Clinical significance of hemoglobin decrease in emergency department elderly hip fracture patients

Objective@#Decreases in the hemoglobin level compared to the pre-injury lab results are often observed in patients with elderly hip fractures visiting the emergency department (ED). This decrease could be the outcome of the fracture itself or a complication caused by comorbidities. This study examined whether significant hemoglobin decreases, as detected in the ED, are related to other-than-hip-fracture bleeding focus or clinical outcomes. @*Methods@#The electronic medical records were reviewed retrospectively at a single university ED from January 2012 to March 2019. ED diagnoses of hip fractures were screened and enrolled if the patient was 60 years or older and had hemoglobin levels recorded within the previous 6 months. A significant decrease in the hemoglobin level is defined as more than 2 g/dL. @*Results@#Three hundred patients were enrolled in this study. Significant hemoglobin decreases were apparent in 43 patients (14.3%). Only four patients (1.3%) had an other-than-hip-fracture bleeding focus. One of those had a significant hemoglobin decrease. In a “significant decrease” versus “non-significant decrease” intergroup comparison, length of hospital stays (median and interquartile range: 17.0 [15.0-21.5] vs. 17.0 [12.0-21.0], P=0.55), survival discharge (4.7% vs. 2.3%, P=0.72), and other-than-hip-fracture bleeding focus (2.3% vs. 1.2%, P>0.99) did not differ significantly. @*Conclusion@#A decrease in hemoglobin level is common among elderly hip fracture patients. On the other hand, the incidence of other-than-hip-fracture bleeding focus was rare and unrelated to a decrease in significant hemoglobin levels. Similarly, neither the hospital length of stay nor survival discharge was unrelated to the hemoglobin level decrease.

Clinical predictors of the positive brain magnetic resonance imaging finding in patients with acute altered mental status in the emergency department

Objective@#This study aimed to determine the clinical factors associated with positive brain magnetic resonance imaging (MRI) findings in patients presenting to the emergency department (ED) with acute altered mental status (AMS). @*Methods@#Patients with acute AMS who presented to the ED were retrospectively analyzed from September 2019 to March 2020. Non-traumatic patients with abnormal alert, verbal, pain, unresponsive (AVPU) scale scores and exhibiting acute change in mental status were included in the study. We evaluated the clinical characteristics of patients with acute AMS according to the results of their brain MRI. A multivariable logistic regression model was used to determine the clinical factors associated with positive brain MRI findings. @*Results@#During the study period, 138 patients underwent brain MRI in the ED, with 36 (26.1%) positive results. A majority of patients with positive brain MRI findings had underlying malignancies, cerebrovascular disease, higher serum total bicarbonate (TCO2) levels, TCO2≥22 mmol/L, lower blood urea nitrogen levels, abnormal findings on brain computed tomography and abnormal findings on neurologic examination. In the multivariable analysis, serum TCO2≥22 mmol/L (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.09-4.12) and the presence of cranial nerve abnormalities (OR, 3.88; 95% CI, 1.55-9.68) and extremity abnormalities (OR, 2.76; 95% CI, 1.11-6.88) were significantly associated with positive brain MRI results. @*Conclusion@#Serum TCO2 level and the presence of cranial nerve and extremity abnormalities in the neurologic examinations were significantly associated with positive brain MRI results in patients with acute AMS.

Magnetic resonance imaging as the first diagnostic imaging modality forpregnant women with suspected acute appendicitis

Objective@#The sensitivity of ultrasonography is poor in pregnant women with suspected appendicitis. Additional magnetic resonance imaging (MRI) is usually required, which can delay the diagnosis and surgical intervention. We hypothesized that the use of MRI as the first diagnostic tool could increase the detection rate and reduce the time for diagnosis. Therefore, we sought to investigate the diagnostic yield of ultrasonography vs. MRI and the emergency department length of stay (ED-LOS) of pregnant women with suspected appendicitis. @*Methods@#This was a retrospective, observational study in the ED of a single tertiary teaching hospital from January 2010 to December 2017. Patients who underwent ultrasonography or MRI or both were enrolled. The primary outcome was the diagnostic yield of acute appendicitis and the ED-LOS. The secondary outcome was the proportion of complicated appendicitis cases. @*Results@#A total of 145 pregnant women were enrolled (ultrasonography only, n=73; MRI only, n=26; both ultrasonography and MRI, n=46). The diagnostic yield was 23.5% (28/119) by ultrasonography and 79.2% (57/72) by MRI. The diagnostic yield of ultrasonography was significantly lower than that of MRI, especially in the second and third trimesters. The ED-LOS was significantly longer in the ultrasonography plus MRI group than that in the MRI-only group (9 hours vs. 6 hours, P=0.002). @*Conclusion@#In this study, MRI had a higher diagnostic yield than ultrasonography and can reduce the time to diagnosis. Thus, MRI should be considered as the first diagnostic tool for suspected acute appendicitis in pregnant women.

Magnetic resonance imaging as the first diagnostic imaging modality forpregnant women with suspected acute appendicitis

Objective@#The sensitivity of ultrasonography is poor in pregnant women with suspected appendicitis. Additional magnetic resonance imaging (MRI) is usually required, which can delay the diagnosis and surgical intervention. We hypothesized that the use of MRI as the first diagnostic tool could increase the detection rate and reduce the time for diagnosis. Therefore, we sought to investigate the diagnostic yield of ultrasonography vs. MRI and the emergency department length of stay (ED-LOS) of pregnant women with suspected appendicitis. @*Methods@#This was a retrospective, observational study in the ED of a single tertiary teaching hospital from January 2010 to December 2017. Patients who underwent ultrasonography or MRI or both were enrolled. The primary outcome was the diagnostic yield of acute appendicitis and the ED-LOS. The secondary outcome was the proportion of complicated appendicitis cases. @*Results@#A total of 145 pregnant women were enrolled (ultrasonography only, n=73; MRI only, n=26; both ultrasonography and MRI, n=46). The diagnostic yield was 23.5% (28/119) by ultrasonography and 79.2% (57/72) by MRI. The diagnostic yield of ultrasonography was significantly lower than that of MRI, especially in the second and third trimesters. The ED-LOS was significantly longer in the ultrasonography plus MRI group than that in the MRI-only group (9 hours vs. 6 hours, P=0.002). @*Conclusion@#In this study, MRI had a higher diagnostic yield than ultrasonography and can reduce the time to diagnosis. Thus, MRI should be considered as the first diagnostic tool for suspected acute appendicitis in pregnant women.

Assessment of clinical and laboratory parameters for the severity ofacute diverticulitis in a Korean emergency department

Objective@#Practice guidelines for diverticulitis have been developed in countries where left-colon diverticulitis is dominant,but there is limited information on right-colon diverticulitis. This study examined the clinical characteristics and riskfactors of clinically severe right-colon diverticulitis. @*Methods@#A retrospective chart review of patients diagnosed with diverticulitis in an emergency department in Koreabetween 2013 and 2017 was performed. Clinically severe diverticulitis was defined as any cause of death, intensive careunit admission, surgery, or invasive intervention due to diverticulitis, and admission for seven or more hospital days.Multivariable logistic regression was used to identify the risk factors for clinically severe diverticulitis. @*Results@#This study analyzed 302 patients. Patients with older age (odds ratio [OR], 1.044; 95% confidence interval [CI],1.009-1.080; P=0.013), complications observed on computed tomography (CT) (OR, 6.906; 95% CI, 2.514-18.968;P<0.001), rebound tenderness on a physical examination (OR, 2.542; 95% CI, 1.041-6.218; P=0.041), high alkalinephosphatase (ALP) levels (OR, 1.014; 95% CI, 1.002-1.026; P=0.026), and high C-reactive protein (CRP) levels (OR,1.095; 95% CI, 1.017-1.178; P=0.013) were at higher risk of clinically severe diverticulitis. @*Conclusion@#Among patients diagnosed with right-colon diverticulitis in the emergency department, those of older age,distinct complications on CT, rebound tenderness on physical examination, high ALP, and high CRP levels are related toclinically severe disease.

Clinical Factors Associated with Obstructive Coronary Artery Disease in Patients with Out-of-Hospital Cardiac Arrest: Data from the Korean Cardiac Arrest Research Consortium (KoCARC) Registry

BACKGROUND: Although coronary artery disease (CAD) is a major cause of out-of-hospital cardiac arrest (OHCA), there has been no convinced data on the necessity of routine invasive coronary angiography (ICA) in OHCA. We investigated clinical factors associated with obstructive CAD in OHCA. METHODS: Data from 516 OHCA patients (mean age 58 years, 83% men) who underwent ICA after resuscitation was obtained from a nation-wide OHCA registry. Obstructive CAD was defined as the lesions with diameter stenosis ≥ 50% on ICA. Independent clinical predictors for obstructive CAD were evaluated using multiple logistic regression analysis, and their prediction performance was compared using area under the receiver operating characteristic curve with 10,000 repeated random permutations. RESULTS: Among study patients, 254 (49%) had obstructive CAD. Those with obstructive CAD were older (61 vs. 55 years, P < 0.001) and had higher prevalence of hypertension (54% vs. 36%, P < 0.001), diabetes mellitus (29% vs. 21%, P = 0.032), positive cardiac enzyme (84% vs. 74%, P = 0.010) and initial shockable rhythm (70% vs. 61%, P = 0.033). In multiple logistic regression analysis, old age (≥ 60 years) (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.36–3.00; P = 0.001), hypertension (OR, 1.74; 95% CI, 1.18–2.57; P = 0.005), positive cardiac enzyme (OR, 1.72; 95% CI, 1.09–2.70; P = 0.019), and initial shockable rhythm (OR, 1.71; 95% CI, 1.16–2.54; P = 0.007) were associated with obstructive CAD. Prediction ability for obstructive CAD increased proportionally when these 4 factors were sequentially combined (P < 0.001). CONCLUSION: In patients with OHCA, those with old age, hypertension, positive cardiac enzyme and initial shockable rhythm were associated with obstructive CAD. Early ICA should be considered in these patients.

Time Interval from Intubation to Return of Spontaneous Circulation in Out-of-hospital Cardiac Arrest Patient with Brain Hemorrhage

PURPOSE: This study was conducted to investigate the relationship of time interval from intubation to return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) patients according to the presence or absence of intracranial hemorrhage (ICH). METHODS: This retrospective study used data from a prospectively collected OHCA registry for patients treated from January 2008 to December 2016. Non-traumatic adult OHCA patients who underwent brain computed tomography were included, while patients who achieved a prehospital ROSC or required advanced airway management were excluded. Utstein variables, initial blood gas analysis, electrolyte levels, and the time interval from intubation to ROSC were used to compare the ICH and non-ICH groups. RESULTS: A total of 448 patients were analyzed. The ICH group was younger and had more females than the non-ICH group. The time interval from intubation to ROSC was significantly shorter in the ICH group than the non-ICH group. The median time and interquartile range were 3 (2 to 7) minutes in the ICH group and 6 (3 to 10) minutes in the non-ICH group. The patient age, gender, potassium level, and time interval from intubation to ROSC were significant variables in the multivariable analysis. In a multivariable logistic regression model that included these variables, the area under the receiver operating characteristic curve was 0.838. CONCLUSION: OHCA patients with ICH achieve ROSC after intubation in a shorter amount of time than those without ICH.

Clinical Features of Acute Epiglottitis in Adults in the Emergency Department

PURPOSE: Acute epiglottitis is a potentially fatal condition that can result in airway obstruction. The aim of this study is to examine the clinical features of adult patients who visited the emergency department (ED) with acute epiglottitis. METHODS: This retrospective observational study was conducted at a single tertiary hospital ED from November 2005 to October 2015. We searched our electronic medical records (EMR) system for a diagnosis of "acute epiglottitis" and selected those patients who visited the ED. RESULTS: A total of 28 patients were included. There was no pediatric case with acute epiglottitis during the study period. The mean age of the patients was 58.0+/-14.8 years. The peak incidences were in the sixth (n=7, 25.0%) and eighth (n=8, 28.6%) decades. The male-to-female ratio was 2.1:1. The most common symptom was sore throat (n=23, 82.1%), followed by dyspnea (n=15, 53.6%), hoarseness (n=7, 25.0%), fever (n=6, 21%), and dysphagia (n=5, 17.9%). The diagnosis of acute epiglottitis was confirmed when edema and hyperemia of the epiglottis were visualized by laryngoscopy. Twenty-six patients were treated conservatively with antibiotics and steroids without definite airway management. Two patients were intubated, but no patients required tracheostomy. CONCLUSION: In adult patients with acute epiglottitis, sore throat and dyspnea were the most common symptoms but fever was infrequent. Most patients improved with conservative management only. Definite airway management was required in only two patients in whom endotracheal intubations were performed successfully in the ED by emergency physicians, and surgical airway management was not required.

Effect of Therapeutic Hypothermia on Mitogen-activated Protein Kinase Pathways in the Brain Tissue of a Swine Cardiac Arrest Model

PURPOSE: To investigate the change in mitogen-activated protein kinase pathways in the brain tissue after therapeutic hypothermia in the swine cardiac arrest model. METHODS: After the return of spontaneous circulation by cardiopulmonary resuscitation, following a 6 min of no-flow time induced by ventricular fibrillation, pigs (n=24) were randomly assigned to one of four groups (sham, normothermia, 24 hr of therapeutic hypothermia, 48 hr of therapeutic hypothermia). After 24 or 48 hr of therapeutic hypothermia (core temperature 32-34℃), the pigs were then rewarmed to 36℃ for a period of 8 hr. At 60 hr upon the return of spontaneous circulation, the pigs were sacrificed and brain tissues were harvested. RESULTS: We measured the tissue levels of p38, JNK, and ERK pathway expressions from the hippocampus of the swine brain in all four groups. The phosphorylated p38-to-p38 ratio and phosphorylated JNK-to-JNK ratio were significantly increased in all of the intervention groups compared with the sham group. The phosphorylated ERK-to-ERK ratio was increased only in the therapeutic hypothermia groups (p-value=0.026 in the 24 hr of therapeutic hypothermia group and p-value=0.002 in the 48 hr of therapeutic hypothermia group, compared with the sham group). CONCLUSION: The p38 and JNK pathways were also activated during therapeutic hypothermia and normothermia. However, the ERK pathway was activated only in therapeutic hypothermia. Therapeutic hypothermia activated the ERK pathway in ischemia-reperfusion injury of the brain tissue after cardiac arrest, which seemed to be dependent on the duration of therapeutic hypothermia.

Changes in Inflammatory Cytokines during Rewarming Period of Therapeutic Hypothermia for Post-Cardiac Arrest Patients

PURPOSE: Therapeutic hypothermia is an important treatment strategy for control of the overwhelming inflammatory reactions of cardiac arrest patients. Rapid rewarming is related to poor outcome, however the kinds of inflammatory processes that occur during the rewarming period are not well understood. Our aim in the current study was to evaluate the changes in inflammatory cytokine levels during cardiac arrest patients' rewarming period. METHODS: This study was conducted in an emergency intensive care unit of a tertiary referral hospital. Blood samples were collected on admission (0 h) and 24, 26, 28, and 32 h after return of spontaneous circulation. Eight inflammatory cytokines (E-selectin, soluble ICAM, interleukin-10, interleukin-1ra, interleukin-6, interleukin-8, monocyte chemotactic protein-1, and tumor necrosis factor-α) were measured. RESULTS: Twenty-eight patients were enrolled and completed a protocol of 24 h hypothermia and 8h rewarming. Eight patients were of the good cerebral performance category (CPC) and 20 of the bad. The IL-1Ra level in the good CPC group was statistically changed at 26 (p=0.039) and 28 (p=0.003) but not at 32 h (p=0.632) when compared with the 24 h level. The IL-10 levels of the bad CPC group were decreased at 26 (p=0.017) and 28h (p=0.013) but not at 32 h (p=0.074) when compared with 24 h. None of the other cytokines showed meaningful differences during the rewarming period. CONCLUSION: Change in inflammatory-cytokine-level change during the rewarming period is not significant.

Optimal Dose of Antivenin for Asymptomatic or Minor Envenomation Patient with Korean Viperidae Injuries

PURPOSE: The aim of this study was to evaluate the feasibility and safety of our antivenin treatment protocol for patients with Korean Viperidae envenomation. METHODS: We developed an antivenin treatment protocol for Korean Viperidae envenomation, based on previous data, and applied this treatment to the enrolled patients. In brief, antivenin was not used for patients with grade 0. Patients with grade I and II received one vial of antivenin. Those with grade III and IV received two and three vials of antivenin, respectively. Adult patients who visited the emergency department (ED) after receiving a snakebite between July 2008 to August 2010 were included. Follow ups were performed at 24 hours, 7 days, and 28 days after the snakebite. RESULTS: A total of 62 patients were enrolled. At the initial evaluation, 6 patients (9.7%) were grade 0, 47 patients (75.8%) were grade I, and 9 patients (14.5%) were grade II. Upon the follow-up evaluation, 14 patients (29.8%) progressed from grade I to grade II and 2 patients (22.2%) progressed from grade II to III. Coagulopathy developed in 5 patients (8.0%) and rhabdomyolysis in 5 patients (8.0%). Urticaria developed in 2 patients (3.2%) and cellulitis in 3 patients (4.8%) as delayed complications. As an antivenin-related complication, serum sickness developed in only 1 patient (1.6%). There were no severe complications and all clinical and laboratory abnormalities disappeared within 28 days. CONCLUSION: Our antivenin treatment protocol was feasible and safe. To confirm our data, multicenter validation studies are needed.