Initial Assessment of the Snakebites with Local effects

PURPOSE: Life-threatening effects from poisonous snakebites seem to be relatively rare in Korea. Therefore, the purpose of our study is to verify a new triage system by using mainly the local effect scoring system to determine whether it may be used as a general guide for snakebite toxicity in the early injury stage. METHODS: A retrospective study of 108 snakebite patients who visited the Emergency Department of Keimyung University Dongsan Medical Center from April 2000 to December 2003 was conducted. A local effect scoring system was used to grade the toxicity, and the results was compared with those obtained using the traditional grading system. RESULTS: According to the grading system for severity, grades 0, I and II was most common ones whereas and grades III and IV were relatively rare (9.3%, 1.9%). Local effect scores of 9 to 16, which were considered to correspond to grades III & IV, were documented in 15 cases (13.9%). For the patients with scores from 9 to 16, the average length of stay and the average dosage of the antivenin were 4.54 days and 2.0 vials compared with 1.43 days and 0.73 vials for those with a score of 8 or less, and these differences were statistically significant (p<0.05). There were 9 complicated cases, but they were not considered to be life-threatening. CONCLUSION: The local effect scoring system correlated well with the traditional grading system for snakebite severity and may provide an instrument for evaluating the severity of snakebites in the early injury stage. Also, our study supports the conclusion that snakebites in Korea should be reevaluated for the severity.

Analysis of Transportation of Victims of the Subway Fire in Daegu

PURPOSE: The purpose of this study was to improve transportation and distribution of mass-casualty patients by reviewing the subway fire that occurred in Daegu on 18 February 2003. METHODS: We used the reports of the Daegu Emergency Medical Information Center and the medical records of each hospital to analyze retrospectively 199 patients who were transported to 22 initial receiving hospitals. We evaluated the appropriateness of transportation based on the distances of transportation, the capability of the receiving hospitals, and the severity of patients. Using the SAS program(version 6.12), the collected data was analyzed by frequency and x(2) test. RESULTS: The more severe the patients were, the nearer and larger the receiving hospitals were. There was no accurate triage at the scene, but the distribution of patients was good because members of Daegu Emergency Medical Information Center were dispatched to the scene and because communications between the scene and receiving hospitals were continuous. CONCLUSION: We do not expect disasters, but they happen. All we can do is plan and prepare appropriate responses for disasters. Appropriate transportation and distribution of patients based on triage is an important aspect of early disaster response.

A Clinical Analysis of the Delirium Tremens

PURPOSE: We performed this study to identify the clinical characteristics of delirium tremens in Korea. METHODS: We reviewed the charts of patients suffering from delirium tremens who visited the Emergency Department of Keimyung University Hospital during the period of Jan. 2001 through Jun. 2002. RESULTS: All patients were mail, and the number was 28. The age distribution was 40~49, and the most common duration of drinking (15 cases) was between 11 and 20 years. The abstinence period before development of Delirium Tremens was, in most cases, less than 4 days, and the average period of symptoms of Delirium Tremens was less than 6 days. Various abnormal laboratory finding were noted: increased bilirubin level in 50%, prolonged pro-thrombin time in 14.3%, increased amylase level in 19.9% and electrolyte imbalance in 25%. CONCLUSION: During the study period, there was no mortalities. The author believes that sufficient vitamins and fluid supplement contributed to the results.

Outcome of Nontraumatic Prehospital Cardiac Arrest

PURPOSE: There has been an increase in the number of nontraumatic prehospital cardiac arrests due to increases in both cardiovascular diseases and the average age of the population. We performed this study to identify the proper resuscitation technique to be used to increase the survival rate in nontraumatic, prehospital cardiac arrest. METHODS: We reviewed the charts of patients with nontraumatic, prehospital cardiac arrest who visited our Emergency Department of Keimyung University Hospital during the period of May 2001 through April 2002. RESULTS: Out of 60 cases of nontraumatic, prehospital cardiac arrest, 27 (45%) experienced no ROSC, 15 (25%) experienced transient ROSC, 6 (10%) died after 24 hours, and 12 (20%) alived and were discharged. Among those discharged, 10 had visited our emergency department for cardiac causes and 2 for non-cardiac causes. EKG findings were VF in 8, PEA in 2, and bradycardia in 2. In the discharged survival cases, the cardiac arrest had been witnessed. CONCLUSION: We failed to find significant statistical survival differences based on the causes of cardiac arrest, the initial EKG monitoring, or the method of visit. Witnessed cases of cardiac arrest had a higher survival rate than nonwitnessed cases (p<0.05).

Clinical Analysis of Electrical Burn Patients

BACKGROUND: Good documentation of electrical injuries at the time of presentation is very important to emergency management, so this study was designed to investigate the clinical characteristics and the outcomes of patients with electrical injury. METHODS: A review of 75 cases of electrical injuries admitted to our hospital via the emergency department over a 4 year period from 1996 to 1999 was conducted. RESULTS: There were 49 patients with high-voltage injuries and 19 patients with low-voltage injuries. All but 4 patients were males, with a mean age of 29.5 years. The most common type of injury was 14.5% TBSA in the high-voltage group and 2.5% in the low-voltage group. Forty-nine(72.1%) of the injuries were work related. The number of patient with compartment syndrome was 19, and fasciotomies were performed in all but one patient. Myoglobinuria was noted in 22 patients, but no patient developed acute renal failure due to myoglobinuria. In the high-voltage group, 10 limb amputations were performed. Complication were observed in 12 patients. The most common complication was neurological injury. The average length of hospital stay was 50.7 days in the high-voltage group and 13.8 days in the low-voltage group. The overall mortality rate was 4.3%. CONCLUSION: Prevention of electrical injuries is very important. Education and compliance with safety measures, as well as basic knowledge and precaution in dealing with electricity, are essential to avoid these injuries.

Adequacy of Siriraj Stroke Score in Differentiation of Stroke Patients

BACKGROUND: The differentiation between hemorrhagic(HS) and norhemorrhagic(NHS) stroke is the most important first step in the management of acute stroke because clinical management of the two disorders differs substantially. Neuroimaging studies are useful in diagnosing and distinctioning between HS and NHS. The use of clinical variables, such as Siriraj stroke scores(SSS), has led to good sensitivity, specificity and predictive values. The aim of our study was to evaluate the use of the SSS in the Korean population and assess whether it could aid to expedite treatment decisions. METHODS: We reviewed 111 cases of stroke patients admitted to our hospital via the emergency department over a 6 months period from July to December 1998. Levels of consciousness, vomiting, headache, and atheroma markers used in the SSS were applied to these patients who met the criteria for a stroke. RESULTS: Of the 111 patients, the SSS classified 83 with sensitivities of 81.1%(NHS) and 73.3%(HS) and positive predictive values of 84.3% and 68.8%, respectively. The overall accuracy rate was 78.3%. CONCLUSION: Our results suggest that the SSS is not reliable in distinguishing stroke types in the Korean population. Definite neuroimaging studies are needed prior to thrombolytic therapy.

Risk Factors Affecting the Mortality of Acute Myocardial Infarction during the First 24 Hour after Onset

BACKGROUND: Recently, the incidence of acute myocardial infaction has been gradually increasing as prolongation of life spans and improvements of diet and life styles in Korea. The rate of mortality and sudden death is higher than other diseases. The purpose of this study is to evaluate factors which can affect on the mortality of AMI during initial 24 hrs. METHODS: A retrospective clinical study was done on 364 consecutive patients with AMI who had been presented to Keimyung University Dong-sang Medical Center from January 1990 to May 1997(M:F ratio=254:110). The subjects were divided two groups. The Group I was patients who had expired during the initial 24hrs period of AMI(47 patients, 13%), the Group II was patients who had survived(317 patients, 87%). We compared clinical features, EKG, laboratory results in both groups and tried to analyse the vulnarable factors. RESULTS: The results were as follows; 1) The mean age in Group I (64.4 yearly) was older than in Group II(61.3 yearly) and female gender was also higher in Group I. The mean systolic/diastolic blood pressures of the Group I(103/61mmHg) were lower than those of the Group II(123/75mmHg). 2) The chest pain and mental change were noted more frequently in Group I than in Group II and the dyspnea was less frequent in Group I than Group II. 3) The higher grades of Killip classification was significantly more frequent in Group I than in Group II. 4) The mean onset to drug time for thrombolytics in Group I and Group II were 14.1 hrs and 6.6 hrs. 5) The mortality rate of the Group I and the Group II were respectively 13%, 6.6%. The most common causes of death were cardiogenic shock and ventricular arrhythmia. CONCLUSION: The mortality rate of initial 24 hrs of onset as form of sudden death was higher than post-24hrs group(66.2%). The factors for the higher mortality group were old age and female gender, and they were unstable in vital signs, higher Killip classifications. Therefore, these groups demand more rapid and aggressive approach than the other groups.

Factors Affecting to Prognosis of Traumatic Hip Dislocation

BACKGROUND: Incidence of traumatic hip dislocation have ween increased with development of transportation. Traumatic hip dislocation demands early recognition as an emergency and prompt reduction. So we designed this study to determine what kinds of factors affect the prognosis of the patient. METHODS: Eighty five patients who admitted emergency department of our hospital with the traumatic hip dislocation were enrolled in this study. Cause of injury, type of dislocation, method of reduction, the time from dislocation to reduction, age, gender and associated patellar injury were evaluated by retrospective chart reviews. RESULTS: Average age of excellent and good group(E&G) is 28+/-17.8 and fair and poor group(F&P) is 39+/-18.6, so the older the age the more poor prognosis(P<0.05). The time to take reduction of E&G group is 18+/-8.2 hours and F&P group is 25+/-12.6 hours, so the faster the better prognosis(P<0.05). We classify the type of hip dislocation by Thompson and Epstein method, type I to type V. The prognosis of type I is better than type V(P<0.05). Fifty five case were associated with patellar injury and they had poor prognosis than the other cases that were not associated with knee joint injury. CONCLUSION: In traumatic dislocated hip patients, the prognosis was poor in old age, delay in reduction, higher type of dislocation and associated with knee joint injury.

Pelvic Fracture Classification, Associated Injury and Hemodynamic Change

In general, pelvic fracture carries higher mortality especially from motor veicle accident, we have retrospectively reviewed charts and radiographs of 185 patients in order to identify clinical fading, kinds of fracture, hemodynamic changes and associated injuries in patients with pelvic fractures. We attempted to classify pelvic fractures according Young classification. The following results were obtained; 1. On age and sex distribution, the pelvic fractures showed peak incidence between 2nd decade and 5th decade. Male was affected more frequently than female, the ratio being male to female, 2.6 to 1. 2. The mechamisn of injury was motor veicle accident in 155(83.8%), fall in 25(13.5%), others in 5(2.7%). 3. The associated injuries of pelvic fractures: extremity, thoracic, urinary system, intraperitoneal and head injury. 4. Of the 185 cases of the pelvic fractures, simple pelvic fractures are 101 cases(54.6%), lateral compression in 39(21.1%), anteroposterior compression in 18(9.7%), vertical shearing in 17(9.2%), mixed pattern in 10(5.4%). 5. Retroperitoneal hematoma and urinary tracts injuries were the most common associated in mixed pattern. 6. The incidence of hemodynamically unstable fractures were 19.8% in simple pelvic fracture but, as expected was higher in major pelvic ring disruptions except to acetabular fracture(52.4%). 7. Mortality rates were 5.9% in all pelvic fractures but 10.7% in major pelvic ring disruptions except to acetabular fractures. Prognostic factor in pelvic fractures were the amount of hemorrhage and associated injuries, therefore early diagnosis and managements are essential to reduce the mortality in pelvic fracture.

A Clinical Study of Acute Pancreatitis

This study was designed retrospectively to evaluate Ranson's criteria and APACHE II scores as a predictor of mortality in patients with acute pancreatitis. Acute pancreatitis is a common disorder. From mild disease to multiorgan failure, it is a disorder that has numerous causes, an obscure pathogenesis. An accurate history and through physical examination will often raise clinical suspicion of acute pancreatitis in the differential diagnosis of a patient with acute abdominal pain. The retrospective analysis by chart review of 86 cases of acute pancreatitis who visited emergency department of Dongsan hospital from Jan to Dec 1996. The results were as follows. The majority of the patients with acute pancreatitis presented with chief complaints of abdominal pain. The male patient outnumbered female by the ratio of 2.9:1. The highest incidence of age group was between 40 and 50. The majority of our patients had past histories of either chronic alcoholic or gallbladder problems e.g.. the number being 53 cases(61.6%) and 31 cases(36%) respectively. Among 7 patients who had changes in consciousness, 5 were expired. Of those expired, 3 patients had less than 90 mmHg of systolic blood pressure. The overall mortality rate was 10.5%(9 cases). It has been known that acute pancreatitis would be the results of traumatic and non-traumatic causes. The exact mechanism of its pathophysiolgy has not been known yet, but it has been well known that the majority of patients who in forties and fifties had history of alcoholic abuse, the rest being mainly gallbladder problem and, some other diseases implicated too. The relationship of acute pancreatitis with familiar Ranson's criteria was such that 3 patients of the Ranson's out of 9 death were noted to have more than 3 of the criteria, but another 3 had less than 3. Among the 60 patients in whom the required physiologic variables were available out of total 86 patients studied, 9 were expired and 51 survived, average APACHE II scores for the survival and the expired being 6.92+/-3.99 & 18.11+/-5.68 respectively (P<0.05). We concluded that the APACHE II score could be used to better than Ranson's criteria to predict hospital mortality in patients with acute pancreatitis.

Clinical Observation in 1211 Cases of Burn Patients

We have reviewed 1211 burn patients who had visited our emergency department of Keimyung University Dongsan medical center between April 1995 to March 1997. The following results were obtained; 1) On age and sex distribution, the highest incidence of age group was under 10 year and old in 321 cases(26.5%). Male was affected more frequently than female, the incidence being 847 cases(70.1%) and 364 cases(29.9%). The ratio of male to female was 2.3:1. 2) No monthly and seasonal differences could be recognized. We found winter season having the highest 319 cases(26.3%), followed by autumn, spring and summer. 3) An analysis of causes in burns showed that flame burns were 527 cases(43.1%), scalding burns, 486 cases(40.2%), electrical burns, 96 cases(8.1%) and chemical burns, 48 cases(4.1%). 4) Domestic accidents accounted for 639 cases(52.7%), occupational for 286 cases(23.6%), traffic accidents for 160 cases(13.2%), suicides for 122 cases(10.1%), formentation for 4 cases(0.4%). 5) Most of patients 699 cases(57.7%) were affected with 2nd degree burn in depth, 1st degree for 413 cases(34.1%) and 3rd degree for 99 cases(8.2%). 6) The trunk was the anatomical region most commonly affected followed by upper and lower limbs. 7) 243 cases(20.5%) of all were accompanied by some complications. The main complications were would infection noted in 212 cases(17.5%), pneumonia in 179 cases(14.8%), acute renal failure in 160 cases(13.2), contracture in 155 cases(13.0), urinary tract infection in 24 cases(2.0%), Curling ulcer in 20 cases(1.6%) in order. 8) The over-all mortality rate was 73 cases(6.1%). The mortality rate of the patients with inhalation injury were 33 cases(45.3%). Causes of death were due to sepsis in 54 cases(4.5%), ARDS in 11 cases(0.9%), acute renal failure in 5 cases(0.4%), upper GI bleeding in 2 cases(0.2%), purmonary edema in 1 cases(0.1%).

CLINICAL ANALYSIS OF THE MUSHROOM POISONING

BACKGROUND: Mushroom poisonings are infrequent but potentially fatal. Most fatalities are due to the amatoxin containing species, particularly Amanita phalloides, Amanita virosa, Amanita verna which cause fulminant hepatic failure often with encephalopathy. METHODS: We experienced twenty two patients with acute mushroom poisoning admitted to Dong San hospital, Keimyung University through emergency department between January 1990 and September 1997. RESULTS: Mean age of the patients was 40.0 years and the ratio of male to female was 1 : 0.83. Seasonal distribution is 10 patients in July, 3 in August and 9 in September. The mean interval between ingestion and early symptom onset was 9.7 hours. Most of the patients had early gastrointestinal symptoms; abdominal pain, nausea, vomiting and diarrhea. except for a patient with associated mental change. The subsequent symptoms and signs follow up admission were fulminant hepatic failure(72.7%), renal failure(31.8%), mental change(27.3%), acute pancreatitis(9.1%), pericardial effusion(4.5%) and erythematous rash(4.5%). The outcomes of the patients were recovery(72.7%), death(18.2%) and hopeless discharge(9.1%). CONCLUSION: The patients who have mushroom poisoning are misdiagnosed as having viral gastroenteritis and are discharged frequently. The doctors and people should be educated not to overlook the severity of mushroom poisoning.

A Study on Diagnosis and Treatment of Acute Myocardial Infarction

As the incidence of acute myocardial infarction been increasing with prolongation of life spans, improvement in foods and life styles in Korea, rapid diagnosis and treatment is critical in survival of acute myocardial infarction patient. Most of the acute myocardial infarction result from atherosclerotic plaque forming thrombus and occlusion of coronary artery. Because early thrombolytic therapy is important to maintain the left ventricular function and survival rate, there have been many trials to reperfuse the occluded coronary artery. We have studied the many aspects of acute myocardial infarction such as sex, age, infarction site, chief complaints, change of ECG, change of serum enzyme, time delay on emergency room arrival, and compared the effectiveness of thrombolytic therapy. Total number of patient was 212, and males were 141(66.5%) and females were 71(33.5%). The most common infarction site was ant, fuel wall(102 cases,48%)of the heart and the most common chief complaint was chest pain(204 cases,97%). Among the 106 patients who received thrombolytic therapy, 101 patients(95%) had survived and 5 patients(5%) had died. Among the 64 patients who didn't receive thrombolytic therapy, 56 patients (87.5%) were alived and 8 patients(12.5%) were dead.