Assessment of Renal Function of Bodybuilders Using Anabolic Androgenic Steroids and Diet Supplements.

Introduction Anabolic androgenic steroids (AAS) and diet supplements (DS) are frequently used by bodybuilders. In this specific group, increased muscle mass, the acute effects of exercise, and the use of creatine may affect the creatinine-based estimated glomerular filtration rate (eGFRcr), potentially leading to an underestimation of the GFR. Cystatin C equations offer a more accurate prediction of GFR that is independent of muscle mass. We aimed to assess the renal functions of bodybuilders who use both AAS+DS, as well as those who only use DS, by calculating the GFR based on cystatin C (eGFRcys) and also using a combination of cystatin C and creatinine (eGFRcys/cr). Methods The study included 12 bodybuilders using AAS+DS and 12 bodybuilders using DS. In both groups, serum cystatin C levels, eGFRcys, eGFRcys/cr, urine albumin excretion rates, urine protein excretion rates, and routine tests were examined. Results In AAS+DS users, the average duration of AAS use was 3.08±2.02 years, while for DS users, the duration of supplement use was 3.67±2.49 years. The spot urine albumin/creatinine and protein/creatinine ratios were higher in AAS+DS users (p<0.001 and p=0.006, respectively). Although eGFRcr was found to be similar in the AAS+DS and DS groups (119.67 ± 24.12 ml/min and 122.08 ± 18.03 ml/min, respectively; p=0.426), eGFRcys and the eGFRcys/cr ratio were significantly lower in the AAS+DS group compared to the DS group (eGFRcys: 120.67 ± 19.48 ml/min vs. 122.08 ± 18.03 ml/min, p=0.039; eGFRcys/cr: 121.83 ± 20.62 ml/min vs. 126.33 ± 21.163 ml/min, p= 0.036, respectively). Conclusion Cystatin-based GFR values were found to be significantly lower in AAS+DS users, and urinary albumin and protein excretion were considerably higher compared to DS users. Although these findings suggest a potential link between early kidney damage and the direct use of AAS, the topic requires further investigation.

The diagnostic value of laboratory tests in detecting solid organ injuries in pediatric patients with blunt abdominal trauma.

BACKGROUND: Computed tomography of the abdomen (CT) is used as the gold standard for detecting solid organ injuries (SOI) after blunt abdominal trauma (BAT). However, patient selection for CT is still controversial due to its potential risks. In this study, we aimed to investigate the usefulness of laboratory tests in the detection or exclusion of SOI in pediatric patients evaluated in the emergency department due to BAT. METHODS: The study was planned as a prospective, observational study and was conducted in the emergency department of a university hospital between February 2018 and February 2019. Patients under the age of 18 who were evaluated for BAT in the emergency department were included in the study. In the study, the diagnostic value of abnormal laboratory tests in detecting SOI was calculated by accepting CT results as the gold standard. RESULTS: Of the 323 patients included in the study, 118 (36%) were male. There were 283 patients who underwent CT. SOI was detected in 18 (6%) patients. Abnormal alanine aminotransferase, aspartate aminotransferase, amylase and lipase tests were found to be statistically significant in predicting SOI (p < 0.05). However, none of the tests were found to have sufficient sensitivity and specificity. Hemoglobin, hematocrit, lactate and base excess values were not found to be statistically significant in predicting SOI (p > 0.005). CONCLUSIONS: The hematologic laboratory tests are insufficient to rule out solid organ injury in pediatric patient with BAT.

Violence Against Women During COVID-19 Pandemic: A Comparative Study from a Turkish Emergency Department.

OBJECTIVE: Violence against women (VAW) is a major public health problem and a violation of women's human rights. The coronavirus disease 2019 (COVID-19) pandemic has worsened gender inequality, resulting in a heightened incidence of VAW. This study aims to assess the characteristics of women who admit to the emergency department (ED), both before the pandemic and during the pandemic. The secondary aim is to compare the frequencies of violence cases between periods. METHODS: By single-center, retrospective, and cross-sectional design, the periods of April 10 - December 31, 2020 and April 10 - December 31, 2019 were compared. The outcomes of the study were the daily ED admission numbers of both sexes, the prevalence of VAW cases in the ED, as well as sociodemographic and clinical variables of the women who were exposed to violence. RESULTS: During the pandemic period, number of VAW cases in the ED increased 13% and the ratio of VAW cases to all ED admissions tripled compared to the pre-pandemic period. Women exposed to VAW were more likely to be without social insurance, injured in the trunk part of their body, and having a life-threatening injury in the pandemic period. In both periods, women were attacked by an intimate partner, dominantly (42.6% and 54.1%, respectively). In addition, among all admissions of adults to the ED, women's percentage decreased while men's admission ratios increased during the pandemic period. Admissions to ED declined 47.7% during the COVID-19 pandemic compared to the year before. CONCLUSION: Cases of VAW tend to increase during the pandemic, and health care settings should be well-organized to respond to survivors.

Lactate and base deficit combination score for predicting blood transfusion need in blunt multi-trauma patients.

BACKGROUND: Lactate and base deficit (BD) values are parameters evaluated as indicators of tissue perfusion and have been used as markers of severity of injury and mortality. OBJECTIVES: The aim of the study was to determine the relationship between combined score (CS) and blood transfusion need within 24 h and comparison of the variables between transfusion and non-transfusion group, correlation lactate with BD and with physiological, laboratory parameters, and determining the major risk factors of patients for the need for blood transfusion. METHODS: The study included a total of 359 patients (245 males, median age: 40, min-max: 18-95) with blunt multi-trauma. De-mographics data, laboratory parameters (hemoglobin [Hb], hematocrit [Htc], lactate, BD, pH), physiologic parameters (systolic blood pressure [SBP], diastolic blood pressure [DBP], heart rate [HR], respiratory rate [RR]), shock index (SI), and revised trauma score (RTS) were recorded. Logistic regression method was used to create the CS formula using lactate and BD values. According to this formula, the probability value of 0.092447509 was calculated for the need for blood transfusion within 24 h. If CS was higher than the probability value, the need for blood transfusion within 24 h was considered. Furthermore, univariate analysis was used to determine major risk for blood transfusion need in 24 h, and the receiver operating characteristic curves were performed to compare CS, lactate, BD, SI and RTS. RESULTS: The comparison between transfusion and non-transfusion group there was significance between SBP, DBP, HR, RR, SpO2, Glasgow coma scale, Hb, Htc, lactate, BD, pH, SI and RTS (for each p<0.05). Lactate value has a positive correlation with SI, HR and has a negative correlation with BD, RTS, SBP, and DBP. BD values has a positive correlation with RTS, SBP, DBP, Hb, and Htc and has a negative correlation with SI, HR, and RR. The main risks for blood transfusion need were SI, lactate, BD, SBP, and SpO2%. CS was 0.09 in 100 (27.85%) patients and 41 with high CS had blood transfusion within 24 h (p<0.001; OR21.803, sensitivity 83.7%, specificity 81%,positive predictive value 41%, and negative predictive value 96.9%). A ROC curve showed that CS (AUC: 86.) was more significant than SI and RTS for the need for blood transfusion. CONCLUSION: CS is effective for predicting blood necessity in 24 h for blunt multi-trauma patients.

The evaluation of intracranial pressure evaluation by optic nerve sheath diameter measurement on bedside ultrasonography after ischemic stroke.

INTRODUCTION: We aimed to predict intracranial pressure(ICP)after cerebral ischemic stroke by measuring diameter of the optic nerve sheath(ONSD)with bedside ultrasonography(US). In order to see the ICP changes,it was planned to record delta ICP changes at the 3rd and 5th day follow-up of the patients METHOTS: Patients aged 18 years or older who were admitted to the emergency department(ED)with stroke symptoms for one year were included.Demographic data,time elapsed since the onset of symptoms,neurogical status assesment scales,ONSD values measured by US in three time periods(the day the patient was admitted to the ED,the 3rd and 5th days of hospitalization),MDCT findings when the patient was admitted,ONSD values in MDCT,whether they received tissue plasminogen activator(tPA)and whether they underwent decompression surgery were recorded. RESULTS: The average age of the 82 patients was 67.5(range 33-89)years.Forty-two patients(51.2%)were male.On both the right and left sides,ONSD on the 3rd day was larger(>5 mm)than on first day(p < 0.05). ONSD on the 5th day was larger than on the first day(p > 0.05). All ONSD results measured using both US and MDCT showed a positive correlation between the same eye and contralateral eye measurements(p < 0.05). DISCUSSION: CT is the most critical radiological method for stroke patients.Transport to radyology unit in unstable patients carries risk and is not recommended.Optic nerve US can be used in the early diagnosis of ICP increase and provides early treatment.The ease of use and safety in unstable patients have increased its popularity. CONCLUSION: We believe that measuring ONSD using US is an appropriate choice on ICP management in stroke patients.

Diagnostic Value of Hounsfield Unit and Hematocrit Levels in Cerebral Vein Thrombosis in the Emergency Department.

BACKGROUND: Unenhanced computed tomography (CT) is a frequently used imaging method in patients who are evaluated in the emergency department with suspected cerebral vein thrombosis (CVT). OBJECTIVES: The aim of this study was to investigate the usefulness of the Hounsfield unit (HU) value determined by CT and its ratio to the patient's hematocrit (Htc) value in the diagnosis of cerebral vein thrombosis. METHODS: This retrospective study evaluated 41 patients with acute cerebral venous sinus thrombosis and 41 age- and sex-matched control participants. Two experienced observers independently evaluated the CT scan and measured the attenuation of the dural sinuses. RESULTS: There was no significant difference in age, gender, hemoglobin, and Htc values between the two groups. The mean HU value was 75 ± 7 HU in the CVT group and 52 ± 6 HU in the control group (p < 0.001). The mean HU/Htc ratio was 1.9 ± 0.3 in the CVT group and 1.3 ± 0.1 in the control group (p < 0.001). The optimal threshold value for HU was determined as 66, and sensitivity at this value was 93%, and specificity was 98%. The optimal threshold value for HU/Htc was determined as 1.64, and the sensitivity at this value was 90% and the specificity was 100%. CONCLUSION: Hyperattenuation in the dural sinuses and the HU/Htc ratio in unenhanced brain CT scans have high diagnostic value in detecting CVT.

Computed Tomographic Findings of Injuries After Mechanical and Manual Resuscitation: A Retrospective Study.

Introduction Cardiopulmonary resuscitation (CPR)-related injuries are complications of chest compressions during CPR. This study aimed to investigate the differences and complications between mechanical and manual CPR techniques by using computed tomography (CT). Methods Patients in whom return of spontaneous circulation was achieved after CPR and thorax CT imaging were performed for diagnostic purposes were included in the study. Results A total of 178 non-traumatic cardiac arrest patients were successfully resuscitated and had CT scans in the emergency department. The complications of CPR are sternum fracture, rib fracture, pleural effusion/hemothorax, and pneumothorax. There were no statistically significant differences in terms of age, first complaint, cardiac arrest rhythm, CPR duration, and complications between mechanical and manual CPR. The number of exitus in the emergency department was similar (p=0.638). The discharge from hospital rate was higher in the mechanical CPR group but there was no statistically significant difference (p=0.196). The duration of CPR was associated with the number of rib fractures and lung contusion, but it did not affect other CPR-related chest injuries. Conclusion There was no significant difference observed in terms of increased complications in patients who received mechanical compression as compared with those who received manual compression. According to our results, mechanical compression does not cause serious complications, and the discharge from hospital rate was higher than for manual CPR; therefore, its use should be encouraged.

The Flatness Index of Inferior Vena Cava can be an Accurate Predictor for Hypovolemia in Multi-Trauma Patients.

INTRODUCTION: Shock is the leading cause of death in multi-trauma patients and must be detected at an early stage to improve prognosis. Many parameters are used to predict clinical condition and outcome in trauma. Computed tomography (CT) signs of hypovolemic shock in trauma patients are not clear yet, requiring further research. The flatness index of inferior vena cava (IVC) is a helpful method for this purpose. METHODS: This is a prospective, cross-sectional study which included adult multi-trauma patients (>18 years) who were admitted to the emergency department (ED) and underwent a thoraco-abdominal CT from 2017 through 2018. The main objective of this study was to investigate whether the flatness index of IVC can be used to determine the hypovolemic shock at an early stage in multi-trauma patients, and to establish its relations with shock parameters. The patients' demographic features, trauma mechanisms, vitals, laboratory values, shock parameters, and clinical outcome within 24 hours of admission were recorded. RESULTS: Total of 327 (229 males with an average age of 40.9 [SD = 7.93]) patients were included in the study. There was no significant difference in the flatness index of IVC within genders (P = .134) and trauma mechanisms (P = .701); however, the flatness index of IVC was significantly higher in hypotensive (systolic blood pressure [SBP] ≤90 mmHg and/or diastolic blood pressure [DBP] ≤60 mmHg; P = .015 and P = .019), tachycardic (P = .049), and hypoxic (SpO2 ≤%94; P <.001) patients. The flatness index of IVC was also higher in patients with lactate ≥ 2mmol/l (P = .043) and patients with Class III hemorrhage (P = .003). A positive correlation was determined between lactate level and the flatness index of IVC; a negative correlation was found between Glasgow Coma Scale (GCS) and Revised Trauma Score (RTS) with the flatness index of IVC (for each of them, P <.05). CONCLUSION: The flatness index of IVC may be a useful method to determine the hypovolemic shock at an early stage in multi-trauma patients.

Therapeutic Dilemmas Regarding Anticoagulation, Pulmonary Embolism, and Diffuse Alveolar Hemorrhage Due to Behçet's Disease.

The use of anticoagulants is still a matter of debate in deep venous thrombosis (DVT) and other thrombotic events in Behcet's disease (BD). Anticoagulant therapy is an integral part of treatment in cases of a pulmonary embolism (PE) that develops in other disorders. The issue of how to act when a pulmonary artery thrombosis is reported in the Behçet's patient may pose a major dilemma among emergency physicians. A 61-year-old male came to our ED with a complaint of chest pain and hemoptysis. The patient had tachypnea, dyspnea, tachycardia, a decrease of breath sounds in the basal regions of both lungs, and a few crackling rales were heard in the left lung field. Chest CT angiography showed pulmonary thromboembolism in the right middle and lower lobe segment arteries with pulmonary infarction as well as ground glass densities compatible with alveolar hemorrhage. High-dose steroid and cyclophosphamide were administered immediately without anticoagulant therapy based on pulmonary vasculitis and de novo clot formation in the pulmonary circulation. Clinical improvement was observed after four days of admission. The patient remained under observation with oral prednisolone and cyclophosphamide monthly. PE is almost non-existent in patients with BD, and signs of pulmonary artery thrombosis are associated with pulmonary vasculitis. Delaying immunosuppressive therapy may result in unwanted results in these kinds of patients. This case underlines the importance of recognizing this manifestation early to prevent potentially fatal consequences.

Hemodynamic Instability in Emergency Department: Giant Rectus Sheath Hematoma and Point-of-Care Ultrasonography.

Iatrogenic rectus sheath hematoma (RSH) developed after paracentesis is a rare but life-threatening complication. Mortality rates of patients may increase due to delays in treatment and comorbid conditions. In this article, we present the case of a patient who was unstable in the emergency department and was diagnosed with RSH using point-of-care ultrasonography (POCUS). The importance of POCUS has increased as hematoma manifestations of patients with severe ascites tend to be obscured. POCUS has varied uses in the emergency department, and in this article we emphasize the use of POCUS in a life-threatening case of RSH.

Comparison of Endotracheal Intubation Skills With Video Laryngoscopy and Direct Laryngoscopy in Providing Airway Patency in a Moving Ambulance.

BACKGROUND: Early and successful management of the airway in the prehospital and hospital settings is critical in life-threatening situations. OBJECTIVE: We aimed to perform endotracheal intubation (ETI) by direct laryngoscopy (DL) and video laryngoscopy (VL) on airway manikins on a moving track and to compare the properties of intubation attempts. METHODS: Overall, 79 participants with no previous VL experience were given 4 h of ETI training with DL and VL using a standard airway manikin. ETI skill was tested inside a moving ambulance. The number of attempts until successful ETI, ETI attempt times, time needed to see the vocal cords, and the degree of convenience of both ETI methods were recorded. RESULTS: Overall, 22 of 79 individuals were men; mean age was 30.3 ± 4.5 years. No difference was found in the comparison of the two methods (p = 0.708). Time needed to see the vocal cords for those who were successful in their first attempt were between 1 and 8 s in both methods. In the VL method, time needed to see the vocal cords (p = 0.001) and the intubation time (p < 0.001) in the first attempt were shorter than in the DL method. The VL method was easier (p < 0.001). The success rate was 97.5% in DL and 93.7% in VL. CONCLUSIONS: The VL method is rapid and easier to see the vocal cords and perform successful ETI. Therefore, it might be preferred in out-of-hospital ETI applications.

Effect of off-hour versus work-hour thrombolysis for acute ischemic stroke on emergency department patients' outcome: a retrospective study.

OBJECTIVE: Early management of patients with acute ischemic stroke is crucial regardless of the time of presentation. The aim of the study was to evaluate the effect of off-hours management of patients with ischemic stroke that underwent thrombolytic therapy in the emergency department. METHODS: This is a single-center retrospective study included ischemic stroke patients who received thrombolysis in the emergency department from January 2009 to April 2017. Patients who presented between 08:00 and 17:00 Monday to Friday were in the 'work-hour group (group 1)' versus others who were considered 'off-hours (group 2)'. Primary endpoint was 3-month mortality. Secondary endpoints included the National Institutes of Health Stroke Scale and dramatic recovery rate at 24 h, intracranial hemorrhage, systemic hemorrhage and modified Rankin Scale at the 3 months. Symptom-to-needle time, door-to-computed tomography time, and door-to-needle time were also compared between groups. RESULTS: A total of 399 ischemic stroke patients were included in the analysis, 137 (34%) during work-hours and 262 (66%) during off-hours. The mortality rate was not different at 3 months between groups: 24 (17.5%) in the work-hours group versus 38 (14.5%) in the off-hours group [odds ratio 1.25; 95% confidence interval (CI), 0. 72-2.19]. There were no differences between groups on secondary endpoints. The mean time of symptom-to-needle was significantly higher during off-hours (mean difference: 18.4 min; 95% CI, 7.81-29.0). CONCLUSIONS: In this study, there were no significant differences in mortality and functional outcomes at 3 months between patients who underwent off-hour or work-hour thrombolysis in the emergency department.

Comparison of manual and mechanical chest compression techniques using cerebral oximetry in witnessed cardiac arrests at the emergency department: A prospective, randomized clinical study.

AIM: We aimed to compare regional cerebral oxygen saturation (rSO2) levels during cardiopulmonary resuscitation (CPR), performed either manually or using a mechanical chest compression device (MCCD), in witnessed cardiac arrest cases in the emergency department (ED), and to evaluate the effects of both the CPR methods and perfusion levels on patient survival and neurological outcomes. METHODS: This single-center, randomized study recruited patients aged ≥18 years who had witnessed a cardiopulmonary arrest in the ED. According to the relevant guidelines, CPR was performed either manually or using an MCCD. Simultaneously, rSO2 levels were continually measured with near-infrared spectroscopy. RESULTS: Seventy-five cases were randomly distributed between the MCCD (n = 40) and manual CPR (n = 35) groups. No significant difference in mean rSO2 levels was found between the MCCD and manual CPR groups (46.35 ± 14.04 and 46.60 ± 12.09, respectively; p = 0.541). However, a significant difference in rSO2 levels was found between patients without return of spontaneous circulation (ROSC) and those with ROSC (40.35 ± 10.05 and 50.50 ± 13.44, respectively; p < 0.001). In predicting ROSC, rSO2 levels ≥24% provided 100% sensitivity (95% confidence interval [CI] 92-100), and rSO2 levels ≥64% provided 100% specificity (95% CI 88-100). The area under the curve for ROSC prediction using rSO2 levels during CPR was 0.74 (95% CI 0.62-0.83). CONCLUSION: A relationship between ROSC and high rSO2 levels in witnessed cardiac arrests exists. Monitoring rSO2 levels during CPR would be useful in CPR management and ROSC prediction. During CPR, MCCD or manual chest compression has no distinct effect on oxygen delivery to the brain. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT03238287.

Plasma Procalcitonin Is Useful for Predicting the Severity of Acute Cholecystitis.

BACKGROUND: Acute cholecystitis is a common complication of cholelithiasis. Delayed diagnosis may constitute morbidity and mortality; therefore, early diagnosis and determining the severity of acute cholecystitis are crucial. OBJECTIVES: This study aimed to determine the validity of blood procalcitonin (PCT) levels in assessing the severity of acute cholecystitis. METHODS: The Emergency Department (ED) patients diagnosed as acute cholecystitis were included in the study. Patients were allocated into three severity grades according to the Tokyo Guidelines 2013. PCT level was measured after the clinical and radiological diagnosis of acute cholecystitis in the ED. RESULTS: Ninety-five patients diagnosed with acute cholecystitis, among them 48 of were male. Forty patients (42.1%) were allocated to grade 1, 19 (20%) to grade 2, and 36 (37.9%) to grade 3. The median values of PCT were 0.104 ng/ml, 0.353 ng/ml, and 1.466 ng/ml for grade 1, 2, and 3 patients, respectively (p < 0.001). CONCLUSION: Blood procalcitonin levels can be used to determine the severity of acute cholecystitis effectively.

Perfusion Index Measurement in Predicting Hypovolemic Shock in Trauma Patients.

BACKGROUND: Perfusion index (PI) derived from pulse oximeter shows the ratio of the pulsatile blood flow to the nonpulsatile blood flow or static blood in peripheral tissue. OBJECTIVES: The aim of this study was to investigate the relationship between PI and blood transfusion necessity in 24 h and stage of hemorrhagic shock, as well as the utility of PI according to laboratory and clinical parameters, and determining the major risk of hemorrhage. METHODS: PI was measured with a pulse oximeter in 338 patients (235 males, average age 41.8 ± 17.94 years). Laboratory parameters (hemoglobin, hematocrit, lactate, base deficits, pH) and clinical parameters (pulse rate, respiratory rate, SpO2, systolic blood pressure [SBP] and diastolic blood pressure [DBP]), shock index (SI) and revised trauma score (RTS) were recorded. Univariate analysis was used to determine major risk for bleeding, and the receiver operating characteristic curves were performed to compare parameters. RESULTS: PI was < 1 in 39 (11.5%) patients. Positive correlation between PI and hemoglobin (p < 0.001; r: 0.320), hematocrit (p < 0.001; r: 0.294), base deficit (p < 0.001; r: 0.315), pH (p < 0.05; r: 0.235), SBP (p < 0.001; r: 0.146), DBP (p < 0.001; r: 0.259), SpO2 (p < 0.001; r: 0.197), RTS (p < 0.001; r: 0.344), and negative correlation with lactate (p < 0.05; r: -0.117), pulse (p < 0.001; r: -0.326), respiratory rate (p < 0.001; r: -0.231), and SI (p < 0.001; r: -0.257) were detected. A difference was detected between class 1 and 2, and class 1 and 3 (both p < 0.05) in hemorrhagic shock. Thirty-one with PI < 1 had blood transfusion within 24 h (p < 0.001; odds ratio 111.98, sensitivity 75.6%, specificity 97.3, positive predictive value 79.5%, negative predictive value 96.7%). The main risk factors of the need for blood transfusions were PI, pulse rate, and SpO2. PI was more significant than lactate, base deficit, RTS, and SI measurements. CONCLUSION: PI might be beneficial in the detection and exclusion of critical patients and blood transfusion needs in the emergency department. PI can be used with vital signs and shock parameters in the early diagnosis of hemorrhage.

Factors Affecting Mortality in Patients Admitted to the Hospital by Emergency Physicians despite Disagreement with Other Specialties.

BACKGROUND: Emergency physicians (EPs) face critical admission decisions, and their judgments are questioned in some developing systems. This study aims to define the factors affecting mortality in patients admitted to the hospital by EPs against in-service departments' decision and evaluate EPs' admission diagnosis with final discharge diagnosis. METHODS: This is a retrospective analysis of prospectively collected data of ten consecutive years (2008-2017) of an emergency department of a university medical center. Adult patients (≥18 years-old) who were admitted to the hospital by EPs against in-service departments' decision were enrolled in the study. Significant factors affecting mortality were defined by the backward logistic regression model. RESULTS: 369 consecutive patients were studied, and 195 (52.8%) were males. The mean (SD) age was 65.5 (17.3) years. The logistic regression model showed that significant factors affecting mortality were intubation (p < 0.0001), low systolic blood pressure (p = 0.006), increased age (p = 0.013), and having a comorbidity (p = 0.024). There was no significant difference between EPs' primary admission diagnosis and patient's final primary diagnosis at the time of disposition from the admitted departments (McNemar-Bowker test, p = 0.45). 96% of the primary admission diagnoses of EPs were correct. CONCLUSIONS: Intubation, low systolic blood pressure on presentation, increased age, and having a comorbidity increased the mortality. EPs admission diagnoses were highly correlated with the final diagnosis. EPs make difficult admission decisions with high accuracy, if needed.

Bradyarrhythmia due to mirtazapine overdose: A case of serious adverse event in a suicidal patient.

There are a limited number of studies on postoverdose clinical findings of mirtazapine in the literature. Our case presented an unlikely junctional rhythm, which we have not seen in the previous studies, in a patient who had bradycardia and hypotension following mirtazapine intake. A 37-year old male was admitted to the emergency department (ED) after his suicide attempt with 300 mg PO of mirtazapine tablets. He took the drug 2 h prior to his ED visit. He did not have any complaints after the mirtazapine intake. His complete physical examination and electrocardiography (ECG) revealed no pathological findings. He was observed in the ED. The results were in the normal range in his blood test and he has 0 mg/dl of blood ethanol. He experienced dizziness after 5 h and 30 min. The blood pressure was 60/30 mmHg. The heart rate was 34 beats/min. The simultaneous ECG showed junctional bradycardia. 0.5 mg atropine IV was given two times at intervals. Norepinephrine infusion was initiated after normal saline therapy. Forty-five minutes later, he did not have any clinically significant complaint. There are no pathological findings in his follow-up ECG and physical examination. He was discharged of his own accord 10 h after his ED admission. His initial mirtazapine level was 145 ng/ml when he came to the ED. Mirtazapine was known to have a safe cardiac profile both for regular dose and overdose. However, physicians should consider that it might induce a life-threatening bradyarrhythmia.