Correlation between the Portable X-ray and the Radiation Exposure dose in the Emergency Department: Cohort Study

PURPOSE: This study was conducted in order to determine the relationship between the number of portable X-rays and the radiation exposure dose for emergency medical service providers working in the emergency department (ED). METHODS: A prospective study was conducted from February 15, 2013 to May 15, 2013 in the ED in an urban hospital. Six residents, seven emergency medical technicians (EMT), and 24 nurses were enrolled. They wore a personal radiation dosimeter on their upper chest while working in the ED, and they stayed away from the portable X-ray unit at a distance of at least 1.8 m when the X-ray beam was generated. RESULTS: The total number of portable x-rays was 2089. The average total radiation exposure dose of emergency medical service providers was 0.504+/-0.037 mSv, and it was highest in the EMT group, 0.85(0.58-1.08) mSv. The average of the total number of portable X-rays was highest in the doctor group, 728.5(657.25-809). The relationship between the number of portable X-rays and the radiation exposure dose was not statistically significant(-0.186, p=0.269). CONCLUSION: Under the condition of staying away from the portable X-ray unit at a distance of least 1.8 m, the relationship between the number of portable X-rays and the radiation exposure dose was not statistically significant.

A Case Study of a Patient with Penetrating Neck Injuries caused by a Nail Gun

Powered by compressed air, a nail gun is an essential alternative tool to a hammer on any construction site. This useful machine launches nails at high speed, automatically embedding them in a piece of wood in only a fraction of a second. In spite of its convenience, life-threatening and fatal nail gun injuries can occur when a nail gun is misused, such as in a suicide attempt, or when the operator has insufficient training because combustion nail guns are capable of firing projectiles at velocities higher than 150 m per second. Although injuries by nail guns are rarely reported, there have been reports of nail gun injuries to the head and the trachea in Korea. In the emergency room, the authors experienced a patient injured by an accidental shooting of a nail gun while working in construction. In that accident, a nail penetrated the patient's cervical vertebra through the left cheek. This report is aimed at studying medical treatment for patients with penetrating injuries caused by nail guns.

Evaluation of Proficiency in Chest Compression by Learning Curve-Cumulative Sum Analysis

PURPOSE: Chest compression is the corner stone of resuscitation. As a result, many studies insist on the importance of retention of skill performance. But there are weak points. First, a unique characteristic of skill is ignored, "the more practice, the better outcome". Second, no one knows when they have a proficiency in a skill. Learning curve-CUSUM analysis is a good tool to evaluate each trainee's performance. Hence, we designed this study to evaluate each trainee's proficiency in performing chest compression using LC-CUSUM analysis. METHODS: Four medical students were enrolled. We asked them to perform chest compression for two minutes per day without any intervention over six weeks. Data included the depth and rate of chest compression. Eventually, all trainees performed chest compression at least 30 times. We plotted the LC-CUSUM curve according to the results of attempts, successes or failures. RESULTS: According to median values of the depth and rate of chest compression through the 30th attempt, trainees had performances within the acceptable range, 40~49 mm (for depth) and 100~105 beats per minutes (for rate) of chest compression. Nonetheless, LC-CUSUM analysis indicated that two trainees no longer were proficient throughout, and even though the rest of them were once proficient, they appear to have lost that proficiency regarding depth of chest compression. LC-CUSUM analysis of rate of compression showed that all trainees had proficiency during the early phase. CONCLUSION: We propose that instructors can evaluate their trainees' proficiency easily, based on LC-CUSUM analysis.

Effectiveness, Preference and Ease of Passive Release Techniques Using a Syringe for Endotracheal Tube Cuff Inflation

PURPOSE: Inappropriate cuff inflations cause many complications. A conventional pilot balloon palpation technique is insufficient to detect high cuff pressures, but is still preferred. Hence, we conducted this study to identify effectiveness, preference and ease of use of a new estimation technique named "passive release technique" for endotracheal tube cuff inflation. METHODS: Twenty-nine nurses inflated cuffs by a pilot balloon palpation technique in manikins inserted with a 7.5 mm endotracheal tube. Then, being educated about passive release techniques, they inflated cuffs using such a passive release technique. Intracuff pressures and air volumes were measured by manometers and syringes. Preference and ease of use between the two methods were scored using a 10-point Likert scale. RESULTS: For the pilot balloon palpation technique, only 4 nurses (13.8%) inflated cuffs within the normal range of pressures (normal: 15 to 30 mb) with an average of 39.3+/-34.0 cmH2O. For the passive release technique, 19 nurses (65.5%) inflated cuffs within the normal range of pressures with an average of 24.2+/-9.3 cmH2O (McNemar's test, p<0.01). In the pilot balloon palpation technique, inflated air volumes of 7.8+/-2.0 ml were not significantly different from inflated air volumes 8.5+/-1.2 ml (p=0.07) for the passive release technique. But the difference was found to be statistically significant in a variance ratio test (F-test) (p<0.01). In view of preference and ease of use between the two methods, mean values were not statistically different, 7.3+/-2.0 vs. 7.0+/-2.0 and 7.0+/-2.3 vs. 7.3+/-2.4, respectively. CONCLUSION: When direct intracuff measurement is not available, a passive release technique using a syringe is an effective and easy method to achieve cuff inflation.

The Diagnostic Efficacy of a Triple Prediction Test including Ischemia-Modified Albumin in Ruling Out Acute Coronary Syndrome

PURPOSE: In emergency departments (ED), the treatment of acute coronary syndrome (ACS) should be rapid and result from comprehensive diagnostic evaluation. There are increasing needs for supplies in the ED both for monitoring patients and for follow-up diagnostic measures to rule out ACS. The purpose of this study was to determine the effectiveness of a triple prediction test including Ischemia-modified albumin (IMA) as a tool for promptly ruling out ACS in lower-risk patients in ED. METHODS: Between September 2005 and July 2006, we analyzed patients with acute chest pain who were older than 28 years, who visited the ED within 3 hours from the last onset of chest pain, and who had normal or non-diagnostic electrocardiograms (ECG). The triple prediction test was defined as a nondiagnostic ECG, negative cardiac markers (creatine kinase-MB, troponin I), and a lower cutoff value for IMA. RESULTS: We analyzed 149 patients (male: female=105 : 44) whose mean age was 57.9+/-12.1 years. Thirty-two patients fell into IMA-negative group and 117 patients were in the IMA-positive group was 117 patients. There was no difference in sex, age, serum albumin level and medical history between groups. The area under the ROC curve was 0.640. At an IMA cutoff value of 85 U/ml, patients without ACS were negative (below the cutoff value) 4.0 times more than patients with ACS by ROC curve analysis. CONCLUSION: In ruling out ACS, triple predictive test including cardiac markers, ECG, and IMA had insufficient efficacy in the ED. Further studies warranted to reveal IMA is a clinical useful diagnostic test to rule out ACS.

Surveillance on Hazardous Materials Preparedness in the Emergency Department in Korea: Personal Protection Equipment

PURPOSE: This study was conducted to evaluate the preparedness of personal protective equipment (PPE) against hazardous material (Hazmat) contamination in emergency departments (EDs). METHODS: Among 443 EDs, 118 emergency centers (16 regional centers, 4 specialized centers, 98 local centers) were surveyed either by returned usable surveys or facsimile or telephone communication. The 27 survey questions addressed the ability of EDs to safely decontaminate and treat contaminated patients. RESULTS: Among 118 EDs (100%), 7 EDs (5.9%) have a written plan for decontamination and treatment of Hazmat contaminated patients in the ED, and 36 (30.5%) have a hospital-wide disaster plan that includes contingencies for decontamination and treatment of Hazmat contaminated patients. 11 EDs (9.3%) conducted any Hazmat drill within recent two years. 8 EDs (6.8%) have a specific treatment area for contaminated patients. A stock space of PPE is maintained in 11 EDs (9.3%) and 6 EDs (5.1%) have a responder decontamination shower. While 11 EDs store PPE, most of these involve only gowns, gloves, and surgical masks; only 10 EDs provide any type of respiratory protection. There was no ED fully equipped level A PEE but only 21 EDs have partially equipped. The levels of PPE were level D in 7 EDs (5.9%) according to the guidelines of EPA/OSHA Personal Protection Equipment Levels CONCLUSION: Emergency department preparedness against Hazmat exposure in Korea varies tremendously. A significant proportion of hospitals lack written plan and equipment to allow EDs to safely and effectively handle the Hazmat contaminated patient. This has the meaning of one of preliminary data that was national-wide surveyed in Korea.

A Case of Tension Viscerothorax: A Rare Complication of Diaphragmatic Rupture after Blunt Abdominal Trauma

Tension viscerothorax (gastrothorax) is rare life-threatening disease which is caused by air trapped in viscera. A distended viscera in the hemi-thorax shifts the mediastinal structures and causes extra-cardiac obstructive shock. A defective diaphragm is caused by abdominal trauma or a congenital anomaly. Traumatic diaphragmatic injury can be missed until herniation develops several years after blunt trauma. In our case, a 10-year old boy developed hemodynamic compromise in the emergency department. Three years earlier, he had suffered blunt abdominal trauma during a pedestrian traffic accident, but there was no evidence of diaphragmatic injury at that time. He was successfully resuscitated by gastric decompression and an emergent thoracic operation. The operation finding revealed a traumatic diaphragmatic injury. Tension viscerothorax is a rare, but catastrophic, condition, so we suggest that addition of tension viscerothorax to the Advanced Trauma and Life Support (ATLS) guidelines may be helpful.

Triage Score as a Predictor of need for Tertiary care Center Transport from Scene by Helicopter

PURPOSE: The number of patients transported by the Helicopter Emergency Medical Service (HEMS) has increased recently. In our review of the Korean HEMS, there was no established helicopter utilization criteria or triage tool on the scene, so many patients with minor injuries were transported to tertiary care centers. The aim of this study is to evaluate the percentage of patients with minor injuries and to propose a more appropriate triage tool for predicting the need for transport to a tertiary care center. METHODS: The subjects of this study were 59 trauma patients transported to Asan Medical Center (AMC) from the scene by Seoul HEMS from January 2004 to December 2005. The Triage score (TS), Injury Severity Score (ISS), and modified Canadian Triage and Acuity Scale (mCTAS) were calculated as severity scales. Patients with minor injuries were defined as those with TS=9, ISS or =3. We evaluated the association of TS, ISS, and mCTAS with the appropriateness of transport. RESULTS: Many of the patients transported to tertiary medical centers were classified as having a minor injury: TS=9 group 35 cases (72.9%), ISS or =3 group 27 cases (56.2%). However, 56.2% (27/59) of the patients were appropriately transported according to need for admission or an operation. The more severely injured patients classified by TS, ISS, and mCTAS were more appropriately transported to a tertiary center (p<0.05). CONCLUSION: Many patients with minor injuries were transported to a tertiary center from the scene directly. The TS can be easily calculated by an emergency medical technician at the scene. Thus, we propose the TS as a useful triage tool for determining the necessity of transport to a tertiary center by helicopter.

Triage Score as a Predictor of need for Tertiary care Center Transport from Scene by Helicopter

PURPOSE: The number of patients transported by the Helicopter Emergency Medical Service (HEMS) has increased recently. In our review of the Korean HEMS, there was no established helicopter utilization criteria or triage tool on the scene, so many patients with minor injuries were transported to tertiary care centers. The aim of this study is to evaluate the percentage of patients with minor injuries and to propose a more appropriate triage tool for predicting the need for transport to a tertiary care center. METHODS: The subjects of this study were 59 trauma patients transported to Asan Medical Center (AMC) from the scene by Seoul HEMS from January 2004 to December 2005. The Triage score (TS), Injury Severity Score (ISS), and modified Canadian Triage and Acuity Scale (mCTAS) were calculated as severity scales. Patients with minor injuries were defined as those with TS=9, ISS or =3. We evaluated the association of TS, ISS, and mCTAS with the appropriateness of transport. RESULTS: Many of the patients transported to tertiary medical centers were classified as having a minor injury: TS=9 group 35 cases (72.9%), ISS or =3 group 27 cases (56.2%). However, 56.2% (27/59) of the patients were appropriately transported according to need for admission or an operation. The more severely injured patients classified by TS, ISS, and mCTAS were more appropriately transported to a tertiary center (p<0.05). CONCLUSION: Many patients with minor injuries were transported to a tertiary center from the scene directly. The TS can be easily calculated by an emergency medical technician at the scene. Thus, we propose the TS as a useful triage tool for determining the necessity of transport to a tertiary center by helicopter.