The prognostic usefulness of the lactate/albumin ratio for predicting multiple organ dysfunction syndrome in severe trauma

Objective@#Early prediction of the multiple organ dysfunction syndrome (MODS) and providing early innovative treatment may improve outcomes in patients with severe trauma. Lactate and serum albumin levels, which are widely used markers predicting the severity of critically ill patients, tend to diverge during clinical deterioration. This study aimed to evaluate the clinical utility of the lactate/albumin ratio (LAR) as a predictive factor for MODS and 30-day mortality in patients with severe trauma. @*Methods@#This retrospective, observational cohort study was performed with patients prospectively integrated into a critical pathway for trauma. We analyzed severe trauma patients (Injury Severity Score≥16) admitted to the emergency department (ED), between January 1, 2011, and May 31, 2017. The outcomes were the development of MODS and 30-day mortality. @*Results@#In total, 348 patients were enrolled, of which 18 (5.2%) died within 96 hours of ED admission, and the remaining 330 patients (94.8%) were evaluated for the development of MODS. An increase in the LAR at admission (odds ratio, 1.618; P=0.028) was an independent predictor of MODS development. The area under the receiver operating characteristic curve (0.755) and Harrell's C-index (0.783) showed that LAR could predict MODS and 30-day mortality. @*Conclusion@#Initial LAR is an independent predictor of MODS development in patients with severe trauma. Our study results suggest that an elevated LAR can be a useful prognostic marker in patients with severe trauma.

Systematic review for economic benefit of poison control center

Purpose@#The purpose of this study was to conduct a systematic review to investigate the socio-economic benefits of the poison control center (PCC) and to assess whether telephone counseling at the poison control center affects the frequency of emergency room visits, hospitalization, and length of stay of patients with acute poisoning. @*Methods@#The authors conducted a medical literature search of the PubMed, EMBASE, and Cochrane Library databases. Two reviewers evaluated the abstracts for eligibility, extracted the data, and assessed the study quality using a standardized tool. Key results such as the cost-benefit ratio, hospital stay days, unnecessary emergency room visits or hospitalizations, and reduced hospital charges were extracted from the studies. When meta-analysis was possible, it was performed using RevMan software (RevMan version 5.4). @*Results@#Among 299 non-duplicated studies, 19 were relevant to the study questions. The cost-benefit ratios of PCC showed a wide range from 0.76 to 36 (average 6.8) according to the level of the medical expense of each country and whether the study included intentional poisoning. PCC reduced unnecessary visits to healthcare facilities. PCC consultation shortened the length of hospital stay by 1.82 (95% CI, 1.07-2.57) days. @*Conclusion@#The systematic review and meta-analysis support the hypothesis that the PCC operation is cost-beneficial. However, when implementing the PCC concept in Korea in the future, it is necessary to prepare an institutional framework to ensure a costeffective model.

Causative Substance and Time of Mortality Presented to Emergency Department Following Acute Poisoning:2014-2018 National Emergency Department Information System (NEDIS)

Purpose@#The purpose of this study was to investigate the cause of acute fatal poisoning and the time of death by analyzing the National Emergency Department Information System (NEDIS) of South Korea. @*Methods@#The NEDIS data from 2014 to 2018 excluding non-medical visits were used for this study. The patients with acute poisoning were extracted using diagnostic codes. The toxic substances were classified into pharmaceuticals, pesticides, gases, artificial poisonous substances, and natural toxic substances. Patients were classified according to the time of death, place of death, and region. In each case, the most causative substances of poisoning were identified. @*Results@#There were 380,531 patients including poisoning-related diagnoses, of which 4,148 (1.1%) died, and the WHO age-standardized mortality rate was 4.8 per 100,000. Analysis of 2,702 death patients whose primary diagnosis was acute poisoning, the most common cause of poisoning death was pesticides (62%), followed by therapeutic drugs, gas, and artificial toxic substances. Herbicides were the most common pesticides at 64.5%. The proportion of mortality by time, hyperacute (7 d) were 9.8%. @*Conclusion@#This study suggests that the most common cause of poisoning death was pesticides, and 60% of deaths occurred within 24 hours. The 71% of mortality from pesticides occurred within 6-24 hours, but mortality from gas was mostly within 6 hours. According to the geographic region, the primary cause of poisoning death was varied to pesticides or pharmaceuticals.

Risk factors to predict post-contrast acute kidney injury after contrast-enhanced computed tomography in the emergency department

Objective@#This study aimed to investigate the risk factors of post-contrast acute kidney injury (PAKI) and the usefulness of the Mehran score for predicting PAKI in patients who underwent contrast-enhanced abdominopelvic computed tomography (CE-APCT) in the emergency department (ED). @*Methods@#This was a retrospective observational study. Patients who underwent CE-APCT and had a follow-up creatinine test within 72 hours in the period January to June, 2017, were enrolled for the study. PAKI is defined as a 25% or higher increase in the level of serum creatinine (sCr) within 72 hours after receiving contrast, or an increase in the level of sCr by 0.5 mg/dL. The odds ratio (OR) of risk factors and incidence of PAKI after CE-APCT were analyzed according to the Mehran risk group, and compared to expected incidence. Univariate and multivariate logistic regression analyses were performed for each risk factor. @*Results@#A total of 1,718 patients were enrolled in the study. Of these, 203 patients (11.8%) developed PAKI, and 2 patients (0.1%) required dialysis. Hypotension (systolic blood pressure <80 mmHg) was determined to be statistically significant (P=0.029; OR, 3.181) among the considered risk factors of PAKI. In the group having abnormal estimatedglomerular filtration rate (<90 mL/min/1.73 m2), the age and rate of the underlying disease (congestive heart failure, hypertension) was found to be higher in the PAKI group. The receiver operating curve of Mehran score (area under the curve: 0.521 in model A, 0.520 in model B) was statistically not significant in the univariate analysis. A higher Mehran score was associated with a higher proportion of patients who underwent prophylactic treatment. @*Conclusion@#There are no definite useful risk factors, including the Mehran score, for predicting PAKI in patients who underwent contrast-enhanced computed tomography in the ED.

Risk factors to predict post-contrast acute kidney injury after contrast-enhanced computed tomography in the emergency department

Objective@#This study aimed to investigate the risk factors of post-contrast acute kidney injury (PAKI) and the usefulness of the Mehran score for predicting PAKI in patients who underwent contrast-enhanced abdominopelvic computed tomography (CE-APCT) in the emergency department (ED). @*Methods@#This was a retrospective observational study. Patients who underwent CE-APCT and had a follow-up creatinine test within 72 hours in the period January to June, 2017, were enrolled for the study. PAKI is defined as a 25% or higher increase in the level of serum creatinine (sCr) within 72 hours after receiving contrast, or an increase in the level of sCr by 0.5 mg/dL. The odds ratio (OR) of risk factors and incidence of PAKI after CE-APCT were analyzed according to the Mehran risk group, and compared to expected incidence. Univariate and multivariate logistic regression analyses were performed for each risk factor. @*Results@#A total of 1,718 patients were enrolled in the study. Of these, 203 patients (11.8%) developed PAKI, and 2 patients (0.1%) required dialysis. Hypotension (systolic blood pressure <80 mmHg) was determined to be statistically significant (P=0.029; OR, 3.181) among the considered risk factors of PAKI. In the group having abnormal estimatedglomerular filtration rate (<90 mL/min/1.73 m2), the age and rate of the underlying disease (congestive heart failure, hypertension) was found to be higher in the PAKI group. The receiver operating curve of Mehran score (area under the curve: 0.521 in model A, 0.520 in model B) was statistically not significant in the univariate analysis. A higher Mehran score was associated with a higher proportion of patients who underwent prophylactic treatment. @*Conclusion@#There are no definite useful risk factors, including the Mehran score, for predicting PAKI in patients who underwent contrast-enhanced computed tomography in the ED.

Usefulness of serial measurement of the mean platelet volume to predict multipleorgan dysfunction syndrome in patients with severe trauma

Objective@#The early prediction of multiple organ dysfunction syndrome (MODS) in trauma patients and provision ofprompt treatment may improve their outcomes. We investigated the efficacy of the mean platelet volume (MPV) for predictingMODS in cases of severe trauma. @*Methods@#This retrospective, observational cohort study was performed with patients prospectively integrated in a criticalpathway of TRAUMA. We analyzed the severe trauma patients admitted to the emergency department (ED), based onthe Advanced Trauma Life Support guideline, between January 1, 2011 and May 31, 2017. The outcomes were developedfrom MODS at least 48 hours after ED admission. @*Results@#A total of 348 patients were enrolled. An increase in the MPV at 12 hours (odds ratio [OR], 2.611; P8.6 fL (OR, 4.831; P<0.001). The area under the receiver operating characteristic curve(AUROC) value of the MPV at 12 hours (0.751; 95% confidence interval [CI], 0.687-0.818; P<0.01) was not inferior thanthat of Acute Physiology and Chronic Health Evaluation II score, injury severity score, lactate, and total CO2 for predictingMODS. @*Conclusion@#MPV was an independent predictor of MODS development in severe trauma patients. Emergency physicianscan use the MPV as an ancillary biomarker for predicting MODS.

Lactate/albumin ratio for the prediction of the development of sepsis-induced acute kidney injury in the emergency department

OBJECTIVE: The early prediction of acute kidney injury (AKI) in sepsis and the provision of prompt treatment may improve the outcomes. This study investigated the efficacy of the lactate/albumin ratio (LAR) in predicting severe AKI in cases of septic shock. METHODS: This retrospective, observational cohort study was performed on patients integrated prospectively in a critical pathway of early-goal-directed therapy (EGDT)/SEPSIS. Adult patients with septic shock, who were admitted to the emergency department with a normal kidney function or stage 1 disease based on the Acute Kidney Injury Network classification between January 1, 2014 and September 30, 2017, were analyzed. The outcomes were the development of sepsis-induced severe AKI within 7 days. RESULTS: A total of 343 patients were enrolled. An increase in the LAR value at admission (odds ratio [OR], 1.85; P=0.001) was a strong independent predictor of the development of severe AKI. The increasing predictability of AKI was closely associated with a L/A ratio≥0.794 at admission (OR, 14.66; P < 0.001). The area under the receiver operating characteristic curve value of the L/A ratio (0.821; 95% confidence interval [CI], 0.774–0.861; P < 0.01) was higher than that of lactate (0.795; 95% CI, 0.747–0.838; P < 0.01) for predicting severe AKI (P=0.032). CONCLUSION: L/A ratio was found to be an independent predictor of the development of severe AKI in septic shock. The prognostic performance of the L/A ratio for predicting AKI of critically ill sepsis patients was superior to that of lactate measurements.

The usefulness of lactate as an early predictor of the severity of emergency department patients with postpartum hemorrhage

OBJECTIVE: Only a few studies have examined the role of lactate reflecting on tissue hypoperfusion determining the severity of postpartum hemorrhage (PPH) patients in the emergency department (ED). This study evaluated the utility of the arterial lactate level as a prognostic marker of severity in PPH patients admitted to an ED. METHODS: This retrospective, observational cohort study was conducted on patients integrated prospectively in a critical pathway of SPEED (Severance Protocol to save postpartum bleeding through Expeditious care Delivery). Adult primary PPH patients admitted to the ED between July 1, 2010 and March 31, 2017 were analyzed. The outcomes were the development of severe PPH including death, hysterectomy, surgical treatment, and massive transfusion. RESULTS: A total of 112 patients were enrolled in this study. An increase in the arterial lactate value was a strong independent predictor of severe PPH. The increasing predictability of severe PPH was closely associated with an arterial lactate ≥3.15 mL/L at admission (odds ratio, 13.870; P < 0.001). CONCLUSION: Lactate is an independent predictor of severe PPH and is suitable for a rapid and simple estimation of the severity of PPH. Emergency physicians can use lactate to determine the initial treatment strategies more precisely.

A Study on the Disaster Medical Response during the Mauna Ocean Resort Gymnasium Collapse

PURPOSE: To investigate and document a disaster medical response during the collapse of the Gyeongju Mauna Ocean Resort gymnasium, which occurred on February 17, 2014. METHODS: The official records of each institution were verified to select the study population. All the medical records and emergency medical service records were reviewed by an emergency physician. Personal or telephonic interviews were conducted without a separate questionnaire if the institutions or agencies crucial to disaster response did not have official records or if information from different institutions was inconsistent. RESULTS: One hundred fifty-five accident victims, who were treated at 12 hospitals mostly for minor wounds, were included in this study. The collapse killed 10 people. Although the news of the collapse was disseminated in 4 minutes, it took at lease 69 minutes for a dispatch of 4 disaster medical assistance teams to take action; 4.5% of patients were treated on-site, 56.7% were transferred to 2 nearest hospitals, and 42.6% were transferred to hospitals with poor preparation to handle disaster victims. CONCLUSION: In the collapse of the Gyeongju Mauna Ocean Resort gymnasium, the initial triage and distribution of patients were inefficient, with delayed arrival of medical assistance teams. These problems had also been noted in prior mass casualty incidents. Government agencies are implementing improvements, and this study could aid the implementation process.

Usefulness of Delta Neutrophil Index to Predict 30-day Mortality in Patients with Mechanical Bowel Obstruction

PURPOSE: Mechanical bowel obstruction (MBO) is a common emergency problem resulting in high morbidity and mortality. The delta neutrophil index (DNI), reflecting the fraction of circulating immature granulocytes, is associated with increased mortality in patients with infection and/or systemic inflammation. This study was conducted to investigate the relationship between DNI and 30-day mortality in patients with MBO. METHODS: We retrospectively identified consecutive patients (>18 years old) with MBO admitted to the emergency department from January 1, 2013 to April 30, 2015. The diagnosis of MBO was confirmed using clinical and radiological findings. The DNI was determined on each day of hospitalization. The outcome of interest was the 30-day mortality and the prognostic value of DNI for 30-day mortality was ascertained by Cox proportional hazards model analysis. RESULTS: A total of 518 patients with MBO were included in this study. According to multivariate Cox proportional hazard models, higher DNI at admission (hazard ratio [HR], 1.080; 95% confidence interval [CI], 1.036-1.126; p1.9% on admission (HR, 9.410; 95% CI, 2.671-33.145; p<0.001) was associated with increased 30-day mortality. Furthermore, the accuracy of DNI for predicting 30-day mortality was superior to that of other parameters. CONCLUSION: The DNI can be measured rapidly and simply on emergency department admission without additional cost or time burden. Increased DNI values are associated with 30-day mortality in patients with MBO.

Disaster medicine: current status and future directions of emergency medical team for overseas disaster crisis

Through the Declaration of Montevideo in 2011, the World Medical Association suggested that doctors worldwide should be trained in basic disaster response regardless of their specialty. The Haiti earthquake in 2010, which had the highest number of foreign medical team dispatched from all over the world, proved that untrained and disorganized team only brought confusion. This event led the World Health Organization to develop the ‘Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters ’ in 2013. This guideline will become the standard for organizing an international emergency medical team. We should be able to provide high standard of care through field hospital set up and continuous training of disaster medicine specialists.

Usefulness of Serial Measurement of the Platelet Volume Indices to Predict 30-day Mortality in Patients with ST Segment Elevation Myocardial Infarction

PURPOSE: Among the survivors of a ST elevation myocardial infarction (STEMI), higher platelet volume indices (mean platelet volume, MPV; platelet distribution width, PDW) are associated with impaired reperfusion and ventricular dysfunction. This study examined the relationship between the platelet volume indices and 30-day mortality with STEMI patients who underwent primary percutaneous coronary intervention (PCI). METHODS: This retrospective cohort study included patients presenting to the emergency department with STEMI between January 2011 and May 2016. The platelet volume indices were measured serially, using an automatic hematology analyzer, from admission to 24 hours after admission. The prognostic value of MPV, PDW for the 30-day mortality was determined by Cox proportional hazards model analysis. RESULTS: A total of 608 STEMI patients, who underwent reperfusion, were enrolled in this study. According to the multivariable Cox proportional hazard model, higher MPV (hazard ratio [HR], 1.414; 95% confidence interval [CI], 1.024-1.953; p=0.035) and PDW (HR, 1.043; 95% CI, 1.006-1.083; p=0.024) values at time-24 (24 hours after admission) were significant risk factors for the 30-day mortality. A MPV value >8.6 fL (HR, 5.953; 95% CI, 2.973-11.918; p56.1% (HR, 5.117; 95% CI, 2.640-9.918; p<0.001) at time-24 were associated with an increased risk of 30-day mortality. CONCLUSION: The platelet volume indices without an additional burden of cost or time, can be measured rapidly and simply. Higher MPV and PDW levels predict independently the 30-day mortality in patients with STEMI after PCI.

A study on the disaster medical response during the Mauna Ocean Resort gymnasium collapse

OBJECTIVE: To investigate and document the disaster medical response during the Gyeongju Mauna Ocean Resort gymnasium collapse on February 17, 2014. METHODS: Official records of each institution were verified to select the study population. All the medical records and emergency medical service run sheets were reviewed by an emergency physician. Personal or telephonic interviews were conducted, without a separate questionnaire, if the institutions or agencies crucial to disaster response did not have official records or if information from different institutions was inconsistent. RESULTS: One hundred fifty-five accident victims treated at 12 hospitals, mostly for minor wounds, were included in this study. The collapse killed 10 people. Although the news of collapse was disseminated in 4 minutes, dispatch of 4 disaster medical assistance teams took at least 69 minutes to take the decision of dispatch. Four point five percent were treated at the accident site, 56.7% were transferred to 2 hospitals that were nearest to the collapse site, and 42.6% were transferred to hospitals that were poorly prepared to handle disaster victims. CONCLUSION: In the Gyeongju Mauna Ocean Resort gymnasium collapse, the initial triage and distribution of patients was inefficient and medical assistance arrived late. These problems had also been noted in prior mass casualty incidents.

Hypoalbuminemia, Low Base Excess Values, and Tachypnea Predict 28-Day Mortality in Severe Sepsis and Septic Shock Patients in the Emergency Department

PURPOSE: The objective of this study was to develop a new nomogram that can predict 28-day mortality in severe sepsis and/or septic shock patients using a combination of several biomarkers that are inexpensive and readily available in most emergency departments, with and without scoring systems. MATERIALS AND METHODS: We enrolled 561 patients who were admitted to an emergency department (ED) and received early goal-directed therapy for severe sepsis or septic shock. We collected demographic data, initial vital signs, and laboratory data sampled at the time of ED admission. Patients were randomly assigned to a training set or validation set. For the training set, we generated models using independent variables associated with 28-day mortality by multivariate analysis, and developed a new nomogram for the prediction of 28-day mortality. Thereafter, the diagnostic accuracy of the nomogram was tested using the validation set. RESULTS: The prediction model that included albumin, base excess, and respiratory rate demonstrated the largest area under the receiver operating characteristic curve (AUC) value of 0.8173 [95% confidence interval (CI), 0.7605–0.8741]. The logistic analysis revealed that a conventional scoring system was not associated with 28-day mortality. In the validation set, the discrimination of a newly developed nomogram was also good, with an AUC value of 0.7537 (95% CI, 0.6563–0.8512). CONCLUSION: Our new nomogram is valuable in predicting the 28-day mortality of patients with severe sepsis and/or septic shock in the emergency department. Moreover, our readily available nomogram is superior to conventional scoring systems in predicting mortality.

Education and Training in Disaster Medicine / 한양의대학술지

Education and training of disaster medicine are the most important part of disaster management. There are so many training and education curriculum all over the world. However education courses based upon core competencies of disaster medicine are lacking. There is still a need to define the specific knowledge, skills, and attitudes that must be mastered by specialized professionals. Standardized core competencies for acute care medical personnel such as emergency department nurses, emergency physicians, and out-of-hospital emergency medical services personnel are needed to ensure that effective emergency medical response can be provided efficiently during all types of disasters. Therefore education and training curriculum of other countries were reviewed in this article.

Comparative Evaluation of Chest Compression in a 30degrees Inclined Lateral Position Designed for Pregnant Cardiac Arrest Patients-Manikin Study

PURPOSE: Appropriate aortocaval compression during cardiopulmonary resuscitation (CPR) plays a significant role in outcomes following cardiac arrest during pregnancy. The existing aortocaval compression women may have due to pregnancy conditions can be relieved by either manual displacement of the gravid uterus or by placing the patient in an inclined lateral position. Hence, the objective of this study was to compare the quality of chest compression in two different positions, supine versus 30degrees inclined lateral, to ascertain whether or not high quality CPR is feasible in an inclined position for treating cardiac arrest during pregnancy. METHODS: A prospective, crossover, randomized study was performed with thirty emergency medicine residents and emergency medical technicians. Each participant performed hands-only CPR for 2 minutes in both supine and 30degrees inclined lateral positions on a manikin. Compression rate, depth, compression depth rate, recoil rate, and hand positioning were evaluated using the Laerdal PC SkillReporting System(R). Participants were scored on the subjective difficulty of chest compression using a visual analogue scale (VAS). RESULTS: There were no significant differences in compression rates, correct recoil rates and correct hand position ratings between the two positions. The compression depth in the supine position was 56.1+/-4.5 mm, and 52.6+/-6.5 mm (p<0.001) in the 30degrees inclined lateral position. However, the latter result met the current guideline recommendation. There was no reported difference in the difficulty of chest compression between the two positions. CONCLUSION: In the 30degrees inclined lateral position, high-quality chest compression is feasible to achieve in simulated cardiac arrest associated with pregnancy.

Relationship of Clinical Manifestation of Renal Colic to Ureteral Stone Size and Location

PURPOSE: This study was designed to correlate the size and position of ureteral stones to their clinical manifestation. METHODS: This study was a retrospective review of medical records of 201 patients who visited the emergency department complaining of renal colic and diagnosed with ureteral stone(s) by use of computed tomography from July to December 2011. The size and position of a stone and the corresponding ipsilateral hydronephrosis, as well as the number and type of administered analgesics, were evaluated. RESULTS: Ureteral stones were located at the ureteropelvic junction in 2.0% of cases, at the proximal ureter between the ureteropelvic junction and the iliac vessels in 41.8% of cases, at the ureter crossing external iliac vessels in 1.0% of cases, at the distal ureter between the iliac vessels and the ureterovesical junction in 12.9% of cases, and at the ureterovesical junction in 42.3% of cases. Where the ureter crossed external iliac vessels, the mean size of stones was significantly larger in the upper ureter, as 5.3+/-2.3 mm, than in the lower ureter, as 4.2+/-1.8 mm. Pain duration and stone size were significant factors associated with hydronephrosis by logistic regression analysis. Ketorolac was selected as the first-line analgesics in 169 patients (94.9%). The factor affecting the response to analgesic treatment was stone size. Patients needing analgesic administration three times or more, had smaller stones. CONCLUSION: Most of the ureteral stones observed were located in the proximal ureter and at the ureterovesical junction. Hydronephrosis occurred more often in patients who had longer periods of pain and larger stones. Patients with smaller stones needed more frequent administration of pain killers.

Validity of Transfusing Group O+ Unmatched Packed Red Blood Cells in Hemorrhagic Shock Patients

PURPOSE: It is important to begin a transfusion safely and appropriately as soon as possible in a hemorrhagic shock patient. A group O+ unmatched pack red blood cell (universal O+) transfusion may satisfy that requirement. We report our experiences with universal O+ to compare its usefulness for hemorrhagic shock patients with that of a matched pack red blood cell transfusion in the emergency department (ED). METHODS: This is a retrospective study. Patients who had systolic blood pressure of less than 90 mmHg or a pulse rate of more than 120 beats per minute in the ED were included, and their medical records were reviewed. The collected data were demographic data, vital signs, blood test results, time to transfusion, the amount of transfusion, complications, and diagnoses. We calculated the emergency transfusion score (ETS) based on the patients' medical records. RESULTS: Two hundred thirty-five patients were included. Forty-eight patients (36 trauma and 12 non-trauma patients) were transfused with a universal O+. These patients had less time to transfusion compared with the cross-matched transfusion groups (35+/-42 versus 170+/-187 minutes, p<0.001). There were no differences in complications between groups (p=0.076). Of the patients who were transfused with universal O+, 94.4% got more than 3 ETS. CONCLUSION: The universal O+ transfusion, compared with matched pack red blood cell transfusion, should be a useful treatment for ED hemorrhagic shock patient due to its having a shorter time to transfusion without an increase in complications.

NEXUS and the Canadian Cervical Spine Rule as a Screening Tool for Computed Tomography Evaluation in Patients with Cervical Spine Injury

PURPOSE: National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian Cervical Spine rule (CCR) are commonly used in cervical trauma patients to determine whether a plain cervical X-ray should be performed. However, plain cervical X-rays are so inaccurate that cervical spine computed tomography (CT) is often considered as a screening test. We studied the usefulness of the NEXUS criteria and the CCR for determining the need for a CT evaluation in the emergency department (ED). METHODS: This prospective observational study was conducted from January 2007 to March 2008. Plain Xray and CT scans of the cervical spine were performed on blunt trauma patients with neck pain. The relevancy of CT was examined using the NEXUS criteria and the CCR. Sensitivity, specificity, positive predicted value, and negative predicted value analyses were performed to diagnose the cervical spine injury. RESULTS: During the study period, 284 patients were enrolled in this study. The sensitivity, specificity, positive predicted value, and negative predicted value of the NEXUS criteria were 87.5%, 1.1%, 5.0%, and 60.0% respectively, while those of the CCR were 87.5%, 8.2%, 5.3%, and 91.6%. There were two missed fracture cases when the NEXUS criteria and the CCR were applied independently, however, no cases were missed when both were applied. CONCLUSION: This study suggests the NEXUS and the CCR in combination can be used as a guide to CT evaluation for cervical spine injury in the ED.

Attitudes of Elderly Persons toward Advanced Directives after Providing Prognostic Information on Cardiopulmonary Resuscitation(CPR)

BACKGROUND: Patients who survive CPR are profoundly disabled and live with reduced quality of life. Therefore advanced directives are needed to ensure that life sustaining therapies are provided appropriately. This study compared the attitudes of elderly subjects toward advanced directives for CPR before and after receiving CPR education. METHODS: Between January and July 2007, 99 ambulatory persons aged older than 64 years were recruited from six community welfare facilities for the elderly. A questionnaire was distributed to obtain demographic data and their basic understanding and attitudes toward CPR. After providing information and showing a video clip on CPR, we compared whether having received this information influenced the thoughts of our subjects on CPR. RESULTS: None had had previous education on CPR, including prognostic information. Most overestimated the survival chance after CPR. Most wished to be resuscitated. After providing prognostic information on CPR and showing a short video clip, there was a change in their decision and the knowledge of CPR outcome seemed to influence their thoughts on CPR. In particular, the information on CPR prognosis greatly influenced their decision. CONCLUSION: Elderly people rarely have a chance to receive information regarding CPR. As a result, their decision to receive CPR may not accurately reflect the patient's wishes in emergency circumstances. It is important to pro- vide accurate prognostic information to help the elderly in their life-sustaining treatment decisions.