Risk factors affecting severe thoracic injuries in motor vehicle collisions based on age group and collision directions

OBJECTIVE

This study aimed to investigate the effect of age and collision direction on the severity of thoracic injuries based on a real-world crash database.

METHODS

This was a retrospective, observational study. We used the Korean In-Depth Accident Study (KIDAS) database, which was collected from crash injury patients who visited emergency medical centers between January 2011 and February 2022 in Korea. Among the 4520 patients enrolled in the database, we selected 1908 adult patients with abbreviated injury scale (AIS) scores between 0 and 6 in the thoracic region. We classified patients with an AIS score of 3 or higher into the severe injury group.

RESULTS

The incidence rate of severe thoracic injuries due to motor vehicle accidents was 16.4%. Between the severe and non-severe thoracic injury groups, there were significant differences in sex, age, collision direction, crash object, seatbelt use, and delta-V parameters. Among the age groups, over 55 years occupants had a higher risk in the thoracic regions than those under 54 years occupants. The risk of severe thoracic injury was highest in near-side collisions in all collision directions. Far-side and rear-end collisions showed a lower risk than frontal collisions. Occupants with unfastened seatbelts were at greater risk.

CONCLUSIONS

The risk of severe thoracic injury is high in near-side collisions among elderly occupants. However, the risk of injury for elderly occupants increases in a super-aging society. To reduce thoracic injury, safety features made for elderly occupants in near-side collisions are required.

A predictive model to analyze the factors affecting the presence of serious chest injury in the occupants on motor vehicle crashes: Logistic regression approach

OBJECTIVE

Chest injuries that occur in motor vehicle crashes (MVCs) include rib fractures, pneumothorax, hemothorax, and hemothorax depending on the injury mechanism. Many risk factors are associated with serious chest injuries from MVCs. The Korean In-Depth Accident Study database was analyzed to identify risk factors associated with motor vehicle occupants' serious chest injury.

METHODS

Among 3,697 patients who visited the emergency room in regional emergency medical centers after MVCs between 2011 and 2018, we analyzed data from 1,226 patients with chest injuries. Vehicle damage was assessed using the Collision Deformation Classification (CDC) code and images of the damaged vehicle, and trauma scores were used to determine injury severity. Serious chest injury was defined as an Abbreviated Injury Scale (AIS) score for the chest code was more than 3. The patients were divided into two groups: serious chest injury patients with MAIS ≥ 3 and those with non-serious chest injury with MAIS < 3. A predictive model to analyze the factors affecting the presence of serious chest injury in the occupants on MVCs was constructed by a logistic regression analysis.

RESULTS

Among the 1,226 patients with chest injuries, 484 (39.5%) had serious chest injuries. Patients in the serious group were older than those in the non-serious group (p=.001). In analyses based on vehicle type, the proportion of light truck occupants was higher in the serious group than in the non-serious group (p=.026). The rate of seatbelt use was lower in the serious group than in the non-serious group (p=.008). The median crush extent (seventh column of the CDC code) was higher in the serious group than in the non-serious group (p<.001). Emergency room data showed that the rates of intensive care unit (ICU) admission and death were higher among patients with serious injuries (p<.001). Similarly, the general ward/ICU admission data showed that the transfer and death rates were higher in patients with serious injuries (p<.001). The median ISS was higher in the serious group than in the non-serious group (p<.001). A predictive model was derived based on sex, age, vehicle type, seating row, belt status, collision type, and crush extent. This predictive model had an explanatory power of 67.2% for serious chest injuries. The model was estimated for external validation using the confusion matrix by applying the predictive model to the 2019 and 2020 data of the same structure as the data at the time of model development in the KIDAS database.

CONCLUSIONS

Although this study had a major limitation in that the explanatory power of the predictive model was weak due to the small number of samples and many exclusion conditions, it was meaningful in that it suggested a model that could predict serious chest injuries in motor vehicle occupants (MVOs) based on actual accident investigation data in Korea. Future studies should yield more meaningful results, for example, if the chest compression depth value is derived through the reconstruction of MVCs using accurate collision speed values, and better models can be developed to predict the relationship between these values and the occurrence of serious chest injury.

Machine learning-based injury severity prediction of level 1 trauma center enrolled patients associated with car-to-car crashes in Korea

Injury prediction models enables to improve trauma outcomes for motor vehicle occupants in accurate decision-making and early transport to appropriate trauma centers. This study aims to investigate the injury severity prediction (ISP) capability in machine-learning analytics based on five-different regional Level 1 trauma center enrolled patients in Korea. We study car crash-related injury data of 1417 patients enrolled in the Korea In-Depth Accident Study database from January 2011 to April 2021. Severe injury classification was defined using an Injury Severity Score of 15 or greater. A planar crash was considered by excluding rollovers to compromise an accurate prediction. Furthermore, dissimilarities of the collision partner component based on vehicle segmentation were assumed for crash incompatibility. To handle class-imbalanced clinical datasets, we used four data-sampling techniques (i.e., class-weighting, resampling, synthetic minority oversampling, and adaptive synthetic sampling). Machine-learning analytics based on logistic regression, extreme gradient boosting (XGBoost), and a multilayer perceptron model were used for the evaluations. Each model was executed using five-fold cross-validation to solve overfitting consistent with the hyperparameters tuned to improve model performance. The area under the receiver operating characteristic curve of 0.896. Additionally, the present ISP model showed an under-triage rate of 6.1%. The Delta-V, age, and Principal ~ were significant predictors. The results demonstrated that the data-balanced XGBoost model achieved a reliable performance on injury severity classification of emergency department patients. This finding considers ISP model selection, which affected prediction performance based on overall predictor variables.

National Follow-up Survey of Preventable Trauma Death Rate in Korea

BACKGROUND

The preventable trauma death rate survey is a basic tool for the quality management of trauma treatment because it is a method that can intuitively evaluate the level of national trauma treatment. We conducted this study as a national biennial follow-up survey project and report the results of the review of the 2019 trauma death data in Korea.

METHODS

From January 1, 2019 to December 31, 2019, of a total of 8,482 trauma deaths throughout the country, 1,692 were sampled from 279 emergency medical institutions in Korea. All cases were evaluated for preventability of death and opportunities for improvement using a multidisciplinary panel review approach.

RESULTS

The preventable trauma death rate was estimated to be 15.7%. Of these, 3.1% were judged definitive preventable deaths, and 12.7% were potentially preventable deaths. The odds ratio for preventable traumatic death was 2.56 times higher in transferred patients compared to that of patients who visited the final hospital directly. The group that died 1 hour after the accident had a statistically significantly higher probability of preventable death than that of the group that died within 1 hour after the accident.

CONCLUSION

The preventable trauma death rate for trauma deaths in 2019 was 15.7%, which was 4.2%p lower than that in 2017. To improve the quality of trauma treatment, the transfer of severe trauma patients to trauma centers should be more focused.

Preventive Effectiveness of Thoracic Side Airbags in Side-Impact Crashes Based on Korea In-Depth Accident Study (KIDAS) Database

Studies on the effectiveness of thoracic side airbags (tSABs) in preventing thoracic injuries is limited and conflicting. This retrospective observational study aims to evaluate the effectiveness of tSABs in side-impact crashes based on data for motor vehicle occupants (MVOs) who visited an emergency department in Korea. The data were obtained from the Korean In-Depth Accident Study (KIDAS) database for patients treated at Wonju Severance Christian Hospital between January 2011 and April 2020. Of the 3899 patients with road traffic injuries, data for 490 patients were used. The overall frequency of tSAB deployment in side-impact crashes was found to be 8.1%. In the multivariate analysis, elderly age, near-side impact, colliding with fixed objects, non-oblique force, and higher crush extent were found to be factors associated with higher thoracic injuries (Abbreviated Injury Scale ≥ 2). MVOs in crashes with tSAB deployment were at an increased risk of injury compared with MVOs in crashes with no deployment, but no statistical difference was observed [adjusted odds ratios (AORs): 1.65 (0.73-3.73)]. Further, the incidence of lung injury and rib fractures increased with tSAB activation (p < 0.05). These results demonstrate the limited capability of tSABs in preventing thoracic injuries in motor vehicle crashes.

National trauma system establishment based on implementation of regional trauma centers improves outcomes of trauma care: A follow-up observational study in South Korea

Although South Korea is a high-income country, its trauma system is comparable to low- and middle-income countries with high preventable trauma death rates of more than 30%. Since 2012, South Korea has established a national trauma system based on the implementation of regional trauma centers and improvement of the transfer system; this study aimed to evaluate its effectiveness. We compared the national preventable trauma death rates, transfer patterns, and outcomes between 2015 and 2017. The review of preventable trauma deaths was conducted by multiple panels, and a severity-adjusted logistic regression model was created to identify factors influencing the preventable trauma death rate. We also compared the number of trauma patients transferred to emergency medical institutions and mortality in models adjusted with injury severity scores. The preventable trauma death rate decreased from 2015 to 2017 (30.5% vs. 19.9%, p < 0.001). In the severity-adjusted model, the preventable trauma death risk had a lower odds ratio (0.68, 95% confidence interval: 0.53-0.87, p = 0.002) in 2017 than in 2015. Regional trauma centers received 1.6 times more severe cases in 2017 (according to the International Classification of Diseases Injury Severity Score [ICISS]; 23.1% vs. 36.5%). In the extended ICISS model, the overall trauma mortality decreased significantly from 2.1% (1008/47 806) to 1.9% (1062/55 057) (p = 0.041). The establishment of the national trauma system was associated with significant improvements in the performance and outcomes of trauma care. This was mainly because of the implementation of regional trauma centers and because more severe patients were transferred to regional trauma centers. This study might be a good model for low- and middle-income countries, which lack a trauma system.

Analysis of the Impact of the Coronavirus Disease Epidemic on the Emergency Medical System in South Korea Using the Korean Triage and Acuity Scale

PURPOSE

Severe acute respiratory syndrome coronavirus 2, which causes coronavirus disease 2019 (COVID-19), has spread worldwide. Global health systems, including emergency medical systems, are suffering from a lack of medical resources. Using a method for classifying patients visiting the emergency department (ED), we aimed to investigate trends in emergency medical system usage during the COVID-19 epidemic in Korea.

MATERIALS AND METHODS

This retrospective observational study included patients who visited emergency medical institutions registered with the National Emergency Department Information System database from January 1, 2017 to May 31, 2020. The primary outcome was identification of changes in the distribution of patients visiting the ED according to the type of emergency medical institution. The secondary outcome was a detailed comparison of Korean Triage and Acuity Scale (KTAS) levels and patient distributions before and during the infectious disaster crisis period.

RESULTS

Severe patients visited regional emergency centers (RECs) and local emergency centers (LECs) more frequently during the COVID-19 period, and disposition status warranting admission to the intensive care unit or resulting in death was more common in RECs and LECs during the COVID-19 period [RECs, before COVID-19: 300686 (6.3%), during COVID-19: 33548 (8.0%) (p<0.001); LECs, before COVID-19: 373593 (3.7%), during COVID-19: 38873 (4.5%) (p<0.001)].

CONCLUSION

During the COVID-19 period, severe patients were shifted to advanced emergency medical institutions, and the KTAS better reflected severe patients. Patient distribution according to the stage of emergency medical institution improved, and validation of the KTAS triage increased more in RECs.

A Predictive Model to Analyze the Factors Affecting the Presence of Traumatic Brain Injury in the Elderly Occupants of Motor Vehicle Crashes Based on Korean In-Depth Accident Study (KIDAS) Database

Traumatic brain injury (TBI), also known as intracranial injury, occurs when an external force injures the brain. This study aimed to analyze the factors affecting the presence of TBI in the elderly occupants of motor vehicle crashes. We defined elderly occupants as those more than 55 years old. Damage to the vehicle was presented using the Collision Deformation Classification (CDC) code by evaluation of photos of the damaged vehicle, and a trauma score was used for evaluation of the severity of the patient’s injury. A logistic regression model was used to identify factors affecting TBI in elderly occupants and a predictive model was constructed. We performed this study retrospectively and gathered all the data under the Korean In-Depth Accident Study (KIDAS) investigation system. Among 3697 patients who visited the emergency room in the regional emergency medical center due to motor vehicle crashes from 2011 to 2018, we analyzed the data of 822 elderly occupants, which were divided into two groups: the TBI patients (N = 357) and the non-TBI patients (N = 465). According to multiple logistic regression analysis, the probabilities of TBI in the elderly caused by rear-end (OR = 1.833) and multiple collisions (OR = 1.897) were higher than in frontal collision. Furthermore, the probability of TBI in the elderly was 1.677 times higher in those with unfastened seatbelts compared to those with fastened seatbelts (OR = 1.677). This study was meaningful in that it incorporated several indicators that affected the occurrence of the TBI in the elderly occupants. In addition, it was performed to determine the probability of TBI according to sex, vehicle type, seating position, seatbelt status, collision type, and crush extent using logistic regression analysis. In order to derive more precise predictive models, it would be needed to analyze more factors for vehicle damage, environment, and occupant injury in future studies.

Characteristics of pediatric thoracic trauma: in view of before and after the establishment of a regional trauma center

Purpose

Pediatric thoracic trauma differs from those of adult in terms of the small anatomy and rapid tissue recovery. Therefore, it is important to know the characteristics of the pediatric thoracic trauma to improve treatment results. In addition, this study examined the changes in pediatric thoracic trauma features and results from the establishment of a level 1 regional trauma center.

Methods

Data of 168 patients’ ≤ 15 years old diagnosed with thoracic trauma between 2008 and 2019 were retrospectively analyzed.

Results

Pedestrian traffic accidents were the most common cause of chest injury. The average injury severity score was 17.1 ± 12.4 and the average pediatric trauma score was 5.6 ± 4.1. Lung contusion was the most common in 134 cases. There were 48 cases of closed thoracostomy. There was one thoracotomy for cardiac laceration, one case for extracorporeal membranous oxygenation, and six cases for embolization. Of all, 25 patients died, providing a mortality rate of 14.9%. In addition, independent risk factors of in-hospital mortality were hemopneumothorax and cardiac contusion. Since 2014, when the level 1 regional trauma center was established, more severely injured thoracic trauma patients came. However, the mortality was similar in the two periods.

Conclusions

Understanding the clinical features of pediatric thoracic trauma patients can help in efficient treatment. In addition, as the severity of pediatric thoracic trauma patients has increased due to the establishment of the regional trauma center, so pediatric trauma center should be organized in regional trauma center to improve the outcomes of pediatric thoracic trauma.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01658-4.

Future development of helicopter emergency medical services in Korea

This paper discusses the future development of air ambulance operations in Korea. Helicopter emergency medical services are a useful means of transporting critically ill patients to the right hospital, at the right time. It is an important element of the emergency medical system to treat acute diseases at the scene, or in transit. For more efficient operations of the emergency medical helicopters (air ambulances or the so-called ‘Doctor Helgi’ in Korea), various challenges are faced. These include, the expansion of air ambulance bases, proper placement of rendezvous points (landing point), increase of field transport requests, and the operation of night missions. First, it is necessary to reduce the disparity in the benefits of emergency medical care for critically ill patients through the expansion of helicopter bases. Second, through the advancement of joint operations of the pan-ministerial emergency medical helicopters, the time from dispatch to helicopter take-off should be minimized, and a quality improvement program for air transportation should be carried out. Third, it is necessary to increase the number of insufficient rendezvous points and ensure the safety of the helicopters during takeoff and landing, to activate field transportation. Finally, the safety of patients and medical staff should be secured through the systematic preparation of the air transport system for future night missions. To solve these tasks, an appropriate legal system for helicopter emergency medical service is required. Based on the improved system, it is expected that everyone will enjoy equal rights for health, regardless of the regions.

Preventable Trauma Death Rate after Establishing a National Trauma System in Korea

BACKGROUND

This study aimed to evaluate the current overall preventable trauma death rate (PTDR) in Korea and identify factors associated with preventable trauma death (PTD).

METHODS

The target sample size for review was designed to be 1,131 deaths in 60 emergency medical institutions nationwide. The panels for the review comprised trauma specialists working at the regional trauma centers (RTCs); a total of 10 teams were formed. The PTDR and factors associated with PTD were analyzed statistically.

RESULTS

Of the target cases, 943 were able to undergo panel review and be analyzed statistically. The PTDR was 30.5% (6.1% preventable and 24.4% possibly preventable). Those treated at a RTC showed a significantly lower PTDR than did those who were not (21.9% vs. 33.9%; P = 0.002). The PTDR was higher when patients were transferred from other hospitals than when they directly visited the last hospital (58.9% vs. 28.4%; P = 0.058; borderline significant). The PTDR increased gradually as the time from accident to death increased; a time of more than one day had a PTDR 14.99 times higher than when transferred within one hour (95% confidence interval, 4.68 to 47.98).

CONCLUSION

Although the PTDR in Korea is still high compared to that in developed countries, it was lower when the time spent from the accident to the death was shorter and the final destined institution was the RTC. To reduce PTDR, it is necessary to make an effort to transfer trauma patients to RTCs directly within an appropriate time.

Assessment of the disaster medical response system through an investigation of a 43-vehicle mass collision on Jung-ang expressway

PURPOSE

It was considered the challenges of the actual response and the potential for improvement, including the activities of the disaster response system, national emergency medical center, and the regional base hospital for the treatment of multiple traffic accident victims. The purpose of this study was to analyze the accident management system through real investigating the multiple collision over 10 vehicles with mass casualty events as a disaster situation.

METHODS

This study was retrospective study to analyze the disaster event with multiple collision traffic accident on the expressway in Korea. We visited five medical centers for eight days since the accident occurred and interviewed the injured patients in this accident to examine the health status and medical records. After that, we visited the sixteen car-repair shops in four cities for real investigate about damaged vehicles. According to the arrangement of the accident situation for the accident vehicles through real-world investigation, we reproduced all parts of the accident scene, which were real-world investigated, by the accident situation sketch program. The collected data were summarized by Collision Deformation Classification (CDC) codes, and the medical records of the occupants were assessed using the Injury Severity Score (ISS).

RESULTS

The cause of the accident was snow freezing of the road. The information about 72 injured patients on 31 damaged vehicles was collected by phone, visit, and actual accident investigation. Of the 72 patients who were examined, 4 were severely injured and 68 were mildly injured. The accident occurred in the order of Sedan 13 (41.9%), SUV 11 (35.5%), Truck 4 (12.9%), Van 2 (6.5%) and Bus 1 (3.2%). The median value of the age [lower quartile and upper quartile] was 43 [34.5-52] years old and the patients included 25 drivers, 11 passengers, 7 back seat passengers, and 29 bus passengers.

CONCLUSION

The primary cause of this mass collision accident was road surface freezing, but the more serious secondary cause was a driver's inability to avoid the accident scene after the first collision. The severely injured occupants were occurred on the roads outside and inside the vehicle. In the event of a disaster, various teams from the police team, firefighting team, DMAT, EMS, road management team are gathered, and communication and command system between each team is important in order to identify and solve the disaster situation. To do this, it is important to develop manuals and prepare for training through repeated simulations.

Correlation between the pre-hospital triage scale and emergency department triage scale

Background:

While emergency patient triage system is effective when the pre-hospital triage acuity scale is linked with the in-hospital triage acuity scale. However, the 119 emergency medical triage system and the Korea Triage and Acuity Scale are not linked in Korea.

Objective:

This study aimed to investigate the correlation between the two triage systems and to utilize the results as basic data for the future development of a pre-hospital triage system.

Methods:

Among the 1114 patients who visited a regional emergency medical center by a 119 ambulance from April to May 2016, we analyzed the correlation between the pre-hospital and in-hospital triage systems based on the general characteristics of the patients and their reason of hospital visit (non-trauma or trauma).

Results:

Upon reclassifying the pre-hospital and in-hospital triage systems into three levels, among the 289 patients (28.1%) in level 3 of the pre-hospital triage, 79 (27.3%) were reclassified as the highest level (Resuscitation) in the in-hospital triage. The kappa coefficient as a measure of agreement between the two triage systems was very low at 0.211 (95% confidence interval, 0.164–0.258), and the kappa coefficient of the paramedic category was 0.232 (95% confidence interval, 0.161–0.303).

Conclusion:

There is a low agreement between the pre-hospital and in-hospital triage systems.

A predictive model to analyze factors affecting the presence of mild whiplash-associated disorders in minor motor vehicle crashes based on the Korean In-Depth Accidents Study (KIDAS) Database

OBJECTIVES

We aimed to analyze factors affecting the severity of mild whiplash-associated disorders (WADs) and to develop a predictive model to evaluate the presence of mild WAD in minor motor vehicle crashes (MVCs).

METHODS

We used the Korean In-Depth Accident Study (KIDAS) database, which collects data from 4 regional emergency centers, to obtain data from 2011 to 2017. The Collision Deformation Classification code was obtained as vehicle's damage information, and Abbreviated Injury Scale (AIS), Maximum Abbreviated Injury Scale (MAIS), and Injury Severity Score (ISS) were used as occupant's injury information. The degree of WAD was determined using the Quebec Task Force (QTF) classification, comprised of 5 stages (QTF 0-4), depending on the occupant's pain and the physician's findings. QTF 1 was defined as mild WAD, and we used QTF 0 to define those who were uninjured. For KIDAS data between 2011 and 2016, a logistic regression model was used to identify factors affecting the occurrence of mild WAD and a predictive model was constructed. Internal validity was estimated using random bootstrapping, and external validity was evaluated by applying 2017 KIDAS data. Of the 2,629 occupants in the KIDAS database from 2011 to 2016, after applying several exclusion conditions, 459 occupants were used to develop the predictive model. The external validity of the derived predictive model was assessed using the 13 MVC occupants from the 2017 KIDAS database meeting our inclusion criteria. Among the 137 MVC occupants from the 2017 KIDAS database for analysis of the external validity of the derived predictive model, the predictive model was verified for 13 MVC occupants.

RESULTS

Logistic regression analysis was used to derive a predictive model based on sex, age, body mass index, type of vehicle, belt status, seating row, crush type, and crush extent. This predictive model had an explanatory power of 65.5% to determine an actual QTF of 0 and 1 (c-statistics: 0.655). As a result of the external validity analysis of the predictive model using data from the 2017 KIDAS database (N = 13), sensitivity, specificity, and accuracy were 0.500, 0.857, and 0.692, respectively.

CONCLUSIONS

Using the predictive model, the results of the external validity analysis showed low sensitivity but high specificity. This predictive model provided meaningful results, with a high success rate for determining no injury to an occupant. Given our study results, future research is needed to create a more accurate predictive model that includes relevant technical and sociological factors.

Validation of the Korean criteria for trauma team activation

OBJECTIVE

We conducted a study to validate the effectiveness of the Korean criteria for trauma team activation (TTA) and compared its results with a two-tiered system.

METHODS

This observational study was based on data from the Korean Trauma Data Bank. Within the study period, 1,628 trauma patients visited our emergency department, and 739 satisfied the criteria for TTA. The rates of overtriage and undertriage in the Korean one-tiered system were compared with the two-tiered system recommended by the American College of Surgery-Committee on Trauma.

RESULTS

Most of the patient's physiologic factors reflected trauma severity levels, but anatomical factors and mechanism of injury did not show consistent results. In addition, while the rate of overtriage (64.4%) was above the recommended range according to the Korean criteria, the rate of undertriage (4.0%) was within the recommended range. In the simulated two-tiered system, the rate of overtriage was reduced by 5.5%, while undertriage was increased by 1.8% compared to the Korean activation system.

CONCLUSION

The Korean criteria for TTA showed higher rates of overtriage and similar undertriage rates compared to the simulated two-tier system. Modification of the current criteria to a two-tier system with special considerations would be more effective for providing optimum patient care and medical resource utilization.

Usefulness of delta neutrophil index for early prediction of overt disseminated intravascular coagulopathy in patients with venomous snakebite

Objective

Clinically, consumptive coagulopathy, such as disseminated intravascular coagulopathy (DIC), is the most important among the common venomous snakebite complications owing to the serious hemorrhage risk associated with this condition. We evaluated the predictive value of the delta neutrophil index (DNI)-a new indicator for immature granulocytes-for DIC diagnosis.

Methods

This retrospective observational study consecutively assessed adult patients with venomous snakebites for over 51 months. Patients were categorized into the no DIC and DIC groups. DNI values were measured within 24 hours after snakebite.

Results

Thirty patients (26.3%) developed DIC. The DIC group had significantly higher median initial DNI than the no DIC group (0% vs. 0.2%, P&lt;0.001). When the DIC group was divided into early and late groups (within and over 24 hours after snakebite, respectively), the DNI of the former was significantly higher than that of the latter and no DIC group. The late DIC group had significantly higher DNI than the no DIC group. Furthermore, DNI positively correlated with the DIC score (r=0.548, P&lt;0.001). The initial DNI (odds ratio, 4.449; 95% confidence interval, 1.738 to 11.388; P=0.002) was an early DIC predictor. The area under the curve based on the initial DNI's receiver operating characteristic curve was 0.724.

Conclusion

DNI values were significantly higher in the DIC group. Additionally, DNI was an early predictor of DIC development in patients with venomous snakebites in the emergency department.

Effect of Automated Simultaneous Sternothoracic Cardiopulmonary Resuscitation Device on Hemodynamics in Out-of-Hospital Cardiac Arrest Patients

BACKGROUND

An automatic simultaneous sternothoracic cardiopulmonary resuscitation (SST-CPR) device is an apparatus that performs CPR by providing simultaneous cyclic compressions of the thorax with a thoracic strap and compression of the sternum with a piston.

OBJECTIVE

This study was conducted to compare the hemodynamic effects of CPR with an automatic SST-CPR device to those with standard CPR (STD-CPR) in cardiac arrest patients.

METHODS

A randomized trial was performed on victims of out-of-hospital cardiac arrest resistant to initial 20 min of CPR after emergency department (ED) arrival. Patients were instrumented with femoral arterial and internal jugular venous lines before enrollment. Informed consent was waived per protocol. Patients were randomized to SST-CPR or STD-CPR based on the day of the month. The primary outcome was a comparison of the mean estimated coronary perfusion pressure (CPP) between SST-CPR and STD-CPR. The secondary outcome was a comparison of compression arterial systolic pressure, compression arterial diastolic pressure, right atrial systolic pressure, right atrial diastolic pressure, return of spontaneous circulation rate, survival to hospital admission, survival at 30 days, favorable neurologic outcomes at 30 days, and adverse events between two groups.

RESULTS

Of 62 patients with non-traumatic, adult, out-of-hospital cardiac arrest who presented to the ED, 24 received CPR with an automatic SST-CPR device (SST-CPR group), and 38 received standard CPR (STD-CPR group). Acquisition and analysis of hemodynamic data were completed in 11 (46%) patients in the SST-CPR group and 14 (37%) patients in the STD-CPR group. Compression arterial systolic pressure, right atrial systolic/diastolic pressures, and end-tidal carbon dioxide tension were not different between the two groups. Median compression arterial diastolic pressure (femoral arterial pressure during relaxation) was 20 mm Hg (mean 22 mm Hg; 95% confidence interval [CI] 5 to 38 mm Hg) and 0 mm Hg (mean -2 mm Hg; 95% CI -21 to 18 mm Hg) in the SST-CPR group and the STD-CPR group (p = 0.002), respectively. Median estimated CPP was 10 mm Hg (mean 16 mmHg; 95% CI 1 to 31 mm Hg) and 2 mm Hg (mean 4 mm Hg; 95% CI -4 to 12 mm Hg) in the SST-CPR group and the STD-CPR group (p = 0.017), respectively.

CONCLUSIONS

CPR with an automatic SST-CPR device results in higher estimated CPP compared to standard CPR in patients with non-traumatic, out-of-hospital cardiac arrest.

Injury analysis of patients according to impact patterns involved in pedestrian traffic crashes

OBJECTIVES

In cases of car-to-person pedestrian traffic crashes (PTCs), the principal issue is determining at what point the car collided with the pedestrian. Accordingly, the objective of the present study was to use the medical records of patients injured in PTCs to investigate the characteristics of crash types and the areas and injury severity and to determine whether there are differences in injuries due to the angle, motion, and position at the point of impact.

METHODS

The present study examined 231 PTC patients admitted to the emergency room (ER) between January and December 2014. Electronic medical records from the hospital were used to divide the patient data according to Abbreviated Injury Scale (AIS) codes for injured areas based on sex, age, time of the crash, outcomes after ER treatment, and major symptoms. Among 231 patients, police reports on 67 crash cases, involving 70 people, were obtained with the help of local police departments, and these reports were used to reconstruct details of the actual crash. For statistical analysis, a chi-square test and a one-way analysis of variance calculation were used to compare the Injury Severity Score (ISS) based on groups and stages, with a statistical significance level set to P < .05.

RESULTS

With respect to patients who were admitted for PTC, 52.4% were females and 47.6% were males. The frequency of crashes was high in middle-aged and elderly groups, as well as for youths between 10 and 19 years old. With respect to outcomes after ER treatment, discharge to home after symptom improvement was the most common outcome (24.6%). Admissions to the intensive care unit (25.1%) and to the general ward (23.8%) were also high. In terms of major symptoms, the most common injuries were to the head, resulting from a rotatory motion post impact (35.9%), and injuries to the legs, resulting from the impact of a direct collision with an object (25.1%).

CONCLUSIONS

This study demonstrated that injuries to the chest and abdomen were the most severe in the fender vault group and head and neck injuries were the most severe in the roof vault group. In particular, the Injury Severity Score was highest in the roof vault group.

Presence of chest tubes does not affect the hemodynamic efficacy of standard cardiopulmonary resuscitation

Background

During cardiopulmonary resuscitation (CPR), chest tubes can hinder increases in intrathoracic pressure by venting the pressure during chest compressions, thus reducing the blood flow generated by the thoracic pump effect. The aim of the present study was to investigate the effects of chest tubes on hemodynamic efficacy during standard CPR in a swine model of cardiac arrest.

Methods

Twelve domestic male pigs weighing 39.6 ± 8.4 kg underwent bilateral tube thoracostomy and received a total of 12 min of standard manual CPR, which comprised of two 6-min courses of CPR after 2 min of electrically induced ventricular fibrillation. Each 6-min set consisted of 3 min of CPR with clamped chest tubes (CCT-CPR) and 3 min of CPR with unclamped chest tubes (UCT-CPR). The sequence of CCT-CPR and UCT-CPR was randomized.

Results

Hemodynamic parameters including aortic pressure, left ventricular pressure, right ventricular pressure, right atrial pressure, and minimal and maximal dp/dt did not differ significantly between CCT-CPR and UCT-CPR. No significant differences were noted in carotid blood flow, end-tidal CO₂, or coronary perfusion pressure between CCT-CPR and UCT-CPR.

Conclusions

The presence of chest tubes did not affect the hemodynamic efficacy of standard CPR. There is no need to clamp chest tubes during standard CPR.

Analysis of injury mechanism of the elderly and non-elderly groups in minor motor vehicle accidents

OBJECTIVE

The purpose of this study is to investigate the injury patterns of noncatastrophic accidents by individual age groups.

METHODS

Data were collected from the Korean In-Depth Accident Study database based on actual accident investigation. The noncatastrophic criteria were classified according to U.S. experts from the Centers for Disease Control and Prevention's recommendations for field triage guidelines of high-risk automobile crash criteria by vehicle intrusions more than 12 in. on occupant sites (including the roof) and more than 18 in. on any site. The Abbreviated Injury Scale (AIS) was used to determine injury patterns for each body region. Severely injured patients were classified as Maximum Abbreviated Injury Scale (MAIS) 3 or higher.

RESULTS

In this study, the most significant injury regions were the head and neck, extremities, and thorax. In addition, the incidence of severe injury among elderly patients was nearly 1.6 times higher than that of non-elderly patients. According to age group, injured body regions among the elderly were the thorax, head and neck, and extremities, in that order. For the non-elderly groups, these were head and neck, extremities, and thorax. Severe injury rates were slightly different for the elderly group (head and neck, abdomen) and non-elderly group (thorax, head and neck).

CONCLUSIONS

In both age groups, the rate of severe injury is proportional to an increase in crush extent zone. Front airbag deployment may have a relatively significant relationship to severe injuries.

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.