Association between continuous renal replacement therapy and mortality after acute herbicide (glyphosate and/or glufosinate) intoxication: propensity score matching approach

Purpose@#We investigated the association between continuous renal replacement therapy (CRRT) and mortality after acute glyphosate or glufosinate intoxication. @*Methods@#The electronic medical records of patients with acute herbicide ingestion who were admitted to the regional emergency center of a metropolitan city in Korea from 3/1/2013 to 2/28/2022 were analyzed and reviewed retrospectively. The case group received CRRT, while the control group did not. In total, 96 patients experienced acute herbicide intoxication in the study period. Baseline characteristics were analyzed and compared between the two groups after propensity score matching. The outcome variable was mortality fitted by a Cox proportional hazard model. @*Results@#After full matching between cases of CRRT use and controls (patients who did not receive CRRT) using propensity scores, 96 patients (27 cases, 69 controls) were analyzed. Propensity matching yielded adequate balance (standardized mean differences <0.25) for all covariates. We fit a Cox proportional hazards model with survival as the outcome and CRRT as a factor, including the matching weights in the estimation. The estimated hazard ratio was 0.41 (95% confidence interval, 0.23–0.76; p=0.0044), indicating that CRRT reduced mortality. @*Conclusion@#In this propensity score-matched analysis, CRRT reduced mortality in patients who visited the hospital with acute glyphosate or glufosinate intoxication. In patients with acute herbicide poisoning with high severity calculated by the APACHE II (Acute Physiology and Chronic Health Evaluation II) score and SOFA (Sequential Organ Failure Assessment) score, CRRT should be actively considered to improve the survival rate.

Serial blood and urine measurement of drugs in a patient with acute intoxication of tramadol and zolpidem resulting in QT prolongation: a case report

We reported a case of acute intoxication by tramadol and zolpidem, resulting in QT prolongation in a patient. A 38-year-old male patient presented to the emergency department (ED) because of poisoning from 3 g of tramadol and 50 mg of zolpidem 4 hours before. During supportive treatment, he developed QT prolongation without clinical manifestations. He was discharged 5 days after admission without any sequelae. We measured the blood and urine concentrations of tramadol and zolpidem at various time points, which revealed a blood tramadol concentration-dependent change in QT intervals and an increased blood tramadol concentration at 8 hours after the ED visit. Tramadol and zolpidem were metabolized by the same enzyme, cytochrome P450 3A4. Therefore, competitive inhibition may increase drug toxicity. In addition, the blood concentration of tramadol may increase and result in QT prolongation even after appropriate initial treatment.

The impact of rescuer’s posture on quality of chest compressions in hospital cardiopulmonary resuscitation: a randomized crossover mannequin study

Objective@#This randomized crossover simulation study aimed to compare the effectiveness of chest compressions, performed during 10 minutes of cardiopulmonary resuscitation, in three different compression postures: standing posture (SP), single-leg kneeling posture (SLKP) and both legs kneeling posture (BLKP) on a manikin lying on a bed. @*Methods@#Enrolled participants were doctors, nurses and emergency medical technicians who worked in the emergency department and performed chest compressions (CCs) without ventilation for 5 sessions (10 minutes) in the three compression postures from June to August 2019. The chest compression parameters (CCPs) such as compression depth, compression rate (CR), the accuracy of compression depth (ACD) and accuracy of relaxation (AR) were collected by the Resusci Anne PC skill report system. The statistical differences of CCPs between three postures were analyzed. @*Results@#A total of 32 participants were enrolled in this study. There were no significant differences between SP, SLKP and BLKP on compression depth (52.6 vs. 53.2 vs. 50.9 mm, P>0.05), CR (110.2 vs. 111.8 vs. 111.6 compressions/min, P>0.05), ACD (43.7% vs. 47.0% vs. 46.3%, P>0.05), and AR (99.4% vs. 99.0% vs. 99.3%, P>0.05). There were no significant differences in CCPs according to chest compression time in the three postures. However, there was a significant difference between the SP and BLKP (16.0 vs. 14.0, P=0.023) on the Borg scale of subjective fatigability. @*Conclusion@#In our study, when rescuers performed chest compression on a hospital bed, the parameters of CCs for the three compression postures were similar.

The impact of rescuer’s posture on quality of chest compressions in hospital cardiopulmonary resuscitation: a randomized crossover mannequin study

Objective@#This randomized crossover simulation study aimed to compare the effectiveness of chest compressions, performed during 10 minutes of cardiopulmonary resuscitation, in three different compression postures: standing posture (SP), single-leg kneeling posture (SLKP) and both legs kneeling posture (BLKP) on a manikin lying on a bed. @*Methods@#Enrolled participants were doctors, nurses and emergency medical technicians who worked in the emergency department and performed chest compressions (CCs) without ventilation for 5 sessions (10 minutes) in the three compression postures from June to August 2019. The chest compression parameters (CCPs) such as compression depth, compression rate (CR), the accuracy of compression depth (ACD) and accuracy of relaxation (AR) were collected by the Resusci Anne PC skill report system. The statistical differences of CCPs between three postures were analyzed. @*Results@#A total of 32 participants were enrolled in this study. There were no significant differences between SP, SLKP and BLKP on compression depth (52.6 vs. 53.2 vs. 50.9 mm, P>0.05), CR (110.2 vs. 111.8 vs. 111.6 compressions/min, P>0.05), ACD (43.7% vs. 47.0% vs. 46.3%, P>0.05), and AR (99.4% vs. 99.0% vs. 99.3%, P>0.05). There were no significant differences in CCPs according to chest compression time in the three postures. However, there was a significant difference between the SP and BLKP (16.0 vs. 14.0, P=0.023) on the Borg scale of subjective fatigability. @*Conclusion@#In our study, when rescuers performed chest compression on a hospital bed, the parameters of CCs for the three compression postures were similar.

Does the direction of J-tip of the guide-wire influence the misplacement of subclavian catheterization?

OBJECTIVE: Central venous catheter (CVC) misplacement can result in incorrect readings of the central venous pressure, vascular erosion, and intravascular thrombosis. Several studies have examined the correlation between the guidewire J-tip direction and misplacement rate. This study examined whether the guidewire J-tip direction (cephalad vs. caudad) affects the misplacement rate in right subclavian venous catheterization. METHODS: This prospective randomized controlled study was conducted between February 2016 and February 2017. The subjects were divided into two groups (cephalad group vs. caudad group) and the misplacement rate was compared according to guidewire J-tip direction in each group. RESULTS: Of 100 patients, the cephalad and caudad groups contained 50 patients each. The age, sex, and operator experience were similar in the two groups. In the cephalad group, misplacement of CVC insertion into the ipsilateral internal jugular vein occurred in two cases. In the caudad group, misplacement of CVC insertion into the contralateral subclavian vein occurred in one case, with loop formation in the brachiocephalic trunk in one case. Guidewire J-tip direction showed no significant correlation with CVC misplacement. CONCLUSION: The guidewire J-tip direction does not influence the rate of misplacement.

The influence of the decision making time by using point-of-care creatinine in patients with acute abdomen

OBJECTIVE: Radio-contrast abdomino-pelvic computed tomography (APCT) is considered the gold standard diagnostic tool for an acute abdomen in the emergency department. On the other hand, APCT has a risk of contrast-induced nephropathy. Emergency physicians evaluate the creatinine (Cr) level prior to taking a APCT for the above reason but it takes time to evaluation the serum Cr level. This study hypothesized that Cr measured by a point-of-care test (POCT) can shorten the time to making clinically important decisions for patients with an acute abdomen. METHODS: This prospective randomized study was conducted between March 2017 and October 2017. The subjects were divided into two groups (Cr measured by laboratory vs. Cr measured by POCT). To analyze the clinical acceptability for creatinine, agreement was demonstrated graphically by Bland-Altman plots. This study compared the time to make a clinically important decision by physicians and the length of stay at the emergency department in both groups. RESULTS: A total of 76 patients were eligible for the study, 38 patients were assigned to each group. There was no statistically significant difference in the time to the first medical examination (P=0.222) and emergency department stay time (P=0.802). On the other hand, the time to recognition of the Cr level (P < 0.001), time to performing APCT (P < 0.001), time to decision making (P < 0.001), and time to initiation of treatment (P < 0.001) were shortened significantly in the point-of-care creatinine group. CONCLUSION: In this study, the POCT for creatinine can allow rapid decision making by shortening the time to performing the radio-contrast APCT than the laboratory for patients with an acute abdomen.

The method to reduce the malposition rate via reposition of guidewire with ultrasound guidance in the central venous catheterization

OBJECTIVE: Malposition of central venous catheterization (CVC) may cause vascular related complications and catheter dysfunctions. The aim of this study was to reduce the malposition rate of CVC by repositioning the malposition after confirming the location of the guide-wire with ultrasound (US) guidance. METHODS: This research assessed the before study (group A) from January to December 2016 and after study (group B) from January to December 2017 in the emergency department. CVCs were performed using the anatomical landmark technique (group A) and US guided technique (group B). In group B, if the guided-wire was misplaced, it was drawn back and repositioned under US guidance. The final location of the catheter tip was confirmed by chest X-ray. The rate of malposition before and after repositioning of the two groups was compared. RESULTS: The subjects were group A (694 cases) and group B (619 cases) with a total of 1,313 patients. The rate of malposition before repositioning of the two groups were 16 cases (2.3%) and 13 cases (2.1%), respectively, and no statistically significant difference was observed (P>0.05). In group B, there were 10 cases (1.6%) of guidewire malposition that was identified and three cases (0.5%) of catheter malposition could not be identified under US examination. The malpositioned guidewires were all corrected by repositioning under ultrasound guidance. The rate of malposition after repositioning of the two groups were 2.3% (n=16) and 0.5% (n=3), respectively, and a statistically significant difference was observed (P=0.009). CONCLUSION: With US guidance, confirming the location and repositioning CVC guidewire can reduce the malposition rate in CVCs.

Vasopressor requirement during targeted temperature management for out-of-hospital cardiac arrest caused by acute myocardial infarction without cardiogenic shock

OBJECTIVE: We investigated whether patients with out-of-hospital cardiac arrest (OHCA) due to an acute myocardial infarction without cardiogenic shock required higher doses of vasopressors with low targeted temperature management (TTM) after return of spontaneous circulation. METHODS: We included consecutive comatose patients resuscitated from OHCA between January 2011 and December 2013. Patients with return of spontaneous circulation, regional wall motion abnormality on echocardiography, and coronary artery stenosis of ≥70% on percutaneous coronary artery angiography were enrolled. These patients received 36°C TTM or 33°C TTM following approval of TTM by patients’ next-of-kin (36°C and 33°C TTM groups, respectively). The cumulative vasopressor index was compared between groups. RESULTS: During induction phase, dose of vasopressors did not differ between groups. In the maintenance phase, the norepinephrine dose was 0.37±0.57 and 0.26±0.91 µg·kg⁻¹·min⁻¹ in the 33°C and 36°C TTM groups, respectively (P<0.01). During the rewarming phase, the norepinephrine and dopamine doses were 0.49±0.60 and 9.67±9.60 mcg·kg⁻¹·min⁻¹ in the 33°C TTM group and 0.14±0.46 and 3.13±7.19 mcg·kg⁻¹·min⁻¹ in the 36°C TTM group, respectively (P<0.01). The median cumulative vasopressor index was 8 (interquartile range, 3 to 8) and 4 (interquartile range, 0 to 8) in the 33°C and 36°C TTM groups, respectively (P=0.03). CONCLUSION: In this study, patients with OHCA due to acute myocardial infarction without cardiogenic shock had an elevated vasopressor requirement with 33°C TTM compared to 36°C TTM during the maintenance and rewarming phases.

How to Decrease the Malposition Rate of Central Venous Catheterization: Real-Time Ultrasound-Guided Reposition / 대한구급학회지

BACKGROUND: The purpose of this retrospective and prospective study is to evaluate the efficiency of ultrasound (US) guidance as a method of decreasing the malposition rate of central venous catheterization (CVC) in the emergency department (ED). METHODS: We retrospectively enrolled 379 patients who underwent landmark-guided CVC (Group A) and prospectively enrolled 411 patients who underwent US-guided CVC (Group B) in the ED of a tertiary hospital. Malposition of the CVC tip is identified when the tip is not located in the superior vena cava (SVC). In Group B, we performed US-guided intravascular guide-wire repositioning and then confirmed the location of the CVC tip with chest radiography when the guide-wire was visible in any three other vessels rather than in the approached vessel. In the case of a guide-wire inserted into the right subclavian vein (SCV), the left SCV and both internal jugular veins (IJV) were referred to as the three other vessels. The two subject groups were compared in terms of the malposition rate using Fisher's exact test (significance = p < 0.05). RESULTS: There were 38 malposition cases out of a total of 790 CVCs. The malposition rates of Groups A and B were 5.5% (21) and 4.1% (17), respectively, and no statistically significant difference in malposition rate between the two groups was found. In Group B, the malposition rate was decreased from 4.1% (17) to 1.2% (5) after the guide-wire was repositioned with US guidance, which led to a statistically significant difference in malposition rate (p < 0.01). CONCLUSIONS: The authors concluded that repositioning the guide-wire with US guidance increased correct placement of central venous catheters toward the SVC.

Bacterial Contamination Conditions in Ambulances and their Equipment in South Korea

PURPOSE: Many patients in South Korea are brought to hospitals by ambulance. As such, bacterial contamination within the ambulance and their critical or semi-critical equipment may be dangerous, especially for immunocompromised patients. No previous studies have examined the distribution patterns of pathogenic bacteria in ambulances or the bacterial contamination rate associated with riding in an ambulance in South Korea. The purpose of this study was to determine the distribution of pathogenic bacteria species in ambulances, and to investigate the bacterial contamination rate associated with ambulances and their equipment, in South Korea. METHODS: Thirty ambulances (17 from private facilities and 13 from regional emergency centers) were enlisted for this study. We took 955 swabs and isolated the resulting bacteria. We surveyed the intervals between cleaning and disinfecting of the ambulances and their equipment. We compared the distributional of the bacterial species, following Spaulding's classification, between critical equipment (CE), semi-critical equipment (SCE) and non-critical equipment (NCE) in the ambulances, using the chi-square test. RESULTS: The ambulances were cleaned and disinfected every 5 and 8 days, respectively. The equipment was cleaned and disinfected once every 22 and 30 days, respectively. Of the 955 swabs, 159 (16.6%) were found to be contaminated by bacteria. Fourteen pathogenic bacteria were isolated from the CE and SCE, but no methicillin-resistant or vancomycin-resistant bacteria were found. CONCLUSION: Approximately 16.6% of the ambulances and their equipment were contaminated by bacteria, and pathogenic bacteria were found on both CE and SCE. Consequently, in South Korea, we find a risk associated with the hazard presented by bacterial contamination in ambulance CE and SCE.

Bacterial Contamination Conditions in Ambulances and their Equipment in South Korea

PURPOSE: Many patients in South Korea are brought to hospitals by ambulance. As such, bacterial contamination within the ambulance and their critical or semi-critical equipment may be dangerous, especially for immunocompromised patients. No previous studies have examined the distribution patterns of pathogenic bacteria in ambulances or the bacterial contamination rate associated with riding in an ambulance in South Korea. The purpose of this study was to determine the distribution of pathogenic bacteria species in ambulances, and to investigate the bacterial contamination rate associated with ambulances and their equipment, in South Korea. METHODS: Thirty ambulances (17 from private facilities and 13 from regional emergency centers) were enlisted for this study. We took 955 swabs and isolated the resulting bacteria. We surveyed the intervals between cleaning and disinfecting of the ambulances and their equipment. We compared the distributional of the bacterial species, following Spaulding's classification, between critical equipment (CE), semi-critical equipment (SCE) and non-critical equipment (NCE) in the ambulances, using the chi-square test. RESULTS: The ambulances were cleaned and disinfected every 5 and 8 days, respectively. The equipment was cleaned and disinfected once every 22 and 30 days, respectively. Of the 955 swabs, 159 (16.6%) were found to be contaminated by bacteria. Fourteen pathogenic bacteria were isolated from the CE and SCE, but no methicillin-resistant or vancomycin-resistant bacteria were found. CONCLUSION: Approximately 16.6% of the ambulances and their equipment were contaminated by bacteria, and pathogenic bacteria were found on both CE and SCE. Consequently, in South Korea, we find a risk associated with the hazard presented by bacterial contamination in ambulance CE and SCE.

The Accuracy of a Simple Radiologic Study for Diagnosing Intra-articular Fractures of the Distal Radius

PURPOSE: To determine the accuracy of a simple radiologic images as a diagnostic tool for intra-articular fractures of the distal radius (IAF). METHODS: This study proceeded prospectively from April 2008 to December 2009. We let 25 ERs (emergency residents) interpret the radiologic images of 45 patients who had injuries of their wrists and presented to a hospital. We used surgical findings or multidetector computed tomography (MDCT) to confirm the final diagnosis of enrolled patients. Finally, we evaluated the sensitivity, specificity, and accuracy of simple radiologic images of IAF. We also compared test performance characteristics between the four grades of the ERs (1st, 2nd, 3rd, and 4th years) via Mann-Whitney and Kruskal-Wallis tests. We considered differences to be significant, if p<0.05 RESULTS: Of 45 patients, 40 (88.9%) had fractures of the distal radius; of the 40, 25 (62.5%) had IAF. There were no differences in sensitivity, specificity, or accuracy between the four grades of the ERs (p=0.86, 0.76, 0.49). The sensitivity of simple radiologic images for diagnosing IAF was 0.69; specificity was 0.77; accuracy was 0.72. CONCLUSION: In this study, we found that simple radiologic images as the primary diagnostic tool for intra-articular fractures of the distal radius were not completely adequate. Therefore, ERs should carefully consider using MDCT imaging to diagnose patients who suffer from wrist pain.