Acute Nicotine Poisoning due to Electronic Cigarette Liquid:Systematic Review of Case Reports

Purpose@#Acute nicotine poisoning by liquid nicotine in electronic cigarettes is becoming an increasing problem worldwide. The current systematic review aimed to determine the harm of acute nicotine poisoning by reviewing published case reports. @*Methods@#An online literature search with PubMed, Embase, Cochrane Library, and KoreaMed database was performed to identify relevant studies addressing acute nicotine poisoning with electronic cigarettes. Two investigators searched the case reports written in English or Korean. @*Results@#Twenty-six cases were included in this study. The routes of intoxication included ingestion in 18 cases, intravenous injection in three cases, subcutaneous injection in two cases, and ocular exposure in two cases. Ten cases had a cardiac arrest, and seven of them died. Seven out of 12 cases with intentional poisoning had a cardiac arrest. Nine children under 18 years were reported, and three of them had a cardiac arrest. Sixteen cases without a cardiac arrest recovered well, except for one case with sudden sensorineural hearing loss. @*Conclusion@#The authors reviewed the risks of electronic cigarette liquid in terms of acute poisoning through a systematic review.The nicotine solution of an e-cigarette can be life-threatening in cases of acute poisoning. Therefore, active emergency treatment with early recognition is necessary. In addition, various management methods and regulations for preventing acute nicotine poisoning, such as restriction of distribution and nicotine concentration, should be considered.

Acute Nicotine Poisoning due to Electronic Cigarette Liquid:Systematic Review of Case Reports

Purpose@#Acute nicotine poisoning by liquid nicotine in electronic cigarettes is becoming an increasing problem worldwide. The current systematic review aimed to determine the harm of acute nicotine poisoning by reviewing published case reports. @*Methods@#An online literature search with PubMed, Embase, Cochrane Library, and KoreaMed database was performed to identify relevant studies addressing acute nicotine poisoning with electronic cigarettes. Two investigators searched the case reports written in English or Korean. @*Results@#Twenty-six cases were included in this study. The routes of intoxication included ingestion in 18 cases, intravenous injection in three cases, subcutaneous injection in two cases, and ocular exposure in two cases. Ten cases had a cardiac arrest, and seven of them died. Seven out of 12 cases with intentional poisoning had a cardiac arrest. Nine children under 18 years were reported, and three of them had a cardiac arrest. Sixteen cases without a cardiac arrest recovered well, except for one case with sudden sensorineural hearing loss. @*Conclusion@#The authors reviewed the risks of electronic cigarette liquid in terms of acute poisoning through a systematic review.The nicotine solution of an e-cigarette can be life-threatening in cases of acute poisoning. Therefore, active emergency treatment with early recognition is necessary. In addition, various management methods and regulations for preventing acute nicotine poisoning, such as restriction of distribution and nicotine concentration, should be considered.

Systematic Review of Vitamin B12 Regimen for Patient with Subacute Combined Degeneration of the Spinal Cord Following Nitrous Oxide Abuse

PURPOSE@#The purpose of this study is to evaluate the effectiveness of vitamin B12 treatment in subacute combined degeneration (SCD) caused by nitrous oxide (Nâ‚‚O) abuse.@*METHODS@#Relevant literature was accessed through PubMed, EMBASE, Scopus, and KoreaMed. All the literature that was relevant to human use of vitamin B12 treatment for SCD caused by Nâ‚‚O abuse was included. Case reports were excluded if the treatment regimens were not precisely described. The literature search was conducted by two investigators during September 2019 for the final publication period. The languages of the publications were restricted to English and Korean.@*RESULTS@#Twenty-three published articles that contained 24 cases were included. Sixteen cases among them were treated with intramuscular vitamin B12 of 1 mg/day and the rest received different doses or routes. Although most cases described significant clinical improvements, one case showed no beneficial effect due to the patient's noncooperation. Another case showed adverse events, including spinal myoclonus, following vitamin B12 therapy.@*CONCLUSION@#Vitamin B12 has been broadly used for the treatment of SCD caused by Nâ‚‚O abuse. However, most of the relevant studies were case reports that reported various regimens of vitamin B12 administration. Further studies are needed to establish a standard regimen of vitamin B12 because the incidence of Nâ‚‚O abuse may increase in South Korea.

Comparison of Silymarin, Penicillin, N-acetylcysteine in Patient with Amatoxin Poisoning: A Systematic Review

PURPOSE: This study was conducted to evaluate the clinical efficacy of pharmacologic treatment of amatoxin poisoning patients. METHODS: Literature was accessed through PubMed, EMBASE, Cochrane library, KoreaMed, KISS and KMBASE. Studies relevant to human use of pharmacologic therapy including silymarin, penicillin and N-acetylcysteine (NAC) for amanita poisoning were included. Case reports, letters, editorials and papers with insufficient information were excluded. Comparison of clinical outcomes (especially mortality and liver transplantation rate) in each study was analyzed. RESULTS: The final analysis included 13 retrospective studies. None of these studies showed direct comparisons of individual agents. Among 12 studies comparing silymarin vs penicillin, eight showed clinical superiority of silymarin. Among eight studies comparing silymarin with NAC, six showed clinical superiority of silymarin. Among seven studies of NAC vs penicillin, five showed clinical superiority of NAC. CONCLUSION: This systematic review suggested that clinical superiority of various pharmacological agents used to treat amatoxin poisoning is debatable. Nevertheless, the available evidence suggests it is reasonable to consider combinations of multiple agents for patients with amanita poisoning. Further studies are required to establish a treatment regimen for amanita poisoning.

The effect of time target on overcrowding and clinical quality in the ED: a systematic review and meta-analysis

OBJECTIVE: Many studies have reported the effectiveness of the ‘time target’ on reducing emergency department (ED) overcrowding and improving clinical quality. This study examined the effects of introducing the time target on ED overcrowding and clinical quality using meta-analysis. METHODS: The electronic databases including PubMed (Medline), Cochrane Library, and Embase until June 2017 were searched. The search keywords were ‘time target,’‘national emergency access target,’‘four-hour rule,’ and ‘shorter stays in ED’. Two investigators selected and reviewed articles according to the predefined inclusion and exclusion criteria. The quality of the articles was evaluated using the RoBANS checklist. The data were abstracted by predetermined criteria and meta-analysis was performed using RevMan software. RESULTS: Of 721 articles, 16 studies were included in the final analysis. A meta-analysis of four studies on the ED length of stay (LOS) showed that the mean EDLOS was reduced by 0.64 hours (95% confidence interval [CI], 0.34–0.94) since the introduction of the time target. Other studies also showed that the EDLOS was reduced. There was no definite trend in the hospital admission rate. Meta-analysis of nine studies on the clinical quality revealed a total odds ratio of 1.02 (95% CI, 0.74–1.32). Time taken until the visitation of a doctor and the initiation of treatment were both reduced. The rate of “left without being seen” was decreased. CONCLUSION: EDLOS was reduced and no significant association was observed between mortality and the application of a time target since the introduction of time target. ‘Rate of revisiting,’‘time to clinician,’‘time to treatment,’ and ‘rate of left without being seen’ was reduced.

Usefulness of Predictors for Hepatotoxicity in Acetaminophen Poisoning Patient

PURPOSE: The purpose of this study was to determine whether hepatotoxicity could be predicted early using biochemical markers in patients with acetaminophen (AAP) poisoning and to assess the usefulness of predictive factors for acute liver injury or hepatotoxicity. METHODS: This study was a retrospective observational study involving a medical records review. The participants were patients who were admitted to the emergency department (ED) with AAP overdose at two hospitals over a 10-year period. Demographic data, age, time from ingestion to visit, initial AAP level, initial hepatic aminotransferases, and initial prothrombin time were recorded. Acute liver injury was defined as a peak serum ALT >50 U/L or double the admission value, and hepatotoxicity was defined as a peak ALT >1,000 U/L. Receiver operating characteristic curve analyses were performed to compare the prognostic performance among variables. RESULTS: A total of 97 patients were admitted to the ED with AAP overdose, of whom 26 had acute liver injury and 6 had hepatotoxicity. Acute liver injury was associated with the time interval after taking the drug, and hepatotoxicity was associated with the initial PT and the ALT level. The scoring system proposed by the authors has a significant ability to predict both acute liver injury and hepatotoxicity. CONCLUSION: To predict the prognosis of AAP poisoning patients, the time interval after taking AAP was important, and initial prothrombin time and ALT level were useful tests. Also a scoring system combining variables may be useful.

Fomepizole for Ethylene Glycol or Methanol Poisoning in Children

PURPOSE: The purpose of this study is to evaluate the effectiveness and adverse effect of fomepizole in the management of acute ethylene glycol or methanol poisoning in children. METHODS: Databases such as PubMed, Embase, Cochrane library, and KoreaMed were searched using terms related to fomepizole, ethylene glycol, methanol and pediatric. All studies, regardless of study design, reporting effectiveness or safety endpoints in children were included. Reference citations from identified publications were reviewed. Only reports written in English or Korean languages were included. The reference search was performed by two authors. RESULTS: Twenty-two relevant literatures were finally included. They were one narrative review, 4 retrospective case series, and 17 case reports (19 cases). Case reports were classified as 5 fomepizole only, 8 fomepizole with other therapies, and 6 no fomepizole. All patients from the literatures were fully recovered without long term sequelae. Adverse effects of fomepizole were reported including anaphylaxis, thrombophlebitis and nystagmus. CONCLUSION: There are insufficient literatures regarding fomepizole treatment in children with ethylene glycol or methanol poisoning. The benefits or harms are not clearly established based on the clinical evidences. More prospective comparative studies are required in the future.

Different Characteristics of Toxic Substance/poison Exposure Data that Collected from Pre-hospital Telephone Response and Emergency Department

PURPOSE: The purpose of this study is to find differences in the demographics of toxic exposed patients and substance between call based poison information data and hospital based poison information data. METHODS: Seoul 1339 call-response data were used as call based poison data and toxic related injury surveillance data of the Korean center for disease control and prevention (KCDC) were used as hospital based poison data. Age, sex, the kind of exposed substance, reasons for exposure, and exposure routes were compared between two data sets. We analyzed the presence or not of documentation on the name and amount of exposed substance, symptoms after exposure in call based poison data. RESULTS: Seoul1339 poison data included a total of 2260 information related to toxic exposure and KCDC poison data included 5650 poison cases. There was no difference in sexual distribution. Pediatric exposure and accidental exposure were more common in call based poison data. The most common exposed substances were household products in call based poison data and medicines in hospital based poison data, respectively. Documents regarding amount and time of toxic exposure and symptoms after toxic exposure were not recorded exactly in call based poison data. CONCLUSION: There were significant differences in age, reasons for toxic exposure, and the kinds of exposed substances. Poison information data from both pre-hospital and hospital must be considered.

Different Characteristics of Toxic Substance/poison Exposure Data that Collected from Pre-hospital Telephone Response and Emergency Department

PURPOSE: The purpose of this study is to find differences in the demographics of toxic exposed patients and substance between call based poison information data and hospital based poison information data. METHODS: Seoul 1339 call-response data were used as call based poison data and toxic related injury surveillance data of the Korean center for disease control and prevention (KCDC) were used as hospital based poison data. Age, sex, the kind of exposed substance, reasons for exposure, and exposure routes were compared between two data sets. We analyzed the presence or not of documentation on the name and amount of exposed substance, symptoms after exposure in call based poison data. RESULTS: Seoul1339 poison data included a total of 2260 information related to toxic exposure and KCDC poison data included 5650 poison cases. There was no difference in sexual distribution. Pediatric exposure and accidental exposure were more common in call based poison data. The most common exposed substances were household products in call based poison data and medicines in hospital based poison data, respectively. Documents regarding amount and time of toxic exposure and symptoms after toxic exposure were not recorded exactly in call based poison data. CONCLUSION: There were significant differences in age, reasons for toxic exposure, and the kinds of exposed substances. Poison information data from both pre-hospital and hospital must be considered.

A Case Report of Envenomation and Injury by a Poisonous Spine of A Marble Motoro (Potamotrygon Motoro)

Potamotrygon motoro, also known as the Marble motoro, is a potamodromous freshwater ray native to the basins of the Amazon River. Marble motoros were introduced to South Korea in the 2000s, and, because they are easy to raise, were sold as aquarium fish. The aim of this report is to illustrate a new case involving envenomation by a Marble motoro. A 35-year-old commercial aquarium assistant came to the hospital after being pricked by a Marble motoro. The clinical picture in this case showed acute local pain with minimal systemic manifestations. This patient recovered after receiving symptomatic treatment and wound care. This case of envenomation accentuates the potential for injury among people coming in contact with a venomous Marble motoro.

Effect of Devices on Defibrillation Skill in the Objective Structured Clinical Examination; A Simulation Study

PURPOSE: Early defibrillation is essential for survival from ventricular fibrillation (VF). In Korea, assessment of clinical skills, including electrical defibrillation, has been part of the medical licensing examination since 2009. Although one defibrillator is used in the exam, various defibrillators are used in the real world. We wanted to know whether unfamiliar devices might affect defibrillation skill. METHODS: Our research was performed during conduct of the objective structured clinical examination (OSCE) for sixth grade medical students. Three different defibrillators were used for the test; CodeMaster, LiFEGAIN, and HEARTSTART MRx. CodeMaster was the defibrillator used for education and training. In the test room, VF was simulated by use of a simulator (SimMan(R)), and one of the three defibrillators was placed randomly. A checklist, where eight items among a total of 13 items were for device operation, was used for assessment of defibrillation skill. The written exam and clinical practice score for emergency medicine and defibrillation skill score were investigated. In addition, each operation time of device (turn-on, charge, and shock) was calculated with review of video resources containing the entire exam process. RESULTS: Among 65 students enrolled, 59 students were included for analysis. Students were divided according to CodeMaster (n=20), LiFEGAIN (n=15), and HEARTSTART MRx (n=24). No significant difference in the score on the written exam and clinical practice was observed among the groups. In addition, the scores for defibrillation skill and the time intervals did not differ among the groups. CONCLUSION: Unfamiliar devices may not affect defibrillation skill in medical students.

A Simulation Study for Quality of Chest Compression Provided by Health Personnel / 대한구급학회지

BACKGROUND: Effective chest compression may improve the return of spontaneous circulation and neurologic outcome in arrest victims. For fear of rescuer's fatigue, guidelines for cardiopulmonary resuscitation (CPR) recommended that chest compression (CC) should be switched every 2 minutes, but there is little evidence. We investigated whether health personnel could provide consistent quality of CC for 2 minutes. METHODS: We recruited prospectively health personnel working on one university hospital. On the day assigned randomly, CPR performance data was collected with use of CPR recording technology. Quality of CPR was calculated every 30 seconds interval. To identify the quality decay, we used repeated measure analysis of variance with SPSS 17.0 for analysis. RESULTS: We analyzed 8,485 CCs performed by 41 subjects. Total number of CC decayed between 90 to 120 seconds (51.6 +/- 3.3 to 50.8 +/- 3.5, p = 0.020) within recommended range. The ratio of correct depth CC decayed between 90 to 120 seconds, falling from 83.4 +/- 24.9% to 68.3 +/- 38.4% (p = 0.002). The ratio of low depth CC increased significantly over time (10.2 +/- 20.7% to 31.3 +/- 38.5%, p < 0.001). CONCLUSIONS: Health personnel may provide adequate number of CC for 2 minutes. But, the number of correct depth CC may decay between 90 to 120 seconds. Also the number of low depth CC may increase over time.

The Transmission Performance Evaluation of Remote Healthcare Data over Secure Satellite Network / 대한의료정보학회지

OBJECTIVES: We have not only examined telemedicine scenario but also applied IPSec(AH, ESP) algorithms under VPN(Virtual Private Network) for performance evaluation of telemedicine system's security and transmission. METHODS: In this study, we applied IPSec(AH, ESP) algorithms under VPN(Virtual Private Network) protocol when transmit healthcare data through Satellite Network. At that time, we evaluated performance of telemedicine system through RTT(Round Trip Time), Jitter, Bandwidth that indicate to QoS(Quality Of Service). RESULTS: It is possible to transfer remote healthcare data over Satellite Network under provided image of 15 frame and bio-signal of 10 kbps and RTT(Round Trip Time) of 774.53ms, Jitter of 25.2ms. But applying IPsec(AH, ESP) under VPN(Virtual Private Network), it is frequently happened distortion of image data affected SHA-1 and 3DES algorithm. CONCLUSION: In this study, it is possible to use telemedicine system for Secure Satellite Network, but demand to be based QoS(Quality Of Service) limited. We expected that it is possible to use the designed system in the disaster area.

Analysis of Patients were Transported by 119 Helicopter from Mountain Accident Scenes in Seoul

PURPOSE: Geographic problems can make it difficult for rescue teams to access emergency patients in the mountains. We developed the aeromedical relief program in conjunction with fire department helicopter EMS teams. This study describes the clinical experience of patients transported from the mountains in this program. METHODS: We reviewed the employed protocols and the medical records of patients transported to our hospital from the mountains by the aeromedical transport system from June 2006 to June 2007. RESULTS: Thirty-one patients were transported by helicopter during the study period, most of them (84%) from Mt. Bukhan. The time interval from call for help to hospital arrival was 80+/-56 min, and rescue time alone was 30+/-24 min. Eleven patients (36%) were pronounced dead on arrival, and 11 patients were admitted for management. The number of trauma patients were 24 (77%), who had an average RTS score (excluding the 11 patients who expired before arrival) of 11.7+/-0.6. When the ground team and the aeromedical team were dispatched at the same time, the total transport time was 54.0+/-22.8 min, compared to 133.0 +/-75.7 min when the aeromedical team was dispatched only upon the request of the ground team, a large and statistically significant difference. CONCLUSION: This study suggests that the helicopter transport system can be successfully employed to achieve early access to patients in the mountains. To optimize the current program, cooperation between hospital and the regional helicopter EMS is required.

Cervicofacial Subcutaneous Emphysema and Pneumomediastinum after a Dental Procedure

The occurrences of subcutaneous emphysema or pneumomediastinum after a dental procedure are rare, but they are potentially life-threatening complications. These complications are reported to occur mainly in patients after dental procedures on the third molar, in particular during mandibular extractions and treatment on the right side. A 22-yearold woman visited the emergency department with neck swelling and chest pain after a right lower third molar extraction. She had a subcutaneous emphysema on the face and neck. Her chest x-ray and computed tomography of the chest showed a pneumomediastinum. She was discharged 6 days later without serious complications. Many cases of subcutaneous emphysema are of limited severity, resulting in minor, localized swelling, and require nothing more than observation and reassurance. However, early recognition of these problems is essential in preventing lifethreatening complications such as airway obstruction, mediastinitis, deep neck infection, and cardiac failure. We review the pathophysiology and clinical course of this disease.

Appropriateness of Emergency Care Depicted in Korean Movies

PURPOSE: As the lay public indirectly acquires medical knowledge through the mass media, it is desirable to show medically correct care in movies or TV dramas. We evaluated whether the emergency care depicted in Korean boxoffice movies is appropriate and medically sound. METHODS: We selected Korean movies which more than 100,000 peoples had seen in Seoul from 1996 to 2001. We excluded fantasy or historical movies from the list. After searching the emergency situations in videos, including cardiopulmonary arrest, loss of consciousness, injuries, and medical emergencies, we evaluated whether the needed care was provided and properly done and whether the result was medically sound. RESULTS: During the 6-year period, we found 46 emergency situations in 80 movies (0.6 per movie). Loss of consciousness was the most common emergency situation (34.8%), followed by cardiopulmonary arrest (15.7%). Emergency care was provided in 24 situations (52.2%), but was appropriate in only 8 among those 24 situations. Regardless of care, 50% improved and another 36.4% improved without any interventions. There was total of 106 necessary actions in the 46 situations: for instance, EMS system activation, airway maintenance, breathing and circulation support, spinal cord protection, and hemostasis. Only 21 among the 106 necessary actions (19.8%) were done. Hemostasis by external compression was the most common action done (44.4%), and airway maintenance was the least (3.6%). CONCLUSION: We found that emergency care and its result were not properly depicted in Korean box-office movies. Emergency physicians and the medical community should pay attention to this problem and serve as medical advisors to guarantee a medically sound portrayal.