Epidemiology and outcomes of traumatic brain injury in Korean children according to age and development

Objective@#Traumatic brain injury (TBI) is one of the major causes of death and disability in children. Understanding the epidemiologic characteristics of TBI in children is the first step for developing preventative strategies, optimizing care systems, and rehabilitating the injury. @*Methods@#This is a cross-sessional study based on the Emergency Department-based Injury In-depth Surveillance (EDIIS) in Korea. We identified children (aged 0 to 18 years) who presented with TBI in emergency departments between January 2011 and December 2018. Subjects were classified into four groups according to age and development: infant and toddler group (0-2 years), pre-school group (3-5 years), school-aged group (6-11 years), and adolescent group (12-18 years). Epidemiologic characteristics and outcomes were compared according to age groups, and temporal variability in incidence was evaluated. @*Results@#During the 8-year study period, 45,734 children with TBI were included in the analysis. A higher incidence of TBI was observed in males, road accidents, and school/educational facilities as compared to the lesser-aged group (all P<0.01). Motor vehicle collisions were more common in the older group, but falls were more common in the younger group. Compared to the infant/toddler group, the adolescent group had higher intracranial injuries (8.1% vs. 16.8%; adjusted odds ratio [AOR], 1.8; 95% confidence interval [CI], 1.6-2.0) and mortality rate (0.2% vs. 1.3%; AOR, 2.0; 95% CI, 1.3-3.0). @*Conclusion@#The epidemiological characteristics of TBI in children are different for each group. It is necessary to develop differentiated preventative strategies and treatment systems based on the age groups of children.

The feasibility of synchronous online learning as a tool for KTAS (Korean Triage and Acuity Scale) education in the COVID-19 era

Objective@#Since 2012, the Korean Triage and Acuity Scale (KTAS) has been used to triage patients in an emergency care setting, and the KTAS provider course was started in 2014. However, due to the coronavirus disease 2019 (COVID-19) pandemic, this course could not be taught to learners face-to-face (FTFL). Therefore, a new KTAS course using synchronous online learning was launched in July 2020. This study investigated whether synchronous online learning (SOL) is as effective as traditional learning (FTFL) for KTAS education. @*Methods@#This was a retrospective study of trainees who participated in the KTAS provider course in Seoul, Korea. The trainees were divided into FTFL and SOL groups. The post-test results of the two training methods were compared, and the association between the type of education and the training results was analyzed. @*Results@#The mean post-test score of the FTFL and SOL groups were 78.16±12.4 points and 80.71±9.91 points, and the post-test pass rates were 79.2% and 82.1%, respectively. The mean difference (MD) between the two groups indicated the non-inferiority of SOL in the post-test scores (MD, 2.55; 95% confidence interval [CI], 1.35 to 3.75) and the pass rate (MD, 2.9%; 95% CI, -1.2 to 0.7). The results of the multivariate analysis revealed that the pass rate was associated with younger age and an emergency department career of over 18 months. However, there was no significant association between the education type and the results. @*Conclusion@#Through this study, SOL was shown to be as effective as FTFL in KTAS education. Furthermore, SOL may be the best alternative educational method during the COVID-19 pandemic because it has the advantage of resolving spatial restrictions.

Bladder injury with vesicocutaneous fistula following acupuncture: a case report

Acupuncture is globally practiced extensively, especially in Northeast Asian countries. We present a case of bladder injury with vesicocutaneous fistula (VCF) subsequent to acupuncture treatment on the lower abdomen. We believe that no similar case has been reported in previous literature. A 54-year-old woman was admitted to our emergency department, complaining of lower abdominal pain with erythema, after undergoing acupuncture. Physical examination revealed swelling with erythema and slight pus-like discharges in the lower abdomen, with accompanying tenderness over the area of the swelling. An abdominal computed tomography showed evidence of bladder injury with VCF and abscess. Considering the underlying disease and the risk of surgical treatment, the patient was successfully treated with percutaneous abscess drainage and an indwelling urinary catheter. Considering the outcome of this case, we recommend that practitioners need to perform acupuncture treatment with sufficient anatomical knowledge and proper technique, to reduce the possibility of subsequent complications.

Clinical course of compressed air injury with pneumocephlaus and orbital emphysema: a case report

Orbital emphysema with pneumocephalus is an unusual condition encountered in non-fracture craniofacial trauma. We report a case of orbital emphysema with disseminated pneumocephalus without any fracture, due to an orbital trauma caused by compressed air.

Public awareness and willingness to use automated external defibrillators in a metropolitan city

Objective@#Early defibrillation is crucial for the survival of patients with out-of-hospital cardiac arrest. This study aimed to examine the trends and associated factors regarding public awareness and willingness to use automated external defibrillators (AEDs) through citywide surveys. @*Methods@#Three-round surveys were conducted in February 2012 (n=1,000), December 2016 (n=1,141), and December 2018 (n=1,001) among citizens in Daegu, South Korea, who were aged ≥19 years. The subjects were selected through a three-stage quota sampling. Awareness and willingness to use an AED were assessed in the three groups. The primary outcome was willingness to use AEDs. @*Results@#Of 3,142 respondents, 3,069 were eligible for analysis. The proportion of respondents who knew how to use AEDs increased from 4.7% in 2012 to 20.8% in 2018. Of the respondents in 2012, 2016, and 2018, 39.7%, 50.0%, and 43.2%, respectively, were willing to use an AED. Factors associated with willingness to use AEDs were male sex (adjusted odds ratio [AOR], 1.39; 95% confidence interval [CI], 1.10–1.75), cardiopulmonary resuscitation training experience in the previous 2 years (AOR, 1.80; 95% CI, 1.43–2.28), recognition of the Good Samaritan law (AOR, 1.45; 95% CI, 1.13–1.86), and awareness of how to use an AED (AOR, 4.40; 95% CI, 3.26–5.93). @*Conclusion@#To increase willingness to use AEDs, education in AED use and the Good Samaritan law, along with re-education to maintain knowledge of AED use, should be considered.

Clinical course of compressed air injury with pneumocephlaus and orbital emphysema: a case report

Orbital emphysema with pneumocephalus is an unusual condition encountered in non-fracture craniofacial trauma. We report a case of orbital emphysema with disseminated pneumocephalus without any fracture, due to an orbital trauma caused by compressed air.

Public awareness and willingness to use automated external defibrillators in a metropolitan city

Objective@#Early defibrillation is crucial for the survival of patients with out-of-hospital cardiac arrest. This study aimed to examine the trends and associated factors regarding public awareness and willingness to use automated external defibrillators (AEDs) through citywide surveys. @*Methods@#Three-round surveys were conducted in February 2012 (n=1,000), December 2016 (n=1,141), and December 2018 (n=1,001) among citizens in Daegu, South Korea, who were aged ≥19 years. The subjects were selected through a three-stage quota sampling. Awareness and willingness to use an AED were assessed in the three groups. The primary outcome was willingness to use AEDs. @*Results@#Of 3,142 respondents, 3,069 were eligible for analysis. The proportion of respondents who knew how to use AEDs increased from 4.7% in 2012 to 20.8% in 2018. Of the respondents in 2012, 2016, and 2018, 39.7%, 50.0%, and 43.2%, respectively, were willing to use an AED. Factors associated with willingness to use AEDs were male sex (adjusted odds ratio [AOR], 1.39; 95% confidence interval [CI], 1.10–1.75), cardiopulmonary resuscitation training experience in the previous 2 years (AOR, 1.80; 95% CI, 1.43–2.28), recognition of the Good Samaritan law (AOR, 1.45; 95% CI, 1.13–1.86), and awareness of how to use an AED (AOR, 4.40; 95% CI, 3.26–5.93). @*Conclusion@#To increase willingness to use AEDs, education in AED use and the Good Samaritan law, along with re-education to maintain knowledge of AED use, should be considered.

The clinical usefulness of radiologic report monitoring system of CT and MRI in emergency department: analysis of missed and incidental findings

Objective@#This study was undertaken to establish a radiologic report monitoring system (RRMS) for missed and incidental findings (MIFs) in computed tomography (CT) and magnetic resonance imaging (MRI) reports, to help determine the clinical significance of MIFs in the emergency department (ED). @*Methods@#Patients presenting to our ED in 2017 were subjected to RRMS. Preliminary reports and final reports were subsequently compared based on the clinical significance of the MIFs. If required, the patient was contacted and instructed to revisit the ED. @*Results@#Totally, 12,132 CT and MRI exams were performed during the study period, and 321 cases (2.6%) encompassed MIFs. We attempted to contact 228 cases (1.9%) who had clinically significant MIF findings; 9 patients were instructed to return to the ED, whereas 105 cases were instructed to report to the outpatient department. Hospitalization was required for 12 patients: 2 cases required surgical intervention, 2 cases had an additional procedure, and 8 cases required medical hospitalization. @*Conclusion@#This study applied RRMS for a timely assessment of MIFs, determine rearrangements required, and present an active response to the MIFs determined in the ED. To improve patient care and safety, we hereby propose monitoring MIFs using the RRMS or similar methods.

Effectiveness of limited airway ultrasound education for medical students: a pilot study

OBJECTIVE: The point-of-care ultrasound of the airway (POCUS-A) is a useful examination method but there are currently no educational programs for medical students regarding it. We designed a POCUS-A training curriculum for medical students to improve three cognitive and psychomotor learning domains: knowledge of POCUS-A, image acquisition, and image interpretation.METHODS: Two hours of training were provided to 52 medical students in their emergency medicine (EM) rotation. Students were evaluated for cognitive and psychomotor skills before and immediately after the training. The validity measures were established with the help of six specialists and eight EM residents. A survey was administered following the curriculum.RESULTS: Cognitive skill significantly improved after the training (38.7±12.4 vs. 91.2±7.7) and there was no significant difference between medical students and EM residents in posttest scores (91.2±7.7 vs. 90.8±4.6). The success rate of overall POCUS-A performance was 95.8%. The students were confident to perform POCUS-A on an actual patient and strongly agreed to incorporate POCUS-A training in their medical school curriculum.CONCLUSION: Cognitive and psychomotor skills of POCUS-A among medical students can be improved via a limited curriculum on EM rotation.

Does the large amount of ascites lateralize the inferior epigastric artery in liver cirrhosis?

OBJECTIVE: The most common cause of hemorrhage after paracentesis is direct needle puncture of the inferior epigastric artery (IEA). This study examined the relationship between the amount of the ascites and the location of the IEA in liver cirrhosis. METHODS: Abdominal computed tomography (CT) examinations of patients with liver cirrhosis were reviewed retrospectively and divided into two groups according to the amount of ascites. The distances between the midline and the IEAs of both sides were measured at the umbilicus, McBurney's point, anterior superior iliac spine, and mid-inguinal level. Branching of the IEAs, abdominal wall and mesenteric varices in the abdomen below the umbilicus level were recorded. RESULTS: A total of 120 abdominal CTs were reviewed. The distances from the midline to the IEA in the large ascites group were longer than those in the small ascites group at the level of the right McBurney's point (44.5±14.6 mm vs. 39.6±11.8 mm, P=0.043) and left McBurney's point (48.6±15.3 mm vs. 43.3±11.5 mm, P=0.035). The incidence of abdominal wall varices was higher in the large ascites group (21.7% vs. 5.0%, P=0.014). CONCLUSION: In patients with liver cirrhosis, the large amount of ascites might be associated with lateralizing the location of the IEA. Moreover, it may be necessary to confirm the blood vessels in the abdominal wall and mesentery near the puncture site by bedside ultrasound before the paracentesis.

Rectal Perforation with Pneumoperitoneum Caused by Compressed Air

Compressed air can cause serious damage to internal organs. The stomach is an organ that is rarely perforated due to its elasticity. However, intestines are weaker and thinner compared to the stomach. A 40-year-old male came to the emergency room with severe abdominal pain due to dyspnea. The patient experienced abdominal pain right after his coworker shot compressed air into the patient's pants. The patient suffered from a rigid abdomen, and bed-side ultrasonography was carried out as soon as possible. Pneumoperitoneum was diagnosed by portable X-ray. After computed tomography, emergency paracentesis was carried out for decompression. After emergency paracentesis, the patient's symptoms and vital signs were stabilized. After the procedure, the patient had an emergency laparotomy.

Adverse Drug Reactions in Adult Patients Visiting an Emergency Department: Based on Spontaneous Reporting System

PURPOSE: Adverse drug reaction (ADR) is known to be a substantial reason for emergency departments (ED) visits. Additionally, it also is a frequent occurrence in ED. The aim of the study was to compare the characteristics between ADRs that occurred in ED and ADRs that occur elsewhere based on the spontaneous reporting system in a hospital. METHODS: In this retrospective observational study, the data was collected by the spontaneous ADR reporting system within an electronic medical record system during a 24-month period. ADR of patients aged more than 18 years were included in this study. RESULTS: Patients with ADR was older in ED (42.6±14.5 vs. 53.9±17.2, p<0.001) and they were administered with less medications (2.0±1.3 vs. 4.4±4.4, p<0.001). The proportion of ADR reported by doctors in ED was higher than that in non-ED (41.2% vs. 28.2%, p<0.001). The proportion of the severe ADR was not significantly different between the ED and non-ED groups (2.9% vs. 3.8%, p=0.701). The most common symptom of ADRs in ED and non-ED groups were cutaneous (52.9%) and gastrointestinal (42.2%), respectively; the most common implicated medication was analgesics (62.7%) and analgesics (41.5%), respectively. CONCLUSION: The characteristics of ADR in ED is different from that in non-ED locations. Further studies are needed to differentiate education and prevention strategies of ADR in ED from those in non-ED locations.

Two cases of incidental Podostroma cornu-damae poisoning

Podostroma cornu-damae is a rare, deadly fungus. However, it can be easily mistaken for antler Ganoderma lucidum. In this case report, two patients made tea with the fungus and drank it over a 2-week period. Both patients presented with bicytopenia, and one patient had desquamation of the palms and soles. Both were treated with prophylactic antibiotics and granulocyte colony-stimulating factor. One patient was admitted to the intensive care unit and received a platelet transfusion. Both patients were discharged without complications. Podostroma cornu-damae infections caused by intoxication were successfully treated using our treatment strategy, which consisted of prophylactic antibiotics, platelet transfusion, and granulocyte colony-stimulating factor. We believe this report can guide future treatment.

Suggestion of a Modified Reduction Maneuvers with Parents in the Pulled Elbow Children

PURPOSE: If radial head subluxation, otherwise known as pulled elbow, occurs, closed reduction can be used in simultaneous diagnosis and treatment of the child. As the guardian seldom understands the maneuver without explanation, we revised a method to involve the caregiver in the treatment. METHODS: This was a prospective controlled study. From January, 2014 to December, 2014, children suspected of radial head subluxation, under the age of 6, were enrolled. Patients were randomly assigned to two groups. One group was treated conventionally and the other group was treated while the parent's finger was on the patient's lateral epicondyle. A total of three attempts were made using the hyperpronation method and the supination-flexion method. The physician then recorded whether the treatment was successful, the number of attempts, easiness of the reduction, and guardian's degree of understanding and satisfaction. RESULTS: A total of 116 patients were enrolled. The number of attempts was 1.27 and 1.35 times in the experimental group and the control group, respectively. The success rate was 96.6% in the experimental group and 94.7% in the control group. There was no statistically significant difference within the two groups. The physicians found that the revised method was as easy as the conventional method and the caregiver's degree of understanding was higher in the experimental group. CONCLUSION: As the revised method increases the degree of guardians' understanding and does not increase the difficulty of the procedure, we recommend using the revised method in treatment of radial head subluxation.

New Intervention Model of Regional Transfer Network System to Alleviate Crowding of Regional Emergency Medical Center

Emergency department (ED) crowding is a serious problem in most tertiary hospitals in Korea. Although several intervention models have been established to alleviate ED crowding, they are limited to a single hospital-based approach. This study was conducted to determine whether the new regional intervention model could alleviate ED crowding in a regional emergency medical center. This study was designed as a "before and after study" and included patients who visited the tertiary hospital ED from November 2011 to October 2013. One tertiary hospital and 32 secondary hospitals were included in the study. A transfer coordinator conducted inter-hospital transfers from a tertiary hospital to a secondary hospital for suitable patients. A total of 1,607 and 2,591 patients transferred from a tertiary hospital before and after the study, respectively (P < 0.001). We found that the median ED length of stay (LOS) decreased significantly from 3.68 hours (interquartile range [IQR], 1.85 to 9.73) to 3.20 hours (IQR, 1.62 to 8.33) in the patient group after implementation of the Regional Transfer Network System (RTNS) (P < 0.001). The results of multivariate analysis showed a negative association between implementation of the RTNS and ED LOS (beta coefficient -0.743; 95% confidence interval -0.914 to -0.572; P < 0.001). In conclusion, the ED LOS in the tertiary hospital decreased after implementation of the RTNS.

Experiences of Disaster Medical Response System in a Fire at Goyang Bus Terminal

PURPOSE: The purpose of this study was to report medical care activities of Disaster Medical Assistance Team (DMAT) and medical facilities that responded to the Goyang Bus Terminal fire on May 26, 2014, and to draw improvement of the current disaster medical response system. METHODS: We retrospectively reviewed emergency medical service (EMS) run sheet and medical records of patients who visited the emergency department the day of the fire. We also interviewed the officials involved in disaster response. RESULTS: A total of 73 patients participated in this study. Among them, 9 were classified as Emergency, 60 as Non-Emergency, and 4 as Death on arrival (DOA). Fifty one patients visited the nearest hospital, and 17 patients were transported by EMS. DMAT arrived at the scene in 58 minutes, however there was little medical activity. CONCLUSION: Initial Triage and distribution of patients was rather inadequate and DMAT arrived late. For the future, we recommend constant training of the paramedics and leaders of 119, and to mend DMAT requesting and response system.

Prospective Evaluation of the Recognition of Stroke In the Emergency Room (ROSIER) Scale in Emergency Department

PURPOSE: Early assessment and rapid intervention in patients with acute stroke can reduce mortality and complication. We conducted a prospective evaluation of the Recognition Of Stroke In the Emergency Room (ROSIER) scale for use in patients with suspected stroke. METHODS: We studied 312 patients with suspected acute stroke who were admitted to the emergency department within 7 months from August 2013 to February 2014. Emergency physicians used the ROSIER scale as a stroke recognition tool, compared with the Face Arm Speech Test (FAST). Patients meeting the inclusion criteria were evaluated for both the FAST and the ROSIER scale and compared with the final discharge diagnoses. Then, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), area under curve of the FAST, and the ROSIER scale were calculated. RESULTS: The patient group consisted of 141 males and 171 females with an average age of 60 years; 112 (35.9%) patients had ROSIER scale > or =1 indicating a stroke, 98 (31.4%) of these patients had stroke as a final diagnosis. The FAST showed sensitivity of 85.8%, specificity of 92.5%, PPV of 86.6%, and NPV of 92.0%. The ROSIER scale showed relative sensitivity of 86.7%, specificity of 93.0%, PPV of 87.5%, and NPV of 92.5%. CONCLUSION: In this study, the ROSIER scale was a useful stroke recognition tool for potential stroke patients, but showed no significant superiority over the FAST.

The Effect of Counting Numbers out for Giving Breaths on the Interrupting Time and Fraction of Chest Compressions in 2-rescuer Cardiopulmonary Resuscitation: A Manikin Pilot Study

PURPOSE: The aim of this study was to estimate the effect of counting numbers out for giving breaths on the interruption time (IT) of chest compressions (CCs) and chest compression fraction (CCF) in the 2-rescuer cardiopulmonary resuscitation (CPR). METHODS: Thirty medical students were enrolled in this randomized control simulation study, and were randomly divided into the control group and the study group. Both groups performed 2-rescuer CPR for 5-cycles with giving breaths using a bag-mask. Only participants in the study group were instructed to count numbers out for each breath verbally ("one, two") at the end point of each inspiration period and immediately perform CCs at the point of counting "two". RESULTS: However, no differences in terms of depth, rate, incorrect location, and duty cycle of CCs, as well as ventilation volume of each breath, time to delivery of two breaths, and counts of breathing during 1 minute were observed between the two groups. CONCLUSION: The study group had significantly shorter IT and higher CCF compared with the control group. And no significant differences in the other measured parameters of CPR quality were observed between the two groups.

A Case of Acute Appendicitis of Children which its Symptoms and Signs were Self-disappeared

Acute appendicitis is a disease resulting from inflammation of the appendix. The most common symptoms and physical examinations are the following: right lower abdomen pain, tenderness, rebound tenderness, nausea, vomiting, and fever. The clinician makes a diagnosis based on these symptoms and physicals along with ultrasonography or radiologic imaging, such as computed tomography (CT), forviewing of the inflamed appendix. In this case a seven-year-old-male visited the Emergency Room with abdominal pain and tendernessin in the right lower quadrant, whose symptoms disappeared spontaneously without treatment, although the bedside ultrasonography showed an inflamed appendix. The patient underwent surgery and the operation findings indicated a concordant diagnosis. We report this case as the cardinal symptom of acute appendicitis has been right lower quadrant pain for many years, which may lead to misdiagnosis.

Prospective Evaluation of the Pediatric Appendicitis Score with Right Lower Quadrant Abdominal Pain Registry

PURPOSE: Acute appendicitis is one of the most common surgical emergencies in the emergency department (ED) and various scoring systems such as the Alvarado score or the pediatric appendicitis score (PAS) have been developed to aid diagnosis. This study was designed to evaluate the diagnostic value of PAS in South Korea children, prospectively. METHODS: All patients visiting our ED with right lower quadrant (RLQ) abdominal pain or RLQ tenderness were enrolled in our registry. Patients under age of 18, whose guardian agreed with the informed consent were included in this study. Those who were diagnosed at previous hospitals were excluded. Appendicitis was confirmed by operative and histopathological findings. A follow up call was made to verify final outcome within 14 days. RESULTS: We collected data on 1648 patients and a total of 512 patients participated in the study. The mean age was 11.9 years. Seventy four patients (14.5%) had pathology-proven appendicitis and negative appendectomy was performed in three patients (3.9%). Statistical analysis showed that with PAS > or =4, sensitivity 70.1%, specificity 60.4%, and area under curve (AUC) 0.708. With the Alvarado score > or =5, sensitivity 72.7%, specificity 67.2%, and AUC 0.748. CONCLUSION: Usefulness of PAS in diagnosis of pediatric acute appendicitis is limited. PAS showed no significant superiority over the Alvarado score. Therefore, it seems reasonable to use both scores for evaluation of pediatric acute appendicitis in South Korea.