Adverse events and preventive measures related to COVID-19 vaccines

The coronavirus disease 2019 (COVID-19) vaccines are categorized according to the manufacturing technique, including mRNA vaccines and adenovirus vector vaccines. According to previous studies, the reported efficacy of the COVID-19 vaccine is excellent regardless of the type of vaccine, and the majority of studies have shown similar results for safety. Most of the adverse reactions after vaccination were mild or moderate grade, and severe reactions were reported in a very small proportion. However, the adverse reactions that might occur after nationwide vaccinations can contribute to crowding of emergency departments, and this can further lead to significant obstacles to providing necessary treatment for life-threatening conditions. Therefore, as emergency physicians, we would like to present some concerns and suggestions to prevent these predictable problems.

Impact of the COVID-19 Outbreak on Emergency Care Utilization in Patients with Acute Myocardial Infarction: a Nationwide Population-based Study

Background@#The coronavirus disease 2019 (COVID-19) pandemic has impacted various aspects of daily living and has influenced the life of every individual in a unique way.Acute myocardial infarction (AMI) is associated with high morbidity and mortality; thus, timely treatment is crucial to prevent poor prognosis. Therefore, an immediate emergency department (ED) visit is required; however, no domestic studies have reported the effect of COVID-19 on ED visits by patients with AMI. Therefore, this study aimed to assess the changes in the pattern of ED visits by patients with AMI by comparing visits during the COVID-19 outbreak period to those during two control periods. @*Methods@#This nationwide, retrospective study used registry data of the National Emergency Department Information System. The ‘outbreak period’ was defined as the period between February 21, 2020 and April 1, 2020, while the ‘control period’ was defined as the same time period in the preceding two years (2018 and 2019). The primary outcome of our study was the number of patients admitted to the ED owing to AMI during the outbreak and control periods. Secondary outcomes were time from symptom onset to ED visit, length of ED stay, and 30-day mortality following admission. @*Results@#During the outbreak period, 401,378 patients visited the ED; this number was lower than that during the control periods (2018: 577,548; 2019: 598,514). The number of patients with AMI visiting the ED was lower during the outbreak period (2,221) than during 2018 (2,437) and 2019 (2,591). @*Conclusion@#The COVID-19 pandemic has caused a reduction in ED visits by patients with AMI. We assume that this could likely be caused by misinterpretation of AMI symptoms as symptoms of respiratory infection, fear of contracting severe acute respiratory syndrome coronavirus 2, and restrictions in accessing emergency medical care owing to overburdened healthcare facilities. This study sheds light on the fact that healthcare and emergency medical staff members must work towards eliminating hurdles due to this pandemic for patients to receive timely emergency care, which in turn will help curb the growing burden of mortality.

Impact of the COVID-19 Outbreak on Emergency Care Utilization in Patients with Acute Myocardial Infarction: a Nationwide Population-based Study

Background@#The coronavirus disease 2019 (COVID-19) pandemic has impacted various aspects of daily living and has influenced the life of every individual in a unique way.Acute myocardial infarction (AMI) is associated with high morbidity and mortality; thus, timely treatment is crucial to prevent poor prognosis. Therefore, an immediate emergency department (ED) visit is required; however, no domestic studies have reported the effect of COVID-19 on ED visits by patients with AMI. Therefore, this study aimed to assess the changes in the pattern of ED visits by patients with AMI by comparing visits during the COVID-19 outbreak period to those during two control periods. @*Methods@#This nationwide, retrospective study used registry data of the National Emergency Department Information System. The ‘outbreak period’ was defined as the period between February 21, 2020 and April 1, 2020, while the ‘control period’ was defined as the same time period in the preceding two years (2018 and 2019). The primary outcome of our study was the number of patients admitted to the ED owing to AMI during the outbreak and control periods. Secondary outcomes were time from symptom onset to ED visit, length of ED stay, and 30-day mortality following admission. @*Results@#During the outbreak period, 401,378 patients visited the ED; this number was lower than that during the control periods (2018: 577,548; 2019: 598,514). The number of patients with AMI visiting the ED was lower during the outbreak period (2,221) than during 2018 (2,437) and 2019 (2,591). @*Conclusion@#The COVID-19 pandemic has caused a reduction in ED visits by patients with AMI. We assume that this could likely be caused by misinterpretation of AMI symptoms as symptoms of respiratory infection, fear of contracting severe acute respiratory syndrome coronavirus 2, and restrictions in accessing emergency medical care owing to overburdened healthcare facilities. This study sheds light on the fact that healthcare and emergency medical staff members must work towards eliminating hurdles due to this pandemic for patients to receive timely emergency care, which in turn will help curb the growing burden of mortality.

Adverse events and preventive measures related to COVID-19 vaccines

The coronavirus disease 2019 (COVID-19) vaccines are categorized according to the manufacturing technique, including mRNA vaccines and adenovirus vector vaccines. According to previous studies, the reported efficacy of the COVID-19 vaccine is excellent regardless of the type of vaccine, and the majority of studies have shown similar results for safety. Most of the adverse reactions after vaccination were mild or moderate grade, and severe reactions were reported in a very small proportion. However, the adverse reactions that might occur after nationwide vaccinations can contribute to crowding of emergency departments, and this can further lead to significant obstacles to providing necessary treatment for life-threatening conditions. Therefore, as emergency physicians, we would like to present some concerns and suggestions to prevent these predictable problems.

Analysis of Characteristics in Children and Adolescents with Poisoning at Emergency Department

PURPOSE: This study was conducted to analyze the features of poisoning in individuals aged 0-18 years to understand the characteristics of potential victims and eventually prevent poisoning. METHODS: We retrospectively analyzed poisoned children and adolescents (0–18 years) who visited the emergency department of one tertiary hospital from January 2003 through December 2013. We collected data including their age, sex, reason for poisoning, components and dose of poison, results of treatment, and psychiatric diagnosis. RESULTS: During the study period, there were 436 cases of poisoning (male 47.2% (n=206); female 52.8% (n=230)). Subjects were classified into four groups (0–1 years, 2–5 years, 6–12 years, 13–18 years). The most common cause of poisoning in all age groups was accidental poisoning (72.9%), but intentional poisoning increased as age increased (p < 0.001). Moreover, females were more often subject to intentional poisoning than males (p < 0.001). The most common poisoning material was drugs (41.7%). Among intentional poisoning patients, 62.7% patients had consulted a psychiatrist, and their most common diagnosis was adjustment disorder (44.6%). CONCLUSION: The most common cause of poisoning in individuals aged 0–18 years was accidental poisoning, while intentional poisoning was most common among adolescents. Guardians should take care to prevent accidental poisoning, while psychiatric consultation and national moderation will be needed to prevent intentional poisoning.

Indication of Hospitalization by Comparing Admission Group with Non-admission Group in Influenza: An Observatory Study at a Single Regional Emergency Medical Center

PURPOSE: Influenza is a self-limiting acute respiratory disease, but can be complicated by pneumonia, encephalitis, or myocarditis. If diagnosed, symptomatic treatment of upper respiratory symptoms, early initiation of antiviral therapy, and careful observation of complication occurrence is vital. However, admission of influenza patients can increase the risk of in-hospital infection to previously admitted patients. For this reason, admission or discharge criteria are required. METHODS: This was a retrospective observational study. The characteristics of hospitalized cases were compared with those of discharged cases. Medical records from November 1, 2013 to February 28, 2014 were reviewed and the patient characteristics, clinical symptoms and signs, and other clinical variables were analyzed. RESULTS: A total of 242 patients who showed positive RAT and underwent laboratory and radiologic testing were enrolled in this study. Among them, 203 patients were discharged from the ER and 39 patients were hospitalized, 32 patients in GW and 7 patients in ICU. In the hospitalized group, compared to the discharged group, the average age, complaint of dyspnea, incidence of leukocytosis, level of ESR and CRP, incidence of hypoxemia, and incidence of acute lesion on chest x-ray was high with statistical significance. CONCLUSION: Admission would be considered for patients with ILI with the findings mentioned above.

The Measurement of Korean Pediatric Subglottic Transverse Diameter Using Computed Tomography Imaging and Validation of the Formulas for the Appropriate Cuffed Endotracheal Tube

PURPOSE: It has been established that the subglottic transverse diameter (SD-T) is the narrowest portion of the pediatric airway. In this study, we aimed to measure SD-T using computed tomography (CT) among Korean pediatrics, and compare and verify the measured SD-T with several formulas for appropriate size of the cuffed endotracheal tube (ETT) in pediatrics. METHODS: This is a retrospective study of 364 children from 0 month to 10 years undergoing facial CT scan. The CT scans were performed in children with spontaneous respiration. We obtained SD-T by these CT scans, and compared them with the Motoyama's formula [internal diameter (ID, mm)=(age/4)+3.5], the formula by Khine et al [ID (mm)= (age/4)+3.0], and the formula by Kim et al [outer diameter (OD, mm)=0.01×age (month)+0.02×height (cm)+3.3]. The obtained ID by these formulas was converted to correspond with OD. RESULTS: SD-T had a strong association with age (Estimate=0.029, R²=0.853, p<0.001), weight (Estimate=0.108, R²=0.698, p<0.001), and height (Estimate=0.048, R²=0.854, p<0.001), according to a linear regression analysis. There was no difference of SD-T between males and females (p=0.636). The intraclass coefficients of OD by the Motoyama's formula and the formula by Khine et al with OD of the cuffed ETT by measured SD-T were high (0.910, p<0.001, 0.897, p<0.001). CONCLUSION: Age based formulas for the appropriate cuffed ETT could be sufficient for emergency endotracheal intubation in Korean pediatrics.

The Utility of CRP Velocity for the Prognostication in Patients with Acute Pyelonephritis

PURPOSE: C-reactive protein (CRP) velocity is value of the CRP level divided by the time after fever start. The aim of this study was to attempt to determine the usefulness of CRP velocity to predict the severity of acute pyelonephritis (APN). METHODS: We retrospectively reviewed medical records of patients who visited the emergency department (ED) and were diagnosed with APN for five years. The patients underwent computed tomography (CT) in the ED. The characteristics and laboratory findings compared with the CT group were classified from group I to group V as severity of APN. The patients were grouped according to mild and severe based on the CT groups for comparison of area under the curve. Patients who had fever within 24 hours were extracted and the same analysis was performed. RESULTS: A total of 199 patients were enrolled in our study. The CT groups were classified as follows: group 1 (N=24); group 2 (N=25); group 3 (N=80); group 4 (N=58); group 5 (N=12). Statistically significant differences in laboratory results including CRP, CRP velocity, age, and past history of hypertension were found between mild and severe group. The area under ROC curve of CRP and CRP velocity was 0.888 and 0.841 (p<0.05). For APN patients within 24 hours, AUROC of CRP and CRP velocity were 0.871 and 0.949 (p<0.05). However, AUROC comparison did not show statistically significant differences within CRP and CRP velocity (p=0.1410). CONCLUSION: In APN patients who had fever within 24 hours, CRP and CRP velocity had predictive value for severity of APN.

What is the Clinical Significance of Cerebrospinal Fluid Biomarkers in Parkinson's disease? Is the Significance Diagnostic or Prognostic?

The clinical diagnostic criteria of Parkinson's disease (PD) have limitations in detecting the disease at early stage and in differentiating heterogeneous clinical progression. The lack of reliable biomarker(s) for early diagnosis and prediction of prognosis is a major hurdle to achieve optimal clinical care of patients and efficient design of clinical trials for disease-modifying therapeutics. Numerous efforts to discover PD biomarkers in CSF were conducted. In this review, we describe the molecular pathogenesis of PD and discuss its implication to develop PD biomarkers in CSF. Next, we summarize the clinical utility of CSF biomarkers including alpha-synuclein for early and differential diagnosis, and prediction of PD progression. Given the heterogeneity in the clinical features of PD and none of the CSF biomarkers for an early diagnosis have been developed, research efforts to develop biomarkers to predict heterogeneous disease progression is on-going. Notably, a rapid cognitive decline followed by the development of dementia is a risk factor of poor prognosis in PD. In connection to this, CSF levels of Alzheimer's disease (AD) biomarkers have received considerable attention. However, we still need long-term longitudinal observational studies employing large cohorts to evaluate the clinical utility of CSF biomarkers reflecting Lewy body pathology and AD pathology in the brain. We believe that current research efforts including the Parkinson's Progression Markers Initiative will resolve the current needs of early diagnosis and/or prediction of disease progression using CSF biomarkers, and which will further accelerate the development of disease-modifying therapeutics and optimize the clinical management of PD patients.

A Case of Saponated Cresol Ingestion which Led to Altered Mentality, Chemical Dermal Burn, and Liver Toxicity

Saponated cresol solutions are common household disinfectants worldwide. Their main component, concentrated cresol, is extremely toxic and fatal; however, precise information on the clinical manifestations of cresol intoxication is not available. We report on a case of suicidal poisoning by ingestion of saponated cresol. A 63-year-old male presented with unconsciousness and brownish discoloration on the neck and anterior chest wall after ingesting 100 ml of 50% saponated cresol solution with suicidal attempt. The patient showed a wide range of clinical features of cresol intoxication, including decreased consciousness, respiratory distress, strong carbolic acid odor, dark brown urine, and chemical dermal burns on multiple areas. General treatment of cresol intoxication is intensive supportive care. In addition, reducing systemic absorption is most important in patients with cresol intoxication who present with cresol burns. Because the rate of cresol absorption through the skin is proportional to the size of the area involved and the duration of contact of the chemical with the skin rather than to the concentration of the cresol solution, gross decontamination, including removal of contaminated clothing and vigorous flushing with water, is very important. Quantitative assays for cresol and its metabolites in blood or urine are needed in order to confirm the diagnosis. However, because these analytical methods are time consuming and are not routinely available in most emergency departments, the clinical manifestations of this case may be useful in early diagnosis and treatment.

A Case of Saponated Cresol Ingestion which Led to Altered Mentality, Chemical Dermal Burn, and Liver Toxicity

Saponated cresol solutions are common household disinfectants worldwide. Their main component, concentrated cresol, is extremely toxic and fatal; however, precise information on the clinical manifestations of cresol intoxication is not available. We report on a case of suicidal poisoning by ingestion of saponated cresol. A 63-year-old male presented with unconsciousness and brownish discoloration on the neck and anterior chest wall after ingesting 100 ml of 50% saponated cresol solution with suicidal attempt. The patient showed a wide range of clinical features of cresol intoxication, including decreased consciousness, respiratory distress, strong carbolic acid odor, dark brown urine, and chemical dermal burns on multiple areas. General treatment of cresol intoxication is intensive supportive care. In addition, reducing systemic absorption is most important in patients with cresol intoxication who present with cresol burns. Because the rate of cresol absorption through the skin is proportional to the size of the area involved and the duration of contact of the chemical with the skin rather than to the concentration of the cresol solution, gross decontamination, including removal of contaminated clothing and vigorous flushing with water, is very important. Quantitative assays for cresol and its metabolites in blood or urine are needed in order to confirm the diagnosis. However, because these analytical methods are time consuming and are not routinely available in most emergency departments, the clinical manifestations of this case may be useful in early diagnosis and treatment.

Serotonin Syndrome After an Overdose of Dextromethorphan and Chlorpeniramine: Two Case Reports

Dextromethorphan and chlorpeniramine are common ingredients of over-the-counter (OTC) cough pills. They are known to be safe when used alone, however, combination with other serotonergic drugs or use of an overdose can cause serotonergic toxicity. We report on a 43-year-old male and a 57-year-old female who ingested an overdose of antitussive drugs containing dextromethorphan and chlorpeniramine. They commonly presented with altered mentality and hyperreflexia on both upper and lower extremities. After conservative therapies, they were discharged with alert mentality. These cases are meaningful in that there are few cases of serotonin syndrome with an overdose of a combination of dextromethorphan and chlorpeniramine. Careful use with medication counseling for OTC cough pills is needed in order to prevent overdose of these ingredients.

A Case of Central Nervous System (CNS) Toxicity in Acute Organophosphate Intoxication

Acute organophosphate intoxication is important because of its high morbidity and mortality. The mortality is still high despite the use of atropine as specific antidotal therapy and oximes for reactivation of acetylcholinesterase. Inhibition of acetylcholinesterase by organophosphate can cause acute parasympathetic system dysfunction, muscle weakness, seizure, coma, and respiratory failure. Acute alteration in conscious state or a coma, which may occur following organophosphate intoxication, is an indication of severe intoxication and poorer prognosis. This acute decline in conscious state often reverses when the cholinergic crisis settles; however, it may be prolonged in some patients. We report on a case of a 60-year-old male who showed prolonged decline in conscious state due to of Central Nervous System (CNS) toxicity after a suicide attempt with organophosphate.

Two Cases of Ethylene Glycol Poisoning

Ethylene glycol poisoning is treated mainly by alcohol dehydrogenase inhibition therapy and hemodialysis. Early recognition and initiation of treatment is important because toxic metabolites increase over time by hepatic metabolism; however, there is no confirmative diagnostic tool in our clinical setting. Therefore, diagnosis is dependent on history, high anion gap acidosis, high osmolal gap, etc.. Diagnosis and treatment are delayed in cases where history taking is not possible, such as a mental changed patient. Authors report on two cases of ethylene glycol poisoning by contrasting clinical outcomes, demonstrating the importance of early diagnosis and treatment for achievement of a good outcome.

A Case of Delayed Carbon Monoxide Encephalopathy

Following are brief statements about the delayed encephalopathy of a patient who recovered without disturbance of consciousness after acute carbon monoxide poisoning. A 72-year-old male was found without consciousness at home and then visited the ER center. Later we learned that the patient was using briquettes as a household heating source. Blood carbon monoxide hemoglobin level was 17.5%. As carbon monoxide poisoning was uncertain after the first interview with the patient, hyperbaric oxygen therapy was not administered at the early stage. After supplying 100% oxygen, the patient recovered consciousness, however, the strength of the lower limb muscle had decreased to class II. The patient showed continued weakening of the lower limb muscle and an increase of CPK; therefore, he was diagnosed as carbon monoxide intoxication and rhabdomyolysis and then admitted to the intensive care unit (ICU) for conservative treatment. During the hospitalization period, continued weakening of the lower limb muscle was observed and he was diagnosed as myopathy after EMG/MCV. However, he suddenly showed altered mentality on the 20th day of hospitalization, and underwent brain MRI. T2 weighted MRI showed typically high signal intensity of both globus pallidus and periventricular white matter; therefore, he was diagnosed as delayed carbon monoxide encephalopathy. This case showed delayed encephalopathy accompanied by rhabdomyolysis and myopathy of a patient who recovered without disturbance of consciousness.

A Case of Fentanyl Toxicity with Misused Durogesic Transdermal Patch

Fentanyl, a synthetic, highly selective opioid micro-receptor agonist, is 50 to 100 times more potent than morphine. The low molecular weight, high potency, great transdermal permeation rate and lipid solubility of fentanyl make it very suitable for transdermal administration. Durogesic is a novel matrix transdermal system providing continuous systemic delivery of fentanyl. In recently, there are many reports that misused or overused fentanyl transdermal patches result in severe intoxication of fentanyl. We present a case of fentanyl toxicity with misused durogesic transdermal patch and discuss the safe and appropriate application of the patches. In conclusion, fentanyl patches should be used in opioid tolerant patients and prescribed at the lowest possible dose and titrated upward as needed. All patients and their caregivers should be educated safe application of fentanyl patches and advised to avoid exposing the patches application site to direct external heat sources, such as heating pads, or electric blankets, heat lamps, sauna, hot tubs, and others. In addition, concomittant medications that affect fentanyl's metabolism should be avoided.

The Clinical Feature and Prognostic Factor of Glyphosate Intoxication Patients

PURPOSE: Glyphosate is widely used and its toxic exposures are not rare. Occasionally, glyphosate intoxication can lead to death. The aim of this study is to analyze clinical findings and fatality in glyphosate intoxication. METHODS: Clinical data on acute glyphosate intoxication were prospectively collected at 28 hospitals nationwide between August 2005 and July 2006. The patients' clinical symptoms and characteristics of fatalities were investigated and statistical analysis was performed. RESULTS: Among 105 patients who were finally included, gastrointestinal symptoms(59%) were the most common. A significant difference in the amount ingested was observed between patients with higher systolic blood pressure and those with systolic blood pressure less than or equal to 80 mmHg (p<0.001). The more the patients ingested, the more aggravated their mental status became (p=0.004). Seven patients(6.7%) died, and all of them had ingested greater than or equal to 200 ml. Patients who died had ingested greater amounts than the survivors (p<0.001), and their mental status was worse (p<0.001), and systolic blood pressure was lower (p<0.001). According to the result of logistic regression analysis, relative risk was 24.1-fold higher in the 'poor' mental status group compared with 'good'. CONCLUSION: Patients who ingested large amounts of glyphosate showed poor mental status and lower blood pressure. Statistical difference in amount ingested, mental status, and systolic blood pressure was observed between survivors and patients who died. Ingested amounts and mental status were the most important factor of the prognosis of glyphosate intoxication.

An Evaluation of the Disaster Medical System after an Accident which Occurred after a Bus fell off the Incheon Bridge

PURPOSE: Field triage, medical care, and transportation are important and life-saving medical tasks performed at the site of a mass-casualty incident (MCI). We experienced a mass-casualty incident when an express bus fell off the Incheon bridge and conducted an evaluation of problems. We are willing to provide information for equipping an local disaster planning. METHODS: We surveyed the local emergency medical system response time, transportation time, and patients' clinical data using paramedics' records and medical records. We evaluated the adequacy of the order of priority of transportation by field triage used using the simple triage and rapid treatment (START) method. We evaluated field medical care, as well preponderance of transportation. RESULTS: Twenty four people who were on the bus were evacuated, and 2 persons were dead on the scene. Two persons died within one week. There was a transport delay for patients who would benefit significantly from medical intervention because dead persons were transported early. Neither advanced airway nor fluid resuscitation was provided. Sixteen patients (66.7%) were transported to one hospital. CONCLUSION: When we reviewed this mass-casualty incident, there was no appropriate medical control, such as triage, field medical care, and transportation. In construction of the emergency medical service system for preparation for MCI or disasters, we suggest integration and unification of 119 rescue services and emergency medical information centers for effective medical control. Disaster drills should be performed according to guidelines for local emergency medical services.

A Case of Multi-organ Failure due to Acute Chromic Acid Poisoning

Chromic acid is a strong metal acid and acute poisoning is very rare. However, chromic acid causes serious complications, such as skin injuries, as well as renal and hepatic failure. We report on a case of a 47-year-old male who accidentally had chromic acid spilled over his nose and face. For the first few days, he was treated with ascorbic acid and massive hydration. However, after three days, his condition began to worsen. He was treated with hemodialysis for anuria and acute renal failure, and antibiotics for pneumonia. On day 10 of hospitalization, he expired of multi-organ failure. We suggest firm control and close supervision of chromic acid in the work place, and, considering severe complications of chromic acid, we propose a nearly and aggressive treatment.

The Clinical Relationship between Intraocular Pressure and Brain Hemorrhage

PURPOSE: Rapid and noninvasive detection of increased intracranial pressure (IICP) is important in evaluating a clinically unstable, unconscious patient. The purpose of this study was to measure the mean intraocular pressure (IOP) of patients with intracranial hemorrhage and correlate the results to the variable clinical features associated with intracranial hemorrhage. METHODS: Patients admitted to the emergency department were sorted into two groups based on their IOP results as measured using a Tono-Pen. The hemorrhage group consisted of patients suffering with intracranial hemorrhage and the normal group consisted of patients without intracranial hemorrhage. Patients with glaucoma or trauma of the ocular or facial area were excluded from this study. RESULTS: Mean IOP (30.45+/-9.13 mmHg) of the hemorrhage group (52 patients, 34 male, 18 female, mean age 58.28+/-14.39 years) was higher than the mean IOP (16.14+/-2.24 mmHg) of the normal group (39 patients, 23 male, 16 female, mean age 52.69+/-17.79 years) (p<0.001). Whether or not the intracranial hemorrhage was traumatic or nontraumatic, severe, or mild to moderate, accompanied with IICP or non-IICP, requiring an emergency or non-emergency operation, the IOP measured did not show any statistical significance. CONCLUSION: The IOP of the hemorrhage group was higher than the IOP of the normal group, but to determine the clinical usefulness of this measurement when accompanying presentation of headache or traumatic brain injury in the emergency department will require further investigation.