The usefulness of the objective structured clinical examination conducted to student during clinical clerkship of emergency medicine

Objective@#The purpose of this study was to determine whether the simplified assessment of Objective Structured Clinical Examination (OSCE), which is conducted during the clinical clerkship of emergency medicine, is related to the graduation ranking and other grades at medical school, and also to successfully passing the Korean Medical Licensing Examination (KMLE). Through this, we wanted to find out whether it can be used as a basic resource to provide effective student management and additional learning opportunities to enable them to pass the KMLE. @*Methods@#The study included graduates who took the KMLE for the last three years. These students were classified into three groups based on their OSCE simplified assessment score (OSCE-4). The results of each group were compared with the results of the emergency medicine grades, Clinical Performance Examination (CPX) scores, OSCE scores, written test scores, and their success in passing the KMLE using analysis of variance and the chi-square test. The relationship between OSCE-4 scores and graduation ranking and CPX, OSCE ranking was determined using Spearman’s ranking correlation analysis. @*Results@#Among the 358 students in the three groups, the upper group included 119 students (33.2%), the middle group had 148 (41.4%), and the lower group had 91 (25.4%). The correlation between the three groups’ CPX scores, OSCE scores, written test scores, and graduation ranking showed statistical relevance. There was no statistical relevance to their success in passing the KMLE, but there was a correlation between trends in OCSE scores and passing the clinical skills assessment of KMLE. @*Conclusion@#OSCE-4 showed a correlation with important scores, and it can be used as an indicator for the management of students preparing for the national examinations.

The usefulness of the objective structured clinical examination conducted to student during clinical clerkship of emergency medicine

Objective@#The purpose of this study was to determine whether the simplified assessment of Objective Structured Clinical Examination (OSCE), which is conducted during the clinical clerkship of emergency medicine, is related to the graduation ranking and other grades at medical school, and also to successfully passing the Korean Medical Licensing Examination (KMLE). Through this, we wanted to find out whether it can be used as a basic resource to provide effective student management and additional learning opportunities to enable them to pass the KMLE. @*Methods@#The study included graduates who took the KMLE for the last three years. These students were classified into three groups based on their OSCE simplified assessment score (OSCE-4). The results of each group were compared with the results of the emergency medicine grades, Clinical Performance Examination (CPX) scores, OSCE scores, written test scores, and their success in passing the KMLE using analysis of variance and the chi-square test. The relationship between OSCE-4 scores and graduation ranking and CPX, OSCE ranking was determined using Spearman’s ranking correlation analysis. @*Results@#Among the 358 students in the three groups, the upper group included 119 students (33.2%), the middle group had 148 (41.4%), and the lower group had 91 (25.4%). The correlation between the three groups’ CPX scores, OSCE scores, written test scores, and graduation ranking showed statistical relevance. There was no statistical relevance to their success in passing the KMLE, but there was a correlation between trends in OCSE scores and passing the clinical skills assessment of KMLE. @*Conclusion@#OSCE-4 showed a correlation with important scores, and it can be used as an indicator for the management of students preparing for the national examinations.

Comparison of Clinical Characteristics and Severity of Glyphosate and Glufosinate Herbicide Poisoning Patients

PURPOSE: The number of glyphosate and glufosinate intoxication cases are increasing in Korea. This study was undertaken is to compare the clinical manifestations of poisoning by these two herbicides and to document severities and clinical outcomes. METHODS: We retrospectively evaluated cases of glyphosate or glufosinate intoxication among patients that visited our emergency department between January 1, 2013, and December 31, 2017. Incidences of intoxications were analyzed over this five year period, and underlying diseases, transportation, mental state, shock occurrence, inotropics, gastric lavage, charcoal administration, intubation and ventilator therapy, and hemodialysis were investigated. In addition, we included transfer to the intensive care unit, incidences of pneumonia and of other complications, death, and hopeless discharge. RESULTS: There were 119 cases of glyphosate intoxication and 42 of glufosinate intoxication. Levels of consciousness were lower for glufosinate and vasopressor usage was higher due to a high shock rate (p=0.019). In addition, many patients were referred to the ICU for intubation and ventilation. The incidences of pneumonia and of other complications were significantly higher for glufosinate. CONCLUSION: Overall glufosinate intoxication was found to be more severe than glyphosate intoxication as determined by complication and ICU admission rates.

The Utility of Measuring the Difference between the Two Optic Nerve Sheath Diameters Using Ultrasonography in Predicting Operation Indication in Patients with Traumatic Brain Hemorrhage

PURPOSE: An increase in optic nerve sheath diameter (ONSD) has been associated with elevated intracranial pressure due to brain lesions, such as hemorrhage, infarction, and tumor. The aim of this study was to evaluate whether the difference of both ONSDs can predict surgical treatment in patients with traumatic brain hemorrhage. METHODS: A prospective analysis of the data acquired between September 2016 and November 2016 was performed. We included 155 patients with traumatic brain hemorrhage undergoing computed tomography in the emergency room. We performed an ultrasonography to measure ONSDs for all included patients. The primary outcome of this study was operation indication in patients with traumatic brain hemorrhage. RESULTS: The average age was 63.4±17.0 years (male 60.3±17.3, female 69.8±14.4). There were 61 (39.35%) patients with an indication for operation and 94 (60.65%) patients with an indication for no operation. Indications for operation showed a strong association with the difference of both ONSDs in patients with subdural hemorrhage (p<0.001), no association between them in patients with epidural and intracerebral hemorrhage. In patients with subdural hemorrhage, the area under the curve was 0.988 (0.653-0.998), and the cut-off value for the difference of ONSDs with respect to determining the indications for operation was 0.295 mm f maximizing the sum of the sensitivity (96.9%) and specificity (90.7%) using the receiver operating curve. CONCLUSION: A difference of both ONSDs above 0.295 mm was useful in predicting the indications for operation in patients with traumatic subdural hemorrhage, but not in patients with epidural and intracerebral hemorrhage.

A Patient with "Rebound Methemoglobinemia" during Treatment of Methemoglobinemia Caused by Propanil Intoxication

Methemoglobinemia results from the oxidation of ferrous iron (Fe++) to ferric iron (Fe+++) within hemoglobin. It is caused by various etiologies, including the herbicide Propanil. Patients with low levels of methemoglobin (metHb) are asymptomatic but symptomatic patients and patients with high levels of metHb require treatment. Methylene blue is the first choice for the treatment of methemoblobinemia, but has some complications such as hemolytic anemia and rebound methemoglobinemia. We report the case of a 91-year-old woman who died of aniline herbicides poisoning. The level of metHb in her blood was initially 20.7% and her mental status was drowsy. She was intravenously treated with methylene blue within a therapeutic range for methemoglobinemia. After treatment with methylene blue, the level of metHb decreased but later increased above 20%. Methylene blue treatment was repeatedly attempted, but the patient suffered from hemolytic anemia and rebound methemoglobinemia. The patient finally died from renal failure and cardiopulmonary collapse. We must be careful because methemoglobinemia can occur even when treated pesticides such as propranil.

A Case of Small Bowel Obstruction and Perforation by Anisakiasis

Anisakiasis is a disease that often occurs after the ingestion of raw marine fish infected with nematodes of the Anisakis genus. Ingested Anisakis causes a variety of symptoms, including abdominal pain, nausea, and vomiting, when they invade the gastric wall. Although invasion of the gastric wall is common, rare cases of Anisakis invading the small bowel have been reported. These rare cases have resulted in small bowel obstruction and perforation and usually require surgical treatment. A 57-year-old man visited the emergency room suffering from abdominal pain and distension. He ate raw marine fish three days prior and suffered from epigastrium pain a day after this meal. X-ray and computed tomography showed small bowel obstruction without adhesion and required an operation for treatment. A laparotomy revealed dilated and congested jejunum and ileum with perforated distal ileum. We found a small thin long worm, confirmed by histopathology as a member of Anisakis. The patient was discharged after surgery without any complication.

Methemglobinemia from Antifreeze Containing Sodium Nitrite

Sodium nitrite is commercially used as a coloring agent, food preservative, and corrosion inhibitor. Accidental poisoning with sodium nitrite from contaminated food and water causes gastrointestinal irritation, vasodilatation, and methemoglobinemia with subsequent tissue hypoxia. We describe an outbreak case of sodium nitrite-induced methemoglobinemia following the ingestion of noodles contaminated with industrial antifreeze. The eEight patients involved initially complained that their noodles tasted 'unpleasant' and soon afterwards experienced nausea, vomiting, dizziness, and fatigue. Some of them noted cyanosis on their lips and fingers. Subsequent investigations demonstrated a high methemoglobin concentration which was corrected by the intravenous administration of methylene blue three hours after the onset of symptoms. The patients made a prompt, uncomplicated recovery and were discharged home 4 four days later. Industrial antifreeze contains sodium nitrite and calcium nitrite. Because an accidental poisoning of industrial antifreeze causes fatal methemoglobinemia, emergency physicians should promptly identify its symptoms and institute treatment with methylene blue promptly. In addition, industrial agencies must caution construction businesses against such contamination events.

Validation of the Pentax-AWS Airwayscope as a Prehospital Intubation Device by Korean Level 1 Emergency Medical Technicians; A Simulation Study Using an Airway Training Manikin

PURPOSE: Tracheal intubation in the pre-hospital setting may be lifesaving in severely ill and injured patients. The aim of the current study was to evaluate whether use of the video laryngoscope, when used by Korean level 1 emergency medical technicians, resulted in faster or more secure facilitation of tracheal intubation, compared with the conventional laryngoscope with the immobilized cervical spine lying on the ground. METHODS: Thirty two level 1 EMTs working as 119 rescuers performed tracheal intubation on a manikin using the Macintosh laryngoscope (McL) and the Pentax-AWS(R) airwayscope (AWS) "on-the-bed" and "on-the-ground" in simulations with or without cervical spine immobilization. We compared intubation time, dental injury, and visual analog scale for both types of laryngoscope. RESULTS: In the McL trial, four participants failed on the bed, and 11 failed on the ground with cervical immobilization. In the AWS trial, all participants successfully secured the airway regardless of cervical spine immobilization both on the bed and on the ground. With the AWS, intubation time was not lengthened due to cervical spine immobilization either on the bed or on the ground. The AWS score was better than the McL on the visual analog scale in ease of handling the laryngoscope both on the bed and on the ground. And use of the AWS resulted in the lowest number of dental compressions. CONCLUSION: We conclude that the AWS is an effective and safe device for use in pre-hospital intubation with cervical spine immobilization, not only on the bed but also on the ground, when used by Korean level 1 EMTs. However, conduct of further studies is required in order to validate the clinical relevance of these findings.

Clinical Experiences Treating Edifenphos and Iprobenfos Intoxication Patients

Organophosphate fungicides include edifenphos, iprobenfos and tolclofos-methyl. Edifenphos inhibits cell wall synthesis by reduction in chitin synthase activity and inhibits the action of acetylcholinesterase. Thus, exposure to this chemical results in excessive salivation, lacrimation, urination, defecation, gastrointestinal motility and emesis symptoms, just like other organophosphate insecticides. Although edifenphos is an organophosphate fungicide, it is the only agricultural chemical which inhibits the action of pralidoxime and atropine, an activity which in turn, inhibits treatment. Thus, we have to treat these cases as soon as possible with atropine and pralidoxime, using the same approach as used for exposure to other organophosphate insecticides. In this report we evaluate the results of treatment of 4 patients who were intoxicated by fungicides (3 cases with edifenphos and 1 case with iprobenfos).

Characteristics of Patients Who Visit the Emergency Department with Self-Inflicted Injury

During visits to emergency medical facilities, the primary care of and risk identification for individuals who have attempted suicide is considered an important element in suicide prevention. With the ultimate goal of helping to prevent suicide, the aim of the present study was to determine the characteristics of patients with self-inflicted injuries who presented in the emergency department. Patients with self-inflicted injuries who visited 1 of 3 sentinel emergency medical centers from 2007 through 2009 were included in the study. The characteristics, methods, and reasons for suicide attempts were evaluated. Moreover, predictors of severe outcomes were evaluated. A total of 2,996 patients with self-inflicted injuries visited the three centers during a period of 3 yr. The male-to-female suicide ratio was 1:1.38 (P or = 50 age group. The reasons for attempting suicide varied among the age groups. The predictors of severe outcome are male gender, older age, and not having consumed alcohol.

Two Cases of Post Traumatic Cerebral Infarction in Head Injury

We present cases of post traumatic infarction after head injury. Two patients were admitted to our emergency room after traffic accidents. They developed neurological deficiency after a few hours to days after the accidents. In both cases, an initial computed tomography scan of the head was normal. A follow-up computed tomography obtained later revealed a hypodense lesion at cerebral hemisphere and a diffusion-weighted magnetic resonance imaging disclosed an area of infarction. The patients were conservatively medicated. One patient died due to a medical complication and the other patient fully recovered in several weeks. Hospital admission, careful observation and early diffusion-weighted magnetic resonance examination should be considered for patients with persistent neurological deficits.

Comparison of Severity in Organophosphate Insecticide Poisoning Patients Treated with Tracheostomy

PURPOSE: This study investigated the effect on survival rate for organophosphate intoxication patients who received tracheostomy. This research was conducted to help identify appropriate treatment of patients who received a trachostomy. METHODS: This research was retrospectively conducted using the medical records of 141 patients who arrived at the Chosun University Hospital emergency medical center between Jan 2007 and Dec 2010, suffering from organophosphate intoxication. They were placed in two groups including one which received trachostomy as part of their treatment and one that did not. The effect of each variable on mortality was evaluated by regressionanalysis. RESULTS: Of 141 patients with organophosphate intoxication, 105 of them did not tracheostomy and 16 were dead cohorts (15.2%). Their size of pupil was 1mm. Factors such as amount of organophosphate ingested, PAM time after ingestion, average body temperature, arrival time, atropinization time after ingestion, AST/ALT, Bun/Cr all appeared to be significant factors in death cohorts (P<0.05). 36 patients among the total had tracheostomy and 11 ones of them were in dead cohort (30.6%) and their average age was 58 years. The facts affect the state of patients in dead cohort include the amount of intoxication which between 327.27+/-194.1 ml, performing intubation 686 mins after intubation, reaching to the hospital after 580mins, injecting PAM 744 mins after intoxication, injecting atropine 627 mins after intoxication. The largest cases of patient's state was found to be stupor with 14 patients (38.9%) the level of Cholinesterase in blood appeared to be significant in dead cohort as 391.00+/-353.9 IU/L (P<0.05). CONCLUSION: Further planned studies are necessary on the use of tracheostomy for treatment of poisoning victims, especially those intoxicated by organophosphorus insecticides.

Analysis of the Factors that Influence the Severity of Injury of Pedestrian Traffic Accident Patients in an Emergency Department

PURPOSE: Pedestrian traffic accident (TA) deaths account for 40% of Korea's annual TA fatalities. With that in mind, we reviewed the cases of traumatic pedestrian TA patients admitted to emergency medical centers in Korea. We analysed factors affecting the severity of injury in order to investigate risk factors for subsequent traumatic threats. METHODS: Prospective methods were applied using a prepared trauma recording format. Trauma records included patient factors (age, gender, occupation, underlying disease), accident factors (time of accident, weather conditions, transportation time, vehicle type causing the accident, influence of alcoholic on both drivers and victims, accident location), and other factors (means of initial hospital admittance transportation). We reviewed medical records to obtain data for vital signs, Glasgow coma scale (GCS), abbreviated injury scale (AIS), injury severity score (ISS), and trauma and injury severity score (TRISS). We divided subjects into 3 groups according to their ISS scores: mild (1-8 points), moderate (9-15 points), severe (>==16 points). These groups were compared with each other regarding degree of severity? RESULTS: We analyzed data for 23,392 traumatized patients that presented at an EMC. Of the 23,392, 252 (3.1%) were pedestrian TA patients. Among this pedestrian cohort, males 156 patients (male 61.9% and female 38.1%; p=0.332). Mean age was 43.1 (+/-19.9). Severity was greater in those over 40 years of age compared those under 40 (p=0.000). Farmer's had the greatest severity than patients in other occupations (p=0.004). Those with an underlying disease showed a higher degree of severity (p=0.028). The most common accident site was city roads (85.7%) but the degree of severity at such sites did not was not significantly greater (p=0.052). Sports utility vehicle (SUV) had the highest rate of accident severity (p=0.004). Cases involving drunken drivers had victims with higher severity (p=0.005). CONCLUSION: Factors that increase the rate of fatalities pedestrian TAs are: older age, underlying illness, working in the agricultural sector, driving an SUV, the patient being in a drunken state.

A Study on the Effect of the Depressive Disorder in Suicidal Attempt Aspect

PURPOSE: The number of suicide attempts has increased in Korea. Depressive disorders are a major cause. This study investigated the clinical characteristics and outcomes of attempted suicide victims who had been admitted to the emergency department based on a psychiatric disorder. METHODS: We performed a retrospective analysis of 168 suicide attempters who visited the Chosun University hospital emergency medical center between June 1st, 2007 and May 31st, 2008. From chart reviews, we divided the victims into three groups by psychiatric histories, especially depressive disorder. We analyzed the effect of various factors including age, sex, previous suicide attempts outcome of suicide attempts. We used Pearson's chi-square test to chart the statistical data. RESULTS: Depressive patients had significantly more suicide attempts than other psychiatric patients and more than those who had no psychiatric history. Repeated attempts were also more frequent in depressive patients (64%). Sixty percent of depressive patients were admitted into our hospital or local clinic and eight percent of depressive suicide attempters died. Compared to other national statistics, there were fewer persons who consulted with a psychiatrist, but depressive patients had more interviews with psychiatrists (62.9%) than did the other groups. CONCLUSION: Even if the depressive disorder patient group shows a high recurrence rate, it also shows a high psychiatric interview acceptance rate and a relatively low rank on physical and psychiatric severity. Therefore, it is possible to prevent the recurrence of suicide attempts for the depressive group and to reduce the fatality rate. This can be done through on-going educational opportunities and psychiatric interviews. The rate of psychiatric consultations in Korea are significantly lower than in other countries. This situation requires more active psychiatric consultations and interviews later on.

A Study on Organophosphate Poisoning Patients: Comparison of the Survivor Group and Dead Group

PURPOSE: Organophosphate insecticide poisoning is common in Korea, but there is no definitive guideline for determining the severity of the poisoning and the predictive factors. Therefore, we evaluated the organophosphate poisoned patients and we divided them into two groups, the survivors and the dead, and the results might be useful for treating organophosphate poisoning patients. METHODS: We performed a retrospective analysis of 68 organophosphate poisoned patients who visited the Chosun University Hospital Emergency Medical Center during a 24-month period from January, 2007 to December, 2008. We made a work sheet of the patients' characteristics and the collected data was analyzed and we compared this data between the survivor group and the dead patient group. RESULTS: There were significant differences between the survivor group and the dead patient group for the mean age, the alcohol intake state and the typically expressed signs. The dead patients had lower blood pressure, tachycardia and a lower Glasgo Coma Score (GCS) score than the survivor group. On the arterial blood gas analysis, the dead patients had more severe acidemia and they had lower saturations. Increased serum amylase levels were found in the dead patients. The survivors' initial and follow up serum pseudocholinesterase activity (after 6~8 days) was significantly higher than that of the dead group. The total amount of atropine injected to patient was less in the survivors than that in the dead patients. CONCLUSION: Old age and expressing the typical intoxication signs, a lower GCS score and blood pressure, showing acidosis on the gas analysis and low serum cholinesterase activity may be useful as poor prognostic indicators for patients with organophosphate poisoning. We suggest that physicians must pay careful attention to the signs and prognostic factors of organophosphate insecticide poisoned patients.

Analysis of the Risk Factors Influencing the Severity of Injury in Pediatric Multiple Trauma Patients

PURPOSE: The purpose of this study is, first, to analyze the risk factors that influence the severity of injury in pediatric multiple trauma patients and, second, to present solutions for the problems related to the treatment of such patients. Our living situations are so complicated that the danger of accidents is truly open to children who are not prepared. We need to draw attention to the increased numbers of various accidents involving children. METHODS: We studied patients who visited the Emergency Medical Center at Chosun University Hospital from January 1, 2006, to December 31, 2008. Using medical records, we evaluated the general characteristics: the mechanism of injury, the vital signs, the revised trauma score (RTS), the injury severity score (ISS), and the hemoglibin value, which was checked at the time of visit, and the presence or the absence of emergent on regular surgery. We divided the level of injury as follows: light level (1-8 points), mid level (9-15 points), and serious level (above 16 points). We analyzed the medical data by using SPSS 17.0 for windows. RESULTS: The average age of the patients examined was 8.6 years. The number of 6- to 11-year-old patients was 96, which was the largest, but the degree of injury severity was the highest among infant (0-2 years), according to ISS 7.95(+/-6.85). The frequency of accidents was highest on sunny days, and most accidents occurred from 16:00 to 20:00. The cause of multiple trauma for children was the greatest in the traffic accident, (95 patients, 49.0%). In addition, the trauma caused by traffic accidents showed the highest ISS value (9.02+/-6.42) and the most serious degree (P=0.004). The ISS level of injury (8.40+/-6.64) for patients moved from a secondary hospital was higher than that (6.49+/-5.57) for patients who visited the medical center directly. The severity of injury was highest for patients who used a 119 ambulance (8.84+/-5.80). According to the injured parts of body, Injuries to the arms and the feet most frequent (79 patients, 40.7%), but the level of injury was the highest for internal organs and chest, 16.42+/-8.56 and 11.23+/-6.97, respectively. CONCLUSION: We used Abbreviated Injury Scale (AIS) in order to examine the characteristics by injured body part for pediatric multiple trauma patients. Because the degree of injury was the highest for internal organs or the chest, we need to more seriously examine and provide for patients who are suspected of having injuries to the internal organs or the chest. We need to quickly determine the need for surgery in patients with serious injuries to the arms and the feet, which is the greatest in frequency. In particular, we need to consider the surgical care of patients who are not very high in the severity of injury to their brains.

Is it Necessary to Study both Creatine Kinase MB and Troponin for an Acute Diagnosis of Myocardial Infarction?

PURPOSE: Cardiac enzymes such as creatine kinase MB (CK-MB) and troponin-T, are useful tools for diagnosing acute myocardial infarction (AMI). However, the cost of assessing cardiac enzymes is not inexpensive. So, this study was performed to learn the necessity of both cardiac enzyme tests to confirm AMI. METHODS:One hundred thirty three patients with AMI visited our emergency center from July 2006 to June 2008. We excluded 39 patients who arrived at the emergency center 24 hours or more after chest pain had begun. We did a retrospective study. We checked cardiac enzymes at about 3, 6, 12 and 24 h after chest pain began. Then, we compared CK-MB and troponin-T values to determine their elevation time after chest pain. RESULTS: The elevation time of CK-MB and troponin-T after chest pain was not related to age, sex, high risk factors such as hypertension and diabetes, or ST segment elevation. We found that CK-MB and troponin-T at about 6 h after chest pain were significantly higher than at 3 h (p<0.05 for both). However, the numerical value for CK-MB became elevated above the normal range faster than the value for troponin-T (67.2% vs. 59.7%, respectively at about 6 h after chest pain onset). CONCLUSION: Although, troponin has been known as a more specific marker than CK-MB, CK-MB increased faster than troponin-T after chest pain began. To diagnose AMI as soon as possible, the measurement of CK-MB appears to be more useful than troponin-T. Serial checks of CK-MB is important.

The Contents of Emergency Treatment Practice Conducted by Emergency Medical Technician and Related Factors / 農村醫學 地域保健

OBJECTIVES: A study was conducted by analysing the contents and frequency of emergency treatment practiced by emergency medical technicians(EMTs) in emergency situations and contains related factors. METHODS: The study subjects included 80 EMTs who participated in ongoing education classes during the period from June 25th to June 26th, 2008. the survey included 53 EMTs employed within 119 first aid teams in fire stations in both a metropolitan city and a medium-sized city. From the survey results relation between frequency of emergency treatment and subjects characteristics explored statistically including t-test, X2 test, Pearson correlation and finally stepwise multiple regression. RESULTS: The most frequent procedure by EMTs checking vital signs. The statistically significant related factors overall of the 23 items of emergency treatment frequency was the working area and the grading of EMT certification. In contrast, significant related factors with frequency of IV linkage were found to be the subjects gender, institution employed and the importance of recognizing the item. The statistically significant related factors of that of ECG monitoring was the gender of respondents. CONCLUSIONS: To keep the appropriate frequency of emergency treatment by EMT, active efforts to promote their individual importance and confidence cognition are necessary, especially towards males and persons who have 2nd class certification. Moreover, EMTs who work in small cities must be supported.

Factors Associated with the Severity of Injuries in Old Driver Trauma Patients

PURPOSE: As medicine has progressed, the human average lifetime has increased. Thus the number of geriatric patients has increased and, in particular, the number of older drivers has increased. Mortality rates for older trauma patients are higher than those for any other age group, but little research has been done about the severity of injuries to older patients involved in vehicle accidents. This study evaluated a number of factors and correlations involving old driver trauma patients. METHODS: We prospectively analyzed clinical information on 155 trauma patients over 65 years of age who were involved in vehicle accidents and visited the emergency department of Chosun University Hospital between Jan 2007 and Aug 2008. The following variables were examined for their ability to predict severity of injury: age, gender, vital signs, and mechanism of injury along with the Glasgow Coma Scale (GCS), the Abbreviated Injury Scale (AIS), and the Injury Severity Score(ISS). We divided the ISS scores into three groups: mild (1~8), moderate (9~15), and severe(above 16). RESULTS: Most cases involved men (94.2%), and a majority involved agriculture (65.8%). The most common vehicle was the motorcycle (48.4%), and 51 (32.9%) patients were drunk at the time of the accident. Many had acquired their driver's licenses more than 30 years earlier (40.7%), and almost all of the patients (81.9%) never wore any safety devices. The patients who had multiple underlying diseases, coupled living type, low blood pressure at admittance, and more time since they had acquired their licenses scored higher on mean ISS than the other cases. CONCLUSION: Old trauma patients had more longer admission days, had longer recovery times, and received more expensive treatment. For the same level of trauma, they took longer to heal than younger patients and experienced higher rates of mortality. Therefore, when the old driver trauma patients visit the emergency department, doctors need to perform more careful studies and provide a higher level of critical care. To lessen the number of old driver trauma patients, we should educate older drivers about safe driving methods and about the use of safety device, and we should enforce traffic laws and laws about drinking and driving.

A Case of Toxic Epidermal Necrolysis (TEN) Induced by Nonsteroidal Anti-Inflammatory Drug (NSAID)

A patient who was transferred to our Emergency Medical Center from a local clinic with a dermatologic disorder of unknown origin presented to us with TEN with a 40% skin slough. The patient was a 53-year-old women with complaints of erythematous rash and blisters on her trunk and both proximal extremities. She had taken NSAIDS, 1300 mg per oral, every 8 h for 5 days. Five days after administration of NSAIDS began, the doctors at the local clinic noted that a rash with blisters had begun on her back and progressed to her extremities. After 4 days of that progression she came to us. On physical examination, she had asymptomatic multiple clear filled bullae and erosion with brown- to black-colored hyperpigmentation on her trunk and proximal extremities involving 40% of the body surface. She was admitted to a private room to prevent secondary infections, and her management included fluid replacement, third-generation cephalosporin and corticosteroid administration, and intensive wound care. Fifteen days after admission, no further treatment was required, and only a small scar and a mild dispigmentation lesion could be seen. Emergency department physicians should think about TEN if the patient has extensive exfolating skin lesions. Treatment of patients with suspected TEN must be directed at minimizing fluid and electrolyte loss and preventing secondary infection, and an effort should be made to identify the suspicious drug and to educate patient to avoid the drug.