Clinical Significance of Hyperlactatemia and Acidosis in Patients with Suspected Generalized Convulsion

PURPOSE: To determine the clinical usefulness of lactic acidosis in an evaluation of patients with suspected generalized convulsion. METHODS: This was retrospective cohort study. The correlation between the lactate level and the time to blood gas analysis (ABGA) was analyzed in patients who had a final diagnosis of seizure to exclude the time effect on the spontaneous clearance of lactate. The patient's data in the true seizure group and false seizure group was then compared. The receiver operating characteristics (ROC) curve of lactate, pH and base deficit for diagnosing true seizure was drawn. The sensitivity and specificity of the presence of hyperlactatemia or acidosis for a diagnosis of seizure and predicting epileptiform discharge at electroencephalography (EEG) was analyzed. RESULTS: Of the 173 patients suspected of having generalized convulsion, 136 patients were diagnosed with a true seizure on hospital discharge and patients whose ABGA was performed within 60 minutes after seizure showed a significantly higher arterial lactate level, lower arterial pH and base deficit than the patients whose ABGA was performed after 60 minutes of seizure onset. 62 patients whose ABGA was performed 60 minutes after symptom onset were excluded. Finally, of 111 patients, 89 patients with true seizure showed a significantly higher arterial lactate level, lower arterial pH and base deficit than the 22 patients with false seizure. The ROC curve of lactate, pH and base deficit showed a significant area under the curve for diagnosing true seizure. The presence of hyperlactatemia or acidosis showed high sensitivity for diagnosing true seizure and expecting epileptiform EEG when they were measured with 60 minutes after symptom onset. CONCLUSION: In patients with suspected generalized convulsion, upon presentation to the ED within 60 min of symptom onset, the presence of hyperlactatemia or acidosis increased the likelihood of a true seizure and might be an objective indicator for further evaluations of seizure. On the other hand, normal lactate levels and no acidosis could not exclude a true seizure.

Availability of Toxicologic Screening Tests in the Emergency Department

PURPOSE: The role of a point of care test (POCT) is currently becoming important when treating patients and making decisions in the emergency department. It also plays a role for managing patients presenting with drug intoxication. But the availability of the test has not yet been studied in Korea. Therefore, we investigated the utility and the availability of POCT for drug screening used in the emergency department. METHODS: This was a retrospective study for those patients with drug intoxication between January 2007 and December 2010 in an urban emergency department. RESULTS: Between the study period, 543 patients were examined with a Triage(R)-TOX Drug Screen. Among those, 248 (45.7%) patients showed negative results and 295 (54.3%) patients showed positive results. The sensitivity of the test for benzodiazepine, acetaminophen and tricyclic antidepressants were 85.9%, 100%, 79.2%, respectively. CONCLUSION: POCT of drug screening in emergency department showed good accuracy especially in patient with benzodiazepine, acetaminophen and tricyclic antidepressant intoxication. Therefore, it can be useful diagnostic tool for the management of intoxicated patients.

Acute Coagulopathy in Non-Traumatic Bleeding

PURPOSE: To find the incidence of acute coagulopathy following non-traumatic bleeding and to evaluate the factors related to the development of coagulopathy. METHODS: Non-traumatic bleeding patients that visited the emergency department of a university teaching hospital from March 2007 to March 2010 were enrolled retrospectively. Patients >18-years-of-age with altered mental status and unstable vital signs, who required resuscitations, transfusion and emergency surgery were included. Patients with liver cirrhosis, chronic renal failure and warfarin medication were excluded. The presence of coagulopathy was defined as prothrombin time (PT) > 18 sec or PT (%) 60 sec. We analyzed the relationship between coagulopathy and age, presence of circulatory shock (systolic blood pressure < 90 mmHg), hypothermia (body temperature (BT) < 36degrees C), acidity of arterial blood (arterial pH < 7.35), tissue hypoperfusion (base deficit < or = -6 mmol/L), thrombocytopenia (< 100000/uL) and sequential organ failure assessment (SOFA) score. Multiple logistic regression analysis was used to find factors that predicted the development of acute coagulopathy. RESULTS: Non-traumatic bleeding patients (n=149) were analyzed. Sixteen patients (10.7%) showed acute coagulopathy. Ten patients (6.7%) expired during hospitalization. There were no significant differences in mortality, age, sex and full term for glasgow coma scale (GCS) according to presence of early coagulopathy. The presence of shock, metabolic acidosis, thrombocytopenia and high SOFA score were risk factors for the development of acute coagulopathy following non-traumatic bleeding. The group that had early coagulopathy received more much fluid and transfusions compared to the group that did not have coagulopathy (p<0.05). CONCLUSION: Acute coagulopathy causes organ dysfunction due to tissue hypoperfusion. Presently, patients who had acute coagulopathy following non-traumatic bleeding required large amounts of fluid and transfusion during acute resuscitation comparison with non-coagulopathy patients. Further study is needed to find whether the correction of coagulopathy improves the outcome of non-traumatic bleeding patients.

Acute Coagulopathy in Non-Traumatic Bleeding

PURPOSE: To find the incidence of acute coagulopathy following non-traumatic bleeding and to evaluate the factors related to the development of coagulopathy. METHODS: Non-traumatic bleeding patients that visited the emergency department of a university teaching hospital from March 2007 to March 2010 were enrolled retrospectively. Patients >18-years-of-age with altered mental status and unstable vital signs, who required resuscitations, transfusion and emergency surgery were included. Patients with liver cirrhosis, chronic renal failure and warfarin medication were excluded. The presence of coagulopathy was defined as prothrombin time (PT) > 18 sec or PT (%) 60 sec. We analyzed the relationship between coagulopathy and age, presence of circulatory shock (systolic blood pressure < 90 mmHg), hypothermia (body temperature (BT) < 36degrees C), acidity of arterial blood (arterial pH < 7.35), tissue hypoperfusion (base deficit < or = -6 mmol/L), thrombocytopenia (< 100000/uL) and sequential organ failure assessment (SOFA) score. Multiple logistic regression analysis was used to find factors that predicted the development of acute coagulopathy. RESULTS: Non-traumatic bleeding patients (n=149) were analyzed. Sixteen patients (10.7%) showed acute coagulopathy. Ten patients (6.7%) expired during hospitalization. There were no significant differences in mortality, age, sex and full term for glasgow coma scale (GCS) according to presence of early coagulopathy. The presence of shock, metabolic acidosis, thrombocytopenia and high SOFA score were risk factors for the development of acute coagulopathy following non-traumatic bleeding. The group that had early coagulopathy received more much fluid and transfusions compared to the group that did not have coagulopathy (p<0.05). CONCLUSION: Acute coagulopathy causes organ dysfunction due to tissue hypoperfusion. Presently, patients who had acute coagulopathy following non-traumatic bleeding required large amounts of fluid and transfusion during acute resuscitation comparison with non-coagulopathy patients. Further study is needed to find whether the correction of coagulopathy improves the outcome of non-traumatic bleeding patients.

Immunomodulatory Effects of Hypertonic Saline: The Effects on Nuclear Translocation of NF-kappaB and TNF-alpha Synthesis in Stimulated PMNs

PURPOSE: According to current research, hypertonic saline has immunomodulatory effects. NF-kappaB is known as an important transcription factor involved in the production of inflammatory mediators during an inflammatory response. The purpose of this study was to determine the effect of hypertonic saline on both the NF-kappaB signaling pathway and on TNF-alphasynthesis in stimulated PMNs. METHODS: Isolated PMNs from healthy volunteers were subdivided into 3 groups by the incubation conditions: control (not stilmulated, isotonic condition), isotonic (stimulated, isotonic condition), hypertonic (stimulated, hypertonic condition). After nuclear proteins were isolated from the incubated PMNs, NF-kappaB was measured by Western blot. TNF-alpha was measured by ELISA from the culture media. RESULTS: The relative densities of nuclear NF-kappaB after 45 minute incubation were 0.28+/-0.14 (control group), 0.97+/- 0.16 (isotonic group), and 0.58+/-0.07(hypertonic group). Isotonic and hypertonic groups (fMLP stimulated groups) showed a significantly higher relative density than control groups. Among the study groups, the hypertonic groups had a smaller increased level compared to isotonic groups and were found to be statistically significant. The results from the 90 minute incubated groups were similar to that of the 45 minute incubated groups. The concentration of TNF- alphameasured from stimulated groups (isotonic group, hypertonic group) were significantly higher than control groups. Similar to the NF-kappaB result, the concentrations of TNF-alphain the hypertonic groups were significantly lower than isotonic groups. Longer incubation times were noted to display higher concentration in the stimulated groups. CONCLUSION: Stimulated PMNs incubated under hypertonic conditions showed a smaller increase in level of nuclear NF-kappaB and TNF-alphasynthesis compared to isotonic conditions. As a result, suppression of the NF-kappaB signaling pathway in stimulated PMNs is considered one of the mechanisms of hypertonic saline's immunomodulatory effect.

Non-invasive Monitoring of Oxygen and Carbon Dioxide Tension: Accuracy of Transcutaneous O2 and CO2 and Endtidal CO2

PURPOSE: To determine the concordance of transcutaneous CO2 (PtcCO2) versus arterial CO2 (PaCO2), end-tidal CO2 (PetCO2) versus PaCO2, and transcutaneous O2 (PtcO2) versus arterial O2 (PaCO2) among healthy adult volunteers, and to determine the normal values of the PtcCO2/PtcO2 and PtcO2/PaO2 that will be used as early signs of shock or as prognostic factors for critically ill patients. METHODS: We measured the PtcO2, PtcCO2, PetCO2, PaO2, and PaCO2 from 11 healthy volunteers while breathing room air or O2 at a flow rate of 6 L/min via nasal cannula. The PtcO2 and PtcCO2 were measured using a Radiometer's transcutaneous sensor that interfaced with the Solar 8000 patient monitor system. The PetCO2 was measured using a side stream capnometer that sampled air from a nasal catheter. The PaO2 and PaCO2 were measured from arterial blood samples. The concordances of the PtcCO2 versus the PaCO2, the PtcO2 versus the PaO2, and the PetCO2 versus the PaCO2 were analyzed using a Bland-Altman plot. We defined the normal values of the P(a-tc)CO2, PtcO2/PaO2, and PtcCO2/PtcO2. RESULTS: Twenty-two pairs of the PtcCO2 versus PaCO2, PtcO2 versus PaO2, and PetCO2 versus PaCO2 were obtained. The mean (+/-SD) values of the P(a-tc)CO2, P(atc) O2, and P(a-et)CO2 were 0(+/-2.2) mmHg, 35.4(+/-24.1) mmHg, and 1.4(+/-1.3) mmHg, respectively (p=0.947, p<0.001, and p<0.001 by paired t-test, respectively). The P(a-tc)CO2 and P(a-et)CO2 showed a high concordance of 95.5% within a range of +/-4 mmHg. The median (25~75%) values of the PtcCO2/PtcO2 and PtcO2/PaO2 at room air were 54.8%(46.8%~62.7%), respectively. CONCLUSION: The PtcCO2 and PetCO2 had a reliable concordance with the PaCO2. However, the PtcO2 was discordant with the PaO2 and this discordance was increased when inspiring O2. Therefore, the absolute values of the PtcO2 cannot be used as a surrogate measurement of the PaO2. However, because the O2 supply did not increase the PtcCO2, but rather the PtcO2, we can use the trend in the change in the PtcCO2/PtcO2 or PtcO2/PaO2 in shock patients.

The Relationship of Shockable ECG Rhythm During Cardiopulmonary Resuscitation to Outcomes in Cardiac Arrest Patients

PURPOSE: The purpose of this study was to investigate the relationship of ECG change during CPR to outcomes in cardiac arrest patients. METHODS: A total of 170 patients who received cardiopulmonary resuscitation (CPR) in the emergency department from January 2005 to December 2006 were included for analysis. Medical records of study patients were reviewed, retrospectively. Age, sex, cause of arrest, location of arrest, arrest time, CPR time, initial ECG rhythme, changes in ECG during CPR, ROSC, 24 h survival, and number discharged alive were extracted from the medical records. Outcomes studied were ROSC rate and , survival rate at 24 h and at discharge. Student's t-test, the Chi-square test and one-way ANOVA were used for statistical analysis. RESULTS: The patients were divided into three groups according to the initial EKG rhythm. The groups showed no difference in ROSC rate, but the initial VF/VT group and the initial PEA group showed higher survival discharge rates than the initial asystole group (p=0.002). Patients whose rhythm changed from asystole to VF/VT showed significantly higher ROSC and 24 h survival rates but showed no difference in the survival to discharge rate. Patients whose rhythm changed from initial PEA to VF/VT showed no significance difference in ROSC rate, 24 h survival rate, or survival discharge rate. CONCLUSIONS: Although patients whose rhythm changed from initial asystole or PEA to shockable rhythm (VF/VT) showed no significant difference in survival discharge rate compared to those without change to shockable rhythm, in the long run, they may benefit from essential therapies to increase survival because of their higher ROSC rate and 24 h survival rate.

Prognostic Factors of Geriatric Trauma Patients

BACKGROUND: It has been documented that certain prognostic factors may affect the outcomes of the old aged victims by trauma. Considering that trauma is the sixth most common cause of death in people over the age of 65 years and there is a rapid growth of elderly population, it is paramount to understand the prognostic factors when dealing with geriatric trauma patients. Hypothesis and Goals : It can be hypothesized that the prognostic factors should be determined independently between populations being consisted of different races, countries, socio-economic states, cultures, or so on. Thus, study was designed to evaluate the factors affecting the outcomes of elderly Korean trauma patients. METHODS: One hundred forty six patients aged over 65 years were retrospectively reviewed, who visited the Emergency Canter of Korea University from January, 1997 to June, 1998. Of 146 patients, 7 were excluded due to discharge against advice or transfer to the other hospitals. Parameters analysed were age, sex, mechanism of injuries, body region injured, Injury Severity Score (ISS), previous medical illness, hospital morbidity, duration of hospital stay, and cost. Each patient was classified into improved or not-improved groups depending on the outcomes, and young-old or old-old group depending on the age. The factors affecting the hospital stay in improved patients were analyzed in the parameters of previous medical illness, hospital morbidity, multiple injuries, ISS, and age. All statistical tests were conducted with two-tailed levels of 0.05. RESULTS: Of 139 patients, the mean age was 74+/-7.1 years, mean ISS 9.3+/-7.26, mean hospital stay 27+/-27.1 days. Most commonly injured body region was the extremities due to fall from a level surface. Rate of previous illness showed 0.94 medical diseases per person and were aggravated after trauma in 39 patients (60.9%). Hospital morbidity rate was 0.46 incidents per person. There were no differences in age and duration of hospital stay between the improved and the not-improved group. Substantial differences were noted in affected body region, incidence of previous illness, and hospital morbidity between the groups (p=NS). Not-improved group had higher ISS (p<0.05). ISS, previous illness and hospital morbidity affected the duration of hospital stay in the improved group. Hospital stay was 40+/-25.1 days in patients with ISS over 6 while 6+/-8.6 days in those with ISS 5 (p<0.05). Hospital stay in the improved was 26+/-26.9 days while 31+/- 24.8 days in the improved old-old group (P=NS). Hospital stay in the young-old minor trauma (ISS5) patients with previous illness and hospital morbidity was 26+/-10.1 days while 4+/-7.3 days in those without previous illness and hospital morbidity (p<0.05). CONCLUSION: Previous medical illness and hospital morbidity, not age, are predictive of outcomes of geriatric trauma patients with respect to hospital stay. As most of the hospital morbidity was a trauma-induced aggravation of previous medical illness and hospital morbidity contributing poor outcomes can be potentially avoidable, routine aggressive care far the geriatric trauma patients with previous medical illnesses is needed.