Predictive factors for acute brain lesions on magnetic resonance imaging in acute carbon monoxide poisoning.

BACKGROUND: Acute brain lesions on diffusion-weighted-magnetic resonance imaging (MRI) after acute carbon monoxide (CO) poisoning were associated with delayed neurological sequelae. This study was conducted to identify the risk factors associated with acute brain lesions on MRI after acute CO poisoning and to help select patients who need acute-phase brain MRI after acute CO poisoning in the emergency department (ED). METHODS: This retrospective observational study included 103 adult patients who were hospitalized at a tertiary-care hospital between November 2016 and September 2019 and underwent brain MRI because of acute CO poisoning. Multivariable logistic regression analysis was applied to identify predictive factors for acute brain lesions on MRI after acute CO poisoning. RESULTS: Multivariable logistic regression analysis showed that Glasgow Coma Scale (GCS) score of <9 at ED presentation (odds ratio [OR] 17.749, 95% confidence interval [CI] 3.098-101.690, P = 0.001) and the initial troponin-I level at presentation in the ED (OR 13.657, 95% CI 1.415-131.834, P = 0.024) were predictive factors for acute brain lesions on MRI in acute CO poisoning. The receiver operating characteristics curve for initial troponin-I showed an area under the curve of 0.761 (95% CI 0.638-0.883, P < 0.001) and the optimal cutoff value was 0.105 ng/mL. CONCLUSIONS: Acute-phase brain MRI in acute CO poisoning can be considered for patients who present at the ED with a GCS score <9 or troponin-I level >0.105 ng/mL.

Risk factors of urinary tract infection caused by extended spectrum ß-lactamase-producing Escherichia coli in emergency department.

OBJECTIVES: The incidence of urinary tract infection (UTI) due to extended-spectrum ß-lactamase (ESBL)-producing Escherichia coli has increased over recent years. Initial empirical therapy is often ineffective for these resistant isolates resulting in prolonged hospitalization and increased mortality. This study was conducted to determine the risk factors of UTI caused by ESBL E. coli in the emergency department (ED). METHODS: This is a retrospective case-control study at a university hospital in Korea with UTI patients who visited ED between June 2015 and December 2016. We compared case patients with ESBL E. coli UTI (n = 50) to control patients with non-ESBL-producing E. coli UTI (n = 100), which were matched for age and sex. Multivariate logistic regression analysis was used to explore risk factors. RESULTS: Our study showed that hospital-acquired infection (OR = 3.86; 95% CI = 1.26-11.8; p = .017), prior UTI within 1 year (OR = 3.26; 95% CI = 1.32-8.05; p = .010), and underlying cerebrovascular disease (OR = 3.24; 95% CI = 1.45-7.25; p = .004) were independent risk factors for acquisition of ESBL-producing E. coli. Notably, 35 (70%) out of 50 case patients had community-acquired infection, and 68% and 54% of ESBL E. coli were resistance to ciprofloxacin and trimethoprim-sulfamethoxazole, respectively. On the contrary, 98% of ESBL E. coli was susceptible to amikacin. CONCLUSION: The main risk factors identified in our study should be considered when treating UTI patients in ED. Amikacin may improve the outcome of empirical treatment without increasing carbapenem utilization.

Hemodynamic changes in patients with influenza A after propacetamol infusion in the emergency department.

OBJECTIVES: Recently, there has been an emerging clinical data suggesting that intravenous propacetamol may cause iatrogenic hypotension. The primary objective of this study was to evaluate hemodynamic changes after propacetamol infusion in the emergency department (ED) with the patients of influenza A. Secondary objective was to assess the incidence of propacetamol-induced significant hypotension and to evaluate factors associated with this adverse effect by comparing two groups of patients with or without a significant reduction in blood pressure (BP). METHODS: We retrospectively reviewed the medical records of the patients with laboratory-confirmed influenza A who received intravenous propacetamol for the control of fever in the ED during the 2015-16 influenza season. RESULTS: 101 patients of influenza A were included in this study. Overall, all the vital signs including BP, pulse rate and body temperature recorded after propacetamol administration were lower than the pre-infusion values. A significant reduction in BP was observed in 30 (29.7%) patients and 6 (20%) of them required crystalloid infusion. Interestingly, pre-infusion BPs were higher in the group of propacetamol-induced significant hypotension, yet there was no difference in post-infusion BPs between the groups. DISCUSSION: To our knowledge this is the first study on the effect of intravenous propacetamol in the ED patients with influenza A infection. We hypothesized that the group with a significant reduction in BP could have higher sympathetic tone, consequently showing higher pre-infusion BPs and pulse rate. And there was no difference in post-infusion BPs because baroreflex homeostasis could compensate further decrease in BPs.

Fatal Pulmonary Edema in a Child After Jellyfish Stings in Korea.

Jellyfish have been increasing at a global scale in recent years. These blooms not only have deleterious effects on marine ecosystems, they also increase the risk of jellyfish stings and accompanying envenomation. Here, we report a fatal case of pulmonary edema caused by jellyfish envenomation in a child in Korea. The patient died 4 h after envenomation despite cardiopulmonary resuscitation. Nemopilema nomurai was the suspected species of jellyfish encountered by the patient, although we are unable to confirm this. With this case report, we aim to inform on the serious issue of toxicity associated with jellyfish species that bloom mainly along Korean, east Chinese, and Japanese shores and to discuss appropriate first aid methods in case of jellyfish stings.

Hospital-based influenza surveillance in Korea: hospital-based influenza morbidity and mortality study group.

Influenza epidemics occur annually with variations in size and severity. Hospital-based Influenza Morbidity & Mortality was established to monitor influenza epidemics and their severity, which is composed of two surveillance systems: emergency room-based and inpatient-based surveillance. Regarding emergency room-based surveillance, influenza-like illness index (influenza-like illness cases per 1,000 emergency room-visiting subjects), number of laboratory-confirmed cases and the distribution of influenza types were estimated weekly. Inpatient-based surveillance included monitoring for hospitalization, complications, and mortality. The emergency room influenza-like illness index correlated well with the number of laboratory-confirmed influenza cases, and showed a bimodal peak at Week 4 (179.2/1,000 emergency room visits) and Weeks 13-14 (169.6/1,000 emergency room visits) of 2012. Influenza A was the predominant strain during the first epidemic peak, while influenza B was isolated exclusively during the second peak. In 2011-2012 season, the mean admission rate of emergency room-visiting patients with influenza-like illness was 16.3% without any increase over the epidemic period. Among the hospitalized patients with influenza, 33.6% (41 out of 122 patients) were accompanied by complications, and pneumonia (28.7%, 35 out of 122 patients) was the most common. Most fatal cases were caused by influenza A (96.2%) after the first epidemic peak. In conclusion, Hospital-based Influenza Morbidity & Mortality was effective for monitoring the trends in circulating influenza activity concurrently with its severity. In the 2011-2012 season, the influenza epidemic persisted for a ≥ 5-month period, with a bimodal peak of influenza A and B in sequence. Overall, influenza A was more severe than influenza B.

Fever phobia in Korean caregivers and its clinical implications.

Fever is the most common complaint among children brought into the emergency department (ED). 'Fever phobia' is a descriptive term for an unrealistic concern about the consequences of fever. 'Fever phobia' is prevalent among parents and even healthcare providers, worldwide. The aim of this study was to determine the implications of fever-phobic ideas in Korean caregivers. A prospective, multi-center survey was conducted on Korean caregivers who visited the EDs with febrile children. In total, 746 caregivers were enrolled. The mean age of the subjects was 34.7 yr (SD±5.0). Three hundred sixty respondents (48.3%) believed that the body temperature of febrile children can reach higher than 42.0℃. Unrealistic concerns about the improbable complications of fever, such as brain damage, unconsciousness, and loss of hearing/vision were believed by 295 (39.5%), 66 (8.8%), and 58 (7.8%) caregivers, respectively. Four hundred ninety-four (66.2%) guardians woke children to give antipyretics. These findings suggest that fever phobia is a substantial burden for Korean caregivers.

Current practices for paediatric procedural sedation and analgesia in emergency departments: results of a nationwide survey in Korea.

OBJECTIVE: Procedural sedation and analgesia (PSA) in children has become a standard tool in emergency settings, but no national PSA guidelines have been developed for the emergency department (ED) in Korea. Therefore, we investigated the practice of PSA and the level of adherence to institutional PSA guidelines in EDs of teaching hospitals. METHODS: This study was a cross-sectional, web-based survey. The study subjects were the faculty of EDs from 96 teaching hospitals. The questionnaire was posted on an internet site, and the participants were requested that the questionnaire be answered by email and telephone in May 2009. RESULTS: The questionnaires were completed by 67.7% of the participants. Only 20% of EDs had institutional PSA guidelines, 21.5% of those had discharge criteria and 13.8% of EDs had a discharge instruction form. Residents were administered PSA at 76.9% of EDs. The airway rescue equipment was near the area where PSA was performed in 76.9% of EDs. The most commonly used medication for both diagnostic imaging and painful procedure was oral chloral hydrate (87.7%, 61.5%). In 64.6% of EDs, patients were monitored. In only 21 cases, EDs (50.0%) monitored the patients to recovery after PSA or discharge. CONCLUSIONS: Current PSA for paediatric patients have not been appropriately applied in Korea. Unified PSA guidelines were rare in the hospitals surveyed, and many patients were not monitored over an appropriate duration, nor did they receive adequate medications for sedation by the best trained personnel. Therefore, the national PSA guidelines must be developed and implemented as early as possible.

Machine learning model for predicting ciprofloxacin resistance and presence of ESBL in patients with UTI in the ED.

Increasing antimicrobial resistance in uropathogens is a clinical challenge to emergency physicians as antibiotics should be selected before an infecting pathogen or its antibiotic resistance profile is confirmed. We created a predictive model for antibiotic resistance of uropathogens, using machine learning (ML) algorithms. This single-center retrospective study evaluated patients diagnosed with urinary tract infection (UTI) in the emergency department (ED) between January 2020 and June 2021. Thirty-nine variables were used to train the model to predict resistance to ciprofloxacin and the presence of urinary pathogens' extended-spectrum beta-lactamases. The model was built with Gradient-Boosted Decision Tree (GBDT) with performance evaluation. Also, we visualized feature importance using SHapely Additive exPlanations. After two-step customization of threshold adjustment and feature selection, the final model was compared with that of the original prescribers in the emergency department (ED) according to the ineffectiveness of the antibiotic selected. The probability of using ineffective antibiotics in the ED was significantly lowered by 20% in our GBDT model through customization of the decision threshold. Moreover, we could narrow the number of predictors down to twenty and five variables with high importance while maintaining similar model performance. An ML model is potentially useful for predicting antibiotic resistance improving the effectiveness of empirical antimicrobial treatment in patients with UTI in the ED. The model could be a point-of-care decision support tool to guide clinicians toward individualized antibiotic prescriptions.

Factors affecting patients who attempted suicide in the emergency department due to the prolonged pandemic of COVID-19.

OBJECTIVE: This study examined the characteristics of patients who attempted suicide in the emergency department before and during the COVID-19 pandemic. METHODS: We compared data from patients in the emergency department following suicide attempts between January 2018 and December 2021. The patients were categorized into two groups: "pre-COVID-19" and "during COVID-19" pandemic. RESULTS: The findings revealed an increasing trend of suicide attempts during the study period. Suicide attempts were reported at 1,107 before the COVID-19 pandemic and 1,356 during the COVID-19 pandemic. Patients who attempted suicide during the COVID-19 pandemic were younger (38.0±18.5 years vs. 40.7±18.4 years, P<0.01), had a smaller proportion of men (36% vs. 44%, P<0.01), and had fewer medical comorbidities (20.2% vs. 23.6%, P<0.05). The group during the COVID-19 pandemic reported better hygiene conditions (50.5% vs. 40.8%, P<0.01) and lower alcohol consumption (27.7% vs. 37.6%, P<0.01). Patients who attempted suicide during the COVID-19 pandemic had higher rates of use of psychiatric medications and previous suicide attempts. The most common reasons for the suicide attempt were unstable psychiatric disorders (38.8%), poor interpersonal relationships (20.5%), and economic difficulties (14.0%). Drug poisoning (44.1%) was the most common method of suicide attempts. Subgroup analysis with patients who attributed their suicide attempts to COVID-19 revealed a higher level of education (30.8%) and employment status (69.2%), with economic difficulties (61.6%) being the primary cause of suicide attempts. CONCLUSION: These findings suggest that the prolonged duration of the COVID-19 pandemic and its effects on social and economic factors have influenced suicide attempts.

A case of angioedema due to acquired C1 esterase inhibitor deficiency masquerading as suspected peritonitis: a case report.

Angioedema due to acquired C1 esterase deficiency is a rare condition and a non-inflammatory disease characterized by episodes of edema of the mucosa of the upper airway or gastrointestinal tract. The purpose of this case report is to heighten awareness among emergency physicians of a peritonitis-like condition that can develop into angioedema due to acquired C1 esterase inhibitor deficiency, and thereby help to prevent false diagnosis resulting in unnecessary surgical intervention. We report the case of a 21-year-old man who presented to the Emergency Department (ED) with abdominal pain. He was later diagnosed with angioedema of the gastrointestinal tract due to acquired C1 esterase deficiency that was initially suspected as peritonitis. Careful evaluation of the acute abdomen in acquired C1 esterase deficiency is very important in the ED to distinguish between medical and surgical causes of an acute abdomen.

Isolated cerebrospinal fluid leakage due to a spinal stab wound in a child.

Spinal stab wounds are relatively rare, especially in children. Moreover, as the pediatric spine anatomy differs from that of an adult, physicians managing stab wounds in this area should keep some special considerations in mind. This study reports an interesting case of spinal cerebrospinal fluid leakage without significant spinal injury in a 32-month-old child.

Tracheal Rupture Related to Endotracheal Intubation during Cardiopulmonary Resuscitation.

Postintubation tracheal rupture is rare, but serious. Emergency intubation is often conducted during cardiopulmonary resuscitation (CPR), and the risk of postintubation tracheal rupture can be increased during CPR. We describe here a case of postintubation tracheal rupture in a 65-year-old female who was transferred from another hospital after CPR. Postintubation tracheal rupture in this case is thought to have been related to malposition of the endotracheal tube (ETT), elevation of the intratrachea pressure due to chest compression, and an overinflated cuff. However, the most important factor is considered to be the overinflated cuff, which is often caused by manual palpation. Therefore, emergency physicians should consider using a manometer to check the cuff pressure of the ETT, even during CPR. When spontaneous circulation is restored, the pressure of the cuff must be measured with a manometer.

Clinical Predictors of Pseudomonas aeruginosa Bacteremia in Emergency Department.

OBJECTIVES: Pseudomonas aeruginosa shows higher mortality rate compared to other bacterial infections and is susceptible to a limited number of antimicrobial agents. Considering inadequate empirical treatment of Pseudomonas bacteremia has been associated with increased mortality, it is important for emergency physicians to identify infections by P. aeruginosa. METHODS: This was a single-center retrospective case-control study to investigate the clinical predictors of patients diagnosed as Pseudomonas bacteremia in the emergency department (ED) from June 2012 to December 2016. Patients with blood culture positive for Escherichia coli in the same period were chosen as the control group, and type of infection was matched for each patient. RESULTS: A total of 54 cases with Pseudomonas bacteremia and 108 controls with E. coli bacteremia were included. In the case group, 76% was community-acquired infection, 44% received inappropriate empirical treatment in the ED, and in-hospital mortality was 30%. Multiple logistic regression showed that respiratory tract infection was an independent risk factor for Pseudomonas bacteremia (OR 6.56, 95% CI 1.78-23.06; p = 0.004), whereas underlying diabetes mellitus (OR 0.22, 95% CI 0.07-0.61; p = 0.004) and presentation as urinary tract infection (OR 0.06, 95% CI 0.02-0.18; p < 0.001) were negative clinical predictors. CONCLUSIONS: We suggest that antipseudomonal antibiotics should be considered beyond simple coverage of Gram-negative bacteria in the ED, especially if the patient is likely to have pneumonia. Having diabetes or presenting with urinary tract infection could be clinical factors unfavorable to use of antipseudomonal antibiotics.

Prognostic Factors Predicting Poor Outcome in Cancer Patients with Febrile Neutropenia in the Emergency Department: Usefulness of qSOFA.

BACKGROUND/AIMS: Febrile neutropenia is considered as one of the most important and potentially life-threatening oncologic emergencies, which requires prompt medical assessment and treatment with antibiotics. This was a single-center retrospective study that investigated the prognostic factors predicting poor outcome in patients with cancer who presented with febrile neutropenia at the emergency department (ED). METHODS: The medical records of patients diagnosed with febrile neutropenia in the ED from January 2014 to December 2017 were reviewed. Patients aged >18 years who were diagnosed with a malignancy were included in the analysis. Febrile neutropenia was defined as an absolute neutrophil count < 1,000/mm3 with a temperature greater than 38°C. Patients were divided into two groups: those who were admitted at the intensive care unit (ICU) or those who died in the hospital (case group) and those who were admitted at general wards and were discharged (control group). The two groups were compared to determine the factors associated with poor prognosis. RESULTS: We identified 104 patients (25 and 79 from the case and control groups, respectively) with cancer who presented with febrile neutropenia at the ED during the study period. Lower blood pressure, platelet count, and HCO3 - level, higher CRP and creatinine level, and the presence of bacteremia were more commonly observed in the case group than in the control group. In the multiple logistic regression analysis, the following independent predictors significantly correlated with ICU admission and in-hospital mortality: quick sequential (sepsis-related) organ failure assessment (qSOFA) score (odds ratio [OR]: 4.62; 95% confidence interval [CI]: 1.17-18.22; p=0.285), hemoglobin level (OR: 0.51; 95% CI: 0.33-0.78; p=0.002), total bilirubin level (OR: 7.69; 95% CI: 1.29-45.8; p=0.025), and respiratory tract infection (OR: 29.65; 95% CI: 3.81-230.7; p=0.0012). CONCLUSIONS: The qSOFA can be a useful bedside tool for patients with cancer who present with febrile neutropenia at the ED. Moreover, it can help emergency physicians in identifying patients at risk of poor prognosis and in initiating prompt empirical antimicrobial therapy. Further studies must be conducted to validate the efficacy of the qSOFA in these patients in the ED.

A Case of Scrub Typhus complicated with a Splenic Infarction.

We present a patient with scrub typhus complicated with a splenic infarction. A 40-year-old man visited the emergency medical center complaining of fever for the previous week. He had no past medical history, but reported engaging in outdoor activities. Examination revealed a maculopapular rash on his trunk and an eschar on his epigastrium. Abdominal computed tomography was performed to examine the cause of the tenderness on the left upper quadrant of his abdomen, which revealed a splenic infarct. The patient was diagnosed with scrub typhus based on the results of blood polymerase chain reaction testing, and genetic sequencing confirmed the presence of Orientia tsutsugamushi Boryong. His symptoms improved following doxycycline treatment.

Bartonella henselae infection presenting with a picture of adult-onset Still's disease.

We report a patient with a clinical picture of suggestive for adult-onset Still's Disease (ASOD) due to Bartonella infection. A 42-year-old immunocompetent man was admitted with fever, rash, arthralgia and sore throat. As his clinical picture suggested ASOD except unusual skin manifestation, we treated him on steroid and ibuprofen. His fever and constitutional symptoms responded immediately within 24hrs of commencing therapy, yet rash and leukocytosis remained. Meanwhile, Bartonella infection was proved by culture of bone marrow. Minocyclin treatment started combined with hydroxychloroquine sulfate and the patient discharged with overall improvement.

A case report of bittern intoxication.

Bittern is made from marine water after extraction of salt, and its major components include magnesium chloride, magnesium sulfate, potassium chloride, sodium chloride and magnesium bromide. For a long time, it has been used as the main ingredient of tofu coagulant and chemical weapons. A 73-year-old woman arrived to the emergency department after a suicide attempt by drinking an unknown amount bittern. She complained of dizziness, general weakness, and altered mental state (Glasgow Coma Scale (GCS) 13/15). The brain computed tomography (CT) and magnetic resonance imaging (MRI) showed no abnormality. But blood chemistry showed hypermagnesemia ([Mg(2+)] 7.8 mEq/L) and hypernatremia ([Na(+)] 149 mEq/L). Electrocardiograph showed QT prolongation of 0.482 s. Electrolyte imbalances were corrected following adequate fluid therapy and injection of calcium gluconate. The patient recovered/was subsequently discharged without any complications. Electrolyte imbalances are a common presentation following bittern poisoning. Severe side effects like respiratory depression, hypotension, arrhythmia, bradycardia, and cardiac arrest can also occur. Patients will require immediate fluid therapy and correction of electrolyte imbalances. The symptoms vary depending on the electrolyte levels. It is mandatory to closely monitor the electrolyte levels and electrocardiograph in these patients.