Progressive Paralysis of the Right Lower Extremity due to Diffuse Idiopathic Skeletal Hyperostosis: A Case Report

Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier's disease, is a common disorder characterized by ossification and calcification of soft tissues such as the enthuses and joint capsules, particularly affecting the spine. This condition affects approximately 3~30% of men older than 50 years of age. We present the case of a 39-year-old woman diagnosed with DISH combined with extensive ossification of the posterior longitudinal ligament (OPLL) and ossification of ligamentum flavum (OLF). The emergency physician should understand the typical radiologic findings associated with DISH and its clinical presentations in order to diagnose and treat this problem.

Effect of Establishing an ECG Transmission System on Time Required for Patients with ST-segment elevation Myocardial Infarction to Receive Reperfusion Therapy

PURPOSE: Prompt reperfusion therapy by means of primary percutaneous coronary intervention is an effective method for treating patients with ST-segment elevation myocardial infarction (STEMI). According to the ACC/AHA guidelines for these patients, the interval between arrival at the hospital and intracoronary balloon inflation (door-to-balloon time) should be 90 minutes or less. The aim of this study was to evaluate the effect of establishing an ECG transmission system and communication procedure in the emergency department (ED) to minimize door-to-balloon time for STEMI patients. METHODS: We established both the out-of hospital and in-hospital aspects of the ECG transmission system. Before patient arrival at our ED, we would attempt to receive initial ECGs from the referring hospitals via fax. In ideal cases, ECG findings were immediately reported to interventional cardiologists by the referring primary ED physician. Door-to-balloon time segments were analyzed in a retrospective manner. We compared the effectiveness in minimizing reperfusion time between the use of inter-hospital 12-lead ECG transmission before patient arrival, and direct communication between emergency physicians and attending interventional cardiologists. RESULTS: Of the total 142 STEMI patients who received percutaneous coronary intervention (PCI) during the study period, 112 (78.9%) received PCI within 90 min. The mean door-to-balloon time of the 27 patients admitted with a pre-arrival 12-lead ECG transmission was significantly less than the others. CONCLUSION: Establishing both out-of hospital and in hospital strategies to reduce door-to-balloon time in patients with STEMI, by using pre-arrival ECG transmission and direct communication between emergency physicians and interventional cardiologists, is an effective approach to minimize time to reperfusion.

Characteristics of a Focused Assessment with Sonography for Trauma (FAST) in Hollow Viscus Injury

PURPOSE: The usefulness of focused abdominal sonography for trauma (FAST) is now included in the frame work of the advanced trauma life support for examination of thoraco- abdominal trauma. Ultrasonographic screening is controversial in patients with hollow viscus injury. The purpose of this study is to determine the characteristics of emergency trauma sonographic findings in patients with hollow viscus injury. METHODS: All patients with isolated viscus injury after blunt abdominal trauma were retrospectively enrolled in this study during the 5-year period from December 1997 to November 2002. The patients were screened by using ultrasonography and an underwent explolaparotomy. The patients were diagnosed with a hollow viscus injury based on the surgical findings. Patients with viscus injury combined with parenchymal organ injury after abdominal trauma were excluded. Ultrasonographic examinations were performed by the experienced emergency physicians during the trauma resuscitation. RESULTS: Sixty patients were included in this study. The most common injury site was jejunum (23.3%). The common findings of emergency trauma sonography were free fluid collection (56.7%), none of fluid collection (38.3%), free air and fluid collection (3.3%), and free air (1.7%). The presence of mesenteric injury was significantly associated with fluid collection (x2=0009). CONCLUSION: The most common sonographic findings in hollow viscus injury patients after blunt abdominal trauma are free intraperitoneal fluid (anechoic or mixed echo pattern), normal, and free air (reverberation) in that order. Massive intraperitoneal fluid is more often detected in patients who have a viscus injury combined with a ruptured mesenteric vessel.

Resuscitation Outcomes and Clinical Characteristics of Non-traumatic Out-of-Hospital Geriatric Cardiac Arrest

PURPOSE: This study was to investigate the resuscitation outcomes and the clinical characteristics of geriatric nontraumatic out-of-hospital cardiac arrest by analyzing data from a single institution's registry. METHODS: We conducted a retrospective study of 804 patients who came to the emergency department with nontraumatic out-of-hospital cardiac arrest during the period 1991-2002. Only patients over 18 years of age were included. Clinical characteristics, variables associated with cardiac arrest, and data during resuscitation were obtained from our cardiac arrest database. Patients were divided into two age groups: less than 65 years of age (non-geriatric group, n=530), and over 65 years of age (geriatric group, n=274). RESULTS: The proportion of cardiac etiology was higher with the geriatric group than with the non-geriatric group (48% vs 39%, chi-square=0.013). A lower incidence of ventricular arrhythmia was observed in the geriatric group (8% vs 13%, chi-square= 0.037). The arrest time, the CPR time, the witnessed arrest, the epinephrine doses, and total defibrillation energy were not different between two groups. Spontaneous circulation was restored in 127 (46%) patients in the geriatric group and in 255 (48%) patients in the non-geriatric group (chi-square=0.382). The patients discharged alive numbered were 33 (6%) in the non-geriatric group and 10 (4%) in the geriatric group (chi-square=0.138). CONCLUSION: Cardiac etiology was predominant in geriatric cardiac arrest and a lower incidence of ventricular arrhythmia was observed. An older age (over 65 years) did not affect the resuscitation outcome.

Optimal Length of a Right Subclavian Venous Catheter in Koreans and the Usefulness of Echocardiography for Evaluation of the Central Venous Catheter Position

PURPOSE: We evaluated the proper length of a central venous catheter (CVC) during subclavian vein catheterization and the usefulness of transthoracic echocardiography in identifying the position of the CVC. METHODS: From August 2002 to September 2002, we studied prospectively 30 consecutive patients who had a CVC inserted. The right subclavian vein was punctured by using the Seldinger method, and the patients were divided into two groups according to the method used to identify the position of the central venous catheter. In the radiology group, after central venous catheterization, we identified the position of the CVC by using a plain chest X-ray; then, we adjusted the length of the catheter. In the echocardiography group, during central venous catheterization, we inserted it deeply enough to observe the tip of the catheter in the right atrium by using echocardiography; then, we withdrew the catheter slowly until it was no longer observed in the right atrium, and we fixed the catheter at that position. We measured the heights, weights, and chest circumferences of the patients. RESULT: The maximal lengths of CVCs were 15.9+/-2.0 cm in the radiology group and 15.9+/-1.7 cm in the echocardiography group. There was no difference between the two groups (p=0.98). The maximal length of the CVC correlated to the height of the patient (Y=0.154X-9.8: Y=the length of the CVC, X=height, p<0.001, R2=0.394) and to the weight of the patient (Y=0.076X+11.2: Y = the length of the CVC, X=weight, p=0.042, R2=0.140), but not to the chest circumference (p=0.371). CONCLUSION: Echocardiography was a useful method in identifying the optimal positioning in central venous catheterization. The maximal length of the CVCs was 15.9 +/-1.9 cm via the subclavian vein approach in Koreans and correlated to the height of the patients.

Comparison of Two Titration Methods of Vasopressor Infusion to Correct Septic Shock

BACKGROUND: Administration of a vasopressor is frequently required in treating septic shock. The conventional method of vasopressor infusion, which includes incremental titration of a vasopressor to raise blood pressure, is sometimes a time-consuming process that might prolong the duration of the shock. PURPOSE: This study was to evaluate whether a method of vasopressor infusion that starts from an acceptable maximal dose has advantages over a method of vasopressor infusion that starts from a low dose in patients with septic shock. SUBJECTS AND METHODS: Twenty-five patients with septic shock, which was not corrected with fluid resuscitation of 20~30 ml/kg, were randomized into two groups. The patients in the low-to-high group (n=13) received a vasopressor in an incremental manner starting from a low dose. The patients in the high-to-low group (n=12) received a vasopressor in a decremental manner starting from an acceptable maximal dose. The shock durations (time from the beginning of vasopressor infusion to correction of the shock), and the hemodynamic and metabolic parameters, including blood pressure, pulse rate, arterial lactate concentration, anion gap, base excess, and central venous oxygen saturation, before vasopressor infusion, and 2, 4, 6, 12, and 24 hours after vasopressor infusion were compared for the two groups. The length of ICU stay, the length of total hospital stay, the type of discharge, and the survival rate were also compared. RESULTS: The shock duration was shorter in the high-to-low group than in the low-to-high group (14.7+/-21 min. vs 41.9 +/-41 min., p=0.01). There were no differences between the two groups as to hemodynamic and metabolic parameters. The ICU stay was shorter in the high-to-low group than in the low-to-high group (7+/-7 days vs 10+/-22 days); however, the difference did not reach statistical significance (p=0.934). CONCLUSION: The method of vasopressor infusion starting from acceptable maximal dose shortens the duration of shock compared to the conventional incremental titration method.

Correlation of the Serum Antithrombin III to Injury Severity in Patients with Severe Trauma

PURPOSE: Antithrombin III (AT-III) is a serum protease inhibitor that inhibits the blood coagulation protease thrombin and is seen to be present in low levels in cases of shock, sepsis, or major trauma. Coagulopathy and hemorrhage are known contributors to trauma prognosis but the actual relationships of AT-III to mortality and to injury severity are unknown. The purpose of this study was to determine the correlation between AT-III and injury severity. METHODS: This study was a retrospective analysis of data collection from January 1, 2003, to December 31, 2003. Sixty patients with multiple trauma were studied. The revised trauma score (RTS), the injury severity score (ISS), the systemic inflammatory response syndrome score (SIRS), the acute physiology and chronic health evaluation III (APACHE III), the length of ICU stay, the base-deficit value and the serum lactate were measured to evaluate injury severity. We estimated the relation between the severity of injury and the serum level of AT-III. RESULTS: In patients with multiple trauma, the serum AT-III level was lower in the non-survival group (12.6 mg/dL) than it was in the survival group (17.2 mg/dL) (p=0.004). Among the previous injury severity evaluation system, the unit of transfusion for 24 hours had the strongest correlation with AT-III (R=0.546, p=0.000). The base deficit (R=0.418, p=0.001), the length of ICU stay (R=0.415, p=0,030), the APACHE III (R=0.367, p=0.021), and the RTS (R=0.247, p=0.006) were also correlated with AT-III. A logistic regression showed a strong association between the AT-III level and the mortality rate (mortality rate = 1.067- 0.370 x AT -III, p= 0.004). CONCLUSION: In patients with severe trauma, The serum AT-III level was correlated with the RTS, the APACHE III, the number of transfusion units, the severity of shock, and the length of ICU stay. The serum AT-III level also showed a strong correlation with mortality.

B-type Natriuretic Peptide in Differentiating Acute Dyspnea

PURPOSE: This study was to test the diagnostic value of Btype natriuretic peptide (BNP) for differentiating between the causes of acute dyspnea. METHODS: We conducted a prospective study of 41 patients who came to the emergency department with acute dyspnea between August 1, 2002, and October 31, 2002. Plasma BNP was measured for a bedside assay. We excluded patients who suffered from dyspnea due to airway obstruction, hyperventilation syndrome, psychiatric causes, drug intoxication, and chronic renal failure or from dyspnea of neuromuscular origin. The clinical diagnosis of congestive heart failure was adjudicated by echocardiographic findings. Two emergency physicians, who were blinded to the results of the BNP assay and the echocardiographic findings, determined the cause of dyspnea as regard to the Framingham criteria. RESULTS: The final diagnosis of dyspnea was due to a cardiogenic origin in 29 patients (71%), and due to a noncardiogenic origin in 12 patients (29%). The plasma BNP levels in themselves were more specific and sensitive in diagnosing cardiogenic dyspnea than was a clinical decision based on the authority of the Framingham criteria. In the echocardiographic findings, the left-ventricular end-systolic dimension and the left- ventricular end-diastolic dimension were positively correlated with the plasma BNP levels(R=0.44, p=0.002 and R=0.40, p=0.005), the ejection fraction was negatively correlated (R=-0.46, p=0.001). In the multiple logistic-regression analysis, measurements of the plasma BNP level added significant independent predictive power to other clinical variables in the models. CONCLUSION: The assay of plasma BNP in the emergency department was useful method for differentiating acute dyspnea based on its cause, and the plasma BNP level was corresponded to the degree of left ventricular dysfunction.

Effects of Compression Rate and Compression/Relaxation Ratio on the Hemodynamics of Simultaneous Sterno-Thoracic Cardiopulmonary Resuscitation in the Canine Model of Cardiac Arrest

PURPOSE: This study was designed to determine the compression rate and the compression/relaxation ratio to produce the optimal hemodynamic effect with simultaneous sterno-thoracic cardiopulmonary resuscitation (SST-CPR)and to investigate the mechanism for the blood flow generated by SST-CPR. METHODS: A canine model of ventricular fibrillation was used. Twelve mongrel dogs were divided into two groups. In the first six animals were resuscitated by using SST-CPR with the compression duration varied randomly at 2-minute intervals, 30%, 40%, and 50% of the CPR cycle, at a constant rate of 80/min. In the other six dogs, SST-CPR was performed with a randomly varied compression rate, 60, 80, 100, and 120/minute, at a 50:50 compression/relaxation ratio. RESULTS: During SST-CPR, increasing the compression relaxation ratio from 30:70 to 50:50 increased the end tidal CO2 from 10+/-2 mmHg to 15+/-3 mmHg. Increasing the compression rate from 60 to 100/minute tended to improve the carotid blood flow. CONCLUSION: The maximal hemodynamic effects with SSTCPR was generated when the compression rate was 100/minute and the compression/relaxation ratio was 50:50. A combination of the cardiac and the thoracic pump theories may be the mechanism for the blood flow produced by SST-CPR.

Effect of Standard Cardiopulmonary Resuscitation on Cerebral Blood Flow and Coronary Perfusion Pressure in the Canine Model of Simulated Ventricular Tachycardia

PURPOSE: The purpose of this study was to evaluate the hemodynamic effects of external chest compression in state of the heart's beating. METHODS: Ten mongrel dogs were used in this study. Ventricular tachycardia was simulated by using a rapid ventricular pacing and ventricular rate was adjusted and maintained at the rate necessary to achieve a 50-mmHg fall in the baseline systolic aortic pressure. External chest compression was initiated after 4 minutes of simulated ventricular tachycardia and was continued for 4 minutes. Hemodynamic measurements, including the systolic and the diastolic aortic pressure, the right atrial pressure, the carotid blood flow, and the end tidal CO2 tension, were done at baseline, during the simulated ventricular tachycardia (VT), and during the simulated ventricular tachycardia with external chest compression (VT+ECC). RESULTS: The systolic aortic pressure, the diastolic aortic pressure, and the mean right atrial pressure were higher during VT+ECC than during VT (99+/-12 vs 92+/-8 mmHg, p=0.157, 59+/-8 vs 55+/-12 mmHg, p=0.140, and 23+/-8 vs 8+/-2 mmHg, p<0.001, respectively). The carotid blood flow was higher during VT+ECC than during VT (273+/-203 vs 136+/-76 mL/min., p=0.011). The calculated coronary perfusion pressure was lower during VT+ECC than during VT ( 26+/-8 vs 40+/-9 mmHg, p<0.001). The end tidal CO2 tension was not different between VT+ECC and VT. CONCLUSION: In the canine model of simulated ventricular tachycardia, external chest compression had a contradictory hemodynamic effect, including an increase in the cerebral blood flow and a decrease in the coronary perfusion pressure.