Characteristics of the pneumonia patients transferred from long-term care hospitals:retrospective study of one regional emergency medical center

Objective@#This study investigated the characteristics of elderly pneumonia patients transferred from long-term care hospitals(LTCH). @*Methods@#The initial emergency department (ED) data of patients, who were transferred from other hospitals and over 65years old and hospitalized from 2014 to 2018 for pneumonia management through the ED, were extracted from the electronicmedical records. The differences in the initial status and prognosis between the LTCH group and non-LTCH groupwere compared, and the initial ED variables that affect the in-hospital mortality of the LTCH group were investigated. @*Results@#The total number of patients was 1,032; 423 (41.0 %) were included in the LTCH group. Compared to the non-LTCH group, the following severity indices, some laboratory data, and mortality were worse in the LTCH group: systemicinflammatory reaction syndrome (SIRS) criteria ≥2 (65.0% vs. 56.7%, P=0.008), quick Sequential Organ FailureAssessment score ≥2 (48.2% vs. 20.4%, P<0.001), CURB-65 (Confusion, Urea nitrogen, Respiration rate, Blood pressure,Age≥65 years) criteria ≥3 (51.8% vs. 29.2%, P<0.001), pneumonia severity index (PSI) class ≥4 (86.5% vs.61.2%, P<0.001), modified early warning score ≥5 (38.8% vs. 18.4%, P<0.001), serum albumin (median [IQR], 2.6 [2.2-2.9] g/dL vs. 2.8 [2.4-3.2] g/dL; P<0.001), blood urea nitrogen/albumin (B/A) ratio (median [IQR], 8.0 [5.0-12.8] vs. 6.6[4.4-10.4]; P<0.001), and in-hospital mortality (26.0% vs. 15.9%, P<0.001). Multivariate regression analysis revealed thealbumin grade, B/A ratio grade, PSI class, and SIRS criteria to independently affect the in-hospital mortality of the LTCHgroup. @*Conclusion@#The LTCH group had poorer initial severity indices and higher in-hospital mortality than the non-LTCHgroup. In addition, the albumin grade, B/A ratio grade, could be used for the severity index of pneumonia patients transferredfrom the LTCH.

Is it possible to reduce intra-hospital transport time for computed tomography evaluation in critically ill cases using the Easy Tube Arrange Device?

OBJECTIVE: Patients are often transported within the hospital, especially in cases of critical illness for which computed tomography (CT) is performed. Since increased transport time increases the risks of complications, reducing transport time is important for patient safety. This study aimed to evaluate the ability of our newly invented device, the Easy Tube Arrange Device (ETAD), to reduce transport time for CT evaluation in cases of critical illness. METHODS: This prospective randomized control study included 60 volunteers. Each participant arranged five or six intravenous fluid lines, monitoring lines (noninvasive blood pressure, electrocardiography, central venous pressure, arterial catheter), and therapeutic equipment (O2 supply device, Foley catheter) on a Resusci Anne mannequin. We measured transport time for the CT evaluation by using conventional and ETAD method. RESULTS: The median transport time for CT evaluation was 488.50 seconds (95% confidence interval [CI], 462.75 to 514.75) and, 503.50 seconds (95% CI, 489.50 to 526.75) with 5 and 6 fluid lines using the conventional method and 364.50 seconds (95% CI, 335.00 to 388.75), and 363.50 seconds (95% CI, 331.75 to 377.75) with ETAD (all P < 0.001). The time differences were 131.50 (95% CI, 89.25 to 174.50) and 148.00 (95% CI, 116.00 to 177.75) (all P < 0.001). CONCLUSION: The transport time for CT evaluation was reduced using the ETAD, which would be expected to reduce the complications that may occur during transport in cases of critical illness.

Survey of emergency medicine residency education programs and suggestion for improvement on the future emergency medicine residency education

OBJECTIVE: This study examined the educational programs for emergency residency in The Korean Society of Emergency Medicine. METHODS: A written survey of the workshop programs with representatives of the related organizations and affiliated organizations was conducted. During the 5-year period, the number of training courses and workshops attended by those who took the professional examination were analyzed. RESULTS: There were 23 workshops in progress. They proceed 2.85 times a year on average. The average number of participants was 22.8 with an average time required for the workshop of 5.6 hours, of which 78.7% is practice time. They received feedback from residency at all workshops, which was reflected in the process. During the 5-year period, the average number of participant training courses was 3.8, and the average number of workshop participants was 2.7. CONCLUSION: The education program for emergency residency is continuing through the affiliated organizations and related organizations as well as The Korean Society of Emergency Medicine. Encouraging opportunities for participation in various educational programs to supplement those that are not fully experienced will be helpful.

Is the Modified AIMS65 Score Suitable for Distinguishing the Low Risk Group and the High Risk Group for Patients with Upper Gastrointestinal Bleeding?

PURPOSE: The goal of this study was to increase the performance of the AIMS65 score in the prediction of outcomes in upper gastrointestinal bleeding by modifying the AIMS65 score. METHODS: Data were collected retrospectively between January 2015 and June 2015. A total of 212 adult patients, who visited the emergency department with an upper gastrointestinal hemorrhage during this period were included for analysis. High risk patients were defined as follows: those who needed an endoscopic or surgical hemostasis, suffered rebleeding, hospitalized in an intensive care unit, and those who were deceased within 30 days or required a blood transfusion. The seven parameters of the modified AIMS65 score were as follows: Albumin levels, international normalized ratio (prothrombin time), altered mental status, systolic blood pressure, age>65 years, hemoglobin levels, and heart rate. RESULTS: The high-risk group was comprised of 163 patients, while the low risk group was comprised of 49 patients. The areas under the curve for AIMS65 and modified AIMS65 scores were 0.727 (95% confidence interval, 0.662-0.786) and 0.847 (95% confidence interval, 0.791-0.892), respectively, which were significantly different (p<0.001). The AIMS65 score had a sensitivity of 53.0% and a specificity of 78.5% at a score of 0. The modified AIMS65 score had a sensitivity of 22.4% and a specificity of 99.3% at a score of 0. For the modified AIMS65 score of 3 or lower, the sensitivity was 97.9% with a specificity of 21.4%. CONCLUSION: The modified AIMS65 score was effective in distinguishing between the low-risk group and the high-risk group among patients with upper gastrointestinal bleeding.

Reduction of intra-hospital transport time using the easy tube arrange device

OBJECTIVE: Critically ill patients sometimes require transport to another location. Longer intra-hospital transport time increases the risk of hemodynamic instability and associated complications. Therefore, reducing intra-hospital transport time is critical. Our objective was to evaluate whether or not a new device the easy tube arrange device (ETAD) has the potential to reduce intra-hospital transport time of critically ill patients. METHODS: We enrolled volunteers for this prospective randomized controlled study. Each participant arranged four, five, and six fluid tubings, monitoring lines, and therapeutic equipment on a cardiopulmonary resuscitation training mannequin (Resusci Anne). The time required to arrange the fluid tubings for intra-hospital transport using two different methods was evaluated. RESULTS: The median time to arrange four, five, and six fluid tubings was 86.00 (76.50 to 98.50), 96.00 (86.00 to 113.00), and 115.50 (93.00 to 130.75) seconds, respectively, using the conventional method and 60.50 (52.50 to 72.75), 69.00 (57.75 to 80.80), and 72.50 (64.75 to 90.50) seconds using the ETAD (all P<0.001). The total duration (for preparing the basic setting and organizing before and after the transport) was 280.00 (268.75 to 293.00), 315.50 (304.75 to 330.75), and 338.00 (319.50 to 360.25) seconds for four, five, and six fluid tubings, respectively, using the conventional method and 274.50 (261.75 to 289.25), 288.00 (271.75 to 298.25), and 301.00 (284.50 to 310.75) seconds, respectively, using the new method (P=0.024, P<0.001, and P<0.001, respectively). CONCLUSION: The ETAD was convenient to use, reduced the time to arrange medical tubings, and is expected to assist medical staff during intra-hospital transport.

Direction of the J-Tip of the Guidewire to Decrease the Malposition Rate of an Internal Jugular Vein Catheter / 대한중환자의학회지

BACKGROUND: We hypothesized that the direction of the J-tip of the guidewire during insertion into the internal jugular vein (IJV) might determine its ultimate location. METHODS: In this study, 300 patients between the ages of 18 and 99 years who required central venous catheterization via IJV in the emergency department enrolled for randomization. IVJ catheterization was successful in 285 of 300 patients. An independent operator randomly prefixed the direction of the J-tip of the guidewire to one of three directions. Based on the direction of the J-tip, patients were allocated into three groups: the J-tip medial-directed group (Group A), the lateral-directed group (Group B), or the downward-directed group (Group C). Postoperative chest radiography was performed on all patients in order to visualize the location of the catheter tip. A catheter is considered malpositioned if it is not located in the superior vena cava or right atrium. RESULTS: Of the total malpositioned catheter tips (8 of 285; 2.8%), the majority (5 of 8; 62.5%) entered the contralateral subclavian vein, 2 (25.0%) were complicated by looping, and 1 (12.5%) entered the ipsilateral subclavian vein. According to the direction of the J-tip of the guidewire, the incidence of malpositioning of the catheter tip was 4 of 92 in Group A (4.3%), 4 of 96 in Group B (4.2%), and there were no malpositions in Group C. There were no significant differences among the three groups (p = 0.114). CONCLUSIONS: The direction of the J-tip of the guidewire had no statistically significant effect on incidence of malpositioned tips.

Video Recording Analysis of Cardiopulmonary Resuscitation Quality in a Wide Regional Emergency Medical Center

PURPOSE: Maintaining the quality of CPR is connected with improvement in survival rates, but CPR performance in the field does not always fulfill the guidelines. Therefore, many ways to obtain the quality of CPR have been studied and tried, including CPR education, manikin training, mechanical CPR, audio-visible feedback system, and video-recording system, et cetera. The aim of our study is to determine how CPR procedures are actually performed on the scene by real-time video recording. METHODS: Digital video of CPR cases was obtained from April 2014 to March 2015 in a wide regional emergency medical center. The video was analyzed by two physicians in the emergency department. We evaluated quality of major CPR variables including compression rate, hands-off time, chest compression fraction, ventilation rate, et cetera. RESULTS: A total of 52 cases were analyzed. Mean chest compression rate was 122.43+/-10.74/min, and mean ventilation rate was 7.47+/-2.58/min. Performance of adequate compression-to-ventilation ratio before insertion of advanced airway was 37%. Mean recognition to compression time was 31.31+/-27.32 seconds, and proportion of chest compression interruption time exceeding 10 seconds was 7.6%. Mean chest compression fraction was 91.12+/- 0.4%. In five out of 25 cases of defibrillation, chest compression was interrupted during charging, resulting in prolongation of chest compression interruption time. CONCLUSION: In this study, overall performance met the qualification of AHA guidelines. However, poor compliance was observed for some parameters. Continuous education and feedback are required in order to make an improvement in these areas.

Direction of the J-Tip of the Guidewire to Decrease the Malposition Rate of an Internal Jugular Vein Catheter / 대한구급학회지

BACKGROUND: We hypothesized that the direction of the J-tip of the guidewire during insertion into the internal jugular vein (IJV) might determine its ultimate location. METHODS: In this study, 300 patients between the ages of 18 and 99 years who required central venous catheterization via IJV in the emergency department enrolled for randomization. IVJ catheterization was successful in 285 of 300 patients. An independent operator randomly prefixed the direction of the J-tip of the guidewire to one of three directions. Based on the direction of the J-tip, patients were allocated into three groups: the J-tip medial-directed group (Group A), the lateral-directed group (Group B), or the downward-directed group (Group C). Postoperative chest radiography was performed on all patients in order to visualize the location of the catheter tip. A catheter is considered malpositioned if it is not located in the superior vena cava or right atrium. RESULTS: Of the total malpositioned catheter tips (8 of 285; 2.8%), the majority (5 of 8; 62.5%) entered the contralateral subclavian vein, 2 (25.0%) were complicated by looping, and 1 (12.5%) entered the ipsilateral subclavian vein. According to the direction of the J-tip of the guidewire, the incidence of malpositioning of the catheter tip was 4 of 92 in Group A (4.3%), 4 of 96 in Group B (4.2%), and there were no malpositions in Group C. There were no significant differences among the three groups (p = 0.114). CONCLUSIONS: The direction of the J-tip of the guidewire had no statistically significant effect on incidence of malpositioned tips.

Could One-Hand Compression for a Small Child Cause Intra-abdominal Injuries?

PURPOSE: We examined the question of whether one-hand chest compression for a small child could compress intraabdominal organs. METHODS: We retrospectively examined medical charts and multidirectional computed tomography (MDCT) images obtained from children aged 1 to 18 years who presented to the hospital from March 2002 to March 2012. We measured the length of the sternum (Stotal) and the length of the lower half of the sternum (Stotal/2~X). We also measured the distance from the diaphragm to the midpoint of the sternum (Stotal/2~D) and half the width of an adult hand (Wtotal/2). Finally, we counted the number of instances at each age in which Stotal/2~X and Stotal/2~D were less than Wtotal/2. RESULTS: This study included records and MDCT images for 301 children with a mean age of 12.05+/-5.59 years. We also enrolled 47 adult rescuers (25 men, 53.2%) with a mean age of 23.20+/-2.13 years. The mean Wtotal/2 was 4.62+/-0.46 cm. All 1-year-old children had Stotal/2~X and Stotal/2~D less than Wtotal/2. Among children aged 2 years, six (60.0%) had Stotal/2~X and Stotal/2~D less than Wtotal/2. Among children aged 3 years, four (26.7%) had Stotal/2~X and Stotal/2~D less than Wtotal/2, and among those aged 4 years, two (13.3%) had Stotal/2~X and Stotal/2~D less than Wtotal/2. However, Stotal/2~X and Stotal/2~D were greater than Wtotal/2 in children aged 5 years or more. CONCLUSION: Our measurements indicate that one-hand chest compression for a small child could cause intraabdominal organ injury.

Clinical applications and contemporary trends of hyperbaric oxygen therapy in Korea

Hyperbaric oxygen therapy (HBOT) is approved in the United States for 14 accepted indications, which are approved by the HBOT committee of the Undersea and Hyperbaric Medical Society and by the Food and Drug Administration. These indications are also used worldwide. HBOT is a mode of medical treatment in which the patient is situated in an enclosed pressure chamber and breathes 100% oxygen at a pressure greater than 1 atmosphere absolute (ATA), with the usual therapeutic pressure set at greater than 1.4 ATA. In South Korea, an expanded knowledge base and formalized education in HBOT do not exist, and numerous HBOT devices are old and nearing the cessation of operation, although HBOT has undergone refinement, with an increased understanding of mechanisms of action and clinical applications. Furthermore, there is no specific board certification of HBO competence for emergency, critical care, and surgical physicians and technicians in South Korea. We summarize the existing literature on the uses of HBO with the aim of enhancing the understanding of this therapeutic technique.

Outcome and Current Status of Therapeutic Hypothermia Following Out-of-hospital Cardiac Arrest in Korea from the Korea Hypothermia Network Registry

PURPOSE: Therapeutic hypothermia (TH) has become a standard strategy for reducing brain damage in the postresuscitation period. The aim of this study is to investigate the outcomes and current performance of TH with out-of-hospital cardiac arrest (OHCA) survivors through the Korean hypothermia network (KORHN) registry. METHODS: We used the KORHN registry, a web-based, multicenter registry that includes 24 participating hospitals throughout the Republic of Korea. Adult comatose OHCA survivors treated with TH from 2007 to 2012 were included. The primary outcomes were neurologic outcome at hospital discharge and in-hospital mortality. The secondary outcomes were TH performance and adverse events during TH. RESULTS: A total of 930 patients were included; of these, 556 (59.8%) patients survived to discharge and 249 (26.8%) were discharged with good neurologic outcomes. The median time from return of spontaneous circulation (ROSC) to the start of TH was 101 (interquartile range (IQR): 46-200) minutes. The induction, maintenance, and rewarming durations were 150 (IQR: 80-267) minutes, 1440 (IQR: 1290-1440) minutes, and 708 (IQR: 420-900) minutes, respectively. The time from the ROSC to coronary angiography was 1,045 (IQR: 121-12,051) hours. Hyperglycemia (46.3%) was the most frequent adverse event. CONCLUSION: Over one quarter of OHCA survivors (26.8%) were discharged with good neurologic outcome. TH performance was managed appropriately in terms of the factors related to the timing of TH, which were the start time for cooling and the rewarming duration.

The Relation between Neurologic Prognosis and Optic Nerve Sheath Diameter Measured in Initial Brain Computed Tomography of Cardiac Arrest and Hanging Patients / 대한구급학회지

BACKGROUND: Early prediction of neurologic outcome is important to patients treated with therapeutic hypothermia after hypoxic brain injury. Hypoxic brain injury patients may have poor neurologic prognosis due to increased intracranial pressure. Increased intracranial pressure can be detected by optic nerve sheath diameter (ONSD) measurement in computed tomography (CT) or ultrasound. In this study, we evaluate the relation between neurologic prognosis and optic nerve sheath diameter measured in brain CT of hypoxic brain injury patients. METHODS: We analyzed the patient clinical data by retrospective chart review. We measured the ONSD in initial brain CT. We also measured and calculated the gray white matter ratio (GWR) in CT scan. We split the patients into two groups based on neurologic outcome, and clinical data, ONSD, and GWR were compared in the two groups. RESULTS: Twenty-four patients were included in this study (age: 52.6 +/- 18.3, 18 males). The mean ONSD of the poor neurologic outcome group was larger than that of the good neurologic outcome group (6.07 mm vs. 5.39 mm, p = 0.003). The GWR of the good neurologic outcome group was larger than that of the poor outcome group (1.09 vs. 1.28, p = 0.000). ONSD was a good predictor of neurologic outcome (area under curve: 0.848), and an ONSD cut off > or = 5.575 mm had a sensitivity of 86.7% and a specificity of 77.8%. CONCLUSIONS: ONSD measured on the initial brain CT scan can predict the neurologic prognosis in cardiac arrest and hanging patients treated with therapeutic hypothermia.

The Safety of Bolus Infusion Through Intraosseous Access Using the EZ-IO in Terms of Extraosseous Flow

PURPOSE: We evaluated the safety of bolus infusion through intraosseous access using the EZ-IO in adults in terms of extraosseous flow. METHODS: We conducted a prospective study of adults (over age 18) in whom intraosseous access through the tibia was performed by emergency physicians or residents from June 2010 to June 2011. We used ultrasonography to confirm extraosseous flow during infusion of 80 mL normal saline with a 4 mL/s flow rate through intraosseous access, immediately after confirmation of intraosseous needle insertion using conventional methods. Finally, we recorded any complications that occurred immediately in the area of intraosseous access. RESULTS: Of 30 patients enrolled in the study, 22(73.3%) were male and eight (26.7%) were female. The mean age of study participants was 62.78+/-15.68 years; mean cortical thickness of participants' tibias was 0.27+/-0.03 cm. The mean time required for performance of the intraosseous access procedure was 16.00+/-4.65 s; success rate on the first attempt, 100.0%. No immediate complications, including swelling or extraosseous flow at the area of intraosseous access, were observed. CONCLUSION: In this study, bolus infusion though intraosseous access using the EZ-IO in adults in emergency departments was a safe option in terms of extraosseous flow.

Clinical Predictors of Cervical Abscess in Adult Emergency Department Patients Presenting a Sore Throat

PURPOSE: To evaluate clinical predictors of cervical abscess in adult patients who present a sore throat. METHODS: We prospectively studied adult patients (18 years of age or older) who presented with a sore throat at one of three hospitals (Chungnam national university hospital, Chungbuk national university hospital, and Konyang university hospital) from June 2010 to June 2011. The enrolled patients received a neck computed tomography scan, and their clinical manifestations were investigated. We evaluated several clinical variables in order to predict the existence of cervical abscess by use of multiple logistic regression analysis, and assessed the ability of the results of these variables to accurately diagnose cervical abscess using a receiver operating characteristic curve. RESULTS: A total of 109 patients were enrolled in this study. We identified two clinical variables (swelling and voice change) useful in predicting the existence of cervical abscess, and the AUC acquired by adding the scores of the two clinical factors was 0.89 (p<0.01). The sensitivity and specificity of these clinical factors to predict cervical abscess were 0.96 and 0.69 when the cut off value was determined to be 2. CONCLUSION: Two clinical factors (swelling and voice change) were useful in predicting the appearance of cervical abscesses. Consideration should be made for the need for incision and drainage of a cervical abscess if a patient presents swelling, or swelling and voice change.

Clinical Predictors of Cervical Abscess in Adult Emergency Department Patients Presenting a Sore Throat

PURPOSE: To evaluate clinical predictors of cervical abscess in adult patients who present a sore throat. METHODS: We prospectively studied adult patients (18 years of age or older) who presented with a sore throat at one of three hospitals (Chungnam national university hospital, Chungbuk national university hospital, and Konyang university hospital) from June 2010 to June 2011. The enrolled patients received a neck computed tomography scan, and their clinical manifestations were investigated. We evaluated several clinical variables in order to predict the existence of cervical abscess by use of multiple logistic regression analysis, and assessed the ability of the results of these variables to accurately diagnose cervical abscess using a receiver operating characteristic curve. RESULTS: A total of 109 patients were enrolled in this study. We identified two clinical variables (swelling and voice change) useful in predicting the existence of cervical abscess, and the AUC acquired by adding the scores of the two clinical factors was 0.89 (p<0.01). The sensitivity and specificity of these clinical factors to predict cervical abscess were 0.96 and 0.69 when the cut off value was determined to be 2. CONCLUSION: Two clinical factors (swelling and voice change) were useful in predicting the appearance of cervical abscesses. Consideration should be made for the need for incision and drainage of a cervical abscess if a patient presents swelling, or swelling and voice change.

A Clinical Study of Acute Appendicitis in Schizophrenia Patients Presenting at an Emergency Center

PURPOSE: To investigate the clinical characteristics and Alvarado scores of schizophrenia with patients acute appendicitis presenting at the emergency department. METHODS: We retrospectively reviewed medical records and identified schizophrenia patients who were diagnosed with acute appendicitis between January 2000 to December 2009 and who presented at the emergency department in 6 University hospitals. Comparisons were made with non-schizophrenic patients with acute appendicitis. Data collected included the patient's age, sex, clinical features, time interval between onset of symptoms and visiting the hospital, Alvarado score, disease complications, and diagnostic imaging modality. RESULTS: We identified 27 schizophrenia patients with acute appendicitis. Mean age was 34.5+/-8.3; 51.9% were women. The median time from onset of symptoms to visiting the emergency department was 3.8+/-1.4 days in the schizophrenic group and 2.3+/-2.1 in the normal control group. The mean Alvarado scores were 5.4+/-1.5 for the schizophrenic group and 6.5+/-2.1 for controls. Perforation of the appendix and formation of abscesses was higher in schizophrenic patients with appendicitis. CONCLUSION: These findings suggest that acute appendicitis is diagnosed late and with difficulty in schizophrenic patients and these patients may be the most vulnerable to failure to obtain timely surgical care. Early and careful access is recommended in suspected cases of appendicitis in schizophrenia patients.

Correlation Between Inferior Vena Cava/Aorta Diameter Index and CVP - A Retrospective Study

PURPOSE: To evaluate whether the inferior vena cava/aorta diameter index correlates with central venous pressure (CVP) in the emergency department. METHODS: We selected patients who had computed tomography and had their central venous pressure checked between September 2008 and December 2008. Measurement of the IVC and aorta diameters was performed in conjunction with computed tomography. Subjects were divided into two groups: those with a CVP of less than 8 cm H2O (group A), and those with a CVP greater than 8 cm H2O (group B). Data collected included the patient's age, sex, height, systolic blood pressure, heart rate, hemoglobin level, IVC diameter and aorta diameter. We analyzed the correlation between the IVC/aorta index and the CVP. RESULTS: A total of 80 patients were enrolled in the study. Of the 80, 39 patients were assigned to group A and 41 to group B. The mean IVC diameter in group A was 14.98+/-2.58 mm; in group B it was and 18.84+/-3.01 (p<0.01). The IVC/aorta index in group A was 0.72+/-0.12; in group B it was 0.96+/-0.20 (p<0.01). The correlation coefficient for CVP and IVC was 0.72 (p<0.01); for CVP and aorta it was - 1.5 (p=0.17); for CVP and the IVC/aorta index it was 0.69 (p<0.01). CONCLUSION: The IVC/aorta index is related to the CVP. There is a difference in the IVC diameter and IVC/aorta index between groups A and B. The IVC/aorta index may be a predictor of body fluid status in the emergency department.

Correlation Between Sonographic Inferior Vena Cava/Aorta Diameter Index and Central Venous Pressure

PURPOSE: Body fluid status of patients in an emergency room environment is a very important parameter during clinical evaluation. In this study, we wanted to know the relationship between the diameter of the inferior vena cava and the diameter of the (IVC/Ao index) and central venous pressure (CVP) in hemodynamically unstable patients. METHODS: This study was done prospectively in an emergency medical center of a hospital from January to August, 2009. We compared the diameter of the IVC, the diameter of inferior vena cava/the body surface area index (IVC/BSA index), the IVC/Ao index, and other variables. Before and after hydration of patients with a systolic blood pressure less than 90 mmHg and who had a central venous catheter in place. Then, we calculated the correlation coefficient for DeltaCVP, DeltaIVC/Ao index, and other indexes. RESULTS: Fifty-nine patients were enrolled in the study. The mean IVC diameter before hydration was 14.3+/-2.7 mm; it was 15.6+/-2.7 mm after hydration (p<0.01). The IVC/BSA index before hydration was 8.75+/-1.72 and 9.55+/-1.79 after hydration (p<0.01). The IVC/Ao index before hydration was 1.08+/-0.23; it was 1.16+/-0.25 after hydration (p<0.01). The correlation coefficient for DeltaCVP and DeltaIVC was 0.37 (p<0.01); for DeltaCVP vs. the DeltaIVC/BSA index it was 0.37 (p<0.01); for the DeltaIVC/Ao index it was 0.27 (p=0.04). CONCLUSION: CVP has a higher correlation to IVC diameter and to IVC/BSA index than to the IVC/Ao index. Hence, we should estimate the IVC/Ao index and use that estimate along with other indexes to evaluate body fluid status when dealing with hemodynamically unstable patients.

The Obturator Hernia: A Challenge for Early Diagnosis with Computed Tomography in Emergency Situations

Obturator hernias usually occur in elderly persons. We sometimes miss the correct diagnosis because of vague symptoms and signs in older patients at initial presentation. For good clinical outcomes, we should make the correct diagnosis earlier, especially in aged patients. Here we report cases of obturator hernia in two aged patients without specific medical or surgical histories. Two older women suffered obturator hernias, which were characterized by clinical and radiographic features. They did not have any specific surgical and medical histories. For further evaluation of abdominal symptoms and signs, we did an abdominopelvic computed tomography (CT) scan in the emergency department. The CT scan revealed findings compatible with an obturator hernia in the area of the obturator foramen. They were treated and discharged without complications. When obturator hernia is suspected in a patient with related symptoms and signs, early CT scans should be considered to detect obturator hernia.

What is the Appropriate Level of Electrocardiography Education Needed for Emergency Medical Technicians (EMT) Students?

PURPOSE: Assess the appropriate level of electrocardiography (EKG) education that should be incorporated into the curriculum of emergency medical technician (EMT) students. METHODS: Consensus by EMT professors and emergency medicine specialists was obtained using two rounds of the Delphi survey. The questionnaire consisted of 70 items; 12 related to demographic information, 8 related to general interpretation of EKG, 26 related to interpretation of arrhythmia, 20 related interpretations of structural anomaly, infarction and systemic disease, and 4 related to interpretation of EKG findings used for advanced cardiac life support. We considered consensus to be agreement of greater than 7 of 9 (66.7%). RESULTS: 59 and 24 subjects were included in the first and second rounds of the Delphi survey, respectively. The response rate was 59% for the first round and 40.7% for the second round. Of 70 items, 40 items came to a consensus by the panel. All items related to interpretation of EKG and advanced cardiac life support and most (10 of 12) items related to basic content were felt to be important by both EMT professors and emergency medicine specialists. However, for items related to arrhythmia and related to structural anomaly, infarction and systemic disease, less than half of the items examined were felt to be necessary in the curriculum of EMT students (12 of 26 and 6 of 20). CONCLUSION: We identified 40 items that should be included into the EKG curriculum of EMT students. These findings should be used to create more effective educational programs for EMT students.