Laboratory analysis of acute acetaminophen overdose patients in Emergency Medical Centers: including analysis of one toxicological laboratory data

Purpose@#Acetaminophen (APAP) is a widely available drug responsible for a large part of drug-induced hepatotoxicity in developed countries. Although acetaminophen overdose cases in Korea are being continuously reported, there are no reports related to the level of this drug in the patient’s blood or of laboratory analysis at emergency departments (ED). This study sought to analyze the acetaminophen overdose cases at a toxicological laboratory and to survey APAP analysis services offered at select EDs. @*Methods@#We analyzed the demographic and analytic data at a toxicological laboratory run by the National Emergency Medical Center (NMC) in 2019-2020. We surveyed the APAP laboratory service in the 38 regional emergency medical centers (EMCs) and 68 local EMCs near the toxicological laboratory. @*Results@#We studied 175 acute poisoning cases (112 women) with positive blood APAP results (mean age 47.0±24.1 years).Suicide attempts comprised 40.0% of the cases and 30.3% APAP overdose events. In the univariate analysis, we observed that patients were significantly younger, with fewer underlying medical diseases. There were a higher number of APAP overdose events, more favorable initial mental status, more toxic quantity intake in the above treatment line group (p<0.05), In multivariate analysis, the toxic amount intake was significantly more frequent in the above treatment line group (p<0.01). Hospital APAP analysis services were available in six EMCs (3/38 regional and 3/68 local). The hospital blood APAP level reporting intervals were shorter than outside-hospital laboratory services (p<0.01, regional 7.0±3.0 vs. 40.6±27.5, local 5.3±3.1 vs. 57.9±45.1 hours).The NMC toxicological laboratory reporting interval was shorter than the other outside-hospital laboratories (p<0.01, regional 5.7± 0.6 vs. 50.2±22.7 local 7.5±3.0 vs. 70.5±41.5 hours). @*Conclusion@#Over the treatment line group, toxic amount intake was significantly more frequent. Only six of 106 EMCs have their own APAP analysis service in their hospitals.

Analysis of Poisoning Patients Using 2017-18 ED Based Injury in-depth Surveillance Data

Purpose@#The annual statistics for poisoning are reported based on the data from poison control centers in many advanced countries. In 2016 a study was conducted to analyze the 2016 Korea Poisoning status. This study was conducted to make a better annual report for poisoning statistics in Korea from a 2017-2018 national representative database. @*Methods@#This study was a retrospective analysis of poisoning patients based on the data from an emergency department (ED) based injury in-depth surveillance project by the Korea Centers for Disease Control and Prevention in 2017-2018. Bite or sting injuries were not included. @*Results@#A total of 17714 patients presented to 23 EDs because of poisoning. Adults above 20 years old age accounted for 84.6% of the population, while the proportion of intentional poisoning was 60.8%. The poisoning substance presented in the ED were therapeutic drugs (51.2%), gas (20.3%), pesticides (16.4%), and artificial substances (11.4%). Overall, 35% of patients were admitted for further treatment. The mortality was 2.4% (422 cases), and the most common fatal substances in order were carbon monoxide, other herbicides, and paraquat. @*Conclusion@#This study showed the 2017-2018 status of poisoning in Korea. The prognosis is different from the cause of poisoning and the initial mental state of the patient. Therefore, appropriate methods for preventing poisoning and therapeutic plans in specific situations are needed.

Analysis of Poisoning Patients Using 2017-18 ED Based Injury in-depth Surveillance Data

Purpose@#The annual statistics for poisoning are reported based on the data from poison control centers in many advanced countries. In 2016 a study was conducted to analyze the 2016 Korea Poisoning status. This study was conducted to make a better annual report for poisoning statistics in Korea from a 2017-2018 national representative database. @*Methods@#This study was a retrospective analysis of poisoning patients based on the data from an emergency department (ED) based injury in-depth surveillance project by the Korea Centers for Disease Control and Prevention in 2017-2018. Bite or sting injuries were not included. @*Results@#A total of 17714 patients presented to 23 EDs because of poisoning. Adults above 20 years old age accounted for 84.6% of the population, while the proportion of intentional poisoning was 60.8%. The poisoning substance presented in the ED were therapeutic drugs (51.2%), gas (20.3%), pesticides (16.4%), and artificial substances (11.4%). Overall, 35% of patients were admitted for further treatment. The mortality was 2.4% (422 cases), and the most common fatal substances in order were carbon monoxide, other herbicides, and paraquat. @*Conclusion@#This study showed the 2017-2018 status of poisoning in Korea. The prognosis is different from the cause of poisoning and the initial mental state of the patient. Therefore, appropriate methods for preventing poisoning and therapeutic plans in specific situations are needed.

Zolpidem Detection and Blood Level in Acute Poisoning-suspected Patients in Emergency Departments: Review of 229 Cases

PURPOSE@#Non-benzodiazepine hypnotic drugs (including zolpidem) are associated with an increased risk of suicide and suicidal ideation. Considering the wide usage of zolpidem, this drug should be considered a possible etiology for stupor or coma in any patient exposed to this drug. However, there are no reports on zolpidem blood levels in emergency department patients in Korea. We therefore reviewed the analyzed data of a toxicology laboratory at one university affiliated hospital.@*METHODS@#The sex, age, chief symptoms, suspiciousness of poisoning, and presumption of poison were analyzed from January 2018 to June 2019. The detection frequency and level of zolpidem in the patient blood were compared to the mental changes presented, which is the main consequence of zolpidem.@*RESULTS@#A total of 229 toxicological analyses, requested to a toxicological laboratory at one university affiliated hospital, were reviewed. Among 229 patients, the mean age was 54.3±20.7 years old with 113 women and 116 men. 8.7% of patients have psychiatric illness and 39.7% were poisoned intentionally. The chief symptoms detected were: mental change 55.0%, gastrointestinal 14.4%, cardiovascular 10.5%, focal neurological 7.4%, respiratory 3.5%, none 8.7%, and unknown 0.4%. A request for detailed reports revealed that causative poisons were specified only in 20.1% cases. Zolpidem was detected in 22.3% cases (51/229), with median blood level 1.26 mg/L (interquartile 0.1, 5.06 mg/L) and urine 0.90 mg/L (interquartile 0.11, 5.6 mg/L). Furthermore, zolpidem was more frequently detected in toxicology analysis of patients where mental change was the primary symptom, as compared to other symptoms (32.5% vs. 9.7%, p<0.01).@*CONCLUSION@#This study reported the blood level of zolpidem in suspected poisoning patients admitted to the emergency department.

Antidotes Stocking and Delivery for Acute Poisoning Patients at 20 Emergency Departments in Korea 2015–2017

PURPOSE: The National Emergency Medical Center has been running a project for the storage and delivery of antidotes for acute poisoning patients of the Department of Health and Welfare, Korea. This study analyzed the results of this project over the past two years. METHODS: The requests received by the National Emergency Medical Center and the data on the delivery process were analyzed. RESULTS: This study analyzed a total of 121 patients with acute poisoning, who were requested to receive an antidote reserved at 20 key hospitals in 2015–2017, and whose age was 52.3±23.5 years; old; 54 were women. Intentional poisoning were 58.7%, and the home was the most common place of exposure (66.9%). The toxic substances were chemicals (32.2%), pesticides (27.3%), medicines (24.8%), and snake venom (4.1%). The patient's poison severity score was 2.4±0.7 (median 3) indicating moderate-to-severe toxicity. Antidote administration was the cases treated in key hospitals 67.8% (82/121), in which transferred patients accounted for 57.3% (47/82). After receiving an antidote request from a hospital other than the key hospitals, the median was 75.5 minutes (range 10 to 242 minutes) until the antidote reached the patient, and an average of 81.5 minutes was required. The results of emergency care were intensive care unit (70.3%), general wards (13.2%), death (10.7%), and discharge from emergency department (5.0%). CONCLUSION: This study showed that the characteristics of acute poisoning patients treated with an antidote were different from previous reports of poisoned patients in the emergency department, and basic data on the time required for delivery from key hospitals was different.

Rapid Collection of Opinions from Healthcare Professionals in Multiple Institutions Using Short Message Service and Google Forms / 대한의료정보학회지

No abstract available.

Analysis of Poisoning Patients Using 2016 ED Based Injury in-depth Surveillance Data

PURPOSE: Some advanced countries have reported annual statistics for poisoning based on data from poison control centers. This study was conducted to propose a baseline format and statistics of poisoning in Korea from a national representative database. METHODS: This study was a retrospective analysis of poisoning patients based on data from an emergency department (ED) based injury in-depth surveillance project by the Korea Centers for Disease Control and Prevention in 2016. Bite or sting injuries were not included. Variables related to poisoning were summarized using a similar format as the National Poison Data System in the United States. RESULTS: A total of 7,820 poisoning patients presented to 23 EDs. Adults ≥20 years accounted for 84% of the population, while the proportion of intentional poisoning was 59.4%. The most common poisoning substances were therapeutic drugs (45%), gas (21%), pesticides (15%), and artificial toxic substances (13%). Overall, 34.5% of patients were admitted for further treatment. The mortality was 3.2% (248 cases), and the most common causative substances were carbon monoxide, glyphosate, and paraquat, in order. CONCLUSION: This study showed the recent status of poisoning in Korea. However, a comprehensive poisoning registry based on poison control centers may be required to provide more accurate national statistics in the future.

Efficient utilization of the limited number of emergency medicine specialists and statistics related to clinical outcomes in the emergency department

OBJECTIVE: The supply of emergency medicine (EM) specialists has not been able to meet demand in the past decade. This study comparatively analyzed clinical findings to provide fundamental data to inform efficient utilization of a limited number of EM specialists. METHODS: This retrospective study included 54,204 patients who visited the emergency department of a tertiary care medical center from March 1 to December 31, 2012. The experimental specialist-supervised (SS) group included patients supervised by an EM specialist, while the control specialist-on-call (SOC) group included patients attended by a senior resident of EM with an EM specialist on call. RESULTS: The mean length of stay in the emergency department was longer in the SS group than in the SOC group for all levels of severe-to-moderate (levels 1 to 3) and mild (levels 4 and 5) patient conditions (P<0.05). The mortality rate of severe-to-moderate patients in the SOC group was 1.63 times higher than that in patient in the SS group. CONCLUSION: Supervision by EM specialists significantly decreased mortality in patients with severe-to-moderate condition. Therefore, EM specialists should focus on this patient group, while training residents should concentrate on patients with relatively mild conditions.

Comparison of Clinical Feature and Prognosis between Unilateral and Bilateral Acute Pyelonephritis

PURPOSE: Acute pyelonephritis (APN) usually presents as a mild disease. However, it has been shown to cause substantial morbidity and mortality on occasion. Therefore, it is important to distinguish between the complicated and uncomplicated APN. The purpose of this study was to determine the clinical significance of bilateral APN compared with unilateral APN in the emergency department (ED). METHODS: We analyzed the data of 303 consecutive patients with APN who underwent a abdominal computed tomography (CT) examination in the ED from January 2012 to December 2014. We compared the clinical presentation, progress, and outcomes between the unilateral and bilateral APNs that were identified on the CT scan. RESULTS: Of these 303 patients, 110 patients (36.3%) were confirmed as bilateral APN by the CT. The proportion of male was higher in the bilateral APN group (20.0% vs. 10.9%, p=0.029). Moreover, patients in the bilateral group visited the ED post symptom onset (6.5±7.8 vs. 3.6±3.1, p<0.001). However, symptom, sign, laboratory test, and CT findings were not statistically different between the two groups. In addition, severity, resistant pathogen, and outcomes such as occurrence of septic shock, hospital days, and mortality were also not different. CONCLUSION: This study suggests that bilateral APN, as determined by a CT, does not have clinical significance compared with unilateral APN.

Can Glasgow-Blatchford Score and Pre-endoscopic Rockall Score Predict the Occurrence of Hypotension in Initially Normotensive Patients with Non-variceal Upper Gastrointestinal Bleeding? / 대한소화기학회지

BACKGROUND/AIMS: The aim of this study was to identify the ability of Glasgow-Blatchford score (GBS) and pre-endoscopic Rockall score (pre-E RS) to predict the occurrence of hypotension in patients with non-variceal upper gastrointestinal bleeding who are initially normotensive at emergency department. METHODS: Retrospective observational study was conducted at Asan Medical Center emergency department (ED) in patients who presented with non-variceal upper gastrointestinal bleeding from January 1, 2011 to December 31, 2013. Study population was divided according to the development of hypotension, and demographics, comorbidities, and laboratory findings were compared. GBS and pre-E RS were estimated to predict the occurrence of hypotension. RESULTS: A total of 747 patients with non-variceal upper gastrointestinal bleeding were included during the study period, and 120 (16.1%) patients developed hypotesion within 24 hours after ED admission. The median values GBS and pre-E RS were statistically different according to the occurrence of hypotension (8.0 vs. 10.0, 2.0 vs. 3.0, respectively; p<0.001). In the receiver operating characteristic curve analysis of hypotension development, the area under the curve of GBS and pre-E RS were 66% and 64%, respectively. The sensitivity and the specificity of GBS using optimal cut-off value were 81% and 46%, respectively, while those based on the pre-E RS were 74% and 46%, respectively. CONCLUSIONS: GBS and pre-E RS were both not sufficient for predicting the occurrence of hypotension in non-variceal upper gastrointestinal bleeding. Development of other scoring systems are needed.

Methemoglobinemia Caused by an Inert Ingredient after Intentional Ingestion of Pesticide / 대한구급학회지

We report two cases of toxic methemoglobinemia caused by an inert ingredient in pesticide product after intentional ingestion of pesticide. First, 51-year-old male visited to the emergency department (ED) after the ingestion of pesticide in a suicide attempt. Initial methemoglobin (MetHb) level was 25.6%. We did not know the cause of methemoglobinemia at that time. Second, 56-year-old female visited to the ED after the ingestion of the same pesticide in a suicide attempt. MetHb level after 30 minutes was 16.1%. The patients were treated with methylene blue. We contacted to the Korean Rural Development Administration and estimated that magnesium nitrate was more likely to cause methemoglobinemia. This report highlights the importance of considering the possibility of methemoglobinemia caused by inert ingredient in pesticide and early antidotal therapy.

Methemoglobinemia Caused by an Inert Ingredient after Intentional Ingestion of Pesticide / 대한중환자의학회지

We report two cases of toxic methemoglobinemia caused by an inert ingredient in pesticide product after intentional ingestion of pesticide. First, 51-year-old male visited to the emergency department (ED) after the ingestion of pesticide in a suicide attempt. Initial methemoglobin (MetHb) level was 25.6%. We did not know the cause of methemoglobinemia at that time. Second, 56-year-old female visited to the ED after the ingestion of the same pesticide in a suicide attempt. MetHb level after 30 minutes was 16.1%. The patients were treated with methylene blue. We contacted to the Korean Rural Development Administration and estimated that magnesium nitrate was more likely to cause methemoglobinemia. This report highlights the importance of considering the possibility of methemoglobinemia caused by inert ingredient in pesticide and early antidotal therapy.

Kind and Estimated Stocking Amount of Antidotes for Initial Treatment for Acute Poisoning at Emergency Medical Centers in Korea

Antidotes for toxicological emergencies can be life-saving. However, there is no nationwide estimation of the antidotes stocking amount in Korea. This study tried to estimate the quantities of stocking antidotes at emergency department (ED). An expert panel of clinical toxicologists made a list of 18 emergency antidotes. The quantity was estimated by comparing the antidote utilization frequency in a multicenter epidemiological study and the nation-wide EDs' data of National Emergency Department Information System (NEDIS). In an epidemiological study of 11 nationwide EDs from January 2009 to December 2010, only 92 (1.9%) patients had been administered emergency antidotes except activated charcoal among 4,870 cases of acute adult poisoning patients. Comparing with NEDIS data, about 1,400,000 patients visited the 124 EDs nationwide due to acute poisoning and about 103,348 adult doses of the 18 emergency antidotes may be required considering poisoning severity score. Of these, 13,224 (1.9%) adult doses of emergency antidotes (575 of atropine, 144 of calcium gluconate or other calcium salts, 2,587 of flumazenil, 3,450 of N-acetylcysteine, 5,893 of pralidoxime, 287 of hydroxocobalamin, 144 of sodium nitrite, and 144 of sodium thiosulfate) would be needed for maintaining the present level of initial treatment with emergency antidotes at EDs in Korea.

Proper Understanding and Application of Gastric Lavage

Gastric lavage is one of gastrointestinal decontamination methods which have been controversial in the clinical toxicology field for a long time. Expert groups of American and European clinical toxicologists have published the position papers regarding gastric lavage three times since 1997. They recommended that gastric lavage should not be used as a routine procedure in the management of acute intoxication, because they thought that there is no certain evidence of improving clinical outcome by its use. However, the studies they reviewed were not well-controlled randomized trials, which cannot be conducted in the clinical toxicology field due to variability of patients and ethical problems. Therefore, the results from these studies should be interpreted with caution. They also insisted that gastric lavage can be undertaken within 60 minutes of ingestion. The limitation of one hour after ingestion is too arbitrary and may cause a lot of misunderstanding. Formation of pharmacobezoar or gastric hypomotility after ingestion may significantly delay the gastric emptying time so that gastric lavage can be useful even after several hours or more in case of highly toxic substances or severe intoxication. Furthermore, as there are a number of serious intoxication by toxic pesticides with large amount in suicidal attempts in Korea, it seems that gastric lavage may be used more frequently in Korea than in Western countries. When deciding whether or not to use gastric lavage, all the indications, contraindications, and possible adverse effects should be taken into account on the basis of risk-benefit analysis. If the procedure is decided to be done, it should only be performed by well-trained experts.

The Experiences of the Emergency Antidote Stock and Delivery Service by the Korean Poison Information Center

PURPOSE: Antidotes for toxicological emergencies can be life-saving. However, there is no nationwide stocking and delivery system for emergency antidotes in Korea. We report on a two-year experience of a nationwide stocking and delivery trial for emergency antidotes at emergency departments in Korea. METHODS: An expert panel of clinical toxicologists reviewed and made a list of 15 stocked antidote. These antidotes were purchased or imported from other countries and delivered from 14 antidote stocking hospitals nationwide 24 hours per day, seven days per week. RESULTS: From August 1, 2011 to April 30, 2013, 177 patients with acute poisoning, with a median age of 48.5 years, were administered emergency antidotes. The causes of poisoning were intentional in 52.0% and 88.0% were intentional as a suicide attempt. Regarding clinical severity, using the poisoning severity score, 40.7% of patients had severe to fatal poisoning and 39.0% had moderate poisoning according to clinical severity. The most frequent presenting symptom was neurologic deficit, such as altered mentality (62.7%). alerted mentality (62.7%). Emergency antidotes were administered as follows: methylene blue (49 cases), flumazenil (31), N-acetylcysteine (25), glucagon (17), 100% ethanol (15), cyanide antidote kit (12), anti-venin immunoglobulin (5), pyridoxine (4), hydroxocobalamine (2), and deferoxamine (1). The median time interval from antidote request to delivery at the patient's bedside was 95 minutes (interquartile range 58.8-125.8). CONCLUSION: Findings of this study demonstrated the possibility of successful operation of the nationwide system of emergency antidotes stocking and delivery in Korea.

Value of Cardiac Biomarkers for Predicting Hypotension in Non-high-risk Patients with Acute Pulmonary Embolism

PURPOSE: Recent and numerous studies have indicated that cardiac biomarker elevation during acute pulmonary embolism (PE) predicts in-hospital death. However, the role of cardiac biomarkers for predicting the occurrence of hypotension is unknown. The aim of the present study was to evaluate whether increased levels of cardiac biomarkers can predict the occurrence of hypotension (sytolic blood pressure (SBP) 0.05 ng/mL) upon admission were an independent predictor for developing hypotension within 24 hours in patients with stable acute PE at the time of ED admission (odds ratio 11.0, 95% confidence interval (CI) 2.8-43.8, p=0.00). CONCLUSION: In stable patients with acute PE, an elevated TnI can predict the in-hospital development of hypotension within 24 hours. This finding is valuable for selecting patients who might benefit from intensive clinical surveillance and escalated treatment.

The Clinical Value of TnI and BNP for the Evaluation of Sepsis-related Cardiac Dysfunction in the Emergency Department

PURPOSE: Acute cardiac dysfunction is a well recognized manifestation of organ failure in severe sepsis and septic shock. Although echocardiography is the golden standard for the evaluation of cardiac dysfunction, it is difficult to use in the emergency department (ED). The purpose of this study was to determine the availability of cardiac biomarkers for the estimation of cardiac dysfunction in septic shock patients. METHODS: All study subjects included consecutive patients with septic shock diagnosed in the ED and treated with an algorithm of early goal-directed therapy between January 2011 and June 2012. We enrolled patients measured for cardiac biomarkers and performed echocardiography within 24 hours. We divided patients into two groups based on the occurrence of left ventricular dysfunction (defined as an ejection fraction< or =40%) and compared serum levels of troponin-I (TnI) and B-type natriuretic peptide (BNP) between the two groups. The area under the receiver operating characteristic (ROC) curve was used to compare the diagnostic ability of TnI and BNP. RESULTS: A total of 127 patients with septic shock and evaluated for cardiac dysfunction were enrolled in this study. TnI and BNP were significantly higher in the left ventricular dysfunction group group (4.2+/-9.0 vs. 0.6+/-1.8 ng/mL, respectively, p<0.05) compared with the non-dysfunction group (1087.6+/-680.1 vs. 633.2+/-859.1 pg/mL, respectively, p<0.05). However, in the ROC curve for predicting left ventricular dysfunction, the area under the curves of TnI and BNP, respectively, were 0.631(95% CI 0.473-0.788, p=0.103) and 0.704 (95% CI 0.552-0.856, p=0.011). TnI and BNP showed a 84.6% negative predictive value. CONCLUSION: Although TnI and BNP were significantly higher in septic shock patients with cardiac dysfunction but demonstrated limited accuracy compared to echocardiography. However, TnI and BNP have high negative predictive value in septic shock patients for the evaluation of cardiac dysfunction. Therefore they could serve as a valuable supplement for the detection of cardiac dysfunction.

Clinical Analysis of Patients with Cardiotoxicity Caused by Himalayan Mad Honey

PURPOSE: The aim of this study was to evaluate the clinical characteristics and outcome of patients who presented to the emergency department (ED) with cardiotoxicity caused by ingestion of Himalayan mad honey. METHODS: Medical records of 12 patients who presented to the ED from January 1, 2005 to December 31, 2012 with cardiotoxicity caused by ingestion of Himalayan mad honey were retrospectively reviewed. RESULTS: The mean age of patients was 54.5 years and 58.3% were men. The median amount of mad honey ingested was 30.0 cc, and the mean time from ingestion to onset of symptoms was 39.4 minutes. All patients had hypotension and bradycardia upon arrival in the ED. The initial electrocardiogram showed sinus bradycardia in seven patients, junctional bradycardia in four patients, and atrial fibrillation with slow ventricular response in one patient. Four patients were treated with intravenous normal saline solution only. Eight patients were treated with intravenous normal saline solution and atropine sulfate in a dose ranging from 0.5 to 2.0 mg. Blood pressure and pulse rate returned to normal limits within 24 hours in all patients. CONCLUSION: Our study showed that all patients with cardiotoxicity caused by ingestion of Himalayan mad honey had severe hypotension, bradycardia, and bradyarrythmias, including sinus bradycardia and junctional bradycardia and all patients responded well to conservative treatment, including intravenous normal saline solution and intravenous atropine sulfate.

A Review on the Clinical Characteristics and Outcomes from Spontaneous Intestinal Intramural Hematoma

PURPOSE: Spontaneous intestinal intramural hematoma (SIMH) is a very rare complication of anticoagulation. Most reports on SIMH have been case reports and case series, not well-established clinical studies. Therefore, the aim of this study was to evaluate the clinical characteristics and outcomes from SIMH. METHODS: A retrospective review of the records of 48 patients with non-traumatic SIMH was performed at an urban academic tertiary hospital between January 2001 and December 2012. These patients were diagnosed with SIMH by computed tomography and confirmed by a radiology specialist. Their clinical characteristics and outcomes from SIMH were determined. RESULTS: Among all SIMH cases, the percentage of warfarin users was 70.8%. The median age at presentation was 66.5 years, whereas warfarin users were older (68.0 years) than non-users (55.0 years) (p<0.01). SIMH patients had abdominal pain (81.3%), nausea and vomiting (50.0%) and 62.5% of them had abdominal tenderness. The most frequently involved site was the small bowel (85.4%) and there was only one patient with bowel obstruction from SIMH. A total of 33(68.6%) patients were admitted for 9.3 days for conservative treatment, including transfusion. On the other hand, two patients had surgical intervention. There were no mortality cases from SIMH during the study period. CONCLUSION: SIMH is rare disease which can treated with supportive care. However, it can cause severe complications, such as bowel obstruction and perforation, requiring surgical intervention. Therefore, emergency physicians have to consider SIMH carefully, especially in patients treated with an anticoagulation agent.

Serum Procalcitonin and C-reactive Protein Level as an Early Diagnostic Marker of Bacterial Meningitis in the Emergency Department

PURPOSE: Immediate identification of bacterial meningitis (BM) is essential in the emergency department. However, diagnosis of BM from analysis of cerebrospinal fluid has low sensitivity. The goal of this study was to determine the ability of serum procalcitonin (PCT) and C-reactive protein (CRP) for differentiation between BM and non-BM in adult patients. METHODS: This retrospective cohort study, which was conducted from Jan 1 2008 to Sep 30 2011, included patients with a diagnosis of meningitis based on compatible clinical features and cerebrospinal fluid (CSF) culture findings with a CSF leukocyte count > 5 /microL. Measurement of Serum PCT and CRP level was performed on initial admission to the emergency department. Patients were divided into two groups, according to the type of meningitis: BM or non-BM. Clinical features, laboratory results, including CSF results, serum PCT, and CRP levels were assessed. RESULTS: A total of 63 patients (age, 49+/-19) with confirmed meningitis were admitted: 43 patients with non-BM and 20 patients with BM. Significantly higher PCT and CRP levels, CSF white blood cell and neutrophil count, CSF glucose, and protein levels were observed in the BM group. The most highly discriminative parameters for differential diagnosis of BM proved to be serum PCT, with a sensitivity of 90%, a specificity of 100%, a positive predictive value of 100%, a negative predictive value of 96% at a diagnostic cut-off level of 1.0 ng/mL (area under the curve 0.98; 95% confidence interval 0.00-1.00) and CRP, with a sensitivity of 85%, a specificity of 88%, a positive predictive value of 77%, a negative predictive value of 93% at a diagnostic cut-off level of 6.0 mg/dL (area under the curve 0.91; 95% confidence interval 0.76-0.97). CONCLUSION: Serum PCT and CRP levels appear to be the most highly discriminative parameters for differential diagnosis of BM and non-BM.