Low-dose Intravenous N-acetylcysteine for the Prevention of Contrast-Induced Nephropathy in Emergency Patients Undergoing Computed Tomography

PURPOSE: To evaluate the effects of low-dose intravenous N-acetylcysteine on the prevention of contrast-induced nephropathy (CIN) in patients undergoing computed tomography (CT). METHODS: All patients presenting to our emergency department and undergoing CT with intravenous contrast media between August 2014 and April 2016 were retrospectively enrolled. We included hospitalized patients with renal dysfunction [estimated glomerular filtration rate (GFR) between 30 and 89 mL/min/1.73 m²]. A 600-mg injection of Nacetylcysteine was given to patients once before and once immediately after CT, depending on the preference of physician. The primary outcome was CIN defined as an increase in creatinine level of ≥25% or ≥0.5 mg/dL from the baseline within 48 to 72 hours after CT. A trained person blindly reviewed all medical records. RESULTS: Of the 1903 admitted patients, CIN occurred in 9.8% of patients who received 1200 mg intravenous N-acetylcysteine (24/244) and 6.8% of patients who did not (113/1659, p=0.090). In a multivariable regression analysis, N-acetylcystine was not relevant to the prevention of CIN (odds ratio=1.42 [95% CI, 0.90–2.26]). Even in the stratified analysis using the propensity score matching, N-acetylcysteine was irrelevant (GFR 30–59: odds ratio=1.06 [95% CI, 0.43–2.60]; GFR 60–89: odds ratio=1.76 [95% CI, 0.75–4.14]). After adjustment, crystalloids were significantly associated with the reduction in CIN compared with dextrose water (odds ratio=0.60 [95% CI, 0.37–0.97]). CONCLUSION: No effect was found when low-dose intravenous N-acetylcysteine was used to prevent CIN. However, there seems to be an association between crystalloids and reduction in CIN.

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

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

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

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

The Effects of Mild Hypothermia on the Expression of the Apoptosis-related Proteins following Transient Global Ischemia in Gerbil Hippocampus / 대한구급학회지

BACKGROUND: The neuroprotective mechanisms of hypothermia remain unclear. Recently, attenuation of apoptosis by hypothermia has been suggested as one of the responsible mechanisms. The aim of this study is to investigate the effects of post-ischemic hypothermia on apoptotic neuronal death as well as expression of some apoptosis-related proteins in a gerbil transient global ischemia model. METHODS: Following 5 minutes of ischemia, normothermia (NT, 37+/-0.5degrees C) or mild hypothermia (HT, 33+/-0.5degrees C) was immediately induced and maintained for 3 hours. The hippocampal CA1 neurons were examined on day 2, 3, 4, and 7 after ischemia for the survived neuronal densities, DNA nick end labeling and immunohistochemical expressions of Bcl-2, Bax, and caspase 3 in each group. Additionally, DNA gel electrophoresis and western blot analysis for each protein in hippocampus were performed. RESULTS: The neuronal death in CA1 area on day 3, 4, and 7 was significantly reduced in HT group compared to NT group. The number of TUNEL positive cells in HT group was also significantly reduced than NT group on day 3, 4, and 7. DNA laddering of hippocampus on day 4 and 7 also reduced in HT group. Expressions of Bax on days 2, 3 and activated caspase 3 on days 3, 4 were reduced in HT group. Western blots also disclosed a decrease in the intensity of the Bax on day 2 and 3 in HT group compared to NT group. CONCLUSIONS: These results suggest that mild post-ischemic hypothermia attenuates the apoptotic neuronal death through the inhibition of the intrinsic pathway of caspase activation following transient global ischemia and these effects may be related to a reduction of pro-apoptotic events.

Clinical Course of Hypoxic-ischemic Coma after Cardiopulmonary Resuscitation in Korea

PURPOSE: This study analyzed the survival and the recovery of consciousness in hypoxic-ischemic coma at different time points till 30 days after cardiopulmonary resuscitation (CPR). METHODS: A survival analysis was done using Kaplan-Meier estimates, and 30-day outcomes were calculated for all unconscious patients at 24 h, 72 h, 5 days, 7 days, and 14 days after CPR. The patient's characteristics and outcomes were compared with those for published patient series. RESULTS: After 30 days, 32.4% of 74 patients were alive and conscious, 16.2% were still unconscious, and 51.4% had died. The proportions of patients who regained conscious were 32.4% of those unconscious within 6 h post CPR, 34.7% of those still unconscious after 72 h, and 21.1% of those still unconscious after 2 weeks. The proportion surviving increased from 16.2% of patients who were unconscious initially to 63.1% of those still unconscious after 2 weeks. CONCLUSION: The outcomes of hypoxic-ischemic coma vary with the duration of unconsciousness after CPR.

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

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

Incidence and Significance of Negative Hematuria in Patients with Urolithiasis Visiting the Emergency Room with Flank Pain

PURPOSE: This research was conducted to determine the incidence of negative hematuria in patients with urolithiasis in Korea and the significance during evaluation of a patient' s complaining of flank pain. METHODS: We evaluated 363 consecutive patients who were suspected of having urolithiasis and who underwent intravenous urography (IVU). All patients underwent urinalysis and a urine dipstick test (UDT). We evaluated the sensitivity, the specificity, the positive predictive value and the negative predictive value of UDT, urinalysis and a combination of these two tests, and we compared the rates of incidence of negative hematuria. In addition, we estimated the relation between the RBC count and the severity of the ureteral obstruction. RESULTS: The IVU was positive in 206 of the 363 patients. The incidence of negative hematuria for urinalysis, UDT, and the combination were 9.2%, 8.7% and 6.3%, respectively. Thirteen patients (3.6%) had another disease. There was no correlation between the degree of ureteral obstruction and the incidence of negative hematuria (p= 0.713). Also, no correlation was established between the degree of ureteral obstruction and RBC count (p=0.742). CONCLUSIONS: In patients with urolithiasis, the incidences of negative hematuria for urinalysis, UDT and a combination of the two tests were 9.2%, 8.7% and 6.3%, respectively. The presence or absence of hematuria in patients with acute renal colic should not determine whether a more definitive study is performed.

Flumazenil Use in the Emergency Department: Benefit or Risk

PURPOSE: Flumazenil is frequently administered to poisoned and benzodiazepine-induced sedated patients. However, seizure, resedation, dysrhythmia, and death may occur in patients who awaken following flumazenil administration. Thus, this study investigated the benefit and the risk of the clinical use of flumazenil in emergency situations because the taking of an accurate history was often impossible METHODS: We included 177 patients given flumazenil in the emergency department. They were divided into four groups: Group I (n=51) was poisoned patients who were treated with flumazenil as an antidote, Group II (n=14) was patients in comas of unknown origin who were treated with flumazenil as a universal antidote, Group III (n=69) was patients who were treated with flumazenil for reversal from conscious, procedural sedation, and Group IV (n=43) was patients who were treated with flumazenil for recovery from unexpected oversedation. The benefits of flumazenil were analyzed based on a decreased need for procedures such as endotracheal intubation and mechanical ventilation. Then, the risks were evaluated based on the incidence of serious complications during flumazenil administration. RESULTS: In group I, removals of ventilators and endotracheal intubation were possible in 7/12 and 6/13 cases. However, more serious complications occurred in group I than in the other groups. In group II, a no-awakening response to flumazenil occurred in 71.4% of the patients. Group III had the lowest risk ratio among the groups. In group IV, removals of ventilator and endotracheal intubation were possible in 18/26 and 10/27 cases. However, in 16/43 (37.2%) cases, risk factors for seizures existed; thus, the use of flumazenil was considered inappropriate. CONCLUSION: Flumazenil may be safer and more effective for reversal action; but its clinical utility as an antidote in the emergency department is questionable.

Prediction of Poor Outcome in Comatose Survivors after Cardiopulmonary Resuscitation with Somatosensory Evoked Potentials and Proton Magnetic Resonance Spectroscopy

PURPOSE: The study was conducted to examine the usefulness of somatosensory evoked potentials (SEP) and proton magnetic resonance spectroscopy (1H-MRS) in predicting poor outcomes for comatose survivors after cardiopulmonary resuscitation. METHODS: We investigated 36 patients who were comatose after cardiac arrest. Among them, 35 had short latency SEP, and 27 had 1H-MRS. Both tests were performed in 26 patients. To estimate the cerebral outcome, we used the cerebral performance category (CPC) to classify the outcomes for our patients as good (CPC 1-2) or poor (CPC 3-5). RESULTS: Of the 36 patients, 11(31%) presented with good outcomes (CPC 1-2). A bilaterally absent N20 peak (n=35) predicted poor outcomes with a sensitivity of 54.2% and a specificity of 100%. A lactate-positive resonance (n=27) predicted poor outcomes with a sensitivity of 78.9% and a specificity of 100%. Using a combination of a bilaterally absent N20 peak and a lactate-positive resonance (n=26) predicted poor outcomes with a sensitivity of 94.4% and a specificity of 100%. CONCLUSION: The combination of a bilaterally absent N20 peak and a lactate-positive resonance is better than either alone in predicting poor outcomes in patients who are comatose after cardiac arrest.

Disaster Planning in the Emergency Department by Using an Analysis of Injuries Related to Assembly and Demonstration

PURPOSE: This study is to enable emergency centers to adequately cope with a vast number of demonstration-related injured patients by using an interventional study. With this analysis, emergency centers can hopefully prepare with adequate manpower, equipment and resources. METHODS: We reviewed the medical records of 117 patients with injuries related assembly and demonstration who visited the Emergency Medical Center of St. Mary's Hospital from Aug 13, 1999, to Jan 31, 2004 (pre-intervention state). These patients were analyzed according to sex, age, the severity of injury, the presence of a laceration, the injury mechanism, the final diagnosis, and the areas of the injury. Using these data, we established a disaster plan, then, we applied that plan to 59 patients who visited the Emergency Medical Center during Feb 2004 (post-interventional preliminary study). RESULTS: The common areas of the injury were the face (35.1%), the head (33.1%), and the extremities (25.4%) during the pre-intervention state. The number of patients with lacerations was 61 (52.1%). According to this, we established our own external hospital disaster plan. During the preliminary post-interventional study, the plan reduced the length of hospital stay, the delayed time to radiology, and the not-sutured rate (p<0.05). CONCLUSION: When patients injured during violent demonstrations are expected, local emergency care hospitals need to prepare manpower, resources, and supplies for facial and head lacerations and apply their disaster plan.

The Report for Emergency Resident's Training Status and Improvement

Emergency Medicine is a medical specialty that provides comprehensive emergency care. The spectrum of emergency medicine includes humanity as well as medical care for emergency patients. Since the Korean Society of Emergency Medicine has been established and the training course for emergency residents has begun, quality improvement of the training course still remains to be one of the most important issues in emergency medicine. This report is to understand the current status of training of emergency residents and to improve the quality of training of emergency residents. The survey was performed with questionnaires regarding current status of training and opinions to improve quality of training. The questionnaires were sent to all emergency physicians and emergency residents registered to the Korean Society of Emergency Medicine via an electronic mail or a printed letter. The response rates were 49.6% for emergency physicians and 35.8% for emergency residents. On the basis of the result of this survey, we suggest five proposals for improving the quality of resident training course. These include complete adherence of each institution to training guidelines presented by the Korean Society of Emergency Medicine, development of the education program compatible to each institution, shortening of length of training duration from 4 years to 3 years, promotion of the training environment, and introduction of evaluation examination to the training course.

The Usefulness of Proton Magnetic Resonance Spectroscopy in Comatose Patients after Successful Cardiopulmonary Resuscitation

PURPOSE: The objective of this study was to investigate whether proton magnetic resonance spectroscopy (1H-MRS) is useful in the prediction of the neurological outcome for comatose patients after successful cardiopumonary resuscitation (CPR). METHODS: We prospectively studied 22 patients with a comatose mentality existing for longer than 1 day after cardiac arrest. 1H-MRS examinations were scheduled to be performed within 5 days after restoration of spontaneous circulation (ROSC). All 1H-MRS readings were performed by a neuro-radiologist blindly. The best cerebral performance category (CPC) during 6 months after ROSC was used as the final outcome and classified as good (CPC 1-2) or poor (CPC 3-5). RESULTS: Elevated cerebral lactate resonances were found in 14 patients. All of the 14 lactate-positive patients experienced a poor outcome. Five of the 8 lactate-negative patients recovered without neurologic defects, but three of them suffered from severe neurologic defects. The elevated cerebral lactate resonance distinguished between good out-comes (n=5) and poor outcomes (n=17) with three false negatives (sensitivity 82%) and no false positives (specificit y 100%). Demonstration of brain lactate in 1H-MRS (p < 0.05) proved to be significant in terms of a poor prognosis. CONCLUSION: 1H-MRS is of great benefit in the prognostic evaluation of comatose patients with anoxic-ischemic encephalopathy after successful CPR.

Delivery Temperature of Warmed Saline or Blood at Variable Flow Rates

PURPOSE: This study was undertaken to determine the effect of the infusion rate on the temperature of the infusate reaching the distal end of an infusion tubing with active fluid warming. METHODS: One-liter bags of normal saline were warmed to 6 0 degrees C using a microwave oven and were then run through standard infusion tubing at rates of 200, 400, 600, 800, and 1,000 mL/hr. The temperatures at the distal end of the infusion tubing were measured every one minute for the first 10 minutes and then every ten minutes for 1 hour. Subsequently, normal saline and packed red blood cells, which were warmed using a fluid warmer, were infused at rates of 200, 400, 600, 800, and 1,000 mL/hr. Temperatures were recorded when the readings had stabilized within a range of +/-0.1 degrees C. RESULTS: Normal saline warmed by a microwave oven could be delivered through standard infusion tubing at a temperature of more than 37 degrees C if the normal saline had been preheated to 60 degrees C and infused through long tubing (210 cm) at rates of 800 and 1,000 mL/hr. Also, normal saline and packed red blood cells, warmed to 41 degrees C with a fluid warmer, could be delivered at a temperature of or near 3 7 degrees C through relatively short tubing (110 cm) at a rate of 1,000 mL/hr. The fluid composition influenced the infusate temperature (p < 0.05). CONCLUSION: When patients with hypothermia or major trauma are treated by infusing warmed normal saline or packed red blood cells, we should consider appropriate flow rates for the fluid so as to maintain a therapeutic delivery temperature when using practical infusion tubing in the ED setting.

Magnetic Resonance Imaging As a Outcome Predictor in Comatose Survivors after Cardiac Arrest

PURPOSE: The prognosis of comatose survivors after cardiac arrest is predicted by various methods such as neuralagic examination, magnetic resonance spectroscopy (MRS), biochemical markers, and somatosensory-evoked potentials (SSEP). The objective of this study was to investigate differences in magnetic resonance imaging (MRI) findings between good (CPC 1-2) and poor (CPC 3-5) outcome for comatose survivors after cardiac arrest. METHODS: We retrospectively studied the cases of 19 comatose survivors after cardiac arrest who underwent MRI between March 1, 1997 and August 31, 1999. All MRI readings were performed by a neuro radiologist blindly and best CPC during 6 months after ROSC was used as final outcome. RESULTS: Sixteen of the 19 patients had abnormal findings on the T2-weighted images: hippocampal infarct in 13 (68%), basal ganglia/thalamic infarct in 9 (47%), cortical infarct in 7 (37%), cortical watershed infarct in 6 (32%), and cerebellar infarct in 5 (26%). Among 6 patients with good outcome (CPC 1-2), 4 patients (67%) had hippocampal infarct, 1 (17%) basal ganglia/thalamic infarct, 1 (17%) white matter infarct, and 1 (17%) cerebellar infarct. Among the 13 patients with poor outcomes (CPC 3-5), 9 patients (69%) had hippocampal infarct, 8 (62%) basal ganglia/thalamic infarct, 7 (54%) cortical infart, 6 (46%) cortical watershed infarct, and 4 (31%) cerebellar infarct. Cortical and cortical watershed infarcts were only detected in patients with poor outcomes (p<0.05). CONCLUSION: On the MRI findings, comatose survivors after cardiac arrest were susceptible to hippocampus, basal ganglia/thalamus, cortex, cortical watershed, and cerebellar infarts. Cortical and cortical watershed infarcts may be useful as a prognostic tool for comatose survivor after cardiac arrest.

Effect of Low Dose Radiation on Tran: sient Global Cerebral Ischemia in Gerbils

PURPOSE: To date, much research has been performed for amelioration of secondary brain damage after cerebral ischemia and reperfusion. We investigated the antioxidative and anti-inflammatory effects of post-ischemic low-dose total-body irradiation (TBI) on transient global cerebral ischemia. METHODS: The gerbils were divided into six groups (8 gerbils in each group): group I and II, sham operation; group III and IV, 10-minutes ischemia without TBI; group V and VI, 10-minutes ischemia with TBI at 10 minutes after reperfusion. The activity of superoxide dismutase (SOD) and the levels of myeloperoxidase (MPO) and malondialdehyde (MDA) in the brains of group I, III, and V at 4 hours after reperfusion were measured. In the brains of group II, IV, and V, the levels of MPO and MDA were measured and the hippocampal areas were stained with hemotoxylineosin (H-E) and TUNEL at 5 days after reperfusion. RESULTS: The activity of Cu/Zn SOD in group V was significantly increased compared to that in group III, but their activities were significantly lower than that of group I. The MPO and MDA levels in groups V and VI were significantly lower than those in group III and IV. The percent dead neurons found in the hippocampal CA1 region by using H-E staining was significantly lower in group VI than in group IV. The number of TUNEL positive cells in the hippocampal CA1 region was significantly lower in group VI and in group IV. CONCLUSION: Anti-oxidative and anti-inflamatory responses induced by post-ischemic low-dose TBI may reduce secondary neuronal damage following 10 minutes of transient global cerebral ischemia.

Effects of Continuous Descending Aortic Balloon Occlusion on Brain Ischemia during Cardiopulmonary Resuscitation in Rabbits

PURPOSE: A recent report introduce a new option for cardiopulmonary resuscitation by using of a continuous descending aortic balloon occlusion. The aim of the present study was to evaluate the effect of balloon occlusion of the descending aorta during cardiopulmonary resuscitation on brain ischemia. METHODS: Twelve rabbits were enrolled in this study. A 4 French Swan-Ganz catheter was advanced through the right femoral artery into the descending aorta. Ventricular fibrillation was induced with an AC current delivered through an electrode catheter advanced into the right ventricle. After 3 minutes of untreated ventricular fibrillation, the rabbits were randomized in two groups: (1) chest compression without balloon occlusion (control group) and (2) chest compression with balloon occlusion of the descending aorta (experimental group). The balloon was inflated for 3 minutes during resuscitation. Defibrillation was attempted at 3 minutes after start of chest compression. At 24 hours after return of spontaneous circulation, brain tissues were fixed in 4% paraformaldehyde and stained with hematoxylin eosin. Then, the ischemic cells in the hippocampal CA1 area were counted. RESULTS: There was significant difference in ischemic neuronal cells between the two groups (control group: 41.8 +/-10.9%, experimental group: 16.8+/-6.8%, p < 0.05). In the experimental group, carotid blood flow was better than it was in the control group during chest compression (control group: 2.4+/-1.0 mL/min, experimental group: 7.6+/-1.9 mL /min, p < 0.05). CONCLUSION: These results suggests that balloon occlusion of the descending aorta during resuscitation decreases brain ischemia in rabbits during cardiac arrest.

Mild resuscitative hypothermia in comatose patients of out-of-hospital cardiac arrest: A preliminary clinical feasibility trial

PURPOSE: No proven neuroprotective treatment exists for ischemic brain damage after cardiac arrest (CA). Although several animal studies have shown that mild to moderate hypothermia markedly mitigates ischemic brain damage after CA, the clinical safety and efficacy of mild hypothermia remain unproven. We conducted this preliminary study to evaluate the clinical feasibility and safety of mild resuscitative hypothermia (RH) for comatose patients of out-of-hospital CA. METHODS: We performed prospectively a preliminary, non-randomized, uncontrolled, clinical feasibility trial over four years in a university-based hospital. Consecutive patients admitted or transferred to the emergency medical center after out-of-hospital CA who met inclusion and exclusion criteria were enrolled. Hypothermia was induced as soon as possible after return of spontaneous circulation (ROSC) by using external surface cooling methods and cold saline gastric lavage at the target temperature (34 degrees C) and was maintained for 24 hours by using external surface cooling methods, which was followed by passive rewarming. RESULTS: Twelve patients were enrolled. Mean arrest time was 20+/-12 minutes (range 2 to 40); the mean advanced cardiac life support (ACLS) time was 12+/-8 minutes (range 4 to 27) and the mean time from start of ACLS to initiation of RH was 129 +/-113 minutes (range 40 to 420). Achieving the target temperature took 160+/-79 minutes (range 80 to 330) and the mean rewarming time was 605+/-190 minutes (range 360 to 960). One patient developed transient atrial fibrillation and premature ventricular complex during the induction period. Hypotension developed in six patients during hypothermia, pneumonia associated with induced hypothermia developed in four patients. Other complications, such as myoclonus (n=4), increased serum amylase (n=7), increased serum creatinine (n=2), and potassium abnormalities (n=2), also occurred. These complications occurred more frequently in patients with poor cardiac function after ROSC. No serious complications, such as ventricular fibrillation, bleeding, or sepsis, occurred. CONCLUSION: Mild RH after CA appears clinically feasible. However, induction with surface external cooling methods is slow, and maintenance of mild hypothermia was difficult. Future efforts to shorten the induction time and to develop more effective maintenance methods and more cautious applications to patients with poor cardiac function after ROSC are needed. Furthermore, well-designed, prospective, randomized, and controlled, multi-center efficacy trials are needed to evaluate the effect of mild RH.

A Case of Hypermobility Syndrome Accompanied by Spontaneous Dislocation of Both Shoulders

Hypermobility syndrome (HMS) was first described as a disease entity by Kirk et al. in 1967. It presents hypermobility of a joint without hereditary connective tissue disorders such as Marfan syndrome (MFS), EhlersDanlos syndrome (EDS), or osteogenesis imperfecta (OI). Arthralgia is a common symptom, and dislocation may occur with minimal trauma or even spontaneously. This symptom is often ignored or recognized as non-specific chronic pain because the diagnostic criteria for HMS varies among reserchers and because HSM has no typical radiologic and laboratory findings. We report a case of hypermobility syndrome, which was accompanied by spontaneous dislocation of both shoulders, along a review of appropriate literature on the subject.

Clinical Analysis of Submerged Patients Treated at an Emergency Medical Center near the Han River

BACKGROUND: There are approximately 2,400 drowning deaths reported every year in Korea, but there are few good reports about submerged patients visiting the emergency room, so this study was designed to investigate the clinical characteristics and outcomes of submerged patients treated at an emergency medical center near the Han river. METHODS: A retrospective review of 123 cases of submerged patients admitted to our emergency medical center over a 5 year period from 1996 to 2000 was conducted. RESULTS: Among the 123 submerged patients, there were 66 males and 57 females, and their mean age was 33.18. The common cause of submersions was a suicide attempt, followed by lack of attention, unknown etiology, and water sports such as swimming. Most of the patients were transported to ER by 119 ambulance. In-hospital CPR was performed on 27(22%) cases. At initial ECG rhythm of these cases, asystole was noted in 25 patients; VF and pulseless electrical activity, respectively, were noted in two others. Prehospital CPR had been performed on all in-hospital CPR cases except 2. Prolonged ROSC after succesful CPR was noted in 13 cases. The mean duration of CPR was 26 minutes. Five patients survived after CPR. Their neurologic outcomes were assessed on CPC(cerebral performance category). Three patients were categorized in CPC1, the other two patients were categorized in CPC3 and CPC4. CONCLUSION: Submerged patient's visits to emergency medical center near the Han river were most frequent in summer for suicide purposes. Drowned patients were more hypothermic than other cardiac arrest cases, and resulted in better outcome even with prolonged arrest time, if they were given appropriate prehospital CPR and aggressive in-hospital resuscitation.

Duration-Dependent Neuroprotective Effect of Post-Ischemic Mild Hypothermia in the Gerbil Global Ischemic-Reperfusion Model

BACKGROUND: The present study was performed in order to evaluate the duration-dependent neuroprotective effect of post-ischemic mild hypothermia against delayed neuronal damage following transient global ischemia and to estimate the optimal duration of brief post-ischemic mild hypothermia. METHODS: Post-ischemic mild hypothermia of different duration(1 hour, 3 hours, and 6 hours) was performed immediately after 10-minute global ischemia in gerbils, and the hippocampal CA1 cell loss after 3 days was evaluated. The duration-dependent neuroprotective effect of post-ischemic mild(33-34degrees C) hypothermia of each duration was compared to the normothermic control by using histopathological methods. RESULTS: 1, 3 and 6 hours of mild hypothermia immediately following reperfusion resulted in progressively increased protection from ischemic damage, 10.0+/-8.2%, 33.7+/-21.9%, and 75.9+/-13.4%, respectively. The 3-hour and the 6-hour post-ischemic mild hypothermia groups revealed significant decreases in hippocampal CA1 area cell loss compared to the normothermic control group(9.0+/-7.7%, p<0.05), and the 6-hour group had a greater preservation than the 3-hour group(p<0.05). CONCLUSION: The results suggest that post-ischemic mild hypothermia protects against delayed neuronal damage in the hippocampal CA1 area following 10-minute transient global ischemia: 3-hour post-ischemic mild hypothermia provides a potential reduction of neuronal damage, but a 6-hour treatment is more effective in preventing neuronal damage than a 3-hour one.