BACKGROUND
In this study, we aimed to compare the efficacy of aggressive fluid resuscitation, low-volume fluid resuscitation and permissive hypotensive resuscitation in an experimental uncontrolled hemorrhagic shock model.
METHODS
Forty-four male Guinea pigs were used in the study in an experimental uncontrolled shock model. Guinea pigs were split into six groups including normovolemic-normotensive fluid treatment group, normovolemic-permissive hypotensive fluid treatment group, low-volume normotensive fluid treatment group, low-volume permissive hypotensive fluid treatment group, no treatment (n=6), and sham-operated groups (n=6). Resuscitation was initiated when mean arterial pressure (MAP) reached 30 mmHg. In the permissive hypotensive resuscitation group, fluid treatment continued until MAP reached 45±5 mmHg and in the aggressive fluid groups until MAP reached 60±5 mmHg. Resuscitation fluid was hetastarch 6% (hydroxyethyl starch) in the low-volume fluid groups and Ringer’s lactate in the normovolemic fluid groups.
RESULTS
Mean survival time was 122.75±4.83 min in the normovolemic-normotensive fluid group, 130.87±16.31 min in the normovolemic-permissive hypotensive group, 122.12±11.53 min in the low-volume-normotensive fluid group, and 152.25±9.10 min in the low-volume-permissive hypotensive fluid group. Survival time was found significantly higher in the group in which low-volume-permissive hypotensive fluid treatment was applied than in the other groups.
CONCLUSION
When pressure effect was compared during treatment, permissive-hypotensive resuscitation was found more effective in both groups that received colloid and crystalloid treatment.

BACKGROUND
This study aimed at analyzing the effect on coagulation of head trauma and other local traumas in patients exposed to multiple traumas in the early stage, and also the relations of Glasgow Coma Scale (GCS) and Injury Severity Score (ISS) with coagulation parameters in these patients.
METHODS
Fifty consecutive patients (9 women, 41 men) with multiple traumas were included in this study. The GCS, ISS and coagulation parameter levels were measured. Presence of a correlation between GCS and ISS with coagulation parameters was analyzed. Patients exposed to multiple traumas were assessed in four categories as the patients with no significant traumas (A), only head traumas (B), head trauma and other local traumas (C), and no head traumas but other local traumas (D).
RESULTS
A marked relationship was found between ISS and international normalized ratio (INR), activated partial thromboplastin time (aPTT), D-dimer, fibrin degradation product (FDP), antithrombin (AT), and fibrinogen (p<0.05). There was a statistically significant difference between Group C and the other groups in INR, D-dimer, fibrinogen, aPTT, and AT parameters (p<0.05). There was also a statistically significant difference between the groups with and without head trauma in INR, D-dimer and fibrinogen (p<0.05).

CONCLUSION
The coagulation parameters were observed to diverge in patients with head trauma, but in cases with head injuries accompanying other local traumas, more coagulation parameters became abnormal.

BACKGROUND
We aimed to examine the accuracy of triage decision-making among emergency physicians, using a multiple casualty scenario. This will assist in determining the necessity of triage training, which is the foundation of emergency medical ethics.
METHODS
A self-administered questionnaire including a multiple casualty scenario requiring each casualty to be prioritized for treatments by Simple Triage and Rapid Treatment (START) was given to 110 emergency physicians working at pre-hospital and hospital emergency services in Kocaeli. The differences between personal/professional characteristics and triage decisions were analyzed using chi-square test.
RESULTS
Accurate triage decision rates of the emergency physicians ranged from 83.6% to 90.0% for four immediate casualties, 26.4% to 78.2% for seven urgent casualties, 70.9% to 91.8% for four delayed casualties, and 82.7% to 97.3% for two dead cases. Personal and professional characteristics were found to be statistically significant in five cases (p<0.05).

CONCLUSION
This study showed that emergency physicians tended to under-triage patients. This result and the discrepancy of the accuracy rates in urgent casualties revealed the necessity for improvement in medical-ethical decision-making in the training programs. This improvement will help in reducing violation of the important duties of justice and of do no harm by the emergency physicians.

BACKGROUND
Snake venom poisoning is a medical emergency requiring immediate attention. Bites from poisonous Turkish snakes can lead to local tissue damage and systemic symptoms. The Vipera ammodytes species accounts for the majority of envenomation in southeast Turkey.
METHODS
The demographic and epidemiological characteristics, clinical symptoms and signs, laboratory findings, treatment, and outcome of 79 consecutive victims of V. ammodytes poisoning admitted to our hospital from 2003 to 2005 were reviewed and analyzed prospectively.
RESULTS
The most common symptoms and signs included fang marks (100%), pain (100%), swelling (83.5%), ecchymosis (92.4%), tachycardia (24.1%), fainting or dizziness (14.5%), fever (19.0%), enlargement of regional lymph nodes (43.0%), nausea (70.9%), hypotension (21.5%), vomiting (36.7%), and dyspnea (3.2%). The main complications were thrombophlebitis, reduced range of motion, local hemorrhagic blister formation, bleeding from skin, rhabdomyolysis, reduced sensation, acute renal failure, necrosis with tissue loss, digit amputation, carpal tunnel syndrome, and compartment syndrome.
CONCLUSION
A V. ammodytes bite is a potentially serious event that requires immediate hospital care. Nevertheless, the majority of victims can be treated successfully with conservative methods. No deaths occurred in our series.

BACKGROUND
Traumatic diaphragmatic hernias commonly occur after blunt and penetrating trauma. The difficulties in diagnosing traumatic diaphragmatic rupture due to coexisting injuries and the silent nature of the diaphragmatic injuries at the first admission are the most common causes of delayed diagnosis.
METHODS
The medical records of 34 patients (28 male, 6 female; mean age 32.3 years; range 1 to 68) treated for post-traumatic diaphragmatic hernias between August 2004 and June 2008 in Alzahra Hospital were analyzed retrospectively.
RESULTS
Rupture of the diaphragm was left-sided in 22 (64.7%) and right-sided in 11 (32.4%) and bilateral in 1 (2.9%) of the patients. Blunt trauma accounted for the injuries of 22 patients (64.7%). In the first operation, diagnosis was established preoperatively in 15 patients (44.1%) and intraoperatively in 13 (38.2%). The diagnosis was missed in 6 (17.7%) patients in the first operation. Strangulation of the viscera was seen in three patients. The longest interval between the onset of trauma and diagnosis was approximately three years in one case. Multiple associated injuries were observed in 22 patients (64.7%), the most common of which were spleen injury (38.2%), fractures of the extremities and hemothorax (29.4%) and liver injury (26.5%). Postoperative complications were seen in nine patients (26.5%). Mortality of isolated blunt traumatic rupture was 0%. Hemorrhagic shock, young age and associated injuries significantly increased the mortality and morbidity.

CONCLUSION
Despite the fact that the incidence of diaphragmatic hernia is uncommon, it should be suspected in all blunt or penetrating traumas of the thorax and abdomen. Because late complications are usually associated with high morbidity, the presence of such an injury should be excluded before terminating the exploratory procedure.

BACKGROUND
Penetrating cardiac traumas in children are dramatic and fatal. Many of the patients are admitted to hospital either in a state of shock or they are dead at presentation. In this study, we aimed to present our experience in penetrating cardiac trauma in children.
METHODS
Seventeen pediatric cases of penetrating cardiac trauma were retrospectively evaluated. The effects on the results of the demographic characteristics of patients, etiology of penetrating trauma, time of presentation to the hospital, physical examination findings in the emergency department, diagnostic methods used, and the surgical techniques applied were evaluated.
RESULTS
The male to female ratio of the 17 retrospectively evaluated cases was 16: 1, with an age range of 3-15 years. The patients’ mean age was 12.94±3.52 years. In all patients, the penetrating cardiac trauma was due to incisive/penetrating tools. The mean Ivatury physiologic index score was 8.23±0.78, whereas the mean cardiac injury organ scale score was 5.00±0.00. The hospital mortality rate was 5.9% due to the loss of one patient.
CONCLUSION
Shock may develop in pediatric penetrating cardiac trauma in a short time due to hemorrhage and/or cardiac tamponade. The prime factors for patient survival are early diagnosis and emergency thoracotomy.

BACKGROUND
In this study, we investigated the effect of voltage levels on muscle damage in patients with electrical injuries.
METHODS
This retrospective study included 36 patients with electrical injury (high voltage, 21; low voltage, 15). Initial serum creatine kinase (CK), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were obtained from each patient on admission.
RESULTS
Although CK levels were observed to be higher in the high-voltage injured patients than in those exposed to a low voltage, the difference was not statistically significant. The serum AST and ALT levels were elevated in both groups, but there was no significant difference between the groups.
CONCLUSION
Skeletal muscle damage can be caused by both high-voltage and low-voltage electrical injury, and in these patients, the degree of muscle damage may be consistent with the elevated initial serum levels of muscle enzymes, especially of CK. However, further researches are necessary to determine if there is strong evidence of a direct correlation between voltage level and the degree of muscle damage.

BACKGROUND
Facial burns are quite common among children. Many different wound-covers can be used for dressing burn wounds, which is usually painful for the patients. These covers can also be combined with local anesthetic creams. Lidocaine-prilocaine cream 5% (LPC) is commonly used as a topical anesthetic by physicians performing plastic surgery. In the present study, we investigated the effects of topical LPC on pain cessation in pediatric patients with face burn and compared results with a control group in which LPC was not used in the wound dressing.
METHODS
Thirty pediatric patients (average age 11.3, range 8-15) among those who admitted to our emergency service and plastic surgery outpatient clinic between 2003 and 2006 were included in this study. The patient’s burned areas ranged between 1 and 5% percent of their total body surface.
RESULTS
The need for analgesic medicine was recorded in the first, second and third 8-hour periods postburn in both groups, and pain level was evaluated at these time points using a verbal rating scale. There was a significant difference between the two groups with respect to values of the first and second 8-hour periods, while in the third 8-hour period, no significant difference was observed. We conclude that topical local anesthetics administered for 16 hours postburn significantly reduce the duration of pain after injury, which suggests a potential use in clinical practice in the treatment of children with face burn.
CONCLUSION
While LPC was found to have an ameliorating effect in the first 16 hours, we recommend oral analgesic co-therapy support since it loses its efficacy in the last 8-hour period.

BACKGROUND
Traumatic acute subdural hematoma is the most lethal of all head injuries.
METHODS
In this study, 113 patients with the diagnosis of posttraumatic acute subdural hematoma, who were operated between 1998 and 2006, were reviewed retrospectively. Statistical analysis was performed to detect any effects of the variables of age, Glasgow Coma Scale (GCS) score on admission, time interval between the trauma and operation, and abnormality in the pupil reaction on the disease mortality and morbidity.
RESULTS
Results obtained in the study are discussed and compared with the related current literature. The overall mortality in 113 patients was 56.6%.
CONCLUSION
According to the results, the most important determinants of the prognosis are GCS score of the patient on admission, abnormality in pupil reaction, timing of the operation, and the patient’s age.

BACKGROUND
Electrical injuries currently remain a worldwide problem. In Turkey, burns are relatively small in number among injuries overall, but they continue to be a major public health problem. Electrical injuries may occur due to high- or low-voltage contact. Injuries due to low voltage usually occur at home. High-voltage injuries are usually work-related and result from a shorter contact, but may cause serious tissue destruction and secondary injuries.
METHODS
The objective of this study was to review a medical institution’s experience with electrical injuries between 1997–2005. The institution admitted 55 electrical injury cases throughout this period. A computerized burns registry was used for data collection and analysis.
RESULTS
The burn causes differed among age groups and between the sexes, with males constituting 89.1% of the electrical burn patients. Forty-one of the injuries were due to high voltage whereas 14 injuries were due to low voltage. Complications were most common in the high-voltage group. Mean length of stay was longest in this group, at 33.69±21.13 days, and the patients in this group also required the most operations.
CONCLUSION
Work-related activity was responsible for the majority of these high-voltage injuries, with the most common occupations being linemen and electricians. These patients tended to be younger men in the prime of their working lives. Our study underlines the need for stronger efforts aimed at prevention, such as better public education and strict regulations regarding the distribution and use of electricity.

BACKGROUND
We aimed to identify the characteristics, causes and rates of injuries associated with occupational accidents.
METHODS
Patients who presented to the Emergency Department due to injuries occurring as a result of occupational accidents were determined retrospectively. In occupational injuries, several parameters were evaluated, such as gender, occurrence mechanism, injury type, injury localization, severity score of the injury, and the type of profession.
RESULTS
The number of occupational injury admissions in the Emergency Departments of our two centers during 2006 was 1038. Mean age of the cases was 31.6±9.6. The most common mechanism of injuries was determined to be caught-in-machinery, at 31.5%, followed by blunt object injury (21.5%), fall from height (18.9%), penetrating-sharp object injury (17%), ocular foreign body (3.9%), and others. Isolated extremity injuries (74.2%) were the most common injury site, followed by multiple bodily injuries (8.5%), facial injuries (5.5%) and head-neck injuries (4.6%). While 90% of cases were discharged after treatment in the Emergency Department, 7% were referred to various departments for hospitalization.
CONCLUSION
In the majority of cases, patients with injuries associated with occupational accidents presented to Emergency Departments. Observations in Emergency Departments may help reveal details of occupational injuries and prevent workplace-related accidents.

BACKGROUND
Acute appendicitis (AA) is one of the most frequent pathologies among surgical illnesses. Diagnosis is easy in typical cases, but difficult in atypical cases. In this study, ultrasonographic (USG) findings and leukocyte counts of patients were examined to determine their values in the diagnosis of AA.
METHODS
Data for 85 patients seen in the first six months of 2006 were examined retrospectively. Histopathological diagnosis together with leukocyte counts and USG findings were compared, and sensitivities in the diagnosis were determined.
RESULTS
The average age of the patients was 33.5, and 44.7% were female. In 95.3% of the patients, leukocyte counts were 10000/mm3 and above. In 74.1% of the patients (63 patients), USG was performed, and 58.7% of the cases (37 patients) were compatible with AA. In four (4.7%) of the patients, AA was not found histopathologically (negative laparotomy). The sensitivity of leukocyte counts (≥10000/mm³) was 98.8% and its selectivity was 75%. The sensitivity of USG was 61.0% and its selectivity was 75%. When the areas under the receiver operating characteristics (ROC) curve were compared, leukocyte counts were more sensitive in determining the diagnosis.
CONCLUSION
In this study, the sensitivity of USG was lower than the high sensitivity ratios reported in the literature. However, the sensitivity of leukocyte counts was significantly higher than that of USG.

BACKGROUND
Amyand’s hernia is a rare hernia in which a normal or inflamed appendix is found in the inguinal hernia sac. Differential diagnosis of Amyand’s hernia prior to surgery is quite difficult. In this study, in order to develop a preoperative diagnostic approach, cases of pediatric patients at different ages were analyzed and their common properties are discussed herein.
METHODS
In the present study, the findings in pediatric patients (ages 0-15) with Amyand’s hernia reported in the literature together with findings in four cases operated in our center were retrospectively assessed with respect to their demographic, preoperative, peroperative, and postoperative characteristics. These 19 cases in total were divided into two groups as age 0-1 and over age 1, and their characteristics were compared.
RESULTS
The two groups revealed different characteristics. However, in children over age 1, in the presence of appendicitis in the hernia sac, criteria like the frequency and order of symptoms, leukocytosis and bowel sounds showed similarity with abdominal appendicitis (acute appendicitis).
CONCLUSION
In children over age 1 with Amyand’s hernia who are admitted to the emergency clinic with suspected incarcerated and strangulated hernia, it is possible to diagnose Amyand’s hernia after a detailed preoperative examination.

BACKGROUND
This study aimed to determine the demographic and epidemiological characteristics and to investigate the outcomes of pediatric medico-legal cases who admitted to the emergency department. It was also aimed to contribute to the national survey.
METHODS
Medico-legal charts of the pediatric cases were reviewed retrospectively. Patients were allocated into two groups as traumatic (Group 1) and non-traumatic (Group 2). Age, sex, presenting complaint and frequencies, local or multiple trauma frequencies, and localizations (based on the Abbreviated Injury Scale) and also admission, discharge and mortality rates were ascertained. Data were evaluated by descriptive methods, Kolmogorov-Smirnov and chi-square tests. Values of p<0.05 were accepted as significant.
RESULTS
There were a total of 486 eligible patients. The mean age was 8.91±5.08 years (95% confidence interval [CI]). The majority (66.3%) were male. The group aged 5-9 years was larger (33.3%) than the others (in Kolmogorov-Smirnov test, p=0.000). Summer was the most common season for admissions. There were 153 patients in Group 1, and the most common complaint was accidental drug intake (13.8%). In Group 2, the most common reason for admission was motor vehicle accident (32.5%).
CONCLUSION
Motor vehicle and home accidents in childhood are preventable health problems. To ensure a safe environment, continuous health education programs on injury and prevention for parents and children and legal controls will be effective in injury control.

For the patient admitted with right lower quadrant abdominal pain, acute appendicitis is the most frequently considered diagnosis. Appendectomy is the most common of all emergency operations. However, there may be several reasons for left lower quadrant abdominal pain. Situs inversus totalis is an anomaly that occurs during embryonic development when intraabdominal and intrathoracic organs have reverse localization. In this case report, we present a patient who was admitted with left lower quadrant abdominal pain and was diagnosed as situs inversus totalis and acute appendicitis. In view of the legal repercussions for doctors as a result of erroneous diagnosis and treatment, we think that adequate evaluation of the studies in the emergency service is important and that the radiological investigations have to be used appropriately and sufficiently.

We aimed to present herein the case of a potentially preventable death involving traumatic aortic rupture and to develop a critical pathway for the management of isthmic aortic ruptures consistent with the available resources. A retrospective record review by a multidisciplinary panel of experts was done, and the probability of survival was estimated based on the Revised Trauma Score and Injury Severity Scale score. Literature review and expert consensus were used in a quality and safety analysis to develop a critical care pathway for future cases. A 32-year-old man, injured in a motorcycle accident, was referred to a trauma center in a state of shock. Thoracic aortic rupture was highly suspected. For educational purposes, the classic signs of a widened mediastinum, right tracheal deviation, and left-sided hemothorax (in a context of significant deceleration injury) are incorporated into an acute care triad for traumatic aortic rupture. In such cases, in the absence of poor access to aortography, we suggest (serial - if needed) contrast-enhanced chest computed tomography scanning for diagnosis confirmation and operative planning. Assumption of hemodynamic stability can be catastrophic, and transferring the patient to a second facility may endanger survival, when operative capacity exists at the initial trauma facility.

Small bowel perforation is a rare complication of femoral artery access in cases of femoral hernia. A 48-year-old woman was admitted to the intensive care unit due to pulmonary insufficiency. After a routine femoral arterial blood gas analysis, severe abdominal pain and nausea began. She underwent emergency laparotomy due to acute abdomen. Laparotomy revealed small bowel perforation. Segmental resection and end-to-end anastomosis were performed. The femoral canal was closed using plaque mesh. Special attention is needed during femoral artery access to avoid accidental small bowel perforation. As seen in this case, a careful examination should be done in cases of femoral hernia.

Post-traumatic diaphragmatic hernia complicated by gastric volvulus may manifest immediately or several years after the incident. Delayed presentation of traumatic diaphragmatic hernia with gastric volvulus is relatively unusual. We report a 28-year-old male patient who admitted with gastric volvulus due to traumatic diaphragmatic hernia after sustaining a knife wound to the left lower chest one year before presentation. The patient has been followed without any symptom for two years since the diaphragmatic hernia was repaired by primary suture plication.

Incidence of acute epidural hematoma is estimated as 1.5% of patients treated for head trauma. The condition can be fatal, and urgent surgical evacuation is recommended. Spontaneous resolution may occur in some cases. Herein, rapid spontaneous resolution of an epidural hematoma is reported and possible mechanisms are discussed.

Acute acalculous cholecystitis (AAC), inflammation of the gallbladder without evidence of calculi, comprises approximately 10% of all cases of acute cholecystitis. Although the mechanism of AAC has not yet been sufficiently clarified, the most commonly postulated theories regarding its pathogenesis are bile stasis, sepsis and ischemia. We present a case of AAC associated with ischemia of the gallbladder caused by aortic dissection Bakey type III.