The Poisoning Information Database Covers a Large Proportion of Real Poisoning Cases in Korea.

The poisoning information database (PIDB) provides clinical toxicological information on commonly encountered toxic substances in Korea. The aim of this study was to estimate the coverage rate of the PIDB by comparing the database with the distribution of toxic substances that real poisoning patients presented to 20 emergency departments. Development of the PIDB started in 2007, and the number of toxic substances increased annually from 50 to 470 substances in 2014. We retrospectively reviewed the medical records of patients with toxic exposure who visited 20 emergency departments in Korea from January to December 2013. Identified toxic substances were classified as prescription drug, agricultural chemical, household product, animal or plant, herbal drug, or other. We calculated the coverage rate of the PIDB for both the number of poisoning cases and the kinds of toxic substances. A total of 10,887 cases of intoxication among 8,145 patients was collected. The 470 substances registered in the PIDB covered 89.3% of 8,891 identified cases related to poisoning, while the same substances only covered 45.3% of the 671 kinds of identified toxic substances. According to category, 211 prescription drugs, 58 agricultural chemicals, 28 household products, and 32 animals or plants were not covered by the PIDB. This study suggested that the PIDB covered a large proportion of real poisoning cases in Korea. However, the database should be continuously extended to provide information for even rare toxic substances.

A Randomized Controlled Trial of Compression Rates during Cardiopulmonary Resuscitation.

UNLABELLED: The objective of this study was to compare the efficacy of cardiopulmonary resuscitation (CPR) with 120 compressions per minute (CPM) to CPR with 100 CPM in patients with non-traumatic out-of-hospital cardiac arrest. We randomly assigned patients with non-traumatic out-of-hospital cardiac arrest into two groups upon arrival to the emergency department (ED). The patients received manual CPR either with 100 CPM (CPR-100 group) or 120 CPM (CPR-120 group). The primary outcome measure was sustained restoration of spontaneous circulation (ROSC). The secondary outcome measures were survival discharge from the hospital, one-month survival, and one-month survival with good functional status. Of 470 patients with cardiac arrest, 136 patients in the CPR-100 group and 156 patients in the CPR-120 group were included in the final analysis. A total of 69 patients (50.7%) in the CPR-100 group and 67 patients (42.9%) in the CPR-120 group had ROSC (absolute difference, 7.8% points; 95% confidence interval [CI], -3.7 to 19.2%; P = 0.183). The rates of survival discharge from the hospital, one-month survival, and one-month survival with good functional status were not different between the two groups (16.9% vs. 12.8%, P = 0.325; 12.5% vs. 6.4%, P = 0.073; 5.9% vs. 2.6%, P = 0.154, respectively). We did not find differences in the resuscitation outcomes between those who received CPR with 100 CPM and those with 120 CPM. However, a large trial is warranted, with adequate power to confirm a statistically non-significant trend toward superiority of CPR with 100 CPM. ( CLINICAL TRIAL REGISTRATION INFORMATION: www.cris.nih.go.kr, cris.nih.go.kr number, KCT0000231).

Carbon monoxide-induced cardiomyopathy.

BACKGROUND: Previous reports demonstrated mechanisms of cardiac toxicity in acute carbon monoxide (CO) poisoning. Still, none established CO-induced cardiomyopathy (CMP) as a clinical entity. The aim of this study is to investigate CO-induced CMP in patients with acute CO poisoning in terms of its epidemiology, clinical characteristics, and prognosis. METHODS AND RESULTS: A retrospective study was conducted on consecutive patients who were diagnosed with acute CO poisoning at the emergency department of Ajou University Hospital during the period of 62 month. Six hundred and twenty-six patients were diagnosed with acute CO poisoning. During the initial echocardiography, 19 patients were abnormal: (1) global hypokinesia/akinesia (n=7), (2) regional wall hypokinesia/akinesia [n=12; takotsubo type (n=6), reverse takotsubo type (n=2), non-specific type (n=4)]. The ejection fraction (EF) was 36.3±13.5% (from 15% to 55%) and less than 45% for 14 patients. In the follow-up echocardiography performed within 12 days after the initial performance, most patients were found to have cardiac wall motion abnormalities, and their EF had returned to normal (ie, EF ≥50%). CONCLUSIONS: CO-induced CMP was identified in 3.04% (n=19) of all patients (n=626). It might not be too critical in acute clinical courses of acute CO poisoning because the prognosis seems favorable. Considering the common factors between CO-induced CMP and takotsubo CMP, myocardial stunning subject to a catecholamine surge most likely plays a central role in the development of CO-induced CMP.

Evaluation of exhaled nitric oxide in acute paraquat poisoning: a pilot study.

BACKGROUND: Fractional exhaled nitric oxide (FENO) is nitric oxide (NO) in the lower airway measured by oral exhalation. FENO can be a useful non-invasive marker for asthma. Paraquat-mediated lung injury can be reflective of an ROS-induced lung injury. We aimed to verify if FENO is a clinical parameter of ROS formation and responsiveness to medical therapies in acute paraquat intoxication. MATERIAL AND METHODS: We recruited 12 patients admitted with acute paraquat poisoning. A portable and noninvasive device called NIOX MINO™ (Aerocrine AB, Solna, Sweden) was used to measure FENO. Measurements were made at the time of hospital admission and at 24, 48, 72, 96, and 120 h after paraquat ingestion. RESULTS: Six out of the total 12 recruited patients had general conditions (e.g. oral pain) that made it difficult for them to exhale with adequate force. Mean plasma paraquat level was 1.4 ± 2.5 g/mL. We found no direct correlation between the paraquat levels (both ingestion amount and plasma concentration) and FENO (initial, maximal, and minimal values). All the measured FENO values were no greater than 20 ppb for the 2 patients who died. FENO did not vary more than 20% from the baseline. Compared to the above findings, FENO measurements were found to be greater than 20 ppb for the patients who survived. FENO tends to reach its peak value at between 50 h and 80 h. CONCLUSIONS: FENO did not predict mortality, and there was no increase of FENO in patients with severe paraquat intoxication.

Characteristics of intentional fall injuries in the ED.

INTRODUCTION: This study was conducted to examine the characteristics of intentional fall injuries and the factors associated with their prognosis. METHODS: The study included 8992 patients with unintentional falls from a height (nonintentional group) and 144 patients with intentional falls from a height (intentional group). General and clinical characteristics were compared between the 2 groups. Intentional fall cases were divided into severe and nonsevere groups, and the factors associated with severe injury were evaluated by comparing these groups. RESULTS: The most common age group was younger than 14 years in the nonintentional group and between 30 and 44 years old in the intentional group. For the nonintentional group, 65% of the patients were male, and 48% were male in the intentional group. Fall heights of more than 4 m were most common in the intentional group. Discharge was the most common result in the nonintentional group; however, death before arrival at the emergency department (ED) or during ED treatment occurred in 54.9% of patients in the intentional group. In the severe injury group within the intentional group, patients were older, and the height of the fall was higher. Factors associated with severe injury in the intentional group included being a high school graduate rather than a college graduate and greater fall height. CONCLUSION: The risk of severe injury increased with fall height in the intentional group, and a high school level of education rather than a college level of education was associated with more severe injury.

Does ondansetron have an effect on intramuscular ketamine-associated vomiting in children? A prospective, randomised, open, controlled study.

AIM: Ketamine is one of the most commonly used sedatives for facilitating painful procedures for paediatric patients in the emergency department (ED). However, the use of ketamine is associated with a common, though not serious, adverse event usually called ketamine-associated vomiting (KAV). The purpose of this study is to evaluate the anti-emetic effect of adjunctive ondansetron in paediatric patients receiving ketamine sedation in the ED. METHODS: We conducted a prospective, randomised, open, controlled study in children from 1 to 18 years of age who had undergone intramuscular ketamine sedation in the ED. The patients were randomised into two groups: a ketamine-only group and a ketamine/ondansetron group. The patients in the first group received ketamine alone, while those in the second group received ketamine with oral ondansetron. The incidence of KAV was estimated in the ED and after discharge, and the time to resumption of a normal diet was measured after sedation. RESULTS: A total of 237 patients were analysed. The incidence of KAV was 29.7% in the ketamine-only group and 25.2% in the ketamine/ondansetron group (P = 0.47). After administration of ketamine, the mean time to resumption of a normal diet was 8 h 54 min in the ketamine-only group and 8 h 39 min in the ketamine/ondansetron group (P = 0.67). CONCLUSIONS: A relatively high rate of KAV (29.7%) was observed, and the time to resumption of a normal diet after ketamine sedation was rather long. It turned out that, however, the adjunctive administration of ondansetron did not effectively reduce the incidence of KAV.

Injuries associated with the 580 km university student grand voluntary road march: focus on foot injuries.

College student volunteers (n = 142) completed a 580 km road march for 21 consecutive days. Each volunteer carried a backpack that weighed 14.1 ± 1.4 kg on the average. We investigated the incidence and location of blisters associated with the road march using a foot map along with other injuries. Overall, 95.1% of the subjects (135 of 142) sustained one or more injuries. All injured subjects had foot blisters, and 18% had other foot injuries. The most common locations of blister development were the right 5th toe (61%) and the left 5th toe (57%). The little toes seem to have been subjected to the greatest friction and shearing forces. March-related injuries, excluding foot injuries, were ankle pain (12.7%), knee pain (12.7%) and Achilles tendon pain (7.7%). Six subjects (4.2%) needed extra medical treatment for more than 2 weeks prior to returning to their daily lives after completion of the march due to associated injuries. The present study observed a very high incidence rate of injuries (95.1%) associated with the 580 km university students grand road march. These injuries posed an obstacle against completion of the road march and against returning to daily life. Active preventive interventions such as physical therapy and customized reinforced shoes and education program are recommended for reducing incidence rate and severity of injuries.

Acute oral poisoning due to chloracetanilide herbicides.

Chloracetanilide herbicides (alachlor, butachlor, metachlor) are used widely. Although there are much data about chronic low dose exposure to chloracetanilide in humans and animals, there are few data about acute chloracetanilide poisoning in humans. This study investigated the clinical feature of patients following acute oral exposure to chloracetanilide. We retrospectively reviewed the data on the patients who were admitted to two university hospitals from January 2006 to December 2010. Thirty-five patients were enrolled. Among them, 28, 5, and 2 cases of acute alachlor, metachlor, butachlor poisoning were included. The mean age was 49.8 ± 15.4 yr. The poison severity score (PSS) was 17 (48.6%), 10 (28.6%), 5 (14.3%), 2 (5.7%), and 1 (2.9%) patients with a PSS of 0, 1, 2, 3, and 4, respectively. The age was higher for the symptomatic patients (1-4 PSS) than that for the asymptomatic patients (0 PSS) (43.6 ± 15.2 vs 55.7 ± 13.5). The arterial blood HCO3⁻ was lower in the symptomatic patients (1-4 PSS) than that in the asymptomatic patients (0 PSS). Three patients were a comatous. One patient died 24 hr after the exposure. In conclusion, although chloracetanilide poisoning is usually of low toxicity, elder patients with central nervous system symptoms should be closely monitored and cared after oral exposure.

Characteristics of patients who visit the emergency department with self-inflicted injury.

During visits to emergency medical facilities, the primary care of and risk identification for individuals who have attempted suicide is considered an important element in suicide prevention. With the ultimate goal of helping to prevent suicide, the aim of the present study was to determine the characteristics of patients with self-inflicted injuries who presented in the emergency department. Patients with self-inflicted injuries who visited 1 of 3 sentinel emergency medical centers from 2007 through 2009 were included in the study. The characteristics, methods, and reasons for suicide attempts were evaluated. Moreover, predictors of severe outcomes were evaluated. A total of 2,996 patients with self-inflicted injuries visited the three centers during a period of 3 yr. The male-to-female suicide ratio was 1:1.38 (P < 0.001). The mean age was 41 yr. Poisoning was the most common method of self-inflicted injury (68.7%) among all age groups. Medication was the primary means of injury in the < 50 age group, and the use of agricultural chemicals was the primary means in the ≥ 50 age group. The reasons for attempting suicide varied among the age groups. The predictors of severe outcome are male gender, older age, and not having consumed alcohol.

The usefulness of albumin-adjusted ischemia-modified albumin index as early detecting marker for ischemic stroke.

This study was conducted to investigate whether albumin-adjusted ischemia-modified albumin index (IMA index) is more sensitive and accurate than ischemia-modified albumin (IMA) as early detection marker of ischemic stroke, and to compare IMA and IMA index in progression and non-progression of ischemic stroke. This case-control study was done at an emergency medical center of a university hospital. 52 patients with neurological symptoms were enrolled (28 Ischemic Stroke Group and 24 Non-Stroke Group). In the ROC analysis of IMA index to diagnose stroke, area under the curve (AUC) was 0.990 (cutoff value 91.4; 95% CI: 0.970-1.000; sensitivity: 96.4%; specificity 95.8%). The AUC for IMA value was 0.928 (cutoff value 98 U/ml; 95% CI 0.857-0.999; sensitivity 89.3%; specificity 88.5%). [corrected] The difference between progression (n = 12) and non-progression group (n = 16) in IMA and IMA index were statistically insignificant (p > 0.01). IMA index was more sensitive than conventional IMA value as diagnostic biomarker of stroke, however, arguable as a predictive biomarker for progression of ischemic stroke.

A clinical overview of a retrospective study about adult intussusceptions: focusing on discrepancies among previous studies.

This study was to determine clinical entity of adult intussusception, focusing on discrepancies among previous studies and to retrospectively investigate the factors associated with malignancy and survival for 10 years. In our study, 3.7% (N=42) of intussusception were adults. The most common symptom was acute abdominal pain (64.3%). Enteric, ileocolic, ileocecal, and colocolic intussusception included 52.4, 9.5, 14.3, and 23.8% of patients, respectively. Two patients (9.1%) with enteric (N=22), no patient with ileocolic (N=4), three patients (50%) with ileocecal (N=6), and five patients (50%) with colocolic (N=10) intussusception were malignant. The factor associated with malignancy was only chronic abdominal pain without acute abdominal pain (P = 0.018) and the absence of fever and ileocecal intussusception were associated with survival (P=0.010, 0.009). In our study, the most common symptom was acute abdominal pain, and enteric intussusception was the most common type. The difference in clinical presentation and location of intussusception might have resulted from small number of cases or selection of cases.

Patients who leave the emergency department against medical advice.

OBJECTIVE: Discharge against medical advice (DAMA) from the emergency department (ED) accounts for 0.1% to 2.7% of all ED discharges. DAMA carries a risk of increased mortality and readmissions. Our aim was to investigate the general characteristics of DAMA patients and the differences between them and non-DAMA patients. METHODS: We reviewed data collected by the National Emergency Medical Center between 2010 and 2011. Subjects were categorized into 2 groups, namely, the DAMA group and the non-DAMA group. We compared these groups with respect to age, gender, trauma or non-trauma status, type of hospital, health insurance, level of consciousness on admission, and diagnosis. RESULTS: Of 8,000,529 patients, 222,389 (2.78%) left against medical advice. The risk factors for DAMA across all age groups were as follows: no medical insurance (odds ratio [OR], 1.993), initial response to voice (OR, 2.753) or pain (OR, 2.101), trauma admission (OR, 1.126), admission to a local emergency medical center (OR, 1.215), and increased age. A high risk of DAMA was observed among patients with immune, endocrine, psychiatric, neurological, circulatory diseases, and external causes of morbidity and mortality. CONCLUSION: Although DAMA cases account for only a small percentage of hospital discharges, they are important because DAMA patients have high readmission and mortality rates. It is therefore important to understand the general characteristics and predictors of DAMA in order to improve patient outcome and minimize the economic burden on the healthcare system.

Treatment of acute carbon monoxide poisoning with induced hypothermia.

OBJECTIVE: The effect of induced hypothermia on severe acute carbon monoxide (CO) poisoning remains to be addressed further. We investigated the effect of induced hypothermia on severe acute CO poisoning. METHODS: Retrospective chart review was conducted for patients who diagnosed as severe acute CO poisoning in emergency department and underwent induced hypothermia from May 2013 to May 2014. Hospital courses with critical medication and major laboratory results were investigated through the chart review. RESULTS: Among total 227 patients with acute CO poisoning during the period of study, patients with severe acute CO poisoning were 15. All patients underwent induced hypothermia with a temperature goal 33°C. Initial and follow-up levels of S100B protein after induced hypothermia were 0.47 µg/L (interquartile range, 0.11 to 0.71) and 0.10 µg/L (interquartile range, 0.06 to 0.37), respectively (P = 0.01). The mean Glasgow Coma Scales at emergency department admission was 6.87 ± 3.36. Except 1 patient who expired after cardiopulmonary resuscitation, Glasgow Coma Scales at 30-day of hospital discharge were 15 in 10 patients (71.4%), 14 in 1 patient (7.1%), 13 in 1 patient (7.1%), and 6 in 2 patients (14.2%). Seven patients (46.7%) developed delayed neurologic sequelae. Four patients showed mild types of delayed neurologic sequelae and 3 showed moderate to severe types of delayed neurologic sequelae. CONCLUSION: Most of patients underwent induced hypothermia had a good recovery from severe acute CO poisoning. Therefore, induced hypothermia may be considered as a possible treatment in severe acute CO poisoning.

Various Echocardiographic Patterns of Left Ventricular Systolic Dysfunction Induced by Carbon Monoxide Intoxication.

Carbon monoxide (CO) intoxication could cause significant cardiac injury. Although cardiac dysfunction after CO intoxication can be presented, the echocardiographic findings after CO intoxication are poorly defined. The purpose of this study was to evaluate the clinical patterns of left ventricular (LV) systolic dysfunction using echocardiography. A total of 132 CO-intoxicated patients were enrolled. Clinical, demographic and laboratory data and echocardiographic findings were analyzed. The LV dysfunction group (29 patients) showed higher lactate level (5.8 ± 3.3 vs. 4.1 ± 3.5 mmol/L, p = 0.024) and lower base excess (BE) (-8.2 ± 6.0 vs. -4.8 ± 4.7 mEq/L, p = 0.001) compared with normal LV function group. Among the LV dysfunction group, three different echocardiographic patterns were presented. Regional wall motion abnormality was presented in 14 patients. Apical ballooning, typical finding of stress-induced cardiomyopathy, was presented in eight patients. Global hypokinesia of LV was presented in seven patients. Laboratory findings indicating the severity of CO intoxication, such as lactate level, pH value, BE and aspartate aminotransferase, showed statistical significance according to the patterns of LV dysfunction (p = 0.033, 0.022, 0.02 and 0.006, respectively). Our results demonstrate that CO intoxication could induce various patterns of LV dysfunction. The patterns of LV dysfunction might affect subsequent clinical outcomes.

Prognostication of cardiac arrest survivors using low apparent diffusion coefficient cluster volume.

INTRODUCTION: We developed a new neuroprognostication method for cardiac arrest (CA) using the relative volume of the most dominant cluster of low apparent diffusion coefficient (ADC) voxels and tested its performance in a multicenter setting. METHODS: Adult (>15 years) out-of-hospital CA patients from three different facilities who underwent an MRI 12h after resuscitation were retrospectively analyzed. Patients with unknown long-term prognosis or poor baseline neurologic function were excluded. Average ADCs (mean and median), LADCV (relative volume of low-ADC voxels) and DC-LADCV (relative volume of most dominant cluster of low-ADC voxels) were extracted using different thresholds between 400 and 800 × 10(-6) mm(2) s(-1) at 10 × 10(-6) mm(2) s(-1) intervals. Area under the receiver operating characteristic curve (AUROC) and sensitivity for poor outcome (6-month cerebral performance category score >2) while maintaining 100% specificity were measured. RESULTS: 110 patients were analyzed. Average ADCs showed fair performance with an AUROC of 0.822 (95% confidence interval [CI], 0.744-0.900) for the mean and 0.799 (95% CI, 0.716-0.882) for the median. LADCV showed better performance with a higher AUROC (maximum, 0.925) in an ADC threshold range of 400 to 690 × 10(-6) mm(2) s(-1). DC-LADCV showed the best performance with a higher AUROC (maximum, 0.955) compared with LADCV in an ADC threshold range of 600 to 680 × 10(-6) mm(2) s(-1). DC-LADCV had a high sensitivity for poor outcomes (>80%) in a wide threshold range from 400 to 580 × 10(-6) mm(2) s(-1) with a maximum of 89.2%. CONCLUSIONS: Quantitative analysis using DC-LADCV showed impressive performance in determining the prognosis of out-of-hospital CA patients in a multicenter setting.

Use of a slit-lamp microscope for treating impacted facial foreign bodies in the emergency department.

Identifying, locating, diagnosing, and treating small foreign bodies (FBs) in soft tissues is a challenge for emergency physicians in the emergency department. Additionally, potential complications owing to the remnant FBs are medico-legally significant. The efficacy of conventional imaging methods such as radiography, computed tomography, and ultrasonography are largely limited in visualizing FBs<2-mm. The slit-lamp microscope, still unfamiliar to some emergency physicians, could be used to facilitate the treatment of FBs impacted in soft tissues. In this paper, we present a case that would have been difficult to treat without the help of the slit-lamp microscope; the patient presented with numerous particulate facially impacted FBs that were too small to be observed under plain sight or with radiography. Based on our experience, the slit-lamp microscope could be a useful tool for treating patients with miniscule and stubborn impacted FBs in the emergency department.

Clinical insights for early detection of acute transverse myelitis in the emergency department.

OBJECTIVE: Acute transverse myelitis (ATM) is characterized by motor weakness, sensory changes, and autonomic dysfunction. However, diagnosis of ATM is based on early-stage clinical features only (and clarification of the cause of disease), which are difficult for emergency department (ED) physicians owing to low incidence rates. We performed retrospective analysis of ATM in order to provide clinical insights for early detection. METHODS: Medical records of patients, who were finally diagnosed with ATM from January 2005 to February 2013, were investigated. Data, including demographics, clinical findings, and radiographic findings, were reviewed. RESULTS: Forty-six patients were included in the present study, with a mean age of 43.4 years. Sensory changes were identified in 45 patients (97.8%), motor weakness in 33 patients (71.7%), and autonomic dysfunction in 35 patients (76.1%). Thirty patients (65.2%) showed high signal intensity in T2-weighted magnetic resonance imaging (MRI), with lesions most frequently found in the thoracic level of the spinal cord (56.7%). There were discrepancies between sensory changes and levels of MRI lesions. Thirty-five patients (76.1%) were diagnosed with idiopathic ATM. Initial diagnostic impressions in the ED were herniated intervertebral disc (38.7%), stroke (19.4%), Guillain-Barré syndrome (12.9%), cauda equina syndrome (9.7%), ATM (9.7%), and others (9.7%). CONCLUSION: When a patient presents with motor weakness, sensory changes, or autonomic dysfunction, ATM should be initially considered as a differential diagnosis, unless the ED physician's impression after initial evaluation is clear.

Pathophysiology of brain injuries in acute carbon monoxide poisoning: a novel hypothesis.

Acute carbon monoxide (CO) poisoning causes the neurologic symptoms and brain lesions during both acute and delayed phase. We propose that catecholamine crises in globus pallidus and deep white matter are the key pathophysiological factors causing acute and delayed brain injuries respectively. Increased sympathetic activities due to acute CO poisoning is followed by increases of catecholamine levels in synapses or nerve terminals in organs including the brain, especially, limbic system. A dopamine excess in the synaptic cleft of the mesolimbic system, including globus pallidus, may cause the destruction of synapses and nuclei in the globus pallidus. Consequently, the striatal lesion is affected in the acute phase of CO intoxication. Moreover, an increase of catecholamine levels in synapses of deep white matter can persist after the acute stage of CO intoxication. A dopamine excess could lead to oxidative metabolism of dopamine, serotonergic axonal injury, or secondary myelin damage.