Diagnosis and treatment of sodium hypochlorite poisoning with ingestion of household bleaching agents

Sodium hypochlorite is commonly used as a household bleaching agent (for example, the Clorox brand). Sodium hypochlorite poisoning with ingestion of a bleaching agent is often observed in clinical practice.Current Concepts: Ingestion (intentional or accidental) is the most common route of exposure to household bleaching agents. Accidental ingestion of household bleaching agents is rarely clinically important. However, ingestion of a large amount of a dilute formulation or a high-concentration preparation of bleaching agents can result in severe and rarely fatal corrosive injury. Therefore, prompt supportive care is essential because a specific antidote is currently unavailable. Severe poisoning requires hospital admission. Emergency endoscopy and thoracic and abdominal computed tomography are warranted to aid with diagnosis and management of hypochlorite-induced corrosive injury in patients with severe poisoning, who develop clinical features suggestive of corrosive injury.Discussion and Conclusion: Intentional poisoning, which accounts for most cases of household bleaching agent poisonings in Korea, is likely to cause severe corrosive injuries. Therefore, it is necessary to gain deeper and accurate understanding of the clinical aspects and treatment of poisoning by household bleaching agents.

Associations between Early Hyperoxia and Long Term Neurologic Outcome in Acute Carbon Monoxide Poisoning

Purpose@#We studied the impact of arterial oxygen tension (PaO2) on the long term neurologic outcome in patients with acute carbon monoxide poisoning. @*Methods@#The study population included 311 patients who presented to emergency department with acute CO poisoning from January 2015 to January 2018. These patients underwent arterial blood gas testing at the time of presentation. The baseline demographic, clinical, laboratory, and clinical outcome data were recorded. The primary outcome of interest was the long term neurologic status. @*Results@#The normoxia group was significantly older and it had a higher incidence of diffusion weighted MRI abnormality, and this group needed multiple HBO sessions compared to the group with moderate or severe hyperoxia. Also, the incidence of altered mentality at discharge was higher in the normoxia group than that of the moderate hyperoxia group. The incidence of a poor long term neurologic outcome was 11.3%. The incidence of a poor long term neurologic outcome decreased as the PaO2 increased. The PaO2 was significantly lower in patients with a poor long term neurologic outcome than that of the patients with a good outcome 198 (165.2 to 231.1) mmHg in the good outcome group vs. 154 (119-162) mmHg in poor outcome, p<0.001). In multivariate logistic regression analysis, PaO2 was selected as an independent factor of the poor long-term neurologic outcome (OR 0.981 (95% CI: 0.968 to 0.995)) @*Conclusion@#Higher PaO2 was independently associated with a lower incidence of a poor long-term neurologic outcome.

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.

PaCOâ‚‚ at Early Stage is Associated with Adverse Cardiovascular Events in Acute Carbon Monoxide Poisoning

PURPOSE@#The objective was to determine the association between PaCO₂ and adverse cardiovascular events (ACVEs) in carbon monoxide (CO)-poisoned patients.@*METHODS@#This retrospective study included 194 self-breathing patients after CO poisoning with an indication for hyperbaric oxygen therapy and available arterial blood gas analysis at presentation and 6 hours later. The baseline characteristics and clinical course during hospitalization were collected and compared. The mean PaCO₂ during the first 6 hours after presentation was calculated.@*RESULTS@#The incidence rates of moderate (30 mmHg< PaCO₂<35 mmHg) or severe (PaCO₂≤30 mmHg) hypocapnia at presentation after acute CO poisoning were 40.7% and 26.8%, respectively. The mean PaCO₂ during the first 6 hours was 33 (31–36.7) mmHg.The incidence of ACVEs during hospitalization was 50.5%. A significant linear trend in the incidence of ACVEs was observed across the total ranges of PaCO₂ variables. In multivariate regression analysis, mean PaCO₂ was independently associated with ACVEs (OR 0.798 (95% CI 0.641–0.997)).@*CONCLUSION@#Mean PaCO₂ during the first 6 hours was associated with increased ACVEs. Given the high incidence of ACVEs and PaCO₂ derangement and the observed association between PaCO₂ and ACVEs, this study suggests that 1) PaCO₂ should be monitored at the acute stage to predict and/or prevent ACVEs; and 2) further study is needed to validate this result and investigate early manipulation of PaCO₂ as treatment.

Different Clinical Courses for Poisoning with WHO Hazard Class Ia Organophosphates EPN, Phosphamidon, and Terbufos in Humans

PURPOSE: Extremely hazardous pesticides are classified as World Health Organization (WHO) hazard class Ia. However, data describing the clinical course of WHO class Ia OP (organophosphate) poisonings in humans are very scarce. Here, we compare the clinical features of patients who ingested hazard class Ia OPs. METHODS: This retrospective observational case study included 75 patients with a history of ingesting ethyl p-nitrophenol thio-benzene phosphonate (EPN), phosphamidon, or terbufos. The patients were divided according to the chemical formulation of the ingested OP. Data regarding mortality and the development of complications were collected and compared among groups. RESULTS: There were no differences in the baseline characteristics and severity scores at presentation between the three groups. No fatalities were observed in the terbufos group. The fatality rates in the EPN and phosphamidon groups were 11.8% and 28.6%, respectively. Patients poisoned with EPN developed respiratory failure later than those poisoned with phosphamidon and also tended to require longer mechanical ventilatory support than phosphamidon patients. The main cause of death was pneumonia in the EPN group and hypotensive shock in the phosphamidon group. Death occurred later in the EPN group than in the phosphamidon group. CONCLUSION: Even though all three drugs are classified as WHO class Ia OPs (extremely hazardous pesticides), their clinical courses and the related causes of death in humans varied. Their treatment protocols and predicted outcomes should therefore also be different based on the chemical formulation of the OP.

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.

Contributing Factors for the Registration Rates within Emergency Department Based Post-suicidal Care Program

PURPOSE: This study was conducted to investigate the independent factors associated with the registration rate for the community-based post suicidal care program in the emergency department (ED). METHODS: This prospective observational study was conducted between January and September 2015 at the academic ED in the tertiary urban hospital. The variables examined included gender, age, address, type of insurance, history of previous psychiatric disease, suicide methods, number of previous attempts, CES-D (The Center for Epidemiologic Studies-Depression Scale), and disposition at ED. Univariate and multivariate logistic regression analysis were conducted to identify factors affecting the registration rate for the community-based post suicidal care program. RESULTS: Overall, 331 suicides were investigated, 61 (18.4%) of which were registered in the post-suicide care program. Factors such as a intervention by psychiatric physician (OR: 3.287, 95%; CI: 1.207-9.624) and levels of depression by CES-D score of 16?24 (OR: 3.635; CI: 1.055-12.526) were significantly correlated with registration for the program. CONCLUSION: The registration rate for the community-based post suicidal care program was influenced by frequent intervention by a psychiatric physician and levels of depression by CES-D score of 16-24.

Contributing Factors for the Registration Rates within Emergency Department Based Post-suicidal Care Program

PURPOSE: This study was conducted to investigate the independent factors associated with the registration rate for the community-based post suicidal care program in the emergency department (ED). METHODS: This prospective observational study was conducted between January and September 2015 at the academic ED in the tertiary urban hospital. The variables examined included gender, age, address, type of insurance, history of previous psychiatric disease, suicide methods, number of previous attempts, CES-D (The Center for Epidemiologic Studies-Depression Scale), and disposition at ED. Univariate and multivariate logistic regression analysis were conducted to identify factors affecting the registration rate for the community-based post suicidal care program. RESULTS: Overall, 331 suicides were investigated, 61 (18.4%) of which were registered in the post-suicide care program. Factors such as a intervention by psychiatric physician (OR: 3.287, 95%; CI: 1.207-9.624) and levels of depression by CES-D score of 16?24 (OR: 3.635; CI: 1.055-12.526) were significantly correlated with registration for the program. CONCLUSION: The registration rate for the community-based post suicidal care program was influenced by frequent intervention by a psychiatric physician and levels of depression by CES-D score of 16-24.

Initial Blood Glucose Can Predict the Outcome of OP Poisoning

PURPOSE: Many studies have examined the mechanisms of impaired glucose homeostasis after organophosphate (OP) exposure, however no study has evaluated the clinical utility of blood glucose measurements in patients with OP poisoning. The current study was conducted to evaluate the initial glucose level at presentation and the glycemic variables during the first 3 days after admission as a predictor of mortality. METHODS: This retrospective observational case series included 228 patients with a history of OP poisoning. Among other clinical data, information on the initial glucose level at presentation and mean glucose level, delta glucose level, and the presence of a hypoglycemic event during the first 3 days of admission, was collected. RESULTS: Survivors had lower initial glucose levels at presentation and glucose variability during the first 3 days of admission compared to non-survivors. The frequency of hypoglycemic events was higher in non-survivors. In multivariate analysis, the initial glucose level (> 233 mg/dl) was an independent predictor of mortality, along with age. CONCLUSION: The initial glucose level at presentation can be helpful in prediction of mortality in cases of OP intoxication at bedside. The physician should pay attention to patients with a glucose level >233 mg/dl at presentation after ingestion of OP.

The Clinical Features and Prognostic Factors in Adults with Acute Etrodotoxin Poisoning Caused by Ingesting Puffer Fish

PURPOSE: We conducted this study in order to determine clinical features and prognostic factors in adults with acute tetrodotoxin (TTX) poisoning caused by ingestion of puffer fish. METHODS: In this retrospective study, 107 patients were diagnosed with TTX poisoning. The subjects were divided into two groups according to duration of treatment; Group I, patients were discharged within 48 hours (n=76, 71.0%), Group II patients were discharged after more than 48 hours (n=31, 29.0%). Group II was subsequently divided into two subgroups [IIa (n=12, 11.2%), IIb (n=19, 17.8%)] according to the need for mechanical ventilation support. RESULTS: In multivariable logistic regression analysis, the predictors of the need for treatment over 48 hours were dizziness (odds ratio [OR], 4.72; 95% confidence intervals [CI], 1.59-12.83), time interval between onset of symptom and ingestion (OR, 0.56; 95% CI, 0.16-0.97), PaCO2<35 mmHg (OR, 8.37; 95% CI, 2.37-23.59). In addition, predictors of the need for mechanical ventilation were a time interval between onset of symptoms and ingestion (OR, 0.54; 95% CI, 0.11-0.96) and PaCO2<35 mmHg (OR, 5.65; 95% CI, 1.96-18.66). CONCLUSION: Overall, dizziness, time interval between onset of symptoms and ingestion, DeltaDBP and PaCO2<35 mmHg predict the need for treatment over 48 hours, time interval between onset of symptoms and ingestion and PaCO2<35 mmHg predict the need for mechanical ventilation support after acute TTX poisoning.

Task and Time Analysis of Intern Physicians in the Emergency Department: Multicenter Cross-sectional Study

PURPOSE: This study was conducted in order to describe how intern physicians in the emergency department (ED) spent their time, and the frequency of tasks performed by them. METHODS: This was an observational, time-motion study for 15 intern physicians in 15 emergency centers. Observers in each hospital shadowed interns for a 60-minute period, two times, both day and night shift. They recorded time spent on various activities, type and number of activities. The proportion of activity that can be replaced by other staff members was calculated. RESULTS: Average number of duty hours of interns was 80.9 hours (63~87.8) per week. A total of 662 activities were observed during 30 hours. Interns' activities were classified as direct patient care 28.2%, personal time 24.2%, documentation 17.0%, procedures 16.7%, communication 8.1%, transportation 2.6%, indirect patient care 2.0%, learning activity 0.8%, and administrative work 0.4%. The proportion of procedural task showed negative correlation with the number of emergency medical technicians (r=-0.710, p=0.003). The proportion of activity that can be replaced by staff members other than doctors was 24.3% (0~47%) of time, except personal or learning activity. CONCLUSION: Results of this study showed that only 24.3% of interns' activity in the emergency department could be replaced by staff members other than doctors. Because the proportion of activities that could be replaced was variable among hospitals, each hospital should perform task analysis of interns' activity in order to forecast alternative manpower.

Early Initiation of Therapeutic Hypothermia after Sudden Out-of-Hospital Cardiac Arrest

PURPOSE: Therapeutic hypothermia (TH) improves the probability of survival and neurologic recovery after resuscitation from out-of-hospital cardiac arrest (OHCA). However, the best time to initiate TH after the return of spontaneous circulation (ROSC) remains unknown. METHODS: The aim of this study was to evaluate the correlation between TH initiation time after ROSC and the resulting neurological outcome. Methods: A retrospective analysis was performed on 122 OHCA patients enrolled between January 2008 and December 2011. Therapeutic hypothermia (32~34degrees C) was induced immediately after ROSC. The primary measure of outcome was neurological function at hospital discharge, as determined by a cerebral performance category (CPC) scale. RESULTS: Out of the 122 patients, 34 patients (27.9%) had a good neurological outcome at hospital discharge. The initiation time following ROSC was shorter, although not statistically significant, in patients with good neurological outcomes compared to those with poor outcomes. Based on subgroup analysis, only the shockable rhythm group showed a significant difference, in the time after ROSC to TH initiation, between good and poor neurological outcome groups. Receiver operator characteristic analysis suggested that an initiation time of 250 min after ROSC was most predictive of CPC 1-2 outcomes compared to other time points. Furthermore, the 250 min initiation time after ROSC correlated with neurological outcome in patients with OHCA undergoing TH treatment. CONCLUSION: Compared to late initiation, early initiation (within 250 min) with TH had neurologic benefits for patients with OHCA.

Antidote for acetaminophen poisoning: N-acetylcysteine

N-acetylcysteine (NAC) is widely recognized as the antidote of choice for acetaminophen overdose. Acetaminophen is a commonly used analgesic and antipyretic agent, and its use is one of the most common causes of poisoning worldwide. Acetaminophen toxicity may occur acutely when supratherapeutic amounts are ingested purposefully or unintentionally. Liver failure may occur in severe toxicity. However, if treated early, patients with acetaminophen poisoning generally recover uneventfully. Acetaminophen is metabolized to N-acetyl-p-benzoquinone imine (NAPQI), which is detoxified by conjugation with glutathione. In overdose, hepatic stores of glutathione are depleted and NAPQI binding to hepatocytes induces cell death and hepatic necrosis. NAC replenishes hepatic glutathione and may also act as a glutathione substitute, combining directly with the toxic metabolite. Intravenous NAC is indicated in patients who present with a history of acetaminophen overdose within the previous 8 to 10 hours, patients unable to tolerate oral NAC, and patients who present with evidence of fulminant hepatic failure. However, caution should be used in patients who have experienced previous hypersensitivity or anaphylactoid reactions to intravenous NAC, as well as in patients with asthma. The most common anaphylactoid reactions include rash, flushing, and bronchospasm. Adults should receive 150 mg/kg administered for 45 minutes, followed by 50 mg/kg administered for 4 hours, followed by 100 mg/kg administered for 16 hours. The total dose is 300 mg/kg delivered over 21 hours. Additionally, caution should always be used when intravenous NAC is prescribed and the amount of diluent is calculated. Monitoring of patients with a should include repeated neurologic and hemodynamic assessment.

Initial Laboratory Parameters and its Correlation to Intermediate Syndrome in Patients with Acute Organophosphate Poisoning

PURPOSE: The association of serial serum cholinesterase (SChE) activity and the occurrence of intermediate syndrome (IMS) in patients orally poisoned with organophosphate (OP) were investigated. In addition, other clinical and laboratory factors were assessed for their ability to predict the subsequent development of IMS. METHODS: A total of 114 patients presented to our emergency department with acute OP ingestion between 2007 and 2012 were enrolled in this prospective study. Of these patients, 67 who needed mechanical ventilation (MV) over five days were divided into the IMS group. The 47 patients weaned from MV within four days after admission, or who did not receive the assistance of MV, were placed in the non-IMS group. The level of SChE at admission, 48 hours, and 96 hours, at discharge after admission were checked. The APACHE II (Acute Physiology, Age, Chronic Health Evaluation II) score, the amount ingested, exposure route, gender, age, and the laboratory test results were collected. All statistical analyses were performed using the Statistical Package for the Social Sciences (version 20.0). RESULTS: The mean age of total enrolled patients was 53.7+/-17.9 years and 73 patients (64.0% of total patients) were male. There were 102(89.5%) patients who intentionally ingested the OP and the mean amount ingested was 102.5+/-64.9 mL. The mean time after patients sought medical care was 5.4+/-10.5 hours after ingestion. The level of SChE at admission was 1,586+/-796 U/L and the APACHE II score was 28.81+/-19.7. The arterial pH, bicarbonate and carbon dioxide pressure, and serum protein and albumin were significantly lower in the IMS group than the non-IMS group (p<0.001). In contrast, the serum amylase, lipase, and glucose were higher in the IMS group. The APACHE II score, serum albumin and amylase, arterial bicarbonate, and the SChE at 48 and 96 hours after ingestion were independent factors that predicted the occurrence of IMS in patients with OP poisoning. The rate of recovery was 86.6% in the IMS group and 100% in the non-IMS group (p<0.001). CONCLUSION: Patients with a higher APACHE II score and levels of serum amylase, and lower levels of serum albumin and arterial bicarbonate, may be associated with the occurrence of IMS. Furthermore, when SChE levels after 48 hours and 96 hours did not increase, compared with the level of SChE at admission, patients tended to show IMS.

Initial Laboratory Parameters and its Correlation to Intermediate Syndrome in Patients with Acute Organophosphate Poisoning

PURPOSE: The association of serial serum cholinesterase (SChE) activity and the occurrence of intermediate syndrome (IMS) in patients orally poisoned with organophosphate (OP) were investigated. In addition, other clinical and laboratory factors were assessed for their ability to predict the subsequent development of IMS. METHODS: A total of 114 patients presented to our emergency department with acute OP ingestion between 2007 and 2012 were enrolled in this prospective study. Of these patients, 67 who needed mechanical ventilation (MV) over five days were divided into the IMS group. The 47 patients weaned from MV within four days after admission, or who did not receive the assistance of MV, were placed in the non-IMS group. The level of SChE at admission, 48 hours, and 96 hours, at discharge after admission were checked. The APACHE II (Acute Physiology, Age, Chronic Health Evaluation II) score, the amount ingested, exposure route, gender, age, and the laboratory test results were collected. All statistical analyses were performed using the Statistical Package for the Social Sciences (version 20.0). RESULTS: The mean age of total enrolled patients was 53.7+/-17.9 years and 73 patients (64.0% of total patients) were male. There were 102(89.5%) patients who intentionally ingested the OP and the mean amount ingested was 102.5+/-64.9 mL. The mean time after patients sought medical care was 5.4+/-10.5 hours after ingestion. The level of SChE at admission was 1,586+/-796 U/L and the APACHE II score was 28.81+/-19.7. The arterial pH, bicarbonate and carbon dioxide pressure, and serum protein and albumin were significantly lower in the IMS group than the non-IMS group (p<0.001). In contrast, the serum amylase, lipase, and glucose were higher in the IMS group. The APACHE II score, serum albumin and amylase, arterial bicarbonate, and the SChE at 48 and 96 hours after ingestion were independent factors that predicted the occurrence of IMS in patients with OP poisoning. The rate of recovery was 86.6% in the IMS group and 100% in the non-IMS group (p<0.001). CONCLUSION: Patients with a higher APACHE II score and levels of serum amylase, and lower levels of serum albumin and arterial bicarbonate, may be associated with the occurrence of IMS. Furthermore, when SChE levels after 48 hours and 96 hours did not increase, compared with the level of SChE at admission, patients tended to show IMS.

Neuron Specific Enolase as a Biomarker Predicting Neurological Outcome after Cardiac Arrest in Patients Treated by Therapeutic Hypothermia

PURPOSE: Neurological outcome prediction is an important aspect of post-resuscitation care in cardiac arrest survivors. The appearance of high serum neuron specific enolase (NSE) is known to be associated with ischemic brain injury and poor neurological outcome. The application of therapeutic hypothermia to cardiac arrest survivors has been shown to improve neurological outcomes. As such, we investigated the predictive value of serial serum NSE levels in patients who were resuscitated from cardiac arrest. METHODS: This study included 123 cardiac arrest survivors who were treated by therapeutic hypothermia from January 2008 to June 2011. Blood samples used for evaluating NSE were collected at return of spontaneous circulation (ROSC) at 6, 24 and 48 hours after initiation of therapeutic hypothermia. Neurological outcome was graded as 'good' or 'poor' at discharge and assessed according to the Cerebral Performance Category scale (CPC). A poor outcome was defined as a CPC value of 3-5. RESULTS: Receiver operating characteristic (ROC) analysis revealed NSE cut-off values of 53.9 microg/L (sensitivity 14.6%), 48.5 microg/L (sensitivity 30.6%), 80.0 microg/L (sensitivity 40.0%), and 52.7 microg/L (sensitivity 55.5%) for poor outcomes with a specificity of 100%, measured at ROSC of 6, 24 and 48 hours after initiation of therapeutic hypothermia, respectively. The poor outcome group showed significant change in NSE concentration over time (p=0.002), while the good outcome group did not. CONCLUSION: Detection of NSE at the cut-off value, 48 hr after initiation of therapeutic hypothermia was a specific but moderately sensitive marker of poor outcome at discharge. Single measurements of NSE should be cautiously interpreted, but NSE change over time was helpful in predicting the neurologic outcome.

Neuron Specific Enolase as a Biomarker Predicting Neurological Outcome after Cardiac Arrest in Patients Treated by Therapeutic Hypothermia

PURPOSE: Neurological outcome prediction is an important aspect of post-resuscitation care in cardiac arrest survivors. The appearance of high serum neuron specific enolase (NSE) is known to be associated with ischemic brain injury and poor neurological outcome. The application of therapeutic hypothermia to cardiac arrest survivors has been shown to improve neurological outcomes. As such, we investigated the predictive value of serial serum NSE levels in patients who were resuscitated from cardiac arrest. METHODS: This study included 123 cardiac arrest survivors who were treated by therapeutic hypothermia from January 2008 to June 2011. Blood samples used for evaluating NSE were collected at return of spontaneous circulation (ROSC) at 6, 24 and 48 hours after initiation of therapeutic hypothermia. Neurological outcome was graded as 'good' or 'poor' at discharge and assessed according to the Cerebral Performance Category scale (CPC). A poor outcome was defined as a CPC value of 3-5. RESULTS: Receiver operating characteristic (ROC) analysis revealed NSE cut-off values of 53.9 microg/L (sensitivity 14.6%), 48.5 microg/L (sensitivity 30.6%), 80.0 microg/L (sensitivity 40.0%), and 52.7 microg/L (sensitivity 55.5%) for poor outcomes with a specificity of 100%, measured at ROSC of 6, 24 and 48 hours after initiation of therapeutic hypothermia, respectively. The poor outcome group showed significant change in NSE concentration over time (p=0.002), while the good outcome group did not. CONCLUSION: Detection of NSE at the cut-off value, 48 hr after initiation of therapeutic hypothermia was a specific but moderately sensitive marker of poor outcome at discharge. Single measurements of NSE should be cautiously interpreted, but NSE change over time was helpful in predicting the neurologic outcome.

Multicenter Survey of Intoxication Cases in Korean Emergency Departments: 2nd Annual Report, 2009

PURPOSE: The purpose of this study was to examine the occurrence of toxic exposure cases in Korean emergency centers using a toxic exposure surveillance system-based report form and to provide guidelines for the prevention and treatment of toxic exposures. METHODS: We retrospectively reviewed the medical records of toxic exposure patients who had visited emergency centers from January 2009 to December 2009. Epidemiology data points for the toxic exposure cases included age, gender, type of exposure, number and kind of substances involved, reason and route of poison exposure, management of the patients in the emergency departments, and the clinical outcome. RESULTS: A total of 3,501 patients from 12 emergency departments were enrolled in the study. 50.0% of the total exposure patients were male and 63.0% of the total cases were fatal. Acute intoxication occurred in 91.3% of the total patients and suicidal intent was the most common (43.3%) reason for exposure. The most common route of exposure was ingestion (75.9%). Of the total cases, pesticides were involved in 26.3%, sedatives/hypnotics/antipsychotics were involved in 22.0%, and bites and envenomations were involved in 15.7%. CONCLUSION: We provided a database of patients who were admitted to emergency departments after poisoning incidents. We recommend that toxicology professionals develop a classification scheme for toxicants which is adequate for Korean domestic circumstances and initiate a toxic surveillance system for all types of exposures. With support of a psychiatric surveillance system for suicidal patients and establishment of social mediation for pesticide poisoning, major reductions in poison exposures can be achieved.

Bispectral Index as a Predictive Factor for Neurological Outcome in Post-Resuscitated Patients who Undergo Hypothermia

PURPOSE: Bispectral index (BIS) is a non-invasive parameter that expresses the level of consciousness using a numerical value that ranges from 0-100. It can be easily conducted at the patient bed-side throughout a day. We studied whether BIS could be used as a predictive factor for neurological outcome in patients who undergo hypothermia after cardiopulmonary resuscitation. METHODS: The prospective study enrolled patients who underwent induced hypothermia with post-resuscitated state after cardiac arrest and presented to Chonnam National University Hospital from June, 2010 to October, 2010. BIS monitoring was conducted from admission at the intensive care unit until normal temperature was attained after the induction of hypothermia. The patients were divided into two groups based on neurological outcome at discharge and the values obtained from BIS monitoring were compared. RESULTS: Fourteen patients were included in this study. The mortality rate was 28.6% and five patients were discharged with Glasgow Pittsburgh Cerebral Performance Categories 1 or 2. The value of BIS at the start of rewarming was significantly different between the two groups according to neurological outcome, while the value of BIS upon reaching normal temperature did not differ statistically. The significant difference between the two groups was observed in the value of BIS from 19 hours after starting hypothermia. CONCLUSION: BIS can be used to predict the neurological outcome of patients who undergo resuscitation after cardiac arrest.