Factors predicting injury severity in driver traffic accidents

Objective@#The factors related to injury severity in accidents in Korea are unclear. This study helps primary physicians treat victims of traffic accidents with a high probability of severe injury during the initial evaluation in the emergency department (ED). @*Methods@#This study was conducted on patients who visited Pusan National University Hospital regional trauma center, Korea, between January 2017 and December 2019 due to involvement in automobile accidents as a driver. Multivariate logistic regression analysis was used to determine the relationship of factors with injury severity. @*Results@#A total of 973 patients were included. Of them, 316 (32.5%) were severely injured. In the multivariate logistic regression analysis, older age was significantly associated with more severe injury (odds ratio [OR], 1.030; 95% confidence interval [CI], 1.017-1.043; P<0.001). A significant difference was noted in injury severity according to the mode of transportation to the ED. Transportation via private ambulance was associated with more severe injury than via public ambulance (OR, 5.853; 95% CI, 3.986-8.594; P<0.001). The severe injury was more likely when the collision involved a large-sized vehicle (OR, 2.369; 95% CI, 1.466-3.826; P<0.001), or a fixed object (OR, 2.077; 95% CI, 1.326-3.254; P<0.001) compared to a small-sized vehicle. The group that did not wear a seat belt had more severe injuries than those who wore a seat belt (OR, 2.218; 95% CI, 1.421-3.463; P<0.001). @*Conclusion@#Injury severity was correlated with age, mode of transportation to the ED, type of collision and seat belt use. These results will help primary physicians assess critically ill patients.

The Comparison of Emergency Medical Service Responses to and Outcomes of Out-of-hospital Cardiac Arrest before and during the COVID-19 Pandemic in an Area of Korea

Background@#Since the declaration of the coronavirus disease 2019 (COVID-19) pandemic, COVID-19 has affected the responses of emergency medical service (EMS) systems to cases of out-of-hospital cardiac arrest (OHCA). The purpose of this study was to identify the impact of the COVID-19 pandemic on EMS responses to and outcomes of adult OHCA in an area of South Korea. @*Methods@#This was a retrospective observational study of adult OHCA patients attended by EMS providers comparing the EMS responses to and outcomes of adult OHCA during the COVID-19 pandemic to those during the pre-COVID-19 period. Propensity score matching was used to compare the survival rates, and logistic regression analysis was used to assess the impact of the COVID-19 pandemic on the survival of OHCA patients. @*Results@#A total of 891 patients in the pre-COVID-19 group and 1,063 patients in the COVID-19 group were included in the final analysis. During the COVID-19 period, the EMS call time was shifted to a later time period (16:00–24:00, P < 0.001), and the presence of an initial shockable rhythm was increased (pre-COVID-19 vs. COVID-19, 7.97% vs. 11.95%, P = 0.004). The number of tracheal intubations decreased (5.27% vs. 1.22%, P < 0.001), and the use of mechanical chest compression devices (30.53% vs. 44.59%, P < 0.001) and EMS response time (median [quartile 1-quartile 3], 7 [5–10] vs. 8 [6–11], P < 0.001) increased. After propensity score matching, the survival at admission rate (22.52% vs. 18.24%, P = 0.025), survival to discharge rate (7.77% vs. 5.52%, P = 0.056), and favorable neurological outcome (5.97% vs. 3.49%, P < 0.001) decreased. In the propensity score matching analysis of the impact of COVID-19, odds ratios of 0.768 (95% confidence interval [CI], 0.592–0.995) for survival at admission and 0.693 (95% CI, 0.446–1.077) for survival to discharge were found. @*Conclusion@#During the COVID-19 period, there were significant changes in the EMS responses to OHCA. These changes are considered to be partly due to social distancing measures. As a result, the proportion of patients with an initial shockable rhythm in the COVID-19 period was greater than that in the pre-COVID-19 period, but the final survival rate and favorable neurological outcome were lower.

The Comparison of Emergency Medical Service Responses to and Outcomes of Out-of-hospital Cardiac Arrest before and during the COVID-19 Pandemic in an Area of Korea

Background@#Since the declaration of the coronavirus disease 2019 (COVID-19) pandemic, COVID-19 has affected the responses of emergency medical service (EMS) systems to cases of out-of-hospital cardiac arrest (OHCA). The purpose of this study was to identify the impact of the COVID-19 pandemic on EMS responses to and outcomes of adult OHCA in an area of South Korea. @*Methods@#This was a retrospective observational study of adult OHCA patients attended by EMS providers comparing the EMS responses to and outcomes of adult OHCA during the COVID-19 pandemic to those during the pre-COVID-19 period. Propensity score matching was used to compare the survival rates, and logistic regression analysis was used to assess the impact of the COVID-19 pandemic on the survival of OHCA patients. @*Results@#A total of 891 patients in the pre-COVID-19 group and 1,063 patients in the COVID-19 group were included in the final analysis. During the COVID-19 period, the EMS call time was shifted to a later time period (16:00–24:00, P < 0.001), and the presence of an initial shockable rhythm was increased (pre-COVID-19 vs. COVID-19, 7.97% vs. 11.95%, P = 0.004). The number of tracheal intubations decreased (5.27% vs. 1.22%, P < 0.001), and the use of mechanical chest compression devices (30.53% vs. 44.59%, P < 0.001) and EMS response time (median [quartile 1-quartile 3], 7 [5–10] vs. 8 [6–11], P < 0.001) increased. After propensity score matching, the survival at admission rate (22.52% vs. 18.24%, P = 0.025), survival to discharge rate (7.77% vs. 5.52%, P = 0.056), and favorable neurological outcome (5.97% vs. 3.49%, P < 0.001) decreased. In the propensity score matching analysis of the impact of COVID-19, odds ratios of 0.768 (95% confidence interval [CI], 0.592–0.995) for survival at admission and 0.693 (95% CI, 0.446–1.077) for survival to discharge were found. @*Conclusion@#During the COVID-19 period, there were significant changes in the EMS responses to OHCA. These changes are considered to be partly due to social distancing measures. As a result, the proportion of patients with an initial shockable rhythm in the COVID-19 period was greater than that in the pre-COVID-19 period, but the final survival rate and favorable neurological outcome were lower.

Carbon monoxide poisoning-induced type 1 Brugada electrocardiographic pattern

Carbon monoxide (CO) can cause a variety of electrocardiogram (ECG) changes. The Brugada ECG patterns are very rare in CO poisoning cases. We detected a patient with a CO-induced type 1 Brugada ECG pattern with chest pain. The panel genetic test and echocardiogram revealed normal findings. The Brugada phenocopy gradually improved over 3 days. We reviewed the literature and suggested possible mechanisms.

Real-time measurement of changes in cardiac output that occur after raising the lower extremities in a supine position in healthy adults

Objective@#Passive leg raising for treating patients with shock involves the elevation of the legs in the supine position and can also be applied to patients showing sudden aggravation after lying down for a certain period. A study involving healthy adults has reported that this type of passive leg raising is ineffective for those who spend a long time in the supine position. The study measured cardiac output intermittently using echocardiography rather than measuring it continuously in real time, making it impossible to examine the overall trend in cardiac output before and after the leg raise. This study aimed to examine changes and trends in cardiac output using a device that measures cardiac output in real time. @*Methods@#The present study was conducted from January to August 2020 and included healthy adults aged 18 years and above. Cardiac output was measured with a noninvasive cardiac output measuring device (electrical cardiometry, ICON) for 30 minutes in the supine position and for another 30 minutes in the supine position with the legs raised at 45° for 60 minutes. @*Results@#A total of 40 participants were included in the study. Cardiac output increased from 5.13±1.42 L/min to 5.14± 1.64 L/min after the passive leg raise. However, the increase was not statistically significant (P=0.958). @*Conclusion@#No statistically significant change was found between the cardiac outputs before the leg raise and after the leg raise.

Use of succimer as an alternative antidote in copper sulfate poisoning: A case report

Copper sulfate is widely used as a fungicide and pesticide. Acute copper sulfate poisoning is rare but potentially lethal in severe cases. Copper sulfate can lead to cellular damage of red blood cells, hepatocytes, and myocytes. Toxic effects include intravascular hemolysis, acute tubular necrosis and, rhabdomyolysis. A 76-year-old man presented with vomiting and epigastric pain. He had ingested a copper-containing fungicide (about 13.5 g of copper sulfate) while attempting suicide 2 hours prior to presentation. From day 3 at the hospital, laboratory findings suggesting intravascular hemolysis were noted with increased serum creatinine level. He was treated with a chelating agent, dimercaptosuccinic acid (succimer). His anemia and acute kidney injury gradually resolved with a 19-day regimen of succimer. Our case suggests that succimer can be used for copper sulfate poisoning when other chelating agents are not available.

A survey of work status of a local emergency medical services (EMS) personnel and the perception between EMS personnel and medical directors about on-line medical oversight

Objective@#This study investigated the current work status of emergency medical services (EMS) personnel and the differences in perception between EMS personnel and medical directors (MD) regarding on-line medical oversight in a province. @*Methods@#A total of 1,781 EMS personnel and 51 medical directors were surveyed. The questionnaire consisted of the basic demographic data, work status, perception of on-line medical oversight, and the upcoming national pilot project of the expanding firefighter EMS personnel’s clinical scope. The survey was conducted from May 17 to 27, 2019. @*Results@#The response rates for EMS personnel and MD were 73.7% and 65.3%, respectively. Of the local EMS personnel, 86.8% were male. The average age and field career was 33.5±6.2 years and 50 months, respectively. The proportion of nurse and 1st-grade emergency medical technicians were 30.6% and 35.7%. The EMS personnel and MD answered ‘on-scene basic life support’ and ‘patient’s refusal of transport’, respectively, as the most unnecessary medical oversight. Both responded to the main problem of current medical oversight as ‘request for unnecessary medical oversight.’ EMS personnel responded that all items in the national pilot project of expanding firefighter EMS personnel’s clinical scope would be helpful, while MD reported that only ‘use of epinephrine in anaphylactic patient’ and ‘use of pre-hospital 12 lead electrocardiogram in chest pain patient’ would helpful (P<0.01). @*Conclusion@#There was a certain difference in perception of the most unnecessary medical oversight and the upcoming national pilot project of expanding the clinical scope of firefighter EMS personnel between EMS personnel and MD.

A survey of work status of a local emergency medical services (EMS) personnel and the perception between EMS personnel and medical directors about on-line medical oversight

Objective@#This study investigated the current work status of emergency medical services (EMS) personnel and the differences in perception between EMS personnel and medical directors (MD) regarding on-line medical oversight in a province. @*Methods@#A total of 1,781 EMS personnel and 51 medical directors were surveyed. The questionnaire consisted of the basic demographic data, work status, perception of on-line medical oversight, and the upcoming national pilot project of the expanding firefighter EMS personnel’s clinical scope. The survey was conducted from May 17 to 27, 2019. @*Results@#The response rates for EMS personnel and MD were 73.7% and 65.3%, respectively. Of the local EMS personnel, 86.8% were male. The average age and field career was 33.5±6.2 years and 50 months, respectively. The proportion of nurse and 1st-grade emergency medical technicians were 30.6% and 35.7%. The EMS personnel and MD answered ‘on-scene basic life support’ and ‘patient’s refusal of transport’, respectively, as the most unnecessary medical oversight. Both responded to the main problem of current medical oversight as ‘request for unnecessary medical oversight.’ EMS personnel responded that all items in the national pilot project of expanding firefighter EMS personnel’s clinical scope would be helpful, while MD reported that only ‘use of epinephrine in anaphylactic patient’ and ‘use of pre-hospital 12 lead electrocardiogram in chest pain patient’ would helpful (P<0.01). @*Conclusion@#There was a certain difference in perception of the most unnecessary medical oversight and the upcoming national pilot project of expanding the clinical scope of firefighter EMS personnel between EMS personnel and MD.

A survey on the perception of emergency medical services (EMS) providers and medical directors toward EMS provider’s field skill proficiency

Objective@#This study aimed to investigate the perception of emergency medical service (EMS) providers and medical directors toward the field skill proficiency of EMS providers. We further examined differences in perception according to the certification and hospital career of individuals. @*Methods@#This survey was conducted enrolling all active EMS providers in Busan, Ulsan, and Gyeongnam, as well as emergency physicians who participated in direct medical direction. Pre-developed questionnaires were sent as text messages to individual EMS providers and emergency physicians using an internet-based survey tool (Google Forms).Questionnaires were composed of 25 items in 7 categories: “airway management”, “ventilatory support”, “circulatory support”, “field assessment and management of trauma patients”, “field assessment and management of patients with chest pain”, “field assessment and management of patients with neurologic symptoms”, and “other items”. The response was based on a five-point Likert scale, where 0 score indicated no experience at all. @*Results@#The questionnaire was distributed to 1,781 EMS providers and 52 medical directors; of these, 1,314 (73.7%) EMS providers and 34 (65.3%) medical directors completed the survey. EMS providers rated themselves as above average (3 points) for most of the questions. However, the majority responded that they had no experience or low proficiency in endotracheal intubation and prehospital delivery (median 2; interquartile range [IQR], 0-3). Conversely, medical directors assessed the EMS provider’s proficiency as above average in use of I-gel, recognition of hypoglycemia, field management of trauma patients, use of oropharyngeal and nasopharyngeal airway, use of laryngeal mask airway, and optimal oxygen supply (median, 4; IQR, 3-4), but responded with low scores for most other questions. Based on the EMS provider certification, nurses scored themselves more proficient than level-1 emergency medical technicians (EMTs) for intravenous access (P<0.001), whereas level-1 EMTs recognized themselves more proficient than nurses for endotracheal intubation (P<0.001), use of Magill forceps (P=0.004), and pediatric cardiopulmonary resuscitation (P<0.001). @*Conclusion@#This study recognized the discrepancies in the perception of EMS provider’s field skill proficiency, as perceived by EMS providers and medical directors, and between level-1 EMTs and nurses. We propose that regional EMS authorities need to make persistent efforts to narrow these perception gaps through effective educational programs for EMS providers and medical directors.

Comparison of medical resources usage between young adult patients and elderly patients: a single center, retrospective observational study

OBJECTIVE@#Under the overcrowding conditions of large emergency departments, the proportion of elderly patients is increasing in Korea. This paper describes the necessity of the preparedness of Korean emergency departments and society for the rapidly aging population.@*METHODS@#This was a retrospective observational study. Patients who presented to a tertiary hospital emergency department (ED) in one year were included. The use of medical resources between young adult (≥20 and <65 years of age) and elderly patients (≥65 years of age) was compared.@*RESULTS@#This study included 26,712 patients. The young adult group and the elderly group was 15,021 (56.2%) and 11,691 (43.8%), respectively. The ratio of firehouse ambulance visit mode (28.6%) and inter-facility transfer visit mode (18.9%) of the elderly group was higher compared to those of the young adult group (26.4% and 10.6%, P<0.001). The elderly group visited more at daytime (P<0.001). With aging, the admission ratios of the elderly group to the general ward (38.9%) and intensive care unit (13.0%) were higher than the young adult group (9.8% and 4.3%, P<0.001). The mean ED length of stay and mean length of hospitalization of the elderly group was longer than that of the young adult group (P<0.001). The medical cost of the elderly group was approximately three times higher than that of the young adult group.@*CONCLUSION@#Elderly patients required more emergency medical resources in both the prehospital and hospital stages. Korean emergency departments and society require efforts for not only expansion but also the appropriate use of medical resources in a rapidly aging population.

Hemorrhagic shock caused by closed internal degloving injury: a case report

A closed internal degloving injury is a soft tissue injury, in which the subcutaneous tissue is ripped from the underlying fascia. In rare cases, a closed internal degloving injury can lead to hemorrhagic shock. A 79-year-old woman was brought to the emergency department following an auto-pedestrian accident, in which she was hit by a car. She was in a stupor and was hypotensive. The initial evaluation was unremarkable. During management, the patient required the transfusion of a large volume of blood, and vasoactive agent. Abdominal computed tomography revealed a large hematoma in her lower back and gluteal area and she was diagnosed with a closed internal degloving injury. Missed or delayed diagnosis of this type of injury may result in a significant increase in transfusion requirements and irreversible hemorrhagic shock.

Relationship between emergency department disposition, level of emergency base on Korean Triage and Acuity Scale, visit mode

OBJECTIVE: The policy to judge the level of emergency (emergent vs non-emergent) based on Korean Triage and Acuity Scale (KTAS) has been introduced by government to control the flow of emergency patients. The purpose of this study is to identify the variables expected to affect the disposition and to compare the relative importance of the variables. And we also evaluate the validity of the policy to judge the level of emergency based on KTAS. METHODS: We enrolled a total of 29,865 patients who visited a Wide Regional Emergency Center in Busan from Jan 2016 to Dec 2016. Data of those patients were extracted from National Emergency Department Information System (NEDIS) and analysed retrospectively. We determined disposition as the outcome variable. We evaluated the relationship between disposition and visit time, visit mode (firehouse ambulance, inter-facility transfer and self-transport), level of emergency based on KTAS, cause of morbidity. And we also evaluated general and conditional dominances of those variables to compare their relative importance each other. RESULTS: The disposition of the patients was discharge to home (53.5%), general ward admission (30.3%), intensive care unit admission (11.6%), and inter-facility transfer (4.8%). In the univariate analysis, age, gender, visit time, visit mode, cause of morbidity, KTAS level had a significant effect on the disposition. All variables that had a significant effect on univariate analysis also had a significant effect on disposition in multivariate analysis. As a result of dominance analysis, visit mode was the most important variable in both general dominance and conditional dominance. However, if KTAS was devided into 5 levels, it was the most important variable. CONCLUSION: Level of emergency based on KTAS was significantly effective on patient disposition, however it was relatively less important compared to the visit mode. If the visit mode is reflected in the triage system, triage accuracy is expected to be improved. And it also can be a good option to construct triage system based on 5 level KTAS.

Is STONE score a useful tool for limiting the use computed tomography in the patients suspected ureter stone? - A single-center retrospective study

OBJECTIVE: The STONE score was developed to gauge the ureter stone probability. On the other hand, it is unclear if the STONE score is also applicable to Koreans. This study evaluated whether the STONE score can identify patients with suspected nephrolithiasis for whom a computed tomography (CT) scan can be obtained in the emergency department, targeting Koreans. METHODS: Patients presenting to the emergency medicine (ED) with flank pain and a suspicion of a ureter stone between January 2016 and December 2016 were reviewed retrospectively. After calculating the STONE score, the enrolled patients were classified into the low, moderate, high score group. In each group, the prevalence of a ureter stone and other clinical diseases on a CT scan were investigated. RESULTS: Among the 156 patients included in the analysis, 124 (79.5%) had a ureter stone and an alternative diagnosis was made in 12 (7.7%). The prevalence of a ureter stone and alternative diseases in the high score group was 87.7% (71/81) and 4.9% (4/81), respectively. The proportion of patients with nephrolithiasis increased significantly (P < 0.001), but the proportion of patients with other clinical diseases did not decrease significantly across the score groups (P=0.196). The area under the receiver operating characteristic curve was 0.711 (95% confidence interval, 0.633–0.780; P=0.001) with a cut off score higher than 8 (sensitivity 82.3%, specificity 50.0%) for the STONE score. CONCLUSION: In this setting, the STONE score had a low specificity and could not accurately assess a ureter stone. More studies aimed at Koreans are warranted before a CT scan can be limited using the STONE score.

Early Predictors of Severe Injury in Motorcycle Crashes

PURPOSE: The severity and mortality of motorcycle accidents are higher than those of other traffic accidents. The majority of risk factors for injury severity identified in previous studies are difficult to apply. This study attempted to identify the clinically useful risk factors for predicting severely injured patients presenting to the emergency department after a motorcycle accident. METHODS: Motorcycle accident patients who visited a Level I trauma center from October 2015 to March 2017 were analyzed. The patients were classified as the severely injured group (Injury Severity Score, ISS≥16) and non-severely injured group (ISS<16). RESULTS: A total of 271 patients were analyzed; 135 (49.8%) patients were included in the severely injured group. Multiple logistic regression analysis was performed with the statistically significant factors between the two groups, including age, systolic blood pressure, heart rate, Glasgow coma scale, alcohol ingestion, and site of injury. The final risk factors predicting severely injured patients were as follows: age (adjusted odds ratio [aOR], 1.023; 95% confidence interval [CI], 1.005– 1.041; p=0.011), systolic blood pressure (aOR, 0.981; 95% CI, 0.970–0.993; p=0.002) and site of injury including abdomen (aOR, 5.785; 95% CI, 2.513–13.316; p<0.001), chest (aOR, 4.567; 95% CI, 2.274–9.173; p<0.001), head and neck (aOR, 5.762; 95% CI, 2.656–12.504; p<0.001), and face (aOR, 2.465; 95% CI, 1.229–4.943; p=0.011). CONCLUSION: Motorcycle accident patients should be assessed promptly for injury to the chest or abdomen by a careful physical examination and focused assessment with sonography for trauma.

Cardiac Arrest in a Patient with a Severely Distended Colon

Toxic megacolon is a devastating complication of colitis, which is commonly caused by inflammatory bowel disease. Frequently reported complications of toxic megacolon are bleeding, sepsis, colon perforation, and shock. Herein, we report a rare case of cardiac arrest that was likely caused by toxic megacolon in a 49-year-old male, who experienced 3 months of intermittent dyspnea and abdominal distension that abruptly worsened before presentation. Our case suggests that severe colon dilation complicated by toxic megacolon, especially accompanied by cardiopulmonary symptoms and signs, has the potential to progress to an abdominal compartment syndrome, which is a rare but life-threatening complication.

Attempted Suicide by Nitrogen Gas Asphyxiation: A Case Report

Nitrogen is an inert gas that is harmless to humans under normal conditions. While it is not inherently toxic, nitrogen gas becomes dangerous when it displaces oxygen, resulting in suffocation. Herein, we report a case of a 34-year-old man who attempted suicide by nitrogen asphyxiation who presenting with decreased mental function and agitation. Lactic acidosis and hyperammonemia were observed on presentation at the emergency department, but these improved after a few hours. After 2 days, the patient regained full consciousness, and was discharged without any complications. Survival after asphyxiation due to nitrogen gas is very rare, and these patients are more likely to have poorer outcomes. There is a potential for the increasing use of nitrogen gas as a method of committing suicide because of the ease of access to this gas.

Serial Measurements of C-reactive Protein and Albumin Levels in Prediction of Prolonged Mechanical Ventilation in Pesticide-Intoxicated Patients

PURPOSE: This study attempted to determine whether serial measurements of serum C-reactive protein (CRP) and albumin levels can be used for prediction of prolonged mechanical ventilation (PMV) in patients with pesticide intoxication. METHODS: We conducted a retrospective analysis of 36 pesticide-intoxicated patients who were admitted to the intensive care unit (ICU) and received mechanical ventilation for >72 hours between January 2010 and December 2011. Patients were divided into two groups: patients on mechanical ventilation for > or =15 days (PMV group; n=9) and patients on mechanical ventilation for 4 days [odds ratio (OR), 2.06; 95% confidence interval (CI), 1.10-3.86] and DeltaAlbumin >2.0 g/dL (OR, 7.81; 95% CI, 1.04-58.67) showed an independent association with PMV. CONCLUSION: Serial measurements of serum CRP and albumin levels can be used for identification of patients at risk for PMV. Increase in serum CRP level for more than four consecutive days and decrease in albumin level greater than 2.0 g/dL could discriminate PMV patients from non-PMV patients.