Effects of emergency doctor’s hospitalization authority from internal medicine and utilizing emergency ward on length of stay in emergency department

Objective@#The emergency department (ED) length of stay (LOS) is related to ED overcrowding and emergency practice. This study aimed to investigate the effects of enabling an ED doctor to have the authority to make hospitalization decisions and utilization of the emergency ward on ED LOS. @*Methods@#This retrospective observational study included patients who were admitted through a local emergency medical center. We compared the ED LOS between the periods' March to July 2018 and March to July 2019. In the latter period, ED doctors were authorized to take decisions on patient hospitalizations from the internal medicine department, and the emergency ward was operated under these new conditions. @*Results@#A total of 6,291 patients were included in the study, with 2,934 in 2018 and 3,357 in 2019. In the comparison of ED LOS for internal medicine inpatients by year, there was a significant reduction in the total ED LOS (1,129.0 [491.0-1,618.0] minutes vs. 539.0 [344.0-1,016.25] minutes, P<0.001), LOS before the admission decision (345.0 [198.0-634.0] minutes vs. 280.0 [176.0-442.3] minutes, P<0.001), and LOS after the admission decision (415.0 [147.0-1,089.0] minutes vs. 179.5 [80.0-422.0] minutes, P<0.001). In a subgroup analysis of internal medicine inpatients in 2019, the admission sheets of an ED doctor showed a significant decrease in LOS before the admission decision (268.0 [170.5-424.5] minutes vs. 404.0 [252.0-570.5] minutes, P<0.001). Also, the utilization of the emergency ward showed a significant decrease in LOS after the admission decision (147.0 [75.0-283.0] minutes vs. 187.0 [81.0-460.0] minutes, P<0.001). @*Conclusion@#The delegation of hospitalization decisions to the ED doctor and the subsequent utilization of the emergency ward shorten the ED LOS of internal medicine inpatients.

Analysis of risk factors between influenza and the occurrence of complicated influenza

Objective@#Influenza is an acute, respiratory viral disease, and may lead to complications such as pneumonia, which presents with significant morbidity and mortality. Previous studies did not have sufficient data regarding the risk factors and complications of the H1N1 flu caused by the influenza A virus subtype H1N1 during the 2009 pandemic in Korea. Therefore, this study was conducted to analyze the characteristics and risk factors of complicated influenza. @*Methods@#Data were collected from influenza patients who visited a local emergency center in Daegu from January 2017 to December 2019. The study population was divided into three groups: influenza, influenza pneumonia, and influenza with a bacterial infection. The patients’ sex, age, influenza type, comorbidities, vital signs, symptoms, laboratory findings, and clinical outcomes were investigated for the risk analysis of complicated influenza. @*Results@#The total number of patients was 574, of which 393 (68.5%) had influenza only, 135 (23.5%) had influenza pneumonia, and 46 (8%) had influenza with a bacterial infection. The odds ratio of complicated influenza was found using multivariate logistic regression analysis; for influenza pneumonia, it was 2.94 for patients aged over 65-years, 3.47 for those with an elevated procalcitonin level, 2.24 for cough, 6.41 for dyspnea, and 3.11 for renal disease. For influenza with bacterial infection, the odds ratio was 2.31 for males, 2.68 for over 80-year-olds, 3.75 for elevated procalcitonin levels, 7.61 for dyspnea, and 3.65 for nursing home residents. @*Conclusion@#The risk factors of complicated influenza were advanced age, elevated procalcitonin level, dyspnea, renal disease, and residing in a nursing home.

Characteristics of alcohol-related non-traffic accident trauma patients

Objective@#The purpose of this study was to analyze the characteristics of alcohol-related non-traffic accident trauma patients. @*Methods@#A total of 2,582 non-traffic accident patients, above 16 years old, who visited the emergency department (ED) from July 1, 2016, to June 30, 2017, were retrospectively analyzed. The patients were categorized as alcohol group (A group) and no alcohol group (NA group) after checking their electronic medical records. Their general characteristics, the severity of their injury, and their ED length of stay were compared. @*Results@#The A group included younger patients, a higher percentage of males, and a higher frequency of visits to the ED via the 119 ambulance route than the NA group. The A group had a higher proportion of patients being struck by a person or object in terms of the mechanism of injury, intentional violence, and head injuries, especially in the face as compared to the NA group. In terms of the severity of the injury, the Injury Severity Score was lower in the A group than in the NA group, and the ratio of bone fracture and/or cerebral hemorrhage was also lower. As per the survey, the A group tended to stay in the ED longer than the NA group. @*Conclusion@#The characteristics of alcohol-related non-traffic accident trauma patients show that they have a relatively long stay in the ED, a high ratio of facial injury with low trauma severity, and need professional treatment facilities with specialized personnel and equipment.

What is the appropriate time for emergent endoscopic retrograde cholangiopancreatography in patients with acute cholangitis?

Objective@#Acute cholangitis is a clinical condition caused by infection of an obstructed biliary system, which is normally managed with intravenous fluids, antibiotics, and biliary drainage. Although endoscopic retrograde cholangiopancreatography (ERCP) is the preferred method of biliary drainage, guidelines for biliary drainage time remain unclear. @*Methods@#The current research is a retrospective study of patients with acute cholangitis who had undergone ERCP between January 2016 and December 2019. We investigated the effect of the time taken from visit to the emergency department and commencement of the ERCP, on hospital length of stay. @*Results@#A total of 441 patients were included in this study. No association was observed between the severity of acute cholangitis and ERCP time. However, the length of hospital stay was significantly shorter for patients who underwent ERCP less than 12 hours after arrival at the emergency department. @*Conclusion@#Conducting ERCP within 12 hours of arrival is associated with reduced hospital stays, regardless of the severity of acute cholangitis.

Characteristics of alcohol-related non-traffic accident trauma patients

Objective@#The purpose of this study was to analyze the characteristics of alcohol-related non-traffic accident trauma patients. @*Methods@#A total of 2,582 non-traffic accident patients, above 16 years old, who visited the emergency department (ED) from July 1, 2016, to June 30, 2017, were retrospectively analyzed. The patients were categorized as alcohol group (A group) and no alcohol group (NA group) after checking their electronic medical records. Their general characteristics, the severity of their injury, and their ED length of stay were compared. @*Results@#The A group included younger patients, a higher percentage of males, and a higher frequency of visits to the ED via the 119 ambulance route than the NA group. The A group had a higher proportion of patients being struck by a person or object in terms of the mechanism of injury, intentional violence, and head injuries, especially in the face as compared to the NA group. In terms of the severity of the injury, the Injury Severity Score was lower in the A group than in the NA group, and the ratio of bone fracture and/or cerebral hemorrhage was also lower. As per the survey, the A group tended to stay in the ED longer than the NA group. @*Conclusion@#The characteristics of alcohol-related non-traffic accident trauma patients show that they have a relatively long stay in the ED, a high ratio of facial injury with low trauma severity, and need professional treatment facilities with specialized personnel and equipment.

Study on the association of air pollution and acute myocardial infarction

Objective@#Air pollutants have attracted increasing interest worldwide, including Korea. Acute and chronic exposure to air pollutants has adverse effects on health. Therefore, this study examined the association of air pollutants with myocardial infarction. @*Methods@#This study included 542 patients who underwent coronary angiography and were diagnosed with acute coronary artery occlusion after visiting a local emergency medical center from January 1, 2016, to December 31, 2018. The days (1,096) were divided into two groups: myocardial infarction days group (the days when symptoms of myocardial infarction developed) and non-myocardial infarction days group (the days when symptoms of myocardial infarction did not develop). This study compared the air pollutants (PM10, PM2.5, O3, SO2, CO, and NO2) and prognosis (survivor, death) from two days ago to the days between the myocardial infarction days and non-myocardial infarction days. @*Results@#The PM10 and PM2.5 of the myocardial infarction days group were 44.332±18.892 and 25.193±12.009 μm/m3, respectively, and those of the non-myocardial infarction days group were 41.906±19.263 and 23.693±12.053 μm/m3, respectively. On day one before symptom development, the PM2.5 of the myocardial infarction days group was 25.316± 11.977 μm/m3, which was higher than that of the non-myocardial infarction days groups (23.642±12.053 μm/m3), and there were no significant differences between the gaseous air pollution and the number of occlusions, except on a 0 day of ozone. The PM2.5 (proximal, middle, and distal according to the vessel size) at day 0 was 25.747±12.361, 22.941± 11.477, and 21.486±10.924 μm/m3, respectively; the proximal group had the highest value. During the study days, the PM10 of the death and survival groups was 51.440 (±20.140)-56.924 (±25.225) μm/m3 and 41.155 (±18.544)-43.002 (±18.858) μm/m3, respectively. PM2.5 of the death and survival groups was 26.968 (±14.140)-30.145 (±12.829) and 23.770 (±11.685)-24.170 (±12.696) μm/m3, respectively. @*Conclusion@#Myocardial infarction was found to develop more on the day with the highest PM2.5 and PM10 on day 0 and -1. A high PM2.5 is related to an occlusion of the proximal coronary artery. Therefore, PM2.5 has a stronger association with myocardial infarction than PM10. Furthermore, increased particulate air pollution for three consecutive days is associated with a poor prognosis.

Appropriateness of triage by emergency medical technician using the Korean Triage and Acuity Scale

Objective@#Appropriate triage in emergency rooms is fundamental. This study assessed the appropriateness of the triage results using the Korean Triage and Acuity Scale (KTAS) by emergency medical technicians (EMT) by comparing an emergency physician and a KTAS instructor. @*Methods@#The medical records of patients who presented to a local emergency room for a month were analyzed retrospectively. This study compared the triage results using KTAS among EMTs, an emergency physician, and a KTAS instructor. @*Results@#Among 2,248 patients, consistent KTAS codes of 1,453 patients (64.6%) were obtained between the EMTs and emergency physicians. In addition, a KTAS instructor had agreed with the results of EMT for 1,686 patients (75%). The Kappa value to evaluate the agreement between an emergency physician and a KTAS instructor was 0.72 (95% confidence interval, 0.55-0.89). @*Conclusion@#The results of triage using KTAS by EMT was appropriate because substantial agreement existed between an emergency physician and KTAS instructor. On the other hand, there were some inappropriate results of triage, and it is proposed that the results would be reflected in KTAS provider education programs aimed at EMTs. It is expected that qualified KTAS providers will be produced, and the quality of triage can be controlled and improved.

Differential Expression of Ca²⁺-buffering Protein Calretinin in Cochlear Afferent Fibers: A Possible Link to Vulnerability to Traumatic Noise

The synaptic contacts of cochlear afferent fibers (CAFs) with inner hair cells (IHCs) are spatially segregated according to their firing properties. CAFs also exhibit spatially segregated vulnerabilities to noise. The CAF fibers contacting the modiolar side of IHCs tend to be more vulnerable. Noise vulnerability is thought to be due to the absence of neuroprotective mechanisms in the modiolar side contacting CAFs. In this study, we investigated whether the expression of neuroprotective Ca²⁺-buffering proteins is spatially segregated in CAFs. The expression patterns of calretinin, parvalbumin, and calbindin were examined in rat CAFs using immunolabeling. Calretinin-rich fibers, which made up ~50% of the neurofilament (NF)-positive fibers, took the pillar side course and contacted all IHC sides. NF-positive and calretinin-poor fibers took the modiolar side pathway and contacted the modiolar side of IHCs. Both fiber categories juxtaposed the C-terminal binding protein 2 (CtBP2) puncta and were contacted by synaptophysin puncta. These results indicated that the calretinin-poor fibers, like the calretinin-rich ones, were afferent fibers and probably formed functional efferent synapses. However, the other Ca²⁺-buffering proteins did not exhibit CAF subgroup specificity. Most CAFs near IHCs were parvalbumin-positive. Only the pillar-side half of parvalbumin-positive fibers coexpressed calretinin. Calbindin was not detected in any nerve fibers near IHCs. Taken together, of the Ca²⁺-buffering proteins examined, only calretinin exhibited spatial segregation at IHC-CAF synapses. The absence of calretinin in modiolar-side CAFs might be related to the noise vulnerability of the fibers.

Clinical characteristics and mortality-predictive factors analyses of glyphosate intoxication

OBJECTIVE: Glyphosate intoxicated patients are increasing as glyphosate use increases. This study was conducted to analyze clinical characteristics of glyphosate intoxication patients to provide early treatment to high risk patients. METHODS: We retrospectively collected data pertaining to glyphosate intoxicated patients who visited emergency department from January 2012 to December 2016 based on medical records. The patients were divided into survivors and deaths, after which their clinical characteristics and laboratory results were compared. RESULTS: Among 84 glyphosate intoxicated patients, 12 died (14.3%). The mortality group showed advanced age (P=0.006), low blood pressure (P=0.001), worse mental status (P=0.000), low arterial blood pH (P=0.000), high serum creatinine (P=0.030), high glucose (P=0.000), high serum lactate (P=0.011), and low serum albumin (P=0.034). Logistic multivariate regression analysis revealed that the mortality group had advanced age (odds ratio [OR], 1.193), high serum glucose (OR, 1.018), and low systolic blood pressure (OR, 0.961) compared to the survivor group. CONCLUSION: On the scene and emergency department, glyphosate intoxicated patients with advanced age, high serum glucose level, and low systolic blood pressure should be provided early supportive treatments and transported to a toxicology facility.

Relevance of emergency level assessment by the Korean Triage and Acuity Scale for adult patients in a local emergency medical center

OBJECTIVE: The Korean Triage and Acuity Scale (KTAS), which was implemented in 2016, needs to be assessed for its validity and reliability. Here we evaluate the relevance of emergency level assessment by analyzing the validity of KTAS as a Korean standardized triage system. METHODS: We retrospectively analyzed the medical records of adults who presented to a local emergency room (ER) during an 18-month period. We compared medical resources used, life-saving interventions performed, length of stay (LOS) in ER, admission rate, and mortality at each KTAS level. RESULTS: Among a total of 40,339 patients, most patients were at KTAS 4 (n=19,532, 48.4%) and the longest median LOS in ER was 450 minutes at KTAS 2. As the KTAS level increased, the percentage of medical resources used and life-saving interventions performed increased significantly. The odds of total admission and intensive care unit admission were significantly higher at KTAS 1 through 4 compared to those at KTAS 5. The odds related to admission and mortality were also significantly higher at KTAS 3 than at KTAS 4. CONCLUSION: We concluded that the KTAS, as a Korean standardized triage system of emergency level assessment, is relevant. Further, KTAS 1-3 and KTAS 4-5 are appropriate criteria to distinguish emergency and non-emergency patients.

A Case of Cement Hardening Agent Intoxication with Acute Kidney Injury

Chronic silica nephropathy has been associated with tubulointerstitial disease, immune-mediated multisystem disease, chronic kidney disease, and end-stage renal disease. On the other hand, acute intentional exposure is extremely rare. The authors' experienced a 44-year-old man who took rapid cement hardener (sodium silicate) in a suicide attempt whilst in a drunken state. He visited the emergency department approximately 1 hour after ingestion. Information on the material was obtained after 3 L gastric lavage. The patient complained of a sore throat, epigastric pain, and swollen to blood tinged vomitus. Proton pump inhibitors, hemostats, steroid, and fluids were administered. Nine hours after ingestion, he was administered 200 mL hematochezia. Immediately after, a gastroenterologist performed an endoscopic procedure that revealed diffuse hyperemic mucosa with a color change and variable sized ulceration in the esophagus, whole stomach, and duodenal 2(nd) portion. Approximately 35 hours later, persistent oligouria and progressive worsening of the renal function parameters (BUN/Cr from 12.2/1.2 to 67.5/6.6 mg/dL) occurred requiring hemodialysis. The patient underwent 8 sessions of hemodialysis for 1 month and the BUN/Cr level increased to 143.2/11.2 mg/dL and decreased to 7.6/1.5 mg/dL. He was discharged safely from the hospital. Follow up endoscopy revealed a severe esophageal stricture and he underwent endoscopic bougie dilatation. Acute cement hardener (sodium silicate) intoxication can cause renal failure and strong caustic mucosal injury. Therefore, it is important to consider early hemodialysis and treatment to prevent gastrointestinal injury and remote esophageal stricture.

The effect of hospital based clinical practice of paramedic students on cardiopulmonary resuscitation performance and recognition: a before and after study

OBJECTIVE: Various educational programs have been implemented to achieve skill, willingness and self-confidence in performing cardiopulmonary resuscitation (CPR). Paramedic students usually participate in clinical practice in emergency department as one of their educational courses. We investigated the effects of hospital based clinical practice and participation in real cardiac arrest situation on paramedic students' CPR performance and recognition. METHODS: Eighty-one paramedic students from 10 different universities who received hospital based clinical practice for 3 or 4 weeks in a regional emergency medical center from December 2016 to August 2017 were enrolled in our study. Subjects were asked, using a questionnaire, about their confidence and willingness to perform CPR before and after clinical practice. We also objectively measured two minute-CPR performance using the Laerdal skill reporter before and after clinical practice. During clinical practice, students participated in real CPR situations and took several theoretical examinations; however, additional CPR practical training was not included. RESULTS: This study included 48.1% male volunteers and 70.4% respondents who had Basic Life Support provider certification. The average number of real CPR situations participated in was 8.35 times. Scores in confidence of CPR increased significantly (3.80 vs. 4.36, P < 0.001) after clinical practice; however, scores in willingness to conduct CPR were high in both groups (4.46 vs. 4.48, P=0.787). Average chest compression depth also increased significantly (51.3 mm vs. 55.5 mm, P < 0.001) after clinical practice, but average compression rate showed no difference (111 vs. 111, P=0.694). Correct hand positioning and chest recoil also showed no difference between groups. CONCLUSION: Hospital based clinical practice of paramedic students could provide extra confidence in student's ability to perform CPR and lead to adequate chest compression depth.

Comparison of symptomatic and asymptomatic pulmonary embolism in proximal deep vein thrombosis / 영남의대학술지

BACKGROUND: Deep vein thrombosis (DVT) and pulmonary embolism (PE) are conditions with significant morbidity and mortality. Proximal DVT has a significant association with PE and possible fatal outcomes. Traditionally, PE is subdivided into symptomatic PE and asymptomatic PE, which have different treatments, preventions and prognoses. The growing utilization of computed tomography pulmonary angiography has led to increased detection of PE in DVT patients. This study examined the clinical characteristics and compared symptomatic PE and asymptomatic PE following proximal DVT. METHODS: The medical records of 258 DVT inpatients from July, 2012 to June, 2015 were reviewed retrospectively. After excluding the patients who did not performed PE evaluation and were not diagnosed with PE, 95 patients diagnosed with PE following proximal DVT were enrolled in this study. They were divided into the symptomatic PE group and asymptomatic PE group. RESULTS: The body weight, body mass index, thrombus size, thrombus length and location were similar in the two groups. The symptomatic PE following proximal DVT group showed an older age, higher incidence of emergency department access (85.0% vs. 38.7%, p < 0.001) and preceding infection (25.0% vs. 1.3%, p < 0.001) as well as a higher incidence of immobilization (45.0% vs 13.3%, p=0.016). In the multivariate logistic regression study, preceding infection and emergency department access showed significant association with symptomatic PE. CONCLUSION: In proximal DVT inpatients, symptomatic PE was associated with emergency department access and preceding infection. The possibility of a symptomatic PE event should be considered in proximal DVT patients, especially those who were admitted through the emergency department and had preceding infection.

A Case of Prehospital Ventricular Fibrillation due to Electrical Injury

These days, the frequency of electrical injuries is increasing with the increased spread of electricity use. Electrical injuries cause various complications, ranging from a local superficial skin injury to extensive internal organ damage, including essential vital organs, such as the cardiovascular or central nervous system. We encountered the patient who collapsed after an electrical injury on the scene and was resuscitated successfully after the prehospital early recognition of ventricular fibrillation, and rapid defibrillation, followed by post cardiac arrest care in the hospital. Prehospital early electrocardiogram monitoring and defibrillation may be needed in electrical injured patients.

Comparison of symptomatic and asymptomatic pulmonary embolism in proximal deep vein thrombosis / 영남의대학술지

BACKGROUND: Deep vein thrombosis (DVT) and pulmonary embolism (PE) are conditions with significant morbidity and mortality. Proximal DVT has a significant association with PE and possible fatal outcomes. Traditionally, PE is subdivided into symptomatic PE and asymptomatic PE, which have different treatments, preventions and prognoses. The growing utilization of computed tomography pulmonary angiography has led to increased detection of PE in DVT patients. This study examined the clinical characteristics and compared symptomatic PE and asymptomatic PE following proximal DVT.METHODS: The medical records of 258 DVT inpatients from July, 2012 to June, 2015 were reviewed retrospectively. After excluding the patients who did not performed PE evaluation and were not diagnosed with PE, 95 patients diagnosed with PE following proximal DVT were enrolled in this study. They were divided into the symptomatic PE group and asymptomatic PE group.RESULTS: The body weight, body mass index, thrombus size, thrombus length and location were similar in the two groups. The symptomatic PE following proximal DVT group showed an older age, higher incidence of emergency department access (85.0% vs. 38.7%, p < 0.001) and preceding infection (25.0% vs. 1.3%, p < 0.001) as well as a higher incidence of immobilization (45.0% vs 13.3%, p=0.016). In the multivariate logistic regression study, preceding infection and emergency department access showed significant association with symptomatic PE.CONCLUSION: In proximal DVT inpatients, symptomatic PE was associated with emergency department access and preceding infection. The possibility of a symptomatic PE event should be considered in proximal DVT patients, especially those who were admitted through the emergency department and had preceding infection.

Relationship between Re-visits and Complaints' Characters of Out Patient Department and Emergency Department in One Tertiary Hospital

PURPOSE: Emergency department (ED) and Outpatient department (OPD) are similar to some extent, but there are differences. The difference is complaints that can be encountered during practice. The aim of this study was to investigate complaints of OPD and ED and factors associated with Re-visits. METHODS: We retrospectively investigated 431 official complaints of visitors and 426 re-visitors in one tertiary university hospital OPD and ED between January 1, 2011 and December 31, 2014. RESULTS: ED complaints were 18 times more common than OPD. The two groups differed in chronic disease, follow up duration and frequency, transportation, visiting day of the week, visiting time, relation between patient and claimant, claimant age, related department, medical department, method of expression, major reason for complaints, treatment result, and re-visit. The factors associated with ED re-visits were chronic disease, follow up duration and frequency, treatment result, and expression method. CONCLUSION: Doctors, particularly emergency physicians in the ED, were the subject of the most common complaints. Patients had more complaints about the subjective time delay than the ED retention time. Emergency physicians should be more alert for first visit patients.

Stenosis or Occlusion of the Right Subclavian and Common Carotid Arteries Is More Common than That of the Innominate Artery in Takayasu Arteritis

PURPOSE: The aim of this study was to introduce the phenomenon that stenosis or occlusion occurs less frequently in the innominate artery than in the right subclavian and common carotid arteries, which are not first-order branches of the aorta, in Takayasu arteritis (TA). MATERIALS AND METHODS: We retrospectively reviewed the medical records and image findings of all patients who were diagnosed with TA from 2006 to 2014. Two vascular surgeons and two radiologists interpreted the images by disease character, location, and extent of occlusion based on computed tomography angiography, magnetic resonance angiography, or digital subtraction arteriography. We have also reviewed the literature on arterial involvement in TA. RESULTS: A total of 42 patients were diagnosed with TA. The mean age was 43.9 years, and 83.3% (35/42) of the patients were women. The left subclavian artery was the most common stenosis or occlusion site (17, 40.5%) among the aortic branches. The innominate artery was a less common site (3, 7.1%) than the right subclavian artery (4, 9.5%) and the right common carotid artery (9, 21.4%). All innominate artery cases were found after endovascular procedures of the right subclavian or common carotid arteries. CONCLUSION: The innominate artery might develop stenosis or occlusion less frequently than the right subclavian and common carotid arteries in Korean TA patients.

Factors Associated with Skeletal Chest Injuries Secondary to Cardiopulmonary Resuscitation of In-Hospital Cardiac Arrest Patients

PURPOSE: Rib and sternal fractures are common complications of chest compressions during cardiopulmonary resuscitation (CPR). The aim of this study is to investigate skeletal chest injuries following chest compressions and factors associated with skeletal chest injuries. METHODS: A retrospective study was conducted for 10 years from January 2005 to February 2015. Skeletal chest injuries in patients who underwent computerized tomography (CT) after return of spontaneous circulation (ROSC) were analyzed. The exclusion criteria were patients with insufficient medical records, under 18 years old, traumatic cardiac arrest, and out-of-hospital cardiac arrest. RESULTS: During the period 106 patients were included. The CT scan after ROSC showed that 47 patients (44.3%) had rib fractures, and 20 patients (18.9%) had sternal fractures. The rib fracture group showed higher age (73 vs 61, p<0.001), longer CPR time (10 vs 6 min, p<0.001), and higher incidence of sternal fracture (34% vs 6.8%, p<0.001). The sternal fracture group showed longer CPR time (10 vs 7, p<0.05) and higher incidence of rib fractures (80% vs 4.7%, p<0.001). In multivariate logistic regression analysis, age (OR 1.087; 95% CI 1.041 to 1.134, p<0.001), CPR time (OR 1.200; 95% CI 1.087 to 1.323, p<0.001), and sternal fracture (OR 4.524; 95% CI 1.259 to 16.697, p=0.021) showed significant association with rib fracture. CONCLUSION: Rib and sternal fractures are frequent complications in patients who underwent CPR. In hospital cardiac arrest patients with older age, longer CPR time, and sternal fracture needed more precaution for rib fractures and other complications.

A Case of Traumatic Cardiac Arrest due to SCIWORA (Spinal Cord Injury without Radiographic Abnormality)

Spinal cord injury without radiographic abnormality (SCIWORA) is a rare injury and reported less frequently in adults than children. The symptoms and prognosis of SCIWORA are associated with injury level of the spinal cord, neurologic impairment, resolution rate, etc. High level injury of the spinal cord can lead to development of quadriplegia, paraplegia, spinal shock, cardiac dysfunction, and respiratory arrest. However initial presenting cardiac arrest is extremely rare in SCIWORA. Therefore we report on a cardiac arrest patient due to SCIWORA after a motorcycle accident. A 50-year-old male was an out of hospital cardiac arrest in a transferred hospital. At the time of local hospital arrival, he was in cardiac arrest state. Therefore he received endotracheal intubation and cardiopulmonary resuscitation for 5 minutes, and spontaneous circulation returned. In our hospital, he underwent whole body computed tomography and echocardiography. He had a fibular fracture and simple multiple rib fractures without pneumothorax and hemothorax. Magnetic resonance imaging showed spinal cord edema from the cervicomedullary junction to C3 level and ossification of the posterior longitudinal ligament at C2-3 level without bony abnormality. In unknown cause of traumatic cardiac arrest, high level spinal cord injury and further evaluation of the cervical spine may be needed.

A Case of a Acute Myocardial Infarction Complicated by a Snake Bite

We experienced a rare case of acute myocardial infarction associated with a coagulopathy-complicating snake bite. A previously healthy 72-year-old Korean woman was bitten on the right thumb by a snake of unknown species. She was admitted to a local medical center for one day and exhibited painful progressive swelling along the entire right arm. She also complained of chest discomfort. She had an ST-elevation and T wave-inversion on an ECG. She was then transferred to our emergency department. We found a regional wall motion abnormality on echocardiography, and elevated cardiac enzymes in a laboratory test. We also observed coagulopathy and a thrombus in the left ventricle on follow-up echocardiography. An acute myocardial infarction was confirmed by percutaneous coronary angiography, which showed the total occlusion and stenosis of several coronary arteries.