Etomidate Should be Used Carefully for Emergent Endotracheal Intubation in Patients with Septic Shock

Etomidate and midazolam are the most popular drugs among the induction agents for emergent endotracheal intubation. The purpose of this study was to compare the incidence of adrenal insufficiency and mortality between the septic shock patients who received etomidate (ETM group) and those who received midazolam (MDZ group). Between November 2004 and September 2006, 65 patients were analyzed in this study. The hospital mortality rate was 36% in the ETM group (n=25) and 50% in the MDZ group (n=40), which was not statistically significant (p=0.269). The incidence of relative adrenal insufficiency was significantly higher in the ETM group than in the MDZ group (84% and 48%, respectively; p=0.003). On multivariate analysis, the use of etomidate was the only significant factor affecting the incidence of relative adrenal insufficiency (odds radio, 5.59; 95% confidence interval, 1.61- 19.4). In conclusion, we think that physicians who treat patients with septic shock should be aware that etomidate can cause adrenal insufficiency, and should start corticosteroids if etomidate is administered.

Factor for The Dissatisfaction of Patient for Emergency Department Services

PURPOSE: To evaluate patient satisfaction with emergency department (ED) services and to identify factors influencing dissatisfaction. METHODS: Direct interviews with questionnaires were administered at 18 EDs during a 6-day period from July 26 to July 31, 2006. All patients and accompanying persons who visited the ED during the survey period were included. Questionnaires consisted of 14 questions regarding the patient's characteristics (determinants), 9 questions about ED services (components) evaluated on a 5-point Likert scale, and 2 questions to gauge overall ED satisfaction rated on a 5-point Likert scale and a visual analogue scale (VAS). Overall dissatisfaction was modeled using logistic regression. RESULTS: Of the 708 patients visiting ED during the survey period, 322 patients consented to an interview (response rate: 45.5%), including 286 who gave complete responses. Among the 286 complete responses, 177 indicated an overall satisfaction of ED service, rating it at 79.2% on the VAS. The determinant "number of ED visits >1 for last 1 year" and all questions in the components category were related to overall dissatisfaction. In logistic regression modeling, the determinants "age> or =45 years" and "number of ED visits >1 for last 1 year" correlated with overall dissatisfaction. In the final model, dissatisfaction with the comfort of the waiting room (OR=2.6, 95% CI:1.3-5.0), care received from the physicians (OR=4.0, 95% CI:2.0-8.3), care received from the nurses (OR=3.6, 95% CI:1.6-7.7), and waiting time to receipt of treatment (OR=5.8, 95% CI:2.9-11.3) were all related to overall dissatisfaction. CONCLUSION: In order to reduce dissatisfaction with ED services, EMS policies should be formulated to improve care by physicians and nurses and to decrease the perceived waiting time.

Are We Using the Appropriate dose of Sedatives during RSI? : Retrospective Observational Study in Two Emergency Centers

PURPOSE: The use of rapid sequence intubation (RSI) by emergency physicians in emergency departments is increasing. Our aim was to evaluate the current practice of RSI, focusing particularly on the appropriateness of sedative dose. METHODS: We retrospectively investigated RSI cases in two urban emergency centers occurring between June 2005 and May 2006. We calculated the sedative dose used per patients' weight and divided into a low dose group (less than the minimum recommended dose) and a full dose group. We investigated the differences between these two groups, including hemodynamic changes, success rates and complication rates. RESULTS: Of 745 cases of endotracheal intubation performed, 211 cases were defined as RSI cases. The mean sedative dose was 0.29 mg/kg (+/-0.08 SD) for etomidate and 0.08 mg/kg (+/-0.03 SD) for midazolam. Sedatives were underdosed in 56.3% of etomidate cases and 82.1% of midazolam cases, for a mean underdose rate of 63.6%. Drops in SBP (systolic blood pressure) were significantly different between the etomidate and midazolam groups (-14.4 mmHg vs -22.43 mmHg, p=0.04), but there was no significant difference in SBP between low dose and full dose groups. The overall complication rate was 17.1%, was again with no significant difference between full dose and low dose groups. CONCLUSION: Overall, sedatives were underdosed in 63.6% of cases with midazolam more frequently underdosed than etomidate. However, the underdosing of sedatives was not significantly correlated with the first pass rate or the complication rate.

Clinical Features of Emergency Department Visits by Patients Infected with Human Immunodeficiency Virus and Need for Infection Control

PURPOSE: The aim of this study was to evaluate the clinical features of emergency department (ED) visits by patients infected with human immunodeficiency virus (HIV) and the need for infection control strategies. METHODS: We retrospectively reviewed electronic ED logs and medical records to find all ED visits by HIV-infected patients from November 1999 to May 2004. The demographic data, the ED disposition, and the length of ED or hospital stay were collected from the ED logs. Clinical and laboratory data were obtained from the medical records. RESULTS: A total of 91 ED visits by HIV-infected 57 patients were considered. The mean age of the patients was 40.7+/-10.9 years, and 91.2% of the patients were male. Among these visits, 53 (58.2%) involved AIDS-related conditions (the AIDS-related group); the other 38 visits by HIV-infected patients were for non-AIDS-related reasons (the non-AIDSrelated group). There was no statistical difference between AIDS-related and non-AIDS-related groups in the length of ED stay (33.2 vs. 39.8 hours, p=.458). Fever was the most common complaint (n=23, 16.0%). As categorized diagnoses, constitutional symptoms were the most common (n=38, 26.4%). A total of 51 patient-visits (56.0%) were admitted to the hospital, and the most common final diagnosis was pulmonary disease (n=22, 43.1%). The number of ED visits by patients with active pulmonary tuberculosis was 15 (16.5%), which represented 22.4% of ED visits by patients with constitutional or respiratory symptoms. CONCLUSION: Fever was the most common cause of ED visits by HIV-infected patients, and pulmonary disease was the most common diagnosis. Patients with the active pulmonary tuberculosis who need respiratory isolation are common among HIV-infected patients.

What to Wear in the Emergency Deparence for Physican's Attire and Appearance in the ED

PURPOSE: This study was done to evaluate patients' and physicians' attitude toward emergency physician's professional appearance in the ED. METHODS: By way of a survey, the patients and guardians of 87 patients presenting to the Emergency Department of Seoul National University Hospital (patients' group) were shown 6 photographs of physician's dress style and asked questions related to their preference for each physician's dress style. The same questions were also given to 52 medical personnel (medical group: physicians, nurses, and paramedics of the emergency department). RESULTS: There was no preference for formal suit or casual suit without white laboratory coat in either group. Fifty-eight (73.4%) of the patients' group preferred a formal suit with white coat whereas 22(44.0%) of the medical group preferred a formal suit with white coat (p=0.008). As to surgical scrubs with or without a white coat, there was a preference in both group. However, the medical group liked 'scrubs+white coat' more than the patients' group (p=0.003). Of 12 other items, 4 items (dyed hair, no tie, a Tshirt, and sports shoes) were preferred and 7 items (longhair/ponytail (man), mustache/beard, blue jeans, sportswear, mini-skirt, earrings (man) and bracelets) were not preferred by the either group. However, there is a disconcordance about slippers/sandals between the patients' group and the medical group (27.8% vs 56.8% preferred them; p=0.003). CONCLUSION: Patients and their guardians preferred emergency department doctors to be dressed in formal dress with a white coat, but also accepted surgical scrubs whereas medical personnel preferred scrub with white coat.

The Antioxidant Effect of vitamin C on the Paraquat Poisoning

BACKGROUND: Paraquat is widely used herbicide. But if it is ingested by accident or by suicidal attempt it causes severe toxicity. And in emergency room, it is a big problem that there is no effective treatment modality for paraquat intoxication. It is reported that the mechanism of toxicity is by oxygen fee radical. And Vitamin C is known as potent antioxidant. This study was designed to evaluate the antioxidant effect of Vitamin C to lipid peroxidaton in paraquat intoxication. METHODS: 24 rats were divided to 6 groups after paraquat injection(20mg/kg), and each groups 4 rats. In 2 control groups we only observed until 6 hours and 24 hours. And Vitamin C of 10 mg per kilogram body weight on the low dose group and 100 mg per kilogram body weight on the high dose group were infected simultaneously. And in 6 hours group, after 6 hours of paraquat and vitamin C injection biochemical levels of malondialdehyde, superoxide dismutase and catalase were measured in liver and lung. And in 24 hours group after 24 hours the same measures were done. The stasistical methods used were ANNOVA and Mann-Whitney test and P-value was 0.05. RESULTS: Malondialdehyde level of high dose Vitamin C group was significantly low compared to that of the control groups in liver tissues after 24 hours(p<0.05). And in lung tissues both low dose and high dose vitamin C groups show significantly low level of malondialdehyde level after 24 hours(p<0.05). On the superoxide dismutase activity, only high dose Vitamin C group shows significantly high level in 24hours both in liver and lung tissues. And the catalase activity is significantly elevated in high dome Vitamin C group after 24hours both in liver and lung tissues. (p<0.05) CONCLUSION: High dose Vitamin C suppresses lipid peroxidation, increases catalase activity and superoxide dismutase activity in paraquat intoxiation. It is thought to by antioxidant elect of vitamin C but it's effect is observed only in 24 hours after intoxication.

A Clinical Review of Esophageal Varix Bleeding Patient in Pediatric Emergency Center

BACKGROUND: Varix bleeding in children is infrequent but it is potentially fatal. It has characteristics different from adult age varix bleeding. But there was little clinical data about it. The purposes of this study is to detect its characteristics of varix bleeding in pediatric patients, and to help an emergency physician make a decision about the management. METHODS: We reviewed medical records of 32 patients who visit Seoul National University Hospital Pediatric Emergency center from Jan. 1, 1995 to Dec. 31, 1996. RESULTS: 1) The peak age was between 1 and 5 years of age, and the ration of males to females was 1: 1. 2) As a underlying cause, intrahepatic disease were more common than extrahepatic diseases(87.1%:12.9%). 3) 10 patients(31.3%) had URI symptoms as a precipitating factor. 4) Varix bleeding has a circardian rhythm, and occured more often during the night. 5) In Child Classification for the hepatic reserve fuction, Child C was the most common(75%). 6) Endoscopic eliminations were performed in 14 patients(43.8%). 7) According to shock classification. the ration of conservative to vasopressin treatment in class I and class II were 13(40.6%)/10(31.3%) and 6(18.8%)/3(9.4%), respectively. 8) Fever was the most common complication(43.8%), and the mortality rate was 3.1%. CONCLUSION: We suggest that the only conservative management can show a good result far pediatric varix bleeding compared to other treatment modalities.