Characteristics of acute renal infarction patient in the emergency department: proteinuria as a prognostic factor of chronic kidney disease progression

Objective@#Acute renal infarction is a rare and easily misdiagnosed disease. Scarce research has been conducted on the predictive factors and prognosis of acute renal infarction due to its rarity. In this study, we analyzed the clinical and laboratory findings of a patient diagnosed with renal infarction to predict clinical outcomes. @*Methods@#In this retrospective clinical study, we collected and analyzed the medical records data of 61 acute renal infarction patients diagnosed in the emergency department (ED) of Konkuk University Hospital, Seoul, South Korea from January 2007 to December 2020. @*Results@#Lactate dehydrogenase (LDH; 93.3%, 28 of 30 patients) and D-dimer (77.8%, 28 of 36 patients) levels of the acute renal infarction patients were higher than the normal. Proteinuria was found in 26 of 47 patients. The only significant prognostic factor for the occurrence of acute kidney injury (AKI) in acute renal infarction is the ratio of the infarction volume to the total renal volume. Age, occurrence of AKI, and proteinuria were correlated with the progression of chronic kidney disease (CKD). @*Conclusion@#The ratio of the infarction volume to the total renal correlated with occurance of AKI. Age, AKI, and proteinuria were correlated with the progression of CKD.

Variance of the COVID-19 occurrence in the community: influence on the emergency medical service and the survival of out-of-hospital cardiac arrest patients

Objective@#This study evaluates the impact of the coronavirus disease 2019 (COVID-19) pandemic on emergency medical service (EMS) responses and out-of-hospital cardiac arrest (OHCA) outcomes. @*Methods@#This is a retrospective comparison study analyzing the OHCA data of a university medical center in Seoul during the COVID-19 pandemic period (January 2020-January 2021) and non-pandemic period (January 2019-January 2020). The EMS response time and OHCA outcomes were compared between both periods. Based on the weekly mean number of confirmed cases and their EMS response time, patients were classified into six groups and OHCA outcomes were compared. @*Results@#This study evaluated 309 OHCA patients (non-pandemic period of 146, pandemic period of 163). Significant delays in the EMS response and transport time were observed during the pandemic period. However, no significant differences were obtained in the rate of return of spontaneous circulation (ROSC) and survival at discharge (12.4% in pandemic vs. 13.8% in non-pandemic; P=0.722). According to the weekly mean COVID-19 incidence when patients were over 100, there was a significant increase in the EMS response and transport time, whereas ROSC and survival rate were dramatically decreased. @*Conclusion@#During the pandemic, the EMS service for OHCA patients was worse than before, with delayed and reduced survival for OHCA patients. We further determined that an increase in the number of COVID-19 cases (especially when weekly mean numbers were over 100) dramatically delayed the EMS response time. This resulted in a very low survival rate of OHCA patients.

A clinical study of comparing the first-attempt success of endotracheal intubation between video laryngoscopy and direct laryngoscopy for trauma patient with suspected cervical injury

Objective@#This study aimed to evaluate the effectiveness of video laryngoscopy (VL; Glidescope) compared to direct laryngoscopy (DL) when performing endotracheal intubation (ETI) in trauma patients with cervical spine immobilization. @*Methods@#This was a retrospective clinical study. A total of 98 trauma patients with cervical spine immobilization were included. These patients underwent intubation using VL and DL from 2009 to 2014 in the emergency department. All data were collected through electronic medical records. The primary outcome was the first-attempt intubation success rate of ETI. Secondary outcomes were complications of ETI, including esophageal intubation and tooth injuries. We compared the outcomes of the two devices. @*Results@#VL showed higher first-attempt ETI success rates compared to DL (94.0% vs. 74.5%, P=0.011). There were no statistically significant differences in the ETI complication rates between VL and DL such as esophageal intubation (2.0% vs. 4.3%, P=0.610) and tooth injuries (6.0% vs. 10.6%, P=0.478). The multivariate analysis showed that VL was an independent factor for predicting higher first-attempt intubation success with an odds ratio of 4.538 (95% confidence interval, 1.084-18.988; P=0.038) @*Conclusion@#For patients with cervical spine immobilization, VL could provide a higher first-attempt ETI success rate compared to DL in a real clinical setting.

How much mechanical chest compression device can reduce rescuer’s exposure in cardiac arrests patients during cardiopulmonary resuscitation in COVID-19 pandemic period

Objective@#In the coronavirus disease 2019 pandemic, virus transmission via exposal to arrest victims infected can be a huge risk to rescuers during cardiopulmonary resuscitation (CPR). We hypothesized that using a mechanical chest compression device can reduce the rescuer’s exposure to cardiac arrest patients during CPR. @*Methods@#This is a retrospective clinical study that compared CPRs using a mechanical chest compression device (mCPR) with CPRs with manual chest compression (c-CPR). All CPR data were obtained by analyzing recorded video clips and the medical charts. The primary outcome was the number of rescuers who participated in CPR. In addition, the length of time rescuers’ staying around the arrested victim and some procedure time were evaluated. @*Results@#There was no significant difference in baseline data of CPR between the m-CPR (n=28) and c-CPR (n=25) groups. The m-CPR group showed a significantly reduced mean number of rescuers (4.4±0.5 vs. 5.5±0.5) and mean total time of rescuer’s staying (2,609.9±315.4 seconds vs. 3,286.0±329.9 seconds) comparing with the c-CPR group (P<0.05). The m-CPR group showed a delay in the first rhythm analysis compared with the c-CPR group (40.0 seconds [30.0-57.5] vs. 27.0 seconds [25.0-43.5]) @*Conclusion@#The usage of a mechanical compression device can reduce the number of rescuers and the length of time staying around the victim. However, a delay in rhythm analysis can occur in the m-CPR group.

A study of comparing the first-attempt success of endotracheal intubation and complication rates between glidescope video laryngoscopy and direct laryngoscopy in the emergency department

Objective@#The study compared the first-attempt success and complication rates of endotracheal intubation (ETI) using video laryngoscopy (VL; GlideScope) with those of direct laryngoscopy (DL) in the emergency department (ED). @*Methods@#This was a retrospectively clinical study of adult patients who underwent intubation using from 2010 to 2014 in the ED. All data were collected from the electronic medical records. The primary outcome was the first-attempt intubation success of ETI. The secondary outcomes were occurrences of desaturation, hypotension, oesophageal intubation, dental injuries, and cardiac arrest. The between-device differences in outcome risks were examined. @*Results@#A total of 431 emergency ETIs were included. The first-attempt intubation success rate was higher in the VL than DL (93.8% vs. 74.8%, P<0.001). The non-expert emergency physicians (first and second-year residents) showed a higher first-attempt intubation success rate in VL than DL, but there was no difference in the first-attempt intubation success rate between the two devices between experts (third and fourth-year residents). The use of VL was associated with a lower rate of desaturation (0.0% vs. 5.0%) and tooth injuries (0.0% vs. 2.7%) compared to the DL. @*Conclusion@#The use of VL was associated with a higher first-attempt success rate compared to DL, particularly in inexperienced intubators. For complications related to ETI, VL showed a lower rate of desaturation and dental injuries in the ED than the DL.

Case of cardiac arrest due to carbon dioxide poisoning following an explosion of a carbon dioxide tank

Carbon dioxide is widely used for a variety of purposes. As it is a normal constituent of air, the public generally regards it as safe. Although low concentrations of carbon dioxide are not harmful to human beings, high concentrations are toxic, and can cause serious harm, including cardiac arrest. Only a limited number of cases of carbon dioxide intoxication have been reported in Korea, and they have all been mild, with no cases of cardiac arrest following acute exposure to high concentrations of carbon dioxide, reported previously. We describe a case of carbon dioxide poisoning following an explosion of a carbon dioxide tank, which led to cardiac arrest in a 66-yearold patient. This cardiac arrest could have been avoided if the patient was fully aware of the hazardous effects and serious consequences of exposure to high concentrations of carbon dioxide.

Absolute Change in High-Sensitivity Cardiac Troponin I at Three Hours After Presentation is Useful for Diagnosing Acute Myocardial Infarction in the Emergency Department

Background@#A rise and/or fall in cardiac troponin value with at least one value above the 99th percentile upper reference limit is essential for acute myocardial infarction (AMI) diagnosis. We evaluated the clinical usefulness of serial high-sensitivity cardiac troponin I (hs-cTnI) measurements in AMI diagnosis, in terms of the predictability of absolute and relative changes. @*Methods@#For this retrospective, forward observational study, we enrolled 281 patients older than 18 years who presented with chest pain at the emergency department (ED) between August 2015 and December 2016. The patients were grouped as AMI and nonAMI, and 73 (26%) were diagnosed as having AMI. Hs-cTnI (Abbott Diagnostics, Abbott Park, IL, USA) was measured at presentation and 3 hours later. We assessed the diagnostic performance of the absolute and relative changes in hs-cTnI. @*Results@#The cut-off values to predict AMI were 16.2 ng/L and 42.1% for the absolute and relative hs-cTnI changes, respectively. The area under the curve of hs-cTnI for AMI diagnosis was larger for absolute changes than for relative changes [0.96 (95% confidence interval [CI], 0.92–0.98) vs 0.89 (95% CI, 0.85–0.93)] (P = 0.014). @*Conclusions@#The absolute hs-cTnI change at 3 hours after presentation was superior to the relative change, and a rise and/or fall in hs-cTnI of > 16.2 ng/L at 3 hours after presentation was useful to identify AMI in patients presenting at the ED.

Albumin-adjusted ischemia modified albumin as a predictor of mortality in patients with sepsis

Objective@#Ischemia-modified albumin (IMA) is a marker of oxidative stress and hypoperfusion that is usually used for acute coronary syndrome. Patients with sepsis undergo hypoperfusion and multi-organ failure that results in death. This study evaluated the efficacy of the albumin-adjusted IMA (AAIMA) level in the emergency department (ED) to predict the 30-day mortality of patients with sepsis @*Methods@#A retrospective analysis study of patients with sepsis was conducted from June 2018 to April 2019 in ED. The data were obtained from the medical records of the patients, and the blood test results were taken from the initial blood tests at the ED. The data and blood test results of the 30-day survival and non-survival groups were compared. @*Results@#Two hundred thirty-three patients were included. The mean age was 75 years, and the overall mortality was 20.6%. The non-survival group had higher AAIMA levels than the survival group (75.1 U/mL vs. 68.4 U/mL). The area under the receiver operating characteristic curve of AAIMA to predict the 30-day mortality was 0.789 (95% confidence interval, 0.730-0.840; P<0.001), and the sensitivity and specificity of predicting mortality was 68.8% and 78.2%, respectively, after setting the AAIMA cutoff value to 72.9 U/mL. @*Conclusion@#The initial albumin-adjusted IMA on ED admission has potential as a predictor of the 30-day mortality in patients with sepsis.

Albumin-adjusted ischemia modified albumin as a predictor of mortality in patients with sepsis

Objective@#Ischemia-modified albumin (IMA) is a marker of oxidative stress and hypoperfusion that is usually used for acute coronary syndrome. Patients with sepsis undergo hypoperfusion and multi-organ failure that results in death. This study evaluated the efficacy of the albumin-adjusted IMA (AAIMA) level in the emergency department (ED) to predict the 30-day mortality of patients with sepsis @*Methods@#A retrospective analysis study of patients with sepsis was conducted from June 2018 to April 2019 in ED. The data were obtained from the medical records of the patients, and the blood test results were taken from the initial blood tests at the ED. The data and blood test results of the 30-day survival and non-survival groups were compared. @*Results@#Two hundred thirty-three patients were included. The mean age was 75 years, and the overall mortality was 20.6%. The non-survival group had higher AAIMA levels than the survival group (75.1 U/mL vs. 68.4 U/mL). The area under the receiver operating characteristic curve of AAIMA to predict the 30-day mortality was 0.789 (95% confidence interval, 0.730-0.840; P<0.001), and the sensitivity and specificity of predicting mortality was 68.8% and 78.2%, respectively, after setting the AAIMA cutoff value to 72.9 U/mL. @*Conclusion@#The initial albumin-adjusted IMA on ED admission has potential as a predictor of the 30-day mortality in patients with sepsis.

The comparison of optic nerve sheath diameter measured by computed tomography and ultrasonography in evaluating increased intracranial pressure

OBJECTIVE: While the optic nerve sheath diameter (ONSD) is measured by computed tomography and ultrasonography as an indicator of an elevation in the intracranial pressure (ICP), it is unclear which ONSD measurement is useful for predicting an increased ICP. This study examined the comparability between the ONSD measured by computed tomography and ultrasonography. METHODS: A prospective study of 150 patients in the emergency center was performed. The ONSD was measured 3 mm behind the globe of all patients by computed tomography and ultrasonography. The receiver operator characteristic (ROC) curve was analyzed to determine the diagnostic utility of detecting ICP through ONSD. RESULTS: A total of 150 patients were enrolled. Thirty-three patients (22.0%) were found to have an increased ICP. The ONSD in patients with increased ICP was significantly higher than that of normal ICP patients measured by computed tomography and ultrasonography. Moreover, computed tomography and ultrasonography revealed an area under the ROC curve value of 0.886 and 0.933, respectively. The ONSD measurement by computed tomography and ultrasonography produced similar results (P=0.256). CONCLUSION: The ONSD measured by computed tomography and ultrasonography is a valuable indicator of an ICP elevation. Therefore, either of the two diagnostic methods for monitoring the ICP can be used in patients with a critical care and resource-limited setup.

Usefulness of the SAFARI score for predicting convulsive seizure in patients with aneurysmal subarachnoid hemorrhage

OBJECTIVE: The SAFARI score was introduced to assess the risk of convulsive seizure during admission for aneurysmal subarachnoid hemorrhage in 2017. This study was conducted to determine whether the SAFARI score derived from the afore-mentioned study could be applied to patients with aneurysmal subarachnoid hemorrhage in Korea. METHODS: We conducted a retrospective study of patients who were diagnosed with aneurysmal subarachnoid hemorrhage from March 2013 to October 2017. Patients' age, sex, blood pressure, pulse rate, body temperature, Glasgow-Coma Scale, Hunt-Hess scale, modified Fisher grade, size of ruptured aneurysm, surgery type, transfusion, and SAFARI score were compared between the seizure and non-seizure groups. The area under the receiver operator characteristic curves was calculated to evaluate the predictive ability for seizure during admission. Logistic regression analysis was used to analyze predictive factors for seizure during admission. RESULTS: A total of 220 patients were included. Ninety-seven (44.1%) were male and 123 (55.9%) were female. The mean age of the patients was 65.8 years old (range, 56–75). The area under the curve of the SAFARI score for predicting seizure was 0.813. The SAFARI score was the only significant predictor of seizure during admission, while other factors were not statistically significant upon logistic regression analysis. CONCLUSION: The SAFARI score could be used for predicting seizure during admission in patients with aneurysmal subarachnoid hemorrhage.

Efficacy of neutrophil-lymphocyte ratio and clinical predicting indexes on differentiating subarachnoid hemorrhage from acute headache patients at emergency department

OBJECTIVE: This study evaluated the clinical usefulness of the neutrophil-lymphocyte ratio (NLR), Ottawa subarachnoid hemorrhage (SAH) rule and EMERALD (Emergency Medicine, Registry Analysis, Learning and Diagnosis) SAH rule for predicting SAH in patients with acute headache. METHODS: This clinical retrospective study was conducted at an urban emergency department between January 2008 and December 2017. Alert, neurologically intact adult patients with acute headache were included. All data were drawn from electrical medical charts. The Ottawa SAH rule (positive if any of age ≥40, neck pain, loss of consciousness, onset during exertion, thunderclap headache, and neck stiffness), EMERALD SAH rule (positive if any of systolic blood pressure >150 mmHg, diastolic blood pressure >90 mmHg, serum glucose >115 mg/dL, or serum potassium 2.1) was added to the last step to have achieve 99.0% sensitivity and 56.7% specificity. CONCLUSION: The stepwise application of the Ottawa, EMERALD SAH rule, and NLR increased the specificity compared to each application. On the other hand, further studies will be needed to increase the sensitivity.

A Clinical Review of Patients Who Visited Emergency Medical Center with Positive Methamphetamine Tests: A Single Institute Study

PURPOSE: Methamphetamine is an ongoing illegal drug problem worldwide, and its use in South Korea has spread over the last few years. In this study, a clinical review of patients who visited emergency medical centers with positive methamphetamine tests was conducted. METHODS: Patients underwent methamphetamine screening based on physician suspicion over a period of 13 years. Their patient characteristics, clinical features, and drug administration properties were described. RESULTS: A total of 297 patients were included, with 19 positive methamphetamine results. Patient age ranged from 21 to 84, with a mean of 37.52. Additionally, 13 were male and 6 were female. The mean BP, PR, RR were 131/82 mmHg, 94/min, 20/min. Saturation levels were all over 95%. Five patients had a psychiatric history. Patient showed varied symptoms ranging from mental changes to chest discomfort. In addition, seven showed abnormal electrocardiography findings and one showed elevated cardiac enzyme levels. Other laboratory results revealed no significantly abnormal results. Six patients also suffered from related trauma. The majority of patients consumed the methamphetamine orally, with unknown motivation at unknown locations. Most were transported by 119 and six CONCLUSION: Patients who showed positive results to a methamphetamine screening test in Korea visited the emergency medical center mostly by 119 and were unaware of or reluctant to reveal the fact that they had ingested methamphetamine. Emergency physicians should be more aware of the possibility that a patient may have consumed methamphetamine.

The clinical usefulness of computed tomography findings as a prognostic factor for patients with acute pyelonephritis in emergency department

OBJECTIVE: This study examined the efficacy of the computed tomography (CT) findings in the emergency department (ED) in predicting the clinical course and severity of acute pyelonephritis (APN). METHODS: This retrospective clinical study included APN patients in the ED. All participants diagnosed with APN had undergone a radiocontrast-enhanced CT evaluation. The radiocontrast-enhanced CT findings of APN revealed the typical findings, such as hypoperfusion on the kidney, extra-renal parenchymal findings, and renal abscess formation. The patients were classified into five groups based on the CT findings. The clinical parameters analyzed were the white blood cell (WBC) count, C-reactive protein (CRP) level, quick sepsis-related organ failure-assessment (qSOFA) score, need for vasopressor, length of stay, and admission to the intensive care unit (ICU). The relationships between the clinical parameters and the five groups based on the APN CT findings were assessed. RESULTS: Among the 264 patients, there were 225 female patients and the mean age of all patients was 57.9±20.5 years: group 1 (n=31), present renal abscess with APN; group 2 (n=118), both typical and extra-renal parenchymal findings; group 3 (n=49), only typical finding; group 4 (n=32), only extra-renal parenchymal findings; and group 5 (n=34), no APN finding on CT. The length of stay increased from groups 5 to 1. The WBC count and CRP level were worsen from groups 4 to 1, except for group 5. Statistically significant trends, such as the WBC count, CRP level and length of stay correlated with each group were observed (P < 0.001, P < 0.001, and P < 0.001). Statistically significant trends in ICU admission, use of vasopressor, and qSOFA score were also observed (P=0.022, P=0.003, and P < 0.001). CONCLUSION: The specific CT findings of APN might be helpful for predicting the clinical severity and prognosis.

The comparative study of predictive factors for prolonged length of stays that adult patients with acute appendicitis in emergency department

OBJECTIVE: This study examined the predictive factors for prolonged length of stays of adult patients with acute appendicitis (AA) in an emergency department (ED). METHODS: This was a retrospectively clinical study including patients in an ED. All patients were diagnosed from the clinical symptoms and a typical physical examination, and had undergone a computed tomography (CT) evaluation on the ED visiting date. All data were collected from the electrical medical records. The clinical parameters analyzed were the laboratory data, including the white blood cell count with differential values, C-reactive protein (CRP) level, initial vital signs, duration of admission, coexisting perforation of the appendix in the CT findings. The relationship between the clinical parameters and length of stay was assessed. RESULTS: A total of 547 patients with AA were enrolled in this study. Among them, there were 270 male patients with a mean age of 40.7±15.8 years. The baseline characteristics, initial clinical features, laboratory, and imaging studies results of 129 patients in the prolonged length of stay (pLOS) group, and 418 patients of the non-pLOS group in AA were compared. Multivariable logistic regression analysis revealed the predictive factors related to pLOS in AA to be as follows: age 40 years or older, body temperature over 37.3℃, CRP level greater than 5.0 mg/dL, and evidence of perforation in CT findings (P < 0.001). CONCLUSION: If we check age, fever, CRP level and find evidence of perforation, it might be helpful for predicting the increasing period of length of hospital stay for patients with AA in ED.

Efficacy of Red Cell Distribution Width as Prognostic Factor for Sepsis-3 Patients in Emergency Department

PURPOSE: Red cell distribution width (RDW) was introduced as a new biomarker for the prognosis of sepsis patients. In addition, the definition of sepsis has changed recently to sepsis-3 criteria. The aim of this study was to compare the efficacy of RDW as a prognostic factor for sepsis-3 patients in the emergency department. METHODS: We conducted a retrospective study of patients who were suspected of having sepsis between October, 2015 and April, 2016. The demographic data, comorbidities, blood test results, including RDW, lactate, C-reactive protein, and procalcitonin at admission, as well as the Mortality in Emergency Department Sepsis score were compared between the 30-day survivors and nonsurvivors. Analysis compared the areas under the receiver operator characteristic curves for 30-day mortality. Multivariate Cox proportional hazards regression analysis was performed to determine the risk factors for mortality. RESULTS: A total of 222 patients were included. The mean age was 75, 51.8% of the patient population was male, and the overall mortality rate was 16.7%. The non-survival group had higher RDW levels than the survivor group (14.5% vs 13.4%). The area under the receiver operating characteristic curve of RDW to predict mortality was 0.724. In a Cox proportional hazards analysis, RDW had 1.292 hazard ratio. Setting the RDW cutoff value to 14.3, we found that sensitivity and specificity of predicting mortality was 75.1% and 70.3%, respectively. CONCLUSION: It may be possible to use RDW to predict mortality in sepsis-3 patients.

Reliability of Korean Triage and Acuity Scale-based Triage System as a Severity Index in Emergency Patients

PURPOSE: Triage is an important process in a hospital emergency department (ED). The Korean Triage and Acuity Scale (KTAS)-based triage system was developed for use in Korean EDs as a triage tool. Nevertheless, there is limited evidence of its reliability in KTAS. This study assessed the KTAS reliability by comparing skilled nurses and poly-clinic students. METHODS: This study was a prospective study. All adult patients over the age of 15 years who visited the ED during the study period were included. The patients were triaged independently by a primary triage nurse and poly-clinic student using KTAS, and their scores were compared. RESULTS: A total of 168 patients were enrolled in this study. In the nurse group, 3%, 8.9%, 45.8%, 38.1%, and 4.2% were assigned to levels 1,2,3,4, and 5, respectively. In the poly-clinic group, 3.6%, 10.7%, 43.5%, 33.9%, and 8.3% were assigned to levels 1,2,3,4, and 5, respectively. The percentage of each level using KTAS was similar. Using the interrater agreement, the weighted Kappa was 0.721 (95% confidence interval, 0.215 to 1.000). CONCLUSION: KTAS appears to be a good tool for triaging patients according to the severity, and it is helpful to order the priority for utilization in a Korean ED.

Hospital Arrival Rate within Golden Time and Factors Influencing Prehospital Delays among Patients with Acute Myocardial Infarction

PURPOSE: This research was done to identify the hospital arrival rate and factors related to prehospital delay in arriving at an emergency medical center within the golden time after symptom onset in patients with acute myocardial infarction (AMI). METHODS: Data used in the research was from the National Emergency Department Information System of the National Emergency Medical Center which reported that in 2014, 9,611 patients went to emergency medical centers for acute myocardial infarction. Prehospital time is the time from onset to arrival at an emergency medical center and is analyzed by subdividing arrival and delay based on golden time of 2 hour. RESULTS: After onset of acute myocardial infarction, arrival rate to emergency medical centers within the golden time was 44.0%(4,233), and factors related to prehospital delay were gender, age, region of residence, symptoms, path to hospital visit, and method of transportation. CONCLUSION: Results of this study show that in 2014 more than half of AMI patients arrive at emergency medical centers after the golden time for proper treatment of AMI. In order to reduce prehospital delay, new policy that reflects factors influencing prehospital delay should be developed. Especially, public campaigns and education to provide information on AMI initial symptoms and to enhance utilizing EMS to get to the emergency medical center driectly should be implemented for patients and/or caregivers.

Clearance of Endo-bronchial Foreign Body by Cough with Epigastric Thrust Prior to Bronchoscopy at the Emergency Department

A healthy 72-year-old male was referred to the emergency department (ED) for removal of a foreign body (FB) in the right bronchi from a local medical clinic. The FB was a dental part measuring 5×15 mm in size, which had been accidently aspirated into the lung during a dental procedure. On arrival at the ED, he only complained of mild chest discomfort, and there were no abnormal findings in on physical examination. ED physicians prepared bronchoscopic FB removal while the patient rested in bed. During the wait for bronchoscopy, the patient felt discomfort in the chest and epigastric area, and then he coughed forcefully and at the same time, epigastric thrust was performed with his fist. After several strong coughs with epigastric thrusts, the FB was expelled from his mouth. Chest roentgenogram showed no FB, and the patient was discharged from the ED with no complications. Bronchoscopy has been the only treatment option for bronchoscopic FB, and self-removal of FB is rare. This case report may be helpful to understanding a possible mechanism of self-clearance of FB in some healthy adult patients with a small-sized endobronchial FB.

Comparing the Usefulness of the Initial Predisposition Infection Response Organ Failure Score and the Mortality in Emergency Department Sepsis Score for Predicting the Prognosis of Septic Patients Admitted to the Intensive Care Unit

PURPOSE: The predisposition infection response organ failure (PIRO) score has been developed to be used in the emergency department (ED) to risk stratify sepsis case but has not been well studied domestically. The aim of this study was to compare the usefulness between the PIRO score and the mortality in emergency department sepsis (MEDS) score in predicting the mortality of septic patients admitted to the intensive care unit (ICU). METHODS: We conducted a retrospective study of patients who were suspected to have sepsis and were admitted to the ICU via the ED during a period between January 2013 and June 2015. PIRO and MEDS scores were calculated from the ED data. A comparative analysis was performed the evaluate the areas under the receiver operator characteristic (ROC) curves for 28-day mortality. RESULTS: During the 30-month period, a total of 199 patients diagnosed with sepsis were enrolled. Fifty-seven patients (28.6%) died within 28 days of presentation. The PIRO score showed increasing mortality with higher scores. The area under the ROC curve (AUC) for mortality was 0.890 (95% confidence interval [CI]=0.830 to 0.950) for PIRO and 0.705 (95% CI=0.609 to 0.801) for MEDS score. CONCLUSION: The MEDS score in the ED did not predict mortality better than PIRO score. The PIRO score was a good predictor of the outcome for patients with suspected sepsis. We believe that the PIRO score may be the most useful and appropriate clinical prediction tool for patients with suspected sepsis in the ED.