Assessment of serum biomarkers and coagulation/fibrinolysis markers for prediction of neurological outcomes of out of cardiac arrest patients treated with therapeutic hypothermia

OBJECTIVE: Despite increased survival in patients with cardiac arrest, it remains difficult to determine patient prognosis at the early stage. This study evaluated the prognosis of cardiac arrest patients using brain injury, inflammation, cardiovascular ischemic events, and coagulation/fibrinolysis markers collected 24, 48, and 72 hours after return of spontaneous circulation (ROSC).METHODS: From January 2011 to December 2016, we retrospectively observed patients who underwent therapeutic hypothermia. Blood samples were collected immediately and 24, 48, and 72 hours after ROSC. Neuron-specific enolase (NSE), S100-B protein, procalcitonin, troponin I, creatine kinase-MB, pro-brain natriuretic protein, D-dimer, fibrin degradation product, antithrombin-III, fibrinogen, and lactate levels were measured. Prognosis was evaluated using Glasgow-Pittsburgh cerebral performance categories and the predictive accuracy of each marker was evaluated. The secondary outcome was whether the presence of multiple markers improved prediction accuracy.RESULTS: A total of 102 patients were included in the study: 39 with good neurologic outcomes and 63 with poor neurologic outcomes. The mean NSE level of good outcomes measured 72 hours after ROSC was 18.50 ng/mL. The area under the curve calculated on receiver operating characteristic analysis was 0.92, which showed the best predictive power among all markers included in the study analysis. The relative integrated discrimination improvement and category-free net reclassification improvement models showed no improvement in prognostic value when combined with all other markers and NSE (72 hours).CONCLUSION: Although biomarker combinations did not improve prognostic accuracy, NSE (72 hours) showed the best predictive power for neurological prognosis in patients who received therapeutic hypothermia.

Differences in youngest-old, middle-old, and oldest-old patients who visit the emergency department

OBJECTIVE: As aging progresses, clinical characteristics of elderly patients in the emergency department (ED) vary by age. We aimed to study differences among elderly patients in the ED by age group. METHODS: For 2 years, patients aged 65 and older were enrolled in the study and classified into three groups: youngest-old, ages 65 to 74 years; middle-old, 75 to 84 years; and oldest-old, ≥85 years. Participants’ sex, reason for ED visit, transfer from another hospital, results of treatment, type of admission, admission department and length of stay were recorded. RESULTS: During the study period, a total 64,287 patients visited the ED; 11,236 (17.5%) were aged 65 and older, of whom 14.4% were 85 and older. With increased age, the female ratio (51.5% vs. 54.9% vs. 69.1%, P < 0.001), medical causes (79.5% vs. 81.3% vs. 81.7%, P=0.045), and admission rate (35.3% vs. 42.8% vs. 48.5%, P < 0.001) increased. Admissions to internal medicine (57.5% vs. 59.3% vs. 64.7%, P < 0.001) and orthopedic surgery (8.5% vs. 11.6% vs. 13.8%, P < 0.001) also increased. The ratio of admission to intensive care unit showed no statistical significance (P=0.545). Patients over age 85 years had longer stays in the ED (330.9 vs. 378.9 vs. 407.2 minutes, P < 0.001), were discharged home less (84.4% vs. 78.9% vs. 71.5%, P < 0.001), and died more frequently (6.3% vs. 10.4% vs. 13.0%, P < 0.001). CONCLUSION: With increased age, the proportion of female patients and medical causes increased. Rates of admission and death increased with age and older patients had longer ED and hospital stays.

Contrast-induced Nephropathy in Major Trauma Patients

PURPOSE: Occult injuries are diagnosed using computed tomography (CT), often with intravenous (IV) contrast CT, in major trauma patients. The contrast dye is known to be potentially nephrotoxic. Thus, we measured the incidence and risk factors for contrast-induced nephropathy (CIN) in major trauma patients. METHODS: A retrospective review was performed on 247 patients who were treated by the activated trauma team between June 2012 and July 2014. The exclusion criteria were underlying renal failure, no IV contrast CT administered, and no creatinine (Cr) follow-up within 72 hours. We examined age, gender, initial vital signs, the Glasgow Coma Scale (GCS), initial Cr levels, Cr level within 72 hours after admission, the IV contrast CT number, Injury Severity Score (ISS). CIN was defined as 25% relative or 0.5 mg/dL absolute increase in serum Cr within 72 hours of presentation. RESULTS: One hundred forty-three patients were included in this study. CIN manifested in 12 patients (8.4%). The injury severity was associated with CIN (ISS≥16, p=0.003; GCS≤8, p<0.001; death, p<0.001). Initial Cr levels, elderly patients, and initial hypotension were not statistically significant (p=0.065, 0.176, and 0.402, respectively). The number of IV contrast CTs administered was also not associated with the occurrence of CIN (p=0.331). CONCLUSION: We found an 8.4% incidence of CIN in multiple trauma patients exposed to IV contrast. The number of IV contrasts, age, initial systolic blood pressure, and initial Cr levels were not associated with CIN. Only injury severity was associated with CIN occurrence; therefore, physicians should pay more attention to severely-injured patients.

Drowning-Related Injuries: Fallen from the Bridge for the Purpose of Suicide

PURPOSE: Jumping off a bridge is one method of suicide. In a recent report, out of the 37 patients with cardiac arrest after drowning, 5 (36%) patients suffered severe traumatic injuries. The objective of this study was to report these injuries, without cardiac arrest, in patients after jumping off a bridge with the purpose of suicide. METHODS: We retrospectively reviewed the charts of all patients admitted to the emergency department in a tertiary care hospital after drowning in the Han River between 1997 and 2012. We analyzed the results of imaging studies. Each injury was described as one of the six body regions, similar to the method of the Injury Severity Score. RESULTS: A total of 469 patients were admitted to the emergency department from drowning. Sixty-six patients had jumped off a bridge with the purpose of suicide. Forty patients experienced cardiac arrest. In cardiac arrest patients, 25 patients (62.5%) underwent radiologic examinations. Only 2 patients (5.0%) received damage on the cervical spine and face. All non-cardiac arrest patients underwent imaging studies. Nine patients (34.6%) showed evidence of injuries. Most injuries occurred in the chest; four patients suffered the following injuries: rib fracture, pneumothorax, pneumomedistinum, and thoracic spine fracture. One patient had abdominal damage, an intra-abdominal hematoma. Last one patient suffered an injury to the chest and abdomen. CONCLUSION: In drowning patients with the purpose of suicide, variable damage could not be ruled out. It is especially not confined to a specific area, and damage to various parts of the body should be considered.

Clinical Characteristics and Risk Factors in Severely Injured Elderly Trauma Presenting to Emergency Department

BACKGROUND: With increasing life expectancy, the number of injured elderly patients has been increasing. We evaluated the clinical characteristics of severely injured elderly patients who presented to the Emergency Department and identified risk factors associated with mortality. METHODS: Injured patients over 18 years of age who visited the Emergency Department with trauma team activation were investigated. We divided the patients into two groups according to age, an older adult group (> or =65 years) and a younger adult group ( or =3 of each body area, and mortality between the two groups. RESULTS: Among 177 severely injured patients, there were 138 younger adults (78%) and 39 older adults (22%). The average ISS of the older adults was higher than the younger adults (20.66 vs. 16.37). The incidences of severe injuries (ISS>15) in the younger adults and the older adults were 50.0% and 71.1%, respectively, and critical injuries (ISS>25) were 16.7% and 36.8%, respectively. Chest injuries and subdural hematoma occurred more often in the older adults. Mortality was higher in the older adults (28.2%) than in the younger adults (8.7%). CONCLUSION: The average ISS was higher in older adults than in younger adults, and older adults were significantly more likely to suffer severe trauma, especially chest injuries and subdural hematoma. The rate of mortality was greater for older adults (28.2%) than younger adults (8.7%).

The Appropriateness of Modified Trauma Team Activation Protocol for Trauma Patients in Emergency Department

PURPOSE: Rapid multidisciplinary trauma care by trauma team is essential for severely injured patients. Different protocols for trauma team activation are used in each hospital. Correct trauma triage is needed to ensure appropriate use of medical resources. The aim of this study was to evaluate the performance of our modified protocol for trauma team activation. METHODS: This is an observational, retrospective cohort study. Injured patients with trauma team activation (TTA) or who had been admitted to a surgical intensive care unit were investigated from 1st March 2010 to 31st May 2012. The TTA protocol was analyzed with respect to sensitivity, positive predictive value (PPV), and overtriage (1-PPV). Undertriage (1-sensitivity) was defined as no TTA despite severe injury (Injury Severity Score (ISS) >15). RESULTS: A total of 229 patients were included. There were 201 patients with TTA and 28 patients without TTA. Of the 201 patients with TTA, 104 were identified as severely injured (ISS>15), yielding sensitivity of 79%, PPV of 51%, and overtriage of 49%. Undertriage was 21% (n=28) when considering all severely injured patients (n=132). Among 12 criteria of our TTA protocol, 'injury in two or more body regions' accounted for 85.6% of the overtriage. Of the patients with undertriage, 75% represented isolated head injury and 28.5% from interhospital transfer. CONCLUSION: The rate of overtriage of TTA protocol in our hospital is appropriate, but the rate of undertriage is relatively high. We believe, to decrease the overtriage of all and undertriage in patients with injury in an isolated specific body region, more research for evaluation of effects of protocol excluding the criteria of 'injury in two or more body regions' is needed.

Predictive Variables of Pneumonia Among Adult Submersion Victims without Out-of-hospital Cardiac Arrest

PURPOSE: Pneumonia is a serious and relatively common complication among submersion victims without out-of-hospital cardiac arrest (OHCA). The purpose of this study was to investigate the risk factors of pneumonia among adult submersion victims without OHCA. METHODS: All adult submersion victims without OHCA who visited our hospital between 2004 and 2013 were included. This study was conducted retrospectively, with collection of data by review of medical records. Among total submersion victims (310 patients), 191 patients did not suffer OHCA. We investigated the characteristics of the patients and classified them according to two groups based on the presence of pneumonia. We then compared clinical variables between the two groups. RESULTS: A total of 191 adult submersion patients without OHCA; 157 patients did not have pneumonia during their hospital stay; 34 patients had pneumonia. In respective analysis, alert mentality, pH and core temperature showed correlation with pneumonia. However, in logistic regression analysis with these 3 variables, only pH was a risk factor of pneumonia. All patients with pneumonia except one were discharged with full recovery. CONCLUSION: The risk of pneumonia among adult submersion victims without OHCA is higher when the lower pH is checked. Further studies are needed in order to evaluate the other risk factors of pneumonia for early prediction and proper management.

Therapeutic Hypothermia Following Emergent Coronary Artery Bypass Grafting After Failed Percutaneous Coronary Intervention in a Comatose Post-Cardiac Arrest Patient

We report the case of 60-yr-old female in which therapeutic hypothermia (TH) was successfully induced maintaining the target temperature of 34degrees C for 12 hr despite a risk of hypothermia-induced coagulation abnormalities following an emergent coronary artery bypass grafting (CABG) due to failed percutaneous coronary intervention, who suffered a cardiac arrest. Emergent CABG may be a relative contraindication for TH in post-cardiac arrest patients because hypothermia may increase the risk of infection and bleeding. However, the possibility of an improved neurologic outcome outweighs the risk of bleeding, although major surgery may be a relative contraindication for TH.

Experiences and Views of a Pilot Emergency Medicine Sub-internship Program: A Focus Group Study of Learners and Teachers

PURPOSE: The aim of this study was to explore participants' experiences and views of a pilot emergency medicine (EM) sub-internship program. METHODS: A pilot 4-week EM sub-internship program involving four academic emergency departments was developed and implemented at the beginning of fourth-year in medical school. Three focus group discussions were separately conducted with ten students, six supervising residents, or four faculty physicians upon completion of the program. Each 60- to 90-minute discussion was recorded, transcribed, and coded by two assessors independently. Contents were thematically analyzed and group interaction examined. RESULTS: The participants identified several strengths of the program, including an opportunity to treat a variety of acute diseases for the first time, an opportunity to apply a symptom-based practice, an opportunity to experience a dynamic workplace, and an opportunity to receive help with career-planning. Commonly identified weaknesses of the program were placed into three categories: 1) not enough bedside teaching time, 2) the workload of the educators, which impacts program efficiency, and 3) a variety of learning experience among the students. Ideas for improving the program included an announcement about the program in advance, the development of faculty skills, the development of new content, and a validation of the evaluation methods and institutional support. CONCLUSION: The EM sub-internship appears to be effective in preparing fourth-year medical students for many of the challenges they will face in the future. However, continuous efforts to strengthen the program are required. These study results will help EM educators develop their own sub-internship program.

Clinical Manifestations of Heat Stroke that Occur during a Marathon

PURPOSE: Due to an increased interest in health, there have been many types of marathon races for athletes and the general population. Marathon is an extremely difficult sport, therefore, many running injuries can occur. In this study, we aimed at characterization of injuries and clinical courses resulting from marathon induced heat stroke. Based on our findings, we provide suggestions for proper management of patients with marathon induced heat stroke. METHODS: We performed a retrospective study of 24 patients who visited the emergency department (ED) at Yeouido St. Mary's hospital between January 2000 and August 2011 with symptoms of heat stroke resulting from participation in a marathon race. We reviewed the medical records, which showed clinical presentation and laboratory findings. RESULTS: Of the 24 patients, 20(83.3%) were men. Their average age was 38.1+/-8.4 years old and their average initial rectal temperature was 39.9+/-1.3degrees C. Seventeen (70.8%) patients came to the ED complaining of syncope and seven(29.2%) came because of mental change. In follow-up laboratory tests, ten patients showed an increased level of serum Creatine phosphokinase (CPK) to over 1,000 IU/L, six showed serum Aspartate aminotransferase (AST)/Alanine aminotransferase (ALT) to over 300 IU/L, four showed serum creatinine to over 2.0 mg/dL, and two showed an increase in serum troponin-I and MB fraction of creatine kinase. Results of initial laboratory tests showed normal AST/ALT levels, however, they started to rise between 12 to 24 hours, and reached the highest record after 2~3 days of hospitalization. CONCLUSION: Marathon induced heat stroke can cause various complications, such as rhabdomyolysis, acute hepatic injury, acute renal failure, and metabolic acidosis. Therefore, we recommend follow-up and observation for patients with marathon induced heat stroke.

Hematuria Testing in Patients with Suspected Urinary Stone Disease: Correlation with Contrast Enhanced Multidetector Computed Tomography Results

PURPOSE: Our aim was to determine the efficacy of hematuria testing in suspected urinary stone disease using contrast enhanced multidetector computed tomography (MDCT) as the reference standard. METHODS: Records of all patients who presented to the emergency department with suspicion of urinary stone that undergone MDCT during a 2-year period were reviewed. The sensitivity, specificity, positive predictive value, and negative predictive value of the positive hematuria on the urinalysis for renal colic were calculated. The rates of incidence of negative hematuria were obtained. In addition, significant alternative CT findings requiring immediate or deferred treatment were classified. RESULTS: A total of 492 enhanced MDCTs were performed. Urinary stone had been identified in 414(84.1%) of the 492 patients, and 78 patients had a negative stone, including 33 (6.7%) with clinically significant alternative diagnoses in the latter group. Microscopic urinalysis had a sensitivity, specificity, positive predictive value, and negative predictive value of 89.4%, 41.1, 88.9%, and 42.1%, respectively. The combination of microscopic urinalysis and Urine Dipstick test (UDT) yielded a sensitivity, specificity, positive predictive value, and negative predictive value of 96.9%, 28.2%, 87.5%, 62.9%, respectively. The incidence of negative hematuria for microscopic urinalysis, UDT, and the combination were 10.6%, 4.4%, 3.1%, respectively. CONCLUSION: The presence or absence of blood on urinalysis alone cannot be used to reliably determine which patients actually have urinary stone. Therefore, patients presenting with an episode of clinically suspected urinary stone should undergo CT scanning because it enhances diagnostic certainty by identifying alternative significant diagnoses not suspected on clinical grounds alone.

Relationship of Plasma Glucose and Hemoglobin A1c Levels Among Emergency Department Patients with Unknown Diabetes Status in Korea

PURPOSE: Diabetes is underdiagnosed. Higher-risk populations, such as emergency department (ED) patients, may provide an opportunity for identification of undiagnosed diabetes. Prior studies have indicated that hemoglobin A1c (HbA1c) is effective in the screening detection of diabetes. The objective of this study was to evaluate the correlation between random plasma glucose and HbA1c in Korean ED patients with unknown diabetes status and to determine the value of ED glucose level as a screening tool for diabetes. METHODS: This was a prospective nonconsecutive case series of adults aged > or =18-years-of-age presenting to the ED with acute illness that involved acquisition of a a plasma glucose sample for clinical management. From June 1-June 30, 2009, consenting patients with no prior history of diabetes underwent additional testing for HbA1c level. ED glucose results were stratified based on outpatient American Diabetes Association Fasting Plasma Glucose classifications. Two HbA1c cut-off points (6.1% and 6.5%) were selected as the optimum cut-offs for identifying diabetes based on International Expert Committee. RESULTS: There were 423 patients enrolled. The ED glucose levels were correlated with the HbA1c levels (r=0.488, p or =200 mg/dL, but most (90%) had an elevated HbA1c level. CONCLUSION: Based on the frequencies of elevated HbA1c levels among patients with elevated ED glucose values, a clinically relevant portion of hyperglycemic patients may have undiagnosed diabetes. ED patients with hyperglycemia may warrant referral for confirmatory diabetes testing.

Relationship of Plasma Glucose and Hemoglobin A1c Levels Among Emergency Department Patients with Unknown Diabetes Status in Korea

PURPOSE: Diabetes is underdiagnosed. Higher-risk populations, such as emergency department (ED) patients, may provide an opportunity for identification of undiagnosed diabetes. Prior studies have indicated that hemoglobin A1c (HbA1c) is effective in the screening detection of diabetes. The objective of this study was to evaluate the correlation between random plasma glucose and HbA1c in Korean ED patients with unknown diabetes status and to determine the value of ED glucose level as a screening tool for diabetes. METHODS: This was a prospective nonconsecutive case series of adults aged > or =18-years-of-age presenting to the ED with acute illness that involved acquisition of a a plasma glucose sample for clinical management. From June 1-June 30, 2009, consenting patients with no prior history of diabetes underwent additional testing for HbA1c level. ED glucose results were stratified based on outpatient American Diabetes Association Fasting Plasma Glucose classifications. Two HbA1c cut-off points (6.1% and 6.5%) were selected as the optimum cut-offs for identifying diabetes based on International Expert Committee. RESULTS: There were 423 patients enrolled. The ED glucose levels were correlated with the HbA1c levels (r=0.488, p or =200 mg/dL, but most (90%) had an elevated HbA1c level. CONCLUSION: Based on the frequencies of elevated HbA1c levels among patients with elevated ED glucose values, a clinically relevant portion of hyperglycemic patients may have undiagnosed diabetes. ED patients with hyperglycemia may warrant referral for confirmatory diabetes testing.

Using Ultrasound to Diagnosis a Radio-lucent Soft Tissue Foreign Body - in Emergency Departments: A Preliminary Study Using a Swine Model -

PURPOSE: The purpose of this study is to estimate the accuracy of diagnosing a radio-lucent soft tissue foreign body with using ultrasound according to the different sizes and depth of the foreign bodies in an experimented model. METHODS: In the forefeet of swine, we made 45 incisions (4 in each forefeet) of 2 mm, 5 mm and 10 mm sized toothpicks at depths of 1 cm, 2 cm and 3 cm each. 15 incisions without foreign bodies were cannulated, simulating damage to the soft tissue made by a non captured foreign body. The twelve emergency physicians kept records not only for the presence or absence of a foreign body, but also for the depth of it. We then calculated the sensitivity, specificity, PPV (positive predictive value) and NPV (negative predictive value) according to the sizes of the toothpicks and the depths. RESULTS: The sensitivity, specificity, PPV and NPV of all the depths and sizes were under 80%. The results of the staff and residents were not significantly different. The result of a 3 cm depth was especially poor. CONCLUSION: In our model, ultrasound performed by emergency physicians was neither sensitive nor specific for diagnosing a soft tissue foreign body of various sizes and depths.

The Benefit of Added Coronal Reformation Images in the MDCT Diagnosis of Acute Appendicitis for Emergency Physicians

PURPOSE: We compared diagnostic accuracy using transverse scans and combined transverse and coronal reformation images in the MDCT diagnosis of acute appendicitis. METHODS: MDCT was performed in 100 patients with acute non-traumatic abdominal pain who visited the emergency department. One half was diagnosed acute appendicitis by radiologic and histologic findings and the other half was not. Transverse scan and combined transverse and coronal reformation images were interpreted by six emergency physicians. Emergency physicians included two board physicians, two senior residents, and two junior residents. For comparison of diagnostic value, the chi-square test and cross tabs test were done. RESULTS: For all emergency physicians except one senior resident, the added coronal reformation images tended to increase the diagnostic accuracy. For board physicians, it increased the diagnostic accuracy from 81.5% to 91% (p=0.003). Senior residents increased from 82.5% to 91.5% (p=0.005), junior residents increased from 75.5% to 87% (p=0.002). The diagnostic accuracy of board physicians and senior residents were higher than junior residents for both image types. CONCLUSION: Coronal reformation images improve the accuracy of emergency physicians in the MDCT diagnosis of acute appendicitis.

Clinical Analysis of Early Death in Severe Drowning Patients

PURPOSE: Historically, acute respiratory failure is the most common cause of death in drowning patients. However, there are an increasing number of severe drowning cases where patients die of circulatory failure or cardiovascular collapse. The aim of this study was to analyze the causes of death in severe drowning patients and evaluate the data in terms of survival curves in order to propose a treatment plan for severe drowning patients in the future. METHODS: The subjects were 58 patients that visited St. Mary's Hospital from January 2000 to September 2006 who had drowned and required CPR and mechanical ventilation. Univariate analysis was performed to evaluate factors known to be predictive of severity. Survival analysis was done to determine the degrees of correlation with acute respiratory distress syndrome (ARDS) and refractory shock. RESULTS: Thirty-nine out of 58 severely drowning patients expired in all, with most deaths occurring in the early stages - 45% expired on the first day, 55% on the second day, and 60% on the third day. Cause of death analysis yielded the following results: the correlation coefficient for the existence of ARDS was 2.96 (p=0.086), which did not achieve statistical significance, but, the coefficient for refractory shock was 9.23 (p=0.002) and was statistically significant. CONCLUSION: Most severe drowning patients expired in the first three days after drowning, and refractory shock was a more significant contributor to patients death than ARDS. This result underscores the need for treatment protocols that includes active management of hemodynamic instability combined with mechanical ventilatory management in the initial stages of treatment.

N-acetylcysteine for Acetaminophen Poisoning Without Hepatotoxicity: the Effect on the Prothrombin Time

PURPOSE: In patients with acetaminophen poisoning, clinical severities are partly based on the prothrombin time. In several conditions, N-acetylcysteine (NAC) infusion has been shown to lower the prothrombin index. Thus, we studied the effect of NAC on the prothrombin time in patients intoxicated with acetaminophen without hepatotoxicity. METHODS: From March 2000 to Aug 2004, we reviewed the medical records of 149 patients with a diagnosis of acetaminophen poisoning. After 88 patients had been excluded (29 had hepatocellular injury, 14 had a probable risk based on their normogram, and 45 had a missing prothrombin index value), 61 patients were included in the analysis. The prothrombin time was recorded before and serially during NAC treatment. RESULTS: The mean baseline prothrombin time was 99.1%, 99.3% after intravenous NAC infusion, and 74.0% at 8 hrs after initiation of NAC infusion. It decreased rapidly at 16 hrs, and reached a steady baseline state between 16 to 24 hrs. A rapid increase in the baseline time occurred after 2-3 days when the NAC infusion was stopped. After oral NAC treatment, it decreased rapidly from 8 to 16 hrs, and reached a steady baseline after 2 days. There was a rapid increase after 3~4 days when the NAC infusion was stopped. CONCLUSION: In patients with uncomplicated acetaminophen poisoning, the decrease in the prothrombin index might be misinterpreted as a sign of liver failure, leading to a prolonged treatment.