Association between the Korean Triage and Acuity Scale level and severity of children with dyspnea in the emergency department

Purpose@#Triage tools play a vital role in classifying the severity of children in emergency departments (EDs). We investigated the association between the Korean Triage and Acuity Scale (KTAS) and severity of dyspnea in the ED. @*Methods@#We conducted a retrospective study of children aged 3-14 years with dyspnea who visited the ED from January 2015 through December 2021. They were divided into severe (KTAS level 1-3) and non-severe (KTAS level 4-5) groups. Between the groups, we compared the clinical characteristics, including age, sex, associated symptoms, vital signs, route of visit, treatment at ED, and outcomes. @*Results@#Among a total of 468 children with dyspnea, 267 and 201 were assigned to the severe and non-severe groups, respectively. The severe group had higher frequencies of fever (21.7% vs. 13.9%; P = 0.031), cough (53.2% vs. 43.3%; P = 0.034), systemic steroids (42.3% vs. 25.9%; P < 0.001), intravenous fluids (47.6% vs. 25.4%; P < 0.001), oxygen therapy (16.5% vs. 6.5%; P = 0.001), inotropics (4.1% vs. 1.0%; P = 0.042), and hospitalization (24.7% vs. 11.9%; P = 0.002). The severe group also showed a higher mean heart rate, respiratory rate, and temperature, and lower mean oxygen saturation (all Ps < 0.001). Among these findings, fever, heart rate, respiratory rate, temperature, intravenous fluids, oxygen therapy, inotropics, and hospitalization remained significantly different between the groups after defining the severe group as a KTAS level 1-2. @*Conclusion@#This study shows the association between KTAS and severity of dyspnea in the ED. Therefore, KTAS may reflect not only the initial clinical conditions but also emergency measures and outcomes in children with dyspnea who visit EDs.

Clinical predicting factors that can distinguish superficial and deep injuries in penetrating neck injury?

Objective@#The frequency of penetrating neck injuries has gradually increased with the development of industry and the rising crime rates. There have been few studies with penetrating neck injuries reported in Korea. Thus, we analyzed clinical factors that could differentiate between superficial and deep injuries in patients with penetrating neck injuries. @*Methods@#We investigated the medical records of 90 patients with penetrating neck injuries who visited the emergency department between January 2010 and March 2020. To identify the degree of injuries, we compared age, sex, onset and arrival time, onset-to-arrival time, initial vital signs, Glasgow Coma Scale, Revised Trauma Score, cause, mechanism, location and number of injuries, anatomical zone, alcohol intake and psychiatric history were classified as early clinical factors. @*Results@#Among 90 patients, 51 had superficial injuries, and 39 had deep injuries. The early clinical factors showing statistically significant differences were the Glasgow Coma Scale, Revised Trauma Score, cause of injury and anatomical zones. As the Glasgow Coma Scale increased by 1 point, deep injuries decreased by 0.807 times compared to superficial injuries. Homicidal injuries were 3.233 times deeper than suicidal injuries. @*Conclusion@#If the Glasgow Coma Scale is low or the cause of injury is homicide, the possibility of a deep penetrating injury is high. Therefore, it is important to treat the patient carefully, considering these factors.

A Study of Predicting the Severity Following Glufosinate Ammonium Containing Herbicide Poisoning Experienced in Single Emergency Medical Institution

PURPOSE: Owing to the increased agricultural use of the herbicide glufosinate ammonium (GLA), the incidence of GLA poisoning has recently increased. Therefore, we investigated the possible predictive factors associated with severe complications following GLA poisoning. METHODS: A retrospective analysis of medical records was conducted based on 76 patients who had visited our regional emergency medical center with GLA poisoning from 2006 to 2017. Severe complications were defined as respiratory failure requiring intubation, systolic blood pressure less than 90 mmHg, Glasgow Coma Scale (GCS) less than 8, and presence of seizure. RESULTS: Age, ingested amount and ingested amount per weight were significantly greater in the severe group (p<0.001). PSS grade 2 or higher was more common in the severe group (p<0.001), and In addition, the APACHE II score was significantly higher in the severe group (p<0.001), as were the SOFA scores (p=0.002). Serum ammonia levels were significantly higher in the severe group (p=0.007), while MDRD-GFR was smaller in the severe group (p=0.002). The spot urine protein levels were significantly higher in the severe group (p=0.005), as was the urine protein to creatinine ratio (p=0.001). Upon multivariate analysis, the amount ingested per weight and PSS grade 2 or higher were identified as significant predictors. CONCLUSION: Our study showed that MDRD-GFR was significantly lower in the severe group after GLA poisoning. PSS grade 2 or higher and ingested amount per weight may be useful to evaluate the severity of complications after GLA poisoning.

High Prevalence of Psychotropics Overdose among Suicide Attempters in Korea

OBJECTIVE: The availability of suicide methods affects the risk of suicide attempts. This study examined the patterns of substances ingested by suicide attempters (SAs) and the characteristics of SAs using psychotropic overdoses. METHODS: Data for 384 of the 462 eligible SAs who used self-poisoning were analyzed. Demographic variables, clinical characteristics, and factors related to the suicide attempts were examined. RESULTS: There were 256 (66.7%) females and 128 (33.3%) males. Roughly half the SAs ingested psychotropics (n=179, 46.6%). Agricultural chemicals (n=84, 21.9%) were the second most frequently ingested substances, followed by analgesics (n=62, 16.1%), household products (n=27, 7.0%), and other prescribed medications (n=23, 6.0%). Among psychotropics, the most frequently overdosed drugs were sedative-hypnotics, including hypnotics (n=104) and benzodiazepines (n=78). SAs favored Z-drugs and alprazolam. When compared with SAs with non-psychotropic overdoses, significantly more SAs with psychotropic overdoses were female (76% vs. 58.5%, p<0.001) and had a psychiatric history (59.8% vs. 29.8%, p<0.001). They had significantly more previous suicide attempts (0.52+/-1.02 vs. 0.32+/-0.80, p<0.05) and lower risk (7.96+/-1.49 vs. 8.44+/-1.99, p<0.01) and medical severity (3.06+/-0.81 vs. 3.37+/-0.93, p<0.005) scores. CONCLUSION: Psychotropic overdose, especially with sedative-hypnotics, was a major method in suicide attempts. It is important that psychiatric patients are carefully evaluated and monitored for suicidality when prescribing psychotropics.

Characteristic Risk Factors Associated with Planned versus Impulsive Suicide Attempters

OBJECTIVE: The present study aimed to investigate predictors for planned suicide attempters. METHODS: This study included 1,003 patients who attempted suicide and visited emergency department. They were divided into two groups, planned suicide attempters (SAs; n=133 [13.3%]) and impulsive SAs (n=870, [86.7%]), and the demographic variables, clinical characteristics, factors related to suicide, and psychiatric resources of the groups were compared. RESULTS: Major depressive disorder and substance use disorders were more common among planned SAs than among impulsive SAs. Additionally, the planned SAs were older, more likely to be divorced, separated or widowed, and more likely to have comorbid medical illnesses, severe depression, higher suicidality, and self-blaming tendencies than the impulsive SAs. Financial problems and physical illnesses were more common in planned SAs but interpersonal conflicts were more frequent in impulsive SAs. Planned SAs had fewer previous suicide attempts but these were more serious suicide attempts. The presence of the hope to die, a written will, and suicidal ideation of a repetitive, intense, and continuous nature were predictive of planned SAs. CONCLUSION: The present findings demonstrated that planned SAs had more severe psychopathology and medical illnesses than impulsive SAs. Therefore, screening for depression, substance use disorders, and suicidal plans among old and medically ill patients may be important for preventing suicide attempts.

Clinical Characteristics of the Suicide Attempters Who Refused to Participate in a Suicide Prevention Case Management Program

Case management interventions for suicide attempters aimed at helping adjust their social life to prevent reattempts have high nonparticipation and dropout rates. We analyzed the clinical characteristics of the group who refused to participate in the suicide prevention program in Korea. A total of 489 patients with a suicide attempt who visited Uijeongbu St. Mary's Hospital, the Catholic University of Korea, from December 2009 to December 2013 were analyzed. All patients were divided into the participation group (n = 262) and the refusal group (n = 227) according to their participation in the case management program. Demographic and clinical characteristics of each group were examined. Results showed that the refusal group had low risks for suicide in terms of risk factors related with psychopathologies and presenting suicide behavior. That is, the refusal group had less patients with co-morbid medical illnesses and more patients with mild severity of depression compared to the participation group. However, the refusal group had more interpersonal conflict, more isolation of social integrity, and more impaired insight about suicide attempt. The results suggest that nonparticipation in the case management program may depend upon the patient's impaired insight about the riskiness of suicide and lack of social support.

Suicide Risk Assessments: Which Suicide Risk Factors Psychiatric Residents Consider Significant?

OBJECTIVE: Patients visiting the emergency department (ED) after a suicide attempt are generally assessed for suicide risk by psychiatric residents. Psychiatric residents' competence in evaluating the risk posed by the patients who attempted suicide is critical to preventing suicide. METHODS: We investigated factors considered important by psychiatric residents when evaluating suicide risk. This study included 140 patients admitted to the ED after attempting suicide. Psychiatric residents rated patients' severity of current and future suicide risk as low/moderate/high using the Brief Emergency Room Suicide Risk Assessment (BESRA). The association between each BESRA variable and level of suicide risk was analyzed. RESULTS: Many factors were commonly considered important in evaluating the severity of current and future suicide risk. However, the following factors were only associated with future suicide risk: female gender, having no religion, family psychiatric history, history of axis I disorders, having a will, harboring no regrets, and social isolation. CONCLUSION: Psychiatric residents use diverse factors when assessing suicide risk. Psychiatric residents might put more emphasis on non-modifiable demographic and clinical factors, concrete evidence showing suicide determination, and social isolation to assess the risk of future suicide.

The Characteristics and Outcomes of Foreign Body Aspiration and Ingestion in Pediatric Patients who Visit an Emergency Department

PURPOSE: Many children visit an emergency department with aspiration or ingestion of a foreign body (FB). As little study based on Korean domestic data has been reported, we conducted a retrospective study in order to investigate the characteristics and outcomes in pediatric patients with FB. METHODS: A retrospective chart review of children with FB aspiration or ingestion who visited one of three emergency departments between January 2009 and December 2012 was conducted. Demographic data including age and sex, time of accident, whether the event was witnessed, time to visit, symptoms, radioopacity, diagnostic and therapeutic modalities, and category of FB were recorded. Stepwise forward logistic regression was performed in order to verify the association between variables and confirmation of FB. RESULTS: A total of 1508 pediatric patients presented to the emergency departments with FB aspiration or ingestion 739(49%) patients were 0 to 3 years old; 922(61.1%) patients visited with food itself or food-related materials, including fishbone. A total of 534(35.4%) patients were finally confirmed as having FB. Of those, the Odds ratio of positive radiologic test in patients presenting with a certain sign or symptom was 1.412(95% Confidence interval, 1.133 to 1.759). The proportion of those witnessed was significantly higher in those confirmed with FB than in those not confirmed (p<0.001). CONCLUSION: An emergency physician should take a detailed history, including whether there is a witness, and perform a careful examination in order to make a decision regarding the need for diagnostic and therapeutic modality when a pediatric patient is under three years old, and has no symptom or positive radiologic finding.

The Characteristics and Outcomes of Foreign Body Aspiration and Ingestion in Pediatric Patients who Visit an Emergency Department

PURPOSE: Many children visit an emergency department with aspiration or ingestion of a foreign body (FB). As little study based on Korean domestic data has been reported, we conducted a retrospective study in order to investigate the characteristics and outcomes in pediatric patients with FB. METHODS: A retrospective chart review of children with FB aspiration or ingestion who visited one of three emergency departments between January 2009 and December 2012 was conducted. Demographic data including age and sex, time of accident, whether the event was witnessed, time to visit, symptoms, radioopacity, diagnostic and therapeutic modalities, and category of FB were recorded. Stepwise forward logistic regression was performed in order to verify the association between variables and confirmation of FB. RESULTS: A total of 1508 pediatric patients presented to the emergency departments with FB aspiration or ingestion 739(49%) patients were 0 to 3 years old; 922(61.1%) patients visited with food itself or food-related materials, including fishbone. A total of 534(35.4%) patients were finally confirmed as having FB. Of those, the Odds ratio of positive radiologic test in patients presenting with a certain sign or symptom was 1.412(95% Confidence interval, 1.133 to 1.759). The proportion of those witnessed was significantly higher in those confirmed with FB than in those not confirmed (p<0.001). CONCLUSION: An emergency physician should take a detailed history, including whether there is a witness, and perform a careful examination in order to make a decision regarding the need for diagnostic and therapeutic modality when a pediatric patient is under three years old, and has no symptom or positive radiologic finding.

Characteristics of Drug Overdose in Young Suicide Attempters

OBJECTIVE: Few studies have focused on the characteristic features of drug overdose in children and adolescents who have attempted suicide in Korea. The present study examined the characteristics of drug overdose in children and adolescents who visited the emergency room following drug ingestion for a suicide attempt. METHODS: The medical records of 28 patients who were treated in the emergency room following a drug overdose from January 2008 to March 2011 were analyzed. Demographic and clinical variables related to the suicide attempts were examined. RESULTS: The mean age of the patients was 16.6+/-1.7 years (range 11-19 years), and 20 of the patients (71.4%) were female. Most of the patients (n=23, 82.1%) overdosed on a single drug; acetaminophen-containing analgesics were the most common (n=12, 42.9%). Depression was the most common psychiatric disorder (n=22, 78.6%), and interpersonal conflict was the most common precipitating factor of the suicide attempts (n=11, 39.3%). This was the first suicide attempt for approximately 80% of the patients. About one fourth of the patients (n=7, 25%) had follow-up visits at the psychiatric outpatient clinic. CONCLUSION: Early screening and psychiatric intervention for depression may be an important factor in preventing childhood and adolescent suicide attempts. Developing coping strategies to manage interpersonal conflicts may also be helpful. Moreover, policies restricting the amount and kind of drugs purchased by teenagers may be necessary to prevent drug overdose in this age group.

Prediction of Systemic Complications from Caustics Ingestion Through Arterial Blood Gas Analysis

PURPOSE: The aim of this study was to analyze the risk factors of systemic complications by caustic substances according to arterial blood gas analysis (ABGA). METHODS: The medical records of patients who visited our emergency department for caustic ingestion from January 2000 to December 2011 were reviewed. There were 129 patients included in this study, with a mean age of 45.4 years, and 46.9% of the patients were men. We performed a univariate analysis of factors associated with systemic complication and a logistic regression analysis of these predictive factors. RESULTS: The most frequent caustic ingested was base (53.8%). Systemic complications were found in 29 patients (22.5%) and advanced age, a low partial pressure of oxygen (PaO2), low bicarbonate ion (HCO3-), low oxygen saturation (SaO2), high anion gap (AG), acid ingestion, and severe acidosis were associated with systemic complications. Low SaO2, high AG, and severe acidosis were independent predictive factors of systemic complications. ED: HIGHLIGHT: Please spell out HCO3. CONCLUSION: Parameters of ABGA such as SaO2, AG, and pH predict the development of systemic complications by caustic ingestion. Therefore, these data have a role in the prognosis and treatment of caustic ingestion.

Methemoglobinemia and Seizure Following Indoxacarb Poisoning

Indoxacarb is an oxadiazine insecticide with selective lethality through blockade of neuronal voltage-dependent sodium channels. It has a low mammalian toxicity, and few cases of human toxicity after indoxacarb ingestion can be found in the literature. A 36 year-old male patient visited our ED after a generalized tonic clonic seizure, which was witnessed by his mother. His past medical history was nonspecific. On initial presentation, he showed a decreased level of consciousness with a Glasgow coma score of 5/15 (E1V1M3), unprotected airway, hypoxia, and cyanosis. The saturation gap and cyanosis after intubation and mechanical ventilation was strongly suggestive of methemoglobinemia due to poisoning. Finally, the methemogobin (metHb) level was 27.4%. Therefore, the patient received 100 mg of methylene blue (2 mg/kg, 1% solution) and 50 g of charcoal. The insecticide was found to be ingested xenobiotic (Steward Gold(R); 5% indoxacarb; 95% inert ingredients and other components). On the second hospital day, the patient became alert. The patient's metHb level was 0.1%. The endotracheal tube was removed. On the fifth hospital day, he was discharged in good condition. Herein we present a case of indoxacarb poisoning with methemoglobiemia and seizure, which are unusual presentations.

Delayed Respiratory Failure after Ingesting Imidacloprid Containing Solution

Compared with organophosphate or carbamate insecticides, neonicotinoids have several pharmacological benefits such as a broad spectrum of insecticidal activity, low application rate, and highly selective toxicity to insects. Imidacloprid was the first neonicotonid introduced in the market, in 1991. It has become one of the best selling insecticides globally. Several cases of imidacloprid intoxication have been reported worldwide, but few have been reported in Korea. Recently, we experienced a severe imidacloprid intoxication with delayed respiratory insufficiency and several toxicities. We report the case with the literature review.

Laparoscopic Splenectomy in a Case of Stable Blunt Abdominal Trauma

Splenic rupture is a frequent surgical emergency in blunt abdominal trauma patients. There are several treatment options, including conservative treatment, a partial splenectomy, splenorrhaphy, and a splenectomy for splenic injury. Although reports on the safety and the efficacy of an elective laparoscopic splenectomy are abundant in the literature, a laparoscopic splenectomy for a ruptured spleen has only been reported in a few cases. We report a case of a laparoscopic splenectomy in the patient with Grade III traumatic splenic injury. To our knowledge, this is the first report in which a laparoscopic splenectomy was performed in Korea for the treatment of a traumatic splenic injury.

Eosinophilic Enteritis Involving the Entire Intestinal Wall Presenting as Small Bowel Obstruction and Acute Abdomen

Eosinophilic enteritis is an uncommon disease that rarely manifests as an acute abdomen. A 50-year-old man visited our hospital and complained of epigastric and periumbilical pain. He reported direct and rebound tenderness over the periumbilical area. Laboratory examinations showed leukocytosis without eosinophilia. Plain abdominal radiography revealed air-fluid levels in the small intestine and computed tomography revealed concentric wall thickening in the small bowel and ascites in the pelvic cavity. We conducted an emergency operation and segmental resection of the jejunum was performed. Histologically, transmural, eosinophilic infiltration was observed. In patients with intestinal obstruction, even when presenting with an acute abdomen with no peripheral eosinophilia, eosinophilic enteritis should be included in the differential diagnosis.

Cardiac Toxicity in Patients with Antidepressant Intoxication

PURPOSE: Although cardiac toxicity is a key parameter of significant toxicity, in antidepressant intoxication, there are few studies on the cardiac toxicity of serotonin reuptake inhibitor and the intoxication with the new generation of antidepressants. The aim of this study is to investigate the relative cardiac toxicity of serotonin reuptake inhibitor and intoxication with the new generation of antidepressants as compared with that of tricyclic antidepressant intoxication. METHODS: We retrospectively reviewed the medical records of 109 antidepressant intoxicated patients who visited the Emergency Department from January, 2005 to December, 2009 to collect and analyze the demographic and clinical data. Sixteen patients were excluded. The enrolled seventy eight patients were classified into three groups: the tricyclic antidepressant group (TCA) (n=32), the selective serotonin reuptake inhibitor subgroup (SSRI) (n=28) and the new generation antidepressant subgroup (NGA) (n=18). RESULTS: The demographic and clinical data of the SSRI and NGA groups were not significantly different from that of the TCA group. The QRS duration of the SSRI subgroup (86.4+/-12.0 msec) and the NGA subgroup (91.8+/-11.9 msec) was not significantly different from that of the TCA group (90.0+/-13.5msec) (p=0.598). CONCLUSION: Intoxication with SSRI and the new generation antidepressants seemed to show significant cardiac toxicity, like what is seen in tricyclic antidepressant intoxication. Clinicians must pay attention to SSRI and new generation antidepressant intoxication.

Clinical Characteristics of Patients with Neonicotinoid Insecticide Poisoning

PURPOSE: Neonicotinoid insecticides are widely used as they have been proven by experimental studies to have low toxicity to mammals, including humans. As the use of neonicotioids increases, the number of patients with neonicotinoid poisoning has also increased. We conducted a study to investigate the clinical manifestations of neonicotinid poisoning. METHODS: We retrospectively analyzed the patients who ingested neonicotinids and who visited the emergency department located in Korea from March 2002 to February 2010. We reviewed the patients' age, gender, the amount of exposure, the elapsed time to presentation, the treatment and the outcome. According to the poisoning severity score, we divided the patients with a Poisoning severity score (PSS) of 0 or 1 into the mild/moderate toxicity group and the patients with a PSS of 2 or 3 into the severe/fatal toxicity group. RESULTS: A total of 24 patients were analyzed. The most common clinical manifestations of neonicotinoid insecticide toxicity were gastrointestinal symptoms (66.7%) such as nausea, vomiting and abdominal pain and the others are respiratory symptoms (16.7%), cardiovascular symptoms (12.5%), metabolic imbalance (12.5%), renal dysfunction (8.3%), CNS symptoms (8.3%), and asymptomatic (29.2%). Twenty patients (83.3%) showed mild/moderate toxicity and 4 patients (16.7%) showed fatal conditions such as shock and mutiorgan failure. The mortality rate was 4.2%. In these fatal cases, the patients developed respiratory failure, hypotension, altered mentality and renal failure at the acute stage and they deteriorated to a more serious condition. This severe toxicity was caused by decreased renal excretion of neonicotinid metabolite, and this was improved after hemodialysis. CONCLUSION: Most patients with neonicotinoid poisoning and who showed mild toxicity usually improved after symptomatic treatment. However, some patients showed significant toxicity with respiratory failure and renal function deterioration, and intensive care needed, including mechanical ventilation and hemodialysis.

Predictive Factors of Blood Transfusion Requirement in Blunt Trauma Patients Admitted to the Emergency Room

PURPOSE: In multiple blunt trauma patients, transfusion may be a significant therapeutic adjunct to non-operative management. The blood products must be expedited and efficiently to patients in impending shock caused by hemorrhage or traumatic coagulopathy, but the decision to perform blood transfusion has been made empirically, based on the clinician's and has not been guided by objective parameters, but own opinion, that may result in an underestimate of or a failure to detect bleeding, in delayed transfusion, and in a reduced outcome. This article presents quickly assessable predictive factors for determining if a blood transfusion is required to improve outcomes in multiple blunt trauma patients admitted to the emergency room. METHODS: In a retrospective review of 282 multiple blunt trauma patients who visited our emergency center by emergency rescuer during a 1-year period, possible factors predictive of the need for a blood transfusion were subjected to univariate and multivariate logistic regression analysis. RESULTS: Of blunt trauma patients ,9.2% (26/282), received red blood cells in the first 24 hours of care. Univariate analysis revealed significant associations between blood transfused and heart rate (HR) > 100 beats/min, respiratory rate (RR) > 20 breaths/min, Glasgow Coma Scale (GCS) 10000, and initial abnormal portable trauma series (Cspine lateral, chest AP, pelvis AP). A multiple regression analysis, with a correction for diagnosis, identified HR > 100 beats/min (EXP 3.2), GCS 65 years, hemoglobin 100 beats/min, and GCS < 14 were quickly assessable useful factors for predicting a need for early blood transfusion in blunt trauma patients visiting the emergency room.

A Case of Lung Necrosis and Abscess after Paint Thinner Ingestion

Paint thinners contain a mixture of volatile organic solvents, including aromatic hydrocarbons such as toluene, xylene, and N-hexane. Hydrocarbon pneumonitis is an acute, intense pneumonitis resulting from the aspiration of volatile hydrocarbon compounds with low viscosity and surface tension. Here we report the case of a 60-year-old man admitted to our hospital with chest pain following the ingestion of paint thinner. Aspiration resulted from inducing emesis after ingestion. Acute chemical pneumonitis developed in the right lower lung. The patient's course was further complicated by lung necrosis, abscess, pleural effusion, and pneumothorax. He was treated with pleural adhesiolysis and a right middle lobe wedge resection via video-assisted thoracoscopic surgery.

Severe Glyphosate Intoxication with a Laryngopharyngeal Corrosive Injury

Glyphosate is an herbicide that is used worldwide. Suicidal attempts with a glyphosate-surfactant herbicides (GlySH) are on the rise. The severity of corrosive injuries is thought to have a close correlation with a higher complication rate or pulmonary aspiration. We report a case with multiple toxic effects associated with a severe laryngopharyngeal corrosive injury following GlySH intoxciation. Specifically, a severe laryngopharyngeal corrosive injury might be significantly associated with the toxic effects and complications, including respiratory failure and chemical pneumonia, bleeding tendency, increased BUN/Cr ratio, and frequent aspiration due to dysphagia. Appropriate evaluation and management of corrosive injuries may be helpful in caring for GlySH-intoxicated patients.