Poison severity score and sequential organ failure assessment score: Carbon monoxide poisoning prognosis.

PURPOSE: We aimed to examine the utility of the Poison Severity Score (PSS) and Sequential Organ Failure Assessment (SOFA) score as early prognostic predictors of short-term outcomes in patients with carbon monoxide (CO) poisoning. We hypothesized that both the PSS and the SOFA score would be useful prognostic tools. METHODS: This was retrospective observational study of patients with CO poisoning who presented to the emergency department and were admitted for more than 24 hours. We calculated PSS, the initial SOFA score, a second (2nd) SOFA score, and a 24-hour delta SOFA score. The primary outcome was reported as the cerebral performance category (CPC) scale score at discharge. We classified those with CPC 1-2 as the good outcome group and those with CPC 3-5 as the poor outcome group. RESULTS: This study included 192 patients: 174 (90.6%) belonged to the good outcome group, whereas 18 (9.4%) belonged to the poor outcome group. The PSS (1.00 [0.00, 1.00] vs 3.00 [3.00, 3.00], p < 0.001), initial SOFA (1.00 [0.00, 2.00] vs 4.00 [3.25, 6.00], p < 0.001), 2nd SOFA score (0.00 [0.00, 1.00] vs 4.00 [3.00, 7.00], p < 0.001), and 24-hour delta SOFA score (-1.00 [-1.00, 0.00] vs 0.00 [-1.00, 1.00], p = 0.047) of the good outcome group were significantly higher than those of the poor outcome group. The areas under the receiver operating characteristic curve for PSS and the initial SOFA and 2nd SOFA scores were 0.977 (95% confidence interval [CI] 0.944-0.993), 0.945 (95% CI 0.903-0.973), and 0.978 (95% CI 0.947-0.994), respectively. CONCLUSION: The PSS, initial SOFA score, and 2nd SOFA score predict acute poor outcome accurately in patients with CO poisoning.

Usefulness of ultrasonography for the evaluation of catheter misplacement and complications after central venous catheterization.

Objective: To assess whether ultrasonographic examination compared to chest radiography (CXR) is effective for evaluating complications after central venous catheterization. Methods: We performed a prospective observational study. Immediately after central venous catheter insertion, we asked the radiologic department to perform a portable CXR scan. A junior and senior medical resident each performed ultrasonographic evaluation of the position of the catheter tip and complications such as pneumothorax and pleural effusion (hemothorax). We estimated the time required for ultrasound (US) and CXR. Results: Compared to CXR, US could equivalently identify the catheter tip in the internal jugular or subclavian veins (P=1.000). Compared with CXR, US examinations conducted by junior residents could equivalently evaluate pneumothorax (P=1.000), while US examinations conducted by senior residents could also equivalently evaluate pneumothorax (P=0.557) and pleural effusion (P=0.337). The required time for US was shorter than that for CXR (P<0.001). Conclusion: Compared to CXR, US could equivalently and more quickly identify complications such as pneumothorax or pleural effusion.

A Case of Methemoglobinemia Successfully Treated with Hyperbaric Oxygenation Monotherapy.

BACKGROUND: Methylene blue is the first-line therapy for methemoglobinemia, but it can be intermittently unavailable due to production issues. For this clinical scenario, alternative treatment options need to be explored. Hyperbaric oxygenation (HBO) is conventionally applied as an adjunctive therapy during the systemic administration of methylene blue. Currently, little is known regarding the effects of HBO monotherapy in methemoglobinemia. We report a case of methemoglobinemia that was successfully treated with HBO monotherapy. CASE REPORT: A 41-year-old man presented to the Emergency Department with dyspnea and dizziness subsequent to smoking in a garage filled with motor vehicle exhaust gas. There were no abnormal heart or lung sounds. While administering oxygen flowing at 15 L/min via a mask with a reservoir bag, blood tests revealed high methemoglobin (MetHb) levels at 59.6%. He was treated with HBO monotherapy, and sequential tests showed that the MetHb level decreased significantly to 34.0%, 12.8%, 6.2%, and eventually, 3.5%. He was discharged with stable vital signs the next day. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: HBO monotherapy is an effective alternative treatment for methemoglobinemia when methylene blue is not available.

Recombinant Activated Factor VII as a Second Line Treatment for Postpartum Hemorrhage.

BACKGROUND: Severe or massive postpartum hemorrhage (PPH) has remained a leading cause of maternal mortality for decades across the world and it results in critical obstetric complications. Recombinant activated factor VII (rFVIIa) has emerged as a gold standard adjunctive hemostatic agent for the treatment of life-threatening PPH refractory to conventional therapies although it remains off-licensed for use in PPH. We studied the effects of rFVIIa on coagulopathy, transfusion volume, prognosis, severity change in Korean PPH patients. METHODS: A retrospective review of medical records between December 2008 and March 2011 indicating use of rFVIIa in severe PPH was performed. We compared age, rFVIIa treatment, transfusion volume, and Sequential Organ Failure Assessment (SOFA) score at the time of arrival in the emergency department and after 24 hours for patients whose SOFA score was 8 points or higher. RESULTS: Fifteen women with SOFA score of 8 and above participated in this study and eight received rFVIIa administration whereas seven did not. Patients' mean age was 31.7 ± 7.5 years. There was no statistically significant difference in initial and post-24 hours SOFA scores between patients administered rFVIIa or not. The change in SOFA score between initial presentation and after 24 hours was significantly reduced after rFVIIa administration (P = 0.016). CONCLUSIONS: This analysis aimed to support that the administration of rFVIIa can reduce the severity of life-threatening PPH in patients. A rapid decision regarding the administration of rFVIIa is needed for a more favorable outcome in severe PPH patients for whom there is no effective standard treatment.

Factors affecting the urologist's decision to administer ureteral stone therapy: a retrospective cohort study.

OBJECTIVE: We aimed to evaluate the factors influencing treatment option selection among urologists for patients with ureteral stones, according to the stone diameter and location. METHODS: We retrospectively reviewed the records of 360 consecutive patients who, between January 2009 and June 2014, presented to the emergency department with renal colic and were eventually diagnosed with urinary stones via computed tomography. The maximal horizontal and longitudinal diameter and location of the stones were investigated. We compared parameters between patients who received urological intervention (group 1) and those who received medical treatment (group 2). RESULTS: Among the 360 patients, 179 (49.7%) had stones in the upper ureter and 181 (50.3%) had stones in the lower ureter. Urologic intervention was frequently performed in cases of upper ureteral stones (P<0.001). In groups 1 and 2, the stone horizontal diameters were 5.5 mm (4.8 to 6.8 mm) and 4.0 mm (3.0 to 4.6 mm), stone longitudinal diameters were 7.5 mm (6.0 to 9.5 mm) and 4.4 mm (3.0 to 5.5 mm), and ureter diameters were 6.4 mm (5.0 to 8.0 mm) and 4.7 mm (4.0 to 5.3 mm), respectively (P<0.001). The cut-off values for the horizontal and longitudinal stone diameters in the upper ureter were 4.45 and 6.25 mm, respectively (sensitivity 81.3%, specificity 91.4%); those of the lower ureter were 4.75 and 5.25 mm, respectively (sensitivity 79.4%, specificity 79.4%). CONCLUSION: The probability of a urologic intervention was higher for patients with upper ureteral stones and those with stone diameters exceeding 5 mm horizontally and 6 mm longitudinally.

Transthoracic echocardiogram in syncope patients with normal initial evaluation.

OBJECTIVES: Despite the low diagnostic yield of echocardiogra0, it is often used in the evaluation of syncope. This study determined whether patients without abnormalities in the initial evaluation benefit from transthoracic echocardiogram (TTE) and the clinical factors predicting an abnormal TTE. METHODS: This study enrolled 241 patients presenting to the emergency department with syncope. The TTE results were analyzed based on risk factors suggesting cardiogenic syncope in the initial evaluation. RESULTS: Of the 115 patients with at least one risk factor, 97 underwent TTE and 27 (27.8%) had TTE abnormalities. In comparison, of the 126 patients without risk factors, 47 underwent TTE and only 1 (2.1%) had TTE abnormalities. Significantly different factors between patients with normal and abnormal TTE findings were entered in a multiple logistic regression analysis, which yielded age [adjusted odds ratio (aOR), 1.09; 95% CI, 1.02-1.15; p=0.006], an abnormal electrocardiogram (ECG) (aOR, 7.44; 95% CI, 1.77-31.26; p=0.010), and a brain natriuretic peptide (BNP) level of >100pg/mL (aOR, 2.64; 95% CI, 1.21-5.73; p=0.011) as independent predictors of TTE abnormalities. The cutoff value of age predicting an abnormal TTE was 59.0years (area under the curve, 0.777; p<0.001). CONCLUSION: A patient who is older than 59years or has an abnormal ECG or an elevated BNP level may benefit from TTE. Otherwise, TTE should be deferred in patients with no risk factors in the initial evaluation.

Comparison between an instructor-led course and training using a voice advisory manikin in initial cardiopulmonary resuscitation skill acquisition.

OBJECTIVE: We compared training using a voice advisory manikin (VAM) with an instructor-led (IL) course in terms of acquisition of initial cardiopulmonary resuscitation (CPR) skills, as defined by the 2010 resuscitation guidelines. METHODS: This study was a randomized, controlled, blinded, parallel-group trial. We recruited 82 first-year emergency medical technician students and distributed them randomly into two groups: the IL group (n=41) and the VAM group (n=37). In the IL-group, participants were trained in "single-rescuer, adult CPR" according to the American Heart Association's Basic Life Support course for healthcare providers. In the VAM group, all subjects received a 20-minute lesson about CPR. After the lesson, each student trained individually with the VAM for 1 hour, receiving real-time feedback. After the training, all subjects were evaluated as they performed basic CPR (30 compressions, 2 ventilations) for 4 minutes. RESULTS: The proportion of participants with a mean compression depth ≥50 mm was 34.1% in the IL group and 27.0% in the VAM group, and the proportion with a mean compression depth ≥40 mm had increased significantly in both groups compared with ≥50 mm (IL group, 82.9%; VAM group, 86.5%). However, no significant differences were detected between the groups in this regard. The proportion of ventilations of the appropriate volume was relatively low in both groups (IL group, 26.4%; VAM group, 12.5%; P=0.396). CONCLUSION: Both methods, the IL training using a practice-while-watching video and the VAM training, facilitated initial CPR skill acquisition, especially in terms of correct chest compression.

Optimal chest compression rate in cardiopulmonary resuscitation: a prospective, randomized crossover study using a manikin model.

OBJECTIVES: When performing cardiopulmonary resuscitation (CPR), the 2010 American Heart Association guidelines recommend a chest compression rate of at least 100 min, whereas the 2010 European Resuscitation Council guidelines recommend a rate of between 100 and 120 min. The aim of this study was to examine the rate of chest compression that fulfilled various quality indicators, thereby determining the optimal rate of compression. METHODS: Thirty-two trainee emergency medical technicians and six paramedics were enrolled in this study. All participants had been trained in basic life support. Each participant performed 2 min of continuous compressions on a skill reporter manikin, while listening to a metronome sound at rates of 100, 120, 140, and 160 beats/min, in a random order. Mean compression depth, incomplete chest recoil, and the proportion of correctly performed chest compressions during the 2 min were measured and recorded. RESULTS: The rate of incomplete chest recoil was lower at compression rates of 100 and 120 min compared with that at 160 min (P=0.001). The numbers of compressions that fulfilled the criteria for high-quality CPR at a rate of 120 min were significantly higher than those at 100 min (P=0.016). CONCLUSION: The number of high-quality CPR compressions was the highest at a compression rate of 120 min, and increased incomplete recoil occurred with increasing compression rate. However, further studies are needed to confirm the results.

Emergency coronary angiography in out-of-hospital cardiac arrest patients without STEMI.

Current guideline recommends that immediate coronary angiography (CAG) should be considered in all postcardiac arrest patients in whom acute coronary syndrome is suspected. In the setting of out-of-hospital cardiac arrest (OHCA), obtaining clinical data such as chest discomfort and medical diseases associated with acute coronary syndrome can be difficult. Therefore, emergency physicians depend on electrocardiographic findings after return of spontaneous circulation (ROSC) when they have to decide whether emergency CAG should be performed. In clinical practice, the usefulness of emergency CAG evaluation of OHCA patients without ST-segment elevation myocardial infarction is debatable. We describe 2 OHCA patients who did not exhibit ST-segment elevation after ROSC and received underwent emergency CAG.

Does cardiac catheterization laboratory activation by electrocardiography machine auto-interpretation reduce door-to-balloon time?

OBJECTIVES: In an attempt to begin ST-segment elevation myocardial infarction (STEMI) treatment more quickly (referred to as door-to-balloon [DTB] time) by minimizing preventable delays in electrocardiogram (ECG) interpretation, cardiac catheterization laboratory (CCL) activation was changed from activation by the emergency physician (code heart I) to activation by a single page if the ECG is interpreted as STEMI by the ECG machine (ECG machine auto-interpretation) (code heart II). We sought to determine the impact of ECG machine auto-interpretation on CCL activation. METHODS: The study period was from June 2010 to May 2012 (from June to November 2011, code heart I; from December 2011 to May 2012, code heart II). All patients aged 18 years or older who were diagnosed with STEMI were evaluated for enrollment. Patients who experienced the code heart system were also included. Door-to-balloon time before and after code heart system were compared with a retrospective chart review. In addition, to determine the appropriateness of the activation, we compared coronary angiography performance rate and percentage of STEMI between code heart I and II. RESULTS: After the code heart system, the mean DTB time was significantly decreased (before, 96.51 ± 65.60 minutes; after, 65.40 ± 26.40 minutes; P = .043). The STEMI diagnosis and the coronary angiography performance rates were significantly lower in the code heart II group than in the code heart I group without difference in DTB time. CONCLUSION: Cardiac catheterization laboratory activation by ECG machine auto-interpretation does not reduce DTB time and often unnecessarily activates the code heart system compared with emergency physician-initiated activation. This system therefore decreases the appropriateness of CCL activation.

A 10-s rest improves chest compression quality during hands-only cardiopulmonary resuscitation: a prospective, randomized crossover study using a manikin model.

OBJECTIVES: This study was designed to assess changes in cardiopulmonary resuscitation (CPR) quality and rescuer fatigue when rescuers are provided with a break during continuous chest compression CPR (CCC-CPR). METHODS: The present prospective, randomized crossover study involved 63 emergency medical technician trainees. The subjects performed three different CCC-CPR methods on a manikin model. The first method was general CCC-CPR without a break (CCC), the second included a 10-s break after 200 chest compressions (10/200), and the third included a 10-s break after 100 chest compressions (10/100). All methods were performed for 10 min. We counted the total number of compressions and those with appropriate depth every 1 min during the 10 min and measured mean compression depth from the start of chest compressions to 10 min. RESULTS: The 10/100 method showed the deepest compression depth, followed by the 10/200 and CCC methods. The mean compression depth showed a significant difference after 5 min had elapsed. The percentage of adequate compressions per min was calculated as the proportion of compressions with appropriate depth among total chest compressions. The percentage of adequate compressions declined over time for all methods. The 10/100 method showed the highest percentage of adequate compressions, followed by the 10/200 and CCC methods. CONCLUSION: When rescuers were provided a rest at a particular time during CCC-CPR, chest compression quality increased compared with CCC without rest. Therefore, we propose that a rescuer should be provided a rest during CCC-CPR, and specifically, we recommend a 10-s rest after 100 chest compressions.

Use of a lipid emulsion in a patient with refractory hypotension caused by glyphosate-surfactant herbicide.

CONTEXT: Circulatory shock is a major cause of mortality in glyphosate-surfactant herbicide (GlySH) poisoning, and this condition responds poorly to conventional therapies. We report a case of GlySH poisoning with shock that was refractory to vasopressors but responsive to intravenous fat emulsion (IFE). CASE DETAILS: A 52-year-old man was brought to the emergency department by ambulance. He was found unconscious in his living room along with an empty bottle of GlySH herbicide, which contained glyphosate, polyoxyethyleneamine (POEA) surfactant, and water. He was drowsy at presentation. His heart rate was 44 beats/min, his blood pressure could not be measured with an arm cuff, but he had a palpable femoral pulse. After about 2.5 h of supportive care after admission, he remained hypotensive, and his systolic blood pressure was 80 mmHg. A 500 mL bottle of 20% IFE product was prepared. As a bolus, 100 mL of IFE was injected, and the remaining 400 mL was then infused. His blood pressure was 100/60 mmHg 1 h after the bolus injection. At 5 h after IFE injection, his blood pressure reached 160/100 mmHg and vasopressors were tapered. CONCLUSION: IFE should be considered in cases of refractory hemodynamic instability caused by GlySH after aggressive fluid and vasopressor support.

A case of human poisoning with a flufenoxuron-containing insecticide.

INTRODUCTION: Flufenoxuron is a recently introduced insecticide. The compound is known to exert its insecticidal activity by inhibiting chitin synthesis in insects. However, its toxic effects on humans are unknown. CASE REPORT: A 72-year-old woman was brought to the emergency department by ambulance. The person accompanying her brought an empty 100-mL bottle of an insecticide (Cascade), which was found at the scene. The active ingredient of the product is flufenoxuron and the other components include surfactants and solvents. A detailed composition obtained from the manufacturer was flufenoxuron, ethoxylated nonylphenol phosphate, polyoxyethylene nonylphenol, N-methyl-2-pyrrolidone, and cyclohexanone. Upon arrival at the intensive care unit (ICU), her arterial pH was 7.093, her bicarbonate level was 7.4 mEq/L, and the anion gap was 33.8 mEq/L. Her lactic acid concentration was 16.5 mmol/L. Lactic acidosis was not considered to be a consequence of circulatory shock, because there was no clinical sign of shock other than lactic acidosis, and cardiac output was never below 4.5 L/min. Her acid-base status began to improve and returned to near normal on the next day. CONCLUSION: It can be hypothesized that the toxicity of the product includes inhibition of the oxygen utilization mechanism at the cellular level. The product is composed of a number of components, similar to many other herbicide products. It is not possible to identify which of the ingredients was specifically responsible for the toxic effects in this case.