Epidemiology and outcomes of traumatic brain injury in Korean children according to age and development

Objective@#Traumatic brain injury (TBI) is one of the major causes of death and disability in children. Understanding the epidemiologic characteristics of TBI in children is the first step for developing preventative strategies, optimizing care systems, and rehabilitating the injury. @*Methods@#This is a cross-sessional study based on the Emergency Department-based Injury In-depth Surveillance (EDIIS) in Korea. We identified children (aged 0 to 18 years) who presented with TBI in emergency departments between January 2011 and December 2018. Subjects were classified into four groups according to age and development: infant and toddler group (0-2 years), pre-school group (3-5 years), school-aged group (6-11 years), and adolescent group (12-18 years). Epidemiologic characteristics and outcomes were compared according to age groups, and temporal variability in incidence was evaluated. @*Results@#During the 8-year study period, 45,734 children with TBI were included in the analysis. A higher incidence of TBI was observed in males, road accidents, and school/educational facilities as compared to the lesser-aged group (all P<0.01). Motor vehicle collisions were more common in the older group, but falls were more common in the younger group. Compared to the infant/toddler group, the adolescent group had higher intracranial injuries (8.1% vs. 16.8%; adjusted odds ratio [AOR], 1.8; 95% confidence interval [CI], 1.6-2.0) and mortality rate (0.2% vs. 1.3%; AOR, 2.0; 95% CI, 1.3-3.0). @*Conclusion@#The epidemiological characteristics of TBI in children are different for each group. It is necessary to develop differentiated preventative strategies and treatment systems based on the age groups of children.

Clinical course of compressed air injury with pneumocephlaus and orbital emphysema: a case report

Orbital emphysema with pneumocephalus is an unusual condition encountered in non-fracture craniofacial trauma. We report a case of orbital emphysema with disseminated pneumocephalus without any fracture, due to an orbital trauma caused by compressed air.

Clinical course of compressed air injury with pneumocephlaus and orbital emphysema: a case report

Orbital emphysema with pneumocephalus is an unusual condition encountered in non-fracture craniofacial trauma. We report a case of orbital emphysema with disseminated pneumocephalus without any fracture, due to an orbital trauma caused by compressed air.

The clinical usefulness of radiologic report monitoring system of CT and MRI in emergency department: analysis of missed and incidental findings

Objective@#This study was undertaken to establish a radiologic report monitoring system (RRMS) for missed and incidental findings (MIFs) in computed tomography (CT) and magnetic resonance imaging (MRI) reports, to help determine the clinical significance of MIFs in the emergency department (ED). @*Methods@#Patients presenting to our ED in 2017 were subjected to RRMS. Preliminary reports and final reports were subsequently compared based on the clinical significance of the MIFs. If required, the patient was contacted and instructed to revisit the ED. @*Results@#Totally, 12,132 CT and MRI exams were performed during the study period, and 321 cases (2.6%) encompassed MIFs. We attempted to contact 228 cases (1.9%) who had clinically significant MIF findings; 9 patients were instructed to return to the ED, whereas 105 cases were instructed to report to the outpatient department. Hospitalization was required for 12 patients: 2 cases required surgical intervention, 2 cases had an additional procedure, and 8 cases required medical hospitalization. @*Conclusion@#This study applied RRMS for a timely assessment of MIFs, determine rearrangements required, and present an active response to the MIFs determined in the ED. To improve patient care and safety, we hereby propose monitoring MIFs using the RRMS or similar methods.

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.

Effectiveness of limited airway ultrasound education for medical students: a pilot study

OBJECTIVE: The point-of-care ultrasound of the airway (POCUS-A) is a useful examination method but there are currently no educational programs for medical students regarding it. We designed a POCUS-A training curriculum for medical students to improve three cognitive and psychomotor learning domains: knowledge of POCUS-A, image acquisition, and image interpretation.METHODS: Two hours of training were provided to 52 medical students in their emergency medicine (EM) rotation. Students were evaluated for cognitive and psychomotor skills before and immediately after the training. The validity measures were established with the help of six specialists and eight EM residents. A survey was administered following the curriculum.RESULTS: Cognitive skill significantly improved after the training (38.7±12.4 vs. 91.2±7.7) and there was no significant difference between medical students and EM residents in posttest scores (91.2±7.7 vs. 90.8±4.6). The success rate of overall POCUS-A performance was 95.8%. The students were confident to perform POCUS-A on an actual patient and strongly agreed to incorporate POCUS-A training in their medical school curriculum.CONCLUSION: Cognitive and psychomotor skills of POCUS-A among medical students can be improved via a limited curriculum on EM rotation.

Rectal Perforation with Pneumoperitoneum Caused by Compressed Air

Compressed air can cause serious damage to internal organs. The stomach is an organ that is rarely perforated due to its elasticity. However, intestines are weaker and thinner compared to the stomach. A 40-year-old male came to the emergency room with severe abdominal pain due to dyspnea. The patient experienced abdominal pain right after his coworker shot compressed air into the patient's pants. The patient suffered from a rigid abdomen, and bed-side ultrasonography was carried out as soon as possible. Pneumoperitoneum was diagnosed by portable X-ray. After computed tomography, emergency paracentesis was carried out for decompression. After emergency paracentesis, the patient's symptoms and vital signs were stabilized. After the procedure, the patient had an emergency laparotomy.

Two cases of incidental Podostroma cornu-damae poisoning

Podostroma cornu-damae is a rare, deadly fungus. However, it can be easily mistaken for antler Ganoderma lucidum. In this case report, two patients made tea with the fungus and drank it over a 2-week period. Both patients presented with bicytopenia, and one patient had desquamation of the palms and soles. Both were treated with prophylactic antibiotics and granulocyte colony-stimulating factor. One patient was admitted to the intensive care unit and received a platelet transfusion. Both patients were discharged without complications. Podostroma cornu-damae infections caused by intoxication were successfully treated using our treatment strategy, which consisted of prophylactic antibiotics, platelet transfusion, and granulocyte colony-stimulating factor. We believe this report can guide future treatment.

Suggestion of a Modified Reduction Maneuvers with Parents in the Pulled Elbow Children

PURPOSE: If radial head subluxation, otherwise known as pulled elbow, occurs, closed reduction can be used in simultaneous diagnosis and treatment of the child. As the guardian seldom understands the maneuver without explanation, we revised a method to involve the caregiver in the treatment. METHODS: This was a prospective controlled study. From January, 2014 to December, 2014, children suspected of radial head subluxation, under the age of 6, were enrolled. Patients were randomly assigned to two groups. One group was treated conventionally and the other group was treated while the parent's finger was on the patient's lateral epicondyle. A total of three attempts were made using the hyperpronation method and the supination-flexion method. The physician then recorded whether the treatment was successful, the number of attempts, easiness of the reduction, and guardian's degree of understanding and satisfaction. RESULTS: A total of 116 patients were enrolled. The number of attempts was 1.27 and 1.35 times in the experimental group and the control group, respectively. The success rate was 96.6% in the experimental group and 94.7% in the control group. There was no statistically significant difference within the two groups. The physicians found that the revised method was as easy as the conventional method and the caregiver's degree of understanding was higher in the experimental group. CONCLUSION: As the revised method increases the degree of guardians' understanding and does not increase the difficulty of the procedure, we recommend using the revised method in treatment of radial head subluxation.

Development of an Emergency Abdominal Ultrasound Course in Korea: 1-Year Experience

PURPOSE: This report describes our 1-year experience with an emergency abdominal ultrasound course that we developed for emergency medicine residents and physicians. METHODS: The five-hour course consisted of didactic lectures and hands-on practice. A 1-hour didactic lecture was provided. The lecture consisted of basic ultrasound physics and principles, and anatomy for abdominal ultrasound. In the hands-on session, the instructors demonstrated the abdominal ultrasound techniques and then the students practiced on standard patients. Participants evaluated the programs using a five or ten point Likert scale. After two months to one year, the participants evaluated the usefulness of the course, their knowledge, and their self confidence. RESULTS: A total of 61 trainees participated in eight courses. The evaluation scores for overall quality of content, clinical utility, quality of educational method, quality of instructor, and time allocation were 4.4+/-0.7, 4.5+/-0.6, 4.3+/-0.6, 4.4+/-0.6, 4.1+/-0.7, respectively. Score of self-confidence of each scan before and after the course were as follows: liver scan, 3.2+/-2.1 to 6.9+/-1.2; gallbladder and bile duct scan 3.0+/-2.5 to 6.9+/-1.2; pancreas scan, 2.4+/-2.1 to 6.3+/-1.3; renal scan, 3.6+/-2.6 to 7.6+/-1.3. Evaluation scores were followed up after two months to one year to estimate self confidence of each scan. Results were as follows: liver scan, 6.1+/-1.5; gallbladder and bile duct scan, 6.5+/-1.6; pancreas scan, 5.5+/-1.8; renal scan, 7.2+/-1.5. CONCLUSION: The Emergency Abdominal Ultrasound Course is a fairly successful course. But continuous improvement of educational content, and development of an objective evaluation tool need to be done.

Emergency Abdominal Ultrasonography for Differential Diagnosis of Acute Abdominal Pain : COUCH (Complaint-oriented Ultrasonography with CHecklist) approach

PURPOSE: The purpose of this study was to verify objectively whether abdominal ultrasonography performed by emergency physicians (EP) in emergency departments (ED) immediately after history taking and physical examination could give effective diagnostic information and to check the feasibility and usefulness of the COUCH method. METHODS: From May 1, 2005 to September 30, 2005 we recruited 368 patients who complained of abdominal pain in the ED. Senior level emergency physicians (EP) conducted history taking and physical examinations, following which they were asked for their suspected diagnosis and their level of confidence (from maximum 5 to minimum 1) regarding each diagnosis. The same EP then performed abdominal ultrasonography (US), using the COUCH method and were again asked for their suspected diagnosis and level of confidence. We compared the suspected diagnoses and levels of confidence before and after abdominal US by using the t-test. RESULTS: A total of 106 patients (55 male, 51 female, average age 35.46+/-18.11 years) were enrolled. The number of patients with a suspected diagnosis of after history taking and physical examination only (2.43+/-0.5) was significantly greater than after abdominal US (1.34+/-0.5) (p<0.01). The level of confidences of suspected diagnosis of after history taking and physical examination only (3.43+/-1.14), by contrast, was less than after abdominal US (4.40+/-1.22) (p<0.01). Each year of postgraduate residents could have the same results after US. CONCLUSION: We found that abdominal ultrasonography could give EP more informations for pronouncing a correct diagnosis for patients with abdominal pain in the ED, and the COUCH method could lead the EP to get better training for ultrasonography and to diagnose more rapidly and accurately.

The Change of the Optic Nerve Sheath Diameter (ONSD) Following Treatment in Patients with Increased ICP

PURPOSE: Many reports have shown that the optic nerve sheath diameter (ONSD) can be measured easily by ultrasonography, and that it becomes wider when the intra-cranial pressure (ICP) is increased. However, there have been no reports comparing the two ONSDs following proper treatment. We measured the 2nd ONSDs of patients who were diagnosed with intra-cranial hemorrhage and increased ICP and who were admitted to an intensive care unit following management of their conditions, and analyzed the changes of the ONSDs and their relationship to the outcomes. METHODS: During the 10 months beginning December 1, 2004, we recruited 29 patients who were suspected to have increased ICP as indicated by computed tomography at the emergency center. Meeting any one of the following criteria was defined as elevated ICP: mid-line shifting of 3 mm or greater due to mass effect; a collapsed 3rd ventricle; hydrocephalus; effacement of sulci with significant edema; abnormal mesencephalic cisterns. We determined initial ONSDs by ultraonography and the Glasgow Coma Scale (GCS). At the 7th hospital day, GCS and ONSDs were re-evaluated and compared against the previous data. RESULTS: 29 patients (21 male, 8 female, average age 55.55 years) were enrolled. Mean GCS at the admission was 7.86+/-3.60. 18 patients had spontaneous hemorrhage (62%) and 11 patients had traumatic hemorrhage (38%). 22 patients received emergency surgery, 18 patients (62%) showed improved neurological outcomes and 11 (38%) failed to achieve any good outcomes. The initial mean ONSD was 5.41+/-0.70 mm. The average ONSD for traumatic hemorrhage (5.51+/-0.45 mm) was not statistically different from the ONSD for non-traumatic hemorrhage (5.35+/-0.84 mm) (p=0.55). The mean ONSD after 7 days of admission was 4.41+/-0.53 mm, which represented a significant decrease compared with the initial measurements (p<0.05). The mean GCS and ONSD showed significant differences between the improved group and the nonimproved group (GCS: 13.44+/-2.15, 3.82+/-3.82 respectively; and ONSD: 4.13+/-0.40 mm, 4.86+/-0.37 mm respectively; p<0.05). CONCLUSION : Among the patients with increased ICP, the ONSDs who progressed to good neurological outcomes after treatment had a significantly smaller diameter than those of the others. Through measurement of the ONSDs using ultrasonography, we could not only predict increased ICP but also determine the correlation between a patient's ICP and clinical course.

The Change of the Optic Nerve Sheath Diameter (ONSD) Following Treatment in Patients with Increased ICP

PURPOSE: Many reports have shown that the optic nerve sheath diameter (ONSD) can be measured easily by ultrasonography, and that it becomes wider when the intra-cranial pressure (ICP) is increased. However, there have been no reports comparing the two ONSDs following proper treatment. We measured the 2nd ONSDs of patients who were diagnosed with intra-cranial hemorrhage and increased ICP and who were admitted to an intensive care unit following management of their conditions, and analyzed the changes of the ONSDs and their relationship to the outcomes. METHODS: During the 10 months beginning December 1, 2004, we recruited 29 patients who were suspected to have increased ICP as indicated by computed tomography at the emergency center. Meeting any one of the following criteria was defined as elevated ICP: mid-line shifting of 3 mm or greater due to mass effect; a collapsed 3rd ventricle; hydrocephalus; effacement of sulci with significant edema; abnormal mesencephalic cisterns. We determined initial ONSDs by ultraonography and the Glasgow Coma Scale (GCS). At the 7th hospital day, GCS and ONSDs were re-evaluated and compared against the previous data. RESULTS: 29 patients (21 male, 8 female, average age 55.55 years) were enrolled. Mean GCS at the admission was 7.86+/-3.60. 18 patients had spontaneous hemorrhage (62%) and 11 patients had traumatic hemorrhage (38%). 22 patients received emergency surgery, 18 patients (62%) showed improved neurological outcomes and 11 (38%) failed to achieve any good outcomes. The initial mean ONSD was 5.41+/-0.70 mm. The average ONSD for traumatic hemorrhage (5.51+/-0.45 mm) was not statistically different from the ONSD for non-traumatic hemorrhage (5.35+/-0.84 mm) (p=0.55). The mean ONSD after 7 days of admission was 4.41+/-0.53 mm, which represented a significant decrease compared with the initial measurements (p<0.05). The mean GCS and ONSD showed significant differences between the improved group and the nonimproved group (GCS: 13.44+/-2.15, 3.82+/-3.82 respectively; and ONSD: 4.13+/-0.40 mm, 4.86+/-0.37 mm respectively; p<0.05). CONCLUSION : Among the patients with increased ICP, the ONSDs who progressed to good neurological outcomes after treatment had a significantly smaller diameter than those of the others. Through measurement of the ONSDs using ultrasonography, we could not only predict increased ICP but also determine the correlation between a patient's ICP and clinical course.

Accuracy of Emergency Physician's Ultrasonography in the Diagnosis of Acute Appendicitis

PURPOSE: Ultrasound (US) is one of the most useful modalities to diagnose appendicitis. However, without expert sonographers, the diagnosis of appendicitis via US is limited because it needs much experience to perform properly. Although many emergency physicians (EP) have used US successfully to diagnose appendicitis, there have been few studies comparing the diagnostic accuracy of EP's US with that of experienced radiologists. The purpose of this study is comparing the agreement and the accuracy rate of diagnosis of EP's US with that of experienced radiologists. METHOD: During 2 months, we enrolled 102 patients clinically suspected of having acute appendicitis; then, US was performed by an EP or a radiologist. The US examiner was selected at the time of the patient's arrival. In group I patients US was performed by a senior EP, while in group II patient's, it was performed by a radiologist. If any Group I patients were still in the ED when the radiology department open, US was performed once more by a radiologist. Pathologic reports and final diagnoses were reviewed later. We calculated the sensitivity, the specificity, and the accuracy for each group; then, we compared the accuracies of the two groups and analyzed the agreement of the US diagnoses between the two groups. RESULTS: Of the 102 patients that were enrolled, 62 patients had US performed by an EP, 66 had US performed by a radiologist, and 26 had US performed by both departments' examiners. The accuracies of US in diagnosing acute appendicitis were 93.5% in group I and 90.9% in group II. The agreement of US diagnoses between the two departments' examiners, in the patients had performed US by both departments, results were significantly similar (Kappa=0.708). CONCLUSION: This study suggested that a properly educated EP's sonographic diagnosis of appendicitis has the same diagnostic accuracy as that of a radiologist. Thus for reducing complications of acute appendicitis, it would be valuable for an EP to use US in the diagnostic process.

Clinical Study of Anaphylactic Patients with Bee stings Who Visited the Emergency Department

PURPOSE: There have been few studies of bee-sting anaphylaxis in patients visiting the Emergency Department. Thus, this study was performed to observe the general characteristics and the various clinical presentations of beesting anaphylaxis. METHODS: The study was performed for two years between January 2001 and December 2002. The objects of the study were 42 patients who were diagnosed as having anaphylaxis due to bee stings among patients who visited Pundang Jae-Saeng Hospital's Emergency Department. Emergency medicine residents directly followed the beesting anaphylaxis protocol. RESULTS: Males were 33 cases (78.6%), and female wewe 9 cases (21.4%). Severe anaphylaxis occurred in 25 cases (59.5%) and mild anaphylaxis in 17 cases (40.5%). The most frequent month was September with 12 cases (28.6%), and the most frequent place was the mountains with 15 cases (35.7% ). Of the 18 cases (42.9%) presenting with a prior bee-sting history, the incidence of severe anaphylaxis was 14 cases (77.8%) whilst of the 24 cases (57.1%) without any prior history, the incidence was 11 (45.8%)(p= 0.037). CONCLUSION: The history of a previous beesting is more related to the incidence of severe anaphylaxis, and of those patients presenting with systemic symptoms, the incidence rate of severe anaphylaxis is higher at 59.5%. Thus, it seems reasonable to treat patients presenting with systemic symptoms from bee stings or with a history of previous bee stings with early administration of epinephrine and to keep them under close observation.

Prognostic Value of an Initial Strong Ion Gap in Critically Ill Patients at the Emergency Department

PURPOSE: This study was performed to determine whether the anion gap, the base excess, the lactate, and the strong ion gap obtained in the emergency department correlate with the prognosis and whether the strong ion gap is the most useful marker compared to the prognostic ability of the anion gap, the base excess, and the lactate. METHODS: We reviewed the records of 106 patients admitted to the intensive care unit via the emergency department. We measured the anion gap, the base excess, and the lactate and we calculated strong anion gap by using a formula. We divided the patients into survivors and nonsurvivors and compared the prognostic abilities of the four variables by using the Student's t-test and receiver operator characteristic curves. RESULTS: The mean age of the patients was 67+/-14, and the numbers of males and females were similar (58 males vs 48 females). The number of survivors was 92 (86.7%), and that of nonsurvivors was 14 (3.2%). The anion gap ( 24.8+/-8.8 vs. 16.4+/-4.8 mmol/L, p value=0.000), the base excess (-11.9+/-8.7 vs. -3.49+/-6.5 mmol/L, p value = 0.001), the lactate (9.1+/-7.7 vs. 4.5+/-3.1 mmol/L, p value = 0.011 ) and the strong ion gap (16.6+/-3.6 vs. 10.9+/-3.7, p value=0.000) of the nonsurvivors were higher. All of the four varibles were associated with the prognosis, but among them, the strong ion gap discriminated most strongly with an area under the receiver operator characteristic curve of 0.866 (95% confidence interval, 0.787 to 0.92). CONCLUSION: The initial emergency-department acid-base variables, the anion gap, the base excess, the lactate and the strong ion gap have prognostic abilities, but the strong ion gap is the variable that most strongly predicts of mortality.

Accuracy of Echocardiography in the Emergency Medicine Department

PURPOSE: At the Emergency Department (ED), echocardiography of patients with chest pain, dyspnea, and syncope is essential to identify the underlying etiology such as acute coronary diseases or other cardiac diseases. Therefore, we studied the accuracy and the clinical value of echocardiography for use by the emergency physician as a tool for the identification and evaluation of cardiac diseases. METHOD: From first, September, 2003 to first, November, 2003, we collected the case histories of 40 patients with suspected cardiac diseases, on whom formal echocardiography had been performed within 2 hours after their initial ED echocardiography. The emergency physicians had a 4-hour didactic training course by cardiologists and 1 month of practical training at a formal echocardiography center, then, they performed the echocardiography using an Acuson ASPENT M ultrasound system with a 3.5-MHz phased-array transducer. Data from the emergency physicians and from the formal echocardiographers were analyzed using the wilcoxson sign test, and the correlation coefficient and p value were calculated. RESULT: There were 28 male patients (70.0%) and 12 female patients (30.0%) and the average age of all patients was 60.9+/-15.5 years. The left ventricular end diastolic diameters (LVEDD) from ED and formal echocardiography were, respectively, 44.6+/-7.9 mm and 48.7+/-6.6 mm (p=0.000), the interventricular septum thicknesses (IVS) were 11.6+/-3.6 mm and 10.9+/-3.0 mm (p=0.064), the left ventricular posterior wall thicknesses (LVPW) were 10.9+/-3.4 mm and 10.1+/-2.00 mm (p=0.178), the ejection fractions (EF) were 59.7+/-15.8% and 60.0+/-16.4%(p=0.312), the left atrium diameters were 36.5+/-6.3 mm and 37.0+/-5.8 mm (p=0.770), the aortic root diameters were 29.2+/-4.0 mm and 33.6+/-3.7 mm (p=0.001), and the inferior vena cava diameters (IVC) were 15.9+/-8.1 mm and 13.3+/-2.5 mm (p=0.444). Except for the LVEDD and the aortic root diameters, there were no significant differences between ED and formal echocardiography, and the presences of regional wall motion abnormalities (RWMA), relaxation abnormalities, right atrium enlargement (RAE), and right ventricle abnormalities were all concordant between the two groups. The correlation coefficients and the p values between ED and formal echocardiography were, respectively, 0.806 and 0.000 for LVEDD, 0.662 and 0.000 for IVS thickness, 0.725 and 0.000 for LVPW thickness, 0.922 and 0.000 for EF, 0.729 and 0.001 for left atrium diameter, 0.331 and 0.037 for aortic root diameter, and 0125 and 0.443 for IVS diameter. CONCLUSION: We suggest that ED echocardiography, like formal echocardiography, with additional focused training can measure and assess the structural and the functional parameters of the heart.

Clinical Value of a Video Otoscope in Diagnosis of Acute Otitis Media

PURPOSE: Acute otitis media(AOM) has variable clinical symptoms and is diagnosed with injection, bulging, and decreased mobility of tympanic membrane. There are many misdiagnoses because children who are suspected of having acute otitis media are uncooperative during diagnosis with an otoscope. An inaccurate diagnosis of acute otitis media when using an otoscope results in wasted of medical resourses and increased tolerance to antibiotics. Therefore, this study was conducted to evaluate the usefulness of a video otoscope as a tool of diagnosis of acute otitis media. METHODS: Among 416 patients who visited Pundang Jesaeng Hospital Emergency Medical Center with a complaint of otalgia from 1 October 2002 to 30 September 2003, we studied 51 patients who were followed up at the otorhinolaryngology depatment. Emergency Medicine residents recorded the findings for tympanic membrane by using an otoscope and by using a video otoscope. we used kappastatistics to carry out a prospective study in which the accuracy of diagnosis of AOM was analyzed by comparison with the confirmed diagnosis by an otolaryngologic specialist. RESULTS: In this study, the number of males was 24 (47%) and that of females was 27 (53%). Of the 51 Patients, 22 (43%) presented with rhinorrhea, 15 (29%) with cough, 11 (22%) with sputum, 10 (20%) with fever, 8 (16%) with a sore throat, 7 (14%) with otorrhea, 4 (8%) with hearing difficulty, 3 (6%) with irritability, 3 (6%) with tinnitus, 3 (6%) with vomiting and 2 (4%) with dizziness. A comparison of the diagnostic accuracy of AOM between otolaryngologic specialist and residents in emergency department, when was undertaken by using kappa statistics, and a diagnostic agreement of 65% (kappa=0.28) for the otoscope, and 76 %( kappa=0.45) for the video otoscope. The diagnostic sensitivity of acute otitis media by video otoscope was 75%, and specificity was 82%. CONCLUSION: When the tympanic membrane of the patient suspected of a having AOM is examined in an emergency medical center, video otoscopy should be a useful diagnostic tool for AOM owing to its high diagnostic accuracy.