Expert opinion on evidence after 2020 Korean Cardiopulmonary Resuscitation Guidelines

Considerable evidence has been published since the 2020 Korean Cardiopulmonary Resuscitation Guidelines were reported. The International Liaison Committee on Resuscitation (ILCOR) also publishes the Consensus on CPR and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR) summary annually. This review provides expert opinions by reviewing the recent evidence on CPR and ILCOR treatment recommendations. The authors reviewed the CoSTR summary published by ILCOR in 2021 and 2022. PICO (population, intervention, comparator, outcome) questions for each topic were reviewed using a systemic or scoping review methodology. Two experts were appointed for each question and reviewed the topic independently. Topics suggested by the reviewers for revision or additional description of the guidelines were discussed at a consensus conference. Forty-three questions were reviewed, including 15 on basic life support, seven on advanced life support, two on pediatric life support, 11 on neonatal life support, six on education and teams, one on first aid, and one related to coronavirus disease 2019 (COVID-19). Finally, the current Korean CPR Guideline was maintained for 28 questions, and expert opinions were suggested for 15 questions.

The Impact of Omicron Wave on Pediatric Febrile Seizure

Background@#The coronavirus disease 2019 (COVID-19) omicron (B.1.1.529) variant reduced the risk of severe disease compared with the original strain and other variants, but it appeared to be highly infectious, which resulted in an exponential increase in confirmed cases in South Korea. As the number of confirmed cases increased, so did the number of pediatric patients’ hospitalization. This study aims to evaluate the frequency and clinical features of febrile seizure associated with the COVID-19 omicron variant in children. @*Methods@#We retrospectively reviewed the medical records of children aged under 18 years with febrile seizure who were tested for COVID-19 from February 2020 to April 2022 at Ajou University Hospital, South Korea. Based on the dominant variants, we divided the period into the pre-omicron (from February 2020 to December 2021) and omicron periods (from January 2022 to April 2022) and compared the clinical characteristics between the two. Also, we compared the clinical characteristics of febrile seizure between COVID-19 positive and negative group during the omicron period. @*Results@#Among the 308 children, 211 patients (9.2 patients/months) and 97 patients (24.3 patients/months) were grouped into pre-omicron and omicron periods, respectively.Compared with the pre-omicron period, patients in the omicron period showed significantly higher mean age (pre-omicron vs. omicron, 22.0 vs. 28.0 months; P = 0.004) and COVID-19 positive results (pre-omicron vs. omicron, 0.5% vs. 62.9%; P < 0.001). As the COVID-19 confirmed cases in the omicron period increased, the number of COVID-19 associated febrile seizure also increased. In the omicron period, 61 children were confirmed to be positive for COVID-19, and COVID-19 positive group showed statistically significant higher mean age (positive vs. negative, 33.0 vs. 23.0 months; P= 0.003) and peak body temperature than the negative group (positive vs. negative, 39.1°C vs. 38.6°C; P = 0.030). Despite the lack of significance, COVID-19 positive group showed longer seizure time, multiple seizure episodes, and higher prevalence of complex febrile seizure. @*Conclusion@#The frequency of COVID-19 associated febrile seizure increased in the omicron periods. In addition, in this period, children with febrile seizure diagnosed with COVID-19 had a higher mean age and higher peak body temperature.

Comparison of Base Deficit and Vital Signs as Criteria for Hemorrhagic Shock Classification in Children with Trauma

Purpose@#Base deficit (BD) is superior to vital signs in predicting trauma outcomes in adults. The authors aimed to compare BD and vital signs as criteria for the four-tiered hemorrhagic shock classification in children with trauma. @*Materials and Methods@#We retrospectively reviewed the data of 1046 injured children who visited a Korean academic hospital from 2010 through 2018. These children were classified separately based on BD (class I, BD ≤2.0 mmol/L; II, 2.1–6.0 mmol/L; III, 6.1–10 mmol/L; and IV, ≥10.1 mmol/L) and vital signs (<13 years: age-adjusted hypotension and tachycardia, and Glasgow Coma Scale; 13–17 years: the 2012 Advanced Trauma Life Support classification). The two methods were compared on a class-by-class basis regarding the outcomes: mortality, early transfusion (overall and massive), and early surgical interventions for the torso or major vessels. @*Results@#In total, 603 children were enrolled, of whom 6.6% died. With the worsening of BD and vital signs, the outcome rates increased stepwise (most p<0.001; only between surgical interventions and vital signs, p=0.035). Mortality more commonly occurred in BD-based class IV than in vital signs-based class IV (58.8% vs. 32.7%, p=0.008). Early transfusion was more commonly performed in BD-based class III than in vital signs-based class III (overall, 73.8% vs. 53.7%, p=0.007; massive, 37.5% vs. 15.8%, p=0.001). No significant differences were found in the rates of early surgical interventions between the two methods. @*Conclusion@#BD can be a better predictor of outcomes than vital signs in children with severe hemorrhagic shock.

Trends of carbon monoxide poisoning patients in emergency department: NEDIS (National Emergency Department Information System)

Objective@#We aimed to investigate the epidemiological characteristics and trends of carbon monoxide (CO) poisoning in the National Emergency Department Information System (NEDIS). @*Methods@#Using the NEDIS data from 2014 to 2018, we included patients who had visited the emergency department (ED) with CO poisoning (T58.0 in 7th Korean Standard Classification of Diseases [KCD-7]). We excluded patients with an uncertain time of onset, uncertain intentionality of poisoning, mental state, and unknown clinical outcome. We surveyed age, sex, time of onset, the intentionality of poisoning, mental state, results of emergency treatment, the proportion of admissions to intensive care units (ICU), the outcome of hospitalization, and the regional distribution. We analyzed the rate of incidence and trends of CO poisoning in patients using time series analysis. @*Results@#A total of 18,533 patients, including 10,671 (57.6%) males and 7,862 (42.4%) females, with a mean age of 40.38±18.41 years, were included in this study. Gyeonggi Province (n=6,354, 34.3%) had the highest distribution of patients, followed by Seoul (n=3,357, 18.1%). The incidence of unintentional CO poisoning was more frequent in January and December, and less frequent in August and September. However, the incidence of intentional CO poisoning showed no seasonal variation. The severity, ICU hospitalization rate, and mortality rate for intentional CO poisoning were higher than unintentional CO poisoning (4.1% vs. 0.8%, 29.9% vs. 16.7%, and 2.0% vs. 0.8% respectively) (P<0.001). Applying Winter’s additive method, we could predict that the rate of unintentional CO poisoning would continue to increase and the seasonal fluctuation, such as cases increasing in January-December and decreasing in August-September, would also increase. @*Conclusion@#Intentional CO poisoning showed higher severity than unintentional CO poisoning. In the time series analysis, the rate of unintentional CO poisoning and seasonal fluctuation is predicted to increase.

Innovative screening tests for COVID-19 in South Korea

Recently, the number of Corona Virus Disease 2019 (COVID-19) cases has increased remarkably in South Korea, so the triage clinics and emergency departments (ED) are expected to be overcrowded with patients with presumed infection. As of March 21st, there was a total of 8,799 confirmed cases of COVID-19 and 102 related deaths in South Korea that was one of the top countries with high incidence rates [1]. This sharp increase in infection is associated with 1) outbreaks in individual provinces, 2) deployment of rapid and aggressive screening tests, 3) dedicated healthcare staffs for virus screening tests, 4) quarantine inspection data transparency and accurate data reporting, and 5) public health lessons from previous Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks. This commentary introduces innovative screening tests that are currently used in South Korea for COVID-19, e.g., Drive-Through and Walk-Through tests, and compare the advantages and disadvantages of both methods.

A case of hemorrhagic gastritis caused by accidental ingestion of fluoride-containing toothpaste

Fluoride is one of the most reactive elements in nature, and commonly used in toothpaste since it helps to prevent cavities. Despite this advantage, excessive ingestion of fluoride can cause acute toxicity and gastric disturbance from hydrofluoric acid that was formed in the stomach. We report a case of previously healthy, 41-month-old girl who visited the emergency department with persistent abdominal pain and hematemesis after ingestion of fluoride-containing toothpaste. Though the ingested dose of fluoride was below the toxic dose, serious symptoms developed. We performed esophagogastroduodenoscopy, and confirmed a hemorrhagic gastritis caused by hydrofluoric acid. The girl was uneventfully discharged on day 3 after receiving conservative care. When managing children who ingested fluoride-containing toothpaste, physicians need to consider their symptoms, not the ingested amount. In addition, parents should be cautious when their children use fluoride-containing toothpaste.

A case of ingested water beads diagnosed with point-of-care ultrasound

A previously healthy 12-month-old girl presented to the emergency department with vomiting of water beads (superabsorbent polymer). The girl did not have clinical or radiographic signs of residual foreign bodies or intestinal obstruction. Point-of-care ultrasound showed well-demarcated, round, and hypoechoic materials in the stomach and first part of the duodenum, indicating ingested beads. Subsequently, the beads were retrieved by the esophagogastroduodenoscopy. Because water beads can be readily found with point-of-care ultrasound, the use of this imaging modality can expedite endoscopic intervention and avoid surgical removal of foreign bodies.

A case of hemorrhagic gastritis caused by accidental ingestion of fluoride-containing toothpaste

Fluoride is one of the most reactive elements in nature, and commonly used in toothpaste since it helps to prevent cavities. Despite this advantage, excessive ingestion of fluoride can cause acute toxicity and gastric disturbance from hydrofluoric acid that was formed in the stomach. We report a case of previously healthy, 41-month-old girl who visited the emergency department with persistent abdominal pain and hematemesis after ingestion of fluoride-containing toothpaste. Though the ingested dose of fluoride was below the toxic dose, serious symptoms developed. We performed esophagogastroduodenoscopy, and confirmed a hemorrhagic gastritis caused by hydrofluoric acid. The girl was uneventfully discharged on day 3 after receiving conservative care. When managing children who ingested fluoride-containing toothpaste, physicians need to consider their symptoms, not the ingested amount. In addition, parents should be cautious when their children use fluoride-containing toothpaste.

A case of ingested water beads diagnosed with point-of-care ultrasound

A previously healthy 12-month-old girl presented to the emergency department with vomiting of water beads (superabsorbent polymer). The girl did not have clinical or radiographic signs of residual foreign bodies or intestinal obstruction. Point-of-care ultrasound showed well-demarcated, round, and hypoechoic materials in the stomach and first part of the duodenum, indicating ingested beads. Subsequently, the beads were retrieved by the esophagogastroduodenoscopy. Because water beads can be readily found with point-of-care ultrasound, the use of this imaging modality can expedite endoscopic intervention and avoid surgical removal of foreign bodies.

Characteristics of poisoning in younger children according to different forms of the drugs

PURPOSE: This study aimed to investigate the characteristics of poisoning drug ingested by younger children, and to compare the clinical outcome by drug forms.METHODS: This was a retrospective analysis based on medical records from the Emergency Department based Injury In-depth Surveillance (EDIIS) registry in Korea from January to December 2015. Patients aged 7 years or younger visiting the emergency department (ED) with drug poisoning were included. We classified the forms of drugs as tablets or syrup, and analyzed the characteristics by size, color, and shape. In addition, clinical outcomes and ED length of stay were compared according to the drug forms.RESULTS: A total of 308 cases were collected, and 202 patients finally were analyzed. Tablets and capsules (TACs) were more common than syrup (67.3% vs. 32.7%). Regarding clinical outcomes, patients who took TACs had higher admission rate (17.6% vs. 7.6%, P = 0.040) without a significant difference in ED length of stay compared to those who took syrups. While commonly ingested drugs in TACs were hormones, sedative and analgesics, frequent drugs in syrup were antihistamines and cold drugs. In 136 case of TACs, median long and short axes were 0.85 cm (interquartile range [IQR], 0.7–1.1 cm) and 0.72 cm (IQR, 0.59–0.82 cm), respectively. Chromatic TACs were 80 cases (58.8%) and more common than achromatic TACs. Round shapes were preferred than angular ones (96.3% vs. 3.7%).CONCLUSION: In younger children poisonings, the TACs showed higher incidence and admission rate compared to syrups. Especially, chromatic TACs and round shapes were preferred. Therefore, drugs with these characteristics need to be stored more carefully.

Epidemiologic Characteristics of Carbon Monoxide Poisoning: Emergency Department Based Injury In-depth Surveillance of Twenty Hospitals

PURPOSE: This study was conducted to describe the characteristics of patients with carbon monoxide (CO) poisoning. METHODS: We retrospectively surveyed data from the Emergency Department based Injury In-depth Surveillance of 20 hospitals (2011-2014). We included patients whose mechanism of injury was acute CO poisoning caused by inhalation of gases from charcoal or briquettes. We surveyed the annual frequency, gender, age, result of emergency treatment, rate of intensive care unit (ICU) admission, result of admission, association with alcohol, and place of accident. We also surveyed the cause and experience of past suicide attempts by intentional poisoning. RESULTS: A total of 3,405 patients were included (2,015 (59.2%) and 1,390 (40.8%) males and females, respectively) with a mean age of 39.83±18.51 year old. The results revealed that the annual frequency of CO poisoning had increased and the frequency of unintentional CO poisoning was higher than that of intentional CO poisoning in January, February and December. The mean age of intentional CO poisoning was younger than that of unintentional CO poisoning (38.41±13.03 vs 40.95±21.83) (p<0.001). The rates of discharge against medical advice (DAMA), ICU care and alcohol association for intentional CO poisoning were higher than for unintentional CO poisoning (36.4% vs 14.0%, 17.8% vs 4.7%, 45.2% vs 5.6%) (p<0.001). The most common place of CO poisoning was in one's residence. CONCLUSION: The annual frequency of total CO poisoning has increased, and unintentional CO poisoning showed seasonal variation. DAMA, ICU care, and alcohol association of intentional CO poisoning were higher than those of unintentional CO poisoning.

The Anesthetic Effect of Modified Subcutaneous Single-Injection Digital Block

PURPOSE: The aim of this study is to investigate the anesthetic effect on a modified subcutaneous single-injection digital block in accordance with the location of the finger. METHODS: We recruited volunteers from the workshop training course. We injected less than 5 mL of 2% lidocaine at the volar side, between the 3rd metacarpal and proximal phalangeal joint, until the swelling in the dorsal side of the finger increased. At 10 minutes post the modified subcutaneous single-injection digital block, we recorded the pain score (0-10) using 11-point numeric rating pain scale (NRPS) according to the location of the finger (volar proximal phalanx, VPP; volar middle phalanx, VMP; volar distal phalanx, VDP; dorsal distal phalanx, DDP; dorsal middle phalanx, DMP; dorsal proximal phalanx, DPP) via a pinprick test. We analyzed and compared the NRPS on the location of the finger by the Friedman test with a Pairwise comparison. RESULTS: Fifty-eight volunteers of healthy adult were enrolled in this study. The pain scales on DPP and DMP were 7.00 (4.00-8.00) and 2.00 (1.00-4.00), respectively. The pain scales on DDP, VDP, VMP and VDP were 0.00 (0.00-2.00), 0.00 (0.00-0.00), 0.00 (0.00-1.00) and 0.00 (0.00-1.00), respectively. The pain scales on DPP and DMP were significantly different among DDP, VPP, VMP and VPP (p0.999; VDP vs. VMP, p>0.999; VMP vs. VPP, >0.999). CONCLUSION: A modified subcutaneous single-injection digital block should be considered useful in regional anesthesia at the volar side of the finger and the dorsal side of the distal phalanx.

A Comparative Study Between Newly Developed Wave-form and Traditional Straight-form Splints

PURPOSE: Widely used fiberglass splints are made from straight-form material. These prove difficult to mold at joints and form wrinkles, causing complications such as pain, pressure sores, and peripheral nerve palsy. We compared the usefulness of wave-form splints with straight-form splints and the level of satisfaction of these designs from care providers and wearers. METHODS: Eighty-nine (n=89) emergency physicians and orthopedic surgeons participated in this study. The subjects (acting as care providers and mock patients) used wave-form and straight-form material to construct and wear short leg splints, long arm splints, and sugar tong splints. The clinicians were surveyed on their satisfaction as providers and wearers. All questions were measured on scores from 0 and 10(10=maximum score). After splints were removed, subjects were surveyed on the extent of splint wrinkling with scores from 1 to 3(3=maximum wrinkling). RESULTS: Provider satisfaction scores for wave-form splints versus straight-form splints in short leg splint applications were 7.76+/-1.30 vs 6.74+/-1.25 (p=0.000). Provider satisfaction scores for wave-form splints versus straight-form splints in long arm splint applications were 7.73+/-1.33 and 6.73+/-1.59 (p=0.004), respectively. The subjects felt more comfortable wearing wave-form splints, compared to straight-form splints (7.79+/-1.49 vs. 6.79+/-1.58, respectively; p=0.004) and more satisfied (8.03+/-1.35 vs. 7.18+/-1.33, respectively; p=0.003). The frequencies of wrinkle occurrence in wave-form and straight-form splints were 29.7% and 42.2%, respectively (p=0.02). CONCLUSION: Wave-form splints may be more practical for molding and wearing than traditional straight-form splints.