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.

A Pediatric Case of Cardiac Myxoma Presenting as an Acute Stroke in the Emergency Department

Occurrence of primary cardiac tumors is rare in all age groups; occurrence is observed in 0.05% of routine postmortem examinations. A 15-year-old Korean female transported by 119 rescue presented with common clinical findings for acute stroke. Brain imaging included computed tomography; magnetic resonance imaging was performed in the emergency department. Findings on brain imaging were compatible with acute cerebral infarction of the territory of the right middle cerebral artery. The patient was treated with reperfusion therapy with IV tissue plasminogen activator and cerebral artery stenting. Echocardiography was performed in the emergency department in order to determine the cause of acute cerebral infarction. We experienced a case of pediatric cardiac myxoma presenting as an acute stroke in the emergency department, which was confirmed by imaging study and biopsy; therefore, we report on it here along with a review of the literature.

A Case of Rapid Progressing Takayasu's Arteritis Presenting as Nausea and Vomiting at Emergency Department

Takayasu's arteritis is a chronic inflammatory disease involving the aorta and the arteries arising from the aorta. The pulmonary arteries also may be involved. The inflammation leads to either stenosis and occlusion of the involved artery or formation of aneurysm or both. The arterial lesions can lead to secondary hypertension, retinopathy, cardiac involvement, cerebrovascular event. The course and prognosis of patients with Takayasu's arteritis shows wide variation. We experienced a case of rapid growing Takayasu's arteritis presenting as nausea and vomiting at emergency department, which was confirmed by computed tomography and angiography, so reported it with a review of literature.

The Prognostic Factors For Alcoholic Ketoacidosis

PURPOSE: This study was undertaken to evaluate the prognostic factors for patients suffering with alcoholic ketoacidosis. METHODS: We retrospectively evaluated and categorized 55 alcoholic ketoacidosis patients into two groups: the survivors (group 1) and non-survivors (group 2). We compared the general characteristics and the laboratory results, including the arterial blood gas analysis (ABGA) and the complications of the two groups, and we assessed the severity of the between the two groups by using the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Simplified Acute Physiology Score (SAPS). RESULTS: There were 50 male patients (90%) and 5 female patients (10%). On laboratory testing, the levels of arterial HCO3-, total protein, albumin and serum glucose were significantly lower in group 2 than that in group 1. The levels of total bilirubin and BUN (blood urea nitrogen), the PT (prothrombin time) and the aPTT (activated partial thromboplastin time) were significantly higher in group 2 than that in group 1. Serial ABGA follow-up showed that unimproved ABGA results meant a poor prognosis. The SAPS was significantly higher for group 2 than that for group 1 (p<0.001) but the APACHE II was not significantly different. The incidence of hepatic encephalopathy, hepatic failure and acute respiratory distress syndrome (ARDS) were higher in group 2 than that in group 1. The total bilirubin, arterial HCO3- and albumin were found to be significant prognostic factors by logistic regression analysis. CONCLUSION: The poor prognostic factors for alcoholic ketoacidosis were low levels of arterial HCO3-, impaired hepatic function, the incidence of ARDS and unimproved ABGA results.

Influence of Multiple Rib Fracture upon Traumatic Hemo-pneumothorax

PURPOSE: Multiple rib fracture (MRF) and a hemopneumothorax accompany with most blunt chest traumas. We aimed to analyze the factors increasing the probability of a hemopneumothorax. In addition, other injuries accompanying MRF were analyzed. METHODS: We retrospectively reviewed the medical records of 154 mutiple rib fracture patients who visited our hospital between January 2005 and December 2007. The medical records were reviewed for sex, age, mechanism of injury, location, number of fractures, distance of dislocated rib fragments, and presence of complications. We measured the distance of bony dislocations by using the PACS (Picture Archiving and Communication System). RESULTS: The average number of rib fractures was 3.7+/-2.1, and the number of rib fractures significantly influenced the incidence of a hemothorax (p<0.001). The risk of a phemothorax was increased in a bilateral MRF compared to a unilateral MRF (p=0.027). The distance of dislocated rib fragments influenced the probability of a hemothorax significantly (p=0.018), and subcutaneous emphysema and lung contusion were significantly associated with a pneumothorax (p=0.021, p=0.036). CONCLUSION: The number of MRFs did not influence the risk for a pneumothorax, but did influence the risk for a hemothorax. The laterality, distance of dislocation, also had an influence on the risk for a hemothorax. Also, subcutaneous emphysema and lung contusion were increased in cases with a pneumothorax. We must consider the possibility of a hemothorax even when the initial chest X-ray shows no evidence of a hemothorax. If a lung contusion is present, then an occult pneumothorax must be considered.

Consideration of Factors associated with Complications and Systemic Symptoms of Snake Bites

PURPOSE: Venomous snakebite is an important medical emergency in Korea, but the factors affecting outcomes are unclear. METHODS: We conducted an 8-year retrospective study of 169 snake bite patients who visited the emergency departments of Keimyung University at Dongsan Medical Center between January, 2000, and December, 2007. Patients were divided by systemic symptoms and complications (group 1) or local symptoms only (group 2). We compared the general characteristics and clinical and laboratory findings of the two groups. RESULTS: The male to female ratio was 1.19. The most common systemic symptom was dizziness (7.6%), and the most common complication was rhabdomyolysis (23.6%). Distal bite sites (finger, toe) in group 1 occurred in 20 (35.7%) cases, and proximal (hand, foot, ankle, arm, calf, perianal area) in 36 (64.3%) cases (p<0.05). The median interval from envenomation to hospital visit was 6.0 (0.3-96.0) h in group 1, which was longer than group 2 (p<0.05). Among 33 (19.5%) patients with local effect scores of 9~16, 25 (75.8%) patients had systemic symptoms and complications. The local effect scores and the interval from bite to antivenin treatment in the hospital were significant risk factors for systemic symptoms and complications in logistic regression analysis. CONCLUSION: Snakebite poisoning is an emergency and we must evaluate risk factors to prevent the development of serious complications.

A Case of Toxic Hepatitis after the Exposure of Dimethylformamide

Dimethylformamide (DMF) is a major solvent predominately used in synthetic leather and electrical equipment production. The effects of DMF exposure in humans are not well known or documented in the medical literature. We present a case of an electrical factory worker who underwent frequent exposure to DMF while making film. The patient complained of abdominal pain, nausea, vomiting and presented with hepatotoxicity serologic evaluation consistent with prior reports in people exposed to DMF. The possibility of viral, drug induced and alcoholic hepatitis were ruled out from his history and serological studies. The patient was eventually diagnosed as having a DMF induced toxic hepatitis and was managed with supportive care and hepatotonics. The clinical presentation and management of DMF induced toxic hepatitis were reviewed with the current literature.

A Case of Primary Epiploic Appendagitis

Primary epiploic appendagitis (PEA) is an uncommon cause of acute abdominal pain that occurs either from appendageal torsion or spontaneous thrombosis of an appendageal vein. It is a benign condition that may present with peritoneal findings. Thus, it is rarely considered in the differential diagnosis of intra-abdominal disease. Until recently, an accurate diagnosis could not be made preoperatively. With the aid of contemporary imaging modalities, however, the diagnosis of PEA need no longer hinge on the pathologic specimen, but may be established by the emergency physician. Common findings include left lower quadrant pain and guarding. Nonmigratory symptoms should also prompt the clinician to consider a CT scan in patients with similar signs and symptoms. Knowledge of this uncommonly diagnosed entity and its usual benign course may allow the emergency physician to order the appropriate studies to help avoid unnecessary surgical treatment. The anatomy, the clinical presentation, the radiologic evaluation, and the emergency management of epiploic appendagitis are reviewed with the literature.