Comparative Analysis of Hydrogen Fluoride-Exposed Patients Based on Major Burn Criteria After the 2012 Gumi City Chemical Leak Disaster.

This study conducted to analyze and compare the epidemiological and clinical characteristics of hydrogen fluoride-exposed patients based on major burn criteria for the appropriate emergency department (ED) response to a mass casualty chemical spill. This retrospective cross-sectional study included the records of patients (n = 199) who visited the ED of Gumi City University Hospital from September 27, 2012, to October 20, 2012. Subjects were included in the major burn group (MBG) if they presented with wounds that required referral to a burn center according to the American Burn Association guidelines or in the nonmajor burn group (NMBG) if not. Males were predominant in both the MBG (n = 55, 48 males) and NMBG (n = 144, 84 males; P < .05). The most prevalent timeline for visiting the ED was the phase which included 9-32 hours post-leak of hydrogen fluoride, including 45 patients (81.8%) in the MBG and 122 patients (84.7%) in the NMBG (P < .001). The respiratory tract was the site of greatest damage in patients in both the MBG and NMBG (n = 47, 85.5% vs n = 142, 98.6%, P < .001). Regarding dispositions, all patients in the NMBG were discharged (n = 144, 100%); however, eight patients (14.5%) in the MBG underwent other dispositions (discharge against medical advice, five patients; admission, one patient; death, two patients, P < .05). Patient outcomes after major chemical contamination events should be characterized in future studies to maximize the quality of patient care.

Lessons learned from reviewing a hospital's disaster response to the hydrofluoric acid leak in Gumi city in 2012.

BACKGROUND: This study analyzed the characteristics of hydrogen fluoride-exposed patients (HFEPs) treated in the emergency department (ED) of a local university hospital, and reviewed the hospital's disaster response according to space, staff, supplies, and systems (4Ss). METHODS: This retrospective observational chart review and descriptive study included 199 HFEPs among 2588 total ED patients who visited a local university emergency medical center for treatment between September 27, 2012 and October 20, 2012, following a hydrofluoric acid leak at the Hube Globe factory in Gumi City, Republic of Korea. Descriptive results concerning the 4Ss were obtained by interviewing ED specialist staff physicians on duty during the study period. In accordance with American Burn Association criteria, patients requiring burn center referral were assigned to the major burn group (MBG) as severe condition. RESULTS: During the acute phase (within 8 h after leak initiation), there were 43 patients in the ED, which was staffed with 3 doctors and 3 nurses, without 4S resources. Of these 43 patients, there were 8 HFEPs (100%) in the MBG and 0 in the non-MBG (NMBG). During the subacute phase (24 h after the acute phase), there were 262 patients in the ED including 167 HFEPs, of whom 45 (26.95%) were in the MBG and 122 (73.05%) were in the NMBG. The ED was then staffed with 6 doctors (3 on day shift and 3 on night shift) and 10 nurses (3 on day shift, 4 on evening shift, and 3 on night shift), and no 4S resources were available. Throughout the study period, no 4Ss were available. First, there was no expansion of ED space or secured disaster reserve beds. Second, there was no increase in manpower with duty time adjustments or duty relocation for ED working personnel. Third, there was no logistics reinforcement (e.g., antidote or personal protective equipment). Fourth, there were no disaster-related measures for the administration department, decontamination zone setup, safety diagnostic testing, or designated disaster triage implementation. CONCLUSIONS: The hospital's disaster response was insufficient for all aspects of the 4Ss. Detailed guidance concerning a hospital disaster management plan is required.

The predictive value of HEART score for acute coronary syndrome and significant coronary artery stenosis.

OBJECTIVE: Rapid determination of acute coronary syndrome (ACS) in the emergency department (ED) is very important for patients presenting with ischemic symptoms. The aim of this study was to determine the predictive value of HEART score for ACS and significant coronary artery stenosis (SCS). METHODS: We retrospectively analyzed data of patients who visited the ED with chest discomfort and were admitted to the cardiology department. Enrolled patients were classified into ACS and non-ACS groups according to their discharge diagnosis. Patients who underwent imaging were further divided into SCS and non-SCS groups according to study results. We compared age, sex, vital signs, risk factors, electrocardiogram, troponin, and HEART score for each group. For ACS and SCS predictive performance, the test characteristics of HEART score was calculated using sensitivity, specificity, predictive value, likelihood ratio, and receiver operating characteristic (ROC) curve analysis. RESULTS: Of 207 patients, 112 had ACS. Among enrolled patients, 155 underwent imaging workup, of whom 67 had SCS. HEART score ≤3 had 93% sensitivity for ACS and 97% for SCS. HEART score ≥7 had 82% specificity for ACS and 83% for SCS. HEART score area under ROC curve for ACS was 0.706 (95% confidence interval, 0.627-0.776) and 0.737 (95% confidence interval, 0.660-0.804) for SCS. CONCLUSION: HEART score was a fair predictor of ACS and SCS in ED patients who presented with chest symptoms and were admitted to the cardiology department. The predictive power of HEART score was better for SCS than for ACS.

Validation of quick sequential organ failure assessment score for poor outcome prediction among emergency department patients with suspected infection.

OBJECTIVE: The quick sequential organ failure assessment (qSOFA) score, which includes mentation, systolic blood pressure, and respiratory rate, was developed to identify serious sepsis in out-of-hospital or emergency department (ED) settings. We evaluated the ability of the qSOFA score to predict poor outcome in South Korean ED patients with suspected infection. METHODS: The qSOFA score was calculated for adult ED patients with suspected infection. Patients who received intravenous or oral antibiotics in the ED were considered to have infection. In-hospital mortality rate, admission rate, intensive care unit (ICU) admission rate, length of hospital stay (LOS), and lactate levels were compared between the qSOFA score groups. Receiver operating characteristic curves and area under the receiver operating characteristic curve values for in-hospital mortality were calculated according to qSOFA cut-off points and lactate levels. RESULTS: Of 2,698 patients, in-hospital mortality occurred in 134 (5.0%). The mortality rate increased with increasing qSOFA score (2.2%, 6.4%, 17.5%, and 42.4% for qSOFA scores 0, 1, 2, and 3, respectively, P<0.001). The admission rate, ICU admission rate, LOS, and lactate level also increased with increasing qSOFA score (all P<0.001). The area under the receiver operating characteristic curve values for predicting in-hospital mortality associated with qSOFA score, lactate ≥2 mmol/L, and lactate ≥4 mmol/L were 0.719 (95% confidence interval [CI], 0.670 to 0.768), 0.657 (95% CI, 0.603 to 0.710), and 0.632 (95% CI, 0.571 to 0.693), respectively. CONCLUSION: Patients with a higher qSOFA score had higher admission, ICU admission, and in-hospital mortality rates, longer LOS, and higher lactate level. The qSOFA score showed better performance for predicting poor outcome than lactate level.

Use of resuscitative endovascular balloon occlusion of the aorta in a patient with gastrointestinal bleeding.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) was developed for controlling intra-abdominal arterial bleeding before definitive bleeding control, and is commonly used in patients with ruptured abdominal aortic aneurysms. Although there is limited evidence for other uses of REBOA, we used REBOA in a patient with massive gastrointestinal bleeding. A 53-year-old man with hematochezia was admitted to our emergency department with an initial systolic blood pressure (SBP) of 83 mmHg. His SBP decreased to 40 mmHg in 10 minutes despite rapid fluid infusion. We decided to resuscitate the patient with REBOA in the emergency department and then move him to an intervention room after stabilization. After aortic occlusion, SBP abruptly increased from 57 to 108 mmHg, and the patient could be transferred to an intervention room. The patient was admitted to intensive care, but died of massive rebleeding 24 hours after admission to the emergency department.

Severe thinness is associated with mortality in patients with community-acquired pneumonia: a prospective observational study.

PURPOSE: This study aimed to investigate the probability of 30-day mortality based on body mass index (BMI) assessment combined with pneumonia severity index (PSI) in patients with community-acquired pneumonia (CAP) and to determine whether being underweight is an independent risk factor contributing to 30-day mortality. BASIC PROCEDURES: A prospectively collected database was analyzed retrospectively. Multivariable logistic regression analysis was performed to determine whether BMI is an independent predictor of mortality in patients with CAP by adjusting for PSI and other factors found significant in univariable analysis. Mortality predictability of BMI and PSI was evaluated using area under the receiver operating characteristic curve analyses. MAIN FINDINGS: A total of 1403 patients were assessed in this study. In multivariable regression analysis, severe thinness (BMI<16 kg/m2), hypoalbuminemia (albumin<3.3 mg/dL), and PSI IV and V were predictive factors for 30-day mortality in patients with CAP. In terms of mortality prediction, the accuracy of PSI was 0.67 (95% confidence interval [CI], 0.63-0.71) as measured by the area under the receiver operating characteristic curve. When hypoalbuminemia was combined with PSI, the predictive accuracy significantly increased to 0.71 (95% CI, 0.66-0.75; P=.02). The addition of severe thinness to PSI and hypoalbuminemia further increased the accuracy significantly to 0.74 (95% CI, 0.70-0.78) (P=.005). PRINCIPAL CONCLUSIONS: Severe thinness (BMI<16 kg/m2) was associated with 30-day mortality in patients with CAP, showing improved prognostic performance when combined with PSI. We propose that physicians consider a patient's nutritional state using BMI when predicting mortality in CAP.

Awareness and knowledge of sepsis in the general Korean population: comparison with the awareness and knowledge of acute myocardial infarction and stroke.

OBJECTIVE: Patients with severe sepsis or septic shock require timely, aggressive management to improve their outcomes, and early presentation of patients to the hospital may also be important. Thus, public awareness about sepsis may be important for improved outcomes. However, there are no studies regarding the public awareness of sepsis in the general Korean population. Therefore, the objective of this survey was to gain insight into the public awareness of sepsis. METHODS: Prospective paper-based and web-based surveys were issued between May and June 2013 to adults aged ≥18 years. RESULTS: A total of 1,081 participants responded to the survey (394 paper-based and 687 web-based). Mean age was 38.7±11.4 years, and 541 participants (50%) were men. Of the 1,081 participants, 831 (76.9%) had heard of the term "sepsis." Of these participants, only 295 (35%) responded correctly regarding the definition of sepsis. However, 1,019 participants (94.3%) had heard of acute myocardial infarction, and 817 of these (80%) correctly defined acute myocardial infarction. Regarding stroke, 1,047 (96.9%) had heard of stroke, and 975 of these responded (93.1%) correctly to the definition of stroke. CONCLUSION: There is poor public awareness about sepsis compared with that of acute myocardial infarction and stroke. This may limit the timely management of severe sepsis and septic shock.

Bacteremia prediction model using a common clinical test in patients with community-acquired pneumonia.

PURPOSE: The aim of this study was to construct a bacteremia prediction model using commonly available clinical variables in hospitalized patients with community-acquired pneumonia (CAP). BASIC PROCEDURES: A prospective database including patients who were diagnosed with CAP in the emergency department was analyzed. Independent risk factors were investigated by using multivariable analysis in 60% of the cohort. We assigned a weighted value to predictive factor and made a prediction rule. This model was validated both internally and externally with the remaining 40% of the cohort and a cohort from an independent hospital. The low-risk group for bacteremia was defined as patients who have a risk of bacteremia less than 3%. MAIN FINDINGS: A total of 2422 patients were included in this study. The overall rate of bacteremia was 5.7% in the cohort. The significant factors for predicting bacteremia were the following 7 variables: systolic blood pressure less than 90 mm Hg, heart rate greater than 125 beats per minute, body temperature less than 35 °C or greater than 40 °C, white blood cell less than 4000 or 12,000 cells per microliter, platelets less than 130,000 cells per microliter, albumin less than 3.3 g/dL, and C-reactive protein greater than 17 mg/dL. After using our prediction rule for the validation cohorts, 78.7% and 74.8% of the internal and external validation cohorts were classified as low-risk bacteremia groups. The areas under the receiver operating characteristic curves were 0.75 and 0.79 for the internal and external validation cohorts. PRINCIPAL CONCLUSIONS: This model could provide guidelines for whether to perform blood cultures for hospitalized CAP patients with the goal of reducing the number of blood cultures.

Blood pressure-targeted stepwise resuscitation for hemorrhagic shock in rats.

BACKGROUND: Generation of reactive oxygen species (ROS) is an important mechanism of ischemia-reperfusion injury. Abrupt reoxygenation compared with slow reoxygenation has been known to increase ROS generation. Thus, slow and stepwise reperfusion can reduce ROS generation and subsequent ischemia-reperfusion injury. This study investigated the effect of slow reperfusion by blood pressure-targeted stepwise resuscitation (PSR) in hemorrhagic shock. METHODS: Pressure-controlled hemorrhagic shock was induced in male Sprague-Dawley rats for 1 hour. Rats were then allocated to one of three groups (no-resuscitation group, n = 14; PSR group, n = 15; rapid normalization of blood pressure (RR) group, n = 15). Survival time and hemodynamic changes were recorded and compared. Blood samples and liver tissue were harvested after 6 hours of resuscitation in surviving rats. RESULTS: All of the rats in the no-resuscitation group were expired before the end of the 6-hour observation period. Survival times were significantly longer in the PSR group than in the RR group (survival rates, 11 of 15 vs. 5 of 15, log rank p = 0.032). Plasma amino alanine transferase, histologic liver injury, and ROS generation in the liver tissue were significantly lower in the PSR group than in the RR group (all findings significant, p < 0.05). In addition, PSR significantly decreased plasma nitric oxide, liver interleukin 1ß, and liver interleukin 6 compared with rapid resuscitation in addition to augmenting Akt survival pathways (all p < 0.05). CONCLUSION: Slow reperfusion by PSR decreased mortality, ROS generation, and liver injury in rats undergoing hemorrhagic shock. Stepwise resuscitation also decreased inflammatory cytokine production and augmented Akt survival pathways.

The clinical significance of a failed initial intubation attempt during emergency department resuscitation of out-of-hospital cardiac arrest patients.

OBJECTIVE: Advanced airway management is one of the fundamental skills of advanced cardiac life support (ACLS). A failed initial intubation attempt (FIIA) is common and has shown to be associated with adverse events. We analysed the association between FIIA and the overall effectiveness of ACLS. METHODS: Using emergency department (ED) out-of-hospital cardiac arrest (OHCA) registry data from 2008 to 2012, non-traumatic ED-resuscitated adult OHCA patients on whom endotracheal intubation was initially tried were identified. Prehospital and demographic factors and patient outcomes were retrieved from the registry. The presence of a FIIA was determined by reviewing nurse-documented CPR records. The primary outcome was achieving a return of spontaneous circulation (ROSC). The secondary outcomes were time to ROSC and the ROSC rate during the first 30min of ED resuscitation. RESULTS: The study population (n=512) was divided into two groups based on the presence of a FIIA (N=77). Both groups were comparable without significant differences in demographic or prehospital factors. In the FIIA group, the unadjusted and adjusted odds ratios (ORs) for achieving a ROSC were 0.50 (95% confidence interval [CI], 0.31-0.81) and 0.40 (95% CI, 0.23-0.71), respectively. Multivariable median regression analysis revealed that FIIA was associated with an average delay of 3min in the time to ROSC (3.08; 95% CI, 0.08-5.80). Competing risk regression analysis revealed a significantly slower ROSC rate during the first 15min (adjusted subhazard ratio, 0.52; 95% CI, 0.35-0.79) in the FIIA group. CONCLUSION: FIIA is an independent risk factor for the decreased effectiveness of ACLS.

Gradual and stepwise increase of blood pressure in hemorrhagic shock: Mimicking ischemic post-conditioning.

Hemorrhagic shock, and subsequent resuscitation leads to global ischemia/reperfusion injury. It may result in multiple organ injury and death. Ischemic post-conditioning has been suggested to reduce organ injury. It may lead to gradual increase in tissue oxygen delivery and tissue acidosis may be reduced gradually. Gradual increase of blood pressure or blood flow in ischemic organs has been reported to decrease tissue injury. We propose that gradual and stepwise increase of blood pressure may decrease tissue injury and mortality in hemorrhagic shock by mimicking ischemic post-conditioning.