Extended Blood Drug Concentrations in Extended Release Formulated Acetaminophen Overdose Patients

PURPOSE: The Rumack-Matthew nomogram cannot be applied in managing overdose by extended release (ER) preparation acetaminophen (AAP). This study analyzed the clinical characteristics of ER preparation AAP overdose in order to develop a treatment recommendation. METHODS: We retrospectively reviewed the medical records of patients presented to the emergency department as a result of AAP overdose from Jan 2008 to Dec 2010. Only those patients who ingested an ER preparation of AAP were included in the study. Their blood AAP concentrations were measured at 4 and 8 hours after ingestion. Clinical variables related to AAP intoxication were analyzed. RESULTS: Of the total 108 AAP overdose patients identified during the 3-year period, 20 suffered specifically with ER preparation AAP overdose. The mean estimated ingestion amount was 167.5 mg/kg. Treatments including gastric lavage, activated charcoal, and N-acetyl cysteine (NAC) were performed on 10, 14, and 11 patients, respectively. Hepatotoxicity was diagnosed in only one patient who was then successfully treated with NAC. In another case, blood AAP concentration continued to increase until at least 11-hours after ingestion. CONCLUSION: This study suggested that blood AAP concentrations associated with ingestion of ER formulations of AAP, may increase in an extended manner. Therefore, multiple sampling and longer periods between samples assessing AAP blood concentration may be required for incidences of extended release overdose.

Validation of Termination Guidelines for Out of Hospital Cardiac Arrest in Korea

PURPOSE: There have been no studies on the termination of resuscitation (TOR) in Korea. We retrospectively applied TOR rules to OHCA patient data in order to validate the BLS and ALS TOR rules for Korea. METHODS: We collected OHCA (out-of-hospital cardiac arrest) data from 3 hospitals for the period January 1 to December 31, 2009. We then retrospectively applied BLS and ALS TOR rules to this data. We measured both the specificity and positive predictive value for each BLS and ALS TOR rule. RESULTS: The overall rate of survival until hospital discharge was 14.5%. Out of 102 patients who met BLS criteria TOR rules, 8 patients survived until hospital discharge. Out of 52 patients who met ALS criteria TOR rules, 4 patients survived until hospital discharge. The BLS rule had a specificity of 0.57 and a positive predictive value of 0.92. The ALS rule had a specificity of 0.78 and a positive predictive value of 0.92. CONCLUSION: In this study, the BLS and ALS TOR rules had relatively low positive predictive value and were not applicable to patients with low survival probability in Korea.

Educational Effects of CPR Instruction to 1,050 Elementary School Classes using Personal Manikins

PURPOSE: This study was designed to evaluate the educational effects of cardiopulmonary resuscitation (CPR) instruction to elementary school children and the perspectives of students and teachers about such instruction. METHODS: A total of 34,232 5th and 6th grade students from 998 elementary schools were instructed using a two-hour CPR lesson from each school teacher using CPR Anytime(R). The school teachers also were instructed by the same lesson from BLS instructors. Survey questionnaires were distributed to students involved. CPR skills were tested using a checklist during the class. We calculated the multiply effect that how many people were instructed CPR secondarily by student after the lesson and analyzed results by grade and gender. RESULTS: Most students (82%) said that CPR was easy to learn; 81% indicated a willingness to do CPR on a stranger. CPR skills were tested in 11,529 students (34%), and 10,269 (89%) passed. Assessment of respiration was the most commonly omitted procedure. The multiply effect was 1.54, and was higher in the 5th grade and among girls. CONCLUSION: This study suggests that the CPR instruction to 5th or 6th grade students in an elementary school setting is feasible and effective. Although the quality of instruction may be low, the children performed CPR on their family and friends.

Development of Assessment Tools for Performance and Leadership of a Cardiopulmonary Resuscitation Team / 대한구급학회지

BACKGROUND: The assessment tools for leadership and performance of resuscitation teams are have not been developed. We evaluated the checklists for resuscitation team performance and teamwork. METHODS: We developed two checklists for team dynamics (D1, D2) and two checklists for team performances (P1, P2). The videotaped mock resuscitation before and after a 2-hr Advanced Cardiovascular Life Support (ACLS) training were also evaluated by two emergency physicians and two nurses using the four checklists. The validity and agreement between assessors were determined. Internal consistency was determined using Cronbach-alpha. RESULTS: There were no significant differences in scores by expert consensus and the checklist score. The average scores between different assessors were different except for the D1 and D2 between doctors. The Cronbach-alpha for internal consistency were within acceptable ranges in the checklists D2 and P2. CONCLUSIONS: This study suggests that the D2 and P2 checklists are provisionally acceptable due to relatively high validity, agreement, and internal consistency. However, further research is needed to develop validated checklists for resuscitation teams.

Usefulness of Tip-to-Carina Distance as a Marker for Detecting Right Atrium Positioning of a Central Venous Catheter on Chest X-Ray

PURPOSE: Our goal was to check the effect of physique on tip-to-carina (TC) distance for detecting the right atrium (RA) position of a central venous catheter tip, and to determine the optimal cut-off value for TC distance. METHODS: We did a retrospective review of patients who were given chest computed tomography within 12 hours after central venous catheterization (CVC) between September 2005 and February 2009. We used electronic medical records (EMR) and a picture archiving communication system (PACS). TC/height ratio and TC/thoracic width ratio were used as height and thoracic width corrected TC distances. We developed receiver operating characteristic (ROC) curves for TC distance, TC/height and TC/thoracic width, and compared the area under curves (AUCs) of each. An optimal cut-off value for TC distance was obtained using ROC curves. RESULTS: A total of 88 patients were enrolled in our study to determine the optimal cut-off value for TC distance. Of the 88, records for 64 included height, which was required for comparing TC with height and thoracic width corrected TC. AUCs of TC, TC/height, and TC/thoracic width were, respectively, 0.966, 0.962, 0.970. There was no statistically significant differences between them. The cut-off value for TC distance for detecting RA positioning of a CVC is 30 mm (Sensitivity = 100%, Specificity = 85.1%). CONCLUSION: TC distance is a useful marker for detecting RA positioning of a CVC regardless of the patient's height and thoracic width. We suggest 30 mm as the optimal cutoff value for TC distance.

Prospective Multi-center Evaluation and Outcome of Cardiopulmonary Resuscitation for Victims of Out-of-Hospital Cardiac Arrest in Seoul

PURPOSE: To evaluate the quality of prehospital CPR (cardiopulmonary resuscitation) performed by 119 rescue personnel and bystanders in Seoul and to recognize the present problems in the pre-hospital emergency medical service system (EMS). METHODS: We enrolled all patients in cardiac arrest visiting the emergency rooms of 9 university hospitals in Seoul via 119 rescue services from 16 October to 26 November 2006, prospectively investigating the environments in which arrest occurred and the factors associated with CPR. RESULTS: Among 73 patients, the most common place of arrest was in the home(45.2%), CPR by bystander was performed in 8 cases(10.7%), endotracheal intubation by EMS personnel was performed in 10 cases(14.1%). Average time from call to CPR was 11.9 minutes and the number of discharges alive was 3 cases(4.1%). CONCLUSION: To improve the rate of alive discharges, development of CPR education program for lay rescue, education in basic and advanced life support, and management of quality for EMS personnel are needed.

Validity of Transfusing Group O+ Unmatched Packed Red Blood Cells in Hemorrhagic Shock Patients

PURPOSE: It is important to begin a transfusion safely and appropriately as soon as possible in a hemorrhagic shock patient. A group O+ unmatched pack red blood cell (universal O+) transfusion may satisfy that requirement. We report our experiences with universal O+ to compare its usefulness for hemorrhagic shock patients with that of a matched pack red blood cell transfusion in the emergency department (ED). METHODS: This is a retrospective study. Patients who had systolic blood pressure of less than 90 mmHg or a pulse rate of more than 120 beats per minute in the ED were included, and their medical records were reviewed. The collected data were demographic data, vital signs, blood test results, time to transfusion, the amount of transfusion, complications, and diagnoses. We calculated the emergency transfusion score (ETS) based on the patients' medical records. RESULTS: Two hundred thirty-five patients were included. Forty-eight patients (36 trauma and 12 non-trauma patients) were transfused with a universal O+. These patients had less time to transfusion compared with the cross-matched transfusion groups (35+/-42 versus 170+/-187 minutes, p<0.001). There were no differences in complications between groups (p=0.076). Of the patients who were transfused with universal O+, 94.4% got more than 3 ETS. CONCLUSION: The universal O+ transfusion, compared with matched pack red blood cell transfusion, should be a useful treatment for ED hemorrhagic shock patient due to its having a shorter time to transfusion without an increase in complications.

Second-tier Instruction of Cardiopulmonary Resuscitation by CPR Anytime(R) Trainees

PURPOSE: CPR Anytime(R), a self-instructional video program, has gained popularity amongst CPR instructors for training non-healthcare providers. This instructional kit enables second-tier instruction. The purpose of this study is to determine the status of second-tier instruction CPR by CPR Anytime(R) trainees. METHODS: Questionnaires were sent to 606 CPR Anytime(R) trainees from 12 BLS training sites. The training period was from October 2006 to July 2007. Questionnaires included provider's basic information, post-course self exercise, amount of second-tier instruction, and multiplier status. RESULTS: The response rate of the questionnaire was 53.6%(325). The mean age was 20.4+/-10.3 years old. The professions of respondents were as follows: students (76.3%), office workers(13.2%), teachers(4.4%), and service providers(1.9%). The post-course self exercise rate was 49% with three fourths of those completing the exercises using both the DVD and MiniAnne(R). Second-tier instruction tools use rates(48%) were as follows: DVD and manikin(35%), manikin only(9%), verbal only(2%), and DVD only(1%). The total multiplier effect was 1.77(575/ 325) with the multiplier effect of teachers significantly higher than others. CONCLUSION: This study found that 48% of CPR Anytime(R) providers perform second-tier instruction to family and friends. Amongst them, the total multiplier effect was 1.77 (575/325).

Cause, effect and coping skills of stress in physicians and nurses of an emergency department

PURPOSE: The emergency department (ED) has been considered highly stressful environment to work in. However, there has been no study evaluating the stresses endured by emergency staffs in Korea. This study aims to evaluate the cause and effect of stress, and coping methods used by doctors and nurses under stress from working in an emergency department. METHODS: Interns, residents and nurses of an emergency center were given questionnaires that included general health questionnaire (GHQ)-12 scale and modified Holmes & Rahe (HR) scale to examine the cause and effect of stress, and determine the coping methods they used to alleviate stress. A score of greater than 20 in the GHQ-12 scale and greater than 80 in the HR scale were considered as significant for stress. The stress scales were compared among the three groups using analysis of variance and chisquare test. RESULTS: A total of 111 participants consisting of 46 interns, 19 residents, and 46 nurses were surveyed. While the GHQ-12 score showed no difference between groups, the HR score showed significant differences among residents (82.4+/-23.0), nurses (73.6+/-13.2), and interns (70.1+/-17.7). Each stress score did not differ according to the age, gender, marital status, or presence of lover. Most frequently recorede effects of stress were difficulty waking up and fatigue. Most frequent coping methods employed were sleeping and smoking. CONCLUSION: This study suggests that ED staffs, especially residents, were exposed to significant amount of stress.

NEXUS and the Canadian Cervical Spine Rule as a Screening Tool for Computed Tomography Evaluation in Patients with Cervical Spine Injury

PURPOSE: National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian Cervical Spine rule (CCR) are commonly used in cervical trauma patients to determine whether a plain cervical X-ray should be performed. However, plain cervical X-rays are so inaccurate that cervical spine computed tomography (CT) is often considered as a screening test. We studied the usefulness of the NEXUS criteria and the CCR for determining the need for a CT evaluation in the emergency department (ED). METHODS: This prospective observational study was conducted from January 2007 to March 2008. Plain Xray and CT scans of the cervical spine were performed on blunt trauma patients with neck pain. The relevancy of CT was examined using the NEXUS criteria and the CCR. Sensitivity, specificity, positive predicted value, and negative predicted value analyses were performed to diagnose the cervical spine injury. RESULTS: During the study period, 284 patients were enrolled in this study. The sensitivity, specificity, positive predicted value, and negative predicted value of the NEXUS criteria were 87.5%, 1.1%, 5.0%, and 60.0% respectively, while those of the CCR were 87.5%, 8.2%, 5.3%, and 91.6%. There were two missed fracture cases when the NEXUS criteria and the CCR were applied independently, however, no cases were missed when both were applied. CONCLUSION: This study suggests the NEXUS and the CCR in combination can be used as a guide to CT evaluation for cervical spine injury in the ED.

Acetaminophen Poisoning

Acetaminophen (AAP) overdose can result in potentially serious hepatotoxicity. The ingested dose and time from ingestion to presentation are important prognostic factors. Toxic dose in adult is thought to be at least 10 g or 200 mg/kg. However, early management of acute overdose should be guided by the plasma AAP concentration. The antidote for AAP poisoning is N-acetylcysteine (NAC). It provides complete protection against hepatotoxicity if given within 8 h of acute overdose. If the concentration is above the possible toxicity line as predicted by the Rumack-Matthew nomogram, either the 72-hr oral or the 20-hr intravenous NAC regimen should be administered. NAC is also effective if started late in patients with established hepatic failure. This article summarizes the current consensus of clinical assessment and management for acute AAP overdose.

A Lethal Case of Sodium Azide Ingestion

Sodium azide (NaN3) is a white to colorless, crystalline powder that is highly water soluble, tasteless, and odorless. It is used mainly as a preservative in aqueous laboratory reagents and biologic fluids and also as an automobile airbag gas generant. Although it has caused deaths for decades, the toxic properties and effects of sodium azide in humans remains unknown. A 31-year-old comatose female was transported to the emergency department with an empty bottle labeled sodium azide. She developed cardiac arrest 15 minutes after arrival and expired in spite of 30 minutes of resuscitative effort. Subsequently, resuscitation team members incidentally suffered from sodium azide's exposure and developed eye discomfort, skin rashes parasthesias, pruritus, sore throat, and headache.

Comparison of Instructional Methods for Teaching Cardiopulmonary Resuscitation to School Children: CPR Anytime(R) and Little Anne(R)

PURPOSE: We compared the effectiveness of CPR Anytime(R) and Little Anne(R) for instructing schoolchildren in CPR. METHODS: We gave CPR instructions to 774 school children (24 classes) from the fifth to the eighth grade in 12 schools. We randomly selected two classes of the same grade from each school. Each class was given two hours of CPR instruction using either the Korean version of CPR Anytime(R) or Little Anne(R). The number of CPR Anytime(R) per student was 1:1 and Little Anne(R) was 1:6. The lesson consisted of didactic lecture, skill practice, and skill test. We compared the skill performance of students according to the instruction method. RESULTS: Three hundred ninety-seven (51%) students were taught using CPR Anytime(R) and 377 (49%) with Little Anne (R). There was no difference in the compression depth, hand position, adequacy of chest recoil, volume of ventilation, self-confidence, and willingness to do CPR between the two instructional methods. The average compression depth was less than 40~50 mm. Elementary school students showed more confidence and willingness to do CPR than middle school students. CONCLUSION: There was no difference in CPR skill performance after instruction using either Anytime CPR(R) or Little Anne(R).

Accuracy of Automated External Defibrillators During Ambulance Transport: Simulation Study

PURPOSE: Current resuscitation guideline recommends not using the automated external defibrillator (AED) in a running ambulance, because artifact arising from movement of the ambulance can interfere with rhythm analysis of AED and can simulate ventricular fibrillation (VF). This study was conducted to determine whether the AED can be operated correctly in a running ambulance. METHODS: Five AEDs were tested for their sensitivity, specificity, positive/negative predictive value, and accuracy. Each AED was connected to a manikin randomly simulating coarse and fine VF, asystole, and normal sinus rhythm, and each rhythm was analyzed 5 times by AEDs on the highway. Data about the shock recommendation given and delivery time interval from analysis to shock were collected. ECGs were also downloaded during the analysis time for a normal volunteer to search for baseline artifacts. RESULTS: All AEDs recommended shock delivery correctly for the simulated rhythms whether the ambulance was stopped (0 km/h) or running on unpaved road (20 km/h). The sensitivity, specificity, positive/negative predictive value, and accuracy of AEDs on the highway (100 km/h) were similar to those obtained in previous studies on AED performance in pre-hospital settings. The recorded ECG rhythm of a volunteer in a running car showed no baseline artifacts. CONCLUSION: All AEDs recommended shock delivery correctly in a running ambulance. Therefore, the current recommendation of not using the AED on a running ambulance should be reconsidered.

Emergency Procedure Training of Residents Using Lightly Embalmed Cadavers; 3-year Experience

PURPOSE: Emergency procedures are highly dependent on the skill and experience of the physician performing them. Recent advances in light embalming techniques have enabled us to train students on more "realistic" cadavers. The purpose of this study was to report on or 3-year experience with lightly embalmed cadaver-based training and evaluate the student satisfaction with this approach. METHODS: Lightly embalmed cadavers were prepared by the Department of Anatomy. The course was held every March for 3 years. In 2007, we held a 6-hour course for 16 first-year emergency medicine residents from various hospitals. We had procedure and demonstration stations for airway management, tube thoracostomy, central venous catheterization, venous cutdown, pericardiocentesis, intraosseous insertion, open thoracostomy, and lumbar puncture. We evaluated the students' level of satisfaction with the course by giving pre- and post-course evaluations to all students. RESULTS: Based on our experience from the two prior courses, the 2007 curriculum was divided into three parts: didactic lecture, procedure stations and demonstration stations. Pre- and post-course scores were compared for the following: knowledge of the indications and contraindications for the procedures; ability and confidence in performing the procedures; and the ability to perform procedures on actual patients. For 26 items out of a total of 32 items(81.3%), the scores from the post-course evaluation were statistically higher than the scores from the pre-course evaluation. CONCLUSION: Lightly embalmed cadavers are excellent training models for emergency procedures. From our 3-year experience with this method, we were able to develop a training course that was satisfactory to students.

Survey of the Management Systems and Decision-making Process of Emergency Medicine and Psychiatry for Patients Attempting Suicide

PURPOSE: Most patients attempting suicide present to the emergency department (ED). Active post-event intervention is helpful in preventing additional self harm. However, the current management system and decision-making processes of individual doctors are highly variable. This survey aimed to describe the ED management system and to compare the decisions of doctors in emergency medicine and psychiatry for patients for attempting suicide. METHODS: Questionnaires were sent by e-mail to directors of both ED and psychiatry departments in all Korean teaching hospitals. The questionnaires surveyed the current management system for suicidal patients in the ED, the medical director's opinion about the management of suicidal patients, and decisions about disposition of the three clinical scenarios. RESULTS: Sixty-four out of 180 surveys(36%) were returned. The average number of suicidal patients visiting the ED was 13.6 per month and the number referred to a psychiatrist was 11.3 per month. Half of EDs(15/30) had established criteria for patient disposition, but only 7% of ED and 82% of psychiatry departments had practice guidelines for doctors. Only 4% of ED performed any active post-event intervention other than psychiatry out-patient visits. Decisions of emergency physicians and psychiatrists about referring a patient to the psychiatrist in the three clinical scenarios were in part statistically different. CONCLUSION: This study suggests that appropriate facilities and standard guidelines for suicidal patients are needed. Each hospital should develop a common management protocol with collaboration between emergency medicine and psychiatry departments.

Attitudes of Elderly Persons toward Advanced Directives after Providing Prognostic Information on Cardiopulmonary Resuscitation(CPR)

BACKGROUND: Patients who survive CPR are profoundly disabled and live with reduced quality of life. Therefore advanced directives are needed to ensure that life sustaining therapies are provided appropriately. This study compared the attitudes of elderly subjects toward advanced directives for CPR before and after receiving CPR education. METHODS: Between January and July 2007, 99 ambulatory persons aged older than 64 years were recruited from six community welfare facilities for the elderly. A questionnaire was distributed to obtain demographic data and their basic understanding and attitudes toward CPR. After providing information and showing a video clip on CPR, we compared whether having received this information influenced the thoughts of our subjects on CPR. RESULTS: None had had previous education on CPR, including prognostic information. Most overestimated the survival chance after CPR. Most wished to be resuscitated. After providing prognostic information on CPR and showing a short video clip, there was a change in their decision and the knowledge of CPR outcome seemed to influence their thoughts on CPR. In particular, the information on CPR prognosis greatly influenced their decision. CONCLUSION: Elderly people rarely have a chance to receive information regarding CPR. As a result, their decision to receive CPR may not accurately reflect the patient's wishes in emergency circumstances. It is important to pro- vide accurate prognostic information to help the elderly in their life-sustaining treatment decisions.

Selection of Target Age for School Education of Cardiopulmonary Resuscitation Using Video Self-instruction Program

PURPOSE: The effectiveness of teaching cardiopulmonary resuscitation (CPR) in schools is known to be higher among older students. However, several easier programs have been successful even for primary school children. The purpose of this study is to determine the optimal target age for teaching CPR in schools. METHODS: Six classes from the fifth to the tenth grade were randomly selected. A video-based self-instructional program was presented by health teachers in each school using the Korean version of CPR Anytime(TM) during normal school hours. Questionnaires were given after training to determine their degree of confidence in performing CPR, their willingness to perform CPR on a family, a friend, and a stranger, and at what age the children wanted to learn CPR. Skill tests were administered for several volunteer students. One week after the training, the students were asked to what extent they had shared their knowledge of CPR technique with other people. RESULTS: Two hundred one students were given the CPR instruction. The confidence in performing CPR was lowest among seventh grade children. The willingness expressed by the students to perform CPR on a family member, a friend, and a stranger were 99.5%, 95.7% and 58.8%, respectively, with boys in the tenth grade most willing to perform CPR on a stranger. The students responded that it is most suitable to learn CPR at grade 6.4+/-2.4. The highest average skill score of 9.5/11 was for sixth grade. The average distribution rate was 1.23, and again this was highest in sixth grade at 3.72. CONCLUSION: This study suggests that the optimal target school age for CPR education using video-based self instruction may be at approximately the sixth grade.

Analysis of Patients were Transported by 119 Helicopter from Mountain Accident Scenes in Seoul

PURPOSE: Geographic problems can make it difficult for rescue teams to access emergency patients in the mountains. We developed the aeromedical relief program in conjunction with fire department helicopter EMS teams. This study describes the clinical experience of patients transported from the mountains in this program. METHODS: We reviewed the employed protocols and the medical records of patients transported to our hospital from the mountains by the aeromedical transport system from June 2006 to June 2007. RESULTS: Thirty-one patients were transported by helicopter during the study period, most of them (84%) from Mt. Bukhan. The time interval from call for help to hospital arrival was 80+/-56 min, and rescue time alone was 30+/-24 min. Eleven patients (36%) were pronounced dead on arrival, and 11 patients were admitted for management. The number of trauma patients were 24 (77%), who had an average RTS score (excluding the 11 patients who expired before arrival) of 11.7+/-0.6. When the ground team and the aeromedical team were dispatched at the same time, the total transport time was 54.0+/-22.8 min, compared to 133.0 +/-75.7 min when the aeromedical team was dispatched only upon the request of the ground team, a large and statistically significant difference. CONCLUSION: This study suggests that the helicopter transport system can be successfully employed to achieve early access to patients in the mountains. To optimize the current program, cooperation between hospital and the regional helicopter EMS is required.

Cardiac Arrhythmia and Pericardial Effusion During Plasmodium vivax Infection / 감염과화학요법

Plasmodium vivax is a typically seen infectious disease in Korea. The incidence of Plasmodium vivax malaria has been increasing in recent year despite of worldwide attempts at control. Fever, anemia, thrombocytopenia, and splenomegaly are the most common manifestations seen in Korean patient with P. vivax. Cardiac involvement is thought to be a very rare complication of malaria infection. Cardiac complication seems to be limited to acute infection with Plasmodium falcifarum. However we have experienced cardiac complication such as pericardial effusion, and complete AV block by Plasmodium vivax. Physicians should consider cardiac involvement in patient who present hypotension, fever and arrhythmia in malaria endemic area.