Predictors of Mortality in Hemodynamically Unstable Traumatic Patients with Pelvic Fracture

PURPOSE: Pelvic fracture is one of the more serious skeletal injuries, resulting in substantial mortality. The large amount of kinetic energy necessary to fracture the bony pelvis often leads to concomitant thoraco-abdominal injury. Pelvic fracture and combined injuries need effective initial resuscitation. However, it is hard to predict mortality due to the complexity of multiple injuries. Therefore, the purpose of this study was to identify factors predicting mortality in patients with pelvic fracture and concomitant thoraco-abdominal injury. METHODS:A retrospective study was performed on 174 cases of pelvic fracture who visited the Emergency Department between January 2003 and June 2008. Data were collected regarding demographic characteristics, mechanism of injury, injury severity score (ISS), Abbreviated Injury Score (AIS), Simplified Acute Physiologic Score II (SAPS II), transfusion requirements, fluid requirements, the findings on angiography, hemoglobin level, platelet count, prothrombin time (PT), fibrinogen, albumin, base deficit, lactate, anti-thrombin III, length of ICU stay, and total hospitalization days. Pelvic fracture categories were derived by adapting the Young-Burgess classification. RESULTS: One hundred forty patients survived (Group I); 34 died (Group II). Blood pressure, pulse rate, hemoglobin, albumin, lactate, base deficit, PT, fibrinogen and Antithrombin III were significantly different between two groups. Transfusion, fluid requirements, ISS and SAPS II were significantly higher in group II. Extravasation on the CT was more frequent found in group II. The ISS 1.194 (95% CI, 1.076~1.325) and SAPS II 1.162 (95% CI,1.042~1.296) were independent significant predictors of mortality. CONCLUSION: Predictors of mortality in pelvic fracture patients should be available during the first attempt at resuscitation. The ISS and SAPS II were the most important predictors in defining mortality.

A Case of Pulmonary Decompression Sickness Presenting as Noncardiogenic Pulmonary Edema and Documented Venous Air Embolism

Pulmonary decompression sickness (DCS) is a relatively uncommon form of type II DCS, with a frequency of only 2.4% as averaged from several studies. The deposition of venous gas emboli in the pulmonary arterial circulation produces progressive dyspnea, cough, chest pain and the physical findings of increased central venous pressure and pulmonary arterial pressure, and right-sided strain on an electrocardiogram. We recently experienced a case of pulmonary DCS presenting as interstitial pulmonary edema combined with low central venous pressure. In this case, air bubbles that were trapped in the most nondependent part of the femoral vein were discovered incidentally, on abdominal computed tomography scan, which may mean that the buoyancy of gas bubbles was sufficient to counteract the venous blood flow propelling such bubbles in the direction of blood flow. In addition, we discuss the current availability of recompression facilities in South Korea since some difficulties are anticipated in treating an unstable patient with a monoplace hyperbaric chamber, which is typically the only available type of hyperbaric chamber in South Korea.

The Variations in Clinical Features According to Intoxicants in High Toxicity Organophosphorus Intoxication

PURPOSE: Organophosphorus (OP) pesticides are differentiated into 3 groups according to their toxicity. The differences in chemical composition of each OP pesticide determines its toxicokinetic characteristics. There are few human studies that address the clinical results of poisoning according to the OP pesticide. In this study, we aimed to examine the differences in clinical features among self-poisoning from 4 highly toxic OP pesticides. METHODS: The 4 kinds of OP poisonings included 17 cases of Dichlorvos, 17 cases of EPN, 17 cases of methidathion, and 13 cases of phosphamidon. We set primary outcomes as GCS, atropine dose required, duration of patient need for atropine, proportion who required ventilation, duration on ventilation, and the interval from ingestion to ventilation. Secondary outcomes were the proportion of OP-induced delayed neuropathy, duration of ICU stay, and proportion who required additional infusion of pralidoxime chloride (PAM). RESULTS: The EPN group required the largest amount of atropine, the longest duration of atropine use, the longest duration for support of mechanical ventilation, and the longest ICU stay. Furthermore the proportion who required additional PAM and neuropathy were in the EPN group. However, the EPN group had the longest interval from ingestion to ventilatory support. Meanwhile, the Dichlorvos group exhibited comparatively mild clinical features. CONCLUSION: Throughout this study, we found different clinical features to each OP pesticide poisoning. It can be explained by differences in chemical composition, which determined the speed of aging, the reactivation rate of OPenzyme, the metabolism, the fat solubility, and other characteristics of the pesticides.

A Case of Fatal Pulmonary Embolism Caused by Bone Cement after Percutaneous Vertebroplasty

Percutaneous vertebroplasty is a safe and effective procedure for the treatment of benign and malignant lesions of the spine, but has been associated with some known complications. Most complications are related to the percutaneous approach, but more severe complications related to the unwanted migration of acrylic cement can occur. We report an unusual case of a fatal pulmonary embolism caused by acrylic cement. Known factors related to cement leakage are incorrect needle position, the consistency of the cement, and the vascularity of the lesion. Emergency physicians should consider acute pulmonary embolism as a diagnosis when evaluating a patient who is suffering from dysnea or chest pain after an orthopedic procedure performed with cement.

A Case of Infective Endocarditis in which Cerebral Infarction and Hemorrhage developed together

Risk factors for infective endocarditis include injection drug abusers and patients with structural heart defects undergoing dental procedures. Infective endocarditis is clinically important because it is hard to diagnose it in its early stage owing to its various clinical manifestations, and because its morbidity and mortality increase when neurologic complications occur. This is a case of infective endocarditis in the course of treatment of which complicating cerebral hemorrhage and infarction progressed rapidly and prompted death.

Clinical Analysis of Elevated Serum AST Level in Emergency Patients

PURPOSE: Serum aspartate aminotransferase (AST) is an enzyme widly used in the diagnosis of acute liver disease. It is also highly sensitive in cases of myocardial infarction and muscular injury. This study is designed to ascertain the utility of AST for diagnosis in emergency room. METHODS: From July 2001 to September 2002, 98 patients with AST greater than ten times (400 U/L) the normal range were identified by the biochemistry laboratory in the Emergency Medical Center of Chonnam National University Hospital. The patients 'clinical records were studied to determine the diagnosis, the clinical course, the physical finding on arrival, the past history, other serological and imaging studies, etc. RESULTS: The most common cause of elevated AST level was hepatic in origin (74 cases, 75.5%). Other causes were soft tissue injury (13 cases, 13.3%) and myocardial infarction (11 cases, 11.2%). In group with hepatic causes for raised AST, 21 (28.3%) patients had pancreaticobiliary desease, 20 (27.0%) patients were in conditions producing hepatic ischemia, 18 (24.3%) patients had hepatocellular desease, 6 (8.1%) patients had traumatic liver injury, and 4 (5.4%) patients had malignancy. The hepatic ischemia was caused by sepsis (6 cases, 30.0%), heart failure (6 cases, 30.0%), hypoxia (5 cases, 25.0%), and prolonged hypotension (3 cases, 15.0%). CONCLUSION: The main cause of a notably increased serum AST level is known to be hepatocellular disease, but this study for emergency patients revealed that other causes, such as hepatic ischemia, traumatic liver injury, and muscular disease, were also remarkable. When the level of serum AST is abnormally high, the clinician must consider not only hepatocellular disease but also prolonged hypotension, circulatory collapse, hypoxia, traumatic liver injury, etc.

Clinical Analysis of Hyponatremia in Emergency Patients

PURPOSE: Hyponatremia is the most common electrolyte imbalance encountered in the hospital, there have been few studies about the clinical characteristics of hyponatremia in emergency patients. This study was performed to evaluate the causes and the initial symptoms of hyponatremia in emergency patients, the relationship between their ages and their initial symptoms and the relationship between the causes and the recovery time. METHODS: A total of 42 patients with hyponatremia, who were treated in the Emergency Department of Chonnam National University Hospital from 2000 to 2001, were studied by chart review. RESULTS: The initial symptoms were generalized weakness (33.3%), seizure (28.6%), mental change (21.6%), confusion (9.5%), dizziness (4.8%), and non-specific (2.4%). There was a significant difference in the initial symptoms between children and older. The initial symptom for younger patients was usually seizure. The most common causes of hyponatremia were dehydration and sodium loss (52.4%), other causes were hypothyroidism (11.9%), SIADH (7.1%), heart failure (7.1%), adrenal insufficiency (4.8%), polydypsia (4.8%), CRF (2.4%), nephrotic syndrome (2.4%) and unidentified causes (7.1%). There were significant differences in the recovery times among the causes of hyponatremia. CONCLUSION: The initial symptoms of hyponatremia in emergency patients were usually generalized weakness in older patients and seizure in the young. There were significant differences in the recovery times among the causes of hyponatremia. There were many more incidences of hypovolemic hyponatremia of emergency patients than normovolemic hyponatremia.

A Case of an Aortic Arch Aneurysm in which a Fistula Formed Between the Pulmonary Parenchyma

Massive hemoptysis represents a major medical emergency that is associated with high mortality. The causes of hemoptysis are various and include pulmonary and cardiovascular disorders and trauma. The causes of pulmonary disorder are tuberculosis, bronchiectasis, abscess, malignancy, bronchitis, and fungal infection. The causes of cardiovascular disorder are mitral stenosis, pulmonary embolism, and congestive heart failure. A fistula between an aortic aneurysm and the pulmonary parenchyma is one of the causes of hemoptysis, but it is a rare. However, if undiagnosed, it is a uniformly fatal cause of massive hemoptysis. This is a case of bleeding from a fistula between an aortic arch aneurysm and a lung parenchyma in a patient with an aortic arch aneurysm who presented with massive hemoptysis. He had suffered intermittent hemoptysis since he was diagnosed with an aortic arch aneurysm three years before. A high clinical suspicion must be maintained when a history of intermittent hemoptysis is obtained in patients with an aortic aneurysm or prior aortic graft surgery.

A Case of Hydatid Disease Diagnosed in Anaphylatic Shock of Unknown Cause

Hydatid disease is a parasitic infection caused by the Echinococcal species. Humans are intermediate hosts and become infected directly by contact with canines or indirectly by contact with food, water, and contaminated objects. This disease involves multiple organs, including liver, lung, heart, muscle, bone, kidney, and brain. Rupture of a hydatid cyst, which is the most common complication of this disease, can cause serious sequelae, including allergic reaction, secondary infection, biliary obstruction, and metastasis. The hydatid disease occurs principally in areas of cattle and sheep ranching. In Korea, this disease is rare, and only a few cases have been reported. We report a case of hydatid disease with anaphylactic shock and suggest that hydatid cyst complications must be kept in mind when dealing with patients who have a history associated with an endemic region.

Analysis of Factors Predicting Recurrence and the Result of Treatment in PSVT Patients at the Emergency Department

PURPOSE: The purpose of this research was to evaluate the factors predicting recurrence and the characteristics of patients who recurred after the treatment of spontaneous paroxysmal supraventricular tachycardia (PSVT) with adenosine. METHODS: From January 1999 to December 2001, 62 patients with PSVT were enrolled in this study. The conversion group included patients who had had a therapeutic response, which was defined as the occurrence of a change in the sinus rhythm after adenosine administration. The recurred group consisted of all patients who had not had a therapeutic response. Clinical features, the results of treatment, ECG findings, and the hemodynamic statuses were analyzed. RESULTS: The treatments were vagal maneuver (5 pts, 7.5 %), adenosine 6 mg (37 pts, 55.2 %), adenosine 12 mg (14 pts, 20.9 %), verapamil 5 mg (9 pts, 13.4 %), and cardioversion (2 pts, 3.0 %). Twenty-five of the 62 patients failed to have a therapeutic response, yielding a recurrence rate of 40.3 %. Atrioventricular reentrant tachycardia (AVRT) was more prevalent in the recurred group. The most common symptom at presentation was chest pain. The recurred group had increased heart rate, and increased blood pressure. When patients were monitered after adenosine, unifocal premature ventricular complex was the most common rhythm encountered in the conversion group, but atrial fibrillation, and multifocal premature ventricular complex was the most common rhythm encountered. CONCLUSION: Age, heart rate, difference in systolic blood pressure from presentation to discharge, previous history of heart disease, and rhythms encountered after adenosine administration were factors predicting recurrence.

A Case of Locked-in Syndrome with Hypoglycemia

Locked in syndrome (LIS) is a state of tetraplegia and lower cranial nerve palsies in which vertical eye movement and blinking are the only means of communication, but consciousness is preserved. LIS is most frequently a sequelae of a basilar artery thrombosis lesion and may be caused by trauma, hemorrhage, a tumor, infection, etc., which results in a ventral pontine lesion or bilateral midbrain lesion. Early diagnosis and treatment must be a priority because the recovery of patients with locked in syndrome caused by a basilar artery occlusion is exceptional, with a 65~75% mortality. Although an improved clinical outcome can be achieved in patients with a basilar artery occlusion by early recanalization after the use of thrombolytic therapy or angioplasty, early diagnosis and treatment of this state is difficult, for the neurologic deficits develope gradually. The diagnosis of LIS in patients who present with hypoxia, metabolic disorder, endocrine disorder, central nerve system disorder, acute alcohol intoxication, acute drug intoxication, etc may be missed. At the emergency department, closer attention and frequent neurologic examinations must be given to patients who complain of altered mental state. We report a case of LIS which was misdiagnosised as hypoglycemic encephalopathy and review the literature.