Clinical Evaluation of Abdominal Stab Wound Patients in the ED

PURPOSE: In Korea, most abdominal penetrating wounds are caused by stab wounds rather than gun-shot wounds. However, not many studies have been performed on stab injuries and their epidemiologic characteristics. Disagreements of opinions of obligatory surgical exploration and conservative treatment exist, and this subject is still being debated. Therefore, the authors studied the epidemiologic characteristics of abdominal stab wound patients visiting the emergency department and reviewed the proportion of patients that received non-therapeutic surgery and conservative treatment. METHODS: This study included patients visiting the emergency department with abdominal stab wounds. A retrospective chart review was done on the abdominal stab wound patients. Sex, age, cause of injury, location of wound, initial vital signs, operation results, injured organs and CT & LWE results were reviewed. RESULTS: The median age of the 121 patients was 40.9 years, of these patients, 88 were males, of which 52 (43.0%) were drunken. Of the patients that received non-therapeutic operations, only 3 patients (15.0%) were drunken, significantly lower than the therapeutic operation group. For the location of the wound, most patients were injured in the right and left upper quadrants, 27 patients each. The most common injured organ was the small bowel; 13 patients were injured in the small bowel. With abdominal CT scans and local wound explorations together, the results exhibited a sensitivity of 97%, a specificity of 44%, a positive predictive value of 56%, and a negative predictive value of 95%. CONCLUSION: In our study, the sensitivity was 97% when CT & LWE were performed together; thus we can conclude that CT and LWE can be used together to select the treatment method. Although in our study, the surgical indications in abdominal stab wound patients is not sufficient, our results showed a higher rate of non-therapeutic surgery compared to previous studies. Therefore, more research is needed to prevent unnecessary laparotomies in hemodynamically-stable patients without symptoms.

Analysis of Patients with Acute Industrial Toxic Exposure at an Emergency Department in an Industrial Complex

PURPOSE: Surveys on poisoning usually involves intoxication rather than inhalation, skin contact, etc. Therefore, we examined the characteristics of patients who visited the emergency department in an industrial complex after acute industrial exposure to toxic materials. METHODS: Medical records of patients exposed to toxic materials in the work places from April, 2006, to March, 2008, were analyzed retrospectively. Inhalation patients due to fire were excluded. RESULTS: Subjects included 66 patients, with a mean age of 35.4+/-10.9 years, mostly men (91%). Toxicity occurred in 51 patients (77%) by contact, 15 patients (23%) by inhalation, and none by oral ingestion. For toxic materials, 10 patients were exposed to hydrofluoric acid, 8 to hydrochloric acid, 7 to sodium hydroxide, 7 to metals, and others. The face and hands were the most frequent exposure site by contact. Most exposures were caused by accidents, with 29 cases (42%) exposed because of carelessness or not wearing protective equipment. Most complaints were pain on exposure site, but 7 of the inhalation patients complained of dyspnea. The majority of patients with contact exposure were discharged after wound care or observation. After inhalation exposure, 1 patient died and 5 patients were admitted to the intensive care unit. CONCLUSION: Major causes of workplace exposure were not wearing protective equipment or carelessness. Although contact exposures are usually benign, cautious observation and management are required in patients with inhalation exposure.

Alveolar Dead Space Ventilation Ratio as an Early Predictor of Acute Respiratory Distress Syndrome in Severe Sepsis and Septic Shock Patients

PURPOSE: Examine the clinical utility of the alveolar dead space ventilation ratio (VdA/VT) as a predictor of acute respiratory distress syndrome (ARDS) in severe sepsis and septic shock patients. METHODS: A prospective observation study was done for 113 patients with severe sepsis and septic shock seen at the emergency department of a university hospital from January 2005 to June 2007. Therapies in the emergency department included central venous access, antibiotics, fluid resuscitation, mechanical ventilation, vasopressors and inotropes as required. The major outcome assessed was the development of ARDS within 3 days after admission. Hemodynamic variables, arterial blood gas values, serum lactate concentration, and estimated VdA/VT were evaluated at presentation (0 hour) and at 4 hours. Briefly the estimated VdA/VT was calculated by dividing the deference of the arterial CO2 and end-tidal CO2 by the PaCO2 value. Data were presented as median+/-SD. RESULTS: ARDS developed in twenty-two patients (<24 hours: 17 persons, 24~48 hour: 4 persons, 48~72 hour: 1 person). Patients who developed ARDS had significantly higher age, higher frequency of pneumonia, greater use of mechanical ventilation and dubutamine during ED therapy, and higher sepsis related organ failure assessment (SOFA) scores. The in-hospital mortality of patients with ARDS was significantly higher than that of patients without ARDS (54.5% vs. 15.4%, p<0.001). Pneumonia, use of dobutamine during ED therapy, and VdA/VT at 4 hours were independent predictive factors for the development of ARDS. The area under the receiving operating characteristic curve for predicting ARDS was 0.891 (95% CI; 0.808-0.980) with a value of VdA/VT at 4 hours. The cut off value of VdA/VT at 4 hours was 0.25 (sensitivity 81.8%, specificity 93.3%). At 4 hours, patients with VdA/VT equal to or greater than 0.25 under resuscitation showed a high rate of fluid and high inhospital mortality when compared with patients with VdA/VT <0.25 (CVP<10 cmH2O; 37.5% vs. 16.9%, p=0.047, mortality; 75.0% vs. 4.5%, p<0.001). In patients with VdA/VT equal to or greater than 0.25 at 0 hour, patients without ARDS showed significantly improvement of VdA/VT at 4 hours. CONCLUSION: VdA/VT was found to be an independent predictive variables for ARDS in the early in-hospital period. Improvement of VdA/VT through early goal directed therapy in emergency department may decrease the development of ARDS in severe sepsis and septic shock patients.

Lactic Acidosis as a Prognostic Factor and a Therapeutic Guideline for Severe Sepsis and Septic Shock

PURPOSE: To examine the clinical utility of lactic acidosis as a predictor of in-hospital mortality and as an early therapeutic marker in severe sepsis and septic shock patients. METHODS: We conducted a prospective observational study. Patients visiting the emergency department from January 2005 to October 2006 who were suspected to have severe sepsis and septic shock were candidates for enrollment. Therapies in the emergency department consisted of early goal-directed resuscitation and employed central venous access, antibiotics, fluid resuscitation, mechanical ventilation, vasoactive agent, and inotropes as required. We measured hemodynamic variables, arterial blood gases, and serum lactate at presentation (0 hours) and at four hours. The SAPS II at emergency department and SOFA score at 0 hours, 4 hours, 24 hours, 48 hours and 72 hours were recorded. RESULTS: A total of 102 patients were enrolled during the study period. Data were presented as mean+/-SD. Thirtyfour patients died in the hospital, eighteen patients of them within 72 hours after admission. Septic shock was encountered in 44 patients. Non-survivors had significantly lower pH, higher serum lactate level, higher SAPS II scores, lower mean arterial blood pressure, higher heart rates, and lower PaO2/FiO2 values at 0 and 4 hours than did survivors. During the first four hours, persistent lactic acidosis and high SAPS II scores were independently associated with mortality. Although most patients achieved the therapeutic goals, excepting central venous oxygen saturation in nonsurvivors, patients with persistent lactic acidosis at 0 and 4 hours had significantly high in-hospital mortality and early overall mortality than other patients (80.0%, p=0.000, 65.0%, p=0.000, respectively). Patients recovering from lactic acidosis at 4 hours showed lower in-hospital mortality and early overall mortality than patients with persistent lactic acidosis (50.0% vs. 80.0%, p=0.070, 14.3% vs. 65.0%, p=0.004). CONCLUSION: Persistent lactic acidosis was found to be an independent variable for predicting mortality and morbidity. Persistent lactic acidosis may be used as a prognostic and treatment indicator during the resuscitation of patients with severe sepsis and septic shock in an emergency department.