The association between the neutrophil-to-lymphocyte ratio and bacteremia in elderly patients admitted to the emergency department

Objective@#Bacteremia is a common cause of increased morbidity and mortality in elderly patients, but early diagnosis and identification are complex. The neutrophil-to-lymphocyte count ratio (NLR) is suggested as a useful indicator for diagnosing bloodstream infections. This study evaluated whether the NLR at admission is associated with bloodstream infections in older patients admitted to the emergency department. @*Methods@#A retrospective, multicenter analysis was performed on patients admitted to the emergency department from November 2016 to February 2017. We included patients aged 65 years and older who visited the emergency department with medical problems. Baseline NLR values were measured upon admission to the emergency department. The primary outcome was a positive blood culture. @*Results@#A total of 1,815 patients were included in this study. The median age was 77.25±7.38 years, and bacteremia was identified in 290 older patients (15.9%). The NLR was significantly higher in the bacteremia group (15.95±22.03) than in the non-bacteremia group (8.76±8.74, P<0.001). In the multivariate logistic regression analysis, the NLR was associated with bacteremia after adjusting for confounding factors as continuous variables (odds ratio [OR], 1.033; 95% confidence interval [CI], 1.009-1.057) and categorical variables (NLR ≥10; OR, 2.018; 95% CI, 1.246-3.268). The area under the curve of the NLR was determined to be 0.667 (95% CI, 0.639-0.694). @*Conclusion@#These results indicate that the NLR at admission to the emergency department is associated with bloodstream infections. Early suspicion of bacteremia, by determining the initial NLR value, will help treat bacteremia in elderly patients.

Prognosis predictability of combination between lactate and SMART-COPin elderly hospitalized patients with community-acquired pneumoniain the emergency department

Objective@#Community-acquired pneumonia (CAP) in older patients is a potentially life-threatening infection with a poorprognosis. Therefore, is important to predict the mortality rate of CAP for older patients. This study examined the effectsof predictive increases on CAP mortality by adding a biomarker to known CAP severity prediction tools. @*Methods@#A retrospective analysis of information was conducted on patients older than 65 years, who were treated withCAP in five emergency departments from October 2016 to February 2017. The primary outcome was the 28-day mortality.The following were calculated for each patient: qSOFA (quick Sequential Organ Failure Assessment), A-DROP (Age,Dehydration, Respiratory failure, Orientation, blood Pressure), CURB-65 (Confusion, Urea level, Respiratory rate, Bloodpressure, age≥65 years), SMART-COP (Systolic blood pressure, Multilobar infiltrates, Albumin, Respiratory rate,Tachycardia, Confusion, Oxygen and pH), NLR (neutrophil:lymphocyte ratio), PLR (platelet:lymphocyte ratio), and CAR(high-sensitivity C-reactive protein:albumin ratio). The prognostic value for the 28-day mortality was determined by multivariatelogistic regression analysis. @*Results@#The 28-day mortality was 12.0% of 693 CAP patients. Multivariate logistic regression analysis showed that lactate(odds ratio [OR], 1.589; P<0.001) and CAR (OR, 1.208; P=0.006) were correlated with the 28-day mortality. NLR(OR, 1.00; P=0.983) and PLR (OR, 1.00; P=0.784) were not correlated. The area under curve (AUC) was significant asCAR 0.649, lactate 0.737, and SMART-COP 0.735 (P<0.001), and the AUC of lactate+SMART-COP increased significantlyto 0.784 compared to SMART-COP (P=0.014). @*Conclusion@#A combination of lactate and SMART-COP can be used as a tool to assess the severity of older hospitalizedCAP patients who visited emergency departments.

Use of the National Early Warning Score for predicting in-hospital mortality in older adults admitted to the emergency department

Objective@#The National Early Warning Score (NEWS), based on the patients’ vital signs, detects clinical deterioration in critically ill patients and is used to reduce the incidence of in-hospital cardiac arrest. However, although mortality prediction based on vital signs may be difficult in older patients, the effectiveness of the NEWS has not yet been evaluated in this population. This study aimed to test the hypothesis that an elevated NEWS at admission increases the mortality risk in older patients admitted to the emergency department (ED). @*Methods@#We conducted a single-center retrospective study, including patients admitted to the ED between November 2016 and February 2017. We included patients aged >65 years who were admitted to the ED for any medical problem. The NEWS was calculated at the time of ED admission. The primary outcome was in-hospital mortality. @*Results@#In total, 3,169 patients were included in this study. Median age was 75 years (interquartile range [IQR], 70 to 80 years), and 1,557 (49.1%) patients were male. The in-hospital mortality rate was 5.1% (161 patients). Median NEWS was higher in non-survivors than in survivors (5 [IQR, 3–8] vs. 1 [IQR, 0–3], P65 years.

Outcome and status of postcardiac arrest care in Korea: results from the Korean Hypothermia Network prospective registry

Objective@#High-quality intensive care, including targeted temperature management (TTM) for patients with postcardiac arrest syndrome, is a key element for improving outcomes after out-of-hospital cardiac arrest (OHCA). We aimed to assess the status of postcardiac arrest syndrome care, including TTM and 6-month survival with neurologically favorable outcomes, after adult OHCA patients were treated with TTM, using data from the Korean Hypothermia Network prospective registry. @*Methods@#We used the Korean Hypothermia Network prospective registry, a web-based multicenter registry that includes data from 22 participating hospitals throughout the Republic of Korea. Adult comatose OHCA survivors treated with TTM between October 2015 and December 2018 were included. The primary outcome was neurological outcome at 6 months. @*Results@#Of the 1,354 registered OHCA survivors treated with TTM, 550 (40.6%) survived 6 months, and 413 (30.5%) had good neurological outcomes. We identified 839 (62.0%) patients with preClinsumed cardiac etiology. A total of 937 (69.2%) collapses were witnessed, shockable rhythms were demonstrated in 482 (35.6%) patients, and 421 (31.1%) patients arrived at the emergency department with prehospital return of spontaneous circulation. The most common target temperature was 33°C, and the most common target duration was 24 hours. @*Conclusion@#The survival and good neurologic outcome rates of this prospective registry show great improvements compared with those of an earlier registry. While the optimal target temperature and duration are still unknown, the most common target temperature was 33°C, and the most common target duration was 24 hours.

Outcome and status of postcardiac arrest care in Korea: results from the Korean Hypothermia Network prospective registry

Objective@#High-quality intensive care, including targeted temperature management (TTM) for patients with postcardiac arrest syndrome, is a key element for improving outcomes after out-of-hospital cardiac arrest (OHCA). We aimed to assess the status of postcardiac arrest syndrome care, including TTM and 6-month survival with neurologically favorable outcomes, after adult OHCA patients were treated with TTM, using data from the Korean Hypothermia Network prospective registry. @*Methods@#We used the Korean Hypothermia Network prospective registry, a web-based multicenter registry that includes data from 22 participating hospitals throughout the Republic of Korea. Adult comatose OHCA survivors treated with TTM between October 2015 and December 2018 were included. The primary outcome was neurological outcome at 6 months. @*Results@#Of the 1,354 registered OHCA survivors treated with TTM, 550 (40.6%) survived 6 months, and 413 (30.5%) had good neurological outcomes. We identified 839 (62.0%) patients with preClinsumed cardiac etiology. A total of 937 (69.2%) collapses were witnessed, shockable rhythms were demonstrated in 482 (35.6%) patients, and 421 (31.1%) patients arrived at the emergency department with prehospital return of spontaneous circulation. The most common target temperature was 33°C, and the most common target duration was 24 hours. @*Conclusion@#The survival and good neurologic outcome rates of this prospective registry show great improvements compared with those of an earlier registry. While the optimal target temperature and duration are still unknown, the most common target temperature was 33°C, and the most common target duration was 24 hours.

Hemoglobin concentration is associated with neurologic outcome after cardiac arrest in patients treated with targeted temperature management

OBJECTIVE: The objective of this study was to test the hypothesis that hemoglobin concentration after return of spontaneous circulation (ROSC) is associated with neurologic outcome after cardiac arrest in patients treated with targeted temperature management. METHODS: We studied consecutive adult patients with out-of-hospital cardiac arrest treated with targeted temperature management between January 2009 and December 2015. We investigated the association between post ROSC hemoglobin concentrations and good neurologic outcome (defined as Cerebral Performance Category of 1 and 2) at hospital discharge using multivariate logistic regression analysis. RESULTS: A total of 246 subjects were ultimately included in this study. The mean age was 54 years (standard deviation, 17); 168 (68%) subjects were male. Eighty-seven (35%) subjects had a good neurologic outcome at hospital discharge. Hemoglobin concentrations were higher in the good outcome group than in the poor outcome group (14.4±2.0 vs. 12.8±2.5 g/dL, P < 0.001). Multivariate logistic regression analysis showed that hemoglobin concentrations were associated with good neurologic outcome at hospital discharge after adjusting for other confounding factors (adjusted odds ratio, 1.186; 95% confidence interval, 1.008 to 1.395). CONCLUSION: In post ROSC patients, hemoglobin concentrations after ROSC were associated with neurologic outcome at hospital discharge.

Variability of extracorporeal cardiopulmonary resuscitation utilization for refractory adult out-of-hospital cardiac arrest: an international survey study

OBJECTIVE: A growing interest in extracorporeal cardiopulmonary resuscitation (ECPR) as a rescue strategy for refractory adult out-of-hospital cardiac arrest (OHCA) currently exists. This study aims to determine current standards of care and practice variation for ECPR patients in the USA and Korea. METHODS: In December 2015, we surveyed centers from the Korean Hypothermia Network (KORHN) Investigators and the US National Post-Arrest Research Consortium (NPARC) on current targeted temperature management and ECPR practices. This project analyzes the subsection of questions addressing ECPR practices. We summarized survey results using descriptive statistics. RESULTS: Overall, 9 KORHN and 4 NPARC centers reported having ECPR programs and had complete survey data available. Two KORHN centers utilized extracorporeal membrane oxygenation only for postarrest circulatory support in patients with refractory shock and were excluded from further analysis. Centers with available ECPR generally saw a high volume of OHCA patients (10/11 centers care for >75 OHCA a year). Location of, and providers trained for cannulation varied across centers. All centers in both countries (KORHN 7/7, NPARC 4/4) treated comatose ECPR patients with targeted temperature management. All NPARC centers and four of seven KORHN centers reported having a standardized hospital protocol for ECPR. Upper age cutoff for eligibility ranged from 60 to 75 years. No absolute contraindications were unanimous among centers. CONCLUSION: A wide variability in practice patterns exist between centers performing ECPR for refractory OHCA in the US and Korea. Standardized protocols and shared research databases might inform best practices, improve outcomes, and provide a foundation for prospective studies.

Satisfaction surveys on major subjects in emergency medical system in Korea: joint investigation of the Korean Society of Emergency Medicine and Korean Science Journalists Association

OBJECTIVE: This study was conducted to investigate satisfaction surveys of the emergency medical system in Korea administered to both members of the Korean Society of Emergency Medicine and patients and their guardians. METHODS: The joint survey was conducted by the Korea Scientist Journalists Association and the Public Affairs Committee of the Korean Society of Emergency Medicine. Questionnaires administered to each group included questions about the general environment, safety, and overcrowding. Satisfaction of medical staffs and awareness of cardiopulmonary resuscitation were only included in the patient questionnaire, while public health was only surveyed in the member questionnaire. The satisfaction was evaluated on a 5-point scale. RESULTS: Patient questionnaires were answered by 20 of 413 national emergency medical centers, and about 4.3% of the medical institutions participated in the questionnaire. A total of 704 reply sheets were returned by patients. Member questionnaires were answered by 280 of the 1,108 members (25%). Among patients, the lowest satisfaction was the item of “medical expenses,” followed by “waiting time”. Among providers, the lowest satisfaction was “appropriateness of medical staff”, while the highest complaint was “overcrowding.” CONCLUSION: Emergency care users had the lowest satisfaction with “medical expenses,” while members had the lowest satisfaction with “lack of manpower” and were most dissatisfied with “violence” and “overcrowding.”

Survey of emergency medicine residency education programs and suggestion for improvement on the future emergency medicine residency education

OBJECTIVE: This study examined the educational programs for emergency residency in The Korean Society of Emergency Medicine. METHODS: A written survey of the workshop programs with representatives of the related organizations and affiliated organizations was conducted. During the 5-year period, the number of training courses and workshops attended by those who took the professional examination were analyzed. RESULTS: There were 23 workshops in progress. They proceed 2.85 times a year on average. The average number of participants was 22.8 with an average time required for the workshop of 5.6 hours, of which 78.7% is practice time. They received feedback from residency at all workshops, which was reflected in the process. During the 5-year period, the average number of participant training courses was 3.8, and the average number of workshop participants was 2.7. CONCLUSION: The education program for emergency residency is continuing through the affiliated organizations and related organizations as well as The Korean Society of Emergency Medicine. Encouraging opportunities for participation in various educational programs to supplement those that are not fully experienced will be helpful.

High-sensitivity C-reactive protein/albumin ratio as a predictor of in-hospital mortality in older adults admitted to the emergency department

OBJECTIVE: The objective of this study was to test the hypothesis that an elevated high-sensitivity C-reactive protein (hs-CRP)/albumin ratio at admission increases the risk of mortality in older patients admitted to the hospital via the emergency department (ED). METHODS: We performed a retrospective analysis of patients admitted to the ED with any medical problem between May 2013 and October 2013 who were older than 65 years. The hs-CRP and albumin levels were measured at the time of admission to the ED. The primary outcome was all-cause in-hospital mortality. Multivariate logistic analysis was performed. RESULTS: A total of 811 patients were finally included in this study. The mean age was 76±7 years, and 438 subjects (54%) were male. The in-hospital mortality rate was 9.0% (73 patients). The hs-CRP/albumin ratio was higher in nonsurvivors than in survivors (34.2±37.6 vs. 16.2±25.5, P<0.001). Multivariate logistic analysis showed that the hs-CRP/albumin ratio was associated with all-cause in-hospital mortality after adjusting for other confounding factors (odds ratio, 1.011; 95% confidence interval [CI], 1.003 to 1.020). The prognostic value of the hs-CRP/albumin ratio for predicting mortality (area under the curve, 0.728; 95% CI, 0.696 to 0.758) was greater than that of hs-CRP alone (area under the curve, 0.706; 95% CI, 0.674 to 0.738; P<0.001). CONCLUSION: The hs-CRP/albumin ratio at admission to the ED is associated with all-cause in-hospital mortality among patients older than 65 years. The hs-CRP/albumin ratio may serve as a surrogate marker of disease severity.

Factors Associated with False-positive ST-segment Elevation Myocardial Infarction Activated by Emergency Physician

PURPOSE: Rapid activation of the cardiac catheterization laboratory (CCL) is fundamental in the treatment of ST-segment elevation myocardial infarction (STEMI), and it is recommended that emergency department physicians activate CCL as soon as possible, however false positive activation is a major concern. The aim of this study is to assess the relationship between false positive activation and clinical factors available at the time of diagnosis. METHODS: All subjects with CCL activation by an emergency physician between August 2009 and May 2012 were included in this study. False-positive CCL activation was defined as absence of a clear culprit lesion on coronary angiography or by assessment of electrocardiographic and biomarker data in the absence of angiography. RESULTS: Of 222 STEMI activations by emergency physicians, 55 (25%) were false-positive STEMI. Coronary spasm, cardiomyopathy, known CAD, and heart failure were the most common diagnoses among false-positive STEMI. A history of cardiomyopathy (adjusted odds ratio, 13.393; 95% CI, 2.550-70.334; p=0.002), systolic blood pressure<100 mmHg at presentation (adjusted odds ratio, 2.817; 95% CI, 1.129-7.026; p=0.026), no chest pain on admission (adjusted odds ratio, 2.460; 95% CI, 1.162-5.209; p=0.019), and prior coronary disease (adjusted odds ratio, 3.966; 95% CI, 1.828-8.606; p<0.001) independently increased the odds of false-positive STEMI activations. CONCLUSION: False-positive CCL activations were relatively common according to the definition in this study. Various patient-level characteristics were significantly associated with false-positive CCL activation.

The Prognostic Value of 20-minute Spot Electroencephalography within 72 hr after Resuscitation for Comatose Cardiac Arrest Survivors Treated with Therapeutic Hypothermia

PURPOSE: This study evaluated the utility of 20-minute spot electroencephalography (sEEG) for prognostication in patients treated with therapeutic hypothermia after cardiac arrest. METHODS: This was a retrospective, observational study using a prospectively collected hypothermia registry conducted at a single tertiary hospital over three years. We included patients who were monitored by sEEG within three days after resuscitation. We evaluated the prognostic value of continuous activity pattern (diffuse slowing or normal wave) for good outcome predictor and malignant pattern (epileptiform, burst suppression, and isoelectric pattern) for poor outcome predictors during hypothermia and normothermia period. RESULTS: Of 98 patients, continuous activity was displayed in 45 patients. Of these, 27 were included in the good outcome group, resulting in a positive predictive value (PPV) of 60.0% (sensitivity and specificity of 100.0 and 74.6%, respectively). Malignant patterns resulted in a PPV of 100.0% for poor outcomes (sensitivity and specificity of 35.2% and 100.0%, respectively). Continuous activity during hypothermia showed better prognostic performance for good outcome than those during normothermia (area under the curve (AUC)=0.900 (95% confidence interval (CI) 0.825-0.975) and AUC=0.827 (95% CI 0.692-0.962), respectively). For the poor outcome prediction, the AUC was 0.712 (95% CI 0.536-0.887) for malignant patterns during normothermia, and 0.656 (95% CI 0.522-0.789) for those during hypothermia. CONCLUSION: For patients treated with TH, continuous activity on sEEG, particularly during hypothermia, could contribute to the prediction of good outcomes with high specificity. Epileptiform discharge, burst suppression, and isoelectric patterns accurately predicted poor outcomes in this cohort.

Red Cell Distribution width in Older Patients with Community-acquired Pneumonia in the Emergency Department

PURPOSE: Red cell distribution width (RDW) is a quantitative measure of variability in the size of circulating erythrocytes. Recent studies have shown that higher RDW is associated with increased mortality risk in patients with several diseases. In particular, community-acquired pneumonia (CAP) is a prevalent and potentially life-threatening infection and has poor prognosis in older patients. We investigated the association of RDW in older patients with CAP. METHODS: We conducted a retrospective analysis study during the period from May, 2013 to October, 2013. Patients older than 65 who were treated with CAP in our emergency department were included in this study. We divided the two groups by RDW 14.5%, the best cutoff value for mortality by receiver operating curve (ROC) analysis. The primary outcome was in-hospital mortality. APACHE II, SOFA, PSI Class, and CURB 65 were calculated. Multivariate logistic regression analysis was performed to determine the risk factors for mortality. RESULTS: A total of 569 patients were analyzed and overall mortality was 10.2%. Mean age was 76.7 years and range of RDW was 10.5%~26.2%. There were 208 patients above 14.5%. Significant differences in in-hospital mortality were observed between the two groups (15.0% vs. 22.1%, respectively). In multivariate logistic regression analysis, RDW>14.5% showed an association with mortality (OR=2.08, 95% CI 1.03-4.19). In ROC analysis, area under the curve of RDW was 0.716 (95%CI, 0.677-0.753). CONCLUSION: RDW at admission is associated with in-hospital mortality in older patients with CAP; and it might be a prognostic marker for mortality of CAP in older patients in the emergency department.

Single Center Experiences to Landslides on Woo-myun Mountain: Preparedness, Response, and Lessons Learned

PURPOSE: On July 27, 2011, landslides occurred on Woomyun Mountain, resulting in development of mass casualties. Seoul St. Mary's Hospital was the primary recipient of patients. This experience prompted the drafting of a formal disaster plan. Therefore, we outline the Emergency Management External Disaster Plan of Seoul St. Mary's Hospital and discuss the time course of presentation and medical characteristics of the patients. METHODS: We conducted a retrospective review of medical records of patients who visited Seoul St. Mary's Hospital from Woo-myun Mountain landslides. In addition, we reviewed the time course of hospital disaster response. RESULTS: A total of 33 patients participated in this study. Mean age was 40.2 (+/-21.8) years; eight patients died at the time of admission and cardiopulmonary resuscitation was performed in one patient. Mean Injury Severity Score (ISS) was 9.19 and four patients were ISS above 15. Six patients were admitted to our hospital and two patients underwent an emergency operation. Overall, the emergency disaster management was appropriate due to the formal disaster plan and experiences in conduct of disaster drills. However, there were also several problems. The major problems of our disaster response were as follows: delayed activation of external disaster, difficulties in securing a treatment section, and absence of a decontamination facility. CONCLUSION: We observed several problems from our experience with Woo-myun Mountain landslides. Reassessment of the disaster plan and additional planning for other possibilities are needed.

Neurologic Outcomes and Factors Related to Outcomes in Patients Transferred for Specialized Post-cardiac Arrest care after Successful Resuscitation at other Facilities: One-year Experience in a Regional Emergency Center in Seoul, Republic of Korea

PURPOSE: We report on neurologic outcomes and experience with specialized post-cardiac arrest (PCA) care of transferred patients at a regional emergency center in Seoul over a one-year period, and we evaluate factors related to neurologic outcomes by analyzing the characteristics of the patients, transport processes, and therapeutic interventions. METHODS: We conducted a retrospective review of patients who were transferred to our facility after successful resuscitation at another hospital. The variables evaluated included clinical variables, whether there was the presence of any critical event on arrival, the transport time, the transport distance, the PCA care delay, and whether or not specialized PCA care was administered. RESULTS: A total of 31 cardiac arrest patients were included in this study. Of these, 27 patients (87.1%) were treated with therapeutic hypothermia. Thirteen patients (41.9%) were ultimately included in the good outcome group (discharge CPC 1, 2), and 18 were included in the poor outcome group (discharge CPC 3-5). During transport, occurrence of re-arrest was uncommon (n=1, 3.2%). Conversely, other critical events were common (11 patients, 35.5%). Transport time, distance, and PCA care delay were not statistically relevant to occurrence of critical events during inter-facility transport. A critical event was more likely to occur in patients who were on vasopressors (p=0.045), and it was an independent risk factor of poor outcome (odds ratio 12.28 [95% confidence interval, 1.44-104.83]). CONCLUSION: The transfer of resuscitated patients is reasonable for specialized PCA care. Because critical events were common during transport and showed correlation with poor neurologic outcomes, a critical care transport team must be used with these patients.

A Comprehensive Combination Method for Cooling Induction After Cardiac Arrest: A Clinical Feasibility Study

PURPOSE: To evaluate the cooling efficacy and safety of a comprehensive combination method for cooling induction in post-cardiac arrest patients. METHODS: Adult out-of-hospital cardiac arrest (OHCA) patients cooled using combination methods in a tertiary teaching hospital from January 2009 to June 2011were enrolled in the study. Patients were placed into one of two groups: 1) a typical combination (combination I) group, in which cold saline infusion, ice bags,and endovascular cooling were applied, and 2) acomprehensive combination (combination II) group, in which cold saline infusion, ice bags, endovascular cooling, skin exposure, and fanning with ice-water massage were applied. The time from cardiac arrest, return of spontaneous circulation (ROSC), and cooling start to 34degrees C, as well asadverse events during cooling, were recorded. RESULTS: Forty-two out of 125(34%) of OHCA patients with ROSC were cooled usingcombination methods. There were no differences in baseline characteristics between the two combination groups. The time [median (IQR)] from arrest, ROSC, and cooling to 34degrees C of the combination II group were significantly shorter than those of the combination I group [215 min(range 156~270 min) vs. 320 min (range 263-385) for median IQR, p=.002; 189 min (range 135-220 min) vs. 288 min (range 227-358 min) for ROSC, p=.002; 150min (range 120-180 min) vs. 210 min (range 180-260 min) for cooling to 34degrees C, p=.030, respectively]. There were no statistical differences in adverse events during and after cooling induction between the two groups. CONCLUSION: A comprehensive combination cooling method is feasible and capable of reducing the induction time for endovascular cooling in post-cardiac arrest patients.

A Comprehensive Combination Method for Cooling Induction After Cardiac Arrest: A Clinical Feasibility Study

PURPOSE: To evaluate the cooling efficacy and safety of a comprehensive combination method for cooling induction in post-cardiac arrest patients. METHODS: Adult out-of-hospital cardiac arrest (OHCA) patients cooled using combination methods in a tertiary teaching hospital from January 2009 to June 2011were enrolled in the study. Patients were placed into one of two groups: 1) a typical combination (combination I) group, in which cold saline infusion, ice bags,and endovascular cooling were applied, and 2) acomprehensive combination (combination II) group, in which cold saline infusion, ice bags, endovascular cooling, skin exposure, and fanning with ice-water massage were applied. The time from cardiac arrest, return of spontaneous circulation (ROSC), and cooling start to 34degrees C, as well asadverse events during cooling, were recorded. RESULTS: Forty-two out of 125(34%) of OHCA patients with ROSC were cooled usingcombination methods. There were no differences in baseline characteristics between the two combination groups. The time [median (IQR)] from arrest, ROSC, and cooling to 34degrees C of the combination II group were significantly shorter than those of the combination I group [215 min(range 156~270 min) vs. 320 min (range 263-385) for median IQR, p=.002; 189 min (range 135-220 min) vs. 288 min (range 227-358 min) for ROSC, p=.002; 150min (range 120-180 min) vs. 210 min (range 180-260 min) for cooling to 34degrees C, p=.030, respectively]. There were no statistical differences in adverse events during and after cooling induction between the two groups. CONCLUSION: A comprehensive combination cooling method is feasible and capable of reducing the induction time for endovascular cooling in post-cardiac arrest patients.

Clinical Manifestations of Heat Stroke that Occur during a Marathon

PURPOSE: Due to an increased interest in health, there have been many types of marathon races for athletes and the general population. Marathon is an extremely difficult sport, therefore, many running injuries can occur. In this study, we aimed at characterization of injuries and clinical courses resulting from marathon induced heat stroke. Based on our findings, we provide suggestions for proper management of patients with marathon induced heat stroke. METHODS: We performed a retrospective study of 24 patients who visited the emergency department (ED) at Yeouido St. Mary's hospital between January 2000 and August 2011 with symptoms of heat stroke resulting from participation in a marathon race. We reviewed the medical records, which showed clinical presentation and laboratory findings. RESULTS: Of the 24 patients, 20(83.3%) were men. Their average age was 38.1+/-8.4 years old and their average initial rectal temperature was 39.9+/-1.3degrees C. Seventeen (70.8%) patients came to the ED complaining of syncope and seven(29.2%) came because of mental change. In follow-up laboratory tests, ten patients showed an increased level of serum Creatine phosphokinase (CPK) to over 1,000 IU/L, six showed serum Aspartate aminotransferase (AST)/Alanine aminotransferase (ALT) to over 300 IU/L, four showed serum creatinine to over 2.0 mg/dL, and two showed an increase in serum troponin-I and MB fraction of creatine kinase. Results of initial laboratory tests showed normal AST/ALT levels, however, they started to rise between 12 to 24 hours, and reached the highest record after 2~3 days of hospitalization. CONCLUSION: Marathon induced heat stroke can cause various complications, such as rhabdomyolysis, acute hepatic injury, acute renal failure, and metabolic acidosis. Therefore, we recommend follow-up and observation for patients with marathon induced heat stroke.

The Efficacy of Ultrasound Diagnosis of a Partial Tendon Injury by Emergency Doctors: Using a Swine Model

PURPOSE: To evaluate the efficacy of ultrasound for the detection of a partial tendon injury of the dorsum of the hand by emergency doctors using a swine model. METHODS: Fifteen swine feet were used for the study. Two tendons from each foot were examined using a 10 MHz hocky stick scan head. A 0%, 10%, 50% and 90% incision was made in each extensor tendon at the proximal site of the skin incision. Four emergency physicians and five senior emergency residents were blinded to the injuries and evaluated the samples for a partial tendon rupture. RESULTS: The difference between the results for the emergency physicians and the emergency senior residents were not statistically significant.The diagnostic sensitivity for all participants was more than 10%; more than a 50% tendon injury was identified in 69.2% and 77.0%, respectively. The specificity was 51.4% and 53.5% for each case. The sensitivity and specificity showed no significant differences. (sensitivity p=0.243, specificity p=0.992) CONCLUSION: The results of this study confirm that ultrasound was useful in the detection of a partial tendon rupture by emergency doctors. The findings of this study have implications for the training of emergency room doctors.

The Expression of Cytochrome c, TNF-R1 and Fas Ligand in Patient's Serum after Successful Cardiopulmonary Resuscitation

PURPOSE: Numerous reports have suggested that apoptosis may play an important role in postresuscitation syndrome. The aim of this study is to assess the levels of molecules that are associated with apoptosis in the serum of patients who underwent successful resuscitation after cardiac arrest. METHODS: The serum levels of cytochrome c, tumor necrosis factor type 1 receptor (TNF-R1) and Fas ligand in 11 patients were measured at 0, 4, 12, 24, 48 and 72 hours after successful resuscitation. The primary endpoint consisted of survival to hospital discharge. Ten healthy volunteers were also evaluated as a control group. RESULTS: Patients with successful resuscitation had increased levels of cytochrome c and TNF-R1 at 0, 4, 12, 24 and 48 hours after return of spontaneous circulation (ROSC), as compared with those levels of the healthy volunteers (p<0.05). Higher levels of TNF-R1 at 12, 24 and 48 hours after ROSC were found in the non-survivors as compared to those levels of the survivors (p=0.01, 0.03, 0.02). The Fas ligand level at ROSC was also higher in the patients with successful resuscitation (p=0.00). However, the Fas ligand levels at 24, 48 and 72 hours after ROSC were lower in the patients with successful resuscitation than those levels in the healthy volunteers. CONCLUSION: These results suggest that apoptosis belonging to the TNF-R1 and cytochrome c pathways may be involved in the pathogenesis of postresuscitation syndrome. The serum levels of the death-receptor TNF-R1 could serve to quantitate the severity of injury and to prognosticate the survival outcomes.