[Show abstract][Hide abstract] ABSTRACT: The Surviving Sepsis Campaign recommends initiating broad-spectrum antibiotic treatment within 1 hour of septic shock recognition. However, there is controversy regarding this owing to contradictory studies. This study investigated the relationship between the antibiotic administration interval and 28-day mortality in septic shock patients treated with an early quantitative resuscitation protocol in an emergency department (ED).
715 consecutive septic shock patients were prospectively collected from January 2010 to December 2012. Of these, 426 patients developed shock at or after initial assessment, and the time of initial antibiotic administration was recorded. The primary outcome was 28-day mortality.
The median antibiotic administration interval was 91.5 (47.0-158.0) minutes, and the 28-day mortality was 20.0%. Mortality did not change with hourly delays in antibiotic administration up to 5 hours after shock recognition: 1 hour (odds ratio [OR]: 0.81, 95% confidence interval [CI]: 0.45-1.45), 2 hours (OR: 0.72, 95% CI: 0.40-1.29) and 3 hours (OR: 0.61, 95% CI: 0.30-1.25). However, inability to achieve early resuscitation goals (OR: 1.94, 95% CI: 1.07-3.51), sequential organ failure assessment score (OR: 1.30, 95% CI: 1.17-1.44) and lactic acid concentration (OR: 1.66, 95% CI: 1.11-2.49) were significantly associated with an increased risk of 28-day mortality.
Among septic shock patients who underwent early quantitative resuscitation in an ED, mortality did not increase with hourly delays in antibiotic administration. These data call into question the strength of the association between hourly delays in antibiotic administration and mortality in septic shock patients.
The American Journal of the Medical Sciences 02/2015; 349(4). DOI:10.1097/MAJ.0000000000000423 · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
Journal of Korean Medical Science 11/2014; 29(11):1562-71. DOI:10.3346/jkms.2014.29.11.1562 · 1.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to assess whether delayed resuscitation bundle compliance from 6 to 12 h after a diagnosis of septic shock has an impact upon 28-day mortality. A prospective observational study on consecutive adult patients with septic shock was performed in the Emergency Department (ED) of a tertiary care university-affiliated hospital between January 2010 and July 2012. Compliance with the resuscitation bundle was assessed at 6 and 12 h after a septic shock diagnosis (time 0). Patients were divided into three groups: early compliance (≤6 h), delayed compliance (>6 but ≤12 h), and non-compliance (>12 h). The 28-day mortality was compared among the groups. A total of 332 patients were included, with an overall 28-day mortality of 17.2 %. The mean age was 63.9 years; 57.8 % were men. Early compliance was achieved in 195 patients (58.7 %), delayed compliance in 59 patients (19.8 %), and non-compliance in 78 patients (23.5 %). The groups did not differ in baseline sequential organ failure assessment illness severity. However, the non-compliance group had a significantly higher mortality (29.5 %) than the delayed-compliance (13.6 %) and early-compliance (13.3 %) groups (p = 0.04). Delayed compliance was associated with a lower mortality risk than non-compliance (adjusted odds ratio 0.32, 95 % confidence interval: 0.13-0.82, p = 0.02). In conclusion, if bundle therapy be started at the time of presentation, the outcome of delayed resuscitation bundle compliance within 12 h is same as that of early resuscitation bundle compliance within 6 h, and these are better than that of the patients who had late or no compliance.
Internal and Emergency Medicine 06/2014; 9(6). DOI:10.1007/s11739-014-1092-5 · 2.62 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report two cases of toxic methemoglobinemia caused by an inert ingredient in pesticide product after intentional ingestion of pesticide. First, 51-year-old male visited to the emergency department (ED) after the ingestion of pesticide in a suicide attempt. Initial methemoglobin (MetHb) level was 25.6%. We did not know the cause of methemoglobinemia at that time. Second, 56-year-old female visited to the ED after the ingestion of the same pesticide in a suicide attempt. MetHb level after 30 minutes was 16.1%. The patients were treated with methylene blue. We contacted to the Korean Rural Development Administration and estimated that magnesium nitrate was more likely to cause methemoglobinemia. This report highlights the importance of considering the possibility of methemoglobinemia caused by inert ingredient in pesticide and early antidotal therapy.
[Show abstract][Hide abstract] ABSTRACT: The aims of this study were to evaluate the clinical characteristics and outcomes of patients with grayanotoxin poisoning due to mad honey brought from Nepal. Medical records of patients with mad honey poisoning admitted to the emergency department between 1 January 2004 and 31 May 2012 were retrospectively reviewed. A total of 15 patients were included in this study. In all patients, mad honey was brought from the Himalayan region of Nepal. The mean age was 52.2 years, and 66.7 % were men. The mean amount of mad honey ingested was 47 cc, and the mean time from ingestion to onset of symptoms was 36 min. In all patients, initial vital signs showed hypotension and bradycardia. The initial electrocardiogram showed sinus bradycardia in eight patients, junctional bradycardia in four patients, complete atrioventricular block in two patients, and atrial fibrillation with slow ventricular response in one patient. Four patients were treated with intravenous normal saline solution only. Eleven patients were treated with intravenous normal saline solution and intravenous atropine sulfate in a dose ranging from 0.5 to 2.0 mg. In all patients, the blood pressure and pulse rate returned to normal limits within 24 h. There were no deaths. The clinical characteristics and outcome of grayanotoxin poisonings caused by the ingestion of mad honey from Nepal are similar with those of mad honey from the Black Sea region of Turkey.
Internal and Emergency Medicine 09/2013; 9(2). DOI:10.1007/s11739-013-0998-7 · 2.62 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to determine whether initial shock index (SI) was independently associated with the requirement of massive transfusion (MT) in emergency department (ED) patients with primary postpartum hemorrhage (PPH). A retrospective cohort study of ED patients with primary PPH was performed at university-affiliated, tertiary referral center between January, 2004 and May, 2012. Patients were classified to two groups: MT group (patients who received ≥ 10 units of packed red blood cells (pRBC) within 24 hours of ED admission) and non-MT group (patients who received < 10 units). Variables of the two groups were compared using univariate and multivariate analyses.A total of 126 patients was included in this study. Of these patients, 26 (20.6%) were included in MT group and 100 (79.4%) in non-MT group. Patients in MT group had significantly lower blood pressure (BP), and higher heart rate (HR) compared with patients in non-MT group (P < 0.01). Initial SI was significantly higher in MT group than in non-MT group (1.3 vs. 0.8, P < 0.01). In multivariate logistic regression analysis, initial SI and HR were the only variables associated with the requirement of MT, with an odds ratio of 9.47 (95% CI, 1.75-51.28; P < 0.01) and 1.06 (95% CI, 1.02-1.09; P < 0.01), respectivelyIn conclusion, initial SI was independently associated with the requirement of MT in ED patients with primary PPH. Routine calculation of initial SI can help clinicians to identify patients who may benefit from timely and appropriate use of MT to improve clinical outcomes.
[Show abstract][Hide abstract] ABSTRACT: 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.
We report a case of accidental poisoning after ingestion of the rhizome of Arisaema amurense, resulting in airway obstruction that required endotracheal intubation.
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.
We describe an emergent treatment course for a patient with acute airway obstruction resulting from the ingestion of Arisaema amurense.
Journal of Emergency Medicine 04/2013; 45(3). DOI:10.1016/j.jemermed.2013.01.029 · 0.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The duration of viral shedding is an important determinant of infectivity and transmissibility and provides vital information for effective infection prevention and control. However, few studies have evaluated viral shedding in patients admitted to hospital with 2009 H1N1 influenza and treated with oseltamivir. OBJECTIVE: To determine the incidence of prolonged 2009 H1N1 influenza viral shedding in patients treated for 5 days with oseltamivir and to identify factors that promote prolonged viral shedding. METHODS: This was a prospective, observational cohort study of 173 patients infected with 2009 H1N1 influenza (confirmed by RT-PCR) who were admitted to isolation rooms in the emergency department of our hospital between August 25, 2009 and December 31, 2009. All of the patients were treated according to institutional protocols and received routine follow-up RT-PCR testing after 5 days of oseltamivir therapy. Prolonged viral shedding was defined as a positive follow-up RT-PCR result. RESULT: Of the 173 patients in our cohort, 88 (50·8%) showed persistent viral shedding after oseltamivir treatment. Viral shedding was significantly prolonged if antiviral therapy was started ≥2 days after symptom onset (OR 2·74, 95% CI 1·29-5·82), if there were major comorbidities (OR 3·07, 95% CI 1·29-7·32), and/or if respiratory symptoms were still present on the day 5 of antiviral treatment (OR 4·13, 95% CI 2·10-8·11). CONCLUSIONS: The presence of major comorbidities, a delay in initiating antiviral treatment, and continuing respiratory symptoms after 5 days of antiviral treatment are associated with prolonged shedding of the 2009 H1N1 influenza virus.
Influenza and Other Respiratory Viruses 12/2012; 7(5). DOI:10.1111/irv.12065 · 2.20 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
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).
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.
During EGDT, intermittent ScvO2 monitoring was not inferior to continuous ScvO2 monitoring when delivered within the first 6 h of intervention.
Emergency Medicine Journal 11/2012; 30(11). DOI:10.1136/emermed-2012-201356 · 1.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
[Show abstract][Hide abstract] ABSTRACT: PURPOSE: Immediate identification of bacterial meningitis (BM) is essential in the emergency department. However, diagnosis of BM from analysis of cerebrospinal fluid has low sensitivity. The goal of this study was to determine the ability of serum procalcitonin (PCT) and C-reactive protein (CRP) for differentiation between BM and non-BM in adult patients. METHODS: This retrospective cohort study, which was conducted from Jan 1 2008 to Sep 30 2011, included patients with a diagnosis of meningitis based on compatible clinical features and cerebrospinal fluid (CSF) culture findings with a CSF leukocyte count > 5 /microL. Measurement of Serum PCT and CRP level was performed on initial admission to the emergency department. Patients were divided into two groups, according to the type of meningitis: BM or non-BM. Clinical features, laboratory results, including CSF results, serum PCT, and CRP levels were assessed. RESULTS: A total of 63 patients (age, 49+/-19) with confirmed meningitis were admitted: 43 patients with non-BM and 20 patients with BM. Significantly higher PCT and CRP levels, CSF white blood cell and neutrophil count, CSF glucose, and protein levels were observed in the BM group. The most highly discriminative parameters for differential diagnosis of BM proved to be serum PCT, with a sensitivity of 90%, a specificity of 100%, a positive predictive value of 100%, a negative predictive value of 96% at a diagnostic cut-off level of 1.0 ng/mL (area under the curve 0.98; 95% confidence interval 0.00-1.00) and CRP, with a sensitivity of 85%, a specificity of 88%, a positive predictive value of 77%, a negative predictive value of 93% at a diagnostic cut-off level of 6.0 mg/dL (area under the curve 0.91; 95% confidence interval 0.76-0.97). CONCLUSION: Serum PCT and CRP levels appear to be the most highly discriminative parameters for differential diagnosis of BM and non-BM.
[Show abstract][Hide abstract] ABSTRACT: PURPOSE: The aim of this study was to describe the epidemiologic characteristics of adult patients with carbon monoxide poisoning who presented to the emergency department in recent years. METHODS: This was a retrospective cohort study on adult consecutive patients with carbon monoxide (CO) poisoning who presented to the emergency department of a tertiary care university-affiliated hospital from January 1, 2008 to December 31, 2011. RESULTS: A total of 91 patients were included in this study; there were 56(61.5%) unintentional and 35(38.5%) intentional poisonings. For the unintentional CO poisonings, the principal sources of exposure to CO were fire (39.3%), charcoal (17.9%), briquette charcoal (7.1%), wood burning boiler (7.1%), gas boiler (5.4%), automobile heater (3.6%), briquette boiler (3.6%), firewood (3.6%), and other items (12.5%). For the intentional CO poisonings, the sources were ignition charcoal (60.0%), briquette (31.4%), charcoal (5.7%) and butane gas (2.9%). For the unintentional CO poisonings, the places of poisoning were the home (58.9%), workplace (10.7%), public accommodation (8.9%), tent (8.9%), automobile (3.6%) and parking place (1.8%). For the intentional CO poisonings, the places of poisoning were the home (77.1%), public accommodation (11.4%) and automobile (11.4%). The proportion of intentional CO poisonings among total poisonings has increased significantly in recent years; 0.0% in 2008, 3.3% in 2009, 5.5% in 2010, and 29.7% in 2011. CONCLUSION: This study showed that in recent years in Korea, the source of CO has diversified broadly and intentional CO poisonings from burning ignition charcoal or briquettes has increased. Prevention efforts should consider these factors.
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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].
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.
European Neurology 02/2011; 65(3):123-8. DOI:10.1159/000324154 · 1.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
[Show abstract][Hide abstract] ABSTRACT: Recently, hands only CPR (cardiopulmonary resuscitation) has been proposed as an alternative to standard CPR for bystanders. The present study was performed to identify the effect of basic life support (BLS) training on laypersons' willingness in performing standard CPR and hands only CPR.
The participants for this study were non-medical personnel who applied for BLS training program that took place in 7 university hospitals in and around Korea for 6 months. Before and after BLS training, all the participants were given questionnaires for bystander CPR, and 890 respondents were included in the final analyses.
Self-assessed confidence score for bystander CPR, using a visual analogue scale from 0 to 100, increased from 51.5+/-30.0 before BLS training to 87.0+/-13.7 after the training with statistical significance (p 0.001). Before the training, 19% of respondents reported willingness to perform standard CPR on a stranger, and 30.1% to perform hands only CPR. After the training, this increased to 56.7% of respondents reporting willingness to perform standard CPR, and 71.9%, hands only CPR, on strangers. Before and after BLS training, the odds ratio of willingness to perform hands only CPR versus standard CPR were 1.8 (95% CI 1.5-2.3) and 2.0 (95% CI 1.7-2.6) for a stranger, respectively. Most of the respondents, who reported they would decline to perform standard CPR, stated that fear of liability and fear of disease transmission were deciding factors after the BLS training.
The BLS training increases laypersons' confidence and willingness to perform bystander CPR on a stranger. However, laypersons are more willing to perform hands only CPR rather than to perform standard CPR on a stranger regardless of the BLS training.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The aim of the present study was to evaluate whether findings on initial chest computed tomography (CT) of influenza pneumonia can help predict clinical outcome. METHODS: We reviewed all adult patients admitted to the Emergency Department (ED) with a confirmed diagnosis of novel influenza A H1N1 virus (2009 H1N1) pneumonia, who underwent chest CT upon admission between Aug 26, 2009 and Jan 31, 2010. Radiologic findings were characterized by type and pattern of opacities and zonal distribution. Clinical outcome measures were intensive care unit (ICU) admission, mechanical ventilation, and inhospital death. RESULTS: Of 59 patients diagnosed with 2009 H1N1 pneumonia, 41 (69.5%) underwent chest CT on admission into ED. Nine (22%) of these patients developed adverse clinical outcomes requiring the following treatments: 9 (22.0%) ICU admissions, 5 (12.2%) mechanical ventilation, and 3 (7.3%) inhospital deaths. Counting the number of patients with more than 4 involved lobes, the sensitivity, specificity, positive predictive value, and negative predictive value for detection of adverse clinical outcome were 67%, 84%, 55% and 80%, respectively. CONCLUSION: Extensive involvement of both lungs (over 4 lobes) is related to ICU admission, mechanical ventilation, and inhospital death. Initial chest CT may help predict an adverse clinical outcome of patients with 2009 H1N1 influenza pneumonia.
Tuberculosis and Respiratory Diseases 01/2010; 69(2-2):103-107. DOI:10.4046/trd.2010.69.2.103