The Prevalence and Emergency Department Utilization of Patients Who Underwent Single and Double Inter-hospital Transfers in the Emergency Department: a Nationwide Population-based Study in Korea, 2016–2018

Background@#Inter-hospital transfer (IHT) for emergency department (ED) admission is a burden to high-level EDs. This study aimed to evaluate the prevalence and ED utilization patterns of patients who underwent single and double IHTs at high-level EDs in South Korea. @*Methods@#This nationwide cross-sectional study analyzed data from the National Emergency Department Information System for the period of 2016–2018. All the patients who underwent IHT at Level I and II emergency centers during this time period were included. The patients were categorized into the single-transfer and double-transfer groups. The clinical characteristics and ED utilization patterns were compared between the two groups. @*Results@#We found that 2.1% of the patients in the ED (n = 265,046) underwent IHTs; 18.1% of the pediatric patients (n = 3,556), and 24.2% of the adult patients (n = 59,498) underwent double transfers. Both pediatric (median, 141.0 vs. 208.0 minutes, P < 0.001) and adult (median, 189.0 vs. 308.0 minutes, P < 0.001) patients in the double-transfer group had longer duration of stay in the EDs. Patient's request was the reason for transfer in 41.9% of all IHTs (111,076 of 265,046). Unavailability of medical resources was the reason for transfer in 30.0% of the double transfers (18,920 of 64,054). @*Conclusion@#The incidence of double-transfer of patients is increasing. The main reasons for double transfers were patient's request and unavailability of medical resources at the firsttransfer hospitals. Emergency physicians and policymakers should focus on lowering the number of preventable double transfers.

The Prevalence and Emergency Department Utilization of Patients Who Underwent Single and Double Inter-hospital Transfers in the Emergency Department: a Nationwide Population-based Study in Korea, 2016–2018

Background@#Inter-hospital transfer (IHT) for emergency department (ED) admission is a burden to high-level EDs. This study aimed to evaluate the prevalence and ED utilization patterns of patients who underwent single and double IHTs at high-level EDs in South Korea. @*Methods@#This nationwide cross-sectional study analyzed data from the National Emergency Department Information System for the period of 2016–2018. All the patients who underwent IHT at Level I and II emergency centers during this time period were included. The patients were categorized into the single-transfer and double-transfer groups. The clinical characteristics and ED utilization patterns were compared between the two groups. @*Results@#We found that 2.1% of the patients in the ED (n = 265,046) underwent IHTs; 18.1% of the pediatric patients (n = 3,556), and 24.2% of the adult patients (n = 59,498) underwent double transfers. Both pediatric (median, 141.0 vs. 208.0 minutes, P < 0.001) and adult (median, 189.0 vs. 308.0 minutes, P < 0.001) patients in the double-transfer group had longer duration of stay in the EDs. Patient's request was the reason for transfer in 41.9% of all IHTs (111,076 of 265,046). Unavailability of medical resources was the reason for transfer in 30.0% of the double transfers (18,920 of 64,054). @*Conclusion@#The incidence of double-transfer of patients is increasing. The main reasons for double transfers were patient's request and unavailability of medical resources at the firsttransfer hospitals. Emergency physicians and policymakers should focus on lowering the number of preventable double transfers.

Tension pneumoperitoneum during pneumatic reduction of pediatric intussusception: case report

This paper presents a case report of tension pneumoperitoneum that occurred in a 4-month-old girl with intussusception during pneumatic reduction. Tension pneumoperitoneum is a rare but life threatening complication in air pressure enema that is commonly used to turn the intussuscepted bowel to its original position. The incidence of a simple pneumoperitoneum due to a bowel perforation associated with attempted pneumatic reduction for intussusception is as high as 4%. The simple pneumoperitoneum changed rapidly to tension pneumoperitoneum and immediate needle decompression was life-saving in this case. Similar to a tension pneumothorax, the diagnosis is clinical and management should not be delayed awaiting other confirmatory tests. The emergency physician must recognize this rare complication of pneumatic reduction and promptly treat the ensuing tension pneumoperitoneum after bowel perforation with immediate needle decompression as a part of the initial resuscitation.

Accuracy for registration of disease codes in pediatric anaphylaxis

PURPOSE: The aim of this study was to survey the accuracy of registration as anaphylaxis codes and the clinical characteristics of anaphylaxis registered correctly and incorrectly in pediatric anaphylaxis. METHODS: This study was conducted retrospectively using the medical records of patients under 15 years who visited a training hospital Emergency Department (ED) for 5 years. The study subjects were divided into the correct group (registered as anaphylaxis codes correctly) and the incorrect group (registered as other anaphylaxis related codes). RESULTS: Of the 133 patients, 14 belonged to the correct group and 119 to the incorrect group. The median age of the correct group was 9 years old and that of the incorrect group was 2 years old. Sex, transportation to the ED, elapsed time from exposure to ED arrival, past history of allergy, causes of anaphylaxis except drug, severity of symptom, mental status, and antihistamine use were not different between the 2 groups. Drugs as the cause of anaphylaxis and cardiovascular/neurologic symptoms were more common in the correct group. Gastrointestinal symptoms were more frequent in the incorrect group. Intravenous fluid, steroid, bronchodilator, and epinephrine were more commonly used as the treatment for anaphylaxis in the correct group. The pediatric patients treated with epinephrine tended to be registered anaphylaxis correctly. CONCLUSION: More patients were registered incorrectly as other anaphylaxis-related disease codes rather than correctly as the anaphylaxis disease codes in pediatric anaphylaxis. Epinephrine use was the associated factor for being registered correctly as the anaphylaxis disease codes in pediatric anaphylaxis.

Recurrent Intussusceptions in Identical Twins, Visited to Emergency Department

This report presents a set of identical twins who had recurrent intussusceptions. One twin had intussusception 3 times, and the other had it 7 times. They were usually diagnosed by ultrasonography and reduced by air contrast enema. Manual operative reduction was performed separately for each one due to failure of the enema. Unfortunately, we still could not determine the exact cause. A few cases of intussusceptions in identical twins within a few days of each other have been reported, which may be the result of a congenital predisposition triggered by an acquired agent. We report a rare case of recurrent intussusceptions in identical twins within 4 years.

Acute Pneumonitis Induced by Intravenous Thinner Injection in a Case of Suicidal Attempt

A 24 year-old man attempted suicide by injection of 1 cc of thinner into his left antecubital vein; 3 hours later, he visited our emergency room because of left chest pain. We suspected a chemical pneumonitis based on the abnormal findings of his chest X-ray and computed tomography. On the 3rd day after admission, a cellulitis also occurred at the injection area. His symptoms were relieved after supportive care for 2 weeks. There is significant experience with intoxication of thinner inhalation, whereas intoxication of intravenous thinner is rare.

Hemopericardium Following Acupuncture

Acupuncture-related hemopericardium is a rare but potentially fatal complication. We describe a hemopericardium that occurred shortly after acupuncture in a 55-year-old woman. A chest CT scan and echocardiography revealed a hemopericardium, and pericardiocentesis was then immediately and successfully performed. Subsequently, her clinical course improved. This case increases the attention of emergency physicians for acupuncture-related complications, especially hemopericardium, and the necessity of rapid diagnosis and management.

Hemopericardium Following Acupuncture

Acupuncture-related hemopericardium is a rare but potentially fatal complication. We describe a hemopericardium that occurred shortly after acupuncture in a 55-year-old woman. A chest CT scan and echocardiography revealed a hemopericardium, and pericardiocentesis was then immediately and successfully performed. Subsequently, her clinical course improved. This case increases the attention of emergency physicians for acupuncture-related complications, especially hemopericardium, and the necessity of rapid diagnosis and management.

Clinical Characteristics of Intraperitoneal and Retroperitoneal Solid Organ Injuries after Trauma

PURPOSE: The aim of this study was to analyze the characteristics and prognosis of intraperitoneal and retroperitoneal solid organ injuries after trauma. METHODS: We analyzed computed tomography (CT) data for 232 patients who had injury to solid abdominal organs between January 2002 and June 2009. The patients who had solid organ injury on CT were categorized into intraperitoneal, retroperitoneal and intra/retroperitoneal injury groups. Medical records were reviewed retrospectively, and data regarding the sex and age of patients, mechanism of injury, initial hemodynamic status, Revised Trauma Score (RTS), Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), amount of transfusion, admission rate to intensive care unit (ICU), and mortality were collected and analyzed. Injury severity of solid organs was classified according to the American Association for the Surgery of Trauma (AAST) grading system. RESULTS: The intraperitoneal injury group had 131 patients, the retroperitoneal injury group 49 patients, and the intra/retroperitoneal injury group 52 patients. The intra/retroperitoneal injury group exhibited low blood pressure, a large number of packed red blood cells that were transfused, and high ISS and abdominal AIS. They tended to stay longer in the ICU and showed a higher mortality. Conservative management was the most common therapeutic modality for all 3 groups. CONCLUSION: The intra/retroperitoneal injury group showed higher fall for the mecahnism of injury, a lower initial blood pressure and a larger number of packed red blood cells that were transfused compared with the other groups. Therefore, physicians should rapidly identify those with a poor prognosis at initial presentation and make a decision quickly when they are caring for intra/retroperitoneal injury patients.

A Case of the Nutcracker Syndrome Presenting as Left Flank Pain

The nutcracker syndrome does not occur frequently. The condition usually results from compression of the left renal vein between the superior mesenteric artery and the abdominal aorta, and leads to varicocele, flank pain and lateralizing hematuria. With a full review of the literature, we now report and discuss a case of nutcracker syndrome in which a 30-year-old female visited the emergency center for left flank pain. She experienced complete recovery after conservative treatment.

Retention of CPR Skills by Nursing Students Received Training in AHA BLS Course for Healthcare Providers

PURPOSE: After initial cardiopulmonary resuscitation (CPR) training, CPR performance declines substantially over time. We undertook this study to evaluate the retention of CPR skills by nursing students who received training in the American Heart Association (AHA) basic life support (BLS) course for healthcare providers. METHODS: Third-year nursing students at Ulsan College received training in an 8-hour AHA BLS course. The sequence of CPR actions follows those of the AHA 2005 guidelines. Six months later, skill retention was tested in some of the students without previous notice. Performance in fifteen discrete skills was tested in a scenario format. Resuscitation skills were measured using skill-reporting manikin connected to a PC using Ambu(R) MegaCode Simulation Software and Philips'AED Trainer-2(R). Each of the tests was recorded in video-tapes and the results were analysed by two emergency physicians. RESULTS: Sixty participants were trained and 22 of them were chosen for testing after 6 months. Although not statistically significant, assessing responsiveness (n=17, 77.3%), correct hand placements for compressions (n=17, 77.3%), delivering adequate compression (n=15, 68.2%), turning on the AED (n=18, 81.8%), and placing pads correctly (n=17, 77.3%) tended to be better than the performance of the other discrete skills. The chest compression rate and depth were 105.6+/-26.4/min and 45.5+/-11.3mm, respectively. These two skills were performed correctly 59.1% and 59.1% in all the participants, respectively. CONCLUSION: This study confirmed the generally poor 6- month retention of CPR skills and demonstrated the need for reeducation in nursing students. Further studies are needed to identify the appropriate re-training interval for different occupations.

Multiple Intraabdominal Solid Organ Injuries after Blunt Trauma

PURPOSE: This study evaluated the characteristics and the prognosis of multiple intraabdominal solid organ injuries, including those to the liver, spleen, and kidney, after blunt trauma. METHODS: From January 2001 to March 2009, 39 patients with multiple intraabdominal solid organ injuries, which had been confirmed by contrast-enhanced computed tomography after blunt trauma, were included in this retrospective study. The injury severity score (ISS), abbreviated injury scale (AIS), revised trauma score (RTS), American Association for the Surgery of Trauma (AAST) injury grade of solid organs, initial hemodynamic status, blood gas analysis, blood transfusion, and the mortality were the main outcome measurements. RESULTS: Injured groups were classified into liver/kidney (n=17), liver/spleen (n=4), spleen/kidney (n=13), and liver/kidney/spleen (n=5) groups. Patients were older in the liver/kidney group than in the liver/kidney/spleen group (43 vs 18 years, p=0.023). The initial systolic blood pressures tended to be lower in the liver/kidney group than in the other groups (84 vs 105, 112, and 114 mmHg, p=0.087). The amounts of 24-hour packed RBC transfusion were 32 units in the liver/kidney group and 4 units in the liver/kidney/spleen group, but the difference was not statistically significant. Differences were found in neither the RTS, ISS, and AIS for head, chest, abdominal, and pelvic injuries nor the AAST injury grade for solid organ, but injuries to the chest were more severe in the liver/spleen group than in the spleen/kidney group (AIS 4.0 vs 2.8, p=0.028). Conservative treatment was the most frequent applied treatment in all groups. There were 6 mortalities : 3 due to hypovolemia, 2 to sepsis, and 1 to brain injury. Mortalities occurred only in the liver/kidney group. CONCLUSION: Patients who had intraabdominal solid organ injuries of the liver and the kidney simultaneously, tended to be transfused more at an early time after trauma, to have lower initial systolic blood pressures, and to have a higher mortality.

Esophageal Hiatal Hernia with GastricPerforation : A Case Report

Esophageal hiatal hernia occurs when a portion of the stomach prolapses through the esophageal hiatus into the thoracic cavity. The most common symptoms are epigastric or substernal pain, nausea, vomiting and dyspepsia, but most people with hiatal hernia are asymptomatic or have nonspecific symptoms. Hiatal hernia is usually discovered as an incidental finding on upper gastrointestinal studies or gastroscopy. We now report a case of type II paraesophageal hiatal hernia with gastric perforation. It is important to consider panperitonitis caused by perforation of a herniated stomach when the patient with hiatal hernia has acute abdominal pain.

Acute Appendicitis with Superior Mesenteric Vein Thrombosis and Portal Vein Thrombosis

Superior mesenteric vein thrombosis and portal vein thrombosis are rare conditions that are difficult to diagnose due to vague symptoms, but they are usually fatal when they occur. Appendicitis is the one of the most common causes of superior mesenteric vein thrombosis, via venous drainage from the appendiceal area into the portal system. We report a case of superior mesenteric vein thrombosis and portal vein thrombosis secondary to appendicitis presenting with diarrhea, low abdominal pain, and jaundice. The patient was treated with antibiotics and anticoagulants, without fatal complications, but developed a chronic sequela of portal vein thrombosis. It is important to consider thrombosis of the superior mesenteric vein and portal vein in patients who have intra-abdominal infection with specific or non-specific symptoms.

Comparison of Survival in Pelvic Bone Fractures with Arterial Embolization

PURPOSE: This study was to evaluate the effect of arterial embolization on survival in patients with pelvic bone fractures and arterial bleeding. METHODS: From January 2001 to December 2007, in all, 18 patients with pelvic bone fractures that had been treated with interventional arterial embolization were included in this retrospective study. The Injury Severity Score (ISS), the Revised Trauma Score (RTS), the initial hemodynamic status, the blood gas analysis, blood transfusion data, and mortality were the main outcome measurements. RESULTS: Pelvic bone fractures were classified into lateral compression (LC), antero-posterior compression (APC), vertical shear (VS), and combined (CM) type according to the Young-Burgess classification. The Survivor group included 11 patients (61.1%), and the non-survivor group included 7 patients (38.9%). The mean ages for the survivor and the non-survivor groups were 40.0 and 45.6 years (p=0.517). The types of pelvic bone fractures were LC 11 (61.1%), APC 6 (33.3%), and VS 1 (5.6%): LC 7 (63.6%), and APC 4 (36.4%) in the survivor group and LC 4 (57.1%), APC 2 (28.6%), and VS 1 (14.3%) in the non-survivor group. The internal iliac artery was the predominant injured vessel among both the survivors (n = 5, 45.5%) and the non-survivors (n = 4, 57.1%). No differences in initial blood pressures, ISS, and RTS existed between the two groups, but the arterial pH was lower in the non-survivor group (pH 7.09 (+/-0.20) vs 7.30 (+/-0.08), p=0.018). The number of transfused 24-hour units of packed RBC was greater in the non-survivor group (24.1+/-12.5 vs 14.4+/-6.8, p=0.046). CONCLUSION: No differences in initial blood pressure and trauma scores existed between survivors and nonsurvivors with pelvic bone fractures, who had been treated with arterial embolization, but arterial pH was lower the in non-survivors.

Bilateral Fatigue Fractures of the Femoral Neck

Stress fractures occur as a result of repetitive loading, which can lead to mechanical failure and fracture of the bone. They occur most commonly in the tibia and are progressively less common in the tarsals, metatarsals, femur, fibula, pelvis, sesamoids, and spine. Femoral neck stress fractures are unusual but not rare. Most cases of them occur in the elderly, in athletic individuals, or in military trainees. But, they often not initially considered when assessing hip pain. Patients often stoically persevere with mobilization, increasing the risk of fracture displacement with its associated morbidity of delayed union, non-union, and avascular necrosis. Radiographic evaluation may be unremarkable, especially if obtained within 1 week of the onset of symptoms. The diagnosis is often missed initially because of that reasons. Bilateral fatigue fractures of the femoral neck with no known medical conditions are very rare. We present the rare case of an apparently healthy military male recruit with bilateral femoral neck fatigue fractures diagnosed by using MRI.

Are Falls of Less Than 6 Meters Safe?

PURPOSE: The committee on trauma of the american college of surgeons, in its manual resources for optimal care of the injured patients involved in falls from less than 20 feet need not be taken to trauma centers. Because triage criteria dictate less urgency for low-level falls, this classification scheme has demerits for early detection and treatment of serious problems in the emergency room. METHODS: A prospective analysis was conducted of 182 patients treated for fall-related trauma from June 2003 to March 2004. Falls were classified as group A ( or =3 m, or =6 m). Collected data included the patient's age, gender, site and height of fall, surface fallen upon, body area of first impact, body regions of injuries, Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), and Injury Severity Score (ISS). RESULTS: The 182 patients were classified as group A (105) 57.7%, group B (61) 33.5%, and group C (16) 8.8%. There was a weak positive correlation between the height of fall and the patients'ISS in the three groups (p<0.001). There were significant differences in GCS (p=0.017), RTS (p=0.034), and ISS (p=0.007) between group A and B. In cases that the head was the initial impact area of the body, the GCS (p<0.001) and the RTS (p=0.002) were lower, but the ISS (p<0.001) was higher than it was for other type of injuries. Hard surfaces as an impact surface type, had an influence on the GCS (p<0.001) and the ISS (p=0.025). CONCLUSION: To simply categorize patients who fall over 6 meters as severely injured patients doesn't have much meaning, and though patients may have fallen less than 6 meters, they should be categorized by using the dynamics (impact surface type, initial body-impact area) of their fall.