Role of N-terminal Pro-brain Natriuretic Peptide in Differentiating Node-first Presentations of Kawasaki Disease and Bacterial Cervical Lymphadenitis

PURPOSE: Kawasaki disease (KD) is an acute, self-limited, febrile disease. For cases of KD in which the first symptom is cervical lymphadenopathy (node-first presentations of KD, NFKD), it is frequently misdiagnosed as bacterial cervical lymphadenitis (BCL). Therefore, we evaluated the usefulness of N-terminal pro-brain natriuretic peptide (NT-proBNP) to differentiate between NFKD and BCL. METHODS: This is a retrospective, observational study. Patients were divided into three groups, KD as 1st diagnosis, NFKD, and BCL. The laboratory and demographic data, intravenous immunoglobulin (IVIG) administration time and total febrile duration, length of hospital stay, and number of coronary artery complications were then compared for each group. RESULTS: A total of 451 patients were diagnosed as KD and 45 patients as BCL. Of the 451 KD patients, 417 (92.5%) were KD as 1st diagnosis, and 34 (7.5%) were NFKD. White blood cell count, absolute neutrophil count, C-reactive protein, erythrocyte sedimentation rate, and NT-proBNP differed significantly between NFKD and BCL. Variables that differed significantly were analyzed using a receiver operating characteristic curve, which revealed that NT-proBNP had the largest area under curve (0.944). Additionally, IVIG administration time, total febrile duration and length of hospital stay differed between KD as 1st diagnosis and NFKD. CONCLUSION: It is difficult to differentiate NFKD from BCL, so proper treatment and length of hospital stay were delayed. NT-proBNP is very useful for differentiating NFKD and BCL. Therefore, in cases of BCL with a long febrile period without reacting general treatments, the NT-proBNP test can be considered.

A Case Report Hemiparesis Caused by Ipsilateral Middle Cerebral Artery Infarction

As the corticospinal tract crosses at the medulla, supratentorial stroke generally influences the opposite extremity. However, new incidences of hemiparesis might occur in the ipsilateral brain if there was a previous infarction in the opposite brain or a congenital structural abnormality. The occurrence of ipsilateral hemiparesis after cerebral infarction is very rare; however, we report here the case of a patient who developed right hemiparesis that was identified as acute right middle cerebral artery infarction.

A Case Report Reversible Cerebral Vasoconstriction Syndrome with Thunderclap Headache During Swimming

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by severe thunderclap headache with multifocal segmental vasoconstriction of the cerebral arteries. RCVS can be diagnosed if the cerebral angiogram shows segmental stenosis and spontaneously resolves within weeks to months. RCVS is reversible, but might cause brain lesions such as subarachnoid hemorrhage or cerebral infarction. We report a 45-year-old woman with severe sudden onset frontal headache who was identified with reversible cerebral vasoconstriction syndrome.

Efficacy of Initial Lactate and Lactate Clearance by Emergency Department Treatment in Diabetic Ketoacidosis Patients

PURPOSE: Diabetic ketoacidosis (DKA) is a fatal complication caused by unregulated diabetes. Lactate is used as a prognostic indicator for a range of serious illnesses and its level is higher in DKA patients. This study examined the utility of lactate and lactate clearance measurements at an emergency department for predicting the prognosis of DKA patients. METHODS: This was a retrospective, observational study of patients with DKA presenting to the emergency department of an urban and rural tertiary hospital between January, 2013 and December, 2016. The demographic and laboratory data were collected through a chart review. RESULTS: Seventy-six patients with DKA were included. Of these 76 patients, 46 (56.8%) had lactic acidosis (lactate >2.5 mmol/L) and 24 (29.6%) had a high lactate level (>4 mmol/L). Lactate and lactate clearance showed a significant difference in terms of the intensive care unit length of stay and mortality. CONCLUSION: Lactate and lactate clearance measurements in DKA patients are favorable and significant prognostic factors. In DKA patients, serial measurements of lactate should be considered.

A Clinical Analysis of Patient Exposure to Sulfuric Acid Injured

PURPOSE: This study was conducted to identify the characteristics associated with sulfuric acid injury in the emergency department. METHODS: Data were collected retrospectively from January 2007 to December 2015 on all sulfuric acid injuries presenting to the emergency department in Gu-mi Soonchunhyung University Hospital. Patients injured by sulfuric acid were recorded over a nine year study period and collected data included demographics, injury mechanism, injured body part, hospital care and final diagnosis. RESULTS: A total of 26 cases were identified. Most patients were male (88.5%) and the face was the most commonly injured body part. The most common mechanism of injury was splashing injury. A total of 16 (61.5%) patients were identified as having lesions worse than second degree burns. CONCLUSION: Sulfuric acid can cause severe and fatal skin burn. When working with sulfuric acid, acid proof protect clothing, goggles and glove should be worn. Furthermore, safety education and workplace environment improvement are necessary to reduce sulfuric acid injury.

Intussusception after Abdominal Trauma in a Child

Intussusception is the most common abdominal emergency in children younger than 2 years old. It is often considered idiopathic. However, an underlying disease can cause a pathological lead point for the intussusception. Its incidence after trauma is uncommon, and traumatic intussusception in children is even rarer. In Korea, traumatic intussusception in a child has never been reported. We experienced a case of traumatic intussusception in a 3-year-old girl. The patient was injured by a plastic bar while playing, and she soon complained of abdominal pain. We identified an ileo-ileal intussusception on computed tomogram. The intussusception was reduced successfully by air reduction in the emergency department. She was sent to home without complication after three hospital days.

A Clinical Analysis of Patients Who Visited Emergency Department due to Chemical Incident Occurred at Industrial Place: A Retrospective Study

PURPOSE: The purpose of this study is to understand what kinds of chemical substances have been used annually and to investigate incidents that occurred due to chemical hazard release and to analyze statistically clinically chemical injury patients who visited one regional emergency medical center in Gumi city with documented references review. METHODS: Annual chemical waste emission quantity (Kg/Year) (Cwep) was reproduced using national web site data governed by the Ministry of Environment and 5 years (from 1 .Jan. 2010 to 31. Dec. 2014) of medical records of chemical injury patients who visited our emergency department were reviewed retrospectively. By applying exclusion criteria, 446 patients of 460 patients were selected. RESULTS: Dichloromethane, Toluene, Trichloroethylene, and Xylene were always included within Top 5 of Cweq. Six cases of chemical incidents were reported and in 3 of 6 cases involving Hydrogen fluoride were included during the study period. Male gender and twenties were the most prevalent group. Injury evoking chemicals were Hydrogen fluoride, unknown, complex chemicals (over 2 substances) in sequence. The most frequent site of wounds and injuries was the respiratory tract. Gas among status, intoxication among diagnosis, and discharge among disposition was most numerous in each group. CONCLUSION: There have been no uniform clinical protocols for chemical wounds and injuries due to various kinds of chemicophysical properties and ignorance of antidotes. Therefore conduct of a multicenter cohort study and experiments for ruling out chemicals according to chemicophysical priority as well as development of antidotes and clinical protocols for chemical injury patients is needed.

A Case of Cardiac Arrest with Pulseless Ventricular Tachycardia Induced by Carthamus tinctorius L. (safflower) Seed Intoxication

Carthamus tinctorius L. is commonly known as safflower. This plant is cultivated mainly for its seed, which is used as essential oil and hot water extract. C. tinctorius has recently been shown to have antioxidant, analgesic, and anti-inflammatory activities. C. tinctorius seed is known as a relatively nontoxic material that is not associated with fatal adverse effects. We experienced a successful outcome in a 62-year-old male patient who was a victim of poisoning due to ingestion of C. tinctorius seed and undergone fatal adverse effects. He ate C. tinctorius seed mixed with alcohol and became lethargic state. In the emergency department, cardiac arrest with pulseless ventricular tachycardia occurred. He was treated by cardiopulmonary resuscitation with cardiac defibrillation. After return of spontaneous circulation, he was managed conservatively and was discharged without deficits approximately ten days after onset.

Epileptic Seizure Revealing a Fahr's Syndrome with Pseudohypoparathyroidism: A Case Report

Fahr's disease is a rare disease characterized by idiopathic abnormal deposits of calcium in intracranial areas. Fahr's syndrome occurs secondarily to other diseases. Endocrine disorders, particularly parathyroid hormone disorders, are most commonly associated with Fahr's syndrome. Common clinical features of Fahr's disease or syndrome include movement disorder, phychiatric disorder, epileptic seizure, dementia, headache, dystonia, myoclonus, tremor, and parkinsonism. We report on a case of a 35-year-old woman with Fahr's syndrome who presented with epileptic seizure and pseudohypoparathyroidism.

Angiomyolipoma Rupture and Spontaneous Pneumothorax in Tuberous Sclerosis Patients: A Case Report

Tuberous sclerosis is a genetic multi-system disorder characterized by wide spread hamartomas in several organs. We present the case of a 28-year-old female patient diagnosed with tuberous sclerosis combined with life threatening complication. She developed a peri-renal hemorrhage due to an angiomyolipoma rupture and spontaneous pneumothorax at a time. In order to diagnose and treat this problem, the emergency physician should understand the clinical presentation and complication associated with tuberous sclerosis.

Investigation of Non-analgesic Subcutaneous Suture and Skin Bond in Patients with Deep Facial Lacerations

PURPOSE: To evaluate the effectiveness of non-analgesic subcutaneous suture with an adhesive agent. METHODS: We sutured lacerated wounds with an adhesive agent using a non-analgesic method and measured pain and patient satisfaction. We classified three steps (I: entering the needle, II: pulling the fiber, III: tying) in the suture sequence and evaluated the pain (painfulness, tolerance, painlessness) for each step. RESULTS: Of 276 patients admitted within the period, 111 were enrolled in this study. The mean wound characteristics were 11+/-4 mm (depth) and 23+/-18 mm (length). Overall, 83(75%) patients were sutured without additional analgesics. On a pain scale, all steps were measured at over 90% with respect to tolerance and painlessness. In step II, tolerance (63%) and painfulness (10%) was higher than in the other steps (p<0.05). The mean rate of satisfaction was 4.7 (group 1, 4.8; group 2, 4.6; group, 3; 4.6, group 4, 4.7 (p=0.673). CONCLUSION: Non-analgesic subcutaneous suture with adhesive agent was very effective for patients who were admitted to the emergency department with deep facial lacerations with a length of no more than 2 cm.

Retrograde Intubation in Patients with Severe Cervical Ankylosing Spondylitis: A Laryngeal Mask Airway (LMA) Combined Technique

Occurrence of cervical spineankylosis is rare, and intubation of patients with this condition can be difficult, particularly when fiberoptic laryngoscopy is not available. We performed successful endotracheal intubation in a 64-year-old male patient using a 7-mm cuffed polyvinyl chloride (PVC) tube with the help of a laryngeal mask airway (LMA). The LMA was initially used for rapid ventilation of the patient, and the guide wire was passed into the airway from the site of puncture of the cricothyroid membrane. This wire was easily observed in the LMA tube, and the use of long forceps was not required.

Manual Removal of a Finger Stuck Tightly in a Door Handle: The Lubricant and Compressor Technique

Until now, tight-fitting material, such as a ring on a digit, has been treated primarily using ring cutter techniques. If this was not available, most physicians would attempt to pull materials out using simple instruments available in the emergency room. The material selected most often was lubricant. However, for cases in which the tight-fitting material was unusual in that the finger was fully covered so that the joint or distal part could not be located in order to check on complications, there have been no methods for consideration with references. Therefore, we treated a patient whose finger was stuck in an unusual circumstance, and removed it manually using the lubricant and compressor technique.

Association of Prescribed Drug intoxication and Neuropsychiatric history

PURPOSE: The purpose of this study was to investigate the relationship between patients with a neuropsychiatric history and features of their suicide attempt, in order to analyze the risk associated with psychiatrist prescribed drugs. METHODS: We retrospectively investigated cases of intentional overdose drug ingestion in patients greater than 14 years of age who visited OO emergency medical center between January 1, 2008 and July 31, 2010. We evaluated patient medical records to ascertain their age, sex, neuropsychiatric history, and components of ingested intoxicant. Information regarding any suicide reattempt was obtained after discharge through follow up telephone survey. SPSS version 13.0 was used for statistical analysis. Fisher's exact test was performed with p<0.05 considered statistically significant. RESULTS: Ninety-six of 209 patients (46%) had a past history of psychological problems. Among those 96 patients with a history of psychological problems, 46(48%) used an overdose of the medicine prescribed by their psychologist in order to attempt suicide. However, for patients without a history of psychological problems, intoxication by neuropsychiatric drugs was insignificant. Neuropsychiatric patients required greater follow up care after discharge and exhibited significantly more suicide reattempts. CONCLUSION: This study revealed that patients sometimes use the medicine prescribed by their psychologist to attempt suicide. Therefore, an exhaustive plan to control the medicines prescribed to psychiatric patients should be established.

Comparison of Infection Rates for Central Venous Catheters Administered in an Intensive Care Unit versus an Emergency Department

PURPOSE: The purpose of this study was to compare the rate of bloodstream infections associated with use of central venous catheters (CVCs) by an emergency department (ED) versus an intensive care unit (ICU). METHODS: Using the hospital administrative and billing database, we identified patients who received CVCs between January 1, 2006, and December 31, 2009 in the ED and ICU at an academic, urban hospital with an annual census of 55,000. We performed a structured, explicit chart review to determine durations of catheterization and rates of bloodstream infections. RESULTS: We screened 4,088 charts and identified 1,480 patients with CVCs that were administered in the ED, (total of 12,888 catheter-days with 47 bloodstream infections), and 982 patients with CVCs that were administered in the ICU (13,326 catheter-days with 52 bloodstream infections). The rate of bloodstream infections associated with CVCs placed in the ED was 3.65 per 1,000 catheter-days (95% confidence interval 2.68 to 4.85), and the rate of bloodstream infections in the ICU was 3.75 per 1,000 catheter-days (95% confidence interval 2.91 to 5.12). The median duration of catheterization was 6.0 days in the ED, and 10.0 days in the ICU. Among the infected CVCs, the median duration of catheterization was 12.0 days in the ED, and 14.0 days in the ICU. Of 1480 total CVCs administered in the ED, 897 were placed in the subclavian veins (61%), 554 in the internal jugular (37%), and 29 were placed in femoral veins (2%). Of the total 982 CVCs administered in the ICU, 779 were placed in the subclavian veins (79%), 158 in the internal jugular veins (16%), and 45 in femoral veins (4.3%). CONCLUSION: The rate of bloodstream infections in the ED is comparable to those in the ICU. The duration of catheterization was found to be a more important factor than the CVC insertion location.

Tissue Adhesive Effectiveness in Laceration Site

PURPOSE: To study tissue adhesive effectiveness in with laceration at various body sites. METHODS: From January 2007 to December 2009, we collected the data of laceration patients treated using tissue adhesive in the emergency department of a university hospital. Data concerning treatment satisfaction were collected twice and analyzed. RESULTS: Of the 8665 patients with laceration, 196 (mean age 23 years, 106 males) were treated using tissue adhesive. Many of the 196 patients were <15-years-of-age. Involved body sites mainly comprised head/neck, followed by the upper extremities. The procedure was the most rapid of all treatments. CONCLUSION: Emergency physicians can reliably use tissue adhesive treatment for various lacerations in the emergency setting.

A Case of Tracheal Compression Caused by a Large Foreign Body in the Esophagus

Foreign bodies that migrate outside the esophagus into the mediastinum or soft tissues usually cause respiratory symptoms. Also, esophageal foreign body granulomas that cause tracheal stenosis, lobar atelectasis, and bronchoesophageal fistulas are reported as complications. Foreign bodies can become lodged above esophageal strictures, and chronically-embedded esophageal foreign bodies can induce stricture formation, although these are less common. This is rare case report that the trachea was directly compressed due to impacted esophagus by foreign body.

Characteristics of Bicycle and Motorcycle Injured Patients in a University Hospital and in an Edited National Injury Surveillance Report

PURPOSE: To study characteristics of bicycle and motorcycle injured patients in a university hospital and in an edited national injury surveillance report. METHODS: Between July 2007 and January 2010, we collected data on bicycle and motorcycle injured patients in a university hospital. First, we compared the characteristics of each group. Second, we analyzed injury severity using their injury severity score (ISS) and their revised trauma score (RTS). We compared the categories of an edited national injury surveillance report with our university-acquired data. RESULTS: The total number of patients in traffic accidents was 4,111 (including 204 bicycle riders and 165 motorcycle riders). For those in bicycle accidents, a large fraction was 51 years old. For those in motorcycle accidents. Those in motorcycle accidents had an increased proportion of liver cirrhosis and of previous experience with a similar accident. Bicycle accidents had a higher proportion of cases where just the driver or just the passenger was injured. Just falling was the most cause of injury. Others were injured by collision with a car or by both. Motorcycle riders who wore helmets were better protected. Most accidents occurred after 19:00: motorcycle accidents most frequently between 0:00 and 7:00 and between 13:00 and 18:00 hours. Injury severity score were not different. Admission to the hospital and fatalities were highest for motorcycle accidents. The place of injury and alcohol intoxication status were reported for traffic accidents. CONCLUSION: Bicycle and motorcycle injuries were already considered as important factors in traffic accidents included in the injury surveillance report. More factors, including age, time, past history, etc. should be added.

Clinical Characteristics and History of Patients with Hemoperitoneum due to Ovarian Cyst Rupture

PURPOSE: To evaluate and analyze the clinical characteristics and history of patients with hemoperitoneum due to ovarian rupture. METHODS: Subjects were fertile females who visited the emergency department between January 2006 and December 2008. We did retrospective chart reviews only for patients diagnosed with hemoperitoneum. We investigated the characteristics and history of enrolled patients. RESULTS: A total of 76 females (mean age = 28 years) were enrolled. Of the 76, 32 (41.8%) were initially checked for coitus history by emergency physicians (EP). Of the 76, 52 (68.4%) were operated on and the remaining 24 (31.6%) were only observed. Only 4 patients had knowledge of a history of ovarian cysts. CONCLUSION: Coitus history and ovarian cyst history should be done by EPs during the initial examination of fertile females who complain of lower abdominal pain.

Cardiac Tamponade Due to Suture Material and this Manifested as Convulsion

Cardiac tamponade is a potentially acute, life threatening emergency that can cause death if it is not promptly diagnosed and treated. Cardiac tamponade is a comparatively uncommon presentation to the emergency department and it is usually associated with penetrating trauma. We report here on a case of cardiac tamponade due to suture material that was used for colectomy ten years previously. A 17-year-old male was admitted to an emergency department with a complaint of loss of consciousness and convulsion. He also complained of chest pain, dyspnea and hypotension. After a while, he displayed cyanosis and his jugular veins were distended. The emergency echocardiogram showed a large amount of pericardial effusion with features of tamponade. Pericardiocentesis was immediately performed. Although 800 cc of fresh blood was drained from the pericardial cavity, his bleeding wouldn't stop. So, the patient was moved immediately to the operation room, and pericardiectomy and median sternotomy were performed. The surgeon found that the foreign suture material had penetrated the pericardium and he successfully removed it. The removed foreign body was a bundle of thread. The patient was discharged without any complications after 9 days.