Usefulness of the BIG Score in Predicting Massive Transfusion and In-Hospital Death in Adult Trauma Patients.

The base deficit (B), international normalized ratio (I), and Glasgow coma scale (GCS) (BIG) score is useful in predicting mortality in pediatric trauma patients; however, studies on the use of BIG score in adult patients with trauma are sparse. In addition, studies on the correlation between the BIG score and massive transfusion (MT) have not yet been conducted. This study aimed to evaluate the predictive value of BIG score for mortality and the need for MT in adult trauma patients. This retrospective study used data collected between 2016 and 2020 at our hospital's trauma center and registry. The predictive value of BIG score was compared with that of the Injury Severity Score (ISS) and Revised Trauma Score (RTS). Logistic regression analysis was carried out to assess whether BIG score was an independent risk factor. Receiver operating characteristic (ROC) curve analysis was performed, and predictive values were evaluated by measuring the area under the ROC curve (AUROC). In total, 5,605 patients were included in this study. In logistic regression analysis, BIG score was independently associated with in-hospital mortality (odds ratio (OR): 1.1859; 95% confidence interval (CI): 1.1636-1.2086) and MT (OR: 1.0802; 95% CI: 1.0609-1.0999). The AUROCs of BIG score for in-hospital mortality and MT were 0.852 (0.842-0.861) and 0.848 (0.838-0.857), respectively. Contrastingly, the AUROCs of ISS and RTS for in-hospital mortality were 0.795 (0.784-0.805) and 0.859 (0.850-0.868), respectively. Moreover, AUROCs of ISS and RTS for MT were 0.812 (0.802-0.822) and 0.838 (0.828-0.848), respectively. The predictive value of BIG score for mortality and MT was significantly higher than that of the ISS. The BIG score also showed a better AUROC for predicting in-hospital mortality compared with RTS. In conclusion, the BIG score is a useful indicator for predicting mortality and the need for MT in adult trauma patients.

Prediction of Severe Injury in Bicycle Rider Accidents: A Multicenter Observational Study.

Introduction: This study aimed to establish a predictive model that includes physiological parameters and identify independent risk factors for severe injuries in bicycle rider accidents. Methods: This was a multicenter observational study. For four years, we included patients with bicycle rider injuries in the Emergency Department-Based Injury In-depth Surveillance database. In this study, we regarded ICD admission or in-hospital mortality as parameters of severe trauma. Univariate and multivariate logistic regression analyses were performed to assess risk factors for severe trauma. A receiver operating characteristic (ROC) curve was generated to evaluate the performance of the regression model. Results: This study included 19,842 patients, of whom 1,202 (6.05%) had severe trauma. In multivariate regression analysis, male sex, older age, alcohol use, motor vehicle opponent, load state (general and crosswalk), blood pressure, heart rate, respiratory rate, and Glasgow Coma Scale were the independent factors for predicting severe trauma. In the ROC analysis, the area under the ROC curve for predicting severe trauma was 0.848 (95% confidence interval: 0.830-0.867). Conclusion: We identified independent risk factors for severe trauma in bicycle rider accidents and believe that physiologic parameters contribute to enhancing prediction ability.

Effect of acute alcohol intoxication on mortality, coagulation, and fibrinolysis in trauma patients.

BACKGROUND: The effect of alcohol on the outcome and fibrinolysis phenotype in trauma patients remains unclear. Hence, we performed this study to determine whether alcohol is a risk factor for mortality and fibrinolysis shutdown in trauma patients. MATERIALS AND METHODS: A total of 686 patients who presented to our trauma center and underwent rotational thromboelastometry were included in the study. The primary outcome was in-hospital mortality. Logistic regression analysis was performed to determine whether alcohol was an independent risk factor for in-hospital mortality and fibrinolysis shutdown. RESULTS: The rate of in-hospital mortality was 13.8% and blood alcohol was detected in 27.7% of the patients among our study population. The patients in the alcohol-positive group had higher mortality rate, higher clotting time, and lower maximum lysis, more fibrinolysis shutdown, and hyperfibrinolysis than those in the alcohol-negative group. In logistic regression analysis, blood alcohol was independently associated with in-hospital mortality (odds ratio [OR] 2.578; 95% confidence interval [CI], 1.550-4.288) and fibrinolysis shutdown (OR 1.883 [95% CI, 1.286-2.758]). Within the fibrinolysis shutdown group, blood alcohol was an independent predictor of mortality (OR 2.168 [95% CI, 1.030-4.562]). CONCLUSIONS: Alcohol is an independent risk factor for mortality and fibrinolysis shutdown in trauma patients. Further, alcohol is an independent risk factor for mortality among patients who experienced fibrinolysis shutdown.

Changes in Relative Importance of the 5-Level Triage System, Korean Triage and Acuity Scale, for the Disposition of Emergency Patients Induced by Forced Reduction in Its Level Number: a Multi-Center Registry-based Retrospective Cohort Study.

BACKGROUND: The 5-level triage tool, the Korean Triage and Acuity Scale (KTAS), was developed based on the Canadian Triage and Acuity Scale and has been used for triage in all emergency medical institutions in Korea since 2016. This study evaluated the association between the decrease in level number and the change in its relative importance for disposition in the emergency department (ED). METHODS: Using the registry of the National Emergency Department Information System (NEDIS) ver. 3.1, data regarding consecutive emergency patients from March 2017 to October 2017 were reviewed retrospectively. Reconfiguring KTAS levels, a total of 15 multinomial logistic regression models (KTAS_0 to KTAS_14), including the KTAS, its variants, and covariates were constructed to determine significant factors affecting ED disposition. The relative importance of each model was obtained using a dominance analysis. RESULTS: A total of 79,771 patients were included in the analysis. In the model KTAS_0, the KTAS and 8 covariates were found to be significantly related to ED disposition. The KTAS and the decision maker of each ED visit, whether it was the physician or others, had the largest relative importance, 34.8% and 31.4%, respectively (P < 0.001). In other models of KTAS variants, including 4-level, 3-level and 2-level, the rates of the KTAS decreased to 31.8% (interquartile range [IQR], 28.9-34.2), 26.4% (IQR, 23.2-31.0), and 18.7% (IQR, 7.5-24.9), respectively (P = 0.016). On the other hand, the rates for covariates tended to be larger for smaller triage levels and so there was a significant interaction effect between the KTAS and the covariates according to the triage level (P < 0.001). CONCLUSION: The 5-level triage tool, the KTAS, had the largest relative importance among the predictors affecting ED disposition only at its original level. Therefore, it is recommended that no attempt should be made to reduce the number of levels in the triage tool.

Usefulness of Rotational Thromboelastometry as a Mortality Predictor of Hyperfibrinolysis in Patients with Severe Trauma.

BACKGROUND: Hemorrhage is the major cause of traumatic death and the leading cause of preventable death. Hyperfibrinolysis is associated with trauma severity. Viscoelastic hemostatic assays show complete clot formation dynamics. The present study was designed to identify the relationship between hyperfibrinolysis and mortality, metabolic acidosis, and coagulopathy in patients with trauma. METHODS: Patients with severe trauma (injury severity score [ISS] of 15 or higher) who were assessed using rotational thromboelastometry (ROTEM) were included in the present study from January 2017 to December 2017. Variables were obtained from the Korea Trauma Database or the medical charts of the patients. To identify whether hyperfibrinolysis is an independent predictor of mortality, univariate and multivariate Cox regression analyses were performed. RESULTS: During the 1-year study period, 190 patients were enrolled. In total, 21 (11.1%) had hyperfibrinolysis according to the ROTEM analysis and 46 (24.2%) died. Patients with hyperfibrinolysis had a higher ISS (P=0.014) and mortality rate (P<0.001) than did those without hyperfibrinolysis. In multivariate Cox analysis, hyperfibrinolysis (hazard ratio [HR], 4.960; 95% confidence interval [CI], 2.447 to 10.053), age (HR, 1.033; 95% CI, 1.013 to 1.055), lactic acid level (HR, 1.085; 95% CI, 1.003 to 1.173), and ISS (HR, 1.037; 95% CI, 1.004 to 1.071) were independent predictors of mortality. CONCLUSIONS: Hyperfibrinolysis is associated with increased mortality, worse metabolic acidosis, and severe coagulopathy and is an independent predictor of mortality in patients with trauma.

A study on the disaster medical response during the Mauna Ocean Resort gymnasium collapse.

OBJECTIVE: To investigate and document the disaster medical response during the Gyeongju Mauna Ocean Resort gymnasium collapse on February 17, 2014. METHODS: Official records of each institution were verified to select the study population. All the medical records and emergency medical service run sheets were reviewed by an emergency physician. Personal or telephonic interviews were conducted, without a separate questionnaire, if the institutions or agencies crucial to disaster response did not have official records or if information from different institutions was inconsistent. RESULTS: One hundred fifty-five accident victims treated at 12 hospitals, mostly for minor wounds, were included in this study. The collapse killed 10 people. Although the news of collapse was disseminated in 4 minutes, dispatch of 4 disaster medical assistance teams took at least 69 minutes to take the decision of dispatch. Four point five percent were treated at the accident site, 56.7% were transferred to 2 hospitals that were nearest to the collapse site, and 42.6% were transferred to hospitals that were poorly prepared to handle disaster victims. CONCLUSION: In the Gyeongju Mauna Ocean Resort gymnasium collapse, the initial triage and distribution of patients was inefficient and medical assistance arrived late. These problems had also been noted in prior mass casualty incidents.

Application of Telemedicine System to Prehospital Medical Control.

OBJECTIVES: Although ambulance-based telemedicine has been reported to be safe and feasible, its clinical usefulness has not been well documented, and different prehospital management systems would yield different results. The authors evaluated the feasibility and usefulness of telemedicine-assisted direct medical control in the Korean emergency medical service system. METHODS: Twenty ambulances in the Busan area were equipped with a telemedicine system. Three-lead electrocardiogram, blood pressure, and pulse oximetry data from the patient and audiovisual input from the scene were transferred to a server. Consulting physicians used desktop computers and the internet to connect to the server. Both requesting emergency medical service (EMS) providers and consulting physicians were asked to fill out report forms and submit them for analysis. RESULTS: In the 41 cases in which telemedicine equipment was used, cellular phones were concomitantly used in 28 cases (68.35%) to compensate for the poor audio quality provided by the equipment. The EMS providers rated the video transmission quality with a 4-point average score (interquartile range [IQR] 2-5) on a 5-point scale, and they rated the biosignal transmission quality as 4 (IQR 3-5). The consulting physicians rated the video quality as 4 (IQR 2.5-4) and the biosignal quality as 4 (IQR 3-4). The physicians' ratings for usefulness for making diagnosis or treatment decisions did not differ significantly in relation to the method of communication used. CONCLUSIONS: Our study did not find any significant advantage of implementing telemedicine over the use of voice calls in delivering on-line medical control. More user-friendly, smaller devices with clear advantages over voice communication would be required before telemedicine can be successfully implemented in prehospital patient care.

Early hyperoxemia may not increase mortality after cardiac arrest: a pilot study.

OBJECTIVE: International Liaison Committee on Resuscitation guidelines advocate an arterial saturation of 94% to 96% after return of spontaneous circulation (ROSC). However, a few clinical trials have investigated the impact of postresuscitative O2 therapy after cardiac arrest. We studied whether early hyperoxemia is associated with a poor post-ROSC outcome after in-hospital cardiac arrest. METHODS: We retrospectively reviewed patients who experienced an in-hospital cardiac arrest from January 2005 to January 2011. Based on the results of the first arterial blood gas analysis (ABGA) within 10 minutes and a second ABGA from 60 to 120 minutes after ROSC, patients were classified into three groups: hyperoxemia (PaO2 ≥ 300 mmHg), normoxemia (300 mmHg > PaO2 ≥ 60 mmHg), and hypoxemia (PaO2 < 60 mmHg or ratio of PaO2 to fraction of inspired oxygen < 300). We examined whether early hyperoxemia was associated with survival and neurological outcome. RESULTS: There were 792 patients who met the inclusion criteria: 638 (80.6%) in the hypoxemia group, 62 (7.8%) in the normoxemia group, and 92 (11.6%) in the hyperoxemia group. Multiple logistic regression analysis showed that hyperoxemia was not associated with survival (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.30 to 3.84) or neurological outcome (OR, 1.03; 95% CI, 0.31 to 3.40). CONCLUSION: Postresuscitation hyperoxemia was not associated with survival or neurological outcome in patients with ROSC after in-hospital cardiac arrest.

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

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

Evaluation of recombinant factor VIIa treatment for massive hemorrhage in patients with multiple traumas.

BACKGROUND: Recent studies and case reports have shown that recombinant factor VIIa (rFVIIa) treatment is effective for reversing coagulopathy and reducing blood transfusion requirements in trauma patients with life-threatening hemorrhage. The purpose of this study is to evaluate the effect of rFVIIa treatment on clinical outcomes and cost effectiveness in trauma patients. METHODS: Between January 2007 and December 2010, we reviewed the medical records of patients who were treated with rFVIIa (N=18) or without rFVIIa (N=36) for life-threatening hemorrhage due to multiple traumas at the Emergency Department of Pusan National University Hospital in Busan, Korea. We reviewed patient demographics, baseline characteristics, initial vital signs, laboratory test results, and number of units transfused, and then analyzed clinical outcomes and 24-hr and 30-day mortality rates. Thromboembolic events were monitored in all patients. Transfusion costs and hospital stay costs were also calculated. RESULTS: In the rFVIIa-treated group, laboratory test results and clinical outcomes improved, and the 24-hr mortality rate decreased compared to that in the untreated group; however, 30-day mortality rate did not differ between the groups. Thromboembolic events did not occur in both groups. Transfusion and hospital stay costs in the rFVIIa-treated group were cost effective; however, total treatment costs, including the cost of rFVIIa, were not cost effective. CONCLUSIONS: In our study, rFVIIa treatment was shown to be helpful as a supplementary drug to improve clinical outcomes and reduce the 24-hr mortality rate, transfusion and hospital stay costs, and transfusion requirements in trauma patients with life-threatening hemorrhage.

Changes in Interhospital Transfer Patterns of Acute Ischemic Stroke Patients in the Regional Stroke Care System After Designation of a Cerebrovascular-specified Center.

The Ministry of Health and Welfare of Korea recently designated cerebrovascularspecified centers (CSCs) to improve the regional stroke care system for acute ischemic stroke (AIS) patients. This study was performed to evaluate the changes in the flow of AIS patients between hospitals and to describe the role of the Emergency Medical Information Center (EMIC) after the designation of the CSCs. Data for coordination of interhospital transfers by the EMIC were reviewed for 6 months before and after designation of the CSCs. The data included the success or failure rate, the time used for coordination of interhospital transfer, and the changes in the interhospital transfer pattern between transfer-requesting and transfer-accepting hospitals. The total number of requests for interhospital transfer increased from 198 to 244 after designation of the CSCs. The median time used for coordination decreased from 8.0 minutes to 4.0 minutes (p<0.001). The success rate of coordination increased from 88.9% to 96.7% (p<0.001). The proportion of requests by CSCs decreased from 3.5% to 0.4% (p=0.017). However, the proportion of acceptance by non-CSC hospitals increased from 15.9% to 25.8% (p=0.015). With the designation of CSCs, the EMIC could coordinate interhospital transfers more quickly. However, AIS patients are more dispersed to CSC and non-CSC hospitals, which might be because the CSCs still do not have sufficient resources to cover the increasing volume of AIS patients and non-CSC hospitals have changed their policies. Further studies based on patients' outcome are needed to determine the adequate type of interhospital transfer for AIS patients.

Decreased emergency department length of stay by application of a computerized consultation management system.

OBJECTIVES: Consultation difficulty occurs in hospitals located in many countries, and it is understood that strategies to improve the emergency department (ED) consultation process are needed. The authors constructed a computerized consultation management system in the ED of a tertiary care teaching hospital to improve the consultation process and evaluate the influence of the consultation management system on ED length of stay (LOS) and the throughput process. METHODS: Consultation management system software was developed and integrated into the hospital information system. The development process took place between June 2008 and May 2009. Before the development of the consultation system, ED personnel contacted on-call physicians of the specialty department, who are usually residents, by cellular phones. After the system had been developed, ED personnel selected the department and on-call physician in the specialty department using the consultation management software and activated the automatic consultation process when specialty consultation was necessary. If the treatment plan had not been registered for 3 hours, all of the residents in the specific department are notified of the delay in the treatment plan with a short message service (SMS) message. If an admission or discharge order had not been made in 6 hours, all of the residents and faculty staff in the specific department receive SMS messages stating the delay in disposition. ED patient data were collected from the hospital information system for 40 days before the system was developed (June 1, 2008, to July 10, 2008) and 40 days after the system was implemented (June 1, 2009, to July 10, 2009). RESULTS: The median ED LOS decreased significantly, from 417.5 minutes (interquartile range [IQR] = 178.8-1,247.5 minutes) in the presystem period to 311.0 minutes (IQR = 128.0-817.3 minutes) in the postsystem period (p < 0.001). Also, the median time to disposition order decreased significantly, from 336.0 minutes (IQR = 145.0-943.0 minutes) to 235.0 minutes (IQR = 103.0-21.5; p = 0.001). No significant reduction was observed in the interval between the time of disposition decision and the time when the patients left the ED. Significant reductions of ED LOS were observed after implementing the system (p < 0.001) regardless of whether the visit occurred during the weekday daytime (09:00-17:00 hours), holiday and weekend daytime (09:00-17:00 hours), or nighttime (17:00-09:00 hours next day). CONCLUSIONS: This study found decreased ED LOS by implementation of a computerized consultation management system in a tertiary care teaching hospital. The automated consultation and monitoring process formalized communication between physicians providing ED patient care in the academic ED with high consultation and admission rates.

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

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

Characteristics and triage of a maritime disaster: an accidental passenger ship collision in Korea.

The aim of this study was to analyze the characteristics of and responses to a maritime disaster, by reviewing the events surrounding the accidental collision of a high-speed passenger ship in South Korea. Of the 215 boarded passengers on a high-speed passenger ship sailing from Fukuoka to Busan, we retrospectively examined information of 114 victims of the ship's collision with a whale on 12 April 2007. We referenced reports from the on-site disaster medical assistance team members; recorded notifications to the Busan 1339 Emergency Medical Information Centre, from the scene of the accident and data from the ship's insurer. The 114 victims were transported to 20 different hospitals. Many patients were transported to nearby local hospitals from the scene of the accident; other patients were transported to more distant hospitals. Eighty-five patients were transported to hospitals through mobile emergency support units, whereas the other patients were transported directly by fire officers from the 119 Fire Officer Centre. One patient died in the transport. In conclusion, our national emergency medical service and disaster response system each suffer from many problems - especially a lack of cooperation among related departments and insufficient communication therein. The onboard planning and practice of a disaster plan is required, and a reliable information system between the scene of a maritime disaster and our emergency medical service system should be developed.

Confirmation of endotracheal intubation by combined ultrasonographic methods in the Emergency Department.

OBJECTIVES: The objective of the present study was to investigate whether the combined use of transcricothyroid membrane ultrasonography and ultrasonographic evaluation for pleural sliding is useful for verifying endotracheal intubation in the ED. METHODS: We performed a prospective clinical trial in the ED from January to July 2008. All patients enrolled in the present study had been admitted to the ED owing to severe airway problems. A linear probe was placed horizontally over the cricothyroid membrane (dynamic phase) during the intubation process. Endotracheal intubation was confirmed by ultrasonographic lung sliding. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. RESULTS: Thirty patients (17 men, 13 women; mean age 59.6 +/- 16.7 [SD] years) were enrolled in the study. Of the 30, 7 had a history of trauma. Four trauma patients were diagnosed with haemopneumothorax. The ratio of initial oesophageal-to-endotracheal intubation was 3:27. Sensitivity, specificity, PPV and NPV for endotracheal intubation were 96.3%, 100%, 100% and 75%, respectively. After verification by ultrasonographic lung sliding, sensitivity, specificity, PPV and NPV were each 100%. CONCLUSIONS: The combination of transcricothyroid membrane ultrasonography and ultrasonographic lung-sliding evaluation could be useful in confirming endotracheal intubation in the ED.