A case of multisystem inflammatory syndrome in children associated with coronavirus disease 2019, presenting as unremitting fever, vomiting, and rash

Multisystem inflammatory syndrome in children, a hyper inflammation syndrome induced by severe acute respiratory syndrome coronavirus 2, may show a fatal progression. Thus, it is important to recognize its symptoms, and provide appropriate treatment at an early stage. We report a 7-year-old boy who presented with unremitted fever, vomiting, and whole-body polymorphic rash. Laboratory findings showed lymphopenia, and elevated erythrocyte sedimentation rate, C-reactive protein, fibrinogen, d-dimer, ferritin, and triglyceride. The boy had negative findings of viruses-related to respiratory disease and meningitis, and positivity for immunoglobulin G against severe acute respiratory syndrome coronavirus 2. He was diagnosed as multisystem inflammatory syndrome in children, and received supportive care, intravenous immunoglobulin, and steroid. He was discharged without complication on day 12.

A case of desmoid tumor-induced external iliac vein compression misidentified as deep vein thrombosis

Desmoid tumor, also known as desmoid-type fibromatosis, is a rare, intermediate, locally aggressive tumor with a high possibility of local infiltration and recurrence, potentially leading to life-threatening problems. We report a case of a 15-year-old girl who visited the emergency department with a 1-week history of the left leg swelling. A point-of-care ultrasound on the leg showed dilated left femoral and popliteal veins. Subsequently, a computed tomography venogram demonstrated a large pelvic mass compressing the left external iliac vein. She underwent tumor resection, and was uneventfully discharged on day 12.

Analysis of proper chest compression position according to abdominal distension using multi-detector computed tomography

Objective@#The purpose of this study was to analyze the effect of abdominal distension on proper chest compression position selection during the use of multi-detector computed tomography (MDCT). @*Methods@#Fifty-eight patients who underwent thoraco-abdominal MDCT for the diagnosis of aortic dissection from January 2013 to August 2018 were included in the study. Abdominal distension was defined as a condition in which the area around the navel in the supine position was higher than the lower half of the sternum. The left ventricle maximal diameter (LVMD) level was scored based on the vertebral body using MDCT. The distance from the end of the sternum (Se), the middle of the lower half of the sternum (Sm), and the upper edge of the liver (Lu) to the LVMD were measured and analyzed. @*Results@#The LVMD level was significantly higher in the abdominal distension group than in the non-abdominal distension group (1.74±1.39 vs. 2.77±1.33, P=0.007). The difference was about 1/2 of the height of a vertebral body, i.e. 1.2 cm. In the abdominal distension group, Lu was higher (19.6±18.0 vs. 29.2±13.1, P=0.034) and the distance from LVMD to Sm was shorter than in the non-abdominal distension group (36.3±17.5 vs. 45.8±11.5, P=0.027). @*Conclusion@#Abdominal distension alters the position of the heart through the elevation of the diaphragm. Therefore, when performing chest compressions in patients with cardiac arrest, it is necessary to select a chest compression location based on the presence or absence of abdominal distension.

Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

A case of chilaiditi syndrome complicated by acute small bowel obstruction

Chilaiditi syndrome is an extremity rare disease that is typically asymptomatic, but can lead to fatal complications, such as volvulus, perforation, and bowel obstruction. This paper reports a case of an 80-year-old female patient who was admitted for right upper quadrant pain and nausea. She showed a positive Murphy sign with tenderness in the right upper quadrant area. Abdominal ultrasound showed that the gall bladder was normal, but abdominal computed tomography revealed multiple small bowel loops interposed among the liver and diaphragm, as well as an abrupt small transition in the bowel caliber with air fluid levels. Therefore, she was diagnosed with an acute small bowel obstruction by Chilaiditi syndrome. She was managed with surgical repair and was discharged without complications after 18 days of admission. Small bowel obstructions by Chilaiditi syndrome is one etiology of which every emergency physician should be aware.

A case of hemophagocytic lymphohistiocytosis caused by an Epstein-Barr virus infection, presenting with unremitting fever and rash

Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome caused by excessive activation of lymphocytes and macrophages, leading to cytokine storm. Infection-associated HLH is most common, and Epstein-Barr virus is the leading triggers. Quick diagnosis is essential for starting the treatment before irreversible damage. We report a case of 16-year-old boy who presented with unremitted fever, jaundice, and erythematous maculopapular rash all over the body. Investigations showed thrombocytopenia, hyperferritinemia, hypertriglycemia, and the bone marrow biopsy showed hemophagocytosis. Epstein-Barr virus antibody was positive. He responded to chemotherapy as per the HLH-2004 protocol and supportive treatment, and was discharged without complication on day 17.

Is hyperbaric oxygen therapy more effective than normobaric oxygen therapy for improving acute neuropsychologic status due to carbon monoxide poisoning?

OBJECTIVE: The evidence that hyperbaric oxygen (HBO) therapy is more effective for improving the acute neuropsychological status (ANS) of carbon monoxide poisoning than normobaric oxygen (NBO) therapy is not convincing. This is because the levels of carboxyhemoglobin (COHb) do not correlate with the clinical severity of carbon monoxide poisoning and there is no universally accepted severity scale of carbon monoxide poisoning. This paper suggests a new scale for the clinical and neurological severity of carbon monoxide poisoning, called the ANS, and assesses the effect of HBO therapy for each level of ANS compared to NBO therapy. METHODS: A total of 217 patients who had been hospitalized because of carbon monoxide poisoning from January 2009 to July 2013 were studied. ANS was suggested as a new severity scale of carbon monoxide poisoning considered in the Glasgow Coma Scale, acute neuro-psychologic signs and symptoms, or cardiac ischemia on the initial medical contact. HBO therapy is indicated in those who have a loss of consciousness, seizure, coma, abnormal findings on a neurological examination, pregnancy, persistent cardiac ischemia, level of COHb >25%, or severe metabolic acidosis (pH < 7.2). The end point is the day of discharge, and recovery is defined as a normal neuro-psychological status without any sequelae. RESULTS: The levels of troponin T and creatinine increased significantly with increasing ANS score. In the moderate to severe group (ANS 2 and 3), the recovery rate was significantly higher when treated with HBO therapy than with NBO therapy (P=0.030). On the other hand, the development of delayed neuro-psychological sequelae (DNS) did not correlate with any level of ANS, type of oxygen therapy, or recovery on discharge. CONCLUSION: In the moderate to severe poisoned group, HBO therapy is more effective for improving the ANS from carbon monoxide poisoning than NBO therapy. On the other hand, the development of DNS of HBO therapy is no more preventable than with NBO therapy. Although the level of ANS is low, the patient needs to be provided with sufficient information and a follow-up visit is recommended for any abnormal symptoms because the ANS does not correlate with the development and degree of DNS.

Long-term outcome of delayed neuropsychiatric sequelae after carbon monoxide poisoning

OBJECTIVE: Delayed neuropsychiatric sequelae (DNS) following carbon monoxide (CO) poisoning, which may result from a demyelinating leukoencephalopathy, is a disease with a poor prognosis. This study examined the factors affecting the long-term prognosis of DNS and the efficacy of hyperbaric oxygen therapy (HBOT) in patients with DNS. METHODS: This retrospective study included 84 patients with DNS following CO poisoning from January 2013 to June 2016. HBOT was given to 24 patients. The patients were divided into an improvement group and non-improvement group based on their clinical condition on a telephone interview at intervals between 3 months and 3 years after the onset of DNS. The improvement group was defined as having Cerebral Performance Category (CPC) scores in their daily life that improve to 1 or 2 grade. RESULTS: Of the 594 patients, DNS were found in 18.2%, and 70.2% (59 of 84) of the patients with DNS improved. The prognostic factors for the improvement of DNS were an age of 45 years or less (odds ratio [OR], 12.068; 95% confidence interval [CI], 2.393–60.858; P 0.1). CONCLUSION: Patients aged less than 45 years, low grade CPC score of 1 and 2, and lucid interval longer than 20 days are more likely to have a good prognosis. On the other hand, HBOT failed to produce a benefit for DNS patients.

A case of left ventricle rupture complicating lay rescuer cardiopulmonary resuscitation

Chest compression is the most important component of cardiopulmonary resuscitation, but excessive chest compression can cause serious mechanical complications. Skeletal injuries are the most frequent complications of chest compression, but lacerations of the heart and great vessels are very rare. We report a case of a 62-year-old woman who developed an acute alteration in mental status, and underwent chest compression by a lay rescuer for 5 minutes. When she arrived at the emergency department, she regained consciousness, but constantly complained of chest pain and hypotension. Chest computed tomography revealed a left ventricular free wall rupture with extravasation and hemopericardium. She was managed with surgical repair and was discharged without complications after 21 days of admission.

A Case of Delayed Tracheo-esophageal Fistula Complicating Acute Intoxication of Hydrogen Peroxide

Hydrogen peroxide is a commonly used oxidizing agent. If injected, it may result in morbidity via direct caustic injury, oxygen gas formation, and lipid peroxidation. We report a 40-year-old male patient who accidentally swallowed undiluted hydrogen peroxide (35%). The initial chest computed tomography scan showed no active lesions. He was admitted to the intensive care unit for conservative treatment. Fourteen days after treatment, uncontrolled fever and foul oder sputum occurred, which was not alleviated despite empirical antibiotics therapy. Findings on a chest computed tomography showed tracheo-esophageal fistula at the lower trachea and left main bronchus. He underwent surgical replacement surgery and was discharged without complication after 52 days of admission.

A Case of Mesentero-axial Gastric Volvulus Presenting as Recurrent Vomiting of a Children

Acute gastric volvulus in children is a rare condition, but a potentially life-threatening cause of upper gastrointestinal obstruction requiring prompt diagnosis and treatment. However, the symptoms are ambiguous, so that it can be easily misdiagnosed. We report on the case of a 3-year-old boy patient with recurrent vomiting despite conservative therapy. Findings of a bedside ultrasonography and upper gastro-intestinal contrast study showed mesentero-axial gastric volvulus without adjacent organ abnormality. He was managed with endoscopic gastropexy and was discharged without complication.

A Case of Spontaneous Spinal Epidural Hematoma Misidentified as a Middle Cerebral Artery Infarction

Spontaneous spinal epidural hematoma (SSEH) is an uncommon cause of spinal cord compression. Early diagnosis and appropriate management are important, however, diagnosis is often difficult due to variable neurologic deficit. We report on the case of a 69-year-old female patient in right hemiparesis. She was treated with thrombolysis therapy for acute cerebral infarction before being transferred to our hospital. Findings on a cervical spine magnetic resonance image showed spinal epidural hematoma and cord compression. She was prepared to undergo decompressive surgery, however, neurologic deficits began to show improvement. She was managed conservatively and was discharged without deficits approximately nine days after onset.

Comparing the fully-automated external defibrillator and semi-automated external defibrillator used by laypersons: A simulation study

PURPOSE: This study compared the performance between the fully-automated external defibrillator (F-AED) and the semi-automated external defibrillator (S-AED) when used by laypersons. METHODS: Thirty-three laypersons participated in a mannequin simulation study as part of Cardio-Pulmonary Resuscitation (CPR) training courses. After 30 minutes of didactic education for the Automated External Defibrillator (AED), they watched a video on how to use the fully-automated external defibrillator (F-AED) and a semi-automated external defibrillator (S-AED) instead of a hands-on education. Laypersons performed the S-AED first, then the F-AED. Performances and shock delivery time intervals were recorded and evaluated. RESULTS: The performances in shock delivery were better with the F-AED, although the overall performance was statistically insignificant. In terms of shock delivery interval, the F-AED was shorter than the S-AED (54.48+/-2.84 sec vs. 64.76+/-3.57 sec, respectively, p<0.01). In the post survey, F-AED had a higher preference (F-AED vs. S-AED 23(70%) vs. 5(15%), respectively, p<0.001). CONCLUSION: The F-AED had a better performance and shorter shock delivery time interval than the S-AED. The F-AED should thus be considered for use, outside of the hospital, on cardiac arrest patients for early defibrillation.

A Massive Pulmonary Embolism with Hemodynamically Unstable Stroke Symptoms

Pulmonary embolisms account for 13~25% of early deaths after stroke. Early diagnosis and appropriate management of thrombolysis are important, however, diagnosis is often difficult, and the consequences for patients can be severe. Echocardiography is useful for evaluation for massive pulmonary embolism, particularly in hemodynamically unstable patients. We report on a case involving a 67-year-old female patient in severe hemodynamic compromise, with an altered mental status and hemiparesis. Findings on brain computerized tomography (CT) showed acute infarction at the left middle cerebral artery territory and transthoracic echocardiography indicated a massive pulmonary embolism. Despite administration of conservative management, the patient died due to a cerebral complication.

Investigation of Non-analgesic Subcutaneous Suture and Skin Bond in Patients with Deep Facial Lacerations

PURPOSE: To evaluate the effectiveness of non-analgesic subcutaneous suture with an adhesive agent. METHODS: We sutured lacerated wounds with an adhesive agent using a non-analgesic method and measured pain and patient satisfaction. We classified three steps (I: entering the needle, II: pulling the fiber, III: tying) in the suture sequence and evaluated the pain (painfulness, tolerance, painlessness) for each step. RESULTS: Of 276 patients admitted within the period, 111 were enrolled in this study. The mean wound characteristics were 11+/-4 mm (depth) and 23+/-18 mm (length). Overall, 83(75%) patients were sutured without additional analgesics. On a pain scale, all steps were measured at over 90% with respect to tolerance and painlessness. In step II, tolerance (63%) and painfulness (10%) was higher than in the other steps (p<0.05). The mean rate of satisfaction was 4.7 (group 1, 4.8; group 2, 4.6; group, 3; 4.6, group 4, 4.7 (p=0.673). CONCLUSION: Non-analgesic subcutaneous suture with adhesive agent was very effective for patients who were admitted to the emergency department with deep facial lacerations with a length of no more than 2 cm.

Angiomyolipoma Rupture and Spontaneous Pneumothorax in Tuberous Sclerosis Patients: A Case Report

Tuberous sclerosis is a genetic multi-system disorder characterized by wide spread hamartomas in several organs. We present the case of a 28-year-old female patient diagnosed with tuberous sclerosis combined with life threatening complication. She developed a peri-renal hemorrhage due to an angiomyolipoma rupture and spontaneous pneumothorax at a time. In order to diagnose and treat this problem, the emergency physician should understand the clinical presentation and complication associated with tuberous sclerosis.

Comparing the Usefulness of the Initial Acute Physiologic and Chronic Health Evaluation (APACHE) II Score in the Emergency Department (ED) and the Mortality in Emergency Department Sepsis (MEDS) Score for Predicting the Prognosis of Septic Patients Admitt / 대한구급학회지

BACKGROUND: To determine the prognostic value of the initial APACHE II score in the ED compared with the classic APACHE II score in the ICU and to check the usefulness of the MEDS score together for more rapid risk stratification of septic patients admitted to the ICU via the ED. METHODS: We prospectively checked the initial APACHE II and MEDS scores of all the patients who had systemic inflammatory response syndrome in the ED and the classic APACHE II scores after admission to the ICU, as well 6 months later. We enrolled the only sepsis cases in the final diagnosis after reviewing the medical records. We evaluated the predictive abilities of the initial APACHE II and MEDS scores compared with the classic APACHE II score. RESULTS: During 6 months, 58 patients diagnosed with sepsis were enrolled. Twenty-four (41.4%) patients died within 28 days of admission and 34 patients survived. The mortality group had a significantly higher mean classic APACHE II score (19 +/- 6.7 vs. 15 +/- 5.0, p < 0.01) and a higher mean MEDS score (16.67 +/- 2.70 vs. 8.91 +/- 3.11, p < 0.01) than the survivor group. The initial APACHE II score at the ED was not significantly different between the two groups. ROC analysis showed the discriminative power of the MEDS score in predicting mortality was much better than the APACHE II score (areas under the curves of the APACHE II score in the ED and ICU, and the MEDS scores were 0.668, 0.807, and 0.967, respectively; p < 0.01). CONCLUSIONS: The initial APACHE II score in the ED did not predict mortality better than the classic APACHE II score. However, the MEDS score predicted the poor prognosis of septic patients more rapidly and accurately in the ED than the APACHE II model.