Pre-hospital Korean Triage and Acuity Scale: the development background and core contents

The Korean Triage and Acuity Scale (KTAS) Committee under the Korean Society of Emergency Medicine developed a Korean pre-hospital emergency patient classification tool (Pre-hospital Korean Triage and Acuity Scale [Pre-KTAS]) under contract from the Ministry of Health and Welfare, Korea. The classification tool was developed separately for adults and children. The patient’ s emergency level is classified into five distinct levels and is the same as the KTAS classification system, which is a hospital-level emergency patient classification tool.

Pre-hospital Korean Triage and Acuity Scale: the results of first and second pilot projects

While the Korean Triage and Acuity Scale (KTAS) was introduced in 2016 as a tool to identify patients at risk of catastrophic events, including death in the ED, the triage system for the pre-hospital stage still lacks evidence. The pre-hospital stage is characterized by time-sensitive and complex scenarios, where rapid and accurate decision-making is paramount to optimize patient outcomes. Despite the vital role of pre-hospital care providers, the invalidated and subjective current triage system consisting of 4-stages is still used at the pre-hospital stage, and hence, it needs to be modified to be more objective, standardized, and reliable. To improve the Korean emergency medical system, the pre-hospital KTAS (Pre-KTAS) was developed in 2020, and then two pilot projects were conducted in 2022 and 2023. This paper not only reveals the results of the first and second pilot projects for Pre-KTAS but also highlights the potential benefits of using this newly developed triage tool in the pre-hospital setting. Furthermore, this paper suggests ways to improve the emergency medical system (EMS) in Korea by improving patient safety, resource allocation, and overall emergency response efficiency.

The impacts of the COVID-19 pandemic on emergency care utilization in patients with major emergency diseases in Chungnam Province

Objective@#This study analyzed the impact of the coronavirus disease 2019 (COVID-19) pandemic on emergency care utilization in Chungnam Province by examining the status of emergency care utilization during this period. @*Methods@#This study retrospectively analyzed 154,946 patients who visited emergency medical institutions in Chungnam Province for a major emergency between January 2015 and December 2021, using the National Emergency Department Information System data. @*Results@#The incidence of the The three major emergency diseases are acute myocardial infarction (AMI), acute stroke, severe trauma decreased. Primary visits to the regional and local emergency medical centers increased, except for local emergency medical institutions. The utilization rate of the 119 ambulance service in 2020 decreased significantly for AMI compared to the previous year and was the lowest among the three major emergency diseases. Air transportation by helicopter decreased during the COVID-19 pandemic. The rate of emergency room arrivals within the golden hour decreased during the COVID-19 pandemic. The transfer and retransfer rates also decreased for all three major emergency diseases. Despite the decreased number of patients during the pandemic, the ratio of primary visits to the local emergency medical centers for the three major emergency diseases increased, and the lengths of stay in the emergency room increased. @*Conclusion@#The COVID-19 pandemic significantly impacted the occurrence, transportation, and therapeutic response to the three major emergency diseases in Chungnam Province. The vulnerability of patients with AMI in the pre-pandemic era was further exacerbated during the pandemic.

Comparison of the effectiveness of cardiopulmonary resuscitation before and after using the LUCAS device in in-hospital cardiac arrest

Objective@#High-quality chest compressions are consistently delivered by mechanical chest compression devices. This study assesses the feasibility of LUCAS in in-hospital cardiac arrest (IHCA) patients. @*Methods@#This was a single-center, retrospective, before and after clinical study comparing the clinical outcomes of LUCAS cardiopulmonary resuscitation (CPR) in IHCA patients. The return of spontaneous circulation (ROSC) rate and 7-day mortality were evaluated to assess short-term outcomes. Additional outcomes included epinephrine dose, CPR time, and the number of medical workers participating in CPR. @*Results@#The number of medical workers who participated in CPR in the LUCAS CPR group was fewer than in the manual CPR group (manual CPR 9.3 vs. LUCAS CPR 4.5; P=0.001). In IHCA patients, no significant differences were obtained in the ROSC rate (manual CPR 46.4% vs. LUCAS CPR 31.4%; P=0.051) and 7-day mortality (manual CPR 81% vs. LUCAS CPR 86.3%; P=0.434) between the two groups. However, the median CPR time (manual CPR 28.1 vs. LUCAS CPR 42.8; P=0.001) and the epinephrine dose (manual CPR 8.3 vs. LUCAS CPR 13.3; P=0.001) were significantly longer in the LUCAS CPR group than the manual CPR group. @*Conclusion@#Compared to manual CPR, CPR with LUCAS required fewer healthcare workers and had no significant difference in the ROSC rate and mortality in patients with IHCA.

Best practice guideline for patients requiring discharge against medical advice from emergency department

Discharge against medical advice remains a problematic issue worldwide because it may not only lead to adverse medical outcomes for the patients but also medicolegal problems for emergency physicians. Recently, there have been cases in Korea in which a patient in the emergency room, who had been discharged from hospital without following medical instructions, filed a lawsuit against the hospital and emergency medical staff for their responsibility for their worsening disease since discharge. The court acknowledged the responsibility of the medical staff. To minimize the legal risk and reach the optimal ethical standard for these patients, this paper suggests the best practice guideline for the emergency physicians for patients who request discharge against medical advice from the emergency department in Korea.

Introduction and characteristics of helicopter emergency medical services

Helicopter emergency medical services (HEMS) are a part of air medical services. The transportation of patients using helicopters or airplanes is a core element of the air medical services. HEMS have developed from militarybased transportation, which used helicopters on the battlefield. HEMS have played an important role in properly transporting critical patients before the golden time elapses. The optimal strategies for the operation of HEMS at any emergency medical system are dependent on the characteristics of the regional emergency medical system, diversitiy of HEMS organizations, and the legal background of each country. Therefore, every participant, including the government, medical personnel, and HEMS organizations, should concentrate their efforts toward the establishment of HEMS. Other than the factors related to patients, the key element in facilitating the establishment of HEMS is the safety of the flight and crew members.

Characteristics and outcomes of public bath-related out-of-hospital cardiac arrests in South Korea

Objective@#To analyze the differences in characteristics and outcomes between public bath (PB)- related and non-PB-related out-of-hospital cardiac arrest (OHCA) patients in South Korea. @*Methods@#We performed a retrospective observational analysis of collected data from the Smart Advanced Cardiac Life Support (SALS) registry between September 2015 and December 2018. We included adult OHCA patients (aged >18 years) with presumed OHCA of non-traumatic etiology who were attended by dispatched emergency medical services. SALS is a field advanced life support with smartphone-based direct medical direction. The primary outcome was the survival to discharge rate measured at the time of discharge. @*Results@#Of 38,995 cardiac arrest patients enrolled in the SALS registry, 11,889 were included in the final analysis. In total, 263 OHCAs occurred in PBs. Male sex and bystander cardiopulmonary resuscitation proportions appeared to be higher among PB patients than among non-PB patients. Percentages for shockable rhythm, witnessed rate, and number of underlying disease were lower in the PB group than in the non-PB group. Prehospital return of spontaneous circulation (11.4% vs. 19.5%, P=0.001), survival to discharge (2.3% vs. 9.9%, P<0.001), and favorable neurologic outcome (1.9% vs. 5.8%, P=0.007) in PB patients were significantly poorer than those in non-PB patients. @*Conclusion@#Patient characteristics and emergency medical services factors differed between PB and non-PB patients. All outcomes of PB-related OHCA were poorer than those of non-PB-related OHCA. Further treatment strategies should be developed to improve the outcomes of PBrelated cardiac arrest.

Experiences of disaster medical assistance activities in a fire accident at the Ramada Encore Hotel, Cheonan

Objective@#This study examined the disaster medical assistance activities at the fire accident scenes at the Ramada Encore Hotel, Cheonan, on January 14, 2019. @*Methods@#This study reviewed the disaster response timelines and patients’medical records retrospectively during the disaster medical assistance activities. The results of field and hospital triage of patients and the medical records of patients who visited the emergency department on the day of the fire accident were analyzed. @*Results@#The disaster medical assistance team arrived at the fire scene 59 minutes after the first emergency medical services (EMS, 119) call. Forty-nine patients were enrolled in this study. Four patients were classified as the ‘Emergency’ group; 44 patients were in the ‘Non-emergency’ group, and one patient was triaged as dead on arrival. Thirty-four out of 49 patients finally visited the nearest hospital. Twenty patients were transported by the EMS who were triaged as 12 patients to ‘minimal (green)’, four patients to ‘delayed (yellow)’, three patients ‘immediate (red)’, and one patient to ‘expectant (black).’ @*Conclusion@#Several mismatches could be observed between disaster preparedness and the real scene activities performed by multi-agencies disaster medical assistance activities in this study. A reassessment of disaster planning and the proper training program for disaster medical assistance activities should be needed.

Analysis of the treatment-time reduction of ST elevation myocardial infarction patients transferred by helicopter-based emergency medical services in Korea

Objective@#ST-elevation myocardial infarction (STEMI) requires timely reperfusion therapy, and the first medical contact (FMC) to percutaneous coronary intervention (PCI) time within 120 minutes is recommended. Therefore, early recognition and rapid transportation of STEMI patients to the PCI-capable hospital are important. This study analyzed the time reduction effect of STEMI patients who were transferred by a helicopter. @*Methods@#This was a retrospective, single-center study. The study period was from 2016 to 2017. An air ambulance was available based on the 24-hour PCI capable hospital. This study selected STEMI patients who were transferred from other hospitals in six regions. The transfer distances, time factors, and treatment outcomes in those transferred by helicopter and those transferred by ambulance were compared. @*Results@#Among 88 STEMI patients from six regions, 38 (43.2%) and 50 (56.8%) were transferred by helicopter and ambulance, respectively. The average transfer distances were longer in the helicopter-transfer group (92.7 km vs. 82.4 km, P=0.004). The transfer time, call-to-lab time, door-to-balloon time, and FMC-to-PCI time were shorter in the helicopter-transfer group. The proportion of FMC-to-PCI within 120 minutes was higher in the helicopter-transfer group (40.5% vs. 11.4%, P=0.002). @*Conclusion@#Helicopter-transfer reduced the FMC-to-PCI time, including the transfer time and call-to-lab time. Therefore, a higher proportion of time-targeted treatment was achieved.

Experiences of disaster medical assistance activities in a fire accident at the Ramada Encore Hotel, Cheonan

Objective@#This study examined the disaster medical assistance activities at the fire accident scenes at the Ramada Encore Hotel, Cheonan, on January 14, 2019. @*Methods@#This study reviewed the disaster response timelines and patients’medical records retrospectively during the disaster medical assistance activities. The results of field and hospital triage of patients and the medical records of patients who visited the emergency department on the day of the fire accident were analyzed. @*Results@#The disaster medical assistance team arrived at the fire scene 59 minutes after the first emergency medical services (EMS, 119) call. Forty-nine patients were enrolled in this study. Four patients were classified as the ‘Emergency’ group; 44 patients were in the ‘Non-emergency’ group, and one patient was triaged as dead on arrival. Thirty-four out of 49 patients finally visited the nearest hospital. Twenty patients were transported by the EMS who were triaged as 12 patients to ‘minimal (green)’, four patients to ‘delayed (yellow)’, three patients ‘immediate (red)’, and one patient to ‘expectant (black).’ @*Conclusion@#Several mismatches could be observed between disaster preparedness and the real scene activities performed by multi-agencies disaster medical assistance activities in this study. A reassessment of disaster planning and the proper training program for disaster medical assistance activities should be needed.

Analysis of the treatment-time reduction of ST elevation myocardial infarction patients transferred by helicopter-based emergency medical services in Korea

Objective@#ST-elevation myocardial infarction (STEMI) requires timely reperfusion therapy, and the first medical contact (FMC) to percutaneous coronary intervention (PCI) time within 120 minutes is recommended. Therefore, early recognition and rapid transportation of STEMI patients to the PCI-capable hospital are important. This study analyzed the time reduction effect of STEMI patients who were transferred by a helicopter. @*Methods@#This was a retrospective, single-center study. The study period was from 2016 to 2017. An air ambulance was available based on the 24-hour PCI capable hospital. This study selected STEMI patients who were transferred from other hospitals in six regions. The transfer distances, time factors, and treatment outcomes in those transferred by helicopter and those transferred by ambulance were compared. @*Results@#Among 88 STEMI patients from six regions, 38 (43.2%) and 50 (56.8%) were transferred by helicopter and ambulance, respectively. The average transfer distances were longer in the helicopter-transfer group (92.7 km vs. 82.4 km, P=0.004). The transfer time, call-to-lab time, door-to-balloon time, and FMC-to-PCI time were shorter in the helicopter-transfer group. The proportion of FMC-to-PCI within 120 minutes was higher in the helicopter-transfer group (40.5% vs. 11.4%, P=0.002). @*Conclusion@#Helicopter-transfer reduced the FMC-to-PCI time, including the transfer time and call-to-lab time. Therefore, a higher proportion of time-targeted treatment was achieved.

Oculomotor nerve palsy associated with internal carotid artery: case reports

Oculomotor nerve palsy limits the specific direction eyeball movement, and represents diplopia, mydriasis, and ptosis. The vascular-associated etiologies of oculomotor nerve palsy are the microvascular ischemia due to hypertension or diabetes, or compression of the nerve by the aneurysm. For the aneurysm, if not treated properly, it may result in mortality or severe neurological impairment. Thorough history taking, physical examinations, and proper imaging modality are needed to make an accurate diagnosis. A 76-year-old female with decreased mentality and anisocoria presented at our emergency department. An 83-year-old female presented with right ptosis and lateral-side deviated of the right eyeball. No definite lesion was noted on the initial non-contrast brain computed tomography (CT) and magnetic resonance imaging diffusion. An aneurysm was detected on CT angiography taken several hours later in the former patient. For the latter patient, a giant aneurysm was detected on magnetic resonance angiography that had been performed at another hospital 4 days earlier. These two patients underwent transfemoral cerebral angiography with coiling. They were discharged with no neurological sequelae.

Inter-rater agreement of Korean Triage and Acuity Scale between emergency physicians and nurses

OBJECTIVE: The Korean Triage and Acuity Scale (KTAS) has been used in all emergency departments (EDs) since 2016. Medical personnel can provide the treatment priority based on the KTAS levels. The inter-rater agreement with KTAS has not been reported, even though most triage assignments are performed by nurses in Korea. This study was aimed to verify the agreement of triage levels between emergency physicians (EPs) and nurses with KTAS. METHODS: This was a prospective, single-center study of an academic tertiary medical center. If the patient visits the ED, the triage nurse and EP meet the patients together. The nurse performed the history taking and physical examinations including vital signs measurements then recorded the KTAS levels. The EP did not interfere with the nurse's decision. The EP also decided the KTAS levels. The designated codes and levels were compared. The EP recorded the detailed reasons for the disagreement if there was discrepancy. RESULTS: Comparisons were performed with 928 patients. The number of patients in each KTAS level was 95 (10.2%) in level I, 263 (28.3%) in level II, 348 (37.5%) in level III, 144 (15.5%) in level IV, and 78 (8.4%) in level V. The overall agreement was 761 (82%), and the Kappa coefficient was 0.691. The errors of history taking were most frequent (131, 78.4%). Insufficient understanding of the disease pathophysiology, inaccurate neurological examinations, and errors that did not consider the vital signs except for the blood pressure were encountered in 12 (7.2%). CONCLUSION: The agreement rate was high between EPs and nurses using KTAS (K=0.691, substantial agreement).

Case Series: Successful Resuscitation of Severe Facial Injuries Caused by a Chainsaw

The treatment outcome remains poor of severe facial injuries because of the high risk of compromised airway or massive bleeding. We experienced two successful treatment cases of severe facial injury by the chainsaw. A 52-year-male had his face injured by the chainsaw during his work. He was transferred to the Level I trauma center using the Doctor-Helicopter. During his flight, bleeding control was tried and the information was given to the trauma surgeons before his arrival. His consciousness was alert and the vital signs were stable. The crushing wound, mandible open fracture, deep laceration of tongue, lip, neck and arterial bleeding were noted around his mandible. Nasotracheal intubation was performed under the bronchoscope-guided. Emergency operation (open reduction & internal fixation, primary repair with neurorrhaphy) was performed. At 30 hospital days, he was discharged with facial palsy on left mandibular area. A 30-year-male had his face injured by the chainsaw. He was transferred to our Level I trauma center from the local hospital. The deep-mutiple lacerations on right upper eyelid and forehead with the bony exposure were noted. The vital signs were stable and emergency operation was performed. He was discharged at 20 hospital days. Bone loss or tissue loss were not devastating than we expected even though the injury was occurred by the chainsaw. Aggressive treatment including airway manipulation or bleeding control and maximal opportunity of therapy are absolutely needed.

Primary visit, transfer, and re-transfer to emergency department in patients with severe emergency diseases in Chungnam

OBJECTIVE: Regionalization is one of the principal subjects for the advancement of rural emergency medical service systems in South Korea. This study shows the characteristics of interhospital transfer and status of the incidence of three major emergency disorders (acute myocardial infarction [AMI], acute stroke, and severe trauma) in one local province. METHODS: A retrospective study was conducted for patients with three major emergency disorders who visited emergency medical facilities in one local province from January 2013 to December 2015, on the basis of the National Emergency Department Information System (NEDIS) data. RESULTS: The incidence of three major emergency disorders had increased annually. Patients with each of these disorders tended to choose distinguishing methods of visiting emergency medical facilities. AMI patients tended to visited emergency medical facilities using private cars or on foot, while severe trauma patients usually visited by 119 ambulance, and acute stroke patients used 119 ambulance and private car in similar amounts. Overall, 65% of AMI patients were treated in intraregional medical facilities, but about 70% of acute stoke and severe trauma patients were transferred outside of the region. CONCLUSION: Because each of these disorders has an individual characteristic, it is difficult to expect a solution for the problems associated with emergency disorders just by assuring the availability of medical resources. Based on regionalization, a policy to provide the optimal treatment for those emergency disorders should be developed by planning public medical service systems based on the individual characteristics of emergency disorders, the standardized transfer plans of emergency patients and the assurance for mobilization and sharing of confined medical resources.

Is hyperbaric oxygen therapy more effective than normobaric oxygen therapy for improving acute neuropsychologic status due to carbon monoxide poisoning?

OBJECTIVE: The evidence that hyperbaric oxygen (HBO) therapy is more effective for improving the acute neuropsychological status (ANS) of carbon monoxide poisoning than normobaric oxygen (NBO) therapy is not convincing. This is because the levels of carboxyhemoglobin (COHb) do not correlate with the clinical severity of carbon monoxide poisoning and there is no universally accepted severity scale of carbon monoxide poisoning. This paper suggests a new scale for the clinical and neurological severity of carbon monoxide poisoning, called the ANS, and assesses the effect of HBO therapy for each level of ANS compared to NBO therapy. METHODS: A total of 217 patients who had been hospitalized because of carbon monoxide poisoning from January 2009 to July 2013 were studied. ANS was suggested as a new severity scale of carbon monoxide poisoning considered in the Glasgow Coma Scale, acute neuro-psychologic signs and symptoms, or cardiac ischemia on the initial medical contact. HBO therapy is indicated in those who have a loss of consciousness, seizure, coma, abnormal findings on a neurological examination, pregnancy, persistent cardiac ischemia, level of COHb >25%, or severe metabolic acidosis (pH < 7.2). The end point is the day of discharge, and recovery is defined as a normal neuro-psychological status without any sequelae. RESULTS: The levels of troponin T and creatinine increased significantly with increasing ANS score. In the moderate to severe group (ANS 2 and 3), the recovery rate was significantly higher when treated with HBO therapy than with NBO therapy (P=0.030). On the other hand, the development of delayed neuro-psychological sequelae (DNS) did not correlate with any level of ANS, type of oxygen therapy, or recovery on discharge. CONCLUSION: In the moderate to severe poisoned group, HBO therapy is more effective for improving the ANS from carbon monoxide poisoning than NBO therapy. On the other hand, the development of DNS of HBO therapy is no more preventable than with NBO therapy. Although the level of ANS is low, the patient needs to be provided with sufficient information and a follow-up visit is recommended for any abnormal symptoms because the ANS does not correlate with the development and degree of DNS.

Analysis of Prognostic Factors Affecting Admission in Acute Alcohol-intoxicated Patients with Traumatic Brain Injury Visiting Emergency Room

PURPOSE: This study analyzed the prognostic factors affecting admission in acute alcohol-intoxicated traumatic brain injury (TBI) patients visiting the emergency room. METHODS: A multicenter, retrospective observational study was conducted on 821 acute alcohol-intoxicated adult trauma patients, who visited 10 university hospital emergency centers from April to November 2016. The primary outcome was hospital admission. The secondary outcome was in-hospital mortality. RESULTS: One hundred sixty-eight patients diagnosed with acute alcohol-intoxicated TBI were analyzed. The increase in blood alcohol concentration was associated significantly with a mild decrease in admission (adjusted odds ratio, 0.993; 95% confidence interval, 0.989 to 0.998; p=0.01). Moderate to severe TBI patients showed a significant increase in admission compared to mild TBI patients (adjusted odds ratio, 12.449; 95% confidence interval, 3.316 to 46.743; p < 0.001). CONCLUSION: This study showed that the admission was inversely correlated with the blood alcohol concentration and is correlated directly with the increase in the severity in TBI. Therefore, emergency physicians may be required to identify the severity of TBI rapidly and accurately in acute alcohol-intoxicated trauma patients visiting the emergency room.

Esophageal Perforation with Delayed Detection of a Foreign Body: A Case Report

Foreign body ingestion in adults is not uncommon in the emergency department. Careful history taking is a key element of correct diagnosis and physical examination should be followed by use of radiographic approaches. We report on a case of esophageal perforation related to the presence of a foreign body in the esophagus. After radiographic studies, the patient was diagnosed as an esophageal perforation. Through an endoscopic approach, we found that the cause of the perforation was a foreign body in the esophagus. Emergency physicians should understand various presentations of foreign bodies in the esophagus and make a proper decision regarding treatment.

A Patient of Lightning Injury Combined with Reversible Neurologic Deficits: A Case Report

Lightning injury can cause systemic deterioration, including neurologic deficits. We present a case of lightning injury with reversible neurologic deficits in a 49-year-old man. Clinical manifestations of neurologic deficits due to lightning injury vary from lightheadedness to paralysis. In order to achieve a favorable outcome, immediate respiratory support and careful neurologic examinations are key elements during initial resuscitation. If secondary injuries due to any type of trauma following lightning were suspected, emergency physicians should make a decision regarding use of advanced diagnostic and therapeutic modalities.

Characteristics of Electrocardiographic Changes in Myocardial Injury with Acute Carbon Monoxide Poisoning

PURPOSE: Electrocardiographic findings such as Tp-Te interval, Tp-Te dispersion, and Tp-Te/QT ratio could be used to predict dysrhythmic events regarding any kind of toxic materials. We investigated the prevalence of cardiac toxicity related to acute carbon monoxide (CO) poisoning and the characteristics of electrocardiographic changes corresponding to the severity of intoxication. METHODS: This retrospective observational study was conducted with 113 patients of acute CO poisoning from May, 2013 to July, 2014. Myocardial injury (MI) was determined based on an elevation of serum troponin T within the first 24 hours of the ED visit. The study population was classified according to Acute Neuropsychiatric Status (ANS) scoring: a mild intoxication group (ANS scores 0 and 1) and a severe intoxication group (ANS scores 2 and 3). RESULTS: Prevalence of MI was higher in the severe intoxication group of acute CO poisoning (p<0.001). QTc was significantly prolonged in the MI group (p=0.007). However, no differences in other electrocardiographic parameters were observed between MI group and non-MI group. CONCLUSION: Myocardial injury was combined more frequently with a severe intoxication group of acute CO poisoning compared to a mild intoxication group. A specific feature of eletrocardiogram in myocardial injury with acute CO poisoning was a QTc prolongation.