The Utility of the Optic Nerve Sheath Diameter in Predicting Post-Thrombolysis Intracranial Hemorrhage

PURPOSE: We tried to identify the factors associated with intracranial hemorrhage (ICH) in patients with acute brain infarction receiving a tissue plasminogen activator. We assumed that ICH is increased if intracranial pressure has been increased in brain infarction patients who underwent IV thrombolysis. In this study, we selected the optic nerve sheath diameter (ONSD) in a way that intracranial pressure (ICP) measurement. ONSD measurements were compared with the occurrence of brain hemorrhage. METHODS: This study was a retrospective analysis of data acquired between January 2013 and December 2015. We included 100 acute brain infarction patients who received brain MRI and underwent IV thrombolysis in the emergency department. The ONSD measurements were taken with MRI in the axial view and compared with the occurrence of brain hemorrhage. The factors contributing to ICH in patients with thrombolysis was analyzed by a binary logistic regression analysis. Receiver operating characteristic (ROC) curves were used to find the cut-off value of ONSD that maximized the sum of the sensitivity and specificity. Statistical analysis was performed using SPSS 20.0. RESULTS: The mean ONSD for patients without ICH was 5.50±0.57 mm, and for those with ICH was 5.97±0.54 mm. ONSD in the ICH group were significantly larger than in the non-ICH group (5.50±0.57 versus 5.97±0.54). CONCLUSION: ONSD in acute brain infarction patients who underwent IV thrombolysis is useful in the assessment of ICH risk.

The Relationship between Rainfall and Traffic Accident Patients in Busan

PURPOSE: Traffic accidents are increasing due to the development and increment of transportation. Previous studies on analysis of the correlation between environmental factors and traffic accidents have rarely been reported. The purpose of this study is to analyze the correlation between rainfall and traffic accidents including accident mechanism, incidence, and trauma severity of patients. METHODS: A retrospective review was conducted in 851 trauma patients who visited the emergency department (ED) after a traffic accident from January 2013 to December 2013; 248 patients due to a traffic accident when it was raining, and 603 patients when it was not raining. Demographic data, clinical data, and meteorological data (rainfall, daily mean air temperature, daily mean wind speed) in Busan were investigated. RESULTS: The incidence of traffic accidents was one-second and the injury severity score of patients was two points higher on rainy days. In addition, the length of hospital stay was three days longer (p=0.037), and the prognosis was poor in the rain group. Comparison of severe injury sustained over rain, injury time, and accident mechanism showed approximately a 3-fold odds increased rate of severe injury on rainy days (OR 2.55, 95% CI: 1.11-5.83, p=0.004) and a seven-fold odds increased rate of pedestrian traffic accidents (OR 7.26, 95% CI: 3.52-9.26, p<0.001) compared with car traffic accidents. In addition, a four-fold increased odds of night time (OR 3.79, 95% CI: 1.98-7.25, p<0.001) compared with day time accidents on rainy days. CONCLUSION: The incidence of traffic accidents and injury severity of patients increased on rainy days. Therefore, we suggest expansion of the scope of the emergency and trauma team activation for proper treatment on rainy days.

Is Atropine Necessary for Cardiopulmonary Resuscitation?

PURPOSE: According to the 2010 guidelines for cardiopulmonary resuscitation (CPR) of the American Heart association, administration of atropine for non-shockable rhythm is no longer recommended, however, there are insufficient data in humans. This study was conducted to evaluate the results of CPR, whether the combined administration of atropine and epinephrine (Atropine combined group, AG) compared with epinephrine only injection (epinephrine only group, EG) for patients with non-shockable rhythm. METHODS: A total of 449 patients who underwent CPR in the emergency department from 2009 to 2012 were included. Retrospective analysis was performed according to atropine administration during CPR. We investigated Return of Spontaneous Circulation (ROSC), sustained ROSC, 30-day survival, and 30-day neurological outcome using Utstein templates. RESULTS: There were 178 (48.9%) patients in the AG. There were no significant differences in the baseline characteristics. The two groups had similar rates of ROSC, sustained ROSC, and 30-day survival. However, AG had a significantly poor neurological outcome compared to EG, with an adjusted odds ratio of 0.074 (95% CI 0.012-0.452, p=0.005). CONCLUSION: The combination therapy of atropine and epinephrine during CPR showed poor neurological outcome compared with epinephrine alone. Atropine is not useful for adults with non-shockable rhythm in terms of 30-day neurological outcome.

Seizure Caused by Pulmonary Embolism: Two Cases Report and Review of the Literature

Pulmonary embolism is a devastating disease that causes significant morbidity and mortality, however, seizure as a presentation of pulmonary embolism is rare. We experienced two such cases of a 25- and a 59-year-old male who visited the emergency center because of new onset seizure activity with no structural lesions by MRI or CT. Despite having alert consciousness, they were found to have hypoxemia of unknown cause with EKG abnormality. Therefore, we performed bedside ultrasound and CT angiography; pulmonary embolism was then diagnosed. The patients had similar patterns-risk factors, deep vein thrombosis, abnormal EKG, hypoxemia, tachycardia, and seizure. Diagnosis of pulmonary embolism is very confusing, particularly in cases presenting with seizure. Therefore, we suggest that physicians should be more aware of the importance of considering pulmonary embolism within the differential diagnosis for unexplained new onset of seizure activity.

Seizure Caused by Pulmonary Embolism: Two Cases Report and Review of the Literature

Pulmonary embolism is a devastating disease that causes significant morbidity and mortality, however, seizure as a presentation of pulmonary embolism is rare. We experienced two such cases of a 25- and a 59-year-old male who visited the emergency center because of new onset seizure activity with no structural lesions by MRI or CT. Despite having alert consciousness, they were found to have hypoxemia of unknown cause with EKG abnormality. Therefore, we performed bedside ultrasound and CT angiography; pulmonary embolism was then diagnosed. The patients had similar patterns-risk factors, deep vein thrombosis, abnormal EKG, hypoxemia, tachycardia, and seizure. Diagnosis of pulmonary embolism is very confusing, particularly in cases presenting with seizure. Therefore, we suggest that physicians should be more aware of the importance of considering pulmonary embolism within the differential diagnosis for unexplained new onset of seizure activity.

Left Facial Swelling Caused by Organophosphate (Dichlorvos) Poisoning: A Case Report and Review of the Literature

In organophosphate intoxication, the neurotransmitter acetylcholine accumulates in synapses, causing excessive stimulation of nicotinic and muscarinic receptors, producing various signs and symptoms. Organophosphates are highly toxic compounds that are readily absorbed through the skin, mucous membranes, and gastrointestinal and respiratory tracts. Organophosphate intoxication leads to many well defined complications, including cholinergic crisis, intermediate syndrome, and acute pancreatitis. However, parotitis caused by organophosphate intoxication is very rare. We experienced such a case of a 55 year old woman who visited the emergency center because of organophosphate intoxication. The next day, she complained of left facial redness, swelling, and pain. We checked serum lipase, amylase, and amylase-isoenzymes, and found elevation of salivary type amylase only. The mechanism of parotitis due to organophosphate intoxication is assumed to be similar to that of pancreatitis caused by organophosphate. In patients with elevated amylase caused by organophosphate intoxication, the possibility of parotitis must be considered.

Characteristics of Geriatric Trauma Patients Transferred from Long-term Care Hospitals: A Propensity Score Matched Analysis

PURPOSE: Transfer from long-term care (LTC) hospitals to the emergency department (ED) of larger hospitals has increased due to limited capability for management of patients needing special diagnostic tools or emergency treatment in the LTC hospital. We investigated the characteristics of geriatric trauma patients transferred from LTC hospitals to the ED. METHODS: A retrospective analysis included data on geriatric trauma patients (age> or =65) who visited two EDs in Korea. All data of patients transferred from the LTC hospital were compared with those of patients who visited the ED from home. Patients visiting from home were selected according to age, sex, and main diagnosis, using the statistical matching method. RESULTS: A total of 44 patients were transferred, and 132 patients were selected after matching. No differences in mechanism of injury, injury severity score (ISS), outcomes, transfusion, length of hospital stay, or mortality were observed between the two groups. The odds ratios (OR) of transferred patients for stroke and dementia were 5.027 (95% confidence interval (CI) 1.292-16.915) and 13.941 (95% CI: 5.112-38.015), respectively. In addition, the OR of transferred patients for dependent activities of daily living was 8.165 (95% CI: 2.886-23.104). Thirty five transferred patients (79.5%) had been injured in the LTC hospital (p<0.001). CONCLUSION: The transferred patients had more stroke, dementia, and dependent activities, but showed no significant difference in severity or prognosis. Most transferred patients had been injured in the hospital. Greater attention to hospitalized patients and system development are required in order to prevent injuries in the LTC hospital.

Clinical Significance of National Patients Sample Analysis: Factors Affecting Mortality and Length of Stay of Organophosphate and Carbamate Poisoned Patients / 대한의료정보학회지

OBJECTIVES: This study considered whether there could be a change of mortality and length of stay as a result of inter-hospital transfer, clinical department, and size of hospital for patients with organophosphates and carbamates poisoning via National Patients Sample data of the year 2009, which was obtained from Health Insurance Review and Assessment Services (HIRA). The utility and representativeness of the HIRA data as the source of prognosis analysis in poisoned patients were also evaluated. METHODS: Organophosphate and carbamate poisoned patients' mortality and length of stay were analyzed in relation to the initial and final treating hospitals and departments, as well as the presence of inter-hospital transfers. RESULTS: Among a total of 146 cases, there were 17 mortality cases, and the mean age was 56.8 +/- 19.2 years. The median length of stay was 6 days. There was no inter-hospital or inter-departmental difference in length of stay. However, it significantly increased when inter-hospital transfer occurred (transferred 11 days vs. non-transferred 6 days; p = 0.037). Overall mortality rate was 11.6%. The mortality rate significantly increased when inter-hospital transfer occurred (transferred 23.5% vs. non-transferred 7.0%; p = 0.047), but there was no statistical difference in mortality on inter-hospital and inter-department comparison at the initial treating facility. However, at the final treating facility, there was a significant difference between tertiary and general hospitals (5.1% for tertiary hospitals and 17.3% for general hospitals; p = 0.024), although there was no significant inter-departmental difference. CONCLUSIONS: We demonstrated that hospital, clinical department, length of stay, and mortality could be analyzed using insurance claim data of a specific disease group. Our results also indicated that length of stay and mortality according to inter-hospital transfer could be analyzed, which was previously unknown.

Criminal Responsibility in Emergency Care

PURPOSE: When a criminal act occurs during emergency care, it becomes fatal to both the patient and doctor. Criminal acts during emergency care and judged by the Supreme Court of Korea were analyzed and investigated to decrease and prevent medical malpractice. METHODS: After assessing the Medical Act in Korea and Act on Emergency Care in Korea, a pattern of emergency care was categorized and applicable provisions were analyzed. Emergency medical malpractice cases were collected from previous reports and an internet site managed by the Supreme Court of Korea (http://glaw.scourt.go.kr). RESULTS: The patterns of emergency care can be categorized into "general emergency care", "interhospital patient transfer", and the "request for medical treatment sent to another department or hospital". Furthermore, inerthospiatl patient transfer can be categorized into "after request for emergency care" and "after medical treatment." There were ten medical malpractice cases in emergency care in which criminal responsibility occurred. There were six cases related to general emergency care and four related to interhospital patient transfer. CONCLUSION: Though the emergency care cases in which criminal responsibility occurred were few, the results critically impacted the patient and doctor. Therefore, emergency physicians must do their best to decrease and prevent medical negligence. In addition, a nation has a primary responsibility to save lives and must support emergency care.

Criminal Responsibility in Emergency Care

PURPOSE: When a criminal act occurs during emergency care, it becomes fatal to both the patient and doctor. Criminal acts during emergency care and judged by the Supreme Court of Korea were analyzed and investigated to decrease and prevent medical malpractice. METHODS: After assessing the Medical Act in Korea and Act on Emergency Care in Korea, a pattern of emergency care was categorized and applicable provisions were analyzed. Emergency medical malpractice cases were collected from previous reports and an internet site managed by the Supreme Court of Korea (http://glaw.scourt.go.kr). RESULTS: The patterns of emergency care can be categorized into "general emergency care", "interhospital patient transfer", and the "request for medical treatment sent to another department or hospital". Furthermore, inerthospiatl patient transfer can be categorized into "after request for emergency care" and "after medical treatment." There were ten medical malpractice cases in emergency care in which criminal responsibility occurred. There were six cases related to general emergency care and four related to interhospital patient transfer. CONCLUSION: Though the emergency care cases in which criminal responsibility occurred were few, the results critically impacted the patient and doctor. Therefore, emergency physicians must do their best to decrease and prevent medical negligence. In addition, a nation has a primary responsibility to save lives and must support emergency care.

Violence in Korean medical dramas

PURPOSE: Although violence occurs frequently in Korean television dramas, its description or definition is unusual. Many studies have shown that TV dramas have a powerful effect on society and the violence shown in medical dramas helps in comprehension of hospital violence occurring in real life. Therefore, this study will cover the types and levels of violence. METHODS: We selected five recent Korean medical dramas. These five dramas, which consisted of 94 episodes and were broadcast from 2007 to 2011, are analyzed. Violence is limited to the occurrence inside the hospital; violence that occurs outside of the hospital is excluded. Media violence is analyzed within PAT (perpetrator-action-target). In addition, the violence levels and violence relationships are analyzed. RESULTS: Among the types of violence, 88.5% is verbal abuse, 3.5% is physical threat, and 8.0% is physical violence. In comparison of the violence relationship, violence between a doctor and a doctor forms the highest rate of 72.6%. In the level of violence, 0 level of violence caused by verbal abuse is the highest (88.5%); however, 5 level of violence level, which is death, is not observed. There are 1475 minutes of violence scenes from 6243 minutes, which is 23.6% of total time. CONCLUSION: Frequency of violence in Korean medical dramas is higher than that of normal dramas. Considering the powerful influence of the mass media, the violence of medical dramas should be controlled. To resolve the problem, the role of advisory doctors seems important.

Usefulness of the Pediatric Risk of Mortality Score III as a Predictor of Severity or Mortality for Injured Children

PURPOSE: The primary prevention and proper initial treatment of childhood injuries is important, as it encompasses a bigger social and economic burden than cancer and ischemic heart disease. The Pediatric Risk of Mortality III (PRISM III) scoring system, used to evaluate the severity or mortality of pediatric patients in critical condition, was investigated for children with injuries in an emergency department (ED). METHODS: A retrospective analysis included data on 293 injured children (age<16) who visited the ED in two hospitals from March 2010 to February 2012. Physiologic and laboratory data were collected to calculate the PRISM III score and the Injury Severity Score (ISS). The correlation was analyzed between PRISM III scores, the Revised Trauma Scale (RTS), and ISS. The PRISM III score and ISS were assessed for their ability to predict mortality by comparing their receiver operating characteristic (ROC) curves. RESULTS: The median PRISM III score was 5.0 (Interquartile Range, 5.0-9.0) and correlated with RTS and ISS (the Spearman's rho were -0.19 (p=0.001) and 0.20 (p=0.001), respectively. Five children did not survive after ED admission. The area under the ROC (AUC) was 1.00 for PRISM III (95% confidence interval [CI], 0.99-1.00), and the cutoff value was placed over 20 to predict mortality. The AUC of ISS and RTS was 0.99 (95% CI, 0.98-1.00) and 0.99 (95% CI, 0.98-1.00), respectively. CONCLUSION: The PRISM III score excellently predicts the mortality of injured children in the ED, and can be used to sort minor pediatric trauma patients in the ED. However, the PRISM III score had no great difference or advantage compared with RTS. The development of other tools for effective prognosis is needed to efficiently predict mortality and severity in the ED.

Comparison of central venous pressure and the inferior vena cava/aorta diameter index for evaluation of body fluid status

PURPOSE: Central venous pressure (CVP) is used almost universally to evaluate patient body fluid status. But historical and more recent data suggest that this approach may be flawed. In this study, we compared the accuracy of CVP versus the inferior vena cava/aorta diameter index (IVC/Ao index), a new approach to assessing body fluid status. METHODS: This study was carried out prospectively with subjects over 18 years of age who visited the emergency department between November 2010 and January 2011. A central venous catheter (CVC) was inserted into patients undergoing computed tomography (CT). IVC and aortic diameter were measured below the renal vein using the CT in axial view. To determine the exact CVP, we measured the distance from the tip of the CVC to the superior vena cava/right atrium (SVC/RA) junction in coronal and axial CT views, and placed the tip of a CVC at the SCV/RA junction. We analyzed the correlation between the CVP, IVC diameter and the IVC/Ao index. RESULTS: A total of 65 patients were enrolled in this study. The mean CVP was 9.25+/-5.99 mmH2O, IVC diameter was 1.456+/-0.568 cm and IVC/Ao index was 0.854+/-0.316. The correlation coefficient for CVP and IVC diameter was 0.625 (p<0.01) and for CVP and IVC/aorta index it was 0.711 (p<0.01). Coefficient of variations (CVs) of the IVC/Ao index was 0.76 at CVP 5 mmH2O and 0.14 at CVP 17 cmH2O. The correlation coefficient for CVP and IVC/Ao index in the group with a CVP result of less than 8 cmH2O was 0.330, and in the group with a CVP result greater than 8 cmH2O, it was 0.660 (p<0.01). CONCLUSION: The CVP results had a higher correlation to the IVC/aorta index than to the IVC diameter. The coefficient of variant (CV) tended to increase as CVP decreased. It is best not to use a single value of CVP or IVC/Ao index to evaluate the body fluid state, as some kind of dynamic parameter should be used.

Comparison of central venous pressure and the inferior vena cava/aorta diameter index for evaluation of body fluid status

PURPOSE: Central venous pressure (CVP) is used almost universally to evaluate patient body fluid status. But historical and more recent data suggest that this approach may be flawed. In this study, we compared the accuracy of CVP versus the inferior vena cava/aorta diameter index (IVC/Ao index), a new approach to assessing body fluid status. METHODS: This study was carried out prospectively with subjects over 18 years of age who visited the emergency department between November 2010 and January 2011. A central venous catheter (CVC) was inserted into patients undergoing computed tomography (CT). IVC and aortic diameter were measured below the renal vein using the CT in axial view. To determine the exact CVP, we measured the distance from the tip of the CVC to the superior vena cava/right atrium (SVC/RA) junction in coronal and axial CT views, and placed the tip of a CVC at the SCV/RA junction. We analyzed the correlation between the CVP, IVC diameter and the IVC/Ao index. RESULTS: A total of 65 patients were enrolled in this study. The mean CVP was 9.25+/-5.99 mmH2O, IVC diameter was 1.456+/-0.568 cm and IVC/Ao index was 0.854+/-0.316. The correlation coefficient for CVP and IVC diameter was 0.625 (p<0.01) and for CVP and IVC/aorta index it was 0.711 (p<0.01). Coefficient of variations (CVs) of the IVC/Ao index was 0.76 at CVP 5 mmH2O and 0.14 at CVP 17 cmH2O. The correlation coefficient for CVP and IVC/Ao index in the group with a CVP result of less than 8 cmH2O was 0.330, and in the group with a CVP result greater than 8 cmH2O, it was 0.660 (p<0.01). CONCLUSION: The CVP results had a higher correlation to the IVC/aorta index than to the IVC diameter. The coefficient of variant (CV) tended to increase as CVP decreased. It is best not to use a single value of CVP or IVC/Ao index to evaluate the body fluid state, as some kind of dynamic parameter should be used.

The Use of Vapocoolant Spray for the Treatment of Minor Trauma in the Hospital Emergency Department

PURPOSE: Vapocoolant spray is used as an agent to relieve localized pain due to sport injury or intravenous cannulation. The aim of this study was to determine the effectiveness of vapocoolant spray in the treatment of minor trauma in a hospital emergency department. METHODS: We carried out a prospective randomized controlled trial of alert patients with minor trauma who visited our emergency department. The total of 90 participants, all over 14 years old, were divided into 3 groups: a 'NSAIDs IM' group (n=30), 'Vapocoolant spray' group (n=30), and 'NSAIDs IM with Vapocoolant spray' group (n=30). Patients rated their pain and satisfaction of treatment using a 100-mm visual analogue scale (VAS). We assessed pain by VAS 4 times: first upon arrival, and then at 15, 30 and 60 minutes after treatment. We also assessed their treatment satisfaction utilizing VAS at the point of discharge. In addition, we calculated the time between subject arrival and initial treatment. RESULTS: Groups did not differ significantly in terms of age or sex distribution. The mean of the VAS score did not differ significantly among the groups upon their arrival (p=0.885) and were observed as follows: 'NSAIDs IM' group 44.80+/-12.70 mm, 'Vapocoolant spray' group 45.20+/-10.49 mm, and 'NSAIDs IM with Vapocoolant spray' group 46.17+/-9.54 mm. At 15, 30 and 60 min after treatment, the mean reduction in VAS score significantly differed between groups (p<0.05). At 15 min after treatment the results were as follows: 'NSAIDs IM' group 5.27+/-3.26 mm, 'Vapocoolant spray' group 15.17+/-7.17 mm, and 'NSAIDs IM with Vapocoolant spray'group 14.57+/-4.07 mm. At 30 min after treatment the results were: 'NSAIDs IM' group 13.57+/-7.86 mm, 'Vapocoolant spray' group 19.47+/-9.96 mm, and 'NSAIDs IM with Vapocoolant spray' group 21.20+/-6.52 mm. At 60 min after treatment the results were: 'NSAIDs IM' group 25.73+/-8.07 mm, 'Vapocoolant spray' group 20.90+/-9.88 mm, and 'NSAIDs IM with Vapocoolant spray' group 28.93+/-6.66 mm. Satisfaction of treatment and initial treatment time differed between groups (p<0.05). For satisfaction of treatment, the median of VAS significantly differed between the 'NSAIDs IM' group and the 'NSAIDs IM with Vapocoolant spray' group [46.50(41-52) mm vs. 57.00(51-62) mm, p<0.0167]. Initial treatment time significantly differed between the 'NSAIDs IM' group and the other groups [22.50(13-34) min vs. 10.00(7-20) min and 13.00(7-20) min, p<0.0167]. CONCLUSION: Vapocoolant spray is effective in reducing pain with minor trauma in the hospital emergency department. We can simultaneously improve the patient treatment satisfaction and reduce initial treatment time by using the vapocoolant spray.

The Use of Vapocoolant Spray for the Treatment of Minor Trauma in the Hospital Emergency Department

PURPOSE: Vapocoolant spray is used as an agent to relieve localized pain due to sport injury or intravenous cannulation. The aim of this study was to determine the effectiveness of vapocoolant spray in the treatment of minor trauma in a hospital emergency department. METHODS: We carried out a prospective randomized controlled trial of alert patients with minor trauma who visited our emergency department. The total of 90 participants, all over 14 years old, were divided into 3 groups: a 'NSAIDs IM' group (n=30), 'Vapocoolant spray' group (n=30), and 'NSAIDs IM with Vapocoolant spray' group (n=30). Patients rated their pain and satisfaction of treatment using a 100-mm visual analogue scale (VAS). We assessed pain by VAS 4 times: first upon arrival, and then at 15, 30 and 60 minutes after treatment. We also assessed their treatment satisfaction utilizing VAS at the point of discharge. In addition, we calculated the time between subject arrival and initial treatment. RESULTS: Groups did not differ significantly in terms of age or sex distribution. The mean of the VAS score did not differ significantly among the groups upon their arrival (p=0.885) and were observed as follows: 'NSAIDs IM' group 44.80+/-12.70 mm, 'Vapocoolant spray' group 45.20+/-10.49 mm, and 'NSAIDs IM with Vapocoolant spray' group 46.17+/-9.54 mm. At 15, 30 and 60 min after treatment, the mean reduction in VAS score significantly differed between groups (p<0.05). At 15 min after treatment the results were as follows: 'NSAIDs IM' group 5.27+/-3.26 mm, 'Vapocoolant spray' group 15.17+/-7.17 mm, and 'NSAIDs IM with Vapocoolant spray'group 14.57+/-4.07 mm. At 30 min after treatment the results were: 'NSAIDs IM' group 13.57+/-7.86 mm, 'Vapocoolant spray' group 19.47+/-9.96 mm, and 'NSAIDs IM with Vapocoolant spray' group 21.20+/-6.52 mm. At 60 min after treatment the results were: 'NSAIDs IM' group 25.73+/-8.07 mm, 'Vapocoolant spray' group 20.90+/-9.88 mm, and 'NSAIDs IM with Vapocoolant spray' group 28.93+/-6.66 mm. Satisfaction of treatment and initial treatment time differed between groups (p<0.05). For satisfaction of treatment, the median of VAS significantly differed between the 'NSAIDs IM' group and the 'NSAIDs IM with Vapocoolant spray' group [46.50(41-52) mm vs. 57.00(51-62) mm, p<0.0167]. Initial treatment time significantly differed between the 'NSAIDs IM' group and the other groups [22.50(13-34) min vs. 10.00(7-20) min and 13.00(7-20) min, p<0.0167]. CONCLUSION: Vapocoolant spray is effective in reducing pain with minor trauma in the hospital emergency department. We can simultaneously improve the patient treatment satisfaction and reduce initial treatment time by using the vapocoolant spray.

Prognostic Factors for Mortality in Emergency Department Patients with Hypotension / 대한구급학회지

BACKGROUND: This study was performed to analyze the effects of differences between initial and follow up amounts of central venous oxygen saturation (Scvo2), lactate, anion gap (AG), and corrected anion gap (CAG). METHODS: Patients with systolic blood pressure that was lower than 90 mmHg participated in this study. Along with Arterial Blood Gas Analysis (ABGA), the amounts of electrolytes, albumin, and Scvo2 were initially checked and then re-checked four hours later. The patients were divided into two groups, which were survived and expired, and the differences in initial and final values were compared in both groups. RESULTS: Out of a total of 36 patients, 29 patients survived and 7 patients died. The data showed almost no difference in mean age, mean arterial pressure, heart rate, respiratory rate, and body temperature between two groups. Comparing the initial amount, there was a statistically significant variation in lactate. Comparing the final values, lactate, AG, and CAG varied significantly. However, for both groups, the differences between the initial and final values were not significant. The area under curve (AUC) of follow up lactate and follow up CAG was 0.89 and 0.88. AUC of ED-APACHEII and original ICU APACHEII was 0.74 and 0.96. CONCLUSIONS: There was no prognostic effect of Scvo2, lactate, AG, and CAG in hypotensive patients. The initial and final values of lactate and CAG were good prognostic factors for the expired group.

Usefulness of Bedside Emergency Ultrasound for Detecting Significant Dehydration in Children

PURPOSE: Using bedside emergency ultrasonography (EUS), measurement of the ratio of inferior vena cava (IVC) to abdominal aorta (Ao) diameter may be useful in objectively assessing children with dehydration. The objectives of this study were (1) to analyze the predictability of the ratio of IVC to Ao diameters (IVC/Ao) in dehydrated children and (2) to determine which measurement method would be best to detect significant dehydration in children. METHODS: This prospective observational study was performed in an urban emergency department. Children between 6 months and 6 years of age with clinical suspicion of dehydration and who were admitted to the hospital were enrolled. Using bedside EUS, measurement of IVC and Ao diameters and body weight check were done before IV hydration. We followed up on their body weight during hospitalization. Dividing subjects into (1) a moderate and severely dehydrated group, which was defined as weight change more than 5% during hospitalization, and (2) a non-dehydrated group, we compared the IVC/Ao ratios of the two groups. RESULTS: A total of 59 patients were enrolled. There were significant differences between dehydrated and nondehydrated groups in IVC/Ao on longitudinal views and in the major diameter of IVC/Ao on transverse views (p=0.010 and <0.01, respectively). Its area under the curve in ROC analysis was 0.69 and 0.81, respectively. The cut-off value for the major diameter of IVC/Ao was 0.879 with 85% sensitivity and 79.9% specificity. Laboratory tests such as the BUN/Cr ratio, total CO2, and bicarbonate didn't show any differences between the two groups. CONCLUSION: The IVC/Ao ratio measured in transverse views by bedside EUS could help the emergency physician identify significant dehydration in clinically suspected pediatric patients.

A Cause Analysis of Missed Fractures in an Emergency Medical Center

PURPOSE: A missed fracture is a very common occurrence in the Emergency Department (ED) and can have serious results because of delays in treatment, resulting in long-term disability. It is also one of the most common causes leading to medical legal issues. We analyzed the causes of missed fractures by using a bone scan which is known to be an effective tool for diagnosing bony lesions. METHODS: We reviewed the medical records of trauma patients who underwent a bone scan after being discharged the ED from September 2006 to March 2008. Cases of missed fractures were identified by using electronic medical records to review each diagnosis. Definition of missed fracture was read after bone scan by radiologist. We decided that there was no fracture if we read 'trauma-related lesion' or 'cannot rule out fracture' on a bone scan read by a radiologist. Enrolled patients were analyzed by age, sex, time until bone scan and Injury Severity Score (ISS). Patients were divided into two groups, alert mentality and not-alert mentality, so there were split between a diagnosis group and a missed fracture group. ISS was also used in determining the severity of the patient's injury upon discharge from the ED. RESULTS: A total of 532 patients were enrolled in this study. Of those, 487 patients were in the diagnosis group, and 45 patients (8.4%) were discovered to have had a fracture. Of the 45 missed fracture patients, 34 patients (6.4%) had one-site fractures, 8 patients (1.5%) had two-site fractures, and 3 patients (0.6%) had threesite fractures. The most commonly missed fracture was multiple rib fractures (18 patients, 30.5%), followed by lumbosacral (LS) spine fractures (10 patients, 16.9%), thoracic spine fractures (8 patients, 13.6%), and clavicle fractures (6 patients, 10.2%). Mean age was 50.12+/-18.54 years in the diagnosis group and 57.38+/-16.88 years in the missed fracture group. For the diagnosis group, the mean ISS was 9.03+/-8.26, but in the missed fracture group it was 17.53+/-9.69. Missed fractures were much more frequent in the not-alert mentality (p or =16) group (p<0.01). CONCLUSION: Missed fractures occur most frequent in patients of old age, not-alert mentality, and high ISS. Multiple rib and spine fractures were found to be the most frequent missed fractures, regardless of trauma severity. This study also shows a high possibility of clavicle and scapula fractures in patients with severe trauma.

An Emergency Ultrasound (EUS)-Enhanced Scoring System for Diagnosing Acute Appendicitis in Patients with Right Lower Quadrant (RLQ) Pain; Constant or Aggravated Pain, Male Sex, and Ultrasound (CAMUS) Scores

PURPOSE: We hypothesized that a new scoring system that included emergency ultrasound (EUS) and clinical or laboratory predictors for diagnosing acute appendicitis (AA) in patients with right lower quadrant (RLQ) pain could decrease the false negative rate when EUS is performed alone. METHODS: During a 10 month period, patients with RLQ pain were evaluated with EUS just after history taking and physical examination. We also checked the 17 well-known predictors of AA. Univariate analyses for each predictor including EUS findings identified 11 predictors. We then tested those predictors with logistic regression analysis. RESULTS: A total 397 patients (mean age=31.13+/-18.25 years: 196 males, 201 females) were enrolled in this study. Among the 397, 247 underwent an operation, but 14 turned out to have normal appendices. Among 233 patients with appendicitis, 75 had a perforated appendix. Four independent correlates of AA (constant pain, aggravated pain, male sex, and positive EUS findings) were identified with logistic regression analysis. We developed a novel scoring system using regression coefficients as follows: 6 points for a positive EUS, 3 points for aggravated pain, 2 points for constant pain, and 2 points for being male. We named the new scoring system "CAMUS" for "Constant or Aggravated pain, Male sex, and UltraSound score". The area under the receiver-operating characteristic curve (ROC) for the CAMUS score for AA was 0.93(95% confidence interval: 0.871 to 0.959). CONCLUSION: Our new CAMUS scoring system can help emergency physicians diagnose AA accurately and rapidly.