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.

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.

Surveillance on Hazardous Materials Preparedness in the Emergency Department in Korea: Personal Protection Equipment

PURPOSE: This study was conducted to evaluate the preparedness of personal protective equipment (PPE) against hazardous material (Hazmat) contamination in emergency departments (EDs). METHODS: Among 443 EDs, 118 emergency centers (16 regional centers, 4 specialized centers, 98 local centers) were surveyed either by returned usable surveys or facsimile or telephone communication. The 27 survey questions addressed the ability of EDs to safely decontaminate and treat contaminated patients. RESULTS: Among 118 EDs (100%), 7 EDs (5.9%) have a written plan for decontamination and treatment of Hazmat contaminated patients in the ED, and 36 (30.5%) have a hospital-wide disaster plan that includes contingencies for decontamination and treatment of Hazmat contaminated patients. 11 EDs (9.3%) conducted any Hazmat drill within recent two years. 8 EDs (6.8%) have a specific treatment area for contaminated patients. A stock space of PPE is maintained in 11 EDs (9.3%) and 6 EDs (5.1%) have a responder decontamination shower. While 11 EDs store PPE, most of these involve only gowns, gloves, and surgical masks; only 10 EDs provide any type of respiratory protection. There was no ED fully equipped level A PEE but only 21 EDs have partially equipped. The levels of PPE were level D in 7 EDs (5.9%) according to the guidelines of EPA/OSHA Personal Protection Equipment Levels CONCLUSION: Emergency department preparedness against Hazmat exposure in Korea varies tremendously. A significant proportion of hospitals lack written plan and equipment to allow EDs to safely and effectively handle the Hazmat contaminated patient. This has the meaning of one of preliminary data that was national-wide surveyed in Korea.

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.

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.

Early Diagnosis of Acute Ischemic Stroke by Using 16 row Multi-slice Computed Tomography

PURPOSE: Conventional spiral computed tomography (CT) has a limitation in the diagnosis of the early phase of cerebral ischemia because ischemic signs may be subtle or even not detectable. The authors carried out this study in order to determine the value of 16 row multi-slice CT (MSCT) in the clinical study of patients with acute stroke. METHODS: Between June 2002 and May 2003, we performed MSCT on 18 consecutive patients who presented within 6 hours of onset of signs and symptoms suggesting stroke. We used an imaging protocol with 3 components, noncontrast CT, perfusion CT, and CT angiography, to evaluate hyperacute stroke patients. In order to evaluate it' s validity, we compared MSCT with MRI. RESULTS: Perfusion parameter maps such as cerebral blood flow, cerebral blood volume, and time to peak showed perfusion deficits in 14 of 18 patients. Perfusion deficits in two patients with brain stem infarcts and in one patient with a lacunar infarct were missed. Hemispheric territorial infarcts were diagnosed with a sensitivity of 93% (14 of 15 patients). MSCT has a significantly shorter interval between the patient's arrival and taking an image (23.1+/-13.3 vs 52.7+/-21.8 minutes, p=0.0001) and a significantly shorter scanning time (13.7+/-2.5 vs 26.8+/-11.2 minutes, p=0.0003) than MRI does. CONCLUSION: In hyperacute stroke, MSCT not only allows early detection of cerebral ischemia but also yields valuable information about the extent of perfusion disturbances. Compared with MRI, MSCT is a more readily available, less time consuming procedure. MSCT may help in therapeutic decision-making if perfusion and diffusion-weighted MRI are not available or cannot be performed on specific patients.

Clinical Implication of Pelvic Ring Disruption in Blunt Trauma

PURPOSE: Existing classifications on types of pelvic fractures in current use usually are orthopedic treatment oriented and depend on the results of late examinations, such as CT scans, in which differentiation of early diagnosis is difficult. The authors carried out this study in order to provide early assessment concerning the prognosis of emergent pelvic fracture patients to classify the type of pelvic fracture by using the Young classification method obtained through an early pelvis AP view study. METHODS: We performed a retrospective review of 89 patients with pelvic bone fractures seen at our hospital between March 2001 and February 2003. The patients were divided into two groups (simple pelvic fracture and pelvic ring disruption) according to the type of injury. We compared clinical data such as age, vital signs, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Revised Trauma Score (RTS), and initial hemoglobin between the two groups. We also compared associated abdominal or urogenital injuries and extra-pelvic injuries between the two groups. RESULTS: Patients with pelvic ring disruption (n=51) had lower blood pressures ( p=0.003), higher pulse rates (p=0.017), higher RTSs ( p=0.034), and higher ISSs (p=0.019) than those with a simple pelvic fracture (n=38). A comparison of associated injuries between the two groups showed that patients with a pelvic ring disruption had higher incidences of retroperitoneal hematoma (p=0.026), urogenital injury (p=0.003), and thoracic injury (p=0.019) than those with a simple pelvic fracture. CONCLUSION: The pelvic ring disruption group showed more unstable hemodynamic changes together with higher incidences of associated injuries than the simple pelvic fracture group. Therefore, early classification by means of the Young method is considered to be beneficial in the treatment of and in the assessment of the prognosis for pelvic fracture patients at an emergency center.

Basic Data for Establishing the Emergency Plan to a Forty-hour workweek

BACKGROUND: Large hospitals should execute the forty-hour workweek from July 2004 as a matter of laws. Some institutes have used this system as the concept of five-day workweek since 2 years ago. To prepare for the forty-hour workweek effectively, all emergency physicians and headquarters of hospitals should make plans from this time. METHOD: We analyzed the emergency patients who visited the ER on two consecutive work-free days and ordinary days of last year. The number of patients, final results, such as admission or home discharge, the clinics participating in emergency care, and other components were analyzed according to two consecutive work-free days and the ordinary days. RESULT: The number of emergency patients who visited ER during the two consecutive work-free days was increased by 39.5~100.8% compared to the ordinary days. Although the number of emergency patients was larger during these days, the admission rate was lowered by 3.8~14.5%. Patients who were cared for by an emergency physician or a pediatric physician were markedly larger during the two consecutive work-free days, and the patients cared by an internal medicine were lower. CONCLUSION: To care for the emergency patients more effectively during the two consecutive work-free days in the forty-hour workweek system, we should increase the number of emergency physicians and pediatric physicians, and space for fast track and pediatric emergency care should be secured.

Nontraumatic Spontaneous Cervical Epidural Hematoma

Nontraumatic spontaneous spinal epidural hematoma is a rare entity, which can be associated with a severe neurologic deficit. The presenting symptoms are usually back or neck pain, either local or radicular, followed by progressive bilateral weakness, and sensory loss hours and even days later. In the absence of precipitating factors such as severe trauma or known coagulopathy, the diagnosis may be delayed. Imaging, including cervical CT or MRI, may play an essential role for the prompt diagnosis and differentiation from other cervical pathologies. With a full review of the literature, we report and discuss a case of nontraumatic cervical epidural hematoma in which a 67-year-old female visited the emergency center for neck and right shoulder pain. She experienced a complete recovery after conservative treatment only.

Comparison of Predicted Outcomes of Trauma and Injury Severity Score (TRISS), Acute Physiology and Chronic Health Evaluation (APACHE) II, and Simplified Acute Physiology Score (SAPS) II Scoring Systems in Intensive-care-unit Trauma Patients

PURPOSE: Several statistical models, such as the TRISS, the APACHE II and the SAPS II scoring systems, have been utilized over the recent decades to accurately predict outcomes in Intensive Care Unit (ICU) trauma patients. This study was performed to evaluate the ability of these three statistical models to predict hospital mortality and to compare the performance of these three statistical models in ICU trauma patients. METHODS: Seven hundred forty-seven trauma patients were admitted to the ICU via the emergency center, Masan Samsung Hospital, from March 1999 to February 2001. Of them, 684 patients were included in this study, and their medical records were retrospectively analyzed. The probability of death was calculated for each patient based on the TRISS, the APACHE II, and the SAPS II equations. RESULTS: The values of the Hosmer and Lemeshow X2 for TRISS, APACHE II, and SAPS II were 41.32, 43.03, and 17.64, respectively, and all of them underestimated mortality (p<0.05). For two-by-two decision matrices with a decision criterion of 0.5, the specificities and percentages correctly classified of APACHE II and SAPS II were higher than those of TRISS (p<0.001). For the ROC curve analysis, the areas under the curves (+/-SEM) of TRISS, APACHE II, and SAPS II were 0.922 +/- 0.011, 0.951 +/- 0.011, and 0.957 +/- 0.009, respectively (95% confidence interval). The areas under the curves of APACHE II and SAPS II were larger than that of TRISS (p<0.05 and p<0.01, respecively). CONCLUSION: All of these three statistical models had good discriminative power, with APACHE II and SAPS II performing better than TRISS. However, all of them showed poor calibration and underestimated mortality. The authors conclude that a new statistical model is needed to accurately predict hospital mortality in severely injured patients.

Patterns of Emergency Department Use During the Korean Doctor's Strike

PURPOSE: From June 20, 2000, to June 24, 2000, for five nationwide hospitals and clinics went on strike in opposition to the government 's policy on the separation of dispensaries from medical practice. The present study examined the present state of medical examination and treatment and the management system of the third medical institution to indicate a model for dealing with such strikes ahead in the future. METHODS: The present state of the medical examination and management system in eight hospitals of the nationwide emergency medical centers was examined. The term of strike, June 20, 2000, to June 24, 2000, for five days, was the subject term; Five weekdays of the week just prior to the strikes and two consecutive holidays, January 1, 2000, and January 2, 2000, were chosen as a contrast group. RESULTS: During the term of strike, the number of patients was larger than it was on the weekdays, but was less than it was on consecutive-holidays. In severity triage, the ratio of emergency patients increased but non-emergency and delayed patients decreased than consecutive-holidays, and the number of medical personnel decreased for all types of visits. The attending hospitals in cases of disease increased, and the ratio of internal medicine, general surgery, obstetrics, orthopedics patients increased than consecutive-holidays level, and the ratio of gynecology, phychiatry, opthalmology patients increased than consecutive-holidays and weekdays level. The ratio of cases in CPR decreased, and deliveries was at the same level as it was on the weekdays. Both radiation tests and emergency tests decreased. CONCLUSION: During a strike, carrying out severity triage and operating emergency outpatient care for non-emergency patients, such as outpatients, may be desirable. Adding emergency-treatment manpower to the areas where the number of patients increased, putting additional nursing and assistance manpower in emergency and operation rooms, providing for administration manning at the consecutive-holidays level, and resetting radiation and examination manpower at the consecutive-holidays level should be considered in managing effectively and emergency medical center.

Simultaneous Sterno-Thoracic Cardiopulmonary Resuscitation Improves the Short-Term Survival Rate in Canine Cardiac Arrests

BACKGROUND AND OBJECTIVES: We previously reported that, compared with standard cardiopulmonary resuscitation(S-CPR), better hemodynamic effects could be achieved by simultaneous sterno-thoracic cardiopulamonary resuscitation(SST-CPR) in which we compressed the sternum and constricted the thorax circumferentially during the systolic period by using a device. This study was designed to assess whether SST-CPR, compared with S-CPR, improve the survival rate of dogs with cardiac arrest. SUBJECTS AND METHODS: Twenty-five mongrel dogs(19~31kg) were enrolled in this study. After four minutes of ventricular fibrillation induced by an AC current, animals were randomized to resuscitate with either S-CPR(n=13) or SST-CPR(n=12). Epinephrine(1mg) was injected into the right atrium every three minutes after the beginning of CPR. Defibrillation was attempted after 6 minutes of CPR. Standard advanced cardiac life support was started if defibrillation was not successful. RESULTS: SST-CPR resulted in significantly(p<0.001) higher systolic arterial pressure(91+/- 47 vs 47+/-24mmHg), diastolic pressure(43+/- 24 vs 17+/- 10mmHg), coronary perfusion pressure(35+/- 25 vs 13+/- 9mmHg), and end tidal CO2 tension(9+/- 4 vs 3+/- 2mmHg). Two of 13 animals(15%) resuscitated with S-CPR and six of 12 animals(50%) resuscitated with SST-CPR survived until 12 hours after cardiac arrest(p<0.05). CONCLUSION: SST-CPR, compared with S-CPR, improves the short-term survival rate in canine cardiac arrests.

Treatment Modality in Patients with Traumatic Pericardial Effusion

BACKGROUND: Current guidelines of advanced trauma life support recommend open thoracotomy when pericardiocentesis reveals bloody pericardial effusion in patients with blunt chest trauma. However, open thoracotomy may not be always required for treating patients alive until arriving emergency department, because rapid accumulation of the blood into pericardial space results in immediate death at scene. We report our experiences of treating traumatic pericardial effusion, and discuss the therapeutic modality in patients with traumatic pericardial effusion. METHODS: The study consisted of 37 patients(20 males and 17 females with the mean age 42) sustaining traumatic pericardial effusion. The patients were divided according to treatment modality into 3 groups(group I : patients receiving conservative management, group II : patients treated with pericardiocentesis, group III : patients required emergency thoracotomy). We compared clinical presentations, hemodynamic profiles and echocardiographic findings among three groups. RESULTS: Cardiac tamponade was present in 14 of 37 patients. Pericardiocentesis was performed in 13 patients, and open thoracotomy in 4 patients. Pericardiocentesis was curative in 9 patients. Thoracotomy was performed in only 3(24%) of 13 patients required pericardiocentesis. 3(75%) of 4 patients having moderate or severe pericardial effusion from penetrating injury were required open thoracotomy. CONCLUSION: In selected patients who have traumatic pericardial effusion by blunt chest injury, pericardiocentesis may be curative, and thoracotomy may not be inquired as long as bleeding via indwelling pericardial catheter is not sustained after pericardiocentesis.

Prediction of Failure to Survive Following In-hospital Cardiopulmonary Resuscitation

BACKGROUND AND PURPOSE: The purpose of this study is to compare two clinical predictive rules, the pre-arrestmorbidity(PAM) index and the prognosis-after-resuscitation(PAR) score, which predict failure to survive following in-hospital cardiopulmonary resuscitation(CPR). METHOD: The study population consisted of 162 consecutive adult patients who underwent CPR at Wonju Christian Hospital over a year period. The PAM index and PAR score were calculated from the most recent data available for each variable prior to cardiac arrest. Each predictive tool was compared between the group of discharge alive and the group of in-hospital mortality. Performance of the predictive scores was also compared by receiver-operating characteristic(ROC) curves where appropriate. RESULTS: PAM index of study population was 4.39+/-2.69 and PAR score was 2.99+/-3.36. PAM index in the group of discharge alive was 1.87+/-2.79, and PAM index in the group of ih-hospital mortality was 4.51+/-2.62. PAR score in the group of discharge alive was 0.75+/-1.75, and PAR score in the group of in-hospital mortality was 3.1+/-3.4. The PAM index identified 15 patients with a score>8, while the PAR score identified 39 patients with a score>4, none of whom survived. The sensitivity of the PAR score for the prediction of failure to survive was 25%, while that of the PAM index was 10%; neither index incorrectly identified a patient as a non-survivor who eventually survived. Both of predictive methods were not significantly different in the ROC curve. CONCLUSION: Although further confirmation is necessary, PAM index and PAR score may provide useful prognostic information to physicians and patients involved with decisions about do-no- resuscitate orders.

Role of Two-Dimensional Echocardiography in Diagnosis of Cardiovascular Injuries in Blunt Chest Trauma

BACKGROUND: Cardiovascular injury is a potentially fatal complication of blunt chest trauma. The diagnosis of cardiovascular injury in blunt chest trauma is not easy because of concomittent injuries of thoracic cage or lungs and early death from cardiovascular injury. Diagnostic tools such as electrocardiography or cardiac enzyme studies are not specific to cardiovascular injury. Two-demensional echocardiography can visualize anatomic and functional disturbances from cardiovascular injuries in patients with blunt chest trauma. Purpose: This study was designed to evaluate the usefulness of echocardiography in detecting cardiovascular injury of patients with blunt chest trauma. METHODS: We performed echocardiography for detecting cardiovascular injury in 151 patients with significant blunt chest trauma including sternal fracture, multiple rib fractures or pulmonary contusion. Echocardiography was performed within 6 hours since patient arrived emergency department. Electrocardiography was traced on arrival and 24 hours after admission. Serial determinations of cardiac enzymes including MB fraction of creatinine phosphokinase were also performed every 8 hours after admission. RESULTS: 37(25%) patients had echocardiographic evidences of cardiovascular injury. Abnormal echocardiographic findings were 10 pericardial effusion, 9 regional wall motion abnormality(RWMA) outright ventricle, 5 aortic injuries, 4 reduced left ventricular ejection fraction, 3 RWMA of left ventricle, 2 right ventricular dilatation, 2 valve injuries, and 2 other cardiovascular injuries. Electrocardiographic abnormalities were associated with echocardiographic findings. However, CK-MB/CK ratio was not associated with echocardiographic findings. Significant proportion(65%) of patients with abnormal echocardiographic findings needed cardiovascular management during hospital stay. CONCLUSION: Two-dimensional echocardiography is useful for detecting cardiovascular injury. Echocardiographic abnormality in blunt chest trauma is associated with high probability of need of cardiovascular management.