Is the shock index a useful tool in trauma patients with alcohol ingestion?

Objective@#Alcohol consumption is a frequent risk factor for trauma. The shock index is widely used to predict the prognosis of trauma, and alcohol can influence the shock index in several ways. This study investigated the usefulness of the shock index in trauma patients who had ingested alcohol. @*Methods@#This was a retrospective, observational, single-center study. We performed a logistic regression analysis to assess the association between alcohol consumption and massive transfusions. A receiver operating characteristic (ROC) curve was constructed to determine the predictive value of the shock index for patients who had ingested alcohol. @*Results@#A total of 5,128 patients were included in the study. The alcohol-positive group had lower systolic blood pressure and higher heart rate; consequently, the shock index in this group was higher. There was no significant difference between the proportion of the alcohol-positive and alcohol-negative groups who underwent massive transfusions and suffered hospital mortality compared to the overall proportion of patients who underwent massive transfusion based on the shock index. In the logistic regression analysis, the alcohol-negative group showed higher odds ratios for massive transfusions compared to the alcohol-positive group. The area under the ROC curve for predicting massive transfusion was 0.831 for the alcohol-positive group and 0.825 for the alcohol-negative group. However, when a cutoff value of 1 was used, the false positive rate was significantly higher in the alcohol-positive group. @*Conclusion@#The shock index is a useful tool for predicting outcomes in patients with trauma. However, in patients who have ingested alcohol, the shock index should be interpreted with caution.

Carbon monoxide poisoning-induced type 1 Brugada electrocardiographic pattern

Carbon monoxide (CO) can cause a variety of electrocardiogram (ECG) changes. The Brugada ECG patterns are very rare in CO poisoning cases. We detected a patient with a CO-induced type 1 Brugada ECG pattern with chest pain. The panel genetic test and echocardiogram revealed normal findings. The Brugada phenocopy gradually improved over 3 days. We reviewed the literature and suggested possible mechanisms.

Clinical analysis of endovascular management in blunt thoracic aortic injury

Objective@#Blunt thoracic aortic injury (BTAI) is a rare but fatal injury. BTAI has been treated surgically, but thoracic endovascular aortic repair (TEVAR) is used as a treatment option and has shown good results. The purpose of this study was to analyze the outcomes of patients with BTAI treated using TEVAR. @*Methods@#BTAI patients who had received TEVAR for five years were analyzed. We investigated injury severity score, aortic injury site, computed tomography findings and mortality. @*Results@#We identified 17 patients, and all were diagnosed using computed tomography. Twelve patients received TEVAR as an emergency, and the remaining five patients received TEVAR delayed. The most common injury site was isthmus (82%), and the median injury severity score was 33. There were 15 cases with a BTAI grade of 3 and two cases with a BTAI grade of 4. The mortality rate was 11.8% (n=2). @*Conclusion@#TEVAR is more meaningful because it is easier and faster and has fewer complications than thoracotomy in patients with traumatic aortic injury.

Use of succimer as an alternative antidote in copper sulfate poisoning: A case report

Copper sulfate is widely used as a fungicide and pesticide. Acute copper sulfate poisoning is rare but potentially lethal in severe cases. Copper sulfate can lead to cellular damage of red blood cells, hepatocytes, and myocytes. Toxic effects include intravascular hemolysis, acute tubular necrosis and, rhabdomyolysis. A 76-year-old man presented with vomiting and epigastric pain. He had ingested a copper-containing fungicide (about 13.5 g of copper sulfate) while attempting suicide 2 hours prior to presentation. From day 3 at the hospital, laboratory findings suggesting intravascular hemolysis were noted with increased serum creatinine level. He was treated with a chelating agent, dimercaptosuccinic acid (succimer). His anemia and acute kidney injury gradually resolved with a 19-day regimen of succimer. Our case suggests that succimer can be used for copper sulfate poisoning when other chelating agents are not available.

Appropriateness of Korean Triage and Acuity Scale-based triage system for dizziness without neurologic symptoms

Objective@#This study aimed to identify the appropriateness of the Korean Triage and Acuity Scale (KTAS) for dizziness without neurological symptoms, which was level 3. @*Methods@#Using the registry of the National Emergency Department Information System (NEDIS), data regarding consecutive emergency patients from January 2016 to July 2018, who were aged 15 years and older, were reviewed retrospectively. The data were classified using KTAS and Dizziness KTAS level 3 were compared with non-dizziness KTAS level 3 including age, total admission rate, intensive care unit (ICU) admission rate, discharge rate, hospital cost, and length of stay in the emergency department (length of stay [LOS]). @*Results@#Of the 76,153 emergency patients, 345 (0.5%) had a KTAS level 1, 4,593 (6.0%) had a KTAS level 2, 21,561 (28.3%) had a KTAS level 3, 45,390 (59.6%) had a KTAS level 4, and 4,264 (5.6%) had a KTAS level 5. As the patient’s triage score decreased, the total admission rate, ICU admission rate, hospital cost, and LOS decreased. Patients discharged to home also had the same result. Dizziness KTAS level 3 had a significantly lower rate of total admission (23% vs. 56.2%, P<0.001) and ICU admission (0.9% vs. 6.2%, P<0.001) compared with non-dizziness KTAS level 3. On the other hand, the hospital cost and LOS were higher when patients were discharged to their home. The predictors of the admission rate of dizziness KTAS level 3 were the transportation method using a private ambulance service and older age, but older age was only slightly associated. @*Conclusion@#This study showed that KTAS level 3 for dizziness needs to be adjusted because of lower severity than other level 3. Old age and the transportation method should be considered factors.

Effect of vasopressin on prognosis in sepsis shock

Objective@#This study analyzed the relationship between the timing of vasopressin treatment and the prognosis ofpatients with septic shock. @*Methods@#Patients who were admitted to a university hospital for one year using vasopressin were studied retrospectively.All records were collected through the medical records; several factors were studied to determine the prognosis of thepatient. The 24-hour, 48-hour mortality, and hospital mortality were examined. The difference in the timing of vasopressinadministration between death and survival patients was analyzed to determine the effect of the vasopressor on the survivalrate using the receiver operating characteristic (ROC) curve. @*Results@#The general characteristics of the patients in the hospital and survivors were similar. Vasopressin infusion wasfaster in the surviving patients than in the death patients, but there was no significant difference (survival, 187.0 minutes;interquartile range [IQR], 95.0-548.0 minutes vs. death, 285.5 minutes; IQR, 92.7-739.2). To determine the effect of vasopressorinjection on the survival rate, the ROC curve was drawn, and the area under curve was not affected significantlyby norepinephrine (NE) 0.416 and vasopressin 0.529. In addition, the duration of the ventilator application was found toincrease with increasing NE injection period in survivors (period of application of ventilator: NE injection time, r=0.460,P=0.048; vasopressin, r=0.369, P=0.120). @*Conclusion@#The prognosis was similar regardless of the timing of vasopressin in patients with septic shock.

Factors and Their Correlation with Injury Severity of Elderly Pedestrian Traffic Accidents

PURPOSE@#No previous study has assessed elderly pedestrian traffic accidents based on a nationwide database. This study aimed to help primary physicians who examine patients in emergency departments to determine and make prompt and accurate treatment decisions.@*METHODS@#This study used data from the Emergency Department-based Injury Indepth Surveillance from 2013 to 2017, managed by the Korea Centers for Disease Control and Prevention. Pedestrians aged ≥65 years were included, and using multivariate logistic regression multiple factors were analyzed to determine their relationship with injury severity.@*RESULTS@#Of 227,695 subjects, 6,498 were included, of whom 2,065 (31.8%) were severely injured. There were more female than male patients in all severity groups. Most accidents occurred in the afternoon and on general roads. In the multivariate analysis, the odds ratio (OR) of injury severity for male pedestrians was 1.165 (95% confidence interval: 1.034–1.313, p=0.012). Older age of patients and the use of ambulances were associated with greater injury severity. The accident time affected the degree of injury severity; i.e., compared to dawn, injury severity increased in the morning (OR: 1.246, p=0.047) and decreased at night (OR: 0.678, p<0.001). A significant difference was noted in the correlation between the type of vehicle causing the accident and the accident severity; i.e., motorcycle accidents had lower severity than bicycle accidents (OR: 0.582, p=0.047).@*CONCLUSIONS@#Injury severity was correlated with sex, age, transportation to the ED, TA onset time, and type of vehicle. The study results suggest that injury severity may be positively reflected in initial assessments and overall integrated treatments by physicians and in the related policies.

Comparison of medical resources usage between young adult patients and elderly patients: a single center, retrospective observational study

OBJECTIVE@#Under the overcrowding conditions of large emergency departments, the proportion of elderly patients is increasing in Korea. This paper describes the necessity of the preparedness of Korean emergency departments and society for the rapidly aging population.@*METHODS@#This was a retrospective observational study. Patients who presented to a tertiary hospital emergency department (ED) in one year were included. The use of medical resources between young adult (≥20 and <65 years of age) and elderly patients (≥65 years of age) was compared.@*RESULTS@#This study included 26,712 patients. The young adult group and the elderly group was 15,021 (56.2%) and 11,691 (43.8%), respectively. The ratio of firehouse ambulance visit mode (28.6%) and inter-facility transfer visit mode (18.9%) of the elderly group was higher compared to those of the young adult group (26.4% and 10.6%, P<0.001). The elderly group visited more at daytime (P<0.001). With aging, the admission ratios of the elderly group to the general ward (38.9%) and intensive care unit (13.0%) were higher than the young adult group (9.8% and 4.3%, P<0.001). The mean ED length of stay and mean length of hospitalization of the elderly group was longer than that of the young adult group (P<0.001). The medical cost of the elderly group was approximately three times higher than that of the young adult group.@*CONCLUSION@#Elderly patients required more emergency medical resources in both the prehospital and hospital stages. Korean emergency departments and society require efforts for not only expansion but also the appropriate use of medical resources in a rapidly aging population.

The influence of symptom to balloon time in ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

OBJECTIVE@#The current guidelines for the treatment of ST-segment elevation myocardial infarction (STEMI) recommends early reperfusion with a door to balloon (DTB) time of 90 minutes or less in patients undergoing primary percutaneous coronary intervention (PPCI). Therefore, the focus of most studies has been the DTB time. On the other hand, the ischemic time is related to the symptom to balloon (STB) time rather than the DTB time. This study examined the clinical effects of the STB time as well as the social and clinical factors affecting the STB time in STEMI patients.@*METHODS@#This study analyzed 286 patients diagnosed with STEMI from December 2008 to December 2016. The STB time (≤4 hours and>4 hours, ≤12 hours, and >12 hours) in the groups was compared. The mortality and ejection fraction were investigated. In addition, the characteristics of patients and socioeconomic factors affecting STB were analyzed.@*RESULTS@#The SBT time is inversely associated with the ejection fraction (R=−0.126, P=0.033), and the ejection fraction of the ≤12 hours group was higher than that of the >12 hours group (54% vs. 50%, P=0.047). On the other hand, there was no significant difference in mortality between the two groups (3.26% vs. 4.84%, P=0.506). In multivariate analysis, the variable related to SBT was only typical chest pain (adjusted odd ratio, 1.931; 95% confidential interval, 1.014-3.792; P=0.045).@*CONCLUSION@#The results of the study support the prognostic value of SBT in STEMI undergoing PPCI. Therefore, efforts should be made to shorten the STB time.

Changes in Relative Importance of the 5-Level Triage System, Korean Triage and Acuity Scale, for the Disposition of Emergency Patients Induced by Forced Reduction in Its Level Number: a Multi-Center Registry-based Retrospective Cohort Study

BACKGROUND: The 5-level triage tool, the Korean Triage and Acuity Scale (KTAS), was developed based on the Canadian Triage and Acuity Scale and has been used for triage in all emergency medical institutions in Korea since 2016. This study evaluated the association between the decrease in level number and the change in its relative importance for disposition in the emergency department (ED). METHODS: Using the registry of the National Emergency Department Information System (NEDIS) ver. 3.1, data regarding consecutive emergency patients from March 2017 to October 2017 were reviewed retrospectively. Reconfiguring KTAS levels, a total of 15 multinomial logistic regression models (KTAS_0 to KTAS_14), including the KTAS, its variants, and covariates were constructed to determine significant factors affecting ED disposition. The relative importance of each model was obtained using a dominance analysis. RESULTS: A total of 79,771 patients were included in the analysis. In the model KTAS_0, the KTAS and 8 covariates were found to be significantly related to ED disposition. The KTAS and the decision maker of each ED visit, whether it was the physician or others, had the largest relative importance, 34.8% and 31.4%, respectively (P < 0.001). In other models of KTAS variants, including 4-level, 3-level and 2-level, the rates of the KTAS decreased to 31.8% (interquartile range [IQR], 28.9–34.2), 26.4% (IQR, 23.2–31.0), and 18.7% (IQR, 7.5–24.9), respectively (P = 0.016). On the other hand, the rates for covariates tended to be larger for smaller triage levels and so there was a significant interaction effect between the KTAS and the covariates according to the triage level (P < 0.001). CONCLUSION: The 5-level triage tool, the KTAS, had the largest relative importance among the predictors affecting ED disposition only at its original level. Therefore, it is recommended that no attempt should be made to reduce the number of levels in the triage tool.

Factors associated hospital admission in patients with low acuity visiting emergency department

OBJECTIVE: Patients with low acuity who need hospitalization may be at risk if they do not receive proper treatment in overcrowded emergency rooms. This study was conducted to investigate factors affecting the hospitalization of patients with low acuity of Korean Triage and Acuity Scale (KTAS). METHODS: This study was a retrospective chart review analysis of patients aged 15 years or older who had triaged as KTAS 4 and 5 grades when visiting a local emergency medical center from January 1, 2016 to December 31, 2017. Multivariate logistic analysis was performed to analyze the effects of age, sex, reasons for visiting, visiting route, ambulance utilization, KTAS grade and major category on patient admission. RESULTS: A total of 10,540 patients were enrolled and the odds ratio (OR) increased with age from those aged over 34 years (P < 0.001). Patients that triaged as KTAS grade 5 (adjusted OR, 1.57; 95% confidence interval [CI], 1.36–1.82), had a condition caused by disease (adjusted OR, 2.31; 95% CI, 2.00–2.68), and visited by using an ambulance (public: adjusted OR, 1.05; 95% CI, 0.91–1.22; private: adjusted OR, 4.60; 95% CI, 3.85–5.49) were more likely to be hospitalized. Individuals in the “general” major category were more likely to be hospitalized than those falling into other major categories (P < 0.001). CONCLUSION: The factors influencing the hospitalization of patients with low acuity were age, reasons for visiting, visiting route, ambulance utilization, KTAS grade and major category on patient admission.

Relationship between emergency department disposition, level of emergency base on Korean Triage and Acuity Scale, visit mode

OBJECTIVE: The policy to judge the level of emergency (emergent vs non-emergent) based on Korean Triage and Acuity Scale (KTAS) has been introduced by government to control the flow of emergency patients. The purpose of this study is to identify the variables expected to affect the disposition and to compare the relative importance of the variables. And we also evaluate the validity of the policy to judge the level of emergency based on KTAS. METHODS: We enrolled a total of 29,865 patients who visited a Wide Regional Emergency Center in Busan from Jan 2016 to Dec 2016. Data of those patients were extracted from National Emergency Department Information System (NEDIS) and analysed retrospectively. We determined disposition as the outcome variable. We evaluated the relationship between disposition and visit time, visit mode (firehouse ambulance, inter-facility transfer and self-transport), level of emergency based on KTAS, cause of morbidity. And we also evaluated general and conditional dominances of those variables to compare their relative importance each other. RESULTS: The disposition of the patients was discharge to home (53.5%), general ward admission (30.3%), intensive care unit admission (11.6%), and inter-facility transfer (4.8%). In the univariate analysis, age, gender, visit time, visit mode, cause of morbidity, KTAS level had a significant effect on the disposition. All variables that had a significant effect on univariate analysis also had a significant effect on disposition in multivariate analysis. As a result of dominance analysis, visit mode was the most important variable in both general dominance and conditional dominance. However, if KTAS was devided into 5 levels, it was the most important variable. CONCLUSION: Level of emergency based on KTAS was significantly effective on patient disposition, however it was relatively less important compared to the visit mode. If the visit mode is reflected in the triage system, triage accuracy is expected to be improved. And it also can be a good option to construct triage system based on 5 level KTAS.

Is STONE score a useful tool for limiting the use computed tomography in the patients suspected ureter stone? - A single-center retrospective study

OBJECTIVE: The STONE score was developed to gauge the ureter stone probability. On the other hand, it is unclear if the STONE score is also applicable to Koreans. This study evaluated whether the STONE score can identify patients with suspected nephrolithiasis for whom a computed tomography (CT) scan can be obtained in the emergency department, targeting Koreans. METHODS: Patients presenting to the emergency medicine (ED) with flank pain and a suspicion of a ureter stone between January 2016 and December 2016 were reviewed retrospectively. After calculating the STONE score, the enrolled patients were classified into the low, moderate, high score group. In each group, the prevalence of a ureter stone and other clinical diseases on a CT scan were investigated. RESULTS: Among the 156 patients included in the analysis, 124 (79.5%) had a ureter stone and an alternative diagnosis was made in 12 (7.7%). The prevalence of a ureter stone and alternative diseases in the high score group was 87.7% (71/81) and 4.9% (4/81), respectively. The proportion of patients with nephrolithiasis increased significantly (P < 0.001), but the proportion of patients with other clinical diseases did not decrease significantly across the score groups (P=0.196). The area under the receiver operating characteristic curve was 0.711 (95% confidence interval, 0.633–0.780; P=0.001) with a cut off score higher than 8 (sensitivity 82.3%, specificity 50.0%) for the STONE score. CONCLUSION: In this setting, the STONE score had a low specificity and could not accurately assess a ureter stone. More studies aimed at Koreans are warranted before a CT scan can be limited using the STONE score.

The Usefulness of the mPTS (modified pediatric trauma score) and Newly Developed Extended mPTS as a High Risk Pediatric Trauma Patients Screening Tool: Support of Two Tiered Trauma Team Activation System

PURPOSE: A secondary triage tool for pediatric trauma patients, “modified pediatric trauma score (mPTS)” was introduced to predict high risk trauma. METHODS: Pediatric trauma patients (≤15 years) presenting to the Pusan National University Hospital trauma center emergency department were analyzed retrospectively. The patients were classified into high risk and low risk groups. The high risk group was assigned an Injury Severity Score ≥12, death, intensive care unit admission, or urgent intervention (intubation, closed thoracostomy, emergency angiography and embolization, emergency surgery). The airway, blood pressure, fractures, level of consciousness, and external wounds were evaluated and the mPTS was calculated. RESULTS: One hundred seventy-seven patients were enrolled in this study. The mPTS had a sensitivity, specificity, positive predictive value, and negative predictive value of 88%, 54%, 60%, and 85%, respectively. Overtriage and undertriage was 39% and 14%, respectively. The mPTS missed 6 high risk patients and all 6 patients were abdominal injury patients. The mPTS was modified to include an abdominal physical examination and/or focused assessment with sonography for trauma. The newly developed scoring system was called the extended mPTS (E-mPTS). The E-mPTS had a sensitivity of 98% and negative predictive value of 98%. The safe level of overtriage (38%) was maintained. CONCLUSION: mPTS was applied to the patients and the undertriage rate was too high. The extended mPTS improved undertriage to 2% while maintaining the overtriage rate at a safe level. The E-mPTS is expected to have a resource saving effect when used as a pediatric trauma team activation standard.

Validity of the Newly Developed Five Level Pediatric Triage System Implemented in a Children's Hospital Emergency Department

PURPOSE: Korean Acuity and Triage Scale (KTAS) has been used nationally since 2016 for triage in emergency departments. After the newly developed triage tool was applied, there have been few studies of the validity of pediatric KTAS. The purpose of this study was to evaluate the validity of KTAS in children under the age of 15 who visited a single children's hospital. METHODS: This retrospective study was conducted on 7,011 pediatric patients under the age of 15 who visited a single child hospital between January 1 and December 31, 2016, the difference in the admission rate, intensive care unit admission rate, length of stay in the emergency department, and total hospital cost in emergency department were analyzed using the KTAS level. RESULTS: The number of patients triaged as KTAS IV was highest with 48.2%. The length of stay was longest in KTAS I and shortest in KTAS V. The medical cost in emergency department was highest in KTAS I and lowest in KTAS V. All dependent variables except for the intensive care unit admission rate showed significant differences according to the KTAS level. CONCLUSION: When the KTAS of the newly developed five level triage system was applied to pediatric patients, there were statistically significant difference in hospitalization, length of stay in emergency department, and total cost to the emergency department according to the KTAS level. Therefore, it will be necessary to evaluate the validity of KTAS through multicenter studies including hospitals with various characteristics.

Early Predictors of Severe Injury in Motorcycle Crashes

PURPOSE: The severity and mortality of motorcycle accidents are higher than those of other traffic accidents. The majority of risk factors for injury severity identified in previous studies are difficult to apply. This study attempted to identify the clinically useful risk factors for predicting severely injured patients presenting to the emergency department after a motorcycle accident. METHODS: Motorcycle accident patients who visited a Level I trauma center from October 2015 to March 2017 were analyzed. The patients were classified as the severely injured group (Injury Severity Score, ISS≥16) and non-severely injured group (ISS<16). RESULTS: A total of 271 patients were analyzed; 135 (49.8%) patients were included in the severely injured group. Multiple logistic regression analysis was performed with the statistically significant factors between the two groups, including age, systolic blood pressure, heart rate, Glasgow coma scale, alcohol ingestion, and site of injury. The final risk factors predicting severely injured patients were as follows: age (adjusted odds ratio [aOR], 1.023; 95% confidence interval [CI], 1.005– 1.041; p=0.011), systolic blood pressure (aOR, 0.981; 95% CI, 0.970–0.993; p=0.002) and site of injury including abdomen (aOR, 5.785; 95% CI, 2.513–13.316; p<0.001), chest (aOR, 4.567; 95% CI, 2.274–9.173; p<0.001), head and neck (aOR, 5.762; 95% CI, 2.656–12.504; p<0.001), and face (aOR, 2.465; 95% CI, 1.229–4.943; p=0.011). CONCLUSION: Motorcycle accident patients should be assessed promptly for injury to the chest or abdomen by a careful physical examination and focused assessment with sonography for trauma.

Pneumoperitoneum due to Gastroesophageal Junction Rupture after Prolonged Cardiopulmonary Resuscitation with Supraglottic Airway

Gastric rupture after cardiopulmonary resuscitation (CPR) is a rare complication. In most cases, it is associated with bystander-provided CPR, bag-mask ventilation, and difficult airway management. To the best of our knowledge, there has been only one previous case report in the literature regarding gastric rupture after CPR via supraglottic airway. We present a case of a gastroesophageal junction rupture secondary to CPR with supraglottic airway. Healthcare providers should consider that gastric rupture can be a complication from performing CPR.

Attempted Suicide by Nitrogen Gas Asphyxiation: A Case Report

Nitrogen is an inert gas that is harmless to humans under normal conditions. While it is not inherently toxic, nitrogen gas becomes dangerous when it displaces oxygen, resulting in suffocation. Herein, we report a case of a 34-year-old man who attempted suicide by nitrogen asphyxiation who presenting with decreased mental function and agitation. Lactic acidosis and hyperammonemia were observed on presentation at the emergency department, but these improved after a few hours. After 2 days, the patient regained full consciousness, and was discharged without any complications. Survival after asphyxiation due to nitrogen gas is very rare, and these patients are more likely to have poorer outcomes. There is a potential for the increasing use of nitrogen gas as a method of committing suicide because of the ease of access to this gas.

The Effect of Head Rotation and Leg Elevation on Skin Depth, Diameter and Relative Position of the Internal Jugular Vein, and its Implications

PURPOSE: The aim of this study was to evaluate the effect of head rotation and leg elevation as it impacts the depth from the skin surface to the internal jugular vein (IJV), the diameter of the IJV, and the relative anatomical location of the IJV to the carotid artery (CA). METHODS: A total of 20 volunteers were enrolled in this study. In a supine position with/without 30degrees head rotation to the left, and with/without 30degrees leg elevation, the depth from skin surface to IJV, the IJV diameters, and the anatomical relationship between IJV and CA were measured using 2-dimensional ultrasound from the right side of the neck. The relative position of the IJV to the CA was depicted as an angle ranging from -180degrees to +180degrees. The measurements observed in each position were compared. RESULTS: As the head was rotated to the left, the depth of the IJV from the skin surface decreased and the anteroposterior IJV diameter increased significantly (all p<0.001). The relative position of the IJV to the CA tended to move in an anterior and medial direction during head rotation. Leg elevation had a significant impact on the transverse diameter of the IJV, but only when the head was rotated (p=0.027). With leg elevation, there was no consistent locational change of the IJV relative to the carotid artery, and there were no significant changes observed for IJV depth relative to the surface of the skin or IJV anteroposterior diameter. CONCLUSION: Our results indicated that head rotation increases the risk of carotid artery puncture by increasing the overlap of the carotid artery and the IJV. To decrease the risk of carotid artery puncture, a neutral head position should be maintained during IJV catheterization, with a central approach.

The Effect of Head Rotation and Leg Elevation on Skin Depth, Diameter and Relative Position of the Internal Jugular Vein, and its Implications

PURPOSE: The aim of this study was to evaluate the effect of head rotation and leg elevation as it impacts the depth from the skin surface to the internal jugular vein (IJV), the diameter of the IJV, and the relative anatomical location of the IJV to the carotid artery (CA). METHODS: A total of 20 volunteers were enrolled in this study. In a supine position with/without 30degrees head rotation to the left, and with/without 30degrees leg elevation, the depth from skin surface to IJV, the IJV diameters, and the anatomical relationship between IJV and CA were measured using 2-dimensional ultrasound from the right side of the neck. The relative position of the IJV to the CA was depicted as an angle ranging from -180degrees to +180degrees. The measurements observed in each position were compared. RESULTS: As the head was rotated to the left, the depth of the IJV from the skin surface decreased and the anteroposterior IJV diameter increased significantly (all p<0.001). The relative position of the IJV to the CA tended to move in an anterior and medial direction during head rotation. Leg elevation had a significant impact on the transverse diameter of the IJV, but only when the head was rotated (p=0.027). With leg elevation, there was no consistent locational change of the IJV relative to the carotid artery, and there were no significant changes observed for IJV depth relative to the surface of the skin or IJV anteroposterior diameter. CONCLUSION: Our results indicated that head rotation increases the risk of carotid artery puncture by increasing the overlap of the carotid artery and the IJV. To decrease the risk of carotid artery puncture, a neutral head position should be maintained during IJV catheterization, with a central approach.