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.

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.

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.

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.

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.

Mismatches Between the Number of Installed Automated External Defibrillators and the Annual Rate of Automated External Defibrillator Use Among Places.

AIM: In South Korea, the law concerning automated external defibrillators (AEDs) states that they should be installed in specific places including apartment complexes. This study was conducted to investigate the current status and effectiveness of installation and usage of AEDs in South Korea. METHODS: Installation and usage of AEDs in South Korea is registered in the National Emergency Medical Center (NEMC) database. Compared were the installed number, usage, and annual rate of AED use according to places of installation. All data were obtained from the NEMC database. RESULTS: After excluding AEDs installed in ambulances or fire engines (n = 2,003), 36,498 AEDs were registered in South Korea from 1998 through 2018. A higher number of AEDs were installed in places required by the law compared with those not required by the law (20,678 [56.7%] vs. 15,820 [43.3%]; P <.001). Among them, 11,318 (31.0%) AEDs were installed in apartment complexes. The overall annual rate of AED use was 0.38% (95% CI, 0.33-0.44). The annual rate of AED use was significantly higher in places not required by the law (0.62% [95% CI, 0.52-0.72] versus 0.21% [95% CI, 0.16-0.25]; P <.001). The annual rate of AED use in apartment complexes was 0.13% (95% CI, 0.08-0.17). CONCLUSION: There were significant mismatches between the number of installed AEDs and the annual rate of AED use among places. To optimize the benefit of AEDs in South Korea, changes in the policy for selecting AED placement are needed.

Diagnosis of aortic dissection by transesophageal echocardiography during cardiopulmonary resuscitation.

OBJECTIVES: Early identification of the causes of cardiac arrest is helpful in determining the resuscitation measures during cardiopulmonary resuscitation (CPR). We aimed to evaluate the feasibility of transesophageal echocardiography (TEE) during CPR in diagnosing aortic dissection and the influence of aortic dissection on resuscitation outcome in adult patients with prolonged non-traumatic cardiac arrest. METHODS: Adult patients aged >20 years with non-traumatic cardiac arrest who underwent prolonged CPR (>10 min) and TEE examination during CPR were enrolled. The enrolled patients were grouped according to the presence of aortic dissection on TEE: the aortic dissection (AD) group and the non-AD group. Variables related to cardiac arrest event, CPR, and resuscitation outcome were compared between the two groups. RESULTS: Forty-five patients (median age, 71 years; 26 men) were enrolled. Ten (22.2%) and 35 (77.8%) patients were included in the AD and non-AD groups, respectively. No patients in the AD group survived. Aortic dissection on TEE was inversely related to the rate of return of spontaneous circulation on multivariate analysis (odds ratio, 0.019; 95% confidence interval, 0.001-0.750; p = .035). CONCLUSION: TEE is a useful tool for diagnosing aortic dissection as a cause of cardiac arrest during CPR. Aortic dissection is associated with poor resuscitation outcomes.

Comparative Study on the Outcome of Stroke Patients Transferred by Doctor Helicopters and Ground Ambulances in South Korea: A Retrospective Controlled Study.

The purpose of this study was to analyze the effectiveness of helicopter emergency medical services (HEMS) for its economic operations in South Korea. This study targeted stroke patients who were transported via HEMS or ground emergency medical services (GEMS) from the scene of an accident to a regional emergency medical center. From this patient population, stroke patients who traveled at least 50 km from the scene of the cerebral infarction to the hospital with analyzable outcome data were extracted and included in this study. This study included 26 HEMS and 102 GEMS stroke patients from a pool of 183 potential patients. The survival-to-discharge rate of patients transported via HEMS (96.2%; 25/26) was significantly higher than that of patients transported via GEMS (83.2%; 104/128) (P=0.001). The HEMS transfer was quicker with respect to the decision-making process because the emergency physician actively evaluates and communicates on-site and during in-transit travel to request an appointment immediately upon arrival at the emergency room. These results indicate that using HEMS increased discharge and survival rates and reduced in-hospital mortality of HEMS of stroke patients with a reduced admission time. This result association leads to reasonable cost-effectiveness and efficient estimates overall. In conclusion, HEMS indicate reduced time taken for stroke patients to be hospitalized and treated and decreased mortality after 24 hours. According to this result, HEMS transport can be more effective than GEMS in long-distance delivery of stroke patients.

Effect of chest compression on skeletal chest injuries: a retrospective study.

OBJECTIVE: Reports indicate that chest compression may induce skeletal chest injuries. We aimed to assess the factors associated with skeletal chest injuries and the probability of skeletal chest injuries following cardiopulmonary resuscitation (CPR) in patients who were successfully resuscitated after cardiac arrest. METHODS: This retrospective analysis used data from adult patients who were successfully resuscitated after cardiac arrest. Skeletal chest injuries were assessed by chest computed tomography images. Multiple logistic regression analysis was used to identify factors associated with skeletal chest injuries and a cubic spline was fitted to visualize the predicted probability of skeletal chest injuries. RESULTS: Among 274 patients (mean age: 62.6 years, 180 males), 185 (68%) had skeletal chest injuries. Patients with skeletal chest injuries were older in age (66.4 ± 12 vs 54.7 ± 17 years, P < 0.001), had a higher frequency of prehospital CPR (78.9 vs 66.3%, P = 0.024), and had a longer CPR duration (26.3 ± 19.4 vs 21.5 ± 14.8 minutes, P = 0.022). Multiple logistic regression analysis showed that age and CPR duration were associated with skeletal chest injuries [odds ratio (OR): 1.06, 95% confidence interval (CI): 1.04-1.08, P < 0.001 for age; OR: 1.03, 95% CI: 1.01-1.04, P = 0.006 for CPR duration). The probability of skeletal chest injuries was higher in patients over 60 years of age than those in patients under 60 years. CONCLUSION: In our study, advanced age and CPR duration were factors associated with a greater risk of skeletal chest injuries in adult patients who were resuscitated after cardiac arrest.

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.

'Knocking-fingers' chest compression technique in infant cardiac arrest: single-rescuer manikin study.

OBJECTIVE: We designed a new chest compression technique, the 'knocking-fingers' chest compression (KF) technique, for a single rescuer in infant cardiac arrest. We compared the effectiveness and feasibility between the KF technique and the two-finger (TF) and two-thumb encircling hands (TT) techniques. PARTICIPANTS AND METHODS: A prospective, randomized, crossover study was carried out to compare the quality of chest compression and ventilation between the KF, TF, and TT techniques using a 30: 2 compression-to-ventilation ratio and mouth-to-mouth ventilation. The area of chest compression, finger(s) pain, and fatigability were measured to compare safety and feasibility. RESULTS: The total frequency of chest compression for 5 min was the highest with the KF technique, followed by the TF and TT techniques. The total frequency of ventilation for 5 min was higher with the KF and TF techniques compared with the TT technique. The total hands-off time was the shortest with the KF technique, followed by the TF and TT techniques. The area of chest compression was the smallest in KF technique. Participants complained of severe finger pain and high fatigability in TF technique. CONCLUSION: The single-rescuer KF chest compression technique is an effective alternative to the TF or TT techniques for infant cardiac arrest.

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.

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<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<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.