Should we consider cutis marmorata as mild or severe decompression sickness?

Objective@#The cutaneous manifestation of decompression sickness (DCS) known as cutis marmorata (CM) is generally mild, but it is often accompanied by severe DCS or may be a prognostic sign. We aimed to analyze the clinical course of patients with CM to improve our understanding of CM. @*Methods@#From January 2016 to December 2020, a retrospective cohort single-center study was conducted on patients with acute DCS who underwent emergency recompression therapy. We analyzed their data and the clinical outcomes after recompression therapy. In addition, we reviewed relevant literature. @*Results@#A total of 341 people were enrolled during the study period. Of them 94 (27.6%) patients presented with CM and the symptoms appeared at an average of about 60.5 minutes after surfacing. Among the CM patients, 76.6% had accompanying DCS type II, and in 23.4%, had accompanying DCS type I (P=0.011). With single recompression therapy, 88.3% of patients with CM immediately recovered. Among these 95.4% of patients with DCS type I and 86.1% with DCS type II recovered immediately. However, there were no statistical differences in the immediate treatment outcomes according to the delay time from the onset of symptoms to recompression therapy, accompanying symptomatic DCS classification, and recompression modalities. Ultimately, all the patients recovered from CM. @*Conclusion@#CM by itself can be considered a mild DCS in terms of treatment progress, but prompt treatment is required to prevent complications. In addition, greater focus is needed on other accompanying DCS symptoms in patients with CM, and the treatment method should be determined accordingly.

Comparison of early warning scores for predicting deterioration in patients with respiratory distress in alert mentality presenting to the emergency department

Objective@#Early identification of patients at risk for deterioration is crucial to reduce in-hospital mortality. Various early warning scores have been widely applied in the emergency department (ED) of hospitals. This study evaluates and compares the effectiveness of three early warning scores_Modified Early Warning Score, Rapid Acute Physiology Score (RAPS), Worthing Physiological Scoring System (WPS), and Rapid Emergency Medicine Score. These scores help predict the need for critical care and 24- and 72-hour mortalities among alert patients presenting to the ED with dyspnea. @*Methods@#This retrospective cohort study used data from electronic medical records of patients admitted between 2018 and 2020 and included all consecutive alert patients who presented with dyspnea in the ED. The primary outcome was to evaluate the performance of early warning scores regarding the need for critical care. The secondary outcomes were the prediction of 24- and 72-hour in-hospital mortalities. @*Results@#Among 4,322 patients evaluated, 255 received critical care, and 17 and 84 died within 24 and 72 hours, respectively. The WPS had the overall highest performance for predicting the need for critical care (area under the curve [AUC], 0.781; 95% confidence interval [CI], 0.751-0.810) and 24-hour (AUC, 0.816; 95% CI, 0.738-0.894) and 72-hour mortalities (AUC, 0.794; 95% CI, 0.750-0.838), but differed significantly only from the RAPS. @*Conclusion@#The WPS might better predict the need for critical care and short-term mortality in alert patients with dyspnea in the ED. However, owing to a lack of its superiority in statistics, further studies are warranted to conclude the optimal tools applicable for these patients.

Hyperbaric oxygen therapy for decompression sickness: five-year experience in a single center

Objective@#Hyperbaric oxygen therapy (HBOT) is the most crucial treatment for decompression sickness (DCS), which needs to be administered as swiftly as possible. This study evaluates the therapeutic responses of DCS patients and analyzes the major factors for clinical outcomes. @*Methods@#This is a retrospective cohort single-center study on patients who arrived at our hospital’s emergency department for diving-related symptoms and were diagnosed with DCS and administered HBOT. @*Results@#Totally, 337 patients were enrolled from June 2015 to May 2020. The proportion of SCUBA diving, rapid ascent, and inter-facility transport cases was higher in the recreational group, with a longer lag time from symptom onset to HBOT. The professional group had a higher proportion of cases with previous DCS history, total diving time, bottom time, in-water decompression, and repetitive diving. Examination of treatment outcomes revealed more type I cases and a shorter lag time from symptom onset to HBOT in the complete recovery group. Conversely, the incomplete recovery group had a higher proportion of type II cases and aggravation of symptoms before HBOT was administered. @*Conclusion@#DCS can occur regardless of professional or recreational divers. Both groups showed a similar level of severity. It is recommended that recreational divers should be cautious of accidents related to safety (such as rapid ascent) and receive swift treatment in case of the onset of symptoms. Occupational divers need more active efforts to get HBOT rather than just performing in-water recompression or home O2 therapy.

Immersion Pulmonary Edema after Scuba Diving: An Undiagnosed Entity / 대한스포츠의학회지

Immersion pulmonary edema (IPE) is a form of pulmonary edema that can occur in divers or swimmers. IPE is a rare condition, but can be life-threatening and recurrent condition. The pathophysiology of IPE is still incompletely understood. We present a case of scuba diving induced pulmonary edema in a 46-year-old woman diving in cold seawater. After 20 minutes of diving at 18 m, she felt difficulty of breathing. Symptoms on surfacing were dyspnea, cough, and frothy sputum. Chest X-ray showed pulmonary edema and she was treated with an intravenous diuretic and supplemental oxygen. The patient showed rapid resolution of symptoms and was discharged on the same day. Sport physician should be aware of this potentially life-threatening recurrent condition.

3.0 T MRI Findings in Cerebral Decompression Sickness: A Case Report

We presented a patient with cerebral decompression sickness, who showed predominant vasogenic edema on a 3.0 Tesla (3T) magnetic resonance imaging (MRI) findings, including diffusion-weighted image (DWI) and apparent diffusion coefficient (ADC) mapping. Within minutes of surfacing, he developed paresis of the right lower limb. During transport, he began shivering, followed by severe spasm that eventually progressed to a tonic-clonic seizure. Emergent hyperbaric oxygen therapy (HBOT) was performed with U.S. Navy treatment table 6A after a treatment of seizure activity. Brain MRI was performed after hyperbaric oxygen therapy to detect any cerebral lesions, which showed subcortical hyperintensity signal changes in the left fronto-parietal region on the ADC map. Overlying cortical hyperintensity on DWI sequences and cortical hypointensity on the ADC map were simultaneously observed. Moreover, these findings disappeared in a followup MRI with complete resolution of symptoms. These findings indicate that vasogenic edema can cause cerebral decompression sickness (DCS) and that 3T MRI with DWI and ADC mapping may be useful for diagnosing cerebral DCS. In addition, these findings suggest that DW-MRI may also be useful in predicting the prognosis of cerebral DCS.

The Efficacy of Fentanyl Transdermal Patch as the First-Line Medicine for the Conservative Treatment of Osteoporotic Compression Fracture / 대한신경손상학회지

OBJECTIVE: There are no strong guidelines on how long or how we should undertake conservative treatment during the acute period of an osteoporotic vertebral compression fracture (VCF). METHODS: We treated 202 patients with conservative treatment on VCF from March 2012 to August 2015. On inclusion criteria, 75 patients (22 males and 53 females) were included in the final analysis. After admission, a transdermal fentanyl patch with low dose (12.5 µg) application was attempted in all patients. In an unresponsive patient, the fentanyl patch was increased by 25 µg. After identifying the tolerable toilet ambulation of the patient without any assistance, hospital discharge was recommended. We classified two patient groups into one favorable group and one unfavorable group and compared several clinical and radiological factors. RESULTS: Among 75 patients, the clinical outcome of 57 patients (76%) was favorable, but that of 18 patients (24%) was unfavorable. In clinical outcomes, the numeric rating scale at 6 and 12 months and Odom's criteria at 12 months was significantly different between the favorable and the unfavorable groups. The dose of the patches used showed statistically significant differences between the two groups (p=0.001). CONCLUSION: The only statistically significant affecting factor for an unfavorable outcome was the use of a higher dose fentanyl patch. Our data inferred that the unresponsiveness to a low-dose fentanyl patch could be helpful to select patients necessary for percutaneous vertebroplasty or kyphoplasty.

Comprehensive Review of Pre-hospital Factors Associated with Field Return of Spontaneous Circulation after Out-of-hospital Cardiac Arrest in One Province

PURPOSE: Return of spontaneous circulation (ROSC) is closely related to a favorable treatment outcome in out-of-hospital cardiac arrest and is also a reliable treatment target in clinical trials. The aim of this study is the identification of major factors affecting field ROSC by analyzing the updated data encompassing the pre-hospital treatment processes. METHODS: This is a retrospective review of cardiopulmonary resuscitation (CPR) cases performed by 119 rescuers before hospital arrival from January 2012 to December 2014 in one province. Cases with traumatic cardiac arrest, unnecessary CPR, arrest occurred during transport, under age 14 years, and incomplete medical records were excluded. RESULTS: Of 1,832 patients enrolled in the study, ROSC was achieved in 99 cases (5.4%). Among them, 50 (50.5%) had ROSC at the event field and others achieved ROSC during the transport process, respectively. Total cases were divided into two groups based on ROSC before arrival at the hospital. Age, underlying cardiovascular illnesses, the event place, presence of a witness, bystander CPR, application of an automated external defibrillator (AED), the initial shockable rhythm, defibrillation, advanced airway, hydration, the arrival time of rescuer CPR, application time of AED, and defibrillation showed significant statistical differences. In multivariate analysis, age, defibrilOf 1,832 patients enrolled in the study, ROSC was achieved in 99 cases (5.4%). Among them, 50 (50.5%) had ROSC at the event field and others achieved ROSC during the transport process, respectively. Total cases were divided into two groups based on ROSC before arrival at the hospital. Age, underlying cardiovascular illnesses, the event place, presence of a witness, bystander CPR, application of an automated external defibrillator (AED), the initial shockable rhythm, defibrillation, advanced airway, hydration, the arrival time of rescuer CPR, application time of AED, and defibrillation showed significant statistical differences. In multivariate analysis, age, defibrillation, hydration, bystander CPR, and the call-to-rescuer CPR interval appeared to be correlated with field ROSC. CONCLUSION: To improve the survival rate through field ROSC, a public campaign to improve bystander CPR, prompt recognition of cardiac arrest, and rapid application of pre-hospital treatment and political support of the public institution are mandatory.

Anaphylaxis and Acute Coronary Syndrome Secondary to Intravenous Gadolinium-based Contrast Agent: Kounis Syndrome

Kounis syndrome refers to an acute coronary syndrome induced by an allergic reaction. Kounis syndrome is not a rare disease but is considered to be underdiagnosed. This syndrome is a potentially life threatening medical emergency. We described a case of Kounis syndrome caused by injection of intravenous gadolinium-based contrast agent. We also discussed emergency drugs used for treatment of Kounis syndrome.

Localized Pigmented Villonodular Synovitis in an Unusual Location in the Knee: A Case Report / 대한정형외과연구학회지

Localized pigmented villonodular synovitis (LPVNS) is a rare lesion that can affect any joint, although it is most frequently found in the knee. When LPVNS affects the knee, it is usually a single mass of pedunculated appearance. We present a LPVNS occurred from the junction of the anterior horn of the lateral meniscus and the joint capsule in the knee. It detached and then moved at an unusual location, which caused pain, limitation of knee flexion and locking.

Acute Mercury Vapor Inhalation Toxicity after Burning Charms: A Case Report / 대한구급학회지

Cinnabar is the mineral with mercury in combination with sulfur, and it has been used to make charms in China and Korea. If cinnabar is overheated, mercury vapor that is extremely hazardous or sometimes fatal can be released. We experienced 5 patients of a family who were exposed to mercury vapor when they burnt charms. One of them developed severe acute respiratory failure and the patient needed mechanical ventilation and extracorporeal membrane oxygenation (ECMO). Despite treatment with cortiocosteroid, D-penicillamine, ECMO and plasmapheresis, the radiologic findings of a patient worsened and he died.

Veratrum patulum intoxication developed in a group of twenty-three patients / 대한내과학회지

Veratrum patulum is a perennial plant with toxicity, which grows wild in the high mountain areas of Korea. Various types of steroidal alkaloids contained in Veratrum patulum are known to cause symptoms such as nausea, vomiting, bradycardia and hypotension. Twenty-three patients were admitted to our center with chief complaints of nausea and vomiting after ingesting leaves of Veratrum patulum. The mean age of the group was 44 years old and was comprised of 19 males and 4 females. Some patients showed hypotension and bradycardia with symptoms such as dizziness. Ten patients with severe bradycardia coupled with other symptoms received atropine administration. Nausea and vomiting were improved after the administration of anti-emetics. Blood pressure and the pulse rate were all normalized on the day after admission, and all of the patients were discharged without any symptoms.

The Usefulness of a Triage Kit for Detecting Abused Drugs / 대한구급학회지

BACKGROUND: The recovery and outcome of intoxicated patients depends on the kind of drugs they took and the total time of their initial management. The purpose of this study is to evaluate the usefulness of a Triage drug kit for detecting abused drugs. METHODS: From 2003 Feb. to 2003 July, we studied the patients who visited the emergency department with suspicious drug intoxication. In this case, we used a Triage drug kit for 134 patients with drug intoxication or who were clinically suspected of taking illegal drugs, with 30 of the patients initially admitting the substance they had used. The kit is an immunoassay kit for qualitative testing drug metabolites in urine. To compare with those cases of the preceding year, we studied 104 patients with drug intoxication that was detected between February 2002 and July 2002. RESULTS: Overall, 60% of the 30 cases who did not know what substance they abused and tested positive for, and 33% of the 27 cases with suspected intoxication confirmed their substance abuse. The positive rate for benzodiazepine use was the highest (46.7%), and there were no positive results regarding amphetamine, methamphetamine or cocaine. An appropriate antidote was administered significantly more frequently in the group for which we used the kit. CONCLUSIONS: A Triage drug kit is probably useful for diagnosing acute drug intoxication and for identifying the causative substance. However, the time required to decide whether or not a patient should be admitted is not reduced. If the kit can detect the frequently abused drugs in Korea, it will be helpful for treating drug intoxicated patients.

Spontaneous Rupture of Mediastinal Teratoma

Mediastinal teratoma is a rare mediastinal tumor. Patients with mediastinal teratoma are usually asymptomatic and are diagnosed incidentally with chest radiography or CT, but they may develop symptoms via a rupture into adjacent structures, which results in chemical pneumonia, massive hemoptysis, hemothorax, pericardial effusion, or respiratory distress. We report a case of a ruptured teratoma in a 31-year-old female presenting with cough and brown-colored sputum. Chest radiography and computed tomography of the chest showed an inhomogenous anterior mediastinal mass with fat and fluid component. It was successfully treated by surgical resection. Although mature teratomas are rare, we should be familiar with the unique CT features of a ruptured teratoma to make sure of a correct diagnosis.

A Comparison of Bioimpedance and Echocardiography in Measuring Cardiac Output in Healthy Male Volunteers

PURPOSE: To manage a critically ill patient effectively, an emergency physician must make an accurate assessment of the patient's hemodynamic status. Although the hemodynamic status can be accurately measured through the use of a pulmonary artery catheter, this device has significant limitations in the emergency department. Instead, the most commonly used method of measuring cardiac output (CO) in the emergency department is transthoracic echocardiography (TTE). However, TTE has been reported to underestimate the CO. Impedance cardiography (ICG) is an established and accurate technique for noninvasive determination of hemodynamic parameters. Thus, this study aimed to assess the agreement between CO measurements made by using TTE and ICG. METHODS: In 20 healthy volunteers, the hemodynamic parameters (stroke volume and CO) obtained by TTE were compared with the parameters derived from simultaneous measurements by ICG. RESULTS: The mean stroke volumes and COs were 63.9+/-11.6 ml and 4.1+/-0.7 L/min, respectively, by TTE, and 77.2+/-10.2 ml and 5.0+/-0.6 L/min by ICG. The correlation coefficients for stroke volume and CO between TTE and ICG were 0.77 and 0.64. The mean difference in stroke volume between TTE and ICG was -13.3+/-6.4 ml (-19.5+/-10.5 %), and the mean difference in CO was -0.88+/-0.48 L/min (-20.1+/-11.6 %). CONCLUSION: In healthy volunteers, the comparison between TTE and ICG showed a good correlation for stroke volume and CO. However, the mean differences in stroke volume and CO between TTE and ICG were -19.5+/-10.5 % and -20.1+/-11.6 %, respectively.

Diagnostic Value of the Brugada Algorithm in Differential Diagnosis of Wide QRS Tachycardia by Electrocardiogram

PURPOSE: In dealing with wide-complex tachycardia (WCT), it is important to distinguish between ventricular tachycardia (VT), supraventricular tachycardia with aberrancy (SVTAC), and preexcited tachycardia by using an accessory pathway. The aim of this study was to investigate and compare the Brugada and the Bayesian algorithms and to analyze the parameters. METHODS: Between January 1999 and December 2003, the Brugada and the Bayesian approaches were retrospectively analyzed in 103 WCTs confirmed by electrophysiologic studies. RESULTS: Seven-eight (75) VTs and 25 SVTs were found. The sensitivity and the specificity for VT achieved by using the Brugada approach were 91.0 and 68.0%, respectively, whereas those achieved by using the Bayesian approach were 84.6 and 60.0%. In the Brugada approach, the most important step was the fourth step (odds ratio: 4.33; 95% CI: 1.75-12.14). In the Bayesian approach, triphasic rsR' or rR' morphology (odds ratio: 3.93; 95% CI: 1.46-10.56), r > or = 0.04 s or notched S downstroke or delayed S nadir > 0.06 s in the V1 or the V2 lead (odds ratio: 5.75; 95% CI: 1.26?26.28), and intrinsicoid deflection > or = 0.08 s in the V6 lead (odds ratio: 6.88; 95% CI: 1.33-27.79) were more important parameters. Seven (7) VTs of 103 tachycardias were mis-classified when the Brugada approach was used. Applying additional criteria (QRS width > 0.16 s and intrinsicoid deflection > or = 0.08 s in V6 lead), three of those VTs were diagnosed correctly. CONCLUSIONS: The Brugada algorithm achieved a lower sensitivity and specificity than those reported by Brugada et al. If both the V1 and the V6 leads do not fulfill the criteria for VT, additional parameters should be evaluated.

B-type Natriuretic Peptide Value for Diagnosis of Congestive Heart Failure in Patients with decreased Renal Function

PURPOSE: A number of studies have examined the B-type natriuretic peptide level in dialysis patients and in patients with lesser degrees of renal insufficiency. However, relationships between BNP and renal function are unknown. We sought to assess the diagnostic utility of BNP in differentiating congestive heart failure (CHF) from non-congestive heart failure (non-CHF) in patients with renal insufficiency. METHODS: BNP levels were obtained in 395 patients presenting to our emergency department with dyspnea. Of those 395 patients, 48 patients showed renal insufficiency. Patients transferred to other hospitals and those in a donot- resuscitate state were excluded. RESULTS: In patients with acute renal failure, patients with CHF (n=8) had BNP levels of 360+/-254 pg/ml whereas patients with non-CHF (n=3) had BNP levels of 114+/-103 pg/ml; however, this difference was not statistically significant. In patients with chronic renal failure, patients with CHF (n=22) had BNP levels of 1147+/-635 pg/ml, which was significantly higher than the BNP levels of 459+/-508 pg/ml for patients with non-CHF (n=7) (p=0.01). The area under the receiver operating curve, which plots sensitivity versus specificity for BNP levels in separating congestive heart failure from non-congestive heart failure in patients with chronic renal failure, was 0.805 (p=0.01). The diagnostic accuracy of BNP at a cutoff of 600 pg/ml was 76 %. CONCLUSION: The BNP cut-off value for diagnosis of CHF in patients with chronic renal failure is 600 pg/ml.

Early Diagnosis of a Cerebral Venous Thrombosis in the Emergency Department

PURPOSE: Early diagnosis and heparin therapy have contributed to a decreased mortality in patients with a cerebral venous thrombosis (CVT). The aim of this study is to evaluate the clinical and the radiologic features of a CVT and to develop an algorithm for diagnosis and treatment. METHODS: Twenty (20) patients who were diagnosed at Asan Medical Center from 1997 to June 2004 as having a CVT were included in this study. The data in their medical records, including clinical features, predisposing factors, and diagnostic modalities, were reviewed. The cranial computed tomography findings of a CVT were investigated in 18 patients. RESULTS: Headache was the most common symptom, followed by seizure and focal neurologic deficits. Initially, 14 patients were misdiagnosed by the emergency physician as having another neurologic disease, though 5 patients had pathognomic CT signs of a CVT. CT signs, such as cord signs and empty delta signs, were present in 10 cases. Among them, the cord sign was positive in eight (8) cases (44.4%), the empty delta sign was positive in six (6) cases (46.2%), and both signs were positive in four (4) cases. The presence of CT signs correlated with the presence of seizure at onset, and the Modified Rankin Scale (MRS) was 1 or 2 at discharge (p<0.05). Parenchymal changes correlated with headache at discharge (p<0.05). CONCLUSION: Emergency physicians should consider CVT and look for pathognomic signs of a CVT when patients complain of sub-acute headaches or when the clinical features do not correlate with the neuroimage findings.

Adaptation Trends of Emergency Medical Personnel after Implementation of the Electronic Medical Record System into Emergency Care

PURPOSE: With many advantages, Electronic Medical Record (EMR) systems have been adopted by numerous edical institutions. However, medical personnel, the direct users of the system, have a negative opinion of it. Especially, medical personnel at the emergency department, in which the most rapid services are required, have a more negative opinion. We performed this study to improve the system from the view points of time factors, which are the most unsatisfactory to medical personnel. METHODS: We compared the time consumed for making patients' medical records before and after the adoption of EMR system in Asan Medical Center. A questionnaire regarding contentment and the presumptive time consumption of the EMR were answered by emergency medical personnel. RESULTS: The actual time consumed for the written and the electronic records was the same. However, from the survey, the time consumed on the electronic recording system was perceived to be longer by medical personnel. 46.7% of the doctors and 53.8% of the nurses answered that EMR was convenient, and 59.3% of them agreed to continue using the system. CONCLUSION: If the EMR system is developed for user convenience, it can also be useful in emergency care as well. Therefore, emergency medical personnel must participate in the initial period of EMR system development.