Sedative dose and patient variable impacts on postintubation hypotension in emergency airway management.

PURPOSE: Postintubation hypotension (PIH) is an adverse event associated with poor outcomes in emergency department (ED) endotracheal intubation. This study aimed to evaluate the association between sedative dose adjustment and PIH during emergency airway management. We also investigated the impact of patient and procedural factors on the incidence of PIH. MATERIALS AND METHODS: This was a single-center, retrospective study that used a prospectively collected registry of airway management performed at the ED from April 2014 to February 2017. Adult patients who received emergency endotracheal intubation were included. Multivariable logistic regression models were used to evaluate the association of PIH with sedative dose, patient variables, and procedural variables. RESULTS: Overall, 689 patients were included, and 233 (33.8%) patients developed PIH. In the patients overall, multivariable logistic regression demonstrated that age > 70 years, shock index >0.8, arterial acidosis (pH < 7.2), intubation indication, and use of non-depolarizing neuromuscular blocking agent were significantly related to PIH. In patients overall, the sedative dose was not related to PIH (overdose; OR: 1.09, 95%CI: 0.57-2.06), (reduction; OR: 0.93, 95%CI: 0.61-1.42), (none used; OR: 1.28, 95%CI: 0.64-2.53). In subgroup analysis, ketamine dose was not related to PIH (overdose; OR: 0.81, 95%CI: 0.27-2.38, reduction; OR: 1.41, 95%CI: 0.78-2.54). Reduction of etomidate dose was significantly associated with decreased PIH (reduction; OR: 0.46, 95%CI: 0.22-0.98, overdose; OR: 1.77, 95%CI: 0.79-3.93). CONCLUSIONS: PIH was mainly related to predisposing patient-related factors. Only adjustment of etomidate dose was associated with the incidence of PIH.

Coronary angiography is related to improved clinical outcome of out-of-hospital cardiac arrest with initial non-shockable rhythm.

OBJECTIVE: Coronary angiography (CAG) for survivors of out-of-hospital cardiac arrest (OHCA) enables early identification of coronary artery disease and revascularization, which might improve clinical outcome. However, little is known for the role of CAG in patients with initial non-shockable cardiac rhythm. METHODS: We investigated clinical outcomes of successfully resuscitated 670 adult OHCA patients who were transferred to 27 hospitals in Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance (CAPTURES), a Korean nationwide multicenter registry. The primary outcome was 30-day survival with good neurological outcome. Propensity score matching and inverse probability of treatment weighting analyses were performed to account for indication bias. RESULTS: A total of 401 (60%) patients showed initial non-shockable rhythm. CAG was performed only in 13% of patients with non-shockable rhythm (53 out of 401 patients), whereas more than half of patients with shockable rhythm (149 out of 269 patients, 55%). Clinical outcome of patients who underwent CAG was superior to patients without CAG in both non-shockable (hazard ratio (HR) = 3.6, 95% confidence interval (CI) = 2.5-5.2) and shockable rhythm (HR = 3.7, 95% CI = 2.5-5.4, p < 0.001, all). Further analysis after propensity score matching or inverse probability of treatment weighting showed consistent findings (HR ranged from 2.0 to 3.2, p < 0.001, all). CONCLUSIONS: Performing CAG was related to better survival with good neurological outcome of OHCA patients with initial non-shockable rhythms as well as shockable rhythms.

Impact of early coronary angiography on the survival to discharge after out-of-hospital cardiac arrest.

OBJECTIVE: Acute myocardial infarction is a major cause of out-of-hospital cardiac arrest (OHCA). Coronary angiography (CAG) enables diagnostic confirmation of coronary artery disease and subsequent revascularization, which might improve the prognosis of OHCA survivors. Non-randomized data has shown a favorable impact of CAG on prognosis for this population. However, the optimal timing of CAG has been debated. METHODS: The clinical outcomes of 607 OHCA patients registered in CAPTURES (Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance), a nationwide multicenter registry performed in 27 hospitals, were analyzed. Early CAG was defined as CAG performed within 24 hours of emergency department admission. The primary outcome was survival to discharge, with neurologically favorable status defined by cerebral performance category scores ≤2. RESULTS: Compared to patients without CAG (n=469), patients who underwent early CAG (n=138) were younger, more likely to be male, and more likely to have received bystander cardiopulmonary resuscitation, pre-hospital defibrillation, and revascularization (P<0.01 for all). Analysis of 115 propensity score-matched pairs showed that early CAG is associated with a 2.3-fold increase in survival to discharge with neurologically favorable status (P<0.001, all). Survival to discharge increased consistently according to the time interval between emergency department visit and CAG (P<0.05). CONCLUSION: Early CAG of OHCA patients was associated with better survival and favorable neurologic outcomes at discharge. However, there was no clear time threshold for CAG that predicted survival to discharge.

Role of coronary angiography for out-of-hospital cardiac arrest survivors according to postreturn of spontaneous circulation on an electrocardiogram.

Survivors of out-of-hospital cardiac arrest (OHCA) have high mortality and morbidity. An acute coronary event is the most common cause of sudden cardiac death. For this reason, coronary angiography is an important diagnostic and treatment strategy for patients with postcardiac arrest. This study aimed to identify the correlation between postreturn of spontaneous circulation (ROSC) on an electrocardiogram (ECG) and results of coronary angiography of OHCA survivors.We collected data from our OHCA registry from January 2010 to November 2014. We categorized OHCA survivors into 2 groups according to post-ROSC ECG results. Emergent coronary artery angiography (CAG) (CAG performed within 12 hours after cardiac arrest) was performed in patients who showed ST segment elevation or new onset of left bundle branch block (LBBB) in post-ROSC ECG. For other patients, the decision for performing CAG was made according to agreement between the emergency physician and the cardiologist.During the study period, 472 OHCA victims visited our emergency department and underwent cardiopulmonary resuscitation. Among 198 OHCA survivors, 82 patients underwent coronary artery intervention. Thirty-one (70.4%) patients in the ST segment elevation or LBBB group and 10 (24.4%) patients in the nonspecific ECG group had coronary artery lesions (P < .01). Seven (18.4%) patients in the nonspecific ECG group showed coronary spasm.OHCA survivors without ST segment elevation or new onset LBBB still have significant coronary lesions in CAG. If there is no other obvious arrest cause in patients without significant changes in post ROSC ECG, CAG should be considered to rule out the possibility of coronary artery problems, including coronary spasm.

Upper airway obstruction resulting from acute mucosal injury induced by direct ingestion of sodium picosulfate/magnesium citrate powder.

A 59-year-old man presented to the emergency department with a chief complaint of sore throat after swallowing sodium picosulfate/magnesium citrate powder for bowel preparation, without first dissolving it in water. The initial evaluation showed significant mucosal injury involving the oral cavity, pharynx, and epiglottis. Endotracheal intubation was performed for airway protection in the emergency department, because the mucosal swelling resulted in upper airway compromise. After conservative treatment in the intensive care unit, he underwent tracheostomy because stenosis of the supraglottic and subglottic areas was not relieved. The tracheostomy tube was successfully removed after confirming recovery, and he was discharged 3 weeks after admission.

Better prognostic value with combined optic nerve sheath diameter and grey-to-white matter ratio on initial brain computed tomography in post-cardiac arrest patients.

AIM: We aimed to evaluate the prognostic value of optic nerve sheath diameter (ONSD) and grey-to-white matter (GWR) either alone or in combination in patients treated with targeted temperature management (TTM) after cardiac arrest (CA). METHODS: We conducted a retrospective single centre study of post cardiac arrest patients treated with TTM. ONSD and GWR on brain computed tomography (CT) was measured by two emergency physicians. We analysed the prognostic performance and cut offs of GWR and ONSD, singly and in combination in predicting poor neurologic outcome (CPC 3-5). RESULTS: Of the 119 patients studied, 74 patients showed poor outcome. The combination of ONSD and GWR significantly (p=0.002) improved prognostic performance (AUROC 0.67, 95% CI: 0.58-0.76, p<0.001) in predicting poor neurologic outcomes rather than each ONSD (AUROC 0.59, 95% CI: 0.50-0.68, p=0.08) or GWR (AUROC 0.65, 95% CI: 0.56-0.74, p=0.002) alone. A combined cut off of 'GWR and ONSD (1.16 and 4.9)' and 'GWR or ONSD (1.13 or 6.5)' improved the sensitivity for predicting poor outcome while maintaining high specificity compared to GWR alone. CONCLUSION: The combination of ONSD and GWR yielded improved prognostic value for predicting poor neurologic outcomes in post cardiac arrest patients treated with TTM.

Early central diabetes insipidus: An ominous sign in post-cardiac arrest patients.

PURPOSE: Central diabetes insipidus (CDI) after cardiac arrest is not well described. Thus, we aim to study the occurrences, outcomes, and risk factors of CDI of survivors after out-of-hospital cardiac arrest (OHCA). MATERIALS AND METHODS: We retrospectively analyzed post-OHCA patients treated at a single center. Central diabetes insipidus was retrospectively defined by diagnostic criteria. One-month cerebral performance category (CPC) scores were collected for outcomes. RESULTS: Of the 169 patients evaluated, 36 patients (21.3%) were diagnosed with CDI. All CDI patients had a poor neurologic outcome of either CPC 4 (13.9%) or CPC 5 (86.1%), and CDI was strongly associated with mortality. Age (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.93-0.99), respiratory arrest (OR, 6.62; 95% CI, 1.23-35.44), asphyxia (OR, 9.26; 95% CI, 2.17-34.61), and gray to white matter ratio on brain computed tomogram (OR, 0.88; 95% CI, 0.81-0.95) were associated with the development of CDI. The onset of CDI was earlier (P < .001) and the maximum 24-hour urine output was larger (P = .03) in patients with worst outcomes. CONCLUSIONS: All patients diagnosed with CDI had poor neurologic outcomes, and occurrence of CDI was associated with mortality. Central diabetes insipidus patients with death or brain death had earlier occurrence of CDI and more maximum urine output.

A new chest compression depth indicator would increase compression depth without increasing overcompression risk.

PURPOSE: Adequate chest compression (CC) depth is critical for effective cardiopulmonary resuscitation. Pediatric resuscitation guidelines recommend that CC be at least one-third of the anterior-posterior (AP) chest diameter or approximately 4 cm in infants and 5 cm in children. We aimed to find a better indicator of CC depth that maximizes CC depth while also minimizing injury. BASIC PROCEDURES: Chest computed tomographic images of patients aged 8 years and younger were measured for external diameter (ED) (AP distance from skin to skin) and internal diameter (AP distance between internal surface of anterior chest wall and anterior surface of vertebral body) at the midway of the lower half of the sternum. Compressible depth was defined as 1 cm short of internal diameter. We determined that up to a 10% estimated risk of overcompression is acceptable and approximated a quantile regression line for the 10th percentile of compressible depth on ED. After rounding coefficients, we used its equation as a new indicator. MAIN FINDINGS: A total of 426 images were analyzed. The new indicator had a slope of 0.5 and an intercept of -1.9 cm (1 fingerbreadth). Compared to one-third ED, the new indicator would provide deeper CC with average difference of 1.9 mm (95% confidence interval, 1.6-2.2 mm) without increasing the risk of overcompression (both 4.9%). Chest compression of 4/5 cm would provide deeper CC compared to the new indicator (difference, 3.5 mm; 95% confidence interval, 2.7-4.1 mm); however, its overcompression risk was too high (31.5%). PRINCIPAL CONCLUSION: Chest compression of one-half ED minus 1 fingerbreadth maximizes CC depth without increasing overcompression in pediatric population.

Effect of multifaceted interventions on reducing return visits within 72 h after non-traumatic emergency department visits.

OBJECTIVE: The objective of the present study is to develop new multifaceted interventions to reduce return visits (RVs) based on identified risk factors related to RVs in the ED and to compare the RV rate before and after the implementation of the intervention. METHODS: The present study was a controlled before and after study that was conducted in the ED of a 900-bed tertiary hospital in an urban area. The primary outcome was the rate of unplanned RVs to the ED and hospital admission after RV. The risk and predictive factors of RVs were identified by a retrospective study of all unscheduled RVs to the ED within 72 h in 2011. We developed five new multifaceted interventions based on the results: (i) daily RV feedback; (ii) prescription set of drugs; (iii) creation of a discharge instruction sheet; (iv) early follow-up appointments of outpatient department (OPD); and (v) enhancement of referral system. A prospective interventional study in which the interventions were implemented was then conducted over 10 months, from 1 June 2012 to 31 March 2013. RESULTS: The five new multifaceted interventions significantly reduced the mean early RV rate and RV admission rate after ED discharge by an average of approximately 25%, with a maximum of approximately 55% and 47%, respectively, compared with the pre-intervention period (RV rate: P < 0.001, RV admission rate: P < 0.001). CONCLUSIONS: Multifaceted interventions based on identified risk factors for early RV after ED discharge had a positive effect on reducing RVs and the admission rate after RVs for adult patients within 72 h of non-traumatic ED visits.

The risk factors and prognostic implication of acute pulmonary edema in resuscitated cardiac arrest patients.

OBJECTIVE: Pulmonary edema is frequently observed after a successful resuscitation in out-of-hospital cardiac arrest (OHCA) patients. Currently, its risk factors and prognostic implications are mostly unknown. METHODS: Adult OHCA patients with a presumed cardiac etiology who achieved sustained return of spontaneous circulation (ROSC) in emergency department were retrospectively analyzed. The patients were grouped according to the severity of consolidation on their initial chest X-ray (group I, no consolidation; group II, patchy consolidations; group III, consolidation involving an entire lobe; group IV, total white-out of any lung). The primary objective was to identify the risk factors of developing severe pulmonary edema (group III or IV). The secondary objective was to evaluate the association between long-term prognosis and the severity of pulmonary edema. RESULTS: One hundred and seven patients were included. Total duration of cardiopulmonary resuscitation (CPR) and initial pCO2 level were both independent predictors of developing severe pulmonary edema with their odds ratio (OR) being 1.02 (95% confidence interval [CI], 1.00 to 1.04; per 1 minute) and 1.04 (95% CI, 1.01 to 1.07; per 1 mmHg), respectively. The long term prognosis was significantly poor in patients with severe pulmonary edema with a OR for good outcome (6-month cerebral performance category 1 or 2) being 0.22 (95% CI, 0.06 to 0.79) in group III and 0.16 (95% CI, 0.04 to 0.63) in group IV compared to group I. CONCLUSION: The duration of CPR and initial pCO2 level were both independent predictors for the development of severe pulmonary edema after resuscitation in emergency department. The severity of the pulmonary edema was significantly associated with long-term outcome.

Perception of radiation dose and potential risks of computed tomography in emergency department medical personnel.

OBJECTIVE: Use of computed tomography (CT) continues to increase, but the relatively high radiation doses associated with CT have raised health concerns such as future risk of cancer. We investigated the level of awareness regarding radiation doses and possible risks associated with CT in medical personnel (MP). METHODS: This study was conducted from April to May 2012 and included physicians and nurses who worked in the emergency department of 17 training hospitals. The questionnaire included measurement of the effect of CT or radiography on health using a 10-point numerical rating scale, estimation of the radiation dose of one abdominal CT scan compared with one chest radiograph, and perception of the increased lifetime risk of cancer associated with CT. RESULTS: A total of 354 MP participated in this study: 142 nurses, 87 interns, 86 residents, and 39 specialists. Interns were less aware of the effects of CT or radiography on health than other physicians or nurses (mean±SD of 4.8±2.7, 5.9±2.7, 6.1±2.7, and 6.0±2.2 for interns, residents, specialists, and nurses, respectively; P<0.05). There was a significant difference in knowledge about the relative radiation dose of one abdominal CT scan compared with one chest radiograph between physicians and nurses (48.6% vs. 28.9% for physicians vs. nurses, P<0.05). MP perceived an increased risk of cancer from radiation associated with CT. CONCLUSION: MP perceive the risk of radiation associated with CT, but their level of knowledge seems to be insufficient.

Effect of pain control in suspected acute appendicitis on the diagnostic accuracy of surgical residents.

OBJECTIVE: To determine the influence of early pain relief for patients with suspected appendicitis on the diagnostic performance of surgical residents. METHODS: A prospective randomized, double-blind, placebo-controlled trial was conducted for patients with suspected appendicitis. The patients were randomized to receive placebo (normal saline intravenous [IV]) infusions over 5 minutes or the study drug (morphine 5 mg IV). All of the clinical evaluations by surgical residents were performed 30 minutes after administration of the study drug or placebo. After obtaining the clinical probability of appendicitis, as determined by the surgical residents, abdominal computed tomography was performed. The primary objective was to compare the influence of IV morphine on the ability of surgical residents to diagnose appendicitis. RESULTS: A total of 213 patients with suspected appendicitis were enrolled. Of these patients, 107 patients received morphine, and 106 patients received placebo saline. The negative appendectomy percentages in each group were similar (3.8% in the placebo group and 3.2% in the pain control group, p=0.62). The perforation rates in each group were also similar (18.9% in the placebo group and 14.3% in the pain control group, p=0.75). Receiver operating characteristic analysis revealed that the overall diagnostic accuracy in each group was similar (the area under the curve of the placebo group and the pain control group was 0.63 v. 0.61, respectively, p=0.81). CONCLUSIONS: Early pain control in patients with suspected appendicitis does not affect the diagnostic performance of surgical residents.

Successful fibrinolytic and therapeutic hypothermic management of cardiac arrest following massive pulmonary embolism.

Massive pulmonary embolism (MPE) with hemodynamic instability is a clinical condition with a poor prognosis and high mortality rates. There are no definitive treatment options for cardiac arrest due to MPE. A 52-year-old female presented at our emergency department with cardiac arrest, and a 62-year-old female presented after achieving return of spontaneous circulation of cardiac arrest from a local hospital, respectively. In each case, computed tomographic pulmonary angiography after return of spontaneous circulation demonstrated heavy burdens of pulmonary embolism in the pulmonary arteries. We immediately started therapeutic hypothermia and fibrinolytic therapy. They were transferred to the thoracic surgery and cardiology departments respectively, and then discharged with a cerebral performance categories scale score of 1. In summary, we report two cases of out-of-hospital cardiac arrest due to MPE in which fibrinolytic therapy was successfully combined with therapeutic hypothermia.

Change in guardians' preference for computed tomography after explanation by emergency physicians in pediatric head injury.

OBJECTIVE: Head injury in children is a common problem presenting to emergency departments, and cranial computed tomography scanning is the diagnostic standard for these patients. Several decision rules are used to determine whether computed tomography scans should be used; however, the use of computed tomography scans is often influenced by guardians' preference toward the scans. The objective of this study was to identify changes in guardian preference for minor head injuries after receiving an explanation based on the institutional clinical practice guideline. METHODS: A survey was conducted between July 2010 and June 2012. Patients younger than 16 years with a Glasgow Coma Scale score of 15 after a head injury and their guardians were included. Pre- and post-explanation questionnaires were given to guardians to assess their preference for computed tomography scans and factors related to the degree of preference. Treating physicians explained the risks and benefits of cranial computed tomography scanning using the institutional clinical practice guideline. Guardian preference for a computed tomography scan was examined using a 100-mm visual analog scale. RESULTS: In total, 208 patients and their guardians were included in this survey. Guardian preference for computed tomography scans was significantly reduced after explanation (46.7 vs. 17.4, P<0.01). Pre-explanation preference and the strength of the physician recommendation to get a computed tomography were the most important factors affecting pre- and post-explanation changes in preferences. CONCLUSION: Explanation of the risks and benefits of cranial computed tomography scans using the institutional clinical practice guideline may significantly reduce guardian preference for computed tomography scans.

Implementation of clinical practices to reduce return visits within 72†h to a paediatric emergency department.

OBJECTIVE: Return visits to the paediatric emergency department (PED) are an important measure of quality of healthcare and are associated with patients' and parents'/guardians' satisfaction. Previous studies have been limited to describing characteristics and factors related to return visits. The objectives of this study were to develop new clinical practices to reduce return visits to the PED and to see whether implementation of these practices had the desired effect. PATIENTS AND METHODS: This was a controlled before-and-after study. New clinical practices were developed by analysing data for patients visiting in 2011 (before) and by surveying emergency physicians and nurses in the PED. New clinical practices were implemented between 16 July and 4 November 2012 (after). The rate of return visits and admission rates after return visits were compared between matched periods in 2011 and 2012. We also investigated return visits at three independent hospitals to overcome the limitation of the intervention application to a single hospital. RESULTS: The new clinical practices included five protocols: set orders for common symptoms; management plans for patients at high risk of a return visit; a daily physician feedback system; protocolised discharge instructions; early planned visits to clinics. After implementation, the rate of return visits was reduced significantly, from 4.4% to 2.6% (p<0.01). The admission rate for return visits was also reduced, but not significantly so, from 22.3% to 17.5% (p=0.37). Return visits at the other hospitals were similar or significantly increased in 2012 compared with 2011. CONCLUSIONS: The development and implementation of clinical practices were effective in reducing return visits of paediatric patients to the ED.

Factors affecting the accuracy of chest compression depth estimation.

OBJECTIVE: We aimed to estimate the accuracy of visual estimation of chest compression depth and identify potential factors affecting accuracy. METHODS: This simulation study used a basic life support mannequin, the Ambu man. We recorded chest compression with 7 different depths from 1 to 7 cm. Each video clip was recorded for a cycle of compression. Three different viewpoints were used to record the video. After filming, 25 clips were randomly selected. Health care providers in an emergency department were asked to estimate the depth of compressions while watching the selected video clips. Examiner determinants such as experience and cardiopulmonary resuscitation training and environment determinants such as the location of the camera (examiner) were collected and analyzed. An estimated depth was considered correct if it was consistent with the one recorded. A multivariate analysis predicting the accuracy of compression depth estimation was performed. RESULTS: Overall, 103 subjects were enrolled in the study; 42 (40.8%) were physicians, 56 (54.4%) nurses, and 5 (4.8%) emergency medical technicians. The mean accuracy was 0.89 (standard deviation, 0.76). Among examiner determinants, only subjects' occupation and clinical experience showed significant association with outcome (P=0.03 and P=0.08, respectively). All environmental determinants showed significant association with the outcome (all P<0.001). Multivariate analysis showed that accuracy rate was significantly associated with occupation, camera position, and compression depth. CONCLUSIONS: The accuracy rate of chest compression depth estimation was 0.89 and was significantly related with examiner's occupation, camera view position, and compression depth.

Finger necrosis after accidental radial artery puncture.

Radial artery puncture, an invasive procedure, is frequently used for critical patients. Although considered safe, severe complications such as finger necrosis can occur. Herein, we review the clinical course of finger necrosis after accidental radial artery puncture. A 63-year-old woman visited the emergency department (ED) with left second and third finger pain after undergoing intravenous (IV) access in her wrist for procedural sedation. During the IV access, she experienced wrist pain, which increased during the 12 hours prior to her ED presentation. Emergency angiography revealed a pseudoaneurysm in her left radial artery and absence of blood flow to the proper palmar digital artery. Subsequent angiointervention and urokinase thrombolysis failed. The second finger was eventually amputated owing to gangrene. Radial artery puncture can occur accidentally during IV wrist access, resulting in severe morbidity. Providers should carefully examine the puncture site and collateral flow, followed by multiple examinations to ensure distal circulation.

Rate of and risk factors for early recurrence in patients with febrile seizures.

OBJECTIVE: Patients with febrile seizures (FSs) are observed in emergency departments or admitted to hospitals because of the possibility of recurrence. There are no guidelines regarding the observation time for recurring FS. The aim of this study was to identify the rate, time, risk factors, and cumulative probability of early recurrence. PATIENTS AND METHODS: This study was a retrospective chart review of patients visiting an emergency department with FS from January to December 2011. Early recurrence was defined as FS recurring within 7 days after the first episode. Patients were divided into 2 groups: early recurrence and nonearly recurrence. The 2 groups were compared in terms of demographics, clinical data, and laboratory findings to identify risk factors for early recurrence. The cumulative probability over time was determined. RESULTS: In total, 228 patients were identified. The recurrence rate was 17.5% (40/228), and the median time to recurrence was 6.0 hours (interquartile range, 1.1-13.0 hours). The overall cumulative probability of early recurrence was 8.8% within 6 hours, 12.7% within 12 hours, and 15.8% within 24 hours. Most recurrences (90.0%) occurred within 24 hours of the first FS. Early recurrence occurred frequently in patients with nongeneralized-type seizures or seizures of 15-minute duration or longer. CONCLUSIONS: The majority of recurrent FSs occurred in the first 24 hours. The type and duration of seizures were significant risk factors for early recurrence.

Bacteremia prediction model using a common clinical test in patients with community-acquired pneumonia.

PURPOSE: The aim of this study was to construct a bacteremia prediction model using commonly available clinical variables in hospitalized patients with community-acquired pneumonia (CAP). BASIC PROCEDURES: A prospective database including patients who were diagnosed with CAP in the emergency department was analyzed. Independent risk factors were investigated by using multivariable analysis in 60% of the cohort. We assigned a weighted value to predictive factor and made a prediction rule. This model was validated both internally and externally with the remaining 40% of the cohort and a cohort from an independent hospital. The low-risk group for bacteremia was defined as patients who have a risk of bacteremia less than 3%. MAIN FINDINGS: A total of 2422 patients were included in this study. The overall rate of bacteremia was 5.7% in the cohort. The significant factors for predicting bacteremia were the following 7 variables: systolic blood pressure less than 90 mm Hg, heart rate greater than 125 beats per minute, body temperature less than 35 °C or greater than 40 °C, white blood cell less than 4000 or 12,000 cells per microliter, platelets less than 130,000 cells per microliter, albumin less than 3.3 g/dL, and C-reactive protein greater than 17 mg/dL. After using our prediction rule for the validation cohorts, 78.7% and 74.8% of the internal and external validation cohorts were classified as low-risk bacteremia groups. The areas under the receiver operating characteristic curves were 0.75 and 0.79 for the internal and external validation cohorts. PRINCIPAL CONCLUSIONS: This model could provide guidelines for whether to perform blood cultures for hospitalized CAP patients with the goal of reducing the number of blood cultures.

Patterns of accidental genital trauma and factors associated with surgical management in girls visiting the emergency department of a referral center.

STUDY OBJECTIVE: To examine our experience with the management of accidental genital trauma (AGT) and to identify variables associated with surgical management or admission in girls aged ≤15 y. DESIGN: A retrospective, observational study. SETTING: Tertiary referral hospital. PARTICIPANTS: Girls with AGT visiting the emergency department (ED) between 2003 and 2011. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Admission rate and surgery rate. RESULTS: AGT was the cause in 159 out of 327 girls (49%) who visited the Gynecologic Division of ED; and in girls aged ≤10 years, AGT accounted for 78% of the visits (145/187). Twenty girls (13%) were admitted to the hospital and 38 girls (24%) underwent surgical management. Girls who visited the ED during daytime and those with laceration-type or large lesions tended to receive surgical management. Girls with large lesions also tended to be admitted to the hospital. CONCLUSION: AGT is the major gynecologic cause of ED visits in girls. Time of visit, type and size of lesion were associated with surgical management. Lesion size was also a determinant for admission in girls with AGT. Gynecologists must be familiar with the evaluation and management of girls with AGT.