Sigmoid volvulus: identifying patients requiring emergency surgery with the dark torsion knot sign.

OBJECTIVES: To determine which clinical or CT imaging factors can help accurately identify complicated sigmoid volvulus (SV), defined as irreversible bowel ischaemia or necrosis requiring emergent surgery in patients with SV. METHODS: We performed a retrospective study of 51 patients admitted consecutively to the emergency department for SV. All patients attempted endoscopic detorsion as the first treatment. Clinical and contrast-enhanced CT factors were analysed. A newly described dark torsion knot sign (sudden loss of mucosal enhancement in the volvulus torsion knot) was included as a CT factor. Patients were diagnosed with complicated versus simple SV based on either surgery or follow-up endoscopic findings. Univariate and multivariate analyses were used to identify predictors of complicated SV. RESULTS: Of 51 study patients, 9 patients (17.6%) had complicated SV. Univariate analysis revealed that three clinical factors (sepsis, elevated C-reactive protein, and elevated lactic acid levels) and four CT factors (reduced bowel wall enhancement, increased bowel wall thickness, dark torsion knot sign, and diffuse omental infiltration) were significantly associated with complicated SV. Multivariate analysis identified only dark torsion knot sign (odds ratio = 104.40; p = 0.002) and sepsis (odds ratio = 16.85; p = 0.043) as independent predictive factors of complicated SV. CONCLUSION: A newly defined CT imaging factor of dark torsion knot sign and a clinical factor of sepsis can predict complicated SV necessitating emergent surgery instead of colonoscopic detorsion as a primary treatment of choice. KEY POINTS: • A newly defined CT imaging factor of dark torsion knot sign and a clinical factor of sepsis can be helpful for predicting complicated SV necessitating emergent surgery instead of endoscopic detorsion.

Renal Complications in Patients with Renal Infarction: Prevalence and Risk Factors.

BACKGROUND/AIMS: This study aimed to investigate the incidence and risk factors for acute kidney injury (AKI) and chronic kidney disease (CKD) in patients with renal infarction. METHODS: A single-center retrospective study was conducted from January 2005 to December 2013. Baseline and clinical characteristics of the enrolled patients with renal infarction were evaluated and analyzed according to the presence of AKI and CKD. In particular, predictors for AKI and CKD were determined using logistic regression analysis. RESULTS: Of the 105 patients included in present study, 41 (39.0%) patients had AKI. A total of 80 patients were followed up for 2 years after hospital discharge. Among these patients, 27 (33.8%) patients had CKD. In the multivariate analysis, the predictors were mean blood pressure (odds ratio [OR] 1.062, 95% confidence interval [CI] 1.015-1.112, p = 0.009) and bilateral involvement (OR 4.396, 95% CI 1.096-17.632, p = 0.037) for AKI, and AKI (OR 14.799, 95% CI 4.173-52.490, p < 0.001) and old age (OR 1.065, 95% CI 1.016-1.116, p = 0.009) for CKD. CONCLUSIONS: Physicians should pay attention to the development of AKI and CKD after renal infarction and follow patients over a long term.

Carbon monoxide poisoning during camping in Korea.

OBJECTIVE: The aim of this study was to evaluate the epidemiology and characteristics of unintentional carbon monoxide (CO) poisoning during camping in Korea. METHODS: We performed a retrospective observational study on patients with unintentional camping-related CO poisoning who were admitted to the emergency department (ED) from 1 January 2010 to 31 December 2014. News reports about incidents of camping-related CO poisoning were collected using news search engines. RESULTS: A total of 72 patients (29 patients involved in 12 incidents, who were admitted to our ED, and 43 victims involved in 17 incidents reported in the media) were identified. Accidental camping-related CO poisoning occurred most frequently in May, late spring in Korea. Gas stove use and the burning of charcoal for tent heating were responsible for camping-related CO exposure. Seventeen victims (39.5%) were found dead when an ambulance arrived at the scene, in the cases reported in the media. In contrast, all the victims at our hospital were alive on hospital discharge. Twelve of the 17 incidents (70.6%) reported in the media were accidental fatalities. The majority of our patients (83.4%) were not aware of the potential danger of charcoal as a source of CO. CONCLUSION: Accidental camping-related CO poisoning occurred because of an ongoing lack of awareness about the potential danger of charcoal grills and stoves, and this caused prehospital mortality. Such accidents could be prevented by increasing the awareness of the potential danger of using charcoal grills and stoves during camping, as well as by establishing appropriate safety regulations.

Kind and estimated stocking amount of antidotes for initial treatment for acute poisoning at emergency medical centers in Korea.

Antidotes for toxicological emergencies can be life-saving. However, there is no nationwide estimation of the antidotes stocking amount in Korea. This study tried to estimate the quantities of stocking antidotes at emergency department (ED). An expert panel of clinical toxicologists made a list of 18 emergency antidotes. The quantity was estimated by comparing the antidote utilization frequency in a multicenter epidemiological study and the nation-wide EDs' data of National Emergency Department Information System (NEDIS). In an epidemiological study of 11 nationwide EDs from January 2009 to December 2010, only 92 (1.9%) patients had been administered emergency antidotes except activated charcoal among 4,870 cases of acute adult poisoning patients. Comparing with NEDIS data, about 1,400,000 patients visited the 124 EDs nationwide due to acute poisoning and about 103,348 adult doses of the 18 emergency antidotes may be required considering poisoning severity score. Of these, 13,224 (1.9%) adult doses of emergency antidotes (575 of atropine, 144 of calcium gluconate or other calcium salts, 2,587 of flumazenil, 3,450 of N-acetylcysteine, 5,893 of pralidoxime, 287 of hydroxocobalamin, 144 of sodium nitrite, and 144 of sodium thiosulfate) would be needed for maintaining the present level of initial treatment with emergency antidotes at EDs in Korea.

Oropharyngeal airway obstruction after the accidental ingestion of Arisaema amurense.

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

Comparison of clinical outcomes between intermittent and continuous monitoring of central venous oxygen saturation (ScvO2) in patients with severe sepsis and septic shock: a pilot study.

BACKGROUND: The Surviving Sepsis Campaign (SSC) to improve patient outcomes in severe sepsis and septic shock contains recommendations for protocolised resuscitation including early goal-directed therapy (EGDT) resuscitation. In EGDT, central venous oxygen saturation (ScvO2) is measured as the target monitoring value. The objective of this study was to determine whether intermittent measurement of ScvO2 is as clinically effective as continuous monitoring in EGDT implementation. METHODS: This prospective, observational, pilot study was performed at an emergency room and general ward in ASAN Medical Centre, a 2680-bed teaching hospital. One hundred and six patients with severe sepsis or septic shock were enrolled and assigned to an intermittent monitoring group (n=53) or continuous monitoring group (n=53). RESULTS: Within 6 h of the EGDT, interventions by the treating physicians were assessed, including intravenous fluid administration, use of vasopressors and compliance with SSC bundles. After 6 h of the EGDT, 41.5% of all goals (primary outcome) were achieved in the intermittent group and 35.8% in the continuous group (p=0.550). Intensive Care Unit (ICU) mortality, hospital mortality and length of ICU stay did not differ between groups. CONCLUSIONS: During EGDT, intermittent ScvO2 monitoring was not inferior to continuous ScvO2 monitoring when delivered within the first 6 h of intervention.

Insignificant role of the N-terminal cobalt-binding site of albumin in the assessment of acute coronary syndrome: discrepancy between the albumin cobalt-binding assay and N-terminal-targeted immunoassay.

The aim of this study was to evaluate whether the N-terminus of human serum albumin (HSA) has a role in the cobalt binding detected using albumin cobalt-binding (ACB) assay. We compared the results obtained using an enzyme-linked immunosorbent assay (ELISA) for N-terminal-modified HSA with those of a conventional ACB assay in two groups: acute coronary syndrome (n = 43) and non-ischemic chest pain (n = 39). ACB and cardiac troponin-I levels were higher in the acute coronary syndrome group. No significant correlation between ACB assay and ELISA results was observed in either of the two patient groups. In acute chest pain patients, the N-terminal site of HSA has a negligible or limited role in cobalt binding in the ACB assay.

Transient global amnesia: seven years of experience with diffusion-weighted imaging in an emergency department.

BACKGROUND/AIMS: Hippocampal lesions on diffusion-weighted imaging (DWI) are commonly described in transient global amnesia (TGA). We evaluated the utility of DWI and the presence of hippocampal lesions in the diagnosis of TGA. METHODS: A total of 203 TGA episodes were diagnosed at our emergency department from January 2003 to May 2010. DWI (5-mm slice thickness) was performed using a 1.5 T scanner. Patients were divided into 2 groups based on the presence of hippocampal lesions on DWI: DWI- and DWI+. The clinical characteristics and the time interval from development of amnesia to magnetic resonance imaging (MRI) were compared. RESULTS: 16 patients had hippocampal lesions on DWI. The DWI- and DWI+ groups had similar clinical characteristics. The overall median time interval from amnesia to MRI was 6 h, and this interval was significantly longer for the DWI+ group than the DWI- group [9 h (IQR 6.5-25) vs. 5 h (IQR 4-9), p = 0.002]. CONCLUSION: DWI has a low diagnostic yield when performed early in the course of TGA. Positive findings can confirm the diagnosis, but in negative results, careful interpretation is required, including the time interval from amnesia to MRI.

Clinical characteristics of pneumonia in hospitalized patients with novel influenza A (H1N1) in Korea.

In March 2009, a novel influenza H1N1 virus (2009 H1N1) emerged and spread worldwide. We describe the clinical course of pneumonia in patients hospitalized with 2009 H1N1 in Korea from August to mid-October 2009. Of 351 patients with a confirmed 2009 H1N1 infection, a total of 17 patients with pneumonia were admitted to an acute care unit. More than half of the patients were between 7 and 23 y of age, and only 2 patients were 65 y of age or older. Only 6 patients (35.3%) had underlying medical conditions. For 10 of the 17 patients, chest radiographs taken on admission had findings of pneumonia with bilateral infiltrates. Despite intensive resuscitative efforts, 1 adult patient arriving with severe hypoxemia in the emergency department died 3 weeks later. However, we were able to discharge most of the patients without any other complication in 5 days. 2009 H1N1 was the cause of pneumonia with mild hypoxemia at admission in previously healthy school-aged persons in Korea.

Clinical Predictors of Acute Brain Injury in Carbon Monoxide Poisoning Patients With Altered Mental Status at Admission to Emergency Department.

OBJECTIVES: Objective screening tool for patients at a high risk of developing acute brain injury (ABI) is necessary for the proper treatment of carbon monoxide (CO) poisoning patients. The aim of this study is to identify clinical factors that could predict ABI due to CO poisoning in patients with an altered mental status. METHODS: A prospectively collected CO poisoning registry at a single academic medical center was retrospectively analyzed. CO poisoning patients with an altered mental status at the emergency department, defined as unalert on the alert/responsive to voice/responsive to pain/unresponsive scale and underwent diffusion-weighted magnetic resonance imaging (DW-MRI) between January 1, 2013, and December 31, 2015, were included. ABI was defined as the presence of acute hypoxic brain lesions. Clinical predictors of ABI were identified by multivariate logistic regression analysis. RESULTS: Of 180 patients, 67 (37.2%) had ABI as revealed by DW-MRI. Multivariate analysis showed that CO exposure duration > 5 hours (adjusted odds ratio [AOR] = 7.082; 95% confidence interval [CI] = 3.463-15.014; p < 0.001) defined as the time between CO exposure and rescue, abnormal white blood cell count (AOR = 2.568, 95% CI = 1.188-5.700, p = 0.02), and abnormal creatinine concentration (AOR = 2.667, 95% CI = 1.110-6.605, p = 0.03) were predictors of ABI. CO exposure duration had the highest predictive value (area under the curve, 0.815), and the optimal cutoff value was 5 hours. Moreover, increasing exposure durations (quartile) indicated a stepwise increase in the risk of ABI. CONCLUSIONS: In CO poisoning patients with an altered mental status, CO exposure duration was useful for predicting ABI, which may help clinicians or paramedics identify high-risk patients and provide treatment on priority.

Acute Brain Lesions on Magnetic Resonance Imaging and Delayed Neurological Sequelae in Carbon Monoxide Poisoning.

Importance: Preventing delayed neurological sequelae is a major goal of treating acute carbon monoxide poisoning, but to our knowledge there are no reliable tools for assessing the probability of these sequelae. Objectives: To determine whether acute brain lesions on diffusion-weighted imaging are related to subsequent development of delayed neurological sequelae after acute carbon monoxide poisoning. Design, Setting, and Participants: This registry-based observational study was conducted at a university hospital in Seoul, Korea, between April 1, 2011, and December 31, 2015. Of 700 patients (aged ≥18 years) with acute carbon monoxide poisoning, 433 patients (61.9%) who underwent diffusion-weighted imaging at an emergency department were considered for the study. Patients who developed cardiac arrest before diffusion-weighted imaging (n = 3), had persistent neurological symptoms at discharge (n = 8), committed suicide soon after discharge (n = 1), and were lost to follow-up (n = 34) were excluded. Exposure: The presence of unambiguous, high-signal-intensity, acute brain lesions on diffusion-weighted imaging (b = 1000 s/mm2). Main Outcomes and Measures: Development of delayed neurological sequelae defined as any neurological symptoms or signs that newly developed within 6 weeks of discharge. Results: Of the 387 included patients (143 women [37.0%]; median age, 42.0 years [interquartile range, 32.0-56.0 years]), acute brain lesions on diffusion-weighted imaging were observed in 104 patients (26.9%). Among these, 77 patients (19.9%) had globus pallidus lesions, 13 (3.4%) had diffuse lesions, and 57 (14.7%) had focal lesions (37 patients [9.6%] had >1 pattern concurrently). Lesions were supratentorial and infratentorial in 101 and 23 patients, respectively. Delayed neurological sequelae occurred in 101 patients (26.1%). Multivariable logistic regression analysis indicated that the presence of acute brain lesions was independently associated with development of delayed neurological sequelae (adjusted odds ratio, 13.93; 95% CI, 7.16-27.11; P < .001). The sensitivity and specificity of acute brain lesions to assess the probability of delayed neurological sequelae were 75.2% (95% CI, 66.8%-83.7%) and 90.2% (95% CI, 86.8%-93.7%), respectively. In addition, the positive and negative predictive values were 73.1% (95% CI, 64.6%-81.6%) and 91.2% (95% CI, 87.9%-94.5%), respectively. Conclusions and Relevance: The presence of acute brain lesions was significantly associated with the development of delayed neurological sequelae. Diffusion-weighted imaging during the acute phase of carbon monoxide poisoning may therefore help identify patients at risk of developing these debilitating sequelae.

Analysis of the development and progression of carbon monoxide poisoning-related acute kidney injury according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria.

CONTEXT: Acute kidney injury (AKI) can occur after carbon monoxide (CO) intoxication; however, limited data are available. This study aimed to evaluate the prognostic value of the development and progression of AKI in patients with acute CO poisoning. MATERIALS AND METHODS: We conducted a retrospective cohort study using a prospective registry of CO poisoning between January 2010 and December 2015. AKI was defined and classified according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Multivariate logistic regression analysis was conducted to determine the association between AKI and adverse outcomes, defined as neurological deficits at discharge or 28-day mortality. RESULTS: A total of 661 patients were evaluated. According to KDIGO criteria, 114 patients (17.2%) had AKI (initial: stage 1, 70.2%; stage 2, 26.3%; stage 3, 3.5%) on admission and 119 (18.0%) finally developed AKI during their hospital stay (maximum: stage 1, 68.9%; stage 2, 23.5%; stage 3, 7.6%). Almost all patients (99.2%) were diagnosed as having their highest KDIGO stage within three days (median, one day). AKI development was associated with adverse outcomes (odds ratio (OR) 17.53, 95% confidence interval 45.00-77.14). Both initial and maximum AKI stages demonstrated a stepwise increase of adjusted OR for adverse outcomes. AKI stage progression occurred in 8.4% of patients with AKI and was an independent factor for adverse outcomes. CONCLUSION: CO poisoning- related AKI occurred in 18% and was mostly detected within one day after CO intoxication. The development and progression of AKI had a strong association with adverse outcomes and deserve further prospective investigation.

Aspiration Pneumonia in Carbon Monoxide Poisoning Patients with Loss of Consciousness: Prevalence, Outcomes, and Risk Factors.

BACKGROUND: Aspiration pneumonia is associated with significant morbidity and mortality; however, little is known about aspiration pneumonia in patients with carbon monoxide intoxication, which is the leading cause of poisoning-related death. This study aimed to evaluate the prevalence, clinical impacts, and risk factors for developing aspiration pneumonia in patients with carbon monoxide poisoning with loss of consciousness. METHODS: A retrospective analysis of a carbon monoxide poisoning registry was performed at our emergency department for the period January 2008 to December 2015. All adult carbon monoxide poisoning patients with loss of consciousness were included. RESULTS: Aspiration pneumonia developed in 103 (19.2%) of 537 patients. It was associated with increased ventilator use (52.4% vs 3.2%), length of hospital stay (median [interquartile range], 3.6 [2.1-5.1] vs 1.3 [0.6-2.1] days), and in-hospital mortality (5.8% vs 0.0%) (all P < .001). Altered mental status on emergency department arrival, white blood cell count, and increased exposure duration were the independent factors associated with development of aspiration pneumonia; odds ratios were 9.46 (95% confidence interval [CI] 4.92-18.19; P < .001), 1.19 (95% CI 1.13-1.26; P < .001), and 1.12 (95% CI 1.06-1.19; P < .001), respectively. For painful or unresponsive mental status and white blood cell count >12,000/mm3, the odds ratio increased up to 17.75 (95% CI 10.65-29.59; P < .001). CONCLUSIONS: The prevalence of aspiration pneumonia was 19.2% in carbon monoxide poisoning patients with loss of consciousness and was associated with poor outcomes. Additionally, altered mental status on emergency department arrival, white blood cell count, and increased exposure duration were independently associated with the development of aspiration pneumonia.

Clinically significant hemodynamic alterations after propacetamol injection in the emergency department: prevalence and risk factors.

Propacetamol, a water-soluble prodrug form of paracetamol, is hydrolyzed by esterase to generate paracetamol in the blood. Each gram of propacetamol is equal to 0.5 g of paracetamol. It has been reported to cause hypotension in critically ill patients with a fever. We aimed to investigate the hemodynamic effects of propacetamol for the control of fever in patients with diverse severities of illness who were managed in the emergency department (ED). We also aimed to identify clinical factors related to significant hemodynamic alterations in ED patients. This was a retrospective study of 1507 ED patients who received propacetamol. Significant hemodynamic alterations were defined as systolic blood pressure (SBP) <90 mmHg or diastolic blood pressure (DBP) <60 mmHg, or a drop in SBP >30 mmHg, which required treatments with a bolus of fluid or vasopressor administration. Postinfusion SBP and DBP were significantly lower than the preinfusion SBP and DBP. A clinically significant drop in BP occurred in 162 (10.7 %) patients, and interventions were necessary. Among the predictors assessed, congestive heart failure (OR 6.21, 95 % CI 2.67-14.45) and chills (OR 3.10, 95 % CI 2.04-4.70) were independent factors for a significant hemodynamic change. Administration of propacetamol can provoke a reduction in BP in ED patients. This reduction was clinically significant for 10 % of infusions. Clinicians should be aware of this potential deleterious effect, especially in patients with congestive heart failure or who experience chills prior to the administration of propacetamol.

Predictors of poor outcomes in patients with wild mushroom-induced acute liver injury.

AIM: To identify early predictive markers of poor outcomes in patients with acute liver injury from wild mushroom intoxication. METHODS: This observational, retrospective record review involved adults aged ≥ 18 years admitted to emergency department with mushroom intoxication from January 2005 to December 2015. The diagnosis of mushroom intoxication was based on the following: (1) a positive history of recent wild mushroom intake (either raw or cooked); (2) the onset of gastrointestinal symptoms, such as watery diarrhea, vomiting, and/or abdominal pain, after ingestion; and (3) the exclusion of other possible causes of acute liver injury. Acute liver injury was defined by a > 5-fold elevation of liver enzymes or moderate coagulopathy [international normalized ratio (INR) > 2.0]. Clinical and laboratory findings were compared in survivors and non-survivors. RESULTS: Of 93 patients with mushroom intoxication, 23, 11 men (47.8%) and 12 women (52.2%), of median age 61 years, developed acute liver injury. The overall in-hospital mortality rate was 43.5% (10/23). Among the laboratory variables, mean serum alkaline phosphatase (73.38 ± 10.89 mg/dL vs 180.40 ± 65.39 mg/dL, P < 0.01), total bilirubin (2.312 ± 1.16 mg/dL vs 7.16 ± 2.94 mg/dL, P < 0.01) concentrations and indirect/direct bilirubin (2.45 ± 1.39 mg/dL vs 0.99 ± 0.45 mg/dL, P < 0.01) ratio as well as prothrombin time (1.88 ± 0.83 mg/dL vs 10.43 ± 4.81 mg/dL, P < 0.01), and activated partial thromboplastin time (aPTT; 32.48 ± 7.64 s vs 72.58 ± 41.29 s, P = 0.01), were significantly higher in non-survivors than in survivors. Logistic regression analysis showed that total bilirubin concentration (OR = 3.58, 95%CI: 1.25-10.22), indirect/direct bilirubin ratio (OR = 0.14, 95%CI: 0.02-0.94) and aPTT (OR = 1.30, 95%CI: 1.04-1.63) were significantly associated with mortality. All patients with total bilirubin > 5 mg/dL or aPTT > 50 s on day 3 died. CONCLUSION: Monitoring of bilirubin concentrations and aPTT may help in predicting clinical outcomes in patients with acute liver injury from wild mushroom intoxication.

Trends in the incidence and outcomes of bicycle-related injury in the emergency department: A nationwide population-based study in South Korea, 2012-2014.

OBJECTIVE: This study aimed to examine trends in the incidence and outcomes of bicycle-related injuries in emergency departments (ED) in South Korea. METHODS: We analysed data from the National Emergency Department Information System database for adult patients (≥20 years) with bicycle-related injuries presenting to EDs in South Korea between January 2012 and December 2014. Riders and bicycle passengers whose injuries were associated with bicycle use were included. Serious outcomes were defined as death at the ED, need for emergency operation, or intensive care unit admission. RESULTS: The number of people who commute to work by bicycle increased by 36% from 205,100 in 2005 to 279,544 in 2015. Of 529,278 traffic-related trauma cases, 58,352 (11.0%) were bicycle-related, which increased from 7,894 (10.2%) in the first half of 2012 to 12,882 (12.2%) in the second half of 2014 (p < 0.001). However, the proportion of serious outcomes decreased from 5.0% to 4.2% during the study period (p < 0.001). Serious outcomes were most frequent in the elderly (65-74 years) and older elderly (≥75 years) groups and decreased for all but the elderly age group from 10.3% to 9.8% (p = 0.204). The helmet use rate increased from 14.2% to 20.3% (p < 0.001) but was the lowest in the older elderly group (3.6%) without change during the study period (from 4.7% to 3.7%, p = 0.656). A lack of helmet use was significantly associated with serious outcomes (odds ratio, 1.811; 95% confidence interval, 1.576-2.082). CONCLUSIONS: Although the incidence of bicycle-related injuries increased, the proportion of serious outcomes decreased, possibly due to increased helmet use. Public education on safety equipment use is required, especially in elderly populations.

Disseminated Intravascular Coagulation in Emergency Department Patients With Primary Postpartum Hemorrhage.

The aim of this study was to evaluate the prevalence of disseminated intravascular coagulation and to determine whether the presence of disseminated intravascular coagulation is associated with major adverse events in patients with primary post-partum hemorrhage (PPH) who present to the emergency department.This retrospective case-control study was conducted in the emergency department of a university-affiliated, tertiary referral center between January 1, 2004 and December 31, 2013. Patients were classified into disseminated intravascular coagulation (disseminated intravascular coagulation score ≥ 5) and non-disseminated intravascular coagulation groups. The two groups were compared in terms of clinical characteristics and the occurrence of major adverse events, defined as massive transfusion (≥ 10 units of packed red blood cells within 24 h of emergency department admission), invasive intervention (uterine artery embolization or emergency hysterectomy), hospital days, ventilator-free days, intensive care unit admission, intensive care unit-free days, and in-hospital mortality.Among 255 patients with primary PPH, 57 patients (22.4%) had overt disseminated intravascular coagulation. The disseminated intravascular coagulation group had significantly lower hemoglobin, hematocrit, platelet counts, and fibrinogen levels than the non-disseminated intravascular coagulation group; in addition, they had higher prothrombin times, and D-dimer levels (P < 0.01). The occurrence of major adverse events was greater in the disseminated intravascular coagulation group than in the non-disseminated intravascular coagulation group (96.5% vs. 44.4%, P < 0.01).In conclusion, disseminated intravascular coagulation was frequently found in combination with primary PPH, and the outcome was worse in these patients than in those without disseminated intravascular coagulation.

Incidence and risk factors of iatrogenic pneumothorax after thoracentesis in emergency department settings.

BACKGROUND: There is a lack of data regarding the incidence and associated factors of pneumothorax following thoracentesis conducted in emergency department (ED) settings. The present study aims to determine the incidence of pneumothorax following thoracentesis in ED settings and evaluate the association of specific demographics, clinical, and procedure factors with thoracentesis-related pneumothorax. METHODS: We retrospectively reviewed the medical records of 3,067 thoracentesis cases in the ED of a tertiary care, university-affiliated hospital between January 2009 and December 2014. To evaluate the factors associated with the occurrence of pneumothorax following thoracentesis, matched controls were used with a case to control ratio of 1:5. RESULTS: Of the 3,067 cases that received thoracentesis, 19 cases of pneumothorax were observed (0.62%). Patients with pneumothorax had significantly lower weight and body mass index (BMI) than those without pneumothorax (51.0 vs. 61.2 kg, 20.0 vs. 22.6; P<0.001, respectively). In the multivariate logistic regression analysis, being underweight, defined as a BMI of <18.5 [OR, 5.2 (95% CI, 1.3-21.2); P=0.021] was significantly associated with the occurrence of pneumothorax. CONCLUSIONS: The incidence of pneumothorax following thoracentesis was very low in the present study. However, clinicians should be aware of the risk of pneumothorax in underweight patients during thoracentesis. Further prospective studies are required to clarify the results of the present study.

Efficient utilization of the limited number of emergency medicine specialists and statistics related to clinical outcomes in the emergency department.

OBJECTIVE: The supply of emergency medicine (EM) specialists has not been able to meet demand in the past decade. This study comparatively analyzed clinical findings to provide fundamental data to inform efficient utilization of a limited number of EM specialists. METHODS: This retrospective study included 54,204 patients who visited the emergency department of a tertiary care medical center from March 1 to December 31, 2012. The experimental specialist-supervised (SS) group included patients supervised by an EM specialist, while the control specialist-on-call (SOC) group included patients attended by a senior resident of EM with an EM specialist on call. RESULTS: The mean length of stay in the emergency department was longer in the SS group than in the SOC group for all levels of severe-to-moderate (levels 1 to 3) and mild (levels 4 and 5) patient conditions (P<0.05). The mortality rate of severe-to-moderate patients in the SOC group was 1.63 times higher than that in patient in the SS group. CONCLUSION: Supervision by EM specialists significantly decreased mortality in patients with severe-to-moderate condition. Therefore, EM specialists should focus on this patient group, while training residents should concentrate on patients with relatively mild conditions.

Long-term neurological outcomes in patients after out-of-hospital cardiac arrest.

AIM: The main treatment goal in survivors of out-of-hospital cardiac arrest (OHCA) is a favorable neurologic outcome. Little is known, however, about long-term trends of neurologic status in OHCA survivors. This study was designed to assess the rates of long-term neurologic recovery and survival according to neurologic status at one month. METHODS: This retrospective observational study assessed all adult OHCA survivors (≥18 years) admitted to a tertiary hospital in an urban area who achieved return of spontaneous circulation (ROSC) between July 2005 and August 2013. Neurologic outcomes were measured by Cerebral Performance Category (CPC) score and patients were categorized according to CPC score at 1 month. Their neurologic status was re-evaluated 6, 12, and 24 months after cardiac arrest. RESULTS: Of 778 OHCA cases, 282 patients (36.2%) were admitted to our hospital, and 279 were included in this study. At one month, 84 (30.1%) survivors were assessed with the CPC with 42.8% (n=36) having good neurologic outcome and 57.1% (n=48) poor neurologic outcome. Only two patients with poor neurologic outcome (4.1%) showed improved neurologic status from CPC 3 to CPC 2, during the first 6 months and none showed neurologic improvement after 6 months. The estimated 3-year survival was much higher for CPC 1 (96.4%) than for CPC 4 (24.2%) survivors. CONCLUSIONS: Neurologic recovery of OHCA survivors with poor neurologic outcomes at one month was rare and did not occur more than 6 months after cardiac arrest.