Clinical Factors for Prediction of Postconcussion Syndrome in Patients with Mild Traumatic Brain Injury

PURPOSE: Mild traumatic brain injury (mTBI) is defined as head injury resulting from blunt trauma with one or more of the following conditions: 1) any period of transient confusion, disorientation, or impaired consciousness; 2) any period of dysfunction of memory (amnesia) around the time of injury; 3) observed signs of other neurological or neuropsychological dysfunction; 4) any period of loss of consciousness lasting 30 minutes or less. As a result of its subtle computed tomography (CT) findings, patients with mTBI were almost ordered discharged in the emergency setting. However, postconcussion syndrome (PCS) could develop in approximately 10 to 20% of these patients. This study was conducted in order to investigate the prognostic factors of PCS, and the role of magnetic resonance imaging (MRI) for diagnosis of PCS in mTBI patients. METHODS: This retrospective study was conducted in 397 patients who were admitted with mTBI (GCS=15, age> or =6 years old) for analysis of the prognostic factors of PCS, and 187 patients who underwent both CT scan and MRI for comparison of the sensitivity of CT to that of MRI from January 2009 to December 2010. PCS was defined as a disorder with somatic, cognitive, or affective symptoms. RESULTS: Of the mTBI patients, 44.2% had PCS. The independent prognostic factors were loss of consciousness (LOC)/posttraumatic amnesia (PTA), headache, and intracranial hemorrhage on CT scans. Strong suggestive CT findings of PCS were lesions located in intra-axial and white matter, subdural hematoma, and intraprenchymal contusion of the frontal or temporal lobe. A decision model for prediction of PCS in mTBI consisted of three risk factors: LOC/PTA, headache, facial fracture, and intracranial hemorrhage on CT scans. The sensitivity of MRI was superior to that of CT in detection of PCS (72.4.4% vs 60.9%, p=0.021). CONCLUSION: The possibility of developing PCS was high in mTBI patients with LOC/PTA, headache, and abnormal CT findings. These patients may require MRI evaluation.

Magnetic Resonance Imaging for the Prediction of Delayed Neuro-psychiatric Sequelae in Patients with Carbon Monoxide Poisoning

PURPOSE: Delayed neuropsychiatric sequelae (DNS) encompass a broad spectrum of neurological deficits, cognitive impairments, and affective disorders which commonly occur after a recovery from acute carbon monoxide (CO) poisoning. The early identification of patients with a high risk of DNS might improve their quality of care. Thus, we studied the role of magnetic resonance imaging (MRI) for the prediction of DNS. METHODS: This retrospective study included 41 patients with CO poisoning from January 2009 to June 2012. Magnetic resonance imaging (MRI) was performed within seven days after CO poisoning. Positive MRI findings were defined as focal or diffuse signals in fluid-attenuated inversion recovery (FLAIR), diffusion weighted imaging (DWI), and T2 weighted imaging (T2WI). DNS was considered present when patients had clinical symptoms and signs of DNS within 3 months after CO poisoning. Clinical and biohumoral data were collected; univariate and multivariate statistical analyses were performed to identify the predictive role of MRI for DNS. RESULTS: DNS occurred at a rate of 58.5%, with abnormal MRI findings associated with the development of DNS in the multivariate analysis. The sensitivity of MRI to DNS was 82.6%. In contrast, a normal MRI was seen in eighteen patients (43.9%). MRI revealed abnormalities in the deep white matter (41.5%), globus pallidus (34.1%), cerebral cortex (12.2%), medial temporal lobe (MTL)/hippocampus (7.3%), and cerebellum (4.9%). Among the MRI abnormalities revealed, lesions in the deep white matter were significantly associated with DNS development. Abnormal findings of the globus pallidus, cerebral cortex, MTL/hippocampus, and cerebellum were not associated with DNS development. CONCLUSION: This study demonstrates the utility of early MRI for the prediction of DNS. Future studies will be required to ascertain the prevention of DNS with hyperbaric treatment in CO poisoning.

Development of Clinical Criteria for Indication of Computed Tomography (CT) Scans in Minor Head Injury Patients

PURPOSE: Most minor head injury (MHI) patients can be discharged without complication but a small percentage of these patients have intracranial lesions which can be observed by computed tomography (CT), and in these cases, neurosurgical intervention may be necessary. Selective use of the CT-scan in cases of MHI is important in reducing the risks associated with unnecessary radiation exposure. We conducted a retrospective study with the goal of creating a set of clinical criteria for deciding when to utilize the CT scan for MHI cases. METHODS: This retrospective study was conducted using 1,735 patients with MHI (GCS=15, > or =6 years old) from January 2009 to December 2010. Based on literature review results, we selected risk factors associated with the presence of intracranial lesions observable by cranial CT-scan, which may have resulted from MHI. The detection of intracranial lesions by CT scan was regarded as the primary clinical outcome. RESULTS: Of the total cases, 87(5.0%) had intracranial lesions as observed by CT scan. All patients with abnormal CT scans had at least one of the following risk factors: headache, loss of consciousness (LOC)/posttraumatic amnesia (PTA), vomiting, focal neurological deficit, coagulopathy, alcohol intoxication, skull fracture, age greater than 65 years, dangerous mechanism of injury, or facial fracture. A decision model for application of CT scanning in MHI cases was derived which consisted of 5 risk factors: headache, LOC/PTA, skull fracture, and age greater than 65 years. The decision model was 100% sensitive (95% CI, 95.8~100%) and 42.4% specific (95% CI, 40.0~44.8%) for predicting intracranial lesions, and would require only 59.8% of patients to undergo CT. CONCLUSION: The decision model developed for CT scanning in MHI cases was highly sensitive. Patients who meet the criteria of the model require evaluation by CT scan.

Development of Clinical Criteria for Indication of Computed Tomography (CT) Scans in Minor Head Injury Patients

PURPOSE: Most minor head injury (MHI) patients can be discharged without complication but a small percentage of these patients have intracranial lesions which can be observed by computed tomography (CT), and in these cases, neurosurgical intervention may be necessary. Selective use of the CT-scan in cases of MHI is important in reducing the risks associated with unnecessary radiation exposure. We conducted a retrospective study with the goal of creating a set of clinical criteria for deciding when to utilize the CT scan for MHI cases. METHODS: This retrospective study was conducted using 1,735 patients with MHI (GCS=15, > or =6 years old) from January 2009 to December 2010. Based on literature review results, we selected risk factors associated with the presence of intracranial lesions observable by cranial CT-scan, which may have resulted from MHI. The detection of intracranial lesions by CT scan was regarded as the primary clinical outcome. RESULTS: Of the total cases, 87(5.0%) had intracranial lesions as observed by CT scan. All patients with abnormal CT scans had at least one of the following risk factors: headache, loss of consciousness (LOC)/posttraumatic amnesia (PTA), vomiting, focal neurological deficit, coagulopathy, alcohol intoxication, skull fracture, age greater than 65 years, dangerous mechanism of injury, or facial fracture. A decision model for application of CT scanning in MHI cases was derived which consisted of 5 risk factors: headache, LOC/PTA, skull fracture, and age greater than 65 years. The decision model was 100% sensitive (95% CI, 95.8~100%) and 42.4% specific (95% CI, 40.0~44.8%) for predicting intracranial lesions, and would require only 59.8% of patients to undergo CT. CONCLUSION: The decision model developed for CT scanning in MHI cases was highly sensitive. Patients who meet the criteria of the model require evaluation by CT scan.

Comparison of Magnetic Resonance Imaging with Computed Tomography in Subarachnoid Hemorrhage

PURPOSE: Misdiagnosis of subarachnoid hemorrhage (SAH) can result in considerable mortality and morbidity. Computed tomography (CT) has high sensitivity for detection of acute SAH, but falls off rapidly over time, and approaches 0% at three weeks. The aim of this study was to conduct a comparison of magnetic resonance imaging (MRI) and CT in detection of SAH in acute and subacute, and chronic stages. METHODS: This retrospective study included 62 patients with spontaneous SAH from January 2006 to December 2011. For each patient, we obtained non-enhanced CT scans, fluid-attenuated inversion recovery (FLAIR), and T2-weighted gradient-echo (T2*) MRI images. We defined SAH based on areas of high attenuation on non-enhanced CT scans, regions of hyperintensity on FLAIR images, and regions of hypointensity on T2* images in intracranial subarachnoid spaces. In order to investigate the superiority of tools for diagnosis of SAH, comparison of sensitivity of CT scans and MRI was performed. RESULTS: Sensitivity of CT to SAH was 93.5% on the first day, but fell off rapidly with time, and approached 0% at 20 days. Sensitivity of MRI was not affected by stages and amounts of bleeding (p>0.05). Sensitivity of MRI was higher than that of CT in SAH of Fisher grade 0-1 of subacute stage of bleeding (p=0.001) and in all cases of chronic stage of bleeding (p=0.000). FLAIR images were superior to T2* images, but without statistical significance (p>0.1). CONCLUSION: MRI was superior to CT in detection of subacute and chronic SAH, as well as a small amount of SAH.

Pattern of Cervical Spine Injury in Patients with a Facial Fracture

PURPOSE: Facial fractures are highly associated with cervical spine or spinal cord injuries. Nevertheless, disagreement exists as to the actual incidence of cervical spinal trauma in conjunction with various facial fracture patterns. The purpose of this study was to evaluate the incidence of cervical spine injuries associated with various types of facial fractures. METHODS: A retrospective review from 2003 to 2009 was performed on 4440 patients with facial fractures who presented to the emergency room of our hospital. Facial fractures were grouped into thirds. Cervical spine injuries were divided into one of two groups including upper cervical injuries (C0-C2) and lower cervical injuries (C3-C7) and included fractures, dislocation, and disc herniation with or without neurological deficits. The chi-square test and multivariate logistic regression analyses were used to identify associations between facial fractures and cervical spine injuries. RESULTS: Among all patients with facial fractures, 80(1.85%) also had cervical spine injuries. Independent risk factors for cervical spine injury in patients with facial fracture were male gender (odds ratio [OR]=2.0), high velocity mechanism of injury (OR=4.0), and upper-third (OR=2.8) or combined facial fractures (OR=1.8). Cervical spine injuries increased in patients with high-force facial fractures. Fractures of the upper face were associated with an increased likelihood of lower cervical spine injuries and lower-third facial fractures were associated with an increased likelihood of having an upper cervical spine injury. CONCLUSION: Facial fractures were commonly associated with cervical spine injuries. The cervical spine must be examined carefully whenever facial injuries are present.

Moderate Head Injury: Predictors of a Repeat CT Scan

PURPOSE: A moderate head injury (Glasgow coma scale 9-13) has the large variability of severity, which accounts for the wide variability in the progression of lesions and in outcomes. Computed tomography (CT) is the standard diagnostic method for head injury, and repeat CTs (RCTs) are often obtained in order to monitor for progression of intracranial lesions. The purpose of this study was to suggest guidelines for RCT for moderate head injury. METHODS: In this study we reviewed data for 219 patients with moderate head injury who were admitted to our hospital via the emergency department between January 2004 and December 2009. The main outcome was worse progression of the intracranial lesions on RCT and neurosurgical intervention. Univariate and multivariate analyses were done for clinical variables to identify risk factors for progression of intracranial lesions and neurosurgical operations. RESULTS: On RCT, progression of injury was seen in 30.1% of patients, and neurosurgical intervention was performed in 14.6% of patients. Sixty percent of CT progression and ninety percent of neurosurgical intervention were occurred in patients with neurological deterioration. Independent risk factors associated with neurosurgical operation were coagulopathy (OR=13.275), amount of intracranial hemorrhage (OR=8.539), Marshall diffuse injury type of III/IV (OR=4.455), and skull fracture (OR=4.495). CONCLUSION: Routine repeat CT is necessary within 6 hour and 24-48 hour post-injury in patients with moderate head injury and without neurological deterioration.

Factors for Computed Tomography Assessed Progression of Lesions in Patients with Traumatic Subarachnoid Hemorrhage

PURPOSE: Traumatic subarachnoid hemorrhage (TSAH) is frequently found after traumatic brain injury (TBI) and its presence is a powerful predictor for the computed tomography (CT) assessed progression of intracranial lesions. The initial CT findings of progressing intracranial lesions in patients with tSAH are poorly understood. The aim of this study was to identify the factors that may predict the progression of lesions on the initial CT scans of patients with tSAH. METHODS: We evaluated 224 patients with tSAH and who were consecutively admitted from January 1, 2004 to December 31, 2008. The CT progression, the amount of SAH, the site of SAH, the presence and volume of associated intracranial lesion and the bilaterality of lesions were examined to identify the factors to predict CT progression of lesion. The initial and "worst" CT scans were compared. The CT scan changes were classified as "any CT progression" or "significant CT progression" (changes in the Marshall score). RESULTS: Eighty-two patients with tSAH (36.6%) had some CT progression and thirty-seven patients with tSAH (16.5%) had significant CT progression among the patients with tSAH. The initial CT findings according to the Marshall classification, the amount of SAH, the site of SAH and the associated intracranial lesions were significantly related to CT progression (p<0.05). The prognostic model to predict CT evolution, which consisted of the four initial CT findings described above, had high sensitivity (96.6~100%) and a high negative predictive value (94.1~100%). The area under the receiver operating characteristic (ROC) curve for the predictive model to predict the CT assessed evolution of SAH lesions was 0.701 (95% CI, 0.633~0.770). CONCLUSION: The prognostic model to predict CT progression of SAH lesions can help emergency medicine physicians decide when to perform repeat head CT scans in patients with tSAH.

Management of Head Injury in the Emergency Department

Despite aggressive management, severe emotional and physical disability or death occurs in the majority of patients with severe head injury. Significant recovery of function of impaired neuronal cells is possible if patients are rapidly and effectively resuscitated after focal or diffuse brain insults. However, if secondary insults such as hypotension, hypoxia, or intracranial hypertension occur, many vulnerable cells may be irreversibly damaged by a cerebral ischemia. The most important points in the management of traumatic brain insults are the maintenance of an adequate cerebral perfusion pressure rather than the control of intracranial hypertension as a means of averting cerebral ischemia, and recognition that aggressive hyperventilation to control increased cerebral pressure may aggravate cerebral ischemia. So it is recommended that cerebral perfusion pressure be maintained at or above 70mmHg and that use of prophylactic hyperventilation (PaCO2 < 35mmHg) should be avoided within the 1st 24 hours after brain injury.

Impact of Interhospital Transfer in Mortality of Critically Ill Patients

PURPOSE: Interhospital transfer of critically ill patients is often necessary for optimal patient care. However it is known that transport of critically ill patients has been associated with high rate of potentially detrimental complications. This study was designed to determine whether mortality of critically ill patients with interhospital transfers is different from critically ill patients with direct admissions. METHODS: The retrospective cohort study was conducted at an academic medical center with 3906 critically ill patients from 2003 to 2004, of whom 1652 were direct admissions and 2254 were interhospital transfers. Death within 48 hours in interhospital transfers and direct admissions were compared using univariate and multivariate regression analyses that adjusted for severity of illness. Severity of illness was measured using Simplified Acute Physiology Score (SAPS) II and Charles comorbidity score. To measure hospital performance standardized mortality ratio (SMR) was calculated by dividing observed mortality by SAPS II-predicted mortality. RESULTS: Death within 48 hours were not significantly higher for interhospital transfer patients than for directly admitted patients (7.5% vs 8.1%, p<0.05). But directly admitted patients had significantly higher SMR than transferred patients (0.94 vs 0.81, p=0.001). Finally, transferred patients with hepatic failure had significantly higher mortality rates (odds ratio=4.636) as compared with directly admitted patients, confirming the "transfer effect"for this patients' subgroup. CONCLUSION: Admission source is not an important determinant of outcome.

Factors Affecting Emergency Department Length of Stay in Traumatic Surgical Critically Ill Patients

PURPOSE: Prolonged emergency department (ED) lengthof-stay (LOS) may cause ED overcrowding and worse outcome in traumatic surgical critically ill patients. In this study, we examined characteristics to be associated with prolonged ED LOS, including use of CT scanning and other ED-based special procedures (eg, radiologic diagnostic tests or therapeutic procedures performed in the ED). METHODS: A retrospective cohort study was conducted at an academic medical center with 458 traumatic surgical critically ill patients from 2003 to 2004. Critical care patients were defined as those sent to the operating room (OR) or intensive care unit (ICU) directly from the ED. Information was extracted from each ED chart on use and the number of CT scanning, other special radiologic diagnostic procedures (eg, magnetic resonance imaging, angiogram, cystogram), the number of plain radiographs performed, the emergent therapeutic procedures (intubation, closed thoracotomy, central venous line), the waiting times and number of consultants called, and holding times for decision of admission. ED LOS was defined as the time from presentation until transfer to the OR or ICU. To assess the effect of multiple simultaneous factors affecting ED LOS, a Cox proportional hazard model of time-to-ED discharge was used. RESULTS: The average overall ED LOS was 256.4+/-153.2 minutes (16 to 1465 minutes). Use of special radiologic diagnostic procedures was most strongly associated with an increased ED LOS. Use of either CT scanning or emergent therapeutic procedures, the number of plain radiographs, waiting times and numbers of consultants, and holding times for decision of admission were also affected a prolonged ED LOS independently. CONCLUSION: ED-based patient management decisions such as use of CT and ED-based special diagnostic and therapeutic procedures strongly associated affected ED LOS in traumatic surgical critically ill patients.

Effects of Weekend on the Prognoses for Patients Visiting to Emergency Medical Centers

PURPOSE: Despite the increased number of patients visiting emergency rooms on weekends, the level of staffing is often lower than it is on weekdays. It is uncertain whether in-hospital mortality rates among patients depend on when they visited the hospital on a weekend or on a weekday. METHODS: We analyzed 21,645 patients who visited our emergency department in 2003. We compared death within 48 hours after a visit to the emergency room between patients who visited on weekends and those with visited on weekdays. The odds of death within 48 hours for patients who visited on a weekend were analyzed by using a multivariate logistic regression. The severity of illness was adjusted by using triage and the Charlson comorbidity score. RESULTS: Compared with patients who visited on weekdays, the number of patients who visited on weekends was increased in 30%. The mortality rates were not statistically different for patients who visited on weekends and patients who visited on weekdays (3.1% vs 2.8%, p=0.399). However, two diagnoses (pneumonia and spontaneous subarachnoid hemorrhage) were associated significantly with a weekend effect. CONCLUSION: Visiting the emergency department on weekends was not associated with a higher mortality than visiting the emergency department on weekdays.

Apoptosis in Respiratory Epithelial Cells: Triggering by Paraquat and Modulation by L-ascorbic acid

PURPOSE: Apoptosis is a programmed cell death that is a selective process of physiological cell deletion. This study was undertaken to evaluate a paraquat-triggered apoptosis and the ability of ascorbic acid to modulate the process in the A549 cell line, a well-characterized cellular model of human lung alveolar cells. METHODS: A 549 cells were incubated with different concentrations of paraquat for up to 24 hour, followed by 24, 48, and 72 hours of recovery in paraquat-free medium. To test the abilities of antioxidants as modulators of paraquatinduced apoptosis, we pre-treated the cells for 4 hours with 250 micrometer L-ascorbic acid (vitamin C) before exposure to paraquat, and we incubated cells with paraquat in the presence of 250 micrometer L-ascorbic acid. Apoptosis was assayed by staining the cells with FITC-annexin V, and the cells were analyzed by using flow cytometry. RESULTS: Paraquat was inducer of apoptosis. A549 cells incubated with paraquat for up to 24 hour showed no apoptotic features, but the following incubation in a paraquat-free medium resulted in a time-dependent appearance of apoptosis. The ascorbic acid proved effective in reducing paraquat-induced apoptosis. CONCLUSION: We propose an experimental model for investigating the steps and mechanism of paraquat-induced apoptosis in alveolar cells

Efficacy of Extracorporeal Extraction Treatment in Paraquat Poisoning

PURPOSE: The value of extracorporeal extraction in treating paraquat poisoning was questioned; some saved their patients by applying hemoperfusion, but others failed. This study was designed to investigate the efficacy of extracorporeal extraction treatment for patients suffering from paraquat poisoning. METHOD: The serum concentrations after ingestion of paraquat by 52 patients were serially checked. Of those 52, 42 were treated with hemoperfusion, and 34 of 42 patients were treated with continuous veno-venous hemodialysis (CVVH) after hemoperfusion. We evaluated the mortality, the survival time, and the hourly elimination rate of paraquat to investigate the efficacy of extracorporeal extraction. Also, we evaluated factors which affected the efficacy of the extracorporeal extraction. RESULT: There was no difference between the hemoperfusion group and the non-hemoperfusion group in mortality, time of survival, and elimination rate of paraquat (p>0.1). The total mortality was 50.0% (26/52) with no difference between the hemoperfusion group and the hemoperfusion +CVVH group. The mortality was closely related with the development of acute renal failure. Hemoperfusion, when applied before the collapse of the renal function, is effective in reducing mortality even in severe poisoning. Hemoperfusion had value in enhancing the hourly elimination rate of circulating paraquat in cases with renal collapse, but had little value in reducing mortality. CONCLUSION: The efficacy of extracorporeal extraction in treating patients with paraqaut poisoning was not proven in this study. However we suggest that early extracorporeal extraction may be effective in treating paraquat poisoning, even in severe cases, due to its possible detoxicating effect and toxin removal.

Diagnostic Value of the Pediatric Appendicitis Score in Pediatric Appendicitis

PURPOSE: This study was performed to evaluate the pediatric appendicitis score (PAS) and to propose diagnostic criteria for acute appendicitis in children. METHODS: The medical records of 194 patients who underwent appendectomies for clinically suspected acute appendicitis and the preoperative evaluations of those patients in our emergency room were, respectively, reviewed. Each of 8 clinical variables, hopping tendereness in the right lower quadrant (RLQ), anorexia, pyrexia, nausea/vomiting, RLQ tenderness, leukocytosis, neutrophilia, and migration of pain, was assigned a score of 1 or 2 to obtain a total of 10. The PAS, ultrasound (US), and combination of the PAS and US were evaluated for sensitivity, specificity, predictive value, and accuracy. RESULTS: Negative appendectomies were performed in 11.3% (22 of 194 patients) of the cases. A PAS > or = 6 was compatible with the diagnosis of appendicitis. However, in cases with a PAS< or =5, US was necessary for the diagnosis of appendicitis. Analysis of the data for the PAS and for combined PAS and US method revealed, respectively sensitivities of 73.8% and 94.6%, specificities of 86.4% and 70.6%, positive predictive values of 97.7% and 96.6%, negative predictive values of 29.7% and 60.0%, and accuracies of 75.3% and 92.1%. CONCLUSION: The PAS is a simple and good diagnostic test for assessing an acute abdomen and diagnosing acute appendicitis in children. However, a combination of the PAS and US is more accurate than the PAS alone in diagnosing acute appendicitis.

Acute Cardiac Ischemia in Young Adults: Characteristics and Risk Factors

PURPOSE: Acute cardiac ischemia under the age of 45 years is uncommon. This study was to evaluate the prevalence of various risk factors, the angiographic characteristics, and the prognosis in young patients with acute cardiac ischemia compared with that in older patients. METHODS: A review was retrospectively done of 554 patients with acute cardiac ischemia from January 2002 to December 2002. The patients were divided into two groups: patients under 45 years old (75 patients) and patients over 45 years old (479 patients). The clinical features which were compared between the two groups were demographic features, risk factors (cigarette smoking, history of hypertension and diabetes, hypercholesterolemia, hypertriglyceridemia, and family history of ischemic cardiac disease), coronary angiographic findings, and prognosis. RESULTS: The incidence of acute cardiac ischemia in patients under 45 years old was 13.5% (75/554). Three clinical risk factors, a history of cigarette smoking, a positive family history coronary artery disease, and hypertriglyceridemia, were significantly more prevalent in the young patients. Angiographically, normal or minimal coronary obstructions were more frequently found in the young patients, and significant coronary obstructions were more frequently found in the older patients. However the incidences of single-vessel disease and multi-vessel disease between young patients and older patients were not different. Young patients with acute cardiac ischemia do not have a more favorable prognosis than older patients. CONCLUSION: Acute cardiac ischemia is found in young patients with less extensive disease, but young patients do not have a more favorable prognosis than older patients.

Differentiation of Central and Peripheral Causes according to Clinical Features of Dizzy Patients in an Emergency Setting

PURPOSE: Central dizziness infrequently develops to a cerebellar or brainstem infarction. However, in the acute phase, central lesions masquerade as peripheral causes. This study was performed to provide the diagnostic guidelines for differentiation between peripheral and central causes. METHODS: From January 2002 to December 2002, we investigated 307 dizzy patients with normal brain computerized tomography. The patients were analyzed according to age, history, associated symptoms, duration of attacks, neurologic examination, and tests of balance such as gait, tandem gait, and nystagmus. RESULTS: The history of cerebral vascular accidents and neurologic symptoms, such as numbness, diplopia, dysarthria, dysphagia, or weakness, suggested central causes. Episodes of dizziness lasting seconds suggested benign positional vertigo. Dizziness associated with vertebrobasilar insufficiency typically last minutes whereas peripheral inner ear causes of recurrent dizziness typically last hours. Patients with peripheral or central causes have impaired balance, but this is more severe with central causes than with peripheral causes. Spontaneous nystagmus of a central origin changed direction with gaze to the side of the fast phase. CONCLUSION: The history, the associated symptoms, and the tests of balance provided the key information for distinguishing between peripheral and central causes, and the guideline applied in this study will be helpful to diagnose the cause of the dizziness.

Diagnostic Value of Cardiac STATus(TM) for Diagnosing Acute Cardiac Ischemia in Patients with Acute Chest Pain in an Emergency Settings

PURPOSE: The purpose of this study was to investigate the usefulness of a qualitative bedside test for detection of cardiac troponin I (Cardiac STATus(TM)) in evaluating patients with acute chest pain in emergency settings. MATERIAL AND METHODS: In 147 patients who had chest pain without ST-segment elevation on their electrocardiograms, we evaluated the sensitivity and the specificity of the new, rapid, bedside troponin I assay for acute myocardial infarction (AMI) and acute cardiac ischemia (ACI). Patients whose samples were taken at least 4 hours after the onset of pain were selected. RESULTS: Cardiac STATus(TM) was positive in 28 patients (19.0%). Among 31 patients with AMI, Cardiac troponin I was positive in 19 (61.3%) patients. Among 95 patients with ACI, Cardiac STATusT M was positive in 24 patients (25.3%). The results were false positive in 12/31 patients (38.7%) for AMI and in 71/119 patients (59.7%) for ACI. The negative predictive value of the Cardiac STATus(TM) was 90.5% for AMI and 65.0% for ACI. During the 30 days of follow-up, there were 4 deaths and 12 cases of non-fatal AMI. Cardiac troponin I proved to be independent predictor of cardiac events. CONCLUSION: In contrast to its excellent specificity (0.92), the sensitivity (0.61) of the Cardiac STATus(TM) assay was poor. Thus, we conclude that this test is not highly sensitive for early detection of myocardial-cell injury. Negative test results were associated with low risk, but did not allow safe discharge of patients with chest pain from the emergency setting. Positive results of Cardiac STATus(TM) were associated with unfavorable outcomes.

Epidemiology of Traumatic Accident Deaths

PURPOSE: Comparing the results of traffic accident deaths between ours and a previous study, we assessed the improvement in the emergency medical service system and the traumatic care system. METHODS: Three hundred twenty-one traumatic accident deaths occurring in Chunan and the nearby region between 1999 and 2000 were reviewed; data were obtained from paramedic trip reports, medical records, and radiological findings. RESULTS: One hundred fifty-eight (49%) deaths occurred in the prehospital setting. The remaining 163 (51%) patients were transported to the hospital. Of these, 89 (55%) died in the first 48 hours (acute), 26 (16%) within three to seven days (early) and 48 (29%) after seven days (late). Central nervous system injuries were the most frequent cause of death (57%), followed by exsanguination (25%) and organ failure (8%). Two distinct peaks of time were found on analysis: 50% of the patients died within the first 60 minutes, and 9% of the patients died at three to seven days after injury. The overall preventable death rate was 24%. CONCLUSION: Access to the prehospital emergency medical system was improved, and there was greater proportion of late deaths due to brain injury. We found the distribution to be a bimodal distribution.

An Evaluation of a Diagnostic Protocol to Screen Acute Cardiac Ischemia in an Emergency Setting

PURPOSE: Evaluating chest pain is one of the greatest challenges facing emergency physicians. Accurate diagnosis and triage of patients with acute cardiac ischemia (ACI) containing acute myocardial infarction (AMI) and unstable angina at the emergency department should increase survival for such patients. METHODS: In 333 patients with chest pain, we evaluated the diagnostic performance of creatine kinase-MB (CK-MB), electrocardiograms (ECG), Cardiac STATus(TH), the Goldman chest-pain protocol, and a combination of Cardiac STATus(TH) and the Goldman chest-pain protocol. Diagnostic performance was assessed using estimates of test sensitivity, specificity, and diagnostic odds ratio. RESULTS: Diagnostic technologies for AMI, such as CK-MB, ECG, Cardiac STATus(TH), and the Goldman chest-pain protocol have good sensitivity (80-90%), but they have poor sensitivity for ACI (60-70%). To increase the diagnostic accuracy for ACI we combined the Cardiac STATus(TH) and the Goldman chest-pain protocol. The combination had excellent sensitivity (97%) for AMI at 4 hours after onset of chest pain. However the combination did not have the desired very high sensitivity to diagnose ACI (78.5%). With serial Cardiac STATus(TH), ECG, and echocardiography measurements in the chest-pain observation unit, we improved the ACI detection rate. CONCLUSION: The combination of Cardiac STATus(TH) and the Goldman chest-pain protocol had excellent diagnostic performance for AMI and good performance for ACI.