aid of night vision goggles (NVG) in nighttime combat scenario. METHODS: Chest tube thoracostomy (CTT), emergency cricothyroidotomy (EC), and needle thoracostomy (NT) interventions were performed by 10 combatant medical staff. The success and duration of interventions were explored in the study. Procedures were performed on the formerly prepared manikins/models in a bright room and in a dark room with the aid of NVG. Operators graded the ease of interventions. RESULTS: All interventions were found successful. Operators stated that both CTT and EC interventions were more difficult in dark than in daytime (p<0.05). No significant difference was observed in the difficulty in the NT interventions. No significant difference was observed in terms of completion times of interventions between in daytime and in dark scenario. CONCLUSION: The operators who use NVGs have to be aware of that they can perform their tactic and medical activities without taking off the NVGs and without the requirement of an extra light source.

A Study on the Tactical Safety of Endotracheal Intubation Under Darkness.

OBJECTIVE: Strict blackout discipline is extremely important for all military units. To be able to effectively determine wound characteristics and perform the necessary interventions at nighttime, vision and light restrictions can be mitigated through the use of tactical night vision goggles (NVGs). The lamp of the classical laryngoscope (CL) can be seen with the naked eye; infrared light, on the other hand, cannot be perceived without the use of NVGs. The aim of the study is to evaluate the safety of endotracheal intubation (ETI) procedures in the dark under tactically safe conditions with modified laryngoscope (ML) model. METHODS: We developed an ML model by changing the standard lamp on a CL with an infrared light-emitting diode lamp to obtain a tool which can be used to perform ETI under night conditions in combination with NVGs. We first evaluated the safety of ETI procedures in prehospital conditions under darkness by using both the CL and the ML for the study, and then researched the procedures and methods by which ETI procedure could be performed in the dark under tactically safe conditions. In addition, to better ensure light discipline in the field of combat, we also researched the benefits, from a light discipline standpoint, of using the poncho liner (PL) and of taking advantage of the oropharyngeal region during ETIs performed by opening the laryngoscope blades directly in the mouth and using a cover. During the ETI procedures performed on the field, two experienced combatant staff simulated the enemy by determining whether the light from the two different types of laryngoscope could be seen at 100-m intervals up to 1,500 m. RESULTS: In all scenarios, performing observations with an NVG was more advantageous for the enemy than with the naked eye. The best measure that can be taken against this threat by the paramedic is to ensure tactical safety by having an ML and by opening the ML inside the mouth with the aid of a PL. The findings of the study are likely to shed light on the tactical safety of ETI performed with NVGs under darkness. CONCLUSION: Considering this finding, we still strongly recommend that it would be relatively safer to open the ML blade inside the mouth and to perform the procedures under a PL. In chaotic environments where it might become necessary to provide civilian health services for humanitarian aid purposes (Red Crescent, Red Cross, etc.) without NVGs, we believe that it would be relatively safer to open the CL blade inside the mouth and to perform the procedures under a PL.

Acute dystonic reaction leading to lingual hematoma mimicking angioedema.

Lingual hematoma is a severe situation, which is rare and endangers the airway. It can develop due to trauma, vascular abnormalities, and coagulopathy. Due to its sudden development, it can be clinically confused with angioedema. In patients who applied to the doctor with complaints of a swollen tongue, lingual hematoma can be confused with angioedema, in particular, at the beginning if the symptoms occurred after drug use. It should especially be considered that dystonia in the jaw can present as drug-induced hyperkinetic movement disorder. Early recognition of this rare clinical condition and taking precautions for providing airway patency are essential. In this case report, we will discuss mimicking angioedema and caused by a bite due to dystonia and separation of the tongue from the base of the mouth developing concurrently with lingual hematoma.