Preventable Trauma Death Rate after Establishing a National Trauma System in Korea

BACKGROUND: This study aimed to evaluate the current overall preventable trauma death rate (PTDR) in Korea and identify factors associated with preventable trauma death (PTD). METHODS: The target sample size for review was designed to be 1,131 deaths in 60 emergency medical institutions nationwide. The panels for the review comprised trauma specialists working at the regional trauma centers (RTCs); a total of 10 teams were formed. The PTDR and factors associated with PTD were analyzed statistically. RESULTS: Of the target cases, 943 were able to undergo panel review and be analyzed statistically. The PTDR was 30.5% (6.1% preventable and 24.4% possibly preventable). Those treated at a RTC showed a significantly lower PTDR than did those who were not (21.9% vs. 33.9%; P = 0.002). The PTDR was higher when patients were transferred from other hospitals than when they directly visited the last hospital (58.9% vs. 28.4%; P = 0.058; borderline significant). The PTDR increased gradually as the time from accident to death increased; a time of more than one day had a PTDR 14.99 times higher than when transferred within one hour (95% confidence interval, 4.68 to 47.98). CONCLUSION: Although the PTDR in Korea is still high compared to that in developed countries, it was lower when the time spent from the accident to the death was shorter and the final destined institution was the RTC. To reduce PTDR, it is necessary to make an effort to transfer trauma patients to RTCs directly within an appropriate time.

Analysis of Neck Trauma Patients Using the Korean National Emergency Department Information System

PURPOSE: Trauma is a leading cause of death, even in previously healthy and disease-free individuals, and the mortality rate is very high in neck trauma patients. On the other hand, there have been few studies related to neck injuries. This study examined the characteristics and treatment results of trauma-related neck injuries using the data from Korean National Emergency Department Information System. METHODS: Neck trauma patients were classified using the 6th Korean Standard Disease Classification system. The patients' demographic factors, number of surgeries, and clinical results were investigated. Statistical analysis was conducted using SPSS to evaluate the annual differences in the demographic factors; mortality according to the site of injury and type of surgery; and mechanisms of injury. RESULTS: From 2011 to 2014, 2,458 neck trauma patients were treated in hospitals in South Korea. The number of patients admitted to regional and local emergency medical centers was 883 (35.9%) and 1,502 (61.1%), respectively. No significant annual differences were observed in age, sex ratio, location of treatment center, mortality, and injury site (vascular, tracheal, or esophageal). In addition, no significant differences in the cause of injury, performed surgery (%), and mortality according to the injured organ were observed. CONCLUSION: This study revealed no annual changes in neck injury patients or differences in mortality according to injured organs. This study can be used as a basis for national research on organ-specific injuries, and may help predict the demand for future support projects for the establishment of regional trauma centers.

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.

Background and progress of regional trauma center development

In a modern medical delivery system, it is very difficult to provide adequate, timely, and equitable medical care for severely injured patients. Trauma is a leading cause of deaths under the age of 40 and a source of expensive socioeconomic losses in Korea. Korean government has been making a major effort to establish a trauma system since 2000, but inadequacies of the current trauma system still result in many preventable deaths from accidental injuries. The designation and support program for regional trauma centers is the first step in a national plan for trauma system development. At present, there are 9 regional trauma centers and 7 candidates for trauma centers. Regional trauma centers must play a key role in a regionally inclusive trauma system that integrates emergency medical services systems and healthcare delivery systems to deliver optimal medical care for injured patients.

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.

Epidemiology and Outcomes in Out-of-hospital Cardiac Arrest: A Report from the NEDIS-Based Cardiac Arrest Registry in Korea

Sudden cardiac death (SCD) is a significant issue affecting national health policies. The National Emergency Department Information System for Cardiac Arrest (NEDIS-CA) consortium managed a prospective registry of out-of-hospital cardiac arrest (OHCA) at the emergency department (ED) level. We analyzed the NEDIS-CA data from 29 participating hospitals from January 2008 to July 2009. The primary outcomes were incidence of OHCA and final survival outcomes at discharge. Factors influencing survival outcomes were assessed as secondary outcomes. The implementation of advanced emergency management (drugs, endotracheal intubation) and post-cardiac arrest care (therapeutic hypothermia, coronary intervention) was also investigated. A total of 4,156 resuscitation-attempted OHCAs were included, of which 401 (9.6%) patients survived to discharge and 79 (1.9%) were discharged with good neurologic outcomes. During the study period, there were 1,662,470 ED visits in participant hospitals; therefore, the estimated number of resuscitation-attempted CAs was 1 per 400 ED visits (0.25%). Factors improving survival outcomes included younger age, witnessed collapse, onset in a public place, a shockable rhythm in the pre-hospital setting, and applied advanced resuscitation care. We found that active advanced multidisciplinary resuscitation efforts influenced improvement in the survival rate. Resuscitation by public witnesses improved the short-term outcomes (return of spontaneous circulation, survival admission) but did not increase the survival to discharge rate. Strategies are required to reinforce the chain of survival and high-quality cardiopulmonary resuscitation in Korea.

Epidemiological and Survival Trends of Pediatric Cardiac Arrests in Emergency Departments in Korea: A Cross-sectional, Nationwide Report

Cardiac arrest (CA) in children is associated with high mortality rates. In Korea, cohort studies regarding the outcomes of pediatric CAs are lacking, especially in emergency departments (EDs) or in-hospital settings. This study was conducted to examine the trends in epidemiology and survival outcomes in children with resuscitation-attempted CAs using data from a cross-sectional, national, ED-based clinical registry. We extracted cases in which cardiopulmonary resuscitation and/or manual defibrillation were performed according to treatment codes using the National Emergency Department Information System (NEDIS) from 2008 to 2012. The total number of ED visits registered in the NEDIS during the 5-yr evaluation period was 20,424,530; among these, there were 2,970 resuscitation-attempted CAs in children. The annual rates of pediatric CAs per 1,000 ED visits showed an upward trend from 2.81 in 2009 to 3.62 in 2012 (P for trend = 0.045). The median number of estimated pediatric CAs at each ED was 7.8 (25th to 75th percentile, 4 to 13) per year. The overall rates for admission survival and discharge survival were 35.2% and 12.8%, respectively. The survival outcome of adults increased substantially over the past 5 yr (11.8% in 2008, 11.7% in 2010, and 13.6% in 2012; P for trend = 0.001); however, the results for children did not improve (13.6% in 2008, 11.4% in 2010, and 13.7% in 2012; P for trend = 0.870). Conclusively, we found that the overall incidence of pediatric CAs in EDs increased substantially over the past 5 yr, but without significantly higher survival outcomes.

Changes in Preventable Death Rates and Traumatic Care Systems in Korea

PURPOSE: This study was performed in order to determine the changes over time in preventable and potentially preventable traumatic death rates, and to assess the factors that affected the deaths of trauma patients which occurred in Korean pre-hospital and hospital settings. METHODS: All trauma deaths occurring either in the emergency department (ED) or after admission at twenty Korean hospitals between August 2009 and July 2010 were retrospectively analyzed. The deaths were initially reviewed by a team of multidisciplinary specialists and classified into non-preventable, potentially preventable, and preventable deaths. Only preventable and potentially preventable deaths were the subject of our analysis. Structured data extraction included patient demographics, vital signs, injury severity, probability of survival, preventability of mortality, reported errors in the evaluation and management of the patient, and classification of error types (system, judgment, knowledge). RESULTS: During the study period, 446 trauma victims died in the ED or within 7 days after admission. The mean age was 52 years, 74.1% were men and the mean time from injury to death was 35.6 hours. The most common cause of death was head injury (44.7%) followed by hemorrhage (30.8%) and multi-organ failure (8.0%). The rates of preventable/potentially preventable deaths were 35.2% overall and 29.8% when limited to patients surviving to admission. Of all death classifications, 31.2% were potentially preventable and 4.0% were preventable. Errors leading to preventable death occurred in the emergency department (51.2%), pre-hospital setting (30.3%) and during inter-hospital transfer (60.8%). Most errors were related to clinical management (48.4%) and structural problems in the emergency medical system (36.5%). CONCLUSION: The preventable death rates for Korean trauma victims were higher than those found in other developed countries, possibly due to poorly established emergency medical systems for trauma victims in pre-hospital and hospital settings. A system wide approach based on the emergency medical system and well-developed in-hospital trauma teams should be adopted in order to improve the quality of care of trauma victims in Korea.

Experience after the Opening of the Gwangju Wide Regional Emergency Medical Center

PURPOSE: As Gwangju Wide Regional Emergency Medical Center was newly opened during February 2001, a comparative analysis was performed of patients who had visited the emergency department before and after the opening in order to measure the difference and to provide basic data for its management. METHODS: The 9,995 patients who had visited between February 1, 1999, and July 31, 1999, before the opening and the 12,457 patients who visited between February 1, 2001, and July 31, 2001, after its opening were compared according to sex, age, non-trauma or trauma, means and form of visit, attending department, length of stay in the emergency department, form of discharge, and time of death verification (dead-on-arrival (D.O.A) versus deadafter-arrival (D.A.A)). RESULTS: The total number of patients increased by 24%. The admission rate was 31.8% before the opening and 40.6% after the opening; the mean length of stay in the emergency department was 15.7 hours before the opening and 12.2 hours after the opening. The mean length of stay of admitted patients decreased from 26.6 hours before the opening to 18.3 hours after the opening. CONCLUSION: The decrease in the mean length of stay in the emergency department from 15.7 hours before the opening to 12.2 hours after the opening is viewed as a positive result, but is still not satisfactory. Accordingly, it is considered urgent that every clinical department take an active part in improving circulation of patients both in the Emergency Intensive Care Unit (EICU) on the second floor and in the emergency ward on the fifth floor, as well as in providing rapid medical care and decisions on treatment strategies in the emergency department on the first floor.

Analysis of cardiovascular change of an Aconitum-containing Chinese Remedy

PURPOSE: The roots of Aconitum plants (e.g.,A carmichaelii, A napellus) have been believed to possess antiinflammatory, analgesic, and cardiotonic effects and have been used in traditional Chinese medicine mainly for the treatment of musculoskeletal disorders. Because of low safety margin, it is not uncommon to visit emergency departments to have variable amounts of highly toxic diterpene alkaloids (e.g., aconitine) contained in their systems. Typical manifestations of aconitine posioning are neurological, cardiovascular, and gastrointestinal problems. The known cardiovascular manifestations are several types of arrhythmia and hypotension. The author experienced a cases of transient ventricular ischemic change in an EKG and elevation in cardiac enzymes. This study aimed to evaluate cardiac ischemia associated with aconitine poisonining. METHODS: The author analyzed 13 patients with aconitine poisoning, who visited the Emergency Department of Chonnam National University Hospital from 1995 to 2001. Variables included in data analysis were age, sex, clinical features, cardiac enzyme levels, and EKG changes. RESULTS: Aconitine had been taken for a variety of medical problems, including arthralgia, neuralgia, and some gastrointestinal complaints. All patients suffered from neurological (tingling of the mouth and skin, followed by numbness and weakness in the extremities), cardiovascular (palpitation, dizzness), and gastrointestinal (nausea, vomiting) manifestations. Most patients had a variety of cardiac rhythm disturbances. Two patients exhibited transient cardiac ischemia, including cardiac enzyme elevation and ischemic changes on their an EKGs. CONCLUSION: Two patients (15.4%) among 13 patients showed transient cardiac ischemia, including cardiac enzyme elevation and ischemic changes on their EKGs. It is important to observe the possibility of myocardial toxicity of aconitum and to evaluate the mechanism of cardiac toxicity through clinical and experimental study

Clinical Significance of Immediate Determination of Plasma Cholinesterase Level in Patients Presenting with Organophosphate Ingestion at the Time of Hospitalization

PURPOSE: Plasma cholinesterase is a sensitive measure determining the severity of organophosphate intoxication. The author evaluated the usefulness of the plasma cholinesterase level as a prognostic indicator of the severity of organophosphate intoxication. METHODS: From June 1999 to May 2001, 55 patients presented with organophosphate insecticide intoxication to the Emergency Medical Center of the Chonnam National University Hospital, and these were enrolled in this study. The plasma cholinesterase activities of these 55 patients were determined at the time of presentation. The relationships between the plasma cholinesterase level and the clinical variables of organophosphate toxicity, quantity of ingested poison, elapsed time to gastric lavage, and the APACHE score at the time of hospitalization were analyzed. RESULTS: The plasma cholinesterase activity significantly decreased in association with the degree of toxicity of the poison (p<0.001), elapsed time to gastric lavage (p<0.001), and the quantity of organophosphate ingested (p=0.013). In the 55 patients, lower plasma values of cholinesterase were observed in patients with longer durations of mechanical ventilation (r=-0.717, p<0.001) and in patients who developed pneumonia during treatment (r=-0.538, p<0.001). Also, decreased cholinesterase activity correlated with a higher APACHE score (r=-0.672, p<0.001). CONCLUSION: These results suggest that immediate determination of the plasma cholinesterase level at the time of hospitalization may be useful as a prognostic indicator in patients with organophosphate intoxication.

Initial Laboratory Parameters Affecting Survival Rate in Patients Poisoned with Paraquat

PURPOSE: Paraquat (1,1-dimethyl-4,4'-bipyridylium chloride) is widely a used non- selective herbicide. In spite of efforts to improve the outcome in patients poisoned with paraquat, the mortality rates still remains high. The purpose of this study is to identify initial stat laboratory parameters which can affect the survival rate of these patients. METHODS: A retrospective analysis by chart review was done on 67 patients who had ingested paraquat and who had presented to the Emergency Medical Center of Chonnam University Hospital from June 1997 to July 2001. RESULTS: The results were as follows: 1) Survivors were significantly younger than the nonsurvivors (38 years vs 44 years, p=0.03). The volume of paraquat ingested by survivors was significantly smaller than that ingested by the deceased (1 mouthful vs 3 mouthfuls, p<0.001). 2) The WBC count and the levels of serum AST, BUN and serum creatinine in the deceased were significantly higher than those in the survivors. The levels of serum potassium and bicarbonate, arterial pH, and base excess in survivors were significantly higher than those in the deceased. 3) A multivariate analysis revealed that serum creatinine, serum potassium, and arterial base excess were associated with the fatality rate. CONCLUSION: Initial stat laboratory parameters including arterial blood gas analysis, renal function test, and serum electrolytes could be used to predict the outcome of patients poisoned with paraquat. However, the development of readily applicable and reliable indices predicting outcome is desired for the future.

Two cases of Anticholinergic Toxicity After Jimson weed Ingestion

Jimson weed, also known as Datura stramonium, is a member of the Solanaceae family. Jimson weed was used by American Indians for medicinal and religious purposes. All parts of the Jimson weed plant are poisons, containing the alkaloids atropine, hyoscyamine and scopolamine. So, it is caused by these components to make a anticholinergic toxicity within 6h after ingestion. Initial manifestations include dry mucus membrane, blurred, vision, thirst, difficulty swallowing and speaking, and photophobia, and may be followed by hyperthermia, confusion, agitation, combative behavior, hallucination, urinary retention, seizure and coma. We experienced two patients who developed combative behavior and agitation with pupil dilation caused by Jimson weed. They discharged with improvement after supportive for 2days.

A CLINICAL STUDY OF FOREIGN BODY INGESTION

We analyzed records at Chonnam university hospital from Sep. 1. 1993 to Aug. 31. 1996 to assess clinical significance of the foreign body in the gastrointestinal tract. There were 133 episodes consisting of 79 pediatric and 54 adult patients as possible to review. In the pediatric patients, the coin was the most common cause of foreign body ingestion, while adult patients were usually caused by bones and meat. We removed foreign bodies in the oral cavity and oropharynx in 12 cases using direct laryngophanmgoscpy and forcep. Endoscopy was performed successfully in 47 of 51 patients in which was attempted; there were two complications composed of an aspiration pneumonia and a mediastinitis due to esophageal perforation. There were spontaneous passage of foreign bodies in 48 cases. We observed complications in 6 cases in which 4 cases needed operations due to complications. Foreign bodies which pass into the stomach can be observed for development of complications, as 94% of foreign bodies which reach the stomach spontaneously pass. Only 4 patients required interventions, which was done without mortality.

Clinical Analysis of Nontraumatic Prehospital Cardiac Arrest for Two Years

BACKGROUND: Care for prehospital cardiac arrest is one of the major concerns of emergency medical services. But, in Korea, prehospital emergency medical service systems are not yet well established. We tried to offer one of the fundamental data for development of these systems. METHODS: After application of exclusion criteria, 183 patients who transferred to emergency center of our hospital after cardiac arrest in consecutive 24 months from Jan,1,1994 to Dec,31,1995 were included in this study. Retrospective review of the hospital charts of these patients was done. For statistical analysis, we divided patients to some categories. t-test or chi-square analysis was used. RESULTS: 24 patients of the 183 patients were secondary visitors(cardiac arrest was occurred during transfer from other hospitals), 159 patients were primary visitors. In the primary visitor group, only one third was ambulance visitors, and there is no statistical differences between arrest time of ambulance visitors and non-ambulance visitors(35+/-27 vs 37+/-24 min, p=NS). No organized bystander CPR was done. After arrival, 131 patients received CPR and 87 patients(66.4%) were not responded, 31 patients(23.1%) experienced transient ROSC, 13 patients(10.0%) survived until discharge, and only 2 patients(1.5%) were returned to their lives. CONCLUSION: We failed to find significant statistical survival differences between ambulance visitors and non-ambulance visitors, between presumed cardiac etiology group and non-cardiac etiology group. Survival rate was high in witnessed arrest group than unwitnessed arrest group(14.5% vs 2.1%, p=0.015).

Emergency Center Ultrasonography in the Evaluation of Hemoperitoneum and solid Organ Injury

The reliability of emergency ultrasonographic(US) detection of hemoperitoneum and solid organ injury in blunt abdominal trauma was evaluated retrospectively. From October 1,1995 to August 31,1996,90 patients were included in the study. Ultra- sonographic findings showed a sensitivity, specificity, and accuracy of 97.6%, 97.9%, and 98.1%, respectively, in detecting intraabdominal fluid collection. We believe that US in an emergency center is a quick, safe screening method in the evaluation of blunt abdominal trauma. In our department, US has replaced diagnostic peritonaeal lavage(DPL) and computed tomography(CT) as the screening study of first choice.