Factors of Determining N-acetylcysteine Administration in Patients with Acute Acetaminophen Poisoning

Purpose@#In acute acetaminophen poisoning, the administration of N-acetylcysteine (NAC) can effectively treat the main complications, such as kidney injury and liver failure. In the current situation, measurements of the acetaminophen concentration are not checked in the usual medical facilities. Therefore, this study examined the factors of determining the administration of NAC in addition to the stated amount of intake. @*Methods@#The medical records of patients who visited Ajou University Hospital emergency center with acetaminophen poisoning from January 2015 to December 2019 were reviewed retrospectively. One hundred and seventy-nine patients were initially included. Among these patients, 82 patients were finally selected according to the inclusion criteria in the study. The inclusion criteria were as follows: patients who were 15 years of age or older; those whose ingested dose, ingested time, and body weight were clearly identified; and patients whose acetaminophen sampling time was within 24 hours. Patients were divided into two groups: NAC administered vs. non-NAC administered. The following variables were compared in these two groups: ingested dose, ingested dose per body weight, hospital arrival time after ingestion, suicide attempt history, psychiatric disease history, classification of toxicon-toxic groups, duration of hospitalization, and laboratory results. @*Results@#Univariate analysis revealed the ingested dose per body weight, hospital arrival time after ingestion, suicide attempt history, and psychiatric disease history to be the determining factors in administering NAC. Logistic regression analysis confirmed that the ingested dose per body weight was the only significant factor leading to an NAC treatment decision. (Odds ratio=1.039, 95% Confidential interval=1.009-1.070, p=0.009) @*Conclusion@#The ingested dose per body weight was the only determining factor for administering NAC in patients with acute acetaminophen poisoning. On the other hand, additional criteria or indicators for the NAC administration decision will be necessary considering the inaccuracy of the ingested dose per body weight and the efficiency of NAC administration.

Factors of Determining N-acetylcysteine Administration in Patients with Acute Acetaminophen Poisoning

Purpose@#In acute acetaminophen poisoning, the administration of N-acetylcysteine (NAC) can effectively treat the main complications, such as kidney injury and liver failure. In the current situation, measurements of the acetaminophen concentration are not checked in the usual medical facilities. Therefore, this study examined the factors of determining the administration of NAC in addition to the stated amount of intake. @*Methods@#The medical records of patients who visited Ajou University Hospital emergency center with acetaminophen poisoning from January 2015 to December 2019 were reviewed retrospectively. One hundred and seventy-nine patients were initially included. Among these patients, 82 patients were finally selected according to the inclusion criteria in the study. The inclusion criteria were as follows: patients who were 15 years of age or older; those whose ingested dose, ingested time, and body weight were clearly identified; and patients whose acetaminophen sampling time was within 24 hours. Patients were divided into two groups: NAC administered vs. non-NAC administered. The following variables were compared in these two groups: ingested dose, ingested dose per body weight, hospital arrival time after ingestion, suicide attempt history, psychiatric disease history, classification of toxicon-toxic groups, duration of hospitalization, and laboratory results. @*Results@#Univariate analysis revealed the ingested dose per body weight, hospital arrival time after ingestion, suicide attempt history, and psychiatric disease history to be the determining factors in administering NAC. Logistic regression analysis confirmed that the ingested dose per body weight was the only significant factor leading to an NAC treatment decision. (Odds ratio=1.039, 95% Confidential interval=1.009-1.070, p=0.009) @*Conclusion@#The ingested dose per body weight was the only determining factor for administering NAC in patients with acute acetaminophen poisoning. On the other hand, additional criteria or indicators for the NAC administration decision will be necessary considering the inaccuracy of the ingested dose per body weight and the efficiency of NAC administration.

Systemic Complications occurring after Korean Venomous Snake Bite, with focus on Hematologic and Neurologic Complications

PURPOSE: This study explored and evaluated the systemic complications resulting from the bite of Korean venomous snake, focussing on hematologic and neurologic features. METHODS: Medical records (demographic data, clinical measurements including laboratory results, severity score, and amount of antidote administration, and hospitalization course) of consecutive patients who presented with snakebites to two university teaching hospital during a 10-year period were retrospectively reviewed. Subgroup analysis was conducted for evaluations of anti-acetylcholine esterase administration in complicated victims. RESULTS: The 170 patients displayed occurrence rates of hematologic and neurologic complications of 12.9% and 20.6%, respectively. Among 22 patients with hematologic complications, isolated thrombocytopenia was evident in eight patients (36.4%), prothrombin time (PT)/activated partial thromboplastin time (aPTT) prolongation in 11 patients (50.0%), and both in three patients (13.6%). The mean time to recovery was 4.5+/-1.8 days for isolated thrombocytopenia, and 5.1+/-1.8 days for PT and aPTT prolongation. Hematologic complications could occur suddenly 1~4 days after hospitalization. Among 35 patients with neurologic complications, dizziness was evident in 16 patients (45.7%), and diplopia / blurred vision in 19 patients (54.3%). The mean time to recovery was 3.4+/-0.6 days in patients receiving anti-acetylcholine esterase and 6.9+/-1.8 days in those not receiving anti-acetylcholine esterase (p=0.00). CONCLUSION: Occurrence rates of hematologic and neurologic complications following venomous snake bite differed as compared to other studies conducted in Korea. Onset of hematologic complications can occur rapidly days after admittance. Anti-acetylcholine esterase administration may be effective in treating neurologic complications.

Comparison of the Accuracies of Tw o Methods of Performing the Tongue Blade Test in Mandibular Fractures

PURPOSE: This study was performed to evaluate the accuracy of two different methods of performing the tongue blade test (TBT) on patients with mandible fractures. METHODS: A prospective randomized trial was performed over 28 months, and the accuracy of TBT for the diagnosis of patients with mandibular fractures was evaluated using the radiographic confirmative diagnosis as the gold standard. A consecutive sample of 126 patients (36 mandibular fractures) were enrolled to this study. Method A is addressed the patient's ability to grasp a tongue blade between his teeth and hold the blade against a twistling motion, and Method B is to addressed the patient's ability to grasp a tongue blade between his teeth and then to hold the tongue blade against the examiner's mild effort to remove it. We compared the accuracy of the two methods. RESULTS: The sensitivity of method A was 95.0% (19/20), and that of method B was 93.8% (15/16). The specificities of the two methods were 68.8% and 64.4%, respectively. No statistically significant difference was found between the two methods (p>0.05). CONCLUSIONS: Based on this study, we conclude that we can choose either of the two method and that both methods of TBT are highly effective screening tests for diagnosing mandibular fractures.

The Etiology and the Efficacy of Diagnostic Tools for Adult Patients Presenting with New-onset Seizure in an Emergency Department

PURPOSE: This study was conducted to evaluate the etiology and the efficacy of diagnostic tools such as physical examination, laboratory studies, cranial computed tomography (CT) scans, and electroencephalograms (EEGs) in adult patients presenting with new-onset seizure in an emergency department. METHODS: This is a retrospective study of a 4-year period during which 67 patients were admitted to an emergeny department complaining of new-onset seizure. Among them, 61 patients were eligible for inclusion in this study, and we reviewed their medical records, laboratory data, CT scans and EEG findings. RESULTS: The etiologies of new-onset seizure were 1) unknown, 2) alcohol withdrawal, 3) ischemic stroke, and 4) central nervous system infection. An abnormal CT lesion was diagnosed in 27.5% of the patients with normal neurological examinations. An abnormal CT lesion was diagnosed in 30% of the patients whose EEG results had a focal-wave pattern. But, No statistical significance could be attached to the relationship between the CT lesion and EEG results (p>0.05). CONCLUSIONS: The principal etiologies of new-onset seizure were 1) unknown, 2) alcohol withdrawl, 3) ischemic stroke. A CT scan should be performed in all patients with newonset seizure. A focal-wave pattern in the EEG may consider a necessity for brain imaging.

A Convenient Method of Adenosine Administration for Paroxysmal Supraventricular Tachycardia

PURPOSE: The purpose of this study was to observe the success rate, the average of total admininstration doses and the complications associated with a convenient method of adenosine administration for paroxysmal supraventricular tachycardia (PSVT). METHODS: A non-blind, randomized, prospective study was conducted during the 30 months from January 1999 to June 2001. We enrolled 65 cases during this period. The number of cases in the standard method group was 35, and that in the mixed method group was 30. In the standard method group, 6 mg of adenosine was administered intravenously; therefore, 15~20 ml of normal saline was immediately flushed. This method is usually used and recommended. In the mixed method group, 6 mg of adenosine had been previously mixed with 15 ml of normal saline was administered intravenously without any additional manipulation. We evaluated the success rate, the average successful doses, and the complications of each group. RESULTS: The success rate was 80% in the standard method group and 85.7 % in the mixed method group, but this difference was not statistically significant (Chi square test, p=0.39). The average of total admininstration doses were 10.3+/-6.3 mg in the standard method group and 11.0+/-6.5 mg in the mixed method group, but this difference is not statistically significant (student t-test, p=0.07). There was no remarkable complication in the mixed method group. CONCLUSION: The mixed method was effective and more convenient than the standard method. A further, larger study is required.

Corneal Foreign Body Removal by Emergency Physicians

PURPOSE: This study was performed to evaluate the success rate and the safety in the treatment of corneal foreign body injury by an emergency physician trained in their removal. METHODS: Any patients presenting at the emergency department of a large university-based residency teaching hospital with corneal foreign body injuries during ninety months were included in this prospective study. Twenty patients were eligible. Junior residents participated in this study. They were taught to remove corneal foreign bodies by the attending emergency physician. Healing evaluation was performed by an ophthalmologist. Patients not presenting for a visit were contacted by telephone, and information was collected on the assessment of discomfort and the presence of symptoms. RESULTS: All corneal foreign bodies were successfully removed, and no adverse effects were noted. CONCLUSION: Corneal foreign body removal by emergency physician, if properly trained, appears to be successful and safe.

The Efficacy and Safety of Rectal Thiopental Sodium for Sedation of Children in the Emergency Department

PURPOSE: This study evaluated rectal administration of thiopental sodium provides an efficient and safe method of sedation for children in the emergency department. METHODS: A prospective, randomized, non-blind study was conducted for 18 months. Thiopental and midazolam were given by rectal administration. Chloral hydrate was given by either oral or rectal administration. Ketamine was given by intramuscular injection. The administration dose of thiopental was 25 mg/kg. We evaluated the induction time, the recovery time, the Ramsay scale, the sedative effects for the procedure and the adverse effects of each drug. RESULTS: Eighty-six (86) children were enrolled in this study. Thiopental was administered to 21 children, ketamine to 21 children, chloral hydrate to 21 children and midazolam to 23 children. The induction time for thiopental, chloral hydrate and ketamine groups were 7.6+/-4.0 min, 36.0+/-7.0 min and 7.4+/-3.8 min, respectively. The recovery time for thiopental, chloral hydrate and ketamine groups were 54.1+/-11.8 min, 76.2+/-11.4 min and 64.8+/-18.2 min, respectively. The differences in the induction time and the recovery time for each group are statistically significant (p<0.001). The Ramsay scale for thiopental, chloral hydrate, ketamine and midazolam groups were 5.4+/-1.0, 5.7+/-0.5, 6.0+/-0.2 and 1.7+/-0.7, respectively. In thiopental group, one child (4.7%) experienced desaturation and one child (4.7%) experienced a decrease in blood pressure, but, no child required hospitalization for any complication from these sedatives. CONCLUSION: Rectal administration of thiopental is efficacious and safe for sedation of pediatric patients in the Emergency Department.

Paradoxical Cerebral Air Embolism Immediately after Ingestion of 5% Hydrogen Peroxide

We report the case of a 58-year-old man who developed multiple cerebral infarctions after ingesting accidently a 5% hydrogen-peroxide detergent solution. A 3~5% hydrogen peroxide solution is commercially available as an oxidant and detergent. Neurologic examination of this patient revealed grade III weakeness in both upper and lower limbs and bilateral positive Babinski signs. CT and MRI revealed bilateral multiple brain infarctions in the anterior and the middle vascular territories. The likely mechanism of pathogenesis must be paradoxical cerebral air embolism. Decompression through Nasogastric tube and hyperbaric oxygenation therapy were used to treating this patient. In spite of our intensive care, the patient expired 21days after ICU admission.

Efficacy and Safety of Etomidate Used as a Sedative for Rapid Sequence Intubation in the Emergency Department

PURPOSE: The purpose of this study was to estimate the efficacy and the safety of etomidate for rapid sequence intubation (RSI) in the emergency department. METHODS: A retrospective analysis by chart review was done for patients who had needed intubation in the emergency department of Ajou university hospital from July 1999 to June 2000. RESULTS: Three hundred (300) patients were enrolled in this study. Etomidates were used for 170 patients and Thiopental for 130 patients. In the Etomidate group, the average systolic blood pressures (SBP) were 127.7+/-42.2mmHg prior to etomidate administration and 125.6+/-40.9mmHg after. The average diastolic blood pressures (DBP) were 78.1+/-22.4 mmHg prior to etomidate administration and 79.1+/-21.3 mmHg after. There was no significant change in blood pressure after the use of etomidate. The average intubation time was about 3.9 minutes. Eight (8) patients experienced myoclonus and three (3) of vomiting after the use of etomidate. In the thiopental group, statistically significant decreases in the average SBP and DBP were seen after the administration of thiopental sodium. Twelve (12) patients had decreased blood pressure and one (1) patient arrhythmia after Thiopental administration. The average intubation time was about 5.9 minutes. CONCLUSION: The intubation time for etomidate group was superior to that for thiopental group. Also, in the etomidate group, no significant changes in the hemodynamic variables were noted during RSI. This study supports the efficacy and the safety of etomidate for RSI in the emergency department.

Removing Blunt Foreign Bodies from Nasal Cavities by Using a Foley Balloon Catheter in the Emergency Department

PURPOSE: This study was performed to determine the success rate and the safety of removing blunt nasal foreign bodies from nasal cavities by using a Foley balloon catheter. METHODS: A prospective study involving 30 pediatric patients was conducted. The ages of the patients range from 18 months to 4 years old. The average age was 3.0+/-2.5 years. A variety of blunt nasal foreign bodies were removed by lifting the tip of the nose, inserting a Foley balloon catheter (6~8 Fr) about 5 cm perpendicular to coronal axis of the head with tight contact with the bottom of the inferior meatus passing the foreign bodies, gently inflating the balloon with 1-2 cc of air, and pulling the Foley ballon catheter perpendicularly with a steady pressure (same axis as insertion). RESULTS: Blunt foreign bodies in nasal cavities were successfully removed in all 30 patients by using this method. There were no significant complications. In only 3 patients were nonsustained minor epistaxis observed, and these required no intervention. CONCLUSION: This method had a high success rate (100%) and was safe. Further well designed comparative studies are required.

Bilateral Posterior Shoulder Dislocation Following an Accidental Fall

Posterior shoulder dislocation is a relatively uncommon event, with an incidence of 1~4% of all shoulder dislocations. Because this condition is rare and because accurately interpreting the radiography is difficult, the diagnosis is often missed. In such a case, significant complications, such as chronic posterior dislocation and degenerative disease of the shoulder, can occur. We experienced the case of a patient in whom bilateral posterior shoulder dislocation occurred following an accidental fall a height of 10m. Fortunately, he had no neurovascular injury of the shoulder and fully recovered after closed reduction, but early diagnosis was missed because other injuries were significant and his vital signs were unstable. A careful history and physical examination, complete radiographic evaluation, and a high level of suspicion are required to identify posterior shoulder dislocation. This case may be helpful for diagnosis of posterior shoulder dislocation.

Antiphospholipid Syndrome Causing a Cerebral Infarction

Antiphospholipid syndrome (APS) is a thrombophilic disorder characterized by recurrent abortion, thrombocytopenia, and prolonged activated partial thromboplastin time (aPTT) in which venous or arterial thrombosis, or both, may occur in patients with antiphospholipid antibodies. Antiphospholipid antibodies have been associated with a variety of neurological disorders, many of which, but not all are manifestations of cerebral or ocular ischemia. Recently, we experienced one case of a cerebral infarct due to APS in a 24-year-old female. She visited the emergency department and presented with dizziness and vomiting. After admission, we conducted a physical examination, blood tests, and brain computed tomography. Her blood tests revealed prolonged aPTT and thrombocytopenia, and brain computed tomography showed a right cerebellar and pons infarct. We treated her with anticoagulants. She was discharged with nearly a full recovery on the seventh hospital day.

Acute Mediastinal Tamponade Secondary to Blunt Chest Trauma: Case report

Sternal fractures are most common in drivers of motor vehicles whose anterior chest hits the steering wheel during sudden deceleration. Sternal fractures may result in mediastinal hematoma secondary to bone marrow oozing. The hematoma usually resolves itself without complications, so an anterior mediastinal hematoma causing tamponade is rarely reported. We describe a case of blunt chest trauma resulting in a sternal fracture with a resultant anterior mediastinal hematoma and mediastinal tamponade.

Objective Criteria for Radiologic Diagnosis of Epiglottitis in Korean Adults

BACKGROUNDs: A retrospective study was performed to define objective radiologic parameters in diagnosing epiglottitis on soft-tissue lateral neck radiographic study. METHODS: Parameters of soft-tissue structures(epiglottis width, third vertebral body width, ratio of epiglottic width to third vertebral body width) in 30 adult patients compared with those of age and sex-matched controls with foreign body in throat whose radiographic reading was normal. RESULTS: Epiglottis width of more than 11mm, ratio of epiglottis width(EW) to the third vertebral body width(C3W) of more than 0.5 were, respectively, found to be 100% sensitive and specific in differentiating between patients with and without epiglottitis. CONCLUSION: These preliminary results suggest that EW/C3W ratio of more than 0.5, EW of more than 11mm, respectively, may be useful in the diagnosis of epiglottitis in adult patients.