Impact of COVID-19 pandemic on interhospital transfer of patients with major trauma in Korea: a retrospective cohort study.

BACKGROUND: Interhospital transfer (IHT) is necessary for providing ultimate care in the current emergency care system, particularly for patients with severe trauma. However, studies on IHT during the pandemic were limited. Furthermore, evidence on the effects of the coronavirus disease 2019 (COVID-19) pandemic on IHT among patients with major trauma was lacking. METHOD: This retrospective cohort study was conducted in an urban trauma center (TC) of a tertiary academic affiliated hospital in Daegu, Korea. The COVID-19 period was defined as from February 1, 2020 to January 31, 2021, whereas the pre-COVID-19 period was defined as the same duration of preceding span. Clinical data collected in each period were compared. We hypothesized that the COVID-19 pandemic negatively impacted IHT. RESULTS: A total of 2,100 individual patients were included for analysis. During the pandemic, the total number of IHTs decreased from 1,317 to 783 (- 40.5%). Patients were younger (median age, 63 [45-77] vs. 61[44-74] years, p = 0.038), and occupational injury was significantly higher during the pandemic (11.6% vs. 15.7%, p = 0.025). The trauma team activation (TTA) ratio was higher during the pandemic both on major trauma (57.3% vs. 69.6%, p = 0.006) and the total patient cohort (22.2% vs. 30.5%, p < 0.001). In the COVID-19 period, duration from incidence to the TC was longer (218 [158-480] vs. 263[180-674] minutes, p = 0.021), and secondary transfer was lower (2.5% vs. 0.0%, p = 0.025). CONCLUSION: We observed that the total number of IHTs to the TC was reduced during the COVID-19 pandemic. Overall, TTA was more frequent, particularly among patients with major trauma. Patients with severe injury experienced longer duration from incident to the TC and lesser secondary transfer from the TC during the COVID-19 pandemic.

Epsilon Wave Masked by ST-Segment Elevation After Cardioversion From Sustained Ventricular Tachycardia: An Exceptional Manifestation of Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy.

BACKGROUND: Early recognition and management of ventricular dysrhythmia (VD) are among the top priorities in the medical field, and are very important in cases of suspected acute coronary syndrome (ACS). Here we present a case of ventricular tachycardia (VT), which should be considered in ACS. CASE REPORT: A 59-year-old man with unstable vital signs visited the emergency department (ED) after a syncopal episode associated with chest discomfort. Initial electrocardiography (ECG) revealed wide complex tachycardia, which was considered monomorphic VT. After successful cardioversion, ST-segment elevation was observed on subsequent ECG with reciprocal ST-segment depression. Immediate pharmacological treatment and coronary angiography were performed because of suspected acute myocardial infarction; however, normal coronary arteries were observed. On subsequent ECG analysis, a small blip at the end of the QRS complex termed an epsilon wave, which is a characteristic finding in arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C), was detected in the V1 lead. A borderline diagnosis of ARVD/C was made based solely on ECG findings, and the definite diagnosis was confirmed using echocardiography. An implantable cardioverter-defibrillator was inserted soon after, and the patient reported no further events. Why Should an Emergency Physician be Aware of This?: ARVD/C is a critical disease entity that is commonly associated with life-threatening VA. However, presentations of ARVD/C resembling ACS are exceptionally rare. Accordingly, accurate diagnosis of ARVD/C in ED settings is clinically challenging. A high clinical suspicion is required to identify ARVD/C and avoid further life-threatening episodes.

Torsion of suprahepatic gall bladder.

Suprahepatic gall bladder is rare, and torsion of the ectopic gall bladder is extremely rare. We report a patient of acute suprahepatic cholecystitis with torsion. A 69-year-old Korean male was admitted to our hospital for sudden-onset, severe epigastric pain. Abdominal computed tomography and ultrasonography showed a distended gall bladder with diffuse wall thickening and scanty pericholecystic fluid, which was located in ectopic suprahepatic position, accompanied by S4 hypotrophy of the liver without gallstones. Emergency laparoscopic cholecystectomy was performed, and intraoperative findings revealed a distended and ischaemic gall bladder that was located in the suprahepatic position and had twisted along the cystic duct and artery pedicle in a clockwise manner. Detorsion was done and the gall bladder was resected. Unfortunately, the pre-operative diagnosis of gall bladder torsion was missed, and a definite diagnosis was made at the time of surgery. The patient was discharged on the 4th post-operative day.

Validation of the 35-mm rule in traumatic pneumothorax in an Asian population.

OBJECTIVES: Thoracic injury crucially threatens human health. Recent studies have suggested using computed tomography (CT) to observe traumatic pneumothorax (PTX). However, cross-ethnic validation is required to overcome potential barriers for the global application of this method. This study aimed to validate the 35-mm rule in traumatic PTX in a Korean population. METHODS: Data from the institutional registry were analyzed, and chest CT images were reviewed. Factors for observation failure were evaluated via logistic regression analysis, and a receiver-operating curve was created to calculate the optimal cutoff value. RESULTS: In total, 286 participants were included in this study. The average PTX size was 8.2 (3.2-26.5) mm, and 210 of 213 (95.3%) initially observed patients with a PTX size of ≤35 mm successfully completed the safety observation. Multivariate regression analysis revealed that a PTX size of >35 mm is associated with observation failure and suggested a cutoff of 24.5 mm. CONCLUSION: Most patients with traumatic PTX of ≤35 mm on CT had undergone successful 4-h observation without thoracostomy. Additionally, PTX of >35 mm was an independent risk factor for observation failure. Considering the lower optimal cutoff value and high failure rates observed in this study, the current guidelines need modifications.

Gastric perforation after polyurethane foam ingestion.

INTRODUCTION: Acute intoxication rarely produces conditions that require urgent surgical care. CASE SUMMARY: A 45-year-old man presented to the emergency department with severe abdominal pain after the deliberate ingestion of 200 cm3 of polyurethane mixed with methylene diphenyl diisocyanate and urethane primers. On an initial laparoscopic examination, foreign material was observed in the peritoneal space with haemoperitoneum. Emergency exploration was then undertaken for suspected gastric perforation. Full-thickness damage was identified on the stomach wall during the operation. The material in the gastrointestinal tract and peritoneal space was gently removed. Moulded casts of the entire stomach and distal oesophagus were extracted successfully. The patient was discharged 14 days after surgery. IMAGES: Computed tomography revealed foreign material occupying the entire gastric chamber, as well as diffuse gastric perforation. CONCLUSIONS: Life-threatening gastric perforation can occur after polyurethane foam ingestion. Clinical/medical toxicologists and emergency physicians need to be aware of the highly expandable nature of this agent.

Causative Activities and Prognostic Factors of Open-Globe Injury: A Registry-Based City-Wide Multicentre Study.

PURPOSE: Traumatic globe injury is classified into closed-globe and open-globe injury (OGI); OGI leads to a worse prognosis. We aimed to identify causative activities and prognostic factors of OGI in a metropolitan city in South Korea. METHODS: This retrospective observational study used a prospective eye-injury registry conducted in Daegu, South Korea, between 1 August 2016 and 31 July 2021. We identified epidemiology and visual outcomes of OGI at four tertiary hospitals. Those with the best visual acuity lower than counting fingers at the 6-month follow-up were considered to have poor visual outcome. RESULTS: Of 9,208 patients with eye injuries, 282 had OGI. Most OGI patients were male (261, 92.6%), with the largest proportion in their 50s (76, 27.0%). The most frequent causative activity was mowing (59, 20.9%), and poor visual outcome was most seen in assault (7, 87.5%) and sports activity (9, 81.8%). Hammering, metal work, and sports activity were prevalent in those under 30, and mowing was most prevalent in those in their 50s (16, 21.1%) and 60s (29, 40.3%). In the multivariable logistic regression analysis, OGI related to traffic accident and sports activity were presented poor prognosis (adjusted odds ratio [aOR] 13.259, 95% confidence interval [CI] 1.202-146.205 for traffic accident; aOR 6.801, 95% CI 1.064-43.487 for sports activity). CONCLUSION: We need to develop advanced vehicle safety equipment, implement public education promoting seat belt usage and hazards of OGI, establish eye protection standards for key causal activities, and provide eye protection equipment for sports activities and mowing.

Clinical effect on major trauma patients during simultaneous or overlapping presentations at an urban level I trauma center in Korea.

OBJECTIVE: Overcrowding in an emergency department (ED) or intensive care unit (ICU) of the trauma center (TC) is an important issue for timely acute health care of a critically injured patient. Accumulated scientific evidence has indicated the negative influence of overcrowding to the process and clinical outcome of trauma care. METHOD: The institutional trauma registry at an urban level I TC was retrospectively evaluated for 5 years (2018-2022). Major trauma was defined as an injury severity score (ISS) of >15. We determined simultaneous or overlapping presentations of major trauma (SOMT) in two or more patients with ISS of >15 who presented within a 4-h time window. When only two patients were included within a single time window, they were classified as SOMT-2, whereas when three or more patient clusters were identified in a single time window, they were classified as SOMT-3. The outcome measurement included process and clinical variables, such as trauma team activation (TTA) ratio, ED length of stay (LOS), time to blood product transfusion (TF), time to emergency surgery or intervention (ESI), ICU LOS, and mortality. RESULT: A total of 2,815 patients were included, of which 39.6% (N = 1,116) classified as SOMT. The SOMT group had lower TTA ratio than the non-SOMT group (69.4% vs. 73.4%, P = 0.022). The TTA ratio exhibited a decreasing trend in non-SOMT, SOMT-2, and SOMT-3 groups (P = 0.006). The time to TF was significantly delayed in the SOMT group (129 vs. 91 min, P < 0.001). CONCLUSION: SOMT regularly occurs and results in fewer trauma team activation and a delayed time to blood transfusion. The current intensive trauma care system should be strategically modified to improve critical trauma care and enhance disaster preparedness.

Abdominal compartment syndrome caused by severe acute gastric distension in a patient with COVID-19: A case report.

RATIONALE: The clinical manifestation of coronavirus disease 2019 (COVID-19) ranges from asymptomatic to critical. The gastrointestinal (GI) tract is involved in the early stages of the disease and is recognized as an important entry site for the virus. Consequently, GI manifestations are common in patients with COVID-19; however, the GI presentation of COVID-19 in relation to bowel dilatation has rarely been reported. Here, we report a case of acute severe gastric distension resulting in aortic compression and abdominal compartment syndrome (ACS) in a patient with COVID-19. PATIENT CONCERNS: A 72-year-old male presented to the emergency department (ED) with severe abdominal distension. The patient had been confirmed to have COVID-19 5 days prior to the visit. DIAGNOSES: Computed tomography revealed critical abdominal distension with severe gastric dilatation, accompanied by compression of the abdominal aorta and distal thrombosis formation. INTERVENTIONS: Intravenous fluid resuscitation and support with inotropic agents were initiated immediately, and a large amount of gastric content was evacuated via a nasogastric (NG) tube. OUTCOME: Finally, the patient was discharged after 12 days of admission without obvious complications. LESSONS: ACS is critical, which can be caused by a severe degree of acute gastric distension (AGD). Evacuation of the intraluminal contents is the most efficient management strategy. Prognosis is poor, and most previous studies of the transition from AGD to ACS have reported unfavorable outcomes.

Impact of COVID-19 outbreak on acute gallbladder disease in the emergency department.

OBJECTIVE: Acute gallbladder disease (AGD) is frequent in the emergency department (ED) and usually requires emergency surgery. However, only a few studies have reported the impact of COVID-19 on AGD. The goal of this study was to evaluate the time between symptom onset and surgery and the perioperative severity of AGD during the COVID-19 pandemic compared to before the era of COVID-19. METHODS: This retrospective, single-center cohort study included patients who presented to the ED with suspected AGD and who underwent emergency cholecystectomy. We designed a before-after comparative study, and the intervention was the COVID-19 outbreak. The 6-month period after the COVID-19 outbreak was defined as the post-COVID group, whereas the pre-COVID group consisted of the same period in the previous year. The primary outcome was the time from symptoms to surgery. We evaluated the time intervals between symptom onset and ED arrival and between ED arrival and surgery. The secondary outcomes were preoperative and postoperative severity indexes. RESULTS: A total of 316 patients was analyzed. The post-COVID group showed longer duration from symptom onset to ED arrival (34.0 hours vs. 15.0 hours, P<0.001) and longer time interval from ED arrival to surgery (16.2 hours vs. 10.2 hours, P<0.001) than the pre-COVID group. The overall time interval between symptom onset to surgery was longer in the post-COVID group than the pre-COVID group (71.5 hours vs. 33.5 hours, P<0.001). The post-COVID group showed higher preoperative Simplified Acute Physiology Score II scores than the pre-COVID group (20.1 vs. 18.2, P=0.045). The proportion of moderate or severe disease increased in the post-COVID group (78% vs. 65%, P=0.017). The durations of hospital stay (7.0 days vs. 5.0 days, P<0.001) and intensive care unit stay (27.1 hours vs. 10.8 hours, P=0.008) were longer in the post-COVID group than in the pre-COVID group. CONCLUSION: During the pandemic, the time interval between symptom onset to surgery was significantly increased among patients with AGD. Concomitantly, higher preoperative severity indexes and longer hospital stay were reported with a delay in emergency surgery.

Emergency contraceptive provision in the emergency department and risk analysis for delayed utilization in South Korea.

In certain nations, the emergency department (ED) has been designated as the primary center to provide emergency contraception (EC). However, analyses of ED visits for EC are limited. Moreover, ED-based research that focuses on time is limited to only a few surveys. The aims of this study were to examine the characteristics of ED visitors for EC and the interval between the coitus and arrival at the ED, and to analyze the factors associated with delays in visiting the ED. This retrospective cohort study involved patients at 2 urban tertiary academic hospitals in South Korea. All patients who presented to the ED for EC between January 2019 and December 2021 were analyzed. The median age of the participants was 26 years. The most common variables were age of 20 to 29 years (42.0%), evening visits (34.9%), weekends or public holidays (62.6%), single status (89.2%), and visits after contraceptive failure (79.1%). The mean time interval was 7.49 hours, and 77.4% of all patients visited the ED within 12 hours. Patients who received public sex education presented earlier (P < .001). ED visits after nonconsensual sexual incidents represented significantly delayed presentations (P < .001). Regression analysis revealed that both the lack of public education and the occurrence of nonconsensual coitus were associated with incident-to-ED visit intervals of >12 hours. Most patients received emergency contraceptive pill (ECP) within the recommended timeframe. In particular, nationwide school-based public sex education positively affected early ECP access. In contrast, ECP provision was delayed for patients who experienced nonconsensual coitus. Strategies for timely ECP access should account for possible concerns about stigmatization and privacy.

Exposure to an accidental trichlorosilane spill: three case reports.

Chlorosilane is a hazardous chemical compound which is used as a raw material in the production of silicone. Despite strict restrictions, accidental spillage of chlorosilane is often reported. However, human exposure was rarely reported in the past decades and the effect on humans is barely known. We report cases of human exposure to an accidental trichlorosilane spill. Three middle aged male industrial workers visited our emergency department after exposure to trichlorosilane. They presented with shortness of breath and burns on multiple sites. Chest radiograph and laboratory studies were performed. None of the reports showed serious results and were discharged after conservative management.

High prevalence of depression and sleep-wake disorders among female emergency medicine residents in South Korea.

BACKGROUND: Depression and sleep-wake disorders are recognized as one of the major problems among emergency physicians. While depression is more common in females than in males, the associated factors linking depression and sleep-wake disorders in emergency physicians, particularly females, remain unknown. OBJECTIVE: To analyze the prevalence of depression and sleep-wake problems among emergency medicine (EM) residents in South Korea and to identify the gender differences and situations that adversely predispose female residents to mental health problems. METHODS: We conducted a cross-sectional analysis using the data collected from the 2019 National EM Residents Wellness Survey targeting all of 630 EM residents in South Korea. The survey included variables potentially influencing depression and sleep-wake problems, such as personal characteristics, work-related stress, and extrinsic environment. Information regarding medical conditions, depression, job stress, and sleep deprivation was obtained using the self-administered Patient Health Questionnaire (PHQ-9), the Apgar Wellness Score (AWS), and the Epworth Sleepiness Scale (ESS). We analyzed the data using IBM SPSS Statistics version 25 and MedCalc version 17. RESULTS: A total of 384 residents participated in the survey. Overall, 27.5% of the EM residents met the criteria for at least moderate depression and 36.9% of the EM residents had sleep-related problems. We found that difficulty in trading the shift schedule and frequent night shifts was associated with depression (p = .001, p = .005; respectively). Female residents demonstrated an increased risk of depression and sleepiness compared to their male counterparts (odds ratio [OR] 1.95, OR 1.81; respectively). In addition, logistic regression analysis revealed significant differences by gender in depression with regards to flexibility of trading shifts (p = .005), level of training in the emergency medical centre (p = .035), and frequent night shifts (p = .010). CONCLUSIONS: Approximately, one-third of EM residents report depression and sleep-wake problems, with female residents showing a higher risk than male residents. Several risk factors were identified, and future strategies should be aimed to address these issues to improve the training environment and overall wellbeing of EM residents.KEY MESSAGESThe prevalence of depression and sleep-related problems were, respectively, 1.95 and 1.81 times higher in female residents compared to their male colleagues.The associated risk factors for depression were flexibility of shift trade, level of training in the emergency medical centre, and frequency of night shifts.Improving the training environment and facilities, as well as offering more flexible duty trading options can provide potential opportunities to reduce the risk.

A comparative analysis of gallbladder torsion and acute gallbladder disease without torsion: a single-center retrospective case series study.

BACKGROUND: Acute gallbladder disease (AGD) is frequent in the emergency department (ED), and usually requires surgical intervention. Gallbladder torsion (GT) is a rare entity among patients with AGD. There are sparse reviews of GT's clinical characteristics, and there is no comparative study between them in the same patient cohort. Therefore, we report the case series of GT, and compare the statistical differences between GT and non-GT with AGD. METHODS: We collected retrospective data from patients who visited ED with AGD and underwent emergency cholecystectomy between January 2005 and December 2020. We combined consecutive case series of GT and compared them with non-GT gallbladder disease. RESULTS: Six GT cases were diagnosed over the study duration. Five were female (83%) and the average age was 77.8 years. All patients presented with abdominal pain, and the median duration of pain was two days. Only two cases were suspected for GT pre-operatively (33%). One patient underwent laparotomy, and the others underwent laparoscopic cholecystectomy with a mean operation time of 59 min. The torsion direction was of the same proportion in both directions; five (83%) were rotated completely. The mean length of hospital stay was 9.3 d and outcomes were favorable in most GT cases. In the comparative study between GT and non-GT, age was higher in the GT group (P=0.048), and duration or severity of pain showed no statistical difference (P=0.528; P=0.637, respectively). Body temperature was higher in the non-GT group without statistical significance (P=0.074). Gallstones were present in 68.8% of the non-GT group, which is significantly higher than that of the GT group (P=0.036). CONCLUSIONS: Six exceptional GT cases were managed successfully. The overall characteristics of each GT case demonstrated similar with previous reviews. Our comparative analysis showed that age, pulse rate, serum creatinine level, and gallstone presence showed statistical differences. Contrary to the traditional knowledge of GT, some distinct features like sex, duration or severity of pain, and fever showed no significant differences within AGD in our research.

Application of calcium nebulization for mass exposure to an accidental hydrofluoric acid spill.

PURPOSE: To determine the long-term prevalence and characteristics of acute hydrofluoric acid (HF) exposure in 2223 patients during the first 30 months after a mass-casualty exposure, and to confirm the antidotal effect of nebulized calcium on inhalation burns caused by HF. METHODS: This observational cohort study included patients after an HF spill in the Republic of Korea on September 27, 2012; registered patients were followed until April 2015. We assessed toxic effects, distance from spill, degree of acute poisoning, and the effect of nebulized calcium in HF-exposed individuals. RESULTS: Overall, 2223 patients received emergency management or antidote therapy for 20 days. Seventy-four of 134 patients with dermal toxicity received calcium-lidocaine gel, and 368 individuals with bronchial irritation signs received calcium gluconate via nebulizer nCG. A total 377 ampoules 786 g of calcium gluconate were used in the nCG formulation. Calcium administration did not cause adverse reactions during the observation period. Long-term cohort observation showed that 120 patients (120/2233, 5.4%) returned to medical facilities for management of HF-related symptoms within 1 month; 18 persons (18/1660, 1.1%) returned 1-3 months later with chronic cough and respiratory symptoms; and 3 patients (3/1660, 0.2%) underwent medical treatment due to upper-airway toxic symptoms more than 2 years after HF exposure. CONCLUSION: Respiratory toxicity after mass exposure to an HF spill was successfully treated by calcium nebulizer. Based on our experience, detoxification processes and the amounts of antidote stocked are important when planning for future chemical disasters at the community level.