Prediction of the Likelihood of Surgical Management in Blow-out Fracture Patients: Using Two CT Measuring Method, DFD and CCD

PURPOSE: The purpose of this study was to evaluate the predictive value of the measured factors that can be used in an emergency department to assess patients with blow-out fractures (BOFs) who are expected to undergo surgical management. METHODS: This study was conducted on patients with BOFs who attended an emergency department in a tertiary teaching hospital from December 2013 to November 2016. The medical records and radiology findings, such as facial computed tomography (CT), were reviewed retrospectively. The depth of floor displacement (DFD) and cranial-caudal dimension (CCD), which were measured using facial CT, were evaluated to determine the power of the CT parameters as predictors expecting surgical management in BOF patients. Statistical analysis was conducted with SPSS statistics ver. 23.0. RESULTS: The final 44 BOF patients were included in the study. Among them, 21 patients had undergone surgery. From this study, using a threshold DFD value of 0.5 cm, the accuracy of DFD was 86.36%, and the sensitivity and specificity in predicting surgery in BOF patients was 100% and 73.91%, respectively. Using a threshold CCD value of 0.4 cm, the accuracy of CCD was 88.64%, and the sensitivity and specificity in predicting surgery in BOF patients was 100% and 78.26%, respectively. CONCLUSION: With the aid of DFD and CCD, which was measured from facial CT, BOF patients who may require surgical management can be detected easily and more promptly by emergency physicians in emergency settings.

Usefulness of Age Shock Index in Predicting the Severity of Acute Cholecystitis in Emergency Department Patients

PURPOSE: This study examined the availability of the age shock index in an assessment of high risk patients with acute cholecystitis in an emergency department. METHODS: Consecutive data of patients who presented to the emergency department with acute cholecystitis during the period, January 2012 and March 2017, were reviewed retrospectively. Univariate and multivariate analyses were performed to determine the relationship between the severity of acute cholecystitis and the clinical factors. RESULTS: A total of 242 patients with acute cholecystitis were included in this study. From univariate analyses, age, Murphy's sign, symptom duration, heart rate, respiratory rate, age shock index, hypertension, diabetes, leukocytes, C-reactive protein and blood urea nitrogen were found to be related to the severity of acute cholecystitis. From multivariate analysis, the symptom duration (OR, 4.271; 95% CI, 2.672-6.827), respiratory rate (OR, 1.482; 95% CI, 1.189-1.847), age shock index (OR, 1.609; 95% CI, 1.060-2.442, 10-point interval), leukocytes (OR, 1.283; 95% CI, 1.156-1.424), and diabetes (OR, 4.590; 95% CI, 1.507-13.976) had a positive relationship with the severity of acute cholecystitis. CONCLUSION: The age shock index, which is calculated easily using the patient's age, heart rate, and systolic blood pressure, can be a predicting factor of severe acute cholecystitis in an emergency department.

Near-complete optic nerve transection by high-pressure air

The use of high-pressure air instruments has become more common. Consequently, there have been a number of cases of orbital emphysema caused by contact with high-pressure air. In this case, a 62-year-old male patient visited an emergency medical center after his left eye was shot by an air compressor gun that was used to wash cars. Lacerations were observed in the upper and lower eyelids of his left eye. Radiological examinations revealed orbital emphysema, optic nerve transection, pneumocephalus, and subcutaneous emphysema in the face, neck, shoulder, and mediastinum. Canalicular injury repair was performed, and the emphysema resolved. However, there was near-complete vision loss in the patient's left eye. Because most optic nerve transections occur after a severe disruption in bone structure, pure optic nerve transections without any injury of the bone structure, as in the present case, is extremely rare.

Educational suitability of endotracheal intubation using a video-laryngoscope / 한국의학교육

PURPOSE: The purpose of this study is to determine the educational suitability of the video-laryngoscope in teaching endotracheal intubation to students. METHODS: Medical students participated in a course on the use of a Macintosh direct laryngoscope and McGrath MAC videolaryngoscope for intubation. The course comprised a 1-hour lecture and 30 minutes of practice on a manikin. After the course, in each of the three simulated patient scenarios-normal airway, cervical spine fixation, and tongue edema-time to intubate, success rate, and chance of complications were measured. A questionnaire was administered before and after the course to determine the suitability of intubation by video-laryngoscope for a medical education course. Also, changes in the perception and stance on the video-laryngoscope were evaluated. RESULTS: Time to intubate decreased as attempts were repeated. The first-attempt success rate in the cervical spine fixation scenario was higher using the video-laryngoscope (p=0.028). Rates if tooth injury were lower in the cervical spine fixation (p=0.005) and tongue edema scenarios (p=0.021) using the video-laryngoscope. Based on the questionnaires, students responded positively with regard to their knowledge of the video-laryngoscope, its practical value, and its suitability for medical education (p<0.001). Also, the preference for the video-laryngoscope was greater (p=0.044). Students felt that repeated attempts and feedback on intubation were helpful. CONCLUSION: The students' evaluations and surveys showed positive results to intubation by video-laryngoscope. Thus, based on its suitability for medical education it is reasonable to consider learning intubation using the video-laryngoscope.

Reexpansion Pulmonary Edema after Initial Treatment of Primary Spontaneous Pneumothorax: Small Bore Catheterization versus Chest Tube Thoracostomy

PURPOSE: Reexpansion pulmonary edema (REPE) is a rare but potentially lethal complication of treatment for pneumothorax. This study was designed to compare the frequency of REPE after treatment of primary spontaneous pneumothorax (PSP) with 6 French (Fr) small bore catheterization and 14-20 Fr chest tube thoracostomy. METHODS: The medical records of PSP patients treated with thoracostomy from January 2010 to May 2015 were reviewed retrospectively. We compared the group treated using a 6 Fr small bore catheter with the group treated using a 14-20 Fr chest tube for clinical and demographic factors. The main outcome was the frequency of REPE between the two groups. RESULTS: A total of 196 patients were enrolled. No significant differences in catheter indwelling time, lengths of hospital stay, and treatment failures were observed between the two groups. REPE developed in 21 patients (10.7%). The frequencies of REPE after 6 Fr small bore catheter and 14-20 Fr chest tube were 6.0% (7 of 114 patients) and 17.1% (14 of 82 patients), respectively (p=0.015). In logistic regression analysis, drainage via 14-20 Fr chest tube showed significant correlation with the occurrence of REPE (odds ratio=3.03, p=0.038). CONCLUSION: A 6 Fr small bore catheter offers a safe and effective alternative to a chest tube for treatment of pneumothorax. We suggest that drainage via a small bore catheter should be considered as the initial treatment of choice for PSP patients in terms of frequency of development REPE.

Clinical Characteristics of Geriatric Patients with Digestive System Foreign Body in Emergency Center

BACKGROUND: In patients with foreign bodies in their digestive systems, old age is associated with higher rates of incidence and complications. Therefore, we compared the characteristics of geriatric patients with nongeriatric patients who were found to have with foreign bodies in their digestive systems. METHODS: We retrospectively analyzed 497 cases of foreign bodies in the digestive system over the period from 2010 through 2014. Patients were divided into two groups: nongeriatric (20-64 years, n=404) and geriatric (> or =65 years, n=93). RESULTS: The geriatric patients had more underlying diseases (12.0% vs. 3.0%), took longer to arrive at the hospital (8.92+/-21.31 hours vs. 4.50+/-14.76 hours, p<0.001), and had higher complication rates (4.3% vs. 0.2%, p<0.001), and longer hospital stays (4.88+/-4.26 days vs. 3.08+/-2.97 days, p<0.001). The following factors were significantly different between the geriatric and nongeriatric patients: type (p<0.001) and the locations (p=0.001) of the foreign bodies and their management (p=0.001). In the geriatric patients, the detected foreign bodies were more frequently located in the esophagus (46.0% vs. 17.4%), especially in the upper esophagus (30.0% vs. 14.5%). Smooth-shaped foreign bodies (18.0% vs. 5.0%) and food lumps (16.0% vs. 3.3%) were also frequently detected in the geriatric patients. CONCLUSION: In comparison with nongeriatric patients, the geriatric patients had more smooth-shaped shaped foreign bodies such as food lumps in their esophagi, and this patient group also showed higher rates of admission and complications. Thus, differences between geriatric and nongeriatric patients should be considered carefully in evaluating foreign bodies in the digestive system to prevent late diagnosis and further complications.

Analysis of Factors Related to Delayed Answer in Interhospital Transfer Refer

PURPOSE: The purpose of this study is to determine the factors related to delayed answer in interhospital transfer in order to reduce the time required to determine interhospital transfer and to provide optimal care for emergency patients. METHODS: This was a retrospective observational study. Data on request for interhospital transfer of emergency patients were collected from July, 2013 to October, 2013 in an urban emergency department with approximately 40,000 annual visits. Time required for determination, receptionist's department and position, decision maker's department and position, patient's general characteristics, and requesting hospital's characteristics were collected. The SPSS package with Student's t-test, Chi-square, one-way ANOVA, and multivariate logistic regression analysis was used for analysis of the data. RESULTS: When the decision maker's department was emergency medicine, the time required to determine inter-hospital transfer was shortest (p<0.001), and position of emergency medicine member was non-significant (p=0.109). When the decision maker's department was non-emergency medicine, specialist had a shorter time required to determine interhospital transfer than resident (p<0.001), but influence of the position of receptionist was non-significant. CONCLUSION: Decision maker for interhospital transfer request should be an emergency medicine member. If one cannot make a decision, one should consult a specialist, not a resident. Hospitals should implement an organized system to shorten the time for interhospital transfer.

Diagnostic Characteristics of Geriatric Patients With Ureterolithiasis in Emergency Center

BACKGROUND: Incidence rate of ureterolithiasis has been increasing worldwide in general, with an especially rapid increase in the elderly, over 65 years of age. Therefore, the characteristics of geriatric patients diagnosed with uureterolithiasis in an Emergency Center were examined. METHODS: A total of 613 consecutive patients who were diagnosed with ureterolithiasis through computed tomography from January 2012 to March 2014 were analyzed retrospectively. The patients were divided in two groups: the geriatric group and nongeriatric group. RESULTS: Among the 613 patients, there were 64 geriatric patients (> or =65 years, 10.4%) and 549 nongeriatric patients (<65 years, 89.6%). In the geriatric patients, 13 patients (20.3%) appeared without any pain or with atypical types of pain, while 39 of the nongeriatric patients (7.1%) had no pain or atypical symptoms, presenting a statistically significant difference (p<0.001). Gastrointestinal symptoms such as nausea and vomiting were more common in geriatric patients than in nongeriatric patients (42.2% vs. 29.9%, p=0.044), while lower positive rate of microscopic hematuria was reported (78.1% vs. 90.5%, p=0.002). Furthermore, in geriatric patients, the positive rate of costovertebral angle tenderness was lower and distal ureter stones were found to be more common, while urine pH and serum creatinine levels were higher. CONCLUSION: In comparison to nongeriatric patients, geriatric patients with ureterolithiasis showed lower rates of renal colic and hematuria, while showing higher rates of having gastrointestinal symptoms such as nausea and vomiting. Thus, differences between these two groups should be considered in evaluating geriatric patients to prevent complications which may be caused from the late diagnosis of ureterolithiasis.

An Association between the Inflammatory Marker and Short-term Risk of Stroke in Patients with Transient Ischemic Attack and Low ABCD2 Score

PURPOSE: A transient ischemic attack (TIA) is a brief episode of neurological dysfunction resulting from focal cerebral ischemia not associated with permanent cerebral ischemia and short-term risk of stroke after TIA is high. Inflammatory markers play an important role in acute brain ischemia. The purpose of this study was to investigate the association between the inflammatory markers and short-term risk of stroke in patients with TIA and low ABCD2 score. METHODS: The authors conducted a retrospective study of patients diagnosed with TIA in the emergency department (ED) from June 2006 to April 2013. A total of 282 patients diagnosed as TIA with low ABCD2 score were enrolled. Patients were divided into two groups according to occurrence of stroke within 90 days. We analyzed demographic characteristics, laboratory data, and comorbidities of each group. RESULTS: The median age of patients was 50.0(45.8-58.0) years, with 44.3% males. Based on the occurrence of stroke within 90 days, the patients were divided into 42 patients with stroke and 240 patients with non-stroke. Patients with stroke showed a high median age (p=0.027), white blood cell count (p=0.031), neutrophil to lymphocyte ratio (NLR) (p=0.033), C-reactive protein (p=0.005), and glucose (p=0.010). Results of multivariate analysis showed that NLR was a significant predictor of short-term prognosis (odds ratio 2.785, 95% confidence interval 1.453-5,340). CONCLUSION: NLR in the ED may be used as a rapid and easy to measure inflammatory marker for prediction of short-term prognosis in patients with transient ischemic attack and low ABCD2 score.

External Validation Study of San Francisco Syncope Rule Based on Standardized Reporting Guidelines for Emergency Department Syncope Risk Stratification Research

PURPOSE: We validated the performance of the San Francisco Syncope Rule (SFSR) for accurate identification of Korean emergency department (ED) syncope patients who will experience a short term serious outcome. METHODS: This retrospective study included patients over 16 years old who fulfilled the inclusion criteria according to the definition of syncope and visited the ED from January 2010 to June 2013. The authors excluded patients with alcohol or illicit drugs use seizure, stroke or transient ischemic attack, head trauma followed by loss of consciousness, or hypoglycemia. The patients were divided into two groups according to the SFSR for the purpose of performing a comparative analysis. The authors calculated sensitivity, specificity, positive predictive value, and negative predictive value of SFSR and analyzed other variables, except five predictor variables of SFSR. RESULTS: Of 1,235 visits screened, 409 were included. The average age of enrolled patients was 55.2+/-20.1 and male population accounted for 45.0%(n=184). A total of 93(27.7%) patients experienced serious outcomes; 41 of 287(14.3%) patients with a serious outcome were not identified as high risk according to the rule. The rule performed with a sensitivity of 55.9%, specificity of 77.8%, positive predictive value of 42.6%, and negative predictive value of 85.7%. CONCLUSION: In this retrospective validation study based on the standardized reporting guidelines for ED syncope risk stratification research, the SFSR performed with significantly lower sensitivity than previously reported. The results suggest that application of the original rule has limited generalizability and conduct of future studies will be needed in order to refine the SFSR.

An Association between the Inflammatory Marker and Short-term Risk of Stroke in Patients with Transient Ischemic Attack and Low ABCD2 Score

PURPOSE: A transient ischemic attack (TIA) is a brief episode of neurological dysfunction resulting from focal cerebral ischemia not associated with permanent cerebral ischemia and short-term risk of stroke after TIA is high. Inflammatory markers play an important role in acute brain ischemia. The purpose of this study was to investigate the association between the inflammatory markers and short-term risk of stroke in patients with TIA and low ABCD2 score. METHODS: The authors conducted a retrospective study of patients diagnosed with TIA in the emergency department (ED) from June 2006 to April 2013. A total of 282 patients diagnosed as TIA with low ABCD2 score were enrolled. Patients were divided into two groups according to occurrence of stroke within 90 days. We analyzed demographic characteristics, laboratory data, and comorbidities of each group. RESULTS: The median age of patients was 50.0(45.8-58.0) years, with 44.3% males. Based on the occurrence of stroke within 90 days, the patients were divided into 42 patients with stroke and 240 patients with non-stroke. Patients with stroke showed a high median age (p=0.027), white blood cell count (p=0.031), neutrophil to lymphocyte ratio (NLR) (p=0.033), C-reactive protein (p=0.005), and glucose (p=0.010). Results of multivariate analysis showed that NLR was a significant predictor of short-term prognosis (odds ratio 2.785, 95% confidence interval 1.453-5,340). CONCLUSION: NLR in the ED may be used as a rapid and easy to measure inflammatory marker for prediction of short-term prognosis in patients with transient ischemic attack and low ABCD2 score.

External Validation Study of San Francisco Syncope Rule Based on Standardized Reporting Guidelines for Emergency Department Syncope Risk Stratification Research

PURPOSE: We validated the performance of the San Francisco Syncope Rule (SFSR) for accurate identification of Korean emergency department (ED) syncope patients who will experience a short term serious outcome. METHODS: This retrospective study included patients over 16 years old who fulfilled the inclusion criteria according to the definition of syncope and visited the ED from January 2010 to June 2013. The authors excluded patients with alcohol or illicit drugs use seizure, stroke or transient ischemic attack, head trauma followed by loss of consciousness, or hypoglycemia. The patients were divided into two groups according to the SFSR for the purpose of performing a comparative analysis. The authors calculated sensitivity, specificity, positive predictive value, and negative predictive value of SFSR and analyzed other variables, except five predictor variables of SFSR. RESULTS: Of 1,235 visits screened, 409 were included. The average age of enrolled patients was 55.2+/-20.1 and male population accounted for 45.0%(n=184). A total of 93(27.7%) patients experienced serious outcomes; 41 of 287(14.3%) patients with a serious outcome were not identified as high risk according to the rule. The rule performed with a sensitivity of 55.9%, specificity of 77.8%, positive predictive value of 42.6%, and negative predictive value of 85.7%. CONCLUSION: In this retrospective validation study based on the standardized reporting guidelines for ED syncope risk stratification research, the SFSR performed with significantly lower sensitivity than previously reported. The results suggest that application of the original rule has limited generalizability and conduct of future studies will be needed in order to refine the SFSR.

A Retrospective Study for Validity of the Denver Seizure Score in Emergency Medical Care Center for Differential Diagnosis of Seizure and Syncope

PURPOSE: The purpose of this study is to validate the Denver seizure score (DSS) compared with a questionnaire and scoring system for symptoms pertaining to loss of consciousness (QSLOC) in patients with loss of consciousness who visited the emergency department (ED). METHODS: This was an observational study. Patients with loss of consciousness who were admitted from January, 2011, to July, 2013 in an urban ED with approximately 30,000 annual visits were eligible. General characteristics, clinical manifestation, hemodynamic, and laboratory data were collected. DSS and QSLOC were calculated as originally described. The SPSS package with Mann-Whitney U test, Fisher's exact test, and logistic regression was used for analysis of the data. The area under the receiver operating characteristics curve (AUC) was used for discrimination of each score. RESULTS: Based on the historical feature, clinical manifestation, and final diagnosis, the patients were divided into 45 seizure and 52 syncope cases. In the seizure group, there were more males than females (p=0.015) and statistically significant findings were observed for serum bicarbonate (p<0.001), anion gap (p<0.001). AUCs were 0.954 and 0.998 for DSS and QSLOC, respectively. CONCLUSION: Compared to QSLOC, DSS did not show a noticeable difference in differentiating seizure disorder, and for patients who lost consciousness, it can be used in determining procedures and for prediction of both treatment method and prognosis in the emergency department.

The Characteristics and Factors Affecting Patients Diagnosed with Lower Limb Arteriosclerosis Obliterans in an Emergency Department

PURPOSE: This study investigated the relationship between the laboratory results of patients diagnosed with lower limb arteriosclerosis obliterans (LASO) in an emergency department (ED), general characteristics, clinical manifestation, hematological conditions, and clinical views of severity. Another purpose of the study was to determine the factors that could contribute to clinical severity to facilitate the prediction and diagnosis of LASO in the ED. METHODS: From January 2005 to December 2012 we conducted a retrospective study on patients diagnosed with LASO in the ED. Included in the study were 52 patients diagnosed with LASO through CT. The patients were divided into two groups according to the Fontaine classification-for comparative analysis: "less severe" (for stage II and below) and "more severe" (for stage III and above). Vital signs, clinical findings, laboratory data, and CT findings were analyzed in each patient. The SPSS package with the Mann-Whitney U test, Fisher's exact test, and logistic regression were used for data analysis. A p-value <0.05 was considered statistically significant. RESULTS: The average age of patients diagnosed with LASO was 73.1+/-10.1 and male saccounted for 76.9% of the population (n=40). Based upon the levels of severity by the Fontaine classification, patients were divided into 28 "more severe" and 24 "less severe" cases. The "more severe" LASO patients showed a high pulse rate (p=0.017) and a higher current smoking rate (p=0.04). The laboratory data from "more severe" LASO patients showed significant differences in total white blood cell count (p=0.040), erythrocyte sedimentation rate (p=0.000), and the levels of lactate dehydrogenase (p=0.002), creatine kinase (p=0.000), creatine kinase-MB (p=0.002), myoglobin (p=0.000), and C-reactive protein (p=0.000). The significant factors that could affect clinical severity were erythrocyte sedimentation rate (OR 1.066, 95% CI 1.010-1.125, p=0.021), and the levels of lactate dehydrogenase (OR 1.015, 95% CI 1.002-1.029, p=0.027), creatine kinase-MB (OR 1.229, 95% CI 1.028-1.468, p=0.023), and C-reactive protein (OR 1.533, 95% CI 1.074-2.188, p=0.019). CONCLUSION: The patients diagnosed with more severe LASO showed a high pulse rate, a higher current smoking rate, high levels of inflammation (erythrocyte sedimentation rate and C-reactive protein), and high levels of muscle enzymes (lactate dehydrogenase, creatine kinase, myogolobin, creatine kinase-MB). The factors that could influence clinical severity were erythrocyte sedimentation rate, and the levels of lactate dehydrogenase, creatine kinase-MB, and C-reactive protein.

The Characteristics and Factors Affecting Patients Diagnosed with Lower Limb Arteriosclerosis Obliterans in an Emergency Department

PURPOSE: This study investigated the relationship between the laboratory results of patients diagnosed with lower limb arteriosclerosis obliterans (LASO) in an emergency department (ED), general characteristics, clinical manifestation, hematological conditions, and clinical views of severity. Another purpose of the study was to determine the factors that could contribute to clinical severity to facilitate the prediction and diagnosis of LASO in the ED. METHODS: From January 2005 to December 2012 we conducted a retrospective study on patients diagnosed with LASO in the ED. Included in the study were 52 patients diagnosed with LASO through CT. The patients were divided into two groups according to the Fontaine classification-for comparative analysis: "less severe" (for stage II and below) and "more severe" (for stage III and above). Vital signs, clinical findings, laboratory data, and CT findings were analyzed in each patient. The SPSS package with the Mann-Whitney U test, Fisher's exact test, and logistic regression were used for data analysis. A p-value <0.05 was considered statistically significant. RESULTS: The average age of patients diagnosed with LASO was 73.1+/-10.1 and male saccounted for 76.9% of the population (n=40). Based upon the levels of severity by the Fontaine classification, patients were divided into 28 "more severe" and 24 "less severe" cases. The "more severe" LASO patients showed a high pulse rate (p=0.017) and a higher current smoking rate (p=0.04). The laboratory data from "more severe" LASO patients showed significant differences in total white blood cell count (p=0.040), erythrocyte sedimentation rate (p=0.000), and the levels of lactate dehydrogenase (p=0.002), creatine kinase (p=0.000), creatine kinase-MB (p=0.002), myoglobin (p=0.000), and C-reactive protein (p=0.000). The significant factors that could affect clinical severity were erythrocyte sedimentation rate (OR 1.066, 95% CI 1.010-1.125, p=0.021), and the levels of lactate dehydrogenase (OR 1.015, 95% CI 1.002-1.029, p=0.027), creatine kinase-MB (OR 1.229, 95% CI 1.028-1.468, p=0.023), and C-reactive protein (OR 1.533, 95% CI 1.074-2.188, p=0.019). CONCLUSION: The patients diagnosed with more severe LASO showed a high pulse rate, a higher current smoking rate, high levels of inflammation (erythrocyte sedimentation rate and C-reactive protein), and high levels of muscle enzymes (lactate dehydrogenase, creatine kinase, myogolobin, creatine kinase-MB). The factors that could influence clinical severity were erythrocyte sedimentation rate, and the levels of lactate dehydrogenase, creatine kinase-MB, and C-reactive protein.

Does the Incidence of Rhabdomyolysis Induced by Doxylamine Overdose Increase in the Elderly?

BACKGROUND: Doxylamine is an over-the-counter drug that is popular in the treatment of insomnia. Doxylamine is relatively safe but can cause rhabdomyolysis. The aim of this study was to evaluate whether the incidence of rhabomyolysis increased in elderly patients (age> or =65 years) with doxylamine overdose. METHODS: This study included 108 patients admitted to an Emergency Department after doxylamine overdose between January 1, 2000, and March 31, 2013. Age, sex, time ingested before admission, amount of drug ingested, gastric lavage, tachycardia, vomiting, hematuria, blood urea nitrogen, blood creatinine, urine pH, and alcohol ingestion were investigated for the risk factors of rhabdomyolysis. RESULTS: Forty-three patients (47.6%) developed rhabdomyolysis. Of 16 elderly patients, 11 developed rhabdomyolysis. Of the 92 patients <65 years-of-age, 34 developed rhabdomyolysis. Advanced age, alcohol ingestion, and increased blood creatinine level were significantly associated with the development of rhabdomyolysis. CONCLUSION: In elderly patients with doxylamine overdose, the incidence rate of rhabdomyolysis may be increased. A high index of suspicion and evaluation of rhabdomyolysis is warranted in elderly patients with doxylamine overdose.

Multidetector Computed Tomographic Image Characteristics of Clinically Severe Pelvic Inflammatory Disease in an Emergency Department

PURPOSE: Diagnosis of pelvic inflammatory disease (PID) is based on clinical history and examination; however, it may be difficult to distinguish from other disease entities. Multidetector computed tomography (MDCT) is a useful radiologic modality, which can be performed in an emergency department (ED). The aim of the current study was to clarify the MDCT characteristics of clinically severe PID by comparison of patients with clinically more severe and less severe forms of PID. In addition, we evaluated the independent predictors of MDCT findings in the severe PID group. METHODS: We conducted a retrospective study of female patients with symptoms and signs of PID who visited the ED at our institution during a five-year period. Patients who underwent abdominal MDCT and were diagnosed with PID were retrospectively enrolled in the study. For determination of CT characteristics, each patient was evaluated for pelvic edema, amount of ascites, Hounsfield units (HU) of ascites, salpingitis, oophoritis, intrauterine devices, peritoneal fat infiltration, cervicitis, abnormal endometrial enhancement, tubo-ovarian abscess, adjacent bowel wall thickening, localized ileus, and perihepatitis. Patients were divided into two groups: clinically more severe and less severe forms of PID. Patients having the clinically more severe form of PID were defined as follows: (1) initial body temperature over 38.3degrees C, (2) initial systolic blood pressure < 90 mmHg, (3) intractable abdominal pain, or (4) uncontrollable nausea or vomiting despite medication. We compared data between the two groups. RESULTS: A total of 136 patients were enrolled in this study. Thirty eight patients had the clinically more severe form (28%) and 98 patients had the less severe form (72%). In comparison with subjects in the group having the less severe form, the amount of ascites (p<0.001), salpingitis (p<0.05), and tubo-ovarian abscess (p<0.01) differed statistically between the groups. The HU value of ascites in the more severe group, 19.56+/-11.14 HU, was significantly greater, compared with that of the group having the less severe form. Results of multivariate logistic regression analysis revealed an association of the amount of ascites, a high HU value, and atubo-ovarian abscess with increased odds of the more severe form (adjusted OR 3.25, 95% CI 1.01-10.45; adjusted OR 5.84, 95% CI 1.80-18.95; and adjusted OR 8.42, 95% CI 1.73-40.96, respectively). CONCLUSION: Patients with clinically more severe PID show more clinically important findings on MDCT, such as a greater amount of ascites, higher HU value of ascites, and tubo-ovarian abscess. Leukocytosis, increased neutrophil percentage, and elevated CRP were observed in patients with severe PID.

An Association Between the Prolonged Heart Rate-corrected QT Interval and Global Functional Outcome in Patients with Subarachnoid Hemorrhage

PURPOSE: Autonomic dysfunctions after subarachnoid hemorrhage (SAH) may lead to various arrhythmias, electrocardiographic abnormalities, and myocardial dysfunction. Prolongation of the heart rate-corrected QT (QTc) interval is frequently observed in patients with SAH. The aim of this study was to examine the associations between the QTc interval and global functional outcome in patients with SAH. METHODS: We studied 413 adult patients admitted via the emergency department within 48 hours after the onset of spontaneous SAH from January 2007 to December 2011. Among 413 patients with SAH, there were 154 male and 258 female patients whose mean age was 58.8+/-12.4 years. QT intervals were measured by standard 12-lead electrocardiography (ECG) and corrected by Bazett formulae. The QTc interval were considered prolonged at >450 ms in men and >470 ms in women. Outcomes were assessed using the length of hospital stay and the Modified Rankin scale (MRS) at discharge. RESULTS: One or more repolarization abnormalities occurred in 61.9% of patients. The most frequently observed ECG abnormality was QTc prolongation (54.9%), followed by non-specific ST-T changes(16.2%), ST-depression(9.2%), T-wave inversion(11.4%), U-wave(2.7%), and ST-segment elevation(1.7%). No correlations were found between age, sex, body mass index (BMI), location of aneurysm, and QTc interval. Multiple logistic regression analysis showed a relationship between prolonged QTc and Hunt Hess grades (p=0.012) in men, length of hospital stay (p=0.038) in women, Fisher grade (p=0.001), and MRS (p=0.006, p=0.011) in both. CONCLUSION: The prolonged QTc interval is more frequently observed in patients with severe hemorrhage and an unfavorable functional outcome (MRS 4-6) in SAH patients.

A Study for Evaluation of the Validity of Mortality in Emergency Department Sepsis Score in Geriatric Patients with Sepsis at the Emergency Department

PURPOSE: The purpose of this study is to validate the Mortality in Emergency Department Sepsis (MEDS) score in older patients with sepsis who visited the emergency department (ED). METHODS: This was an observational study. Patients 65 years of age or older with sepsis who were admitted from January, 2010, to May, 2011, in an urban ED with approximately 30,000 annual visits were eligible. Demographic, anthropometric, hemodynamic, and laboratory data were collected. MEDS and Geriatric Nutritional Risk Index (GNRI) scores were calculated as originally described. The area under the receiver operating characteristics curve (AUC) was used for discrimination of each score. Univariate and multivariate analyses were performed. The primary end-point was 28-day in-hospital mortality. RESULTS: Of 397 patients, 11.8%(95% confidence interval, 8.7%~15.0%) died. Mortality stratified according to MEDS was as follows: 0 to 4 points, 0.0%; 5 to 7 points, 4.8%; 8 to 12 points, 11.4%; 13 to 15 points, 22.2%; and > or = 16 points, 35.7%. Mortality stratified according to GNRI was as follows: > 98 points, 3.9%; 92 to 98 points, 9.8%; 87 to < 92 points, 6.9%; 82 to < 87 points, 20.0%; and < 82 points, 34.6%. AUCs were 0.707 and 0.734 for MEDS and GNRI, respectively. In multiple logistic regression analysis, GNRI was found to be an independent predictor of 28-day in-hospital mortality, however, MEDS was not. CONCLUSION: The MEDS score performed with moderate accuracy for prediction of 28-day in-hospital mortality in older ED patients with sepsis. These results suggest the need of geriatric-specific risk assessment tools in the ED.

The Relationship between Rhabdomyolysis and Alcohol Ingestion in Doxylamine Intoxicated Patients

PURPOSE: Doxylamine is commonly used for relief of insomnia; in addition, it is also a drug that is freguently used for intoxication in Korea. This drug is relatively safe; however, it is known to occasionally induce rhabdomyolysis. We have seen many cases of alcohol ingestion in doxylamine intoxications; however, few previous studies have documented the effects of alcohol on rhabdomyolysis. Therefore, the purpose of this study is to determine the effect of alcohol on rhabdomyolysis in doxylamine intoxicated patients. METHODS: This study was conducted on 91 patients admitted to an emergency department after doxylamine intoxication during the period from January 2001 to March 2012. Using the protocol developed beforehand, the amount of drug ingestion, past history, laboratory results, and whether or not alcohol was ingested were recorded. Rhabdomyolysis was defined as serum creatine kinase (CK) over 1,000 U/L. The SPSS package with logistic regression, t-test, and Fisher's test was used for analysis of data. RESULTS: Alcohol ingestion was detected in 52% of the study patients. The presence of hematuria and alcohol ingestion showed a significant association with development of rhabdomyolysis. CONCLUSION: Doxylamine intoxicated patients with alcohol ingestion may have a high rate of incidence of rhabdomyolysis. Therefore, doxylamine intoxicated patients who drink alcohol at the same time should be aware of rhabdomyolysis.