The usefulness of diffusion-weighted magnetic resonance imaging performed in the acute phase as an early predictor of delayed neuropsychiatric sequelae in acute carbon monoxide poisoning

Delayed onset of neuropsychiatric symptoms after apparent recovery from acute carbon monoxide (CO) poisoning has been described as delayed neuropsychiatric sequelae (DNS). No previous study has determined whether early use of diffusion-weighted magnetic resonance imaging (DWI) can predict which patients will develop DNS in the acute CO poisoning. This retrospective observational study was performed on adult patients with acute CO poisoning consecutively treated over a 17-month period. All included patients with acute CO poisoning underwent DWI to evaluate brain injury within 72 h after CO exposure. DWI was evaluated as follows: (1) presence of pathology, (2) number of pathologies, (3) asymmetry, and (4) location of pathology. Patients were divided into two groups. The DNS group was composed of patients with delayed sequelae, while the non-DNS group included patients with no sequelae. A total of 102 patients with acute CO poisoning were finally enrolled in this study. DNS developed in 10 patients (9.8%). Between the DNS group and the non-DNS group, presence of pathology on DWI and initial Glasgow Coma Scale (GCS) showed significant difference. There was also a statistical difference between the non-DNS group and DNS group in terms of CO exposure time, troponin I, rhabdomyolysis, acute kidney injury, and pneumonia. The presence of pathology in DWI and initial GCS (cutoff: <12) at the emergency department served as an early predictors of DNS.

The relationship between serum ammonia level and neurologic complications in patients with acute glufosinate ammonium poisoning: A prospective observational study

Glufosinate ammonium poisoning can cause neurological complications even after a symptom-free period. We prospectively investigated the predictors of neurologic complications in acute glufosinate ammonium poisoning and the change of serum ammonia level as a predictor of patient’s presence and recovery of neurologic complication. This prospective observational study collected data from consecutive patients diagnosed with acute glufosinate ammonium poisoning between September 2014 and June 2016. Serum ammonia was serially measured. The patients were divided into two groups: the neurologic complication group and the nonneurologic complication group. We also defined 25 other insecticide- or herbicide-poisoned patients as controls. The neurologic complication group included 18 patients (72.0%). The latency period for neurologic complications was within 48-h postingestion. The peak ammonia level was statistically higher in the neurologic complication group than in the control group ( p < 0.001) and the nonneurologic complication groups ( p = 0.001). There was a statistical difference between the nonneurologic complication group and the neurologic complication group ( p = 0.0085) in terms of ingested amount. The peak ammonia was the only predictor for the development of neurologic complications (the optimal cutoff: 90 μg/dL). In patients with mental changes, the mean serum ammonia levels before and after recovery of the mental changes were statistically different ( p = 0.0019). In acute glufosinate ammonium poisoning, serial serum ammonia level measurements are needed and a serum peak ammonia level greater than 90 μg/dL is a predictor of neurologic complications. Also, it is important to treat the hyperammonemia in acute glufosinate ammonium poisoning.

Reduced Mortality in Severely Injured Patients Using Hospital-based Helicopter Emergency Medical Services in Interhospital Transport

Recent evidence has demonstrated the survival benefits of helicopter transport for trauma patients. The purpose of this study was to evaluate the effectiveness of hospital-based helicopter emergency medical services (H-HEMS) in comparison with ground ambulance transport in improving mortality outcomes in patients with major trauma. Study participants were divided into 2 groups according to type of transport to the trauma center; that is, either via ground emergency medical services (GEMS) or via H-HEMS. The study was conducted from October 2013 to July 2015. Mortality outcomes in the H-HEMS group were compared with those in the GEMS group by using the Trauma and Injury Severity Score (TRISS) analysis. The number of participants finally included in the study was 312. Among these patients, 63 were adult major trauma patients transported via H-HEMS, and 47.6% were involved in traffic accidents. For interhospital transport, the Z and W statistics revealed significantly higher scores in the H-HEMS group than in the GEMS group (Z statistic, 2.02 vs. 1.16; P = 0.043 vs. 0.246; W statistic, 8.87 vs. 2.85), and 6.02 more patients could be saved per 100 patients when H-HEMS was used for transportation. TRISS analysis revealed that the use of H-HEMS for transporting adult major trauma patients was associated with significantly improved survival compared to the use of GEMS.

Serum neuron-specific enolase as an early predictor of delayed neuropsychiatric sequelae in patients with acute carbon monoxide poisoning

Delayed onset of neuropsychiatric symptoms after apparent recovery from acute carbon monoxide (CO) poisoning has been described as delayed neuropsychiatric sequelae (DNS). To date, there have been no studies on the utility of serum neuron-specific enolase (NSE), a marker of neuronal cell damage, as a predictive marker of DNS in acute CO poisoning. This retrospective observational study was performed on adult patients with acute CO poisoning consecutively treated over a 9-month period. Serum NSE was measured after emergency department arrival, and patients were divided into two groups. The DNS group comprised patients with delayed sequelae, while the non-DNS group included patients with none of these sequelae. A total of 98 patients with acute CO poisoning were enrolled in this study. DNS developed in eight patients. The median NSE value was significantly higher in the DNS group than in the non-DNS group. There was a statistical difference between the non-DNS group and the DNS group in terms of CO exposure time, Glasgow Coma Scale (GCS), loss of consciousness, creatinine kinase, and troponin I. GCS and NSE were the early predictors of development of DNS. The area under the curve according to the receiver operating characteristic curves of GCS, serum NSE, and GCS combined with serum NSE were 0.922, 0.836, and 0.969, respectively. In conclusion, initial GCS and NSE served as early predictors of development of DNS. Also, NSE might be a useful additional parameter that could improve the prediction accuracy of initial GCS.

The use of delta neutrophil index and myeloperoxidase index as diagnostic predictors of strangulated mechanical bowel obstruction in the emergency department

Early detection of bowel strangulation is difficult in patients with mechanical bowel obstruction (MBO). There have been no previous reports of predicting strangulation in MBO cases using the delta neutrophil index (DNI), which is a measure of the proportion of circulating immature granulocytes, or the myeloperoxidase index (MPXI), which is a measure of serum myeloperoxidase level. Therefore, we evaluated differences in initial DNI and MPXI upon presentation at the emergency department (ED) according to strangulation presence in MBO patients.This is a retrospective observational study of consecutive patients older than 18 years who were diagnosed with MBO over a 31-month period. MBO was ultimately confirmed by computed tomography (CT) findings by a radiology specialist. Patients were categorized by a strangulation group (SG) and nonstrangulation group (NSG). The SG was defined by surgical and pathologic findings after the surgical operation. Initial serum counts of white blood cells and neutrophils, C-reactive protein levels, and DNI and MPXI scores were investigated in the ED.Fifteen of 160 patients were allocated to the SG (9.4%), and among the inflammatory markers, median initial DNI value was the only one that was significantly higher in the SG (0% vs 3.2%, P = 0.003). Although the areas under the receiver operation characteristic (ROC) curves for initial DNI and CT for differentiating strangulated from nonstrangulated bowel obstruction were 0.713 (95% confidence interval [CI]: 0.636-0.782) and 0.883 (95% CI: 0.823-0.928), respectively; there was no significant difference between DNI and CT (P = 0.147). The area under the curve (AUC) for predicting strangulated bowel disease from a combination of initial DNI score and CT findings (0.983, 95% CI: 0.948-0.997) was higher than the AUC for CT alone, although the difference was not significant (P = 0.052).In conclusion, initial DNI, which was performed in the ED, was found to be significantly higher in the SG than in the NSG. Initial DNI might be a useful additional parameter for improving the prediction accuracy of CT.

Parenchymal lung injuries related to standard cardiopulmonary resuscitation

OBJECTIVES

We analyzed chest computed tomographic scan to evaluate parenchymal lung injury and its clinical significance in patients who received standard cardiopulmonary resuscitation and were resuscitated from cardiac arrest.

METHODS

We enrolled nontraumatic out-of-hospital cardiac arrest patients older than 19 years who had been admitted to the emergency department in cardiac arrest and successfully resuscitated after cardiopulmonary resuscitation. Chest computed tomography was obtained immediately after return of spontaneous circulation (ROSC). To allocate the area of lung contusion, we divided both hemithoraces into 3 regions longitudinally, and each part was subdivided into 4 segments except the lower part of the left lung. To stratify the severity of lung contusion, each segment was scored depending on the area of lung contusion. Oxygen index (OI) was measured at the time of ROSC, 24, 48, and 72 hours and 1 week after cardiac arrest.

RESULTS

Lung contusion was developed in 37 (41%) patients and median lung contusion score (LCS) was 17 (12-26). Lung contusion was not associated with hospital mortality (P = .924) or length of intensive care unit stay (P = .446). The OI at the time of ROSC was lower in patients with LCS greater than 23 than that in patients with LCS less than or equal to 23 (126 [93-224] vs 278 [202-367]; P = .008); however, the OI at the other timelines was not different between patients with LCS greater than 23 and patients with LCS less than or equal to 23.

CONCLUSION

Extensive lung contusion is associated with a lower oxygenation index at the time of ROSC, but did not affect the resuscitation outcome.

Activation of Autophagy by Everolimus Confers Hepatoprotection Against Ischemia-Reperfusion Injury

As the criteria for liver donation have been extended to include marginal donors, liver grafts are becoming particularly vulnerable to hepatic ischemia-reperfusion injury (IRI). However, no specific measures have been validated to ameliorate hepatic IRI. In this article, we explored whether everolimus has protective effects against hepatic IRI in relation with autophagy. The effects of everolimus were investigated in both in vitro and in vivo hepatic IRI models. Mouse hepatocyte AML12 cells and BALB/c mice were utilized for the establishment of each model. In the IRI-induced AML12 cells, everolimus treatment increased the expressions of autophagic markers (microtubule-associated protein 1 light chain 3 and p62) and decreased pro-apoptotic proteins (cleaved caspase 3 and cleaved poly-ADP ribose polymerase). The blockage of autophagy, using either bafilomycin A1 or si-autophagy-related protein 5, abrogated these anti-apoptosis effects of everolimus. Subsequently, everolimus administration to the hepatic IRI-induced mice provided hepatoprotective effects in terms of (1) decreasing the expressions of pro-apoptotic proteins, (2) inhibiting the release of pro-inflammatory cytokines (IL-6 and tumor necrosis factor-α), (3) reducing elevated liver enzymes (aspartate transaminase, alanine transaminase, and ammonia), and (4) restoring liver histopathology. These findings suggest that everolimus protects the liver against hepatic IRI by way of activating autophagy, and thus could be a potential therapeutic agent for hepatic IRI.

The usefulness of serum delta neutrophil index for differentiating bacterial and viral meningitis in the emergency department

OBJECTIVE

When managing patients with acute meningitis in an emergency department (ED), early diagnosis of the type of infection (bacterial or viral) considerably affects the clinical course and treatment because of the high mortality and morbidity associated with bacterial meningitis (BM). The serum delta neutrophil index (DNI), a new inflammatory marker, reflects the fraction of circulating immature granulocytes and is elevated in cases of bacterial infection. The objective of this study was to evaluate whether serum DNI can be used to differentiate between BM and viral meningitis (VM) in the ED.

METHODS

This retrospective, observational study included 104 consecutive patients (aged >18 years) diagnosed with acute meningitis from January 2012 to November 2014 in a regional emergency center. White blood cell and neutrophil counts, C-reactive protein level, and DNI were evaluated regarding their usefulness for differentiating BM and VM.

RESULTS

Serum DNI was not significantly higher in the BM group (n=12) than in the VM group (n=92) (0 [interquartile range, 0% to 2.73%] vs. 0 [interquartile range, 0 to 0%], P=0.057). However, the white blood cell count and C-reactive protein level were statistically higher in the BM group (P=0.034 and P=0.026, respectively). Serum DNI was not found to be a statistically useful differential diagnostic parameter (area under the curve, 0.628; 95% confidence interval, 0.438 to 0.818).

CONCLUSION

Currently, there is no evidence that the serum DNI aids in differentiating acute BM from acute VM in the ED.

The utility of noninvasive nasal positive pressure ventilators for optimizing oxygenation during rapid sequence intubation

OBJECTIVES

The objective of the study is to investigate the feasibility of noninvasive nasal positive pressure ventilation (NINPPV) for optimizing oxygenation during the rapid sequence intubation in critically ill patients.

METHODS

A prospective, observational study was performed in an emergency department. Noninvasive nasal positive pressure ventilation was applied in the preoxygenation step and maintained until successful intubation. A pulse oximetry (Spo2) was continuously monitored throughout the procedure and recorded 5 times. The degree of interfering was surveyed with 10-point Likert scale.

RESULTS

Thirty patients were enrolled. The most of enrolled patients were diagnosed as pneumonia, acute heart failure, and traumatic brain injury. The Spo2 was increased to 100% (98%-100%) at the time of starting endotracheal intubation with NINPPV and maintained as 97% (95%-100%) until successful intubation (P< .001). Total apnea duration was 195 seconds (190-196). The degree of interfering intubation was 1 (0-1).

CONCLUSIONS

Noninvasive nasal positive pressure ventilation would be useful for optimizing oxygenation during rapid sequence intubation.

Incidence and patterns of cardiomyopathy in carbon monoxide-poisoned patients with myocardial injury

OBJECTIVES

Sustained myocardial injury is a significant predictor of mortality in carbon monoxide (CO) poisoning. There are few reports in the literature regarding the presence of CO-induced cardiomyopathy from early stages in the emergency department (ED). We prospectively investigated the early incidence of CO-induced cardiomyopathy and its patterns in patients with cardiomyopathy.

MATERIALS AND METHODS

During a 10-month period, transthoracic echocardiography (TTE) was performed in 43 consecutive patients with CO poisoning and myocardial injury, which was defined as elevated high-sensitive troponin I within 24 h after ED arrival. Measurements of left ventricular ejection fraction and wall motion abnormalities were performed to evaluate cardiac function. If a patient had CO-induced cardiomyopathy, we measured cardiac function at the time of patient admission, day 1, day 2, and once within seven days of hospitalization.

RESULTS

The incidence of cardiomyopathy was as high as 74.4% (32 of 43 patients) in CO-poisoned patients with myocardial injury based on initial ED results. Echocardiographic patterns included non-cardiomyopathy (25.6%), global dysfunction (51.2%), and Takotsubo-like cardiomyopathy (23.2%). Patients in the global dysfunction group had significantly more normalized cardiac dysfunction within 72 h than did those in the Takotsubo-like cardiomyopathy group (81.8% vs. 22.2%, p = 0.001).

DISCUSSION AND CONCLUSION

Patients with CO poisoning and myocardial injury experienced cardiomyopathy, including reversible global dysfunction and a Takotsubo-like pattern. Investigation of cardiomyopathy needs to be considered in patients with CO poisoning and myocardial injury.

Clinical outcomes of adverse cardiovascular events in patients with acute dapsone poisoning

Objective

Adverse cardiovascular events (ACVEs) account for a large proportion of the morbidities and mortalities associated with drug overdose emergencies. However, there are no published reports regarding outcomes of ACVEs associated with acute dapsone poisoning. Here, the authors retrospectively analyzed ACVEs reported within 48 hours of treatment in patients with acute dapsone poisoning and assessed the significance of ACVEs as early predictors of mortality.

Methods

Sixty-one consecutive cases of acute dapsone poisoning that were diagnosed and treated at a regional emergency center between 2006 and 2014 were included in the study. An ACVE was defined as myocardial injury, shock, ventricular dysrhythmia, cardiac arrest, or any combination of these occurring within the first 48 hours of treatment for acute dapsone poisoning.

Results

Nineteen patients (31.1%) had evidence of myocardial injury (elevation of serum troponin-I level or electrocardiography signs of ischemia) after dapsone overdose, and there were a total of 19 ACVEs (31.1%), including one case of shock (1.6%). Fourteen patients (23.0%) died from pneumonia or multiple organ failure, and the incidence of ACVEs was significantly higher among non-survivors than among survivors (64.3% vs. 21.3%, P=0.006). ACVE was a significant predictor of mortality (odds ratio, 5.690; 95% confidence interval, 1.428 to 22.675; P=0.014).

Conclusion

The incidence of ACVE was significantly higher among patients who died after acute dapsone poisoning. ACVE is a significant predictor of mortality after dapsone overdose, and evidence of ACVE should be carefully sought in these patients.

Adverse Cardiovascular Events after a Venomous Snakebite in Korea

PURPOSE

Although cardiac involvement is an infrequently recognized manifestation of venomous snakebites, little is known of the adverse cardiovascular events (ACVEs) arising as a result of snakebite in Korea. Accordingly, we studied the prevalence of ACVEs associated with venomous snakebites in Korea and compared the clinical features of patients with and without ACVEs.

MATERIALS AND METHODS

A retrospective review was conducted on 65 consecutive venomous snakebite cases diagnosed and treated at the emergency department of Wonju Severance Christian Hospital between May 2011 and October 2014. ACVEs were defined as the occurrence of at least one of the following: 1) myocardial injury, 2) shock, 3) ventricular dysrhythmia, or 4) cardiac arrest.

RESULTS

Nine (13.8%) of the 65 patients had ACVEs; myocardial injury (9 patients, 13.8%) included high sensitivity troponin I (hs-TnI) elevation (7 patients, 10.8%) or electrocardiogram (ECG) determined ischemic change (2 patients, 3.1%), and shock (2 patient, 3.1%). Neither ventricular dysrhythmia nor cardiac arrest was observed. The median of elevated hs-TnI levels observed in the present study were 0.063 ng/mL (maximum: 3.000 ng/mL) and there was no mortality in the ACVEs group. Underlying cardiac diseases were more common in the ACVEs group than in the non-ACVEs group (p=0.017). Regarding complications during hospitalization, 3 patients (5.4%) in the non-ACVEs group and 3 patients (33.3%) in the ACVEs group developed bleeding (p=0.031).

CONCLUSION

Significant proportion of the patients with venomous snakebite is associated with occurrence of ACVEs. Patients with ACVEs had more underlying cardiac disease and bleeding complication.

The Use of Delta Neutrophil Index and Myeloperoxidase Index for Predicting Acute Complicated Appendicitis in Children

BACKGROUND

In children with acute appendicitis, 30% to 75% present with a complication, such as perforation, and the early diagnosis of complications is known to improve outcomes. Serum delta neutrophil index (DNI) and myeloperoxidase index (MPXI) are new inflammatory markers, and thus, in the present study, the authors evaluated the predictive values of these two markers for the presence of a complication in children with acute appendicitis.

METHODS

This retrospective observational study was conducted on 105 consecutive children (<12 years old) with acute appendicitis treated over a 31-month period. DNI, MPXI, C-reactive protein (CRP), and white blood cells (WBCs) were measured in an emergency department and investigated with respect to their abilities to predict the presence of acute complicated appendicitis.

RESULTS

Twenty-nine of the 105 patients (median age, 9 years) were allocated to the complicated group (27.6%) and 76 to the non-complicated group (72.4%). Median serum DNI and CRP were significantly higher in the complicated group [0% vs. 2.2%, p<0.001 and 0.65 mg/dL vs. 8.0 mg/dL, p<0.001], but median MPXI was not (p = 0.316). Area under curve (AUC) for the ability of serum DNI and CRP to predict the presence of acute complicated appendicitis were 0.738 and 0.840, respectively. Multiple logistic regression analyses showed initial CRP [odds ratio 1.301, 95% confidence interval (1.092-1.549), p = 0.003] significantly predicted the presence of a complication. The optimal cutoff for serum CRP was 4.0 mg/dL (sensitivity 69%, specificity 83%, AUC 0.840).

CONCLUSIONS

Although serum DNI values were significantly higher in children with acute complicated appendicitis, no evidence was obtained to support the notion that serum DNI or serum MPXI aid the differentiation of acute complicated and non-complicated appendicitis in the ED setting.

Initial Serum Ammonia as a Predictor of Neurologic Complications in Patients with Acute Glufosinate Poisoning

PURPOSE

Glufosinate poisoning can cause neurologic complications that may be difficult to treat due to delayed manifestation. Studies assessing possible predictors of complications are lacking. Although serum ammonia level is a potential predictor of severe neurotoxicity, it has only been assessed via case reports. Therefore, we investigated factors that predict neurologic complications in acute glufosinate-poisoned patients.

MATERIALS AND METHODS

We conducted a retrospective review of 45 consecutive glufosinate-poisoning cases that were diagnosed in the emergency department (ED) of Wonju Severance Christian Hospital between May 2007 and July 2014. Patients with a Glasgow Coma Scale (GCS) score of <8, seizure, and/or amnesia were defined to a neurologic complication group.

RESULTS

The neurologic complication group (29 patients, 64.4%) comprised patients with GCS<8 (27 patients, 60.0%), seizure (23 patients, 51.1%), and amnesia (5 patients, 11.1%). Non-neurologic complications included respiratory failure (14 patients, 31.1%), intubation and ventilator care (23 patients, 51.1%), shock (2 patients, 4.4%), pneumonia (16 patients, 35.6%), acute kidney injury (10 patients, 22.2%), and death (4 patients, 8.9%). Complications of GCS<8, seizure, respiratory failure, and intubation and ventilator care appeared during latent periods within 11 hrs, 34 hrs, 14 hrs, and 48 hrs, respectively. Initial serum ammonia was a predictor of neurologic complications [odds ratio 1.039, 95% confidence interval (1.001-1.078), p=0.046 and area under the curve 0.742].

CONCLUSION

Neurologic complications developed in 64.4% of patients with acute glufosinate poisoning. The most common complication was GCS<8. Initial serum ammonia level, which can be readily assessed in the ED, was a predictor of neurologic complications.

Comparison Between 30:1 and 30:2 Compression-to-ventilation Ratios for Cardiopulmonary Resuscitation: Are Two Ventilations Necessary?

OBJECTIVES

Controversy is continuing over the need for ventilation and the optimal compression-ventilation (CV) ratio during cardiopulmonary resuscitation (CPR). The aim of this study was to comparatively elucidate the effect on hemodynamics and arterial oxygen saturation of a single ventilation relative to two consecutive ventilations during CPR in a dog model of cardiac arrest.

METHODS

Twenty mongrel dogs were divided into two groups. After 3 minutes of ventricular fibrillation (VF), the single-ventilation group received CPR with a 30:1 CV ratio, and the two-ventilation group received CPR with a 30:2 CV ratio, all with room air for 7 minutes. Thereafter, continuous chest compressions and intermittent ventilation at rate of 10 per minute were followed for both groups for 10 minutes. Hemodynamic parameters, arterial blood gas profiles, and variables from CPR were compared at baseline and at 5, 10, 15, and 20 minutes after induction of VF.

RESULTS

Hemodynamic parameters including aortic systolic and diastolic pressures, right atrial systolic and diastolic pressures, coronary perfusion pressure, end-tidal carbon dioxide tension, and arterial blood gas profiles including arterial oxygen tension, arterial oxygen saturation, and arterial carbon dioxide tension were not different between two groups during CPR. In the 30:1 group, the period of compression interruption was shorter and chest compression fraction was higher than that in the 30:2 group (6 sec/min vs. 10.9 sec/min, p < 0.001; 90.0% vs. 81.8%, p < 0.001).

CONCLUSIONS

CPR with a 30:1 CV ratio, compared to CPR with a 30:2 CV ratio, results in comparable arterial oxygenation saturation and hemodynamics.

Shock duration after resuscitation is associated with occurrence of post-cardiac arrest acute kidney injury

This retrospective observational study investigated the clinical course and predisposing factors of acute kidney injury (AKI) developed after cardiac arrest and resuscitation. Eighty-two patients aged over 18 yr who survived more than 24 hr after cardiac arrest were divided into AKI and non-AKI groups according to the diagnostic criteria of the Kidney Disease/Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for AKI. Among 82 patients resuscitated from cardiac arrest, AKI was developed in 66 (80.5%) patients (AKI group) leaving 16 (19.5%) patients in the non-AKI group. Nineteen (28.8%) patients of the AKI group had stage 3 AKI and 7 (10.6%) patients received renal replacement therapy during admission. The duration of shock developed within 24 hr after resuscitation was shorter in the non-AKI group than in the AKI group (OR 1.02, 95% CI 1.01-1.04, P < 0.05). On Multiple logistic regression analysis, the only predisposing factor of post-cardiac arrest AKI was the duration of shock. In conclusion, occurrence and severity of post-cardiac arrest AKI is associated with the duration of shock after resuscitation. Renal replacement therapy is required for patients with severe degree (stage 3) post-cardiac arrest AKI.

Differential outcome of fissure-positioned tube in closed thoracostomy for primary spontaneous pneumothorax

Closed tube thoracostomy is often used to evacuate a primary spontaneous pneumothorax (PSP). Occasionally, this procedure is complicated by placement of the chest tube location in the fissural area instead of pleural space. There is a paucity of studies on outcomes according to chest tube placement. As such, we investigated outcomes of chest tube placement in fissural versus pleural area in closed thoracostomy for PSP. Patients between 14 and 65 years of age who had been treated with chest tube insertion to evacuate PSP were selected based on retrospective review of medical records. Patients selected for this study received chest tube placement at either the fissural or pleural spaces. Those with pre-existing lung disease or those transferred into our hospital after closed thoracostomy were excluded. Of the 255 patients with PSP treated with chest tube insertion, 172 patients were enrolled in this study. Twenty-nine (16.9%) had fissural tube placement and 143 (83.1%) had pleural tube placement. A higher proportion of patients in the fissural versus pleural group required additional chest tube insertion (20.7% vs 4.9%, P = 0.010, respectively). There was no significant difference in body mass index, smoker status, symptom duration, number of episodes, post-thoracostomy complications, need for subsequent management, and duration of hospitalization in either group. In closed thoracostomy for PSP, there is a higher chance of tube dysfunction when the chest tube is positioned at fissural area as compared with the pleural space.

Differential Outcome of Fissure-positioned Tube in Closed Thoracostomy for Primary Spontaneous Pneumothorax

Closed tube thoracostomy is often used to evacuate a primary spontaneous pneumothorax (PSP). Occasionally, this procedure is complicated by placement of the chest tube location in the fissural area instead of pleural space. There is a paucity of studies on outcomes according to chest tube placement. As such, we investigated outcomes of chest tube placement in fissural versus pleural area in closed thoracostomy for PSP. Patients between 14 and 65 years of age who had been treated with chest tube insertion to evacuate PSP were selected based on retrospective review of medical records. Patients selected for this study received chest tube placement at either the fissural or pleural spaces. Those with pre-existing lung disease or those transferred into our hospital after closed thoracostomy were excluded. Of the 255 patients with PSP treated with chest tube insertion, 172 patients were enrolled in this study. Twenty-nine (16.9%) had fissural tube placement and 143 (83.1%) had pleural tube placement. A higher proportion of patients in the fissural versus pleural group required additional chest tube insertion (20.7% vs 4.9%, P = 0.010, respectively). There was no significant difference in body mass index, smoker status, symptom duration, number of episodes, post-thoracostomy complications, need for subsequent management, and duration of hospitalization in either group. In closed thoracostomy for PSP, there is a higher chance of tube dysfunction when the chest tube is positioned at fissural area as compared with the pleural space.

Evaluation of usefulness of myeloperoxidase index (MPXI) for differential diagnosis of systemic inflammatory response syndrome (SIRS) in the emergency department

BACKGROUND

The myeloperoxidase index (MPXI) is elevated in infection. We ascertained whether MPXI might be useful in differentiation of sepsis versus non-infectious systemic inflammatory response syndrome (SIRS) in emergency department (ED).

METHODS

After exclusion of patients with an age of <18 years, trauma, haematological disease and on anticancer chemotherapy, 444 consecutive cases with SIRS (sepsis: 224, 50.3%; and non-infectious SIRS: 220, 49.7%) diagnosed and treated at the ED of The Wonju Severance Christian Hospital from May 2012 to June 2012 were retrospectively reviewed.

RESULTS

Median MPXI was higher in sepsis versus non-infectious SIRS (0.1 (IQR: -3.1 to 2.5) vs -1.2 (-4.1 to 1.6), respectively, p=0.020). Median white cell count, neutrophil percentage, C reactive protein level and δ neutrophil index were also higher. However, MPXI resulted as not statistically useful for differential diagnostic parameter in analysis.

CONCLUSIONS

MPXI is higher in sepsis than in non-infectious SIRS. However, there is currently no evidence that the MPXI adds any additional benefit to differentiate sepsis from non-infectious SIRS in the ED. Therefore, further study will be needed.

Pyrethroid poisoning: features and predictors of atypical presentations

BACKGROUND

Although pyrethroids are known for low toxicity to humans, clinical systemic characteristics of pyrethroid poisoning remain undefined. We investigated atypical presentations of pyrethroid poisoning and the predictors, among those readily assessed in the emergency department.

METHODS

59 pyrethroid poisoning cases that were diagnosed and treated at the emergency department of Wonju Severance Christian Hospital from September 2004 to December 2012 were retrospectively reviewed.

RESULTS

Atypical presentations were seen in 22 patients (39.3%). Atypical presentations after pyrethroid poisoning included respiratory failure requiring ventilator care (10 patients, 17.9%), hypotension (systolic blood pressure <90 mm Hg) (6 patients, 10.7%), pneumonia (4 patients, 7.1%), acute kidney injury (6 patients, 10.7%), Glasgow Coma Scale (GCS) <15 (19 patients, 33.9%), seizure (2 patients, 3.6%) and death (2 patients, 3.6%). There were differences between atypical versus typical groups in terms of age (62.1±3.7 vs 51.0±2.9, p=0.020), ingested amounts (300 (IQR 100-338) cc vs 100 (IQR 50-300) cc, p=0.002), and bicarbonate and serum lactate (17.4±1.1 vs 20.5±0.4, p=0.011; and 4.42 (IQR 3.60-7.91) mmol/L vs 3.01 (IQR 2.16-4.73) mmol/L, p=0.010, respectively) in initial arterial blood gas analysis. Predictors of the atypical presentations were ingested amount and serum lactate ((OR 1.004, 95% CI 1.001 to 1.008, p=0.013) and (OR 1.387, CI 1.074 to 1.791, p=0.012), respectively). The optimal points were 250 cc and 3.5 mmol/dL.

CONCLUSIONS

39.3% of pyrethroid poisoned patients had atypical presentations with the most common being respiratory failure requiring ventilator care. Predictors of atypical presentation were ingested amount >250 cc and serum lactate >3.5 mmol/L.