Identifying the optimal hand placement site for chest compression by measuring hand width and sternal length in young adults.

OBJECTIVE: There are no specific guidelines regarding the exact hand placement location for effective chest compressions. This study was designed to identify the optimal hand placement site over the chest during cardiopulmonary resuscitation (CPR). METHODS: The sternal length (SL) of young Korean adults was measured as the distance from the suprasternal notch (SN) to the lower end of the sternum. In addition, the heel width of the hand (H) was measured 1 cm (H1) and 2 cm (H2) distal to the proximal end of the carpal bones. RESULTS: A total of 300 men and 300 women were enrolled. SL positively correlated with height (R(2)=14.2), weight (R(2)=15.3), BMI (R(2)=10.3), H1 (R(2) =3.4), and H2 (R(2) = 5.0). Mean H2 and half of the SL (SL/2) for the subgroups were M 8.4 and 10.1 cm, M' 8.3 and 9.7 cm, W 7.6 and 10.1 cm, and W' 7.4 and 9.5 cm, respectively (M, men taller than the mean; M', men shorter than the mean; W, women taller than the mean; W', women shorter than the mean). Mean H2 in men was 1.1 to 1.6 cm shorter than SL/2, whereas mean H2 in women was 2.2 to 2.9 cm shorter than SL/2. CONCLUSIONS: To find the most optimal chest compression point, from the patients' left side, CPR providers need to palpate the SN using the right little finger and placing the left heel one heel width (H2) from the SN. From the patient's right side, CPR providers should use the left little finger to palpate the SN and place the right heel one heel width (H2) from the SN.

Controlled cortical impact before or after fear conditioning does not affect fear extinction in mice.

Post-traumatic stress disorder (PTSD) is characterized in part by impaired extinction of conditioned fear. Traumatic brain injury (TBI) is thought to be a risk factor for development of PTSD. We tested the hypothesis that controlled cortical impact (CCI) would impair extinction of fear learned by Pavlovian conditioning, in mice. To mimic the scenarios in which TBI occurs prior to or after exposure to an aversive event, severe CCI was delivered to the left parietal cortex at one of two time points: (1) Prior to fear conditioning, or (2) after conditioning. Delay auditory conditioning was achieved by pairing a tone with a foot shock in "context A". Extinction training involved the presentation of tones in a different context (context B) in the absence of foot shock. Test for extinction memory was achieved by presentation of additional tones alone in context B over the following two days. In pre- or post-injury paradigms, CCI did not influence fear learning and extinction. Furthermore, CCI did not affect locomotor activity or elevated plus maze testing. Our results demonstrate that, within the time frame studied, CCI does not impair the acquisition and expression of conditioned fear or extinction memory.

Role of Akt and mammalian target of rapamycin in functional outcome after concussive brain injury in mice.

Akt (protein kinase B) and mammalian target of rapamycin (mTOR) have been implicated in the pathogenesis of cell death and cognitive outcome after cerebral contusion in mice; however, a role for Akt/mTOR in concussive brain injury has not been well characterized. In a mouse closed head injury (CHI) concussion traumatic brain injury (TBI) model, phosphorylation of Akt (p-Akt), mTOR (p-mTOR), and S6RP (p-S6RP) was increased by 24 hours in cortical and hippocampal brain homogenates (P<0.05 versus sham for each), and p-S6RP was robustly induced in IBA-1+ microglia and glial fibrillary acidic protein-positive (GFAP+) astrocytes. Pretreatment with inhibitors of Akt or mTOR individually by the intracerebroventricular route reduced phosphorylation of their respective direct substrates FOXO1 (P<0.05) or S6RP (P<0.05) after CHI, confirming the activity of inhibitors. Rapamycin pretreatment significantly worsened hidden platform (P<0.01) and probe trial (P<0.05) performance in CHI mice. Intracerebroventricular administration of necrostatin-1 (Nec-1) before CHI increased hippocampal Akt and S6RP phosphorylation and improved place learning (probe trials, P<0.001 versus vehicle), whereas co-administration of rapamycin or Akt inhibitor with Nec-1 eliminated improved probe trial performance. These data suggest a beneficial role for Akt/mTOR signaling after concussion TBI independent of cell death that may contribute to improved outcome by Nec-1.

Oropharyngeal airway obstruction after the accidental ingestion of Arisaema amurense.

BACKGROUND: Arisaema amurense is widely known in Korean folklore as a poisonous plant, and its lethal toxicity has long been recognized. The toxicity of Arisaema amurense is due to its content of calcium oxalate, which causes painful oropharyngeal edema, hypersalivation, aphonia, oral ulceration, esophageal erosion, and hypocalcemia. OBJECTIVE: We report a case of accidental poisoning after ingestion of the rhizome of Arisaema amurense, resulting in airway obstruction that required endotracheal intubation. CASE REPORT: A 60-year-old man developed oral pain and swelling after accidentally ingesting a rhizome from the Arisaema amurense plant as a medicinal herb. His symptoms worsened upon his arrival in the Emergency Department, and he was unable to speak due to oral swelling and hypersalivation. The patient underwent endotracheal intubation to protect his airway and was treated with antihistamines and corticosteroids. Three days after treatment, he had improved and was extubated. CONCLUSION: We describe an emergent treatment course for a patient with acute airway obstruction resulting from the ingestion of Arisaema amurense.

The frequency of reexpansion pulmonary edema after trocar and hemostat assisted thoracostomy in patients with spontaneous pneumothorax.

PURPOSE: Several risk factors for development of reexpansion pulmonary edema (REPE) after drainage of pneumothoraces have been reported, but the association between the method of thoracostomy and the development of REPE is unknown. The aim of this study was to compare the frequency of REPE after treatment of spontaneous pneumothorax with trocar or hemostat assisted closed thoracostomy. MATERIALS AND METHODS: We performed a prospective, observational study including 173 patients with spontaneous pneumothorax who visited the emergency department from January 2007 to December 2008. In 2007, patients were treated with hemostat-assisted drainage, whereas patients in 2008 were treated with trocar-assisted drainage. The main outcome was the development of REPE, determined by computed tomography of the chest 8 hours after closed thoracostomy. Outcomes in both groups were compared using univariate and multivariate analyses. RESULTS: Ninety-two patients were included, 48 (42 males) of which underwent hemostat-assisted drainage and 44 (41 males) underwent trocar-assisted drainage. The groups were similar in mean age (24 ± 10 vs. 26 ± 14 respectively). The frequencies of REPE after hemostat- and trocar-assisted drainage were 63% (30 patients) and 86% (38 patients) respectively (p=0.009). In multivariate analysis, trocar-assisted drainage was the major contributing factor for developing REPE (odds ratio=5.7, 95% confidence interval, 1.5-21). Age, gender, size of pneumothorax, symptom duration and laboratory results were similar between the groups. CONCLUSION: Closed thoracostomy using a trocar is associated with an increased risk of REPE compared with hemostat- assisted drainage in patients with spontaneous pneumothorax.

Transmission of hepatitis C virus by occupational percutaneous injuries in South Korea.

Korea is an endemic area of hepatitis. Hepatitis C virus (HCV) infections caused by occupational percutaneous injuries are a serious problem for healthcare workers and there has been a gradual increase in the number of HCV infections. We therefore determined the transmission rate of HCV after occupational percutaneous injury. This was a retrospective cohort study reviewing all occupational blood exposure reports made between January 1, 2004, and December 31, 2008, at a university-affiliated acute care hospital. Over the 5-year study period, there were 1,516 accidents of occupational exposure to blood; of these, 327 (21.6%) were to the blood of HCV-infected patients and 3 (0.9%) healthcare workers became infected with HCV (95% CI 0.6-8.8). In Korea, although the bloodborne accidents leading to exposure to HCV occurred frequently (21.6%), the transmission rate was very low (0.92%).

The effects of incorporating a pneumonia severity index into the admission protocol for community-acquired pneumonia.

BACKGROUND: Community-acquired pneumonia (CAP) is a common reason for admissions in the emergency department (ED). However, patient disposition is not always standardized. OBJECTIVE: To evaluate the effect of incorporating a pneumonia severity index (PSI) on admission rates and medical costs in CAP patients presenting to the ED. METHODS: From April 2008 to March 2009, CAP patients presenting to the ED were prospectively screened and low-risk CAP patients (PSI I, II, or III) were enrolled (after group). Discharge and outpatient care were recommended for this group in the absence of other medical conditions requiring hospitalization. Data from low-risk CAP patients from May 2003 to October 2006 were also collected for comparative analysis (before group). RESULTS: There were 365 and 174 patients in the before and after groups, respectively. The admission rate of the after group was significantly lower than that of the before group (30.4% vs. 68.2%, p < 0.01). The subsequent admission rates after ED discharge due to CAP were similar (3.2% vs. 7.7%, p = 0.10). The ultimate admission rate in the after group was significantly lower than that in the before group (32.5% vs. 70.7%, p < 0.01). Direct medical costs per patient for the before and after groups were $US 1532 and $US 1186, respectively (p = 0.03). CONCLUSIONS: Incorporation of the PSI into the admission protocol for ED patients with CAP significantly reduced the admission rates and medical costs.

Deliberate self-poisoning: factors associated with recurrent self-poisoning.

OBJECTIVE: To investigate potential risk factors associated with the repetition of deliberate self-poisoning (DSP). METHODS: Retrospective medical record review of all patients who presented to the emergency department of a tertiary teaching hospital after DSP between January 1, 2000, and December 31, 2009. Repetition of a suicide attempt was determined from reported episodes before the index episode or from 2 visits to the same hospital during the study period. Demographic information, clinical variables, and other variables at the first suicide attempt were investigated for factors associated with repetition of DSP. RESULTS: Of the 967 patients, 203 (21%) presented with repeated suicide attempts. Patients with repeat suicide attempts differed in sex, occupation, living condition, method of DSP, history of psychiatric treatment, reversibility, and psychiatric diagnosis. In the multivariate regression analysis, the only reliable associated factors for repeat suicide attempt were sex (P = .001), living condition (P < .001), method of DSP (P < .036), and history of psychiatric treatment (P < .001). CONCLUSION: Early psychological intervention and close observation is required for patients who are female, living without a family, use antidepressants, and have a history of psychiatric treatment.

Visitor injuries on Jeju Island, Korea.

BACKGROUND: Jeju Island is the most visited spot in South Korea; however, it had the highest death rate in the country due to injury in 2008. We investigated injured patients who presented to an emergency department (ED) in Jeju and compared patients who were visitors with those who were residents of Jeju. METHODS: A retrospective study was conducted on injured patients visiting the ED at the Jeju National University Hospital from March 2008 to February 2010. The following factors were investigated: demographic data, new injury severity score (NISS), alcohol use, intention of injury, mechanism of injury, place of occurrence, activity when injured, patient outcome, and final mortality. RESULTS: A total of 9,226 injured patients visited the ED during the study: 8,392 residents and 834 visitors (9.04%). The sex ratio and NISS were not different between the two groups. The mean age was younger in visitors (33.96 ± 23.37 vs 30.83 ± 18.79, p < 0.001). More intentional injuries and alcohol-related injuries occurred in residents than visitors (p < 0.001 and p < 0.005, respectively). In both groups, the most common reasons for injury were falling, stumbling, jumping, and being pushed. Visitors had more transportation-related injuries and were injured more often during leisure or play or when traveling. Injuries to visitors occurred more often in commercial, countryside, recreational, and cultural areas. Forty-three deaths were reported, including two visitors who died from suffocation and drowning. CONCLUSIONS: To prevent accidents, safety information should be provided for visitors and injury prevention education should be provided for students on school trips and tour guides. Legislation should be passed on the use of protective equipment for motorcyclists and bicyclists. These results support taking measures to decrease the rate of injury among visitors on Jeju Island.

Heart-type fatty acid binding protein as an adjunct to cardiac troponin-I for the diagnosis of myocardial infarction.

We hypothesized that when used in combination with cardiac troponins, heart-type fatty acid binding protein (H-FABP) would have greater diagnostic value than conventional markers for the early diagnosis of myocardial infarction (MI). Patients with typical chest pain at a single emergency department were consecutively enrolled. Initial blood samples were drawn for H-FABP, myoglobin, creatine kinase isoenzyme MB (CK-MB), and cardiac troponin-I (cTnI) measurements. MI was defined by serial cTnI measurements. To evaluate the adjunctive role of biochemical markers, we derived and compared logistic regression models predicting MI in terms of their discrimination (area under the receiver operating characteristics curve, AUC) and overall fit (Bayesian information criterion, BIC). Seventy-six of 170 patients were diagnosed as having MI. The AUC of cTnI, H-FABP, myoglobin, and CK-MB were 0.863, 0.827, 0.784, and 0.772, respectively. A logistic regression model using cTnI (P = 0.001) and H-FABP (P < 0.001) had the biggest AUC (0.900) and the best fit determined by BIC. Sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of this model at 30% probability were 81.6%, 80.9%, 4.26, and 0.23, respectively. H-FABP has a better diagnostic value than both myoglobin and CK-MB as an adjunct to cTnI for the early diagnosis of MI.

Low-dose diltiazem in atrial fibrillation with rapid ventricular response.

OBJECTIVES: Diltiazem is one of the most commonly used medications to control the rapid ventricular response in atrial fibrillation (AF). The recommended starting dose is an intravenous bolus of 0.25 mg/kg over 2 minutes. To avoid hypotension, we have empirically used a lower dose of diltiazem. We compared the efficacy and safety of different doses of diltiazem in rapid AF. METHODS: A retrospective chart review was undertaken in patients who presented to the emergency department with rapid AF. Patients were divided into 3 groups according to diltiazem dosage: low dose (≤ 0.2 mg/kg), standard dose (> 0.2 and ≤ 0.3 mg/kg), and high dose (> 0.3 mg/kg). We compared the rates of therapeutic response (adequate rate control) and complications (such as hypotension). Multivariate regression analysis was used to determine the effect of diltiazem dose on the occurrence of complications. RESULTS: A total of 180 patients were included in the analysis. There were no significant differences in the rates of therapeutic response for the low-, standard-, and high-dose groups (70.5%, 77.1%, and 77.8%; P = .605). The rates of hypotension in the low-, standard-, and high-dose groups were 18%, 34.9%, and 41.7%, respectively. After adjusting confounding variables, the rate of hypotension was significantly lower in the low-dose group in comparison with the standard-dose group (adjusted odds ratio, 0.39; 95% confidence interval, 0.16-0.94). CONCLUSIONS: Low-dose diltiazem might be as effective as the standard dose in controlling rapid AF and reduce the risk of hypotension.

Prognostic value of N-terminal pro-brain natriuretic peptide in hospitalised patients with community-acquired pneumonia.

BACKGROUND: The prognostic role of N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with community-acquired pneumonia (CAP) has not been evaluated. The aim of the present study was to investigate whether NT-proBNP level could predict mortality in hospitalised CAP patients. METHODS: We performed a structured medical record review of all hospitalised CAP patients from May 2003 to October 2006, and classified patients into the 30-day survival and non-survival group. Data included demographic and clinical characteristics, and laboratory findings including NT-proBNP levels. The APACHE II scores, PSI (pneumonia severity index) and CURB65 (confusion, urea, respiratory rate, blood pressure and aged 65 or more) scores were calculated. Comparisons between survivors and non-survivors were made with χ(2), non-parametric tests and logistic regression and ROC analysis were used to compare the ability of NT-proBNP (adjusted for age, heart failure and creatinine), APACHE II, PSI and CURB65 to predict mortality. RESULTS: Of 502 patients, 61 (12.2%) died within 30 days. NT-proBNP levels were measured in 167 patients and were significantly higher in non-survivors compared to survivors (median 841.7 (IQR 267.1-3137.3) pg/ml vs 3658.0 (1863.0-7025.0) pg/ml, p=0.019). NT-proBNP was an independent predictor of mortality (adjusted OR 1.53; 95% CI 1.16 to 2.02, p=0.002). The AUC for NT-proBNP was 0.712 (95% CI, 0.613 to 0.812), which was comparable to those of PSI (0.749, p=0.531) and CURB65 (0.698, p=0.693), but inferior to that of APACHE II (0.831, p=0.037). Adding NT-proBNP to APACHE II, PSI and CURB65 did not significantly increase the AUCs, respectively. CONCLUSIONS: NT-proBNP level is an independent predictor of mortality in hospitalised CAP patients. The performance of NT-proBNP level is comparable to those of PSI and CURB65 in predicting mortality.

Risk stratification nomogram for nephropathy after abdominal contrast-enhanced computed tomography.

OBJECTIVES: Abdominal contrast-enhanced computed tomography (A-CECT) is widely used in emergency departments despite the risk of contrast-induced nephropathy. We attempted to develop a risk stratification nomogram for nephropathy in patients receiving emergency A-CECT. METHODS: Seven hundred fifty patients who received emergency A-CECT between August 2003 and January 2007, with available serum creatinine (SCr) measurements before and after A-CECT were included. Nephropathy was defined as either an absolute increase of 0.5 mg/dL or greater (44 µmol/L) or a relative increase of 25% or more in the SCr from baseline. A nomogram was developed based on multivariate logistic regression analysis using clinical variables available before A-CECT. The model was internally validated with a bootstrapping method, and performance was assessed by area under the receiver operating characteristics curve (AUC) and calibration curve. RESULTS: Nephropathy was observed in 34 of 750 patients. A nomogram was developed using age (odds ratio, 1.04 per 1-year increment) and baseline SCr (odds ratio, 2.51 per 1-mg/dL increment) as risk factors. Diagnostic accuracy of the model was fair by bias-corrected calibration plot. The AUC of the model was 0.794 (95% confidence interval, 0.734-0.854), and the AUC with bootstrapping samples of 200 repetitions was 0.794 (95% confidence interval, 0.737-0.851). CONCLUSION: The risk of nephropathy after emergency A-CECT can be individually predicted by internally validated nomogram using clinical variables available before the procedure.

The lack of association between age and diabetes and hospitalization in women with acute pyelonephritis.

BACKGROUND: Traditional management of acute pyelonephritis (APN) involves hospitalization and intravenous antibiotics. However, recently issued guidelines recommend that women with mild APN can be treated with oral antibiotics. OBJECTIVES: Many emergency practitioners feel compelled to admit all elderly and diabetic women with APN to the hospital. We explored the association between age and presence of diabetes with hospital admission in women with APN. METHODS: A retrospective chart review was undertaken on women with a diagnosis of APN made in the Emergency Department between May 2003 and December 2005. Exclusion criteria were as follows: pregnancy, immune suppression other than diabetes, urinary stone, septic shock, and hydronephrosis. Standardized chart review was performed and the primary outcome was admission to the hospital. Univariate and multivariate analyses were used to identify factors associated with hospital admission. RESULTS: Of the 388 patients included, 185 (47.7%) were admitted. After adjusting for confounding variables, the odds ratios of admission for those who had been recently hospitalized or had a low serum albumin level or a high C-reactive protein level were 2.10 (95% confidence interval [CI] 1.09-4.02), 1.96 (95% CI 1.09-6.05), and 2.57 (95% CI 1.11-3.46), respectively. Older age and the presence of diabetes were not found to be independently associated with admission. CONCLUSIONS: In women with acute pyelonephritis, an older age and diabetes were not found to be independently associated with hospital admission.

The accuracy of emergency medicine and surgical residents in the diagnosis of acute appendicitis.

OBJECTIVE: This study was conducted to compare the diagnostic accuracy for acute appendicitis between emergency medicine residents (EMRs) and surgical residents (SRs). METHODS: We conducted a prospective cohort study of adult patients with right lower quadrant pain. Each patient was evaluated by an EMR and an SR, and physicians predicted the probability of appendicitis into 4 groups from highest (group 1) to lowest (group 4). The diagnostic accuracies of EMR and SR for the diagnosis of appendicitis were compared by constructing receiver operating characteristics curves. In each case, an Alvarado score was calculated and a computed tomography (CT) scan of the abdomen and pelvis was performed, and their diagnostic accuracies were also compared with the predicted probabilities. RESULTS: Of a total 191 patients, 120 underwent surgery, and the negative appendectomy rate was 6.8%. There was a significant correlation between the predicted probabilities of EMR and SR. The areas under the curve for EMR and SR were 0.698 and 0.657, which were not statistically different. The areas under the curve of the Alvarado score and the CT were 0.735 and 0.978, respectively. The diagnostic accuracy of the CT scan was significantly higher than those of the Alvarado score and the resident-predicted probabilities. CONCLUSION: In patients with right lower quadrant abdominal pain who have already been evaluated by EMR, consultation evaluation by SR does not appear to improve clinical diagnostic accuracy, and routine performance of CT before surgical consultation should be considered for these patients.

Effectiveness of mouth-to-mouth ventilation after video self-instruction training in laypersons.

BACKGROUND: Mouth-to-mouth ventilation is a skill taught in cardiopulmonary resuscitation (CPR) training for laypersons. However, its effectiveness is questioned. Our aim was to determine the effectiveness of mouth-to-mouth ventilation training using a self-instruction CPR training video for laypersons. METHODS: Video-self-instruction CPR training was conducted with CPR Anytime (American Heart Association [AHA] & Laerdal Corporation) for laypersons who had not received CPR training during the recent 5 years. Immediately before, immediately after, and 8 weeks after the CPR training, an AHA basic life support instructor carried out a skill performance test using a standardized checklist. Also, 8 weeks after the training, a skill test concerning chest compression and mouth-to-mouth ventilation was conducted using a trained reporter. RESULTS: Cardiopulmonary resuscitation training of 84 laypersons was conducted. The mean performance score (from 0 to 2) for mouth-to-mouth ventilation was 0.24 right before the training, 1.58 right after the training, and 0.95 eight weeks after the training. The mean performance scores for chest compression were 0.13, 1.79, and 1.40, right before, right after, and 8 weeks after the CPR training, respectively. The rates of successful mouth-to-mouth ventilation and compression were 11.9%, and 39.1%, respectively. CONCLUSIONS: The effectiveness and short-term retention rate of mouth-to-mouth ventilation after video self-instruction CPR training in laypersons was significantly lower than for chest compressions.

Predicting change of hemoglobin after transfusion in hemodynamically stable anemic patients in emergency department.

BACKGROUND: To investigate factors associated with change of post-transfusion hemoglobin level, and to derive an equation that predicts post-transfusion changes in hemoglobin levels in hemodynamically stable anemic patients who visited emergency department. METHODS: A retrospective medical record review of patients who were hemodynamically stable and transfused with packed red blood cells was undertaken. Patients were randomly divided into two groups. One group (derivation group, 70% of total patients) was analyzed for factors associated with changes in post-transfusion hemoglobin levels, and linear regression analysis was performed to derive a prediction equation. The derived prediction equation was then externally validated with the other group (validation group, 30% of total patients). RESULTS: A total of 196 patients were enrolled. The 137 patients (70% of total patients) in the derivation group were analyzed for factors associated with changes in post-transfusion hemoglobin. Of those, body surface area and initial hemoglobin level were significantly correlated with changes in post-transfusion hemoglobin levels (p < 0.05). From these variables, linear regression analysis resulted in a prediction equation. The derived equation was validated externally with the 59 patients (30% of total patients) in the validation group and found to have an excellent correlation (r = 0.73, intraclass correlation = 0.84, p < 0.05). CONCLUSIONS: Post-transfusion hemoglobin level in hemodynamically stable adult patients was associated with initial hemoglobin levels and body surface area. These factors must be considered when transfusing hemodynamically stable adult patients with anemia.