Malignant Cerebral Infarction after Pulmonary Resection for Lung Cancer / 대한구급학회지

Malignant cerebral infarction as postoperative complication after pulmonary resection occurs rarely, but can be rather serious. We report a case of 81-year-old man who suffered from malignant cerebral infarctions after pulmonary resection for lung cancer. He had a history of well-controlled hypertensions, but no evidences of arrhythmia, and neither stenosis nor atheroma in the carotid arteries and intracranial arteries. There were no specific events during his operation except that an inadvertent left carotid artery puncture occurred during the central line insertion. In intensive care unit (ICU), he had a delayed recovery of consciousness and dysarthria with right hemiplegia. Computed tomography revealed malignant middle cerebral infarctions due to the occlusion of left middle cerebral artery. It could be the thromboembolism due to pulmonary resections or carotid artery punctures in the patient without high risk factors.

Usefulness of Blood Cultures in Children Aged Under 3 Years with Fever at the Emergency Department

PURPOSE: Blood cultures are commonly performed in evaluation of febrile children without an obvious source of infection. Pediatric clinicians treat patients with a positive blood culture before final identification of the organism. This study sought to determine the yield and the clinical usefulness of blood cultures in pediatric patients younger than 3 years with fever at the emergency department. METHODS: We conducted a retrospective review of all children between the ages of 1 and 36 months with a body temperature of at least 38.0degrees C who underwent blood culture in the emergency department (ED) from January 2008 to December 2010. RESULTS: Bacteria growth occurred in 126(10.3%) out of 1,219 blood cultures. True positives (TPs), defined as true pathogens, were observed in 2.5% of cultures, representing 23.8% of positives. False positives (FPs), defined as contaminants, were observed in 7.9% of cultures, representing 76.2% of positives. Patients with TP cultures had lower mean pH (7.36+/-0.17 vs 7.41+/-0.08, p=0.031), higher mean base deficit (4.9+/-6.0 mmol/L vs 2.9+/-2.5 mmol/L, p=0.012), and higher mean C-reactive protein (CRP) level (3.3+/-3.7 mg/dL vs 1.8+/-3.2 mg/dL, p=0.034) than those with FP cultures. CONCLUSION: True positive results were observed relatively infrequently in blood cultures of febrile children younger than 3 years in the ED; therefore, changes in treatment of pediatric patients with fever are uncommon. However, bacteria identified by blood cultures are likely to be the true pathogen in a pediatric patient with a large base deficit or a high CRP level.

Clinical Characteristics of Patients with Indoxacarb Insecticide Poisoning

PURPOSE: Indoxacarb insecticide poisoning causes methemoglobinemia, which is occasionally life-threatening. However, there is limited data on indoxacarb effects after human ingestion. The purpose of this study was to examine the clinical features, complications, management, and medical outcome of patients with indoxacarb insecticide poisoning. METHODS: We retrospectively reviewed the medical records of 10 patients with indoxacarb insecticide poisoning who had visited our emergency centers from January 2008 to December 2011. We collected data on the general characteristics of the patients, their clinical symptoms and signs, laboratory data, management of their condition, and clinical results. RESULTS: Among the 10 patients, 8 were diagnosed with methemoglobinemia. The clinical manifestations of indoxacarb insecticide poisoning were hypotension (3 patients), altered mentality (5 patients), cyanosis (5 patients), dyspnea (2 patients), seizure (3 patients), and cardiac arrest (2 patients). Four patients had a poisoning severity score of 3 and 2 patients had a poisoning severity score of 2. Four patients were treated with methylene blue for methemoglobinemia and one patient was treated with a high dose (150 mg/kg) of ascorbic acid. The serum methemoglobin saturation of five patients who were treated with methylene blue or a high dose of ascorbic acid was nearly normalized. Four patients experienced rhabdomyolysis, pneumonia, hemolytic anemia, acute pancreatitis, and heart failure as a complication of indoxacarb insecticide poisoning. CONCLUSION: We observed a variety of clinical features, complications, management, medical outcome, and clinical course of patients with indoxacarb insecticide poisoning. We could also ascertain the efficacy of methylene blue and high dose ascorbic acid for indoxacarb-induced metheglobinemia.

The Safety of Bolus Infusion Through Intraosseous Access Using the EZ-IO in Terms of Extraosseous Flow

PURPOSE: We evaluated the safety of bolus infusion through intraosseous access using the EZ-IO in adults in terms of extraosseous flow. METHODS: We conducted a prospective study of adults (over age 18) in whom intraosseous access through the tibia was performed by emergency physicians or residents from June 2010 to June 2011. We used ultrasonography to confirm extraosseous flow during infusion of 80 mL normal saline with a 4 mL/s flow rate through intraosseous access, immediately after confirmation of intraosseous needle insertion using conventional methods. Finally, we recorded any complications that occurred immediately in the area of intraosseous access. RESULTS: Of 30 patients enrolled in the study, 22(73.3%) were male and eight (26.7%) were female. The mean age of study participants was 62.78+/-15.68 years; mean cortical thickness of participants' tibias was 0.27+/-0.03 cm. The mean time required for performance of the intraosseous access procedure was 16.00+/-4.65 s; success rate on the first attempt, 100.0%. No immediate complications, including swelling or extraosseous flow at the area of intraosseous access, were observed. CONCLUSION: In this study, bolus infusion though intraosseous access using the EZ-IO in adults in emergency departments was a safe option in terms of extraosseous flow.

Validity of Corrected Flow Time (FTc) as a Predictor of Fluid Responsiveness in Patients with Sepsis-induced Hypotension

PURPOSE: To determine the validity of corrected flow time (FTc) as a predictor of fluid responsiveness for patients with sepsis-induced hypotension in the emergency department. METHODS: A total of 26 adult patients, who presented in the emergency department with sepsis-induced hypotension with spontaneous breathing, were enrolled in this prospective, interventional study. These patients were monitored by Esophageal Doppler (ED); FTc, central venous pressure (CVP), stroke volume index (SVI), and inferior vena cava diameter (IVCD) were measured before and after fluid challenge. Responsiveness to fluid challenge was defined as an SVI increase> or =10%. Receiver operating characteristic (ROC) curves were constructed and compared to evaluate the overall performance of preload indices (CVP, FTc, IVCD) in terms of predicting fluid responsiveness. RESULTS: Of the hemodynamic parameters initially measured, there were statistically significant differences in FTc and CVP between the responsive and unresponsive groups. Before and after fluid challenge, noticeable changes were observed in mean arterial pressure (MAP), CVP and IVCD between the two groups. Only the responsive group demonstrated statistical difference in FTc. The areas under the curves for FTc (0.870; 95% CIs, 0.708-0.979; p=.009) were significantly greater than those for CVP and IVCD. CONCLUSION: The corrected flow time (FTc) method may be a good predictor of fluid responsiveness relative to sepsis-induced hypotension for patients in the emergency department.

Validity of Corrected Flow Time (FTc) as a Predictor of Fluid Responsiveness in Patients with Sepsis-induced Hypotension

PURPOSE: To determine the validity of corrected flow time (FTc) as a predictor of fluid responsiveness for patients with sepsis-induced hypotension in the emergency department. METHODS: A total of 26 adult patients, who presented in the emergency department with sepsis-induced hypotension with spontaneous breathing, were enrolled in this prospective, interventional study. These patients were monitored by Esophageal Doppler (ED); FTc, central venous pressure (CVP), stroke volume index (SVI), and inferior vena cava diameter (IVCD) were measured before and after fluid challenge. Responsiveness to fluid challenge was defined as an SVI increase> or =10%. Receiver operating characteristic (ROC) curves were constructed and compared to evaluate the overall performance of preload indices (CVP, FTc, IVCD) in terms of predicting fluid responsiveness. RESULTS: Of the hemodynamic parameters initially measured, there were statistically significant differences in FTc and CVP between the responsive and unresponsive groups. Before and after fluid challenge, noticeable changes were observed in mean arterial pressure (MAP), CVP and IVCD between the two groups. Only the responsive group demonstrated statistical difference in FTc. The areas under the curves for FTc (0.870; 95% CIs, 0.708-0.979; p=.009) were significantly greater than those for CVP and IVCD. CONCLUSION: The corrected flow time (FTc) method may be a good predictor of fluid responsiveness relative to sepsis-induced hypotension for patients in the emergency department.

Effect of a SMS (short message service) System on Emergency Department Overcrowding

PURPOSE: Emergency departments (ED) are always overcrowded. Overcrowding is an important problem associated with emergency department treatment and patient satisfaction. Overcrowding can be caused by specific and complex issues and is affected by multiple influences. In an effort to reduce the degree of overcrowding, we evaluated relationships within the SMS (short message service) specialist's notification system. METHODS: This study involved establishment of a SMS specialist's notification system and other activity for resolution of emergency department overcrowding. We conducted a comparative analysis of ED patients from January 2010 to December 2010, before establishment of the system, and from January 2011 to December 2011, after establishment of the system. Data on ED patients were obtained from electronic medical records and the clinical data warehouse. Data were compared for mean length of stay and patient admission number. RESULTS: Results of comparison showed that the mean length of stay for discharge, admission, operation, and transfer had been effectively reduced. Mean residence time for patients in each administration sector was reduced 80.3, 462.3, 127.3, and 89.3 minutes, respectively, after overcrowding had been diminished. Significant differences for mean residence time were observed in each sector (p<0.001). In addition, comparison of before and after adoption of the SMS specialist's notification system for each clinical department showed that mean length of stay of patients admitted to the emergency department was significantly shorter after its adoption. CONCLUSION: By establishing a SMS specialist notification system, overcrowding can be resolved and length of stay can be shortened, which would result in improved satisfaction of both patients and emergency department professionals.

Early Factors Affecting Prognosis of Patients with Hanging Injury

PURPOSE: Hanging is a common method of suicide around the world. The prognosis after hanging injury is highly variable. Some patients die despite intensive treatment, while other patients recover without neurologic sequelae. The purpose of this study was to identify several prognostic factors affecting the outcome in patients with hanging injury. METHODS: Thirty-five patients presented at Gyeongsang National University Hospital between May 2005 and July 2009 following hanging injury. Patients, of whom 30 were unconscious, were classified as being in the initial mental status. For these patients, we investigated several factors and identified correlations between factors and prognosis. We investigated the type of hanging, mental status, presence of pupillary light reflex, glasgow coma scale (GCS), laboratory findings, presence of cardiopulmonary resuscitation (CPR) and intubation, history of psychiatric disease, alcohol use, hanging duration, brain computed tomography (CT), and injury of the spine and neck soft tissue. RESULTS: Factors suggesting a poor prognosis factors were complete hanging, poor mental status, the absence of pupillary light reflex, initial GCS, pH, bicarbonate and excess level of base, the practice of CPR and intubation. In particular, patients who showed GCS scores lower than 4.5 in the emergency room were highly likely to die. CONCLUSION: Patients after hanging injury can recover without neurologic sequelae despite altered mental status. The prognosis of patients who present with hanging injury can be established by the type of hanging, initial mental status, the presence of pupillary light reflex, initial GCS, arterial blood gas analysis (ABGA), and the practice of CPR and intubation. Therefore patients with hanging injury should be treated aggressively with consideration of prognostic factors.