Extracorporeal Therapy as a Treatment Method in Patients with Acute Ethylene Glycol Poisoning

PURPOSE: Extracorporeal treatment has been used increasingly to treat patients with acute ethylene glycol poisoning. We analyzed all patients with acute poisoning of ethylene glycol during a recent 10-year period to provide clinical recommendations for adequate application of continuous renal replacement therapy for these patients. METHODS: A retrospective chart review study was conducted for patients whose final diagnosis were “toxic effects of glycols or other alcohols,” between October 2006 and September 2016. The basal characteristics of patients, suspected amount of ingestion, intention of poisoning, concomitant alcohol ingestion, mental state at admission, time from exposure to admission, chief complaint, length of hospital stay, method of treatments, laboratory results including acute kidney injury and urine oxalate crystal, as well as treatment results were examined. RESULTS: A total number of 14 patients were included in this study. Nine patients (64.3%) underwent continuous renal replacement therapy; 5 patients (35.7%) underwent ethanol mono-therapy. Between the antidote therapy group and the extracorporeal treatment group, there was a significant difference in the levels of plasma bicarbonate, chloride, anion gap, pH, and base excess in arterial blood gas analysis, as well as the calculated osmolar gap. One patient expired due to multi-organ failure, while the others recovered completely. CONCLUSION: Continuous renal replacement therapy was most frequently chosen as a treatment method in patients with acute ethylene glycol poisoning. Further research regarding indication of continuous renal replacement therapy and combing therapy with other treatment will be necessary to determine the best treatment method.

Flumazenil administration in suspected patients with acute hypnotics and sedatives poisoning: risk-benefit re-evaluation

PURPOSE: The use of flumazenil administration in the emergency department is still controversial because of concerns about adverse effects. The present study was conducted to re-evaluate the risk-benefit ratio associated with flumazenil administration to patients suspected of having acute hypnotics and sedatives poisoning in the emergency department. METHODS: A retrospective chart review study was conducted for patients whose final diagnoses were “poisoning” and “benzodiazepine” or “sedatives-hypnotics” from Mar. 2006 to Feb. 2015. The basal characteristics of the patients, including past medical history, ingredients and dose of ingested drug and co-ingested drugs were investigated. For patients administered flumazenil, responsiveness and time from admission to flumazenil administration were investigated with supplement. All collected data were analyzed in aspect terms of risk/benefit. RESULTS: A total of 678 patients were included in our study. Benzodiazepine was the most common sedative/hypnotic drug prescribed, and the frequency of prescription continuously increased. The proportion of TCA as co-ingestion decreased from 13.1% to 3.9% in patients with acute sedative/hypnotic poisoning. Flumazenil was administered to 55 patients (8.1%), of which 29 patients (52.7%) were applied to contraindications. Fifty-three patients (96.4%) showed positive responsiveness, including partial responsiveness after flumazenil administration. No severe adverse events were identified. CONCLUSION: Based on the current trends in prescription patterns for sedative/hypnotic drugs, increased use of non-TCA antidepressants, and responsiveness to administration of flumazenil, benefit seemed weighted more in this study, although the observed benefits were based on limited results. Further prospective multicenter studies will be needed to optimize benefit-risk ratio.

Characteristics of Suicidal Attempters with Acute Poisoning Who Discharged Against Psychiatric Medical Advice and Emergency Department Admission as an Acute Intervention

PURPOSE: Discharge against medical advice (DAMA) carries a risk of increased mortality and readmissions in the emergency department (ED). The aim of the current study was to examine characteristics of suicidal attempters with acute poisoning who were discharged against psychiatric medical advice and other clinical department admission as acute intervention. METHODS: We retrospectively selected a consecutive series of suicidal attempters with acute poisoning who were admitted to the emergency department between 2011 and 2012. Sex, age, admission time, psychiatric DAMA, impressions by the Psychiatrist-in-charge, and psychiatry follow-up after discharge were reviewed in the medical records. DAMA was defined as an unplanned discharge for which the psychiatrist-in-charge documented in the medical record that the patient or one's legally authorized representatives decided to refuse hospitalization against the psychiatrist's medical advice including closed ward admission. RESULTS: A total of 883 patients who had attempted suicide who visited the emergency department were included. Of these, 155 patients were suicidal attempters with acute poisoning for ED ward admission. Among these patients, the rate of psychiatric DAMA was 66.5% (n=103). Psychiatric impressions were 1) adjustment disorder 51.5% (n=53), 2) major depressive disorder 28.2% (29%). The rate of DAMA was higher in the adjustment disorder group than in the major depressive disorder group (82.8% vs 58.7%, p <0.001). The rate of follow-up after hospital discharge to the psychiatric outpatient department was 26.5% (n=27). CONCLUSION: Admission to the emergency department may improve psychiatric outpatient department referral in suicidal attempters with acute poisoning. In addition, customized plans according to psychiatric diagnosis will be considered for effective acute intervention and continuous psychiatric referral.

A Study on Heuristic Transportation Routes of Patients with Acute Dysbarism for the Best Prognosis

PURPOSE: Acute dysbarism is a potentially lethal injury associated with environmental medicine. Therefore, prompt treatment, including transportation of victims, is important for the best prognosis. The aim of this study was to examine transportation routes of patients with acute dysbarism for the best prognosis in Korea. METHODS: Geography of South Korea was analyzed using the geographic information system (GIS). The study examined two scenarios using transportation analysis, which relies on a GIS base and pressure variation during air and ground transportation. Given the practical assumptions, we propose some heuristic transportation routes based on the simulation of altitude, transportation time, and availability of related factors. RESULTS: Currently, transportation by ground to the treatment facilities always passes high altitude areas above 152 feet. Also, available helicopters for air transportation could not approach the treatment facilities due to the limitation of flying distance and insufficiency of medical staff and treatment equipment. Altitude variation and delayed time were identified during the period of transportation by ground from Ganneung or Incheon to Tongyoung. Heuristic algorism through the above facts recommends air transport along coasts as the best method for transportation from Ganneung or Incheon to Tongyoung. CONCLUSION: In Korea, transportation by ground was not expected to result in the best prognosis for patients with acute dysbarism. Transportation by air should be considered first as the method of transportation. Also, for the best treatment of patients with acute dysbarism, additional treatment facilities need to be established in the west coast region.

Comparison of Manual Versus Mechanical Chest Compression During Simulative out of Hospital Cardiac Arrest

PURPOSE: The quality of cardiopulmonary resuscitation (CPR) has been identified as an important factor for improving survival rate. This prospective study was conducted for comparison of manual chest compression and mechanical chest compression during simulative out of hospital cardiac arrest. And evaluation of quality of manual compression was performed on-scene and during ambulance transportation. METHODS: A total of 24 emergency medical technicians (EMTs) participated in our study. During a period of one month, they were educated by E-learning on the importance of decreasing hands off time during CPR and anything else about CPR. We instituted the scenario of out of hospital cardiac arrest. They performed CPR twice in each same situation: they performed manual chest compression the first time. And, the second time, they used the mechanical chest compression device (X-CPR(TM)). We evaluated the performance by camcorder monitoring and Q-CPR(TM) for measurement of manual compression depth and flow time. RESULTS: A total of 48 cases were performed in this study. Twenty four cases were included in the manual CPR group (H-Group) and 24 cases were included in the mechanical group (M-group). CPR of the H group vs. the M group was performed for a mean 19.71+/-2.97 min, 21.95+/-4.16 min on scene, and in a moving ambulance. The average compression rate was 122+/-14.80 min-1 vs 104.38+/-6.40 min-1 (p<0.001), and the compression depth was 44.25+/-8.50 mm vs 42.37+/-4.28 mm (p=0.34), respectively. No statistical difference was observed in the flow time ratio between manual and mechanical chest compression (67.04+/-11.12 vs 64.13+/-6.61, p=0.28). However, the quality of compression of the H-group, the ratio of insufficient compression, and the ratio of insufficient release during transport were higher than those on-scene (p=0.02, p=0.01). CONCLUSION: In comparison of chest compression rates between the two groups, the M-group showed a higher rate of chest compression. However, no significant difference in chest compression depth and flow time ratio was observed between the H- and M-groups. When performing manual chest compression during transport, EMTs should be careful of adequate chest compression and release.

Considerations for Cancellation Reception in an Emergency Department

PURPOSE: The cancellation of reception in emergency department (ED) in Korea is similar to leaving without being seen in another country. But there are differences. We studied the actual conditions and reasons for cancellation of reception in the ED in each of several hospitals. METHODS: Thirty-six emergency centers and one hundred sixty-seven emergency physicians participated in this survey. We obtained information through a questionnaire about total hospital bed counts, emergency center bed counts, number of emergency physicians, number of cancellations of reception for one day, and emergency physicians' opinions about cancellation of reception. Also, we prospectively investigated reasons for cancellation of reception for emergency physicians and patients. We recorded the reason for cancellation of reception at the time of cancellation and then interviewed the patient by telephone within 10 days after their leaving the ED. RESULTS: Nine regional emergency centers, three specialized emergency centers, twenty-two local emergency centers and two local emergency facilities were involved in this study. We surveyed patient cancellation of reception from August 1, 2008, to October 31, 2008 in our hospital. The results of our study were variable but the average of cancellation of reception was 10% of all ED patients. The most common reason for cancellation of reception was the emergency physician sending the patient to an outpatient clinic, typically because they thought the patient had mild symptoms. The most common reasons causing emergency physicians to think about cancellation of reception were mild symptoms and too long a delay time. There was a significant difference of opinion between emergency physician and patient regarding cancellation of reception (p<0.01). The emergency physicians considered the reasons to be patient factors, while the patients considered the reasons to be doctor-related factors. CONCLUSION: There are many adverse effects from cancellation of reception in an ED for both emergency physicians and patients. We should considered methods for developing a consensus on ways to improve the situation.