The Comparison of Sedative Efficacy and Safety of Oral Chloral Hydrate and Intramuscular Ketamine in Children for Primary Repair in Emergency Department

PURPOSE: To compare the sedation quality of oral chloral hydrate against intramuscular ketamine in children requiring primary repair in the emergency department. METHODS: Patients needing primary repair of lacerations (range 1.6 years of age) were blindly randomized to either chloral hydrate or ketamine groups. One group received intramuscular ketamine at 4 mg/kg and the other group received oral chloral hydrate at 50 mg/kg. Both groups received lidocaine for local anesthesia. Physiologic parameters (heart rate, blood pressure and respiratory rate), the time from sedation to recovery, and the degree of sedation as measured by the Ramsay sedation score and the Modified Aldrete recovery score were recorded during the treatment. Overall behavior and complication were assessed both at baseline and at the end of the treatment. RESULTS: Data are mean+/-SD. We enrolled 80 consecutive patients into the study; 39 received intramuscular ketamine and 41 were administered oral chloral hydrate. The two groups were similar with regard to age, sex, and body weights. No patient had a clinically significant change in vital signs and the time from sedation to recovery. Changes in the Modified Aldrete recovery score after sedation were not statistically significant. However, statistically significant differences were observed for the Ramsay sedation score at 15 minutes after sedation (4.89+/-0.32 versus 4.23+/-0.48; p=0.024). No differences at other time points achieved statistical significance in the Ramsay sedation score. CONCLUSION: Both oral chloral hydrate and intramuscular ketamine are safe and effective for the sedation of children requiring laceration repair in the emergency department.

Effect of Treatment in Patient with Rhabdomyolysis: Comparison between Single Hydration and Hydration with Urine Alkalinization

PURPOSE: Urine alkalinization is commonly used to treat rhabdomyolysis and to prevent the rapid progression of rhabdomyolysis into acute renal failure. However, there are no prospective studies on the beneficial effect of urine alkalinization on rhabdomyolysis. We prospectively examined whether fluid hydration with urine alkalinization treatment would be more effective than single hydration treatment in treating rhabdomyolysis and preventing acute renal failure in the emergency department. METHODS: We performed a prospective randomized trial with fifty-eight patients who were diagnosed with rhabdomyolysis. Thirty-five patients were treated with crystalloid alone, while the others were treated with crystalloid mixed with sodium bicarbonates. Creatine phosphokinase (CPK) and creatinine levels were checked every 4 hours for the first 24 hours and then checked every 8 hours thereafter. Data collected included "peak CPK time"(time from the start of treatment to achievement of the maximal CPK value), increasing and decreasing rate of CPK, and whether acute renal failure developed. RESULTS: Patient's age, sex, initial CPK concentrations, and initial creatinine concentrations were not statistically different between the single hydration treatment group and the hydration with urine alkalinization group. Mean time to peak CPK was 10.2+/-13.7 hours in the single hydration group and 8.1+/-10.2 hours in the hydration with urine alkalinization group. Neither the time to peak CPK nor the CPK change rates was statistically different between the two groups (p=0.547, p=0.176, p=0.696). CONCLUSION: Hydration with urine alkalinization as a treatment for rhabdomyolysis and prevention of acute renal failure did not improve patient results over single hydration treatment.

A Case with Ophthalmoplegia Following Snake Bite

Ophthalmoplegia following snake bite is a rare but not serious neurotoxic complication. However, symptoms like diplopia, blurred vision, and ocular discomfort can be emotionally devastating for a patient. We experienced one case f ophthalmoplegia following a snake bite. The patient complained of diplopia and ptosis that had developed several hours after the snake bite. The symptoms were completely resolved after pyridostigmine medication with antivenin treatment.

Evaluation of the Educational Efficacy of a Cadaver-based Model for Teaching a Simple Suture Technique to Medical Students

PURPOSE: There is ongoing demand to deliver better procedural training to medical students in the emergency department. Thus, we studied the efficacy of a cadaver-based training model for teaching simple suture techniques to medical students. METHODS: We investigated ten fourth-year medical students, who were rounding and being trained in the Emergency Department of Chungnam National University Hospital. They were educated with slides about a simple suture technique for 30 minutes to evaluate the efficacy of the cadaver-based training model. We prospectively measured their skill by administering a test on the cadaver-based simple suture technique in 3cm sized linar wound separately to each of them. RESULTS: A total of ten fourth-year medical students completed the investigation. The tension, the direction of suture, the degree of cleanness, the number of sutures, the adequacy of the cutting thread length, and the suturing time in the first attempt were compared with those in the second one. The second results were compared with those in the third one, and the third results were compared with those in the fourth one. All the results had statistical significance. CONCLUSION: These findings support the value of the cadaver-based simple suture technique training model as a medical student teaching model. The cadaver-based simple suture technique teaching model is a good way of teaching several medical skills to medical students.

Evaluation of the Educational Efficacy of a Cadaver-based Model for Teaching a Simple Suture Technique to Medical Students

PURPOSE: There is ongoing demand to deliver better procedural training to medical students in the emergency department. Thus, we studied the efficacy of a cadaver-based training model for teaching simple suture techniques to medical students. METHODS: We investigated ten fourth-year medical students, who were rounding and being trained in the Emergency Department of Chungnam National University Hospital. They were educated with slides about a simple suture technique for 30 minutes to evaluate the efficacy of the cadaver-based training model. We prospectively measured their skill by administering a test on the cadaver-based simple suture technique in 3cm sized linar wound separately to each of them. RESULTS: A total of ten fourth-year medical students completed the investigation. The tension, the direction of suture, the degree of cleanness, the number of sutures, the adequacy of the cutting thread length, and the suturing time in the first attempt were compared with those in the second one. The second results were compared with those in the third one, and the third results were compared with those in the fourth one. All the results had statistical significance. CONCLUSION: These findings support the value of the cadaver-based simple suture technique training model as a medical student teaching model. The cadaver-based simple suture technique teaching model is a good way of teaching several medical skills to medical students.

A Case of Thrombotic Thrombocytopenic Purpura

A thrombotic thrombocytopenic purpura (TTP) is a disorder characterized by microangiopathic hemolytic anemia, thrombocytopenia, neurologic symptoms, fever, and impairment of renal function, which are thought to be due to endothelial cell injury, platelet activation, and subsequent formation of thrombi in the microcirculation. The most common neurologic symptoms are alteration of mental status, headache, coma, focal weakness, aphagia, dysarthria, seizure, and visual changes. Avoiding platelet transfusions, which can exacerbate microvascular thrombosis, is prudent. We experienced a case of TTP which was aggravated after platelet transfusion. We report that case with a literature review.

A Case of Primary Mesenteric Venous Thrombosis Presenting with Acute Abdominal Pain

Mesenteric venous thrombosis (MVT) is a rare, but lifethreatening condition and may induce ischemia or necrosis of small intestine. The predisposing factors of MVT are variable and include previous abdominal surgery, a hypercoagulable state, etc. When no possible predisposing factors exist, we call it primary MVT. A 29-year-old man was presented with upper abdominal pain and was diagnosed as having a MVT by using an abdominal computed tomography scan. The protein C and S levels were decreased at the ED, but were normal on the 49th hospital day. We did not find any predisposing factors, so we classified this patient as having primary MVT. We report this case along with a literature review.

Cross-sectional Study of Physical Restraint Use in an Emergency Department

PURPOSE: Physical restraint may be more frequently done in the emergency departments (ED). The purpose of this study was to identify the frequency, method, and the complication of physical restraint use in an ED. METHOD: All restrained patients in the Chungnam National University Hospital ED were prospectively enrolled from April to December 2004. They were restrained on a bed in the supine position by using an elastic and a cotton band. A restraint checklist was completed by the emergency physician on all patients who were restrained in the ED. RESULT: One hundred thirty-six patients were restrained (0.56% of the total ED visits). The mean age was 55.4+/-18.9 years(range 4~95). Ninety-two patients(67.6%) were men. Most patients were restrained for confusion(53.7%) and agitation(40.4%), and the most patients(87.5%) were restrained for less than 24 hours. Thirty-seven patients (27.2%) had chemical restraint in addition to physical restraint. Medical records about restraint were absent in 86% of the cases. Four patients(2.9%) developed complications such as increased agitation(3) and untied restraint (1). CONCLUSION: This study demonstrated low incidences of restraint-related complications and of documentation of restraint events, therapeutic manual for ED restraint is required.