Analysis of Prognostic Factors Early in Emergency Department (ED) and Late in Intensive Care Unit (ICU) of the Critically Ill Patients Admitted in the ICU via ED / 대한구급학회지

BACKGROUND: Many critically ill patients in the ED are hospitalized to the ICU, but most prognosis predicting systems have been developed based on the physiochemical variables of the critically ill in the ICU. The objective of this study is to identify prognostic predictors early in the ED when compared with well-known predictors in the ICU and estimate their predictive abilities. METHODS: An observational prospective study was performed in an urban ED. Information of all the critically ill patients admitted to the ICU via the ED including vital signs, laboratory results, and physiochemical scoring systems were checked during 6 months and divided into the early stage for the ED and the late stage in the ICU. Poor outcome was defined as 28-days mortality. After checking for significant predictors among them through univariate analysis, we identified the most discriminating predictors in each stage using logistic regression and a decision tree analysis. RESULTS: A total of 246 patients were enrolled. In univariate analysis, the significant predictors including central venous pressure, fraction of inspired oxygen (FiO2), pressure of arterial oxygen/fraction of inspired oxygen (PaO2/FiO2), albumin, mortality in emergency department sepsis, acute physiology and chronic health evaluation II, simplified acute physiology score II, and sequential organ failure assessment scores were identified in the early stage, while PaO2/FiO2, base excess, unmeasured anion, albumin, anion gap, albumin-corrected anion gap, APACHEII, SAPSII, SOFA, and rapid emergency medicine score were identified in the late stage. Through a decision tree analysis, PaO2/FiO2 and SAPSII were revealed as the most discriminating predictors in the ED and ICU, respectively. CONCLUSIONS: The prognosis discriminating predictor in critical patients was different between the ED and ICU. Emergency physicians should pay more attention to the critical patients having low PaO2/FiO2.

The Effect of Inclusion of Rhythmic Music on the Effectiveness of Basic Life Support (BLS) Education

PURPOSE: An adequate chest compression rate during CPR is associated with improved hemodynamics and primary survival rate. The purpose of this study was to compare performance based measures of chest compression (CC), including compression rate and depth, from two versions of a CPR course: Instructor-led (IL) training, and the same IL training but augmented with rhythmic music. METHODS: Ninety-one medical students having completed the BLS provider course, 4 months prior, participated in CPR quality improvement education. Participants performed 2 min of CC on a manikin utilizing an accelerometer-based system that measured both rate (CC/min) and depth (cm) of CC. CC parameters were evaluated three times: prior to the education, immediately after the education, and again after four months. CPR quality was analyzed using the manikin/accelerometer system. The primary outcome measures included: (1) compression rate, (2) compression depth, (3) percentage of compressions performed with adequate rate, (4) percentage of compressions performed with adequate depth, (5) absolute deviation from 100 in terms of compression rate, and (6) each 2 minute test was divided into 4 30 second sections, and any rate differences between the 4 sections were assessed. For the augmented IL study, popular music with a tempo of 100 beats per minute was utilized. RESULTS: There were no differences in CC rate and depth between the two IL trainings. However, students offered IL training augmented with musical rhythm performed CC with a higher percentage of adequate rate and depth. They also had less absolute deviation and variation of CC rate difference between the four, 30 second sections, than students instructed without the use of rhythmic music. CONCLUSION: Students receiving IL training augmented with music performed adequate, standardized CC with a steadier rate than those who received IL training without the benefit of music. This result provides evidence to support the use of rhythmic music in improving BLS education results.

Development of an Emergency Abdominal Ultrasound Course in Korea: 1-Year Experience

PURPOSE: This report describes our 1-year experience with an emergency abdominal ultrasound course that we developed for emergency medicine residents and physicians. METHODS: The five-hour course consisted of didactic lectures and hands-on practice. A 1-hour didactic lecture was provided. The lecture consisted of basic ultrasound physics and principles, and anatomy for abdominal ultrasound. In the hands-on session, the instructors demonstrated the abdominal ultrasound techniques and then the students practiced on standard patients. Participants evaluated the programs using a five or ten point Likert scale. After two months to one year, the participants evaluated the usefulness of the course, their knowledge, and their self confidence. RESULTS: A total of 61 trainees participated in eight courses. The evaluation scores for overall quality of content, clinical utility, quality of educational method, quality of instructor, and time allocation were 4.4+/-0.7, 4.5+/-0.6, 4.3+/-0.6, 4.4+/-0.6, 4.1+/-0.7, respectively. Score of self-confidence of each scan before and after the course were as follows: liver scan, 3.2+/-2.1 to 6.9+/-1.2; gallbladder and bile duct scan 3.0+/-2.5 to 6.9+/-1.2; pancreas scan, 2.4+/-2.1 to 6.3+/-1.3; renal scan, 3.6+/-2.6 to 7.6+/-1.3. Evaluation scores were followed up after two months to one year to estimate self confidence of each scan. Results were as follows: liver scan, 6.1+/-1.5; gallbladder and bile duct scan, 6.5+/-1.6; pancreas scan, 5.5+/-1.8; renal scan, 7.2+/-1.5. CONCLUSION: The Emergency Abdominal Ultrasound Course is a fairly successful course. But continuous improvement of educational content, and development of an objective evaluation tool need to be done.

Combining Tissue Doppler Echocardiography and Lung Rockets Sign in the Differential Diagnosis of Acute Dyspnea

PURPOSE: We tried (1) to determine the discriminating ability of lung rockets sign in lung ultrasound and E/Ea (the ratio of peak early diastolic mitral inflow velocity to peak early mitral annular velocity measured by tissue Doppler echocardiography) known as an indicator of pulmonary edema in acute dyspnea and (2) to develop a new algorithm using two variables. METHODS: This prospective observational study was performed in an urban emergency department. For the patient with dyspnea at rest, we performed bedside emergency ultrasound assessing the presence of lung rockets sign and measuring the E/Ea. Patients were divided into two groups depending on the cause of dyspnea: pulmonary edema or other cause. We compared the two variables and developed an algorithm using decision tree analysis. RESULTS: A total of 66 patients (39 pulmonary edema, 27 other causes) were enrolled. By univariate analyses, there were significant differences between the two groups in the presence of lung rockets sign (p 13.27 had 100% specificity and positive predictive value for pulmonary edema. CONCLUSION: Lung rockets sign in lung ultrasound and measurement of E/Ea could be helpful in the differential diagnosis of shortness of breath quickly and easily in ED.