Validation of the finger counting method using the Monte Carlo simulation

PURPOSE: The dose of drug and the size of instrument are determined based on children's weight. We aimed to validate the finger counting method (FCM) for weight estimation in Korean children using the Monte Carlo simulation. METHODS: We estimated the weight of Korean children aged 1 to 9 years by the FCM. These measurements were compared with the weight extracted by the Monte Carlo simulation applied to the “2007 Korean Children and Adolescents Growth Standard”. Pearson correlation coefficients (r) were measured to assess the correlation between the weight extracted by the simulation and that estimated by FCM. Bland-Altman analyses were performed to assess the agreement between the weight extracted by the simulation and that estimated by FCM and 2 other well-known pediatric weight estimation formulas (the Advanced Pediatric Life Support and Luscombe formulas). RESULTS: Data regarding 9,000 children's weight selected by age and gender was randomly extracted using the simulation. We found a positive correlation between the weight estimated by the FCM and the weight extracted (in boys, r = 0.896, P < 0.001; in girls, r = 0.899, P < 0.001). The FCM tended to underestimate weight in the children aged 7 years or old. CONCLUSION: This article suggests the usefulness of FCM in weight estimation, particularly in children younger than 7 years. With appreciation of the limitation in older children, the FCM could be applied to emergency practice.

Part 5. Pediatric basic life support: 2015 Korean Guidelines for Cardiopulmonary Resuscitation

No abstract available.

Part 6. Pediatric advanced life support: 2015 Korean Guidelines for Cardiopulmonary Resuscitation

No abstract available.

Effect of Alcohol on Death Rate in Organophosphate Poisoned Patients

PURPOSE: Many patients who are acutely poisoned with organophosphorus pesticides have co-ingested alcohol. The purpose of this study was to identify the factors that influence mortality in organophosphate intoxication and the differences between alcohol coingested patients and non-coingested patients, looking at vital signs, length of admission, cholinesterase activity, complications, and mortality. METHODS: All patients visiting one Emergency Department (ED) with organophosphate intoxication between January 2000 and December 2012 were reviewed retrospectively. The patients were divided into two groups, alcohol coingested group and non-coingested group. RESULTS: During the study period, 136 patients (alcohol coingested group, 95 patients; non-coingested group, 41 patients) presented to the ED with organophosphate intoxication. Seventy-one alcohol coingested patients (74.1%) vs. 16 non-coingested patients (39.0%) received endotracheal intubation, with results of the analysis showing a clear distinction between the two groups (p=0.001). Twenty-three alcohol coingested patients (24.2%) vs. 1 non-coingested patient (2.4%) required inotropics, indicating a significant gap (p=0.002). Twenty-eight alcohol coingested patients (29.5%) vs. 2 non-coingested patients (4.9%) died, with results of the analysis showing a clear distinction between the two groups (p=0.002). CONCLUSION: In cases of organophosphate intoxication, alcohol coingested patients tended to receive endotracheal intubation, went into shock, developed central nervous system complications, and more died.

Commotio Cordis by a Traffic Accident Visited the Emergency Department

Commotio cordis is induction of sudden cardiac arrest and ventricular fibrillation (VF) by chest blunt trauma and nonpenetrating injury without damage to the rib, sternum, and heart in a person without underlying cardiovascular disease. Commotio cordis has been rarely reported worldwide, and it is particularly rare in the case of traffic accident (TA). We experienced a case of commotio cordis in a healthy 20-year-old man who was involved in a TA. The patient had no other signs of trauma except blunt chest trauma, and the initial electrocardiography (ECG) rhythm checked by the emergency medical technician (EMT) team was VF. They performed defibrillation and cardiopulmonary resuscitation (CPR) during transfer. CPR including defibrillation was performed because VF continued upon arrival at the emergency department, and therapeutic hypothermia (THT) was performed because glasgow coma scale (GCS) score was 3 after return of spontaneous circulation (ROSC). The patient's mental status became alert after performance of THT and cerebral performance category (CPC) score was 1 without neurological symptoms at the time of discharge. In trauma patients who may be have blunt chest trauma, including TA, emergency medical service providers must perform continuous monitoring with commotio cordis in mind, and perform defibrillation and CPR immediately if VF arises. With training in basic CPR and a supply of automated external defibrillators (AED) for application to trauma patients, the survival rate of commotio cordis patients can be increased.

Treatment of Carbon Monoxide Poisoning with Therapeutic Hypothermia / 대한구급학회지

Carbon monoxide (CO) is a well-known chemical asphyxiant, which causes tissue hypoxia with prominent neurological injury. Therapeutic hypothermia (TH) has been shown to be an effective neuroprotective method in post-cardiac arrest patients. A 26-year-old man presented to the emergency department with severe CO poisoning. On arrival, the patient was comatose. His vital signs were blood pressure, 130/80 mm Hg; heart rate, 126/min; respiratory rate, 26/min; body temperature, 36degrees C; and O2 saturation, 94%. Initial carboxyhemoglobin was 45.2%. Because there was no available hyperbaric chamber in our local area, he was intubated and treated with TH. The target temperature was 33 +/- 1degrees C for 24 hours using an external cooling device. The patient was then allowed to reach normothermia by 0.15-0.25degrees C/hr. The patient was discharged after normal neurological exams on day 11 at the hospital. TH initiated after exposure to CO may be an effective prophylactic method for preventing neurological sequelae.

The Features and Prognoses in Organophosphate Intoxication according to Age

BACKGROUND: The purpose of this study was to identify the factors that influence mortality in organophosphate intoxication and the differences between the elderly (> or =65 years) and younger adults (18-64 years) looking at vital sign, length of admission, cholinesterase activity, complications, and prognosis. METHODS: All patients visiting one Emergency Department (ED) with organophophate intoxication between January 2000 and December 2011 were reviewed retrospectively. We divided the patients into two groups, geriatric adults (> or = 65 years) and nongeriatric adults (18-64 years). RESULTS: During the study period, 155 patients (45 patients, > or =65 years; 110 patients, 18-64 years) presented to the ED with organophosphate intoxication. Thirty-six elderly patients (80.0%) vs. 63 younger adult patients (57.3%) were intubated endotracheally, with the analysis showing a clear distinction between the two groups (p=0.026). Twenty-two elderly patients (48.9%) vs. 23 younger adult patients (20.9%) went into shock, displaying a significant gap (p=0.008). Thirtyfive elderly patients (81.4%) vs. 62 younger adult patients (59.0%) developed respiratory complications and 20 elderly patients (46.5%) vs. 19 younger adult patients (18.1%) developed central nervous system complications, with obvious differences seen in each of the comparison at (p=0.031) and (p=0.005), respectively. Comparing plasma cholinesterase levels at 1st, 3rd, 5th, 10th, 15th, and 20th days, the rate of increase was faster in the younger adults (p=0.022). CONCLUSION: With organophosphate intoxication, elderly patients tended to be intubated endotracheally, went into shock, developed central nervous system complications, were more severe, and showed a slower increase in cholinesterase level.

Changes in Preventable Death Rates and Traumatic Care Systems in Korea

PURPOSE: This study was performed in order to determine the changes over time in preventable and potentially preventable traumatic death rates, and to assess the factors that affected the deaths of trauma patients which occurred in Korean pre-hospital and hospital settings. METHODS: All trauma deaths occurring either in the emergency department (ED) or after admission at twenty Korean hospitals between August 2009 and July 2010 were retrospectively analyzed. The deaths were initially reviewed by a team of multidisciplinary specialists and classified into non-preventable, potentially preventable, and preventable deaths. Only preventable and potentially preventable deaths were the subject of our analysis. Structured data extraction included patient demographics, vital signs, injury severity, probability of survival, preventability of mortality, reported errors in the evaluation and management of the patient, and classification of error types (system, judgment, knowledge). RESULTS: During the study period, 446 trauma victims died in the ED or within 7 days after admission. The mean age was 52 years, 74.1% were men and the mean time from injury to death was 35.6 hours. The most common cause of death was head injury (44.7%) followed by hemorrhage (30.8%) and multi-organ failure (8.0%). The rates of preventable/potentially preventable deaths were 35.2% overall and 29.8% when limited to patients surviving to admission. Of all death classifications, 31.2% were potentially preventable and 4.0% were preventable. Errors leading to preventable death occurred in the emergency department (51.2%), pre-hospital setting (30.3%) and during inter-hospital transfer (60.8%). Most errors were related to clinical management (48.4%) and structural problems in the emergency medical system (36.5%). CONCLUSION: The preventable death rates for Korean trauma victims were higher than those found in other developed countries, possibly due to poorly established emergency medical systems for trauma victims in pre-hospital and hospital settings. A system wide approach based on the emergency medical system and well-developed in-hospital trauma teams should be adopted in order to improve the quality of care of trauma victims in Korea.

A Case of a Male Presenting with Periocular Pain and Diplopia at an Emergency Department: Tolosa-Hunt Syndrome

Tolosa-Hunt syndrome is a rare self-limiting disease characterized by a painful, unilateral ophthalmoplegia caused by an idiopathic granulomatous inflammation in cavernous sinus, the superior orbital fissure or the orbital apex. We report a case of a 51-year-old man who presented at the emergency department with periocular pain and diplopia. Physical examination, and radiological and laboratory testing performed at that time were diagnostically inconclusive. After hospitalization, the patient was diagnosed with Tolosa-Hunt syndrome. Treatment with high dose steroid was started; by 2 days later, the periocular pain was relieved and other symptoms had improved. The rarity of Tolosa-Hunt syndrome calls for knowledge of the disease and attention by an emergency physician. The case report includes as summary of the syndrome, its' diagnosis and treatment.

A Case of Myxedema Coma Presenting as a Brain Stem Infarct in a 74-Year-Old Korean Woman

Myxedema coma is the extreme form of untreated hypothyroidism. In reality, few patients present comatose with severe myxedema. We describe a patient with myxedema coma which was initially misdiagnosed as a brain stem infarct. She presented to the hospital with alteration of the mental status, generalized edema, hypothermia, hypoventilation, and hypotension. Initially her brain stem reflexes were absent. After respiratory and circulatory support, her neurologic status was not improved soon. The diagnosis of myxedema coma was often missed or delayed due to various clinical findings and concomitant medical condition and precipitating factors. It is more difficult to diagnose when a patient has no medical history of hypothyroidism. A high index of clinical suspicion can make a timely diagnosis and initiate appropriate treatment. We report this case to alert clinicians considering diagnosis of myxedema coma in patients with severe decompensated metabolic state including mental change.

E-learning can be Helpful for Mastering Basic Life Support Skills on Public

PURPOSE: Barriers to cardiopulmonary resuscitation (CPR) education are magnified by relative cost and course availability. E-learning has emerged as a viable solution for continuous, on-demand training and organizational learning. We assessed the hypothesis that E-learning is a viable strategy for CPR training of the general public and sought to evaluate its effects on CPR quality compared to traditional classroom-based methods. METHODS: The E-learning program was specifically designed to teach basic life support skills, and consisted of 50 minutes internet lectures and simulation videos. The training session was freely available to twenty two officers in rural South Korea. The trainees were able to practice with a mannequin and an automated external defibrillator (AED) trainer at their place of employment over the course of 3 days. The control group was trained at a hospital by certified instructors using the same equipment during a 2 hour period. At the end of the course, the participant's skills were evaluated using a checklist and a skill performance test. RESULTS: Forty two subjects were enrolled finally with 19 and 23 belonging to the E-learning and the control groups, respectively. One E-learning trainee was excluded because he was absent from the skills test. The mean time to learn CPR and AED techniques was 29.0+/-24.5 minutes in the elearning group. The mean age of the E-learning group was significantly older than that of the control group (32.4+/-4.0 vs. 26.0+/-1.5, p<0.001). However, we did not find any significant differences in their weight, height or CPR educational status. Before the education sessions, the willingness to perform CPR and their confidence in performing CPR were not significantly different among the two groups. Regarding skill performance, there were no significant differences between the groups except the volume of ventilation. The control group showed a higher volume of ventilation than the elearning group (1,031.7+/-521.6 vs. 548.8+/-303.3, p=0.004). CONCLUSION: E-learning accompanied with appropriate practice can be a helpful tool for public CPR training. The demand for E-learning will increase, and this study shows that e-learning programs can be successful, yielding similar results as traditional, classroom-based training.

E-learning can be Helpful for Mastering Basic Life Support Skills on Public

PURPOSE: Barriers to cardiopulmonary resuscitation (CPR) education are magnified by relative cost and course availability. E-learning has emerged as a viable solution for continuous, on-demand training and organizational learning. We assessed the hypothesis that E-learning is a viable strategy for CPR training of the general public and sought to evaluate its effects on CPR quality compared to traditional classroom-based methods. METHODS: The E-learning program was specifically designed to teach basic life support skills, and consisted of 50 minutes internet lectures and simulation videos. The training session was freely available to twenty two officers in rural South Korea. The trainees were able to practice with a mannequin and an automated external defibrillator (AED) trainer at their place of employment over the course of 3 days. The control group was trained at a hospital by certified instructors using the same equipment during a 2 hour period. At the end of the course, the participant's skills were evaluated using a checklist and a skill performance test. RESULTS: Forty two subjects were enrolled finally with 19 and 23 belonging to the E-learning and the control groups, respectively. One E-learning trainee was excluded because he was absent from the skills test. The mean time to learn CPR and AED techniques was 29.0+/-24.5 minutes in the elearning group. The mean age of the E-learning group was significantly older than that of the control group (32.4+/-4.0 vs. 26.0+/-1.5, p<0.001). However, we did not find any significant differences in their weight, height or CPR educational status. Before the education sessions, the willingness to perform CPR and their confidence in performing CPR were not significantly different among the two groups. Regarding skill performance, there were no significant differences between the groups except the volume of ventilation. The control group showed a higher volume of ventilation than the elearning group (1,031.7+/-521.6 vs. 548.8+/-303.3, p=0.004). CONCLUSION: E-learning accompanied with appropriate practice can be a helpful tool for public CPR training. The demand for E-learning will increase, and this study shows that e-learning programs can be successful, yielding similar results as traditional, classroom-based training.

Validation of a Monitoring System for CPR Quality in a Manikin Model

PURPOSE: The 2005 resuscitation guidelines stipulate the need for monitoring CPR (cardiopulmonary resuscitation) quality. Recently, several clinical investigations have shown that a real time monitoring and feedback system is effective for improving the quality of chest compressions during resuscitation. However little data exists regarding the accuracy of the monitoring system using an accelerometer sensor and a pressure sensor for the measuring of compression rate and depth. Our goal for this study was to investigate how well chest compression rate and depth can be estimated using the monitoring system. METHODS: Thirty seconds of continuous chest compressions were delivered on a standard skillmeter manikin lying on the floor with the monitoring system. The chest compressions were delivered with variations in compression rate (67~142 /min) and with variations in compression depth (22~61 mm). A total of 120 sets of compressions were delivered for validation of rate and depth. RESULTS: The correlation coefficient for compression rate between the monitoring system and the standard method was 0.999 (p<0.001), and Bland-Altman analysis showed a mean bias of -0.10+/-0.77/min, with limits of agreement ranging from -1.60 to 1.40 /min. The correlation coefficient for compression depth between two methods was 0.983 (p<0.001), and Bland-Altman analysis showed a mean bias of 4.2+/-2.0 mm, with limits of agreement ranging from 0.24 to 8.10 mm. CONCLUSION: Compared with a skillmeter manikin, a monitoring system for the quality of CPR estimates chest compression rate precisely, but overestimates chest compression depth by an average of 10.3%.

A one-year Follow-up Study of Patients Exposed to Chlorine Gas

PURPOSE: Chlorine gas is a common irritant that usually causes mild respiratory symptoms. One severe symptom, RADS (Reactive Airway Dysfunction Syndrome), is not well known to physicians. We analyzed the clinical features of chlorine gas exposure. METHODS: We prospectively collected 25 cases of chlorine gas exposure near our emergency center on January 10th, 2007, and analyzed demographic data, event-to-ER interval, symptoms, and laboratory results based on medical records. RESULTS: Only 2 patients out of 25 were admitted because of severe symptoms, the rest were discharged without complications. Sixty percent of them visited the ER within 12 h of exposure. The most common symptoms were chest discomfort (60%), headache (40%), nausea (40%), throat irritation (26%), and cough (32%). Two out of eight dyspnea cases showed abnormal pulmonary function, but only one case was diagnosed as RADS. CONCLUSION: Most symptoms after chlorine gas exposure can be treated conservatively. However, patients with chlorine exposure should be followed up long term for delayed complications.

A Case of Colchicine Intoxication Presenting as Acute Gastroenteritis

A 47-year-old woman ingested about 12 mg of colchicine with suicidal intent. Colchicine, a highly poisonous alkaloid, is a commonly used treatment for gout, Bechet's disease, and familial Mediterranean fever. Despite the knowledge of its side effects, the risk of a significant overdose is under-appreciated. She suffered from acute multisystem toxicity, including gastrointestinal disorders, bone marrow suppression, alopecia, and probable pancreatitis, but she ultimately recovered with supportive therapy. We report a case of acute colchicine toxicity from a single overdose with a review of the literature.

S-100B Protein as a Useful Serologic Marker of Acute Stroke with Nonspecific Neurologic Symptoms

PURPOSE: There is a distinct probability of severe complications with stroke unless patients are administered proper treatment at the optimal time. S-100B protein has been reported to be elevated in brain injuries. The current study investigates the efficacy of serum S-100B protein administration during the diagnostic process for patients who have had an acute stroke. METHODS: We prospectively recruited the patients with nonspecific neurological symptoms. Non-specific neurological symptoms were defined as no focal neurological deficits or stroke suspected symptoms with NIHSS score zero. We grouped the patients according to the presence of a brain lesion (positive vs negative group) by computed tomography or magnetic resonance imaging. Using serum S-100B protein together with CT/MRI imaging at the time of diagnosis, the cutoff value, sensitivities, and specificities were calculated in making a diagnosis of acute stroke. RESULTS: Thirty one patients were enrolled. The level of serum S-100B protein was higher in positive group (median 0.201, interquartile range 0.134-0.469) than in negative group (0.085, 0.060-0.106, p=0.001). In diagnosing acute stroke, the sensitivity was 90.9% at a cutoff value for serum S-100B protein of 0.10 microgram/L . At the cutoff level of serum S-100B protein and the specificity was 75.0%. CONCLUSION: The current results suggest that serum S-100B protein may be a useful serologic marker for detecting acute stroke that is suspected with non-specific neurological abnormalities. Further studies are necessary to use the marker as a screening method for acute strokes.

Fatal Ingestion of Hydrofluoric Acid in a Dementia Patient

As the elderly population continues to grow, the number of geriatric patients reported to poison centers continues to increase. Older poisoned patients are at an increased risk of death compared to younger adult patients. The purpose of this paper is to report a case of hydrofluoric acid poisoning along with a discussion of poisoning characteristics. A 79 year-old male with dementia visited emergency department presenting epigastic discomfort after ingestion of 50% hydrofluoric acid solution. At admission, he presented with a stable vital sign but progressed to pulseless electrical activity. In spite of advanced resuscitation efforts and administration of calcium gluconate, he rapidly detoriated and died 3 hours after the ingestion.

Comparison of Clinical and Anatomical Differences of Vertebral Artery Dissection between Minor Trauma and Non-trauma Causes

PURPOSE: This study aimed to find any difference in the clinical or the anatomical findings of vertebral artery dissection (VAD) between the trauma and the non-trauma groups. METHODS: We retrospectively reviewed the clinical data and radiologic images of VAD patients. We compared data on symptoms, neurologic deficit, National institutes of health stroke scale (NIHSS) at admission, Rankin score (RS) at admission and discharge, and radiological findings including anatomical features, between the trauma and the non-trauma groups. RESULTS: From January 1997 to May 2006, 42 patients were enrolled and 13 patients (31%) had a history of earlier trauma. Focal neurologic deficit (trauma group 11/13 vs. non-trauma group 11/29), cerebral stroke (10/13 vs. 9/29), and extradural lesions of dissection (6/13 vs. 3/28) were more common in the trauma group than non-trauma group (p=0.007, p=0.017, p=0.018, respectively) and NIHSS at admission and discharge were significantly higher (p=0.012, p=0.001, respectively). Dissecting aneurysms were less frequent in the trauma group (2/13 vs. 19/29, p=0.006). Subarachnoid hemorrhage and unfavorable prognostic value (Rankin score at discharge> or =2) showed no differences between the groups (p=0.540, p=0.267, respectively). CONCLUSION: In VAD patients after trauma, focal neurologic deficit due to ischemic stroke and a steno-occlusive pattern are more frequent than they are in non-trauma patients. The location of dissection was most frequent at the extradural vertebral artery in the trauma group. NIHSS was higher in the trauma groups but the incidence of an unfavorable prognostic value (RS> or =2) was not significantly different between the groups.

Early Diagnosis of a Cerebral Venous Thrombosis in the Emergency Department

PURPOSE: Early diagnosis and heparin therapy have contributed to a decreased mortality in patients with a cerebral venous thrombosis (CVT). The aim of this study is to evaluate the clinical and the radiologic features of a CVT and to develop an algorithm for diagnosis and treatment. METHODS: Twenty (20) patients who were diagnosed at Asan Medical Center from 1997 to June 2004 as having a CVT were included in this study. The data in their medical records, including clinical features, predisposing factors, and diagnostic modalities, were reviewed. The cranial computed tomography findings of a CVT were investigated in 18 patients. RESULTS: Headache was the most common symptom, followed by seizure and focal neurologic deficits. Initially, 14 patients were misdiagnosed by the emergency physician as having another neurologic disease, though 5 patients had pathognomic CT signs of a CVT. CT signs, such as cord signs and empty delta signs, were present in 10 cases. Among them, the cord sign was positive in eight (8) cases (44.4%), the empty delta sign was positive in six (6) cases (46.2%), and both signs were positive in four (4) cases. The presence of CT signs correlated with the presence of seizure at onset, and the Modified Rankin Scale (MRS) was 1 or 2 at discharge (p<0.05). Parenchymal changes correlated with headache at discharge (p<0.05). CONCLUSION: Emergency physicians should consider CVT and look for pathognomic signs of a CVT when patients complain of sub-acute headaches or when the clinical features do not correlate with the neuroimage findings.

A Case of Ovarian Hyperstimulation Syndrome with Left Hemiparesis

Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of sterility treatment, such as pharmacological ovulation induction therapy. OHSS is clinically characterized by ovarian enlargement, abdominal distension, electrolyte imbalance, ascites, hypovolemia and hemoconcentration. But, the exact pathophysiology of OHSS is not fully understood. We believe that an increased capillary permeability leading to enhanced fluid extravasation seems to play a major pathogenic role, and also an imbalance in the rennin-angiotensin system is involved. Thromboembolic disease is usually considered to be a rare complication of OHSS. The common factors known to contribute to the risk of thrombosis are hemoconcentration, leukocytosis, thrombocytosis, and alteration in coagulation and fibrinolysis. But the majority of reported cases are venous in origin (75%), the remaining 25% are arterial thromboses. Especially in arterial thromboses, stroke is a rare event and potentially fatal complication. We report that a case of stroke combined with OHSS was received intravenous thrombolytics and recommend that emergency physicians keep in mind that one of possible causes of stroke in young woman who had been ovarian induction therapy is OHSS, and the timely intervention in OHSS with stroke is critical.