Usefulness of ultrasonography for the evaluation of catheter misplacement and complications after central venous catheterization.

Objective: To assess whether ultrasonographic examination compared to chest radiography (CXR) is effective for evaluating complications after central venous catheterization. Methods: We performed a prospective observational study. Immediately after central venous catheter insertion, we asked the radiologic department to perform a portable CXR scan. A junior and senior medical resident each performed ultrasonographic evaluation of the position of the catheter tip and complications such as pneumothorax and pleural effusion (hemothorax). We estimated the time required for ultrasound (US) and CXR. Results: Compared to CXR, US could equivalently identify the catheter tip in the internal jugular or subclavian veins (P=1.000). Compared with CXR, US examinations conducted by junior residents could equivalently evaluate pneumothorax (P=1.000), while US examinations conducted by senior residents could also equivalently evaluate pneumothorax (P=0.557) and pleural effusion (P=0.337). The required time for US was shorter than that for CXR (P<0.001). Conclusion: Compared to CXR, US could equivalently and more quickly identify complications such as pneumothorax or pleural effusion.

Multiple cerebral infarct with cerebral vasculitis in a young patient with ulcerative colitis.

Ulcerative colitis (UC) is a chronic and debilitating disorder, characterized by inflammation of the colonic mucosa. UC can be considered a systemic disorder but UC-related manifestations in the central nervous system (CNS) are quite rare. A 29-year-old man was admitted to the emergency department with repeated generalized tonic-clonic (GTC) type seizures. Based on brain CT, brain metastasis or hemorrhagic infarct was suspected. Diffusion-weighted image of brain MRI showed high signal in the left thalamus and heterogenous enhancement in the right parietal and left frontal lobes. This image indicated a cerebral infarct, but could not completely rule out cerebral metastasis and vasculitis, or any other pathology. However, the brain biopsy revealed multiple thromboemboli with acute inflammation and necrosis. Thus, the patient was diagnosed with multiple cerebral infarcts with cerebral vasculitis, occurring as a complication of UC. In conclusion, CNS manifestations of UC are rare. However, clinicians should consider uncommon diagnoses like vasculitis and thromboembolism in patients with UC presenting with seizures.

Extension of a coronary intramural hematoma after blunt chest trauma.

Coronary artery dissection and intramural hematoma after blunt chest trauma are rare, but life-threatening, complications. Coronary intramural hematoma extension is even rarer. A 31-year-old man was transferred to our hospital for worsening left chest pain during while he was admitted at a nearby hospital due to blunt chest trauma. Bedside echocardiography showed akinesis of the left ventricular apex and anterior wall as well as hypokinesis of the mid-to-basal anteroseptal wall and mid-to-basal lateral and posterior walls of the left ventricle. Computed tomography coronary angiography revealed intramural hematoma in the left main (LM) coronary and proximal left anterior descending (LAD) arteries. Percutaneous coronary intervention, with bare metal stent implantation from the LM coronary artery to the proximal LAD artery, was performed to treat the occlusion caused by the hematoma. After stenting, the hematoma that compressed the LM coronary artery shifted the left circumflex (LCX) artery, and the intramural hematoma developed and extended to the LCX artery. To resolve this occlusion, a drug-eluting stent was successfully implanted in the LCX artery. The patient was discharged without complications. At 2-month follow-up, he remained asymptomatic, with no recurrence of cardiovascular symptoms. Delayed chest pain after trauma should be suspected during coronary dissection, and on treatment, care must be taken to extend the hematoma.

The effect of hydraulic bed movement on the quality of chest compressions.

OBJECTIVES: The hydraulic height control systems of hospital beds provide convenience and shock absorption. However, movements in a hydraulic bed may reduce the effectiveness of chest compressions. This study investigated the effects of hydraulic bed movement on chest compressions. MATERIALS AND METHODS: Twenty-eight participants were recruited for this study. All participants performed chest compressions for 2min on a manikin and three surfaces: the floor (Day 1), a firm plywood bed (Day 2), and a hydraulic bed (Day 3). We considered 28 participants of Day 1 as control and each 28 participants of Day 2 and Day 3 as study subjects. The compression rates, depths, and good compression ratios (>5-cm compressions/all compressions) were compared between the three surfaces. RESULTS: When we compared the three surfaces, we did not detect a significant difference in the speed of chest compressions (p=0.582). However, significantly lower values were observed on the hydraulic bed in terms of compression depth (p=0.001) and the good compression ratio (p=0.003) compared to floor compressions. When we compared the plywood and hydraulic beds, we did not detect significant differences in compression depth (p=0.351) and the good compression ratio (p=0.391). CONCLUSIONS: These results indicate that the movements in our hydraulic bed were associated with a non-statistically significant trend towards lower-quality chest compressions.

Factors affecting the urologist's decision to administer ureteral stone therapy: a retrospective cohort study.

OBJECTIVE: We aimed to evaluate the factors influencing treatment option selection among urologists for patients with ureteral stones, according to the stone diameter and location. METHODS: We retrospectively reviewed the records of 360 consecutive patients who, between January 2009 and June 2014, presented to the emergency department with renal colic and were eventually diagnosed with urinary stones via computed tomography. The maximal horizontal and longitudinal diameter and location of the stones were investigated. We compared parameters between patients who received urological intervention (group 1) and those who received medical treatment (group 2). RESULTS: Among the 360 patients, 179 (49.7%) had stones in the upper ureter and 181 (50.3%) had stones in the lower ureter. Urologic intervention was frequently performed in cases of upper ureteral stones (P<0.001). In groups 1 and 2, the stone horizontal diameters were 5.5 mm (4.8 to 6.8 mm) and 4.0 mm (3.0 to 4.6 mm), stone longitudinal diameters were 7.5 mm (6.0 to 9.5 mm) and 4.4 mm (3.0 to 5.5 mm), and ureter diameters were 6.4 mm (5.0 to 8.0 mm) and 4.7 mm (4.0 to 5.3 mm), respectively (P<0.001). The cut-off values for the horizontal and longitudinal stone diameters in the upper ureter were 4.45 and 6.25 mm, respectively (sensitivity 81.3%, specificity 91.4%); those of the lower ureter were 4.75 and 5.25 mm, respectively (sensitivity 79.4%, specificity 79.4%). CONCLUSION: The probability of a urologic intervention was higher for patients with upper ureteral stones and those with stone diameters exceeding 5 mm horizontally and 6 mm longitudinally.

Comparison between an instructor-led course and training using a voice advisory manikin in initial cardiopulmonary resuscitation skill acquisition.

OBJECTIVE: We compared training using a voice advisory manikin (VAM) with an instructor-led (IL) course in terms of acquisition of initial cardiopulmonary resuscitation (CPR) skills, as defined by the 2010 resuscitation guidelines. METHODS: This study was a randomized, controlled, blinded, parallel-group trial. We recruited 82 first-year emergency medical technician students and distributed them randomly into two groups: the IL group (n=41) and the VAM group (n=37). In the IL-group, participants were trained in "single-rescuer, adult CPR" according to the American Heart Association's Basic Life Support course for healthcare providers. In the VAM group, all subjects received a 20-minute lesson about CPR. After the lesson, each student trained individually with the VAM for 1 hour, receiving real-time feedback. After the training, all subjects were evaluated as they performed basic CPR (30 compressions, 2 ventilations) for 4 minutes. RESULTS: The proportion of participants with a mean compression depth ≥50 mm was 34.1% in the IL group and 27.0% in the VAM group, and the proportion with a mean compression depth ≥40 mm had increased significantly in both groups compared with ≥50 mm (IL group, 82.9%; VAM group, 86.5%). However, no significant differences were detected between the groups in this regard. The proportion of ventilations of the appropriate volume was relatively low in both groups (IL group, 26.4%; VAM group, 12.5%; P=0.396). CONCLUSION: Both methods, the IL training using a practice-while-watching video and the VAM training, facilitated initial CPR skill acquisition, especially in terms of correct chest compression.

Optimal chest compression rate in cardiopulmonary resuscitation: a prospective, randomized crossover study using a manikin model.

OBJECTIVES: When performing cardiopulmonary resuscitation (CPR), the 2010 American Heart Association guidelines recommend a chest compression rate of at least 100 min, whereas the 2010 European Resuscitation Council guidelines recommend a rate of between 100 and 120 min. The aim of this study was to examine the rate of chest compression that fulfilled various quality indicators, thereby determining the optimal rate of compression. METHODS: Thirty-two trainee emergency medical technicians and six paramedics were enrolled in this study. All participants had been trained in basic life support. Each participant performed 2 min of continuous compressions on a skill reporter manikin, while listening to a metronome sound at rates of 100, 120, 140, and 160 beats/min, in a random order. Mean compression depth, incomplete chest recoil, and the proportion of correctly performed chest compressions during the 2 min were measured and recorded. RESULTS: The rate of incomplete chest recoil was lower at compression rates of 100 and 120 min compared with that at 160 min (P=0.001). The numbers of compressions that fulfilled the criteria for high-quality CPR at a rate of 120 min were significantly higher than those at 100 min (P=0.016). CONCLUSION: The number of high-quality CPR compressions was the highest at a compression rate of 120 min, and increased incomplete recoil occurred with increasing compression rate. However, further studies are needed to confirm the results.

Does cardiac catheterization laboratory activation by electrocardiography machine auto-interpretation reduce door-to-balloon time?

OBJECTIVES: In an attempt to begin ST-segment elevation myocardial infarction (STEMI) treatment more quickly (referred to as door-to-balloon [DTB] time) by minimizing preventable delays in electrocardiogram (ECG) interpretation, cardiac catheterization laboratory (CCL) activation was changed from activation by the emergency physician (code heart I) to activation by a single page if the ECG is interpreted as STEMI by the ECG machine (ECG machine auto-interpretation) (code heart II). We sought to determine the impact of ECG machine auto-interpretation on CCL activation. METHODS: The study period was from June 2010 to May 2012 (from June to November 2011, code heart I; from December 2011 to May 2012, code heart II). All patients aged 18 years or older who were diagnosed with STEMI were evaluated for enrollment. Patients who experienced the code heart system were also included. Door-to-balloon time before and after code heart system were compared with a retrospective chart review. In addition, to determine the appropriateness of the activation, we compared coronary angiography performance rate and percentage of STEMI between code heart I and II. RESULTS: After the code heart system, the mean DTB time was significantly decreased (before, 96.51 ± 65.60 minutes; after, 65.40 ± 26.40 minutes; P = .043). The STEMI diagnosis and the coronary angiography performance rates were significantly lower in the code heart II group than in the code heart I group without difference in DTB time. CONCLUSION: Cardiac catheterization laboratory activation by ECG machine auto-interpretation does not reduce DTB time and often unnecessarily activates the code heart system compared with emergency physician-initiated activation. This system therefore decreases the appropriateness of CCL activation.

Acupuncture as analgesia for non-emergent acute non-specific neck pain, ankle sprain and primary headache in an emergency department setting: a protocol for a parallel group, randomised, controlled pilot trial.

INTRODUCTION: This study aims to assess the feasibility of acupuncture as an add-on intervention for patients with non-emergent acute musculoskeletal pain and primary headache in an emergency department (ED) setting. METHODS AND ANALYSIS: A total of 40 patients who present to the ED and are diagnosed to have acute non-specific neck pain, ankle sprain or primary headache will be recruited by ED physicians. An intravenous or intramuscular injection of analgesics will be provided as the initial standard pain control intervention for all patients. Patients who still have moderate to severe pain after the 30 min of initial standard ED management will be considered eligible. These patients will be allocated in equal proportions to acupuncture plus standard ED management or to standard ED management alone based on computer-generated random numbers concealed in opaque, sealed, sequentially numbered envelopes. A 30 min session of acupuncture treatment with manual and/or electrical stimulation will be provided by qualified Korean medicine doctors. All patients will receive additional ED management at the ED physician's discretion and based on each patient's response to the allocated intervention. The primary outcome will be pain reduction measured at discharge from the ED by an unblinded assessor. Adverse events in both groups will be documented. Other outcomes will include the patient-reported overall improvement, disability due to neck pain (only for neck-pain patients), the treatment response rate, the use of other healthcare resources and the patients' perceived effectiveness of the acupuncture treatment. A follow-up telephone interview will be conducted by a blinded assessor 72±12 h after ED discharge. ETHICS AND DISSEMINATION: Written informed consent will be obtained from all participants. The study has been approved by the Institutional Review Boards (IRBs). The results of this study will guide a full-scale randomised trial of acupuncture in an ED context. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT02013908.

A 10-s rest improves chest compression quality during hands-only cardiopulmonary resuscitation: a prospective, randomized crossover study using a manikin model.

OBJECTIVES: This study was designed to assess changes in cardiopulmonary resuscitation (CPR) quality and rescuer fatigue when rescuers are provided with a break during continuous chest compression CPR (CCC-CPR). METHODS: The present prospective, randomized crossover study involved 63 emergency medical technician trainees. The subjects performed three different CCC-CPR methods on a manikin model. The first method was general CCC-CPR without a break (CCC), the second included a 10-s break after 200 chest compressions (10/200), and the third included a 10-s break after 100 chest compressions (10/100). All methods were performed for 10 min. We counted the total number of compressions and those with appropriate depth every 1 min during the 10 min and measured mean compression depth from the start of chest compressions to 10 min. RESULTS: The 10/100 method showed the deepest compression depth, followed by the 10/200 and CCC methods. The mean compression depth showed a significant difference after 5 min had elapsed. The percentage of adequate compressions per min was calculated as the proportion of compressions with appropriate depth among total chest compressions. The percentage of adequate compressions declined over time for all methods. The 10/100 method showed the highest percentage of adequate compressions, followed by the 10/200 and CCC methods. CONCLUSION: When rescuers were provided a rest at a particular time during CCC-CPR, chest compression quality increased compared with CCC without rest. Therefore, we propose that a rescuer should be provided a rest during CCC-CPR, and specifically, we recommend a 10-s rest after 100 chest compressions.

Prognostic significance of different subgroup classifications of critical illness-related corticosteroid insufficiency in patients with septic shock.

The purpose of this study was to evaluate the prognostic significance of classification of patients with septic shock into different critical illness-related corticosteroid insufficiency subgroups. A retrospective observational study was conducted in patients with septic shock who underwent a short corticotropin stimulation test within 72 h of the onset of shock. Patients were classified into normal adrenal function (NOM), low basal cortisol (LBC) (basal cortisol, <10 µg/dL), or low Δ cortisol (LDC) (basal cortisol, ≥10 µg/dL; cortisol, <9 µg/dL) groups. A total of 168 septic shock patients were recruited. Forty-two patients (25%) were assigned to the NOM group, 39 (23.2%) to the LBC group, and 87 (51.8%) to the LDC group. All of the patients received hydrocortisone therapy. Patients in the LDC group had significantly higher Simplified Acute Physiology Score 3 (P < 0.001) and Sequential Organ Failure Assessment score (P < 0.001) than did patients in the NOM group. The 28-day mortalities of the NOM, LBC, and LDC groups were 40.5%, 38.5%, and 63.2%, respectively (P = 0.007). Classification into the LDC group significantly increased the odds of 28-day mortality (odds ratio, 2.717; 95% confidence interval, 1.452-5.082; P = 0.002) and remained an independent risk factor for mortality even after controlling for all the other potential risk factors identified (odds ratio, 3.638; 95% confidence interval, 1.418-9.028; P = 0.006). Classification into the LDC group is an independent risk factor for mortality in hydrocortisone-treated septic shock patients.

Outcomes in critically ill patients with hematologic malignancies who received renal replacement therapy for acute kidney injury in an intensive care unit.

INTRODUCTION: In critically ill patients with hematologic malignancies, acute kidney injury (AKI) usually occurs in the context of multiple organ failure due to various etiologies and is associated with poor prognosis. The objective of the present study was to identify the prognostic factors associated with intensive care unit (ICU) mortality in patients with hematologic malignancies and AKI requiring renal replacement therapy (RRT). METHODS: We retrospectively evaluated 94 patients with hematologic malignancies and AKI who received RRT in the ICU of Samsung Medical Center, Seoul, Korea, between January 2004 and December 2007. RESULTS: The study sample included 65 men and 29 women with a median age of 49 years (interquartile range [IQR], 36-61 years). The median Simplified Acute Physiology Score II and Sequential Organ Failure Assessment (SOFA) scores at ICU admission were 64 (IQR, 46-79) and 13 (IQR, 9-16), respectively. The RRT for AKI was initiated at a median time of 1 day (IQR, 0-4 day) after ICU admission. Seventy-two (77%) patients died in the ICU after a median time of 4 days (IQR, 2-20 days) after the initiation of RRT. Among the 22 patients who survived, 5 (23%) required RRT after ICU discharge. Intensive care unit mortality was associated with an etiology of AKI, Simplified Acute Physiology Score II score, and SOFA score. Modified SOFA (mSOFA) score (defined as the sum of the 5 nonrenal components of the SOFA score) at the initiation of RRT was lower in survivors than in nonsurvivors. In a multiple logistic regression analysis, ICU mortality was independently associated with mSOFA score (odds ratio, 1.83 per mSOFA score increase; 95% confidence interval, 1.38-2.42) at the initiation of RRT. The estimated area under the curve for mSOFA score was 0.902 (95% confidence interval, 0.831-0.972). CONCLUSION: The severity of organ failure, excluding renal failure, at initiation of RRT was independently associated with ICU mortality in patients with hematologic malignancies and AKI requiring RRT.

Validation of the Simplified Acute Physiology Score 3 scoring system in a Korean intensive care unit.

PURPOSE: The Simplified Acute Physiology Score (SAPS) 3 was recently proposed to reflect contemporary changes in intensive care practices. SAPS 3 features customized equations for the prediction of mortality in different geographic regions. However, the usefulness of SAPS 3 and its customized equation (Australasia SAPS 3) have never been externally validated in Korea. This study was designed to validate SAPS 3 and Australasia SAPS 3 for mortality prediction in Korea. MATERIALS AND METHODS: A retrospective analysis of the prospective intensive care unit (ICU) registry was conducted in the medical ICU of Samsung Medical Center. Calibration and discrimination were determined by the Hosmer-Lemeshow test and area under the receiver operating characteristic (aROC) curve from 633 patients. RESULTS: The mortalities (%) predicted by SAPS 3, Australasia SAPS 3, and SAPS II were 42 ± 28, 39 ± 27 and 37 ± 31, respectively. The calibration of SAPS II was poor (p = 0.003). SAPS 3 and Australasia SAPS 3 were appropriate (p > 0.05). The discriminative power of all models yielded aROC values less than 0.8. CONCLUSION: In Korea, mortality rates predicted using general SAPS 3 and Australasia SAPS 3 exhibited good calibration and modest discrimination. However, Australasia SAPS 3 did not improve the mortality prediction. To better predict mortality in Korean ICUs, a new equation may be needed specifically for Korea.