Hyuksool Kwon

Effectiveness of education in point-of-care ultrasound-assisted physical examinations in an emergency department: A before-and-after study

Abstract Implementation of point-of-care ultrasonography (POCUS)-assisted physical examination (PE) in emergency departments (EDs) was conducted in the ED of an urban tertiary teaching hospital. This study examines the effect of POCUS implementation in emergency medicine departments by using a systematic education program on image acquisition to analyze decision making. Educating staff on POCUS involved a technique related to image acquisition and then accurately diagnosing subsequent POCUS results. The quasi-experimental, uncontrolled before-and-after study was performed to evaluate the education effect. POCUS orders for eligible patients, length of stay (LOS) in ED, and return visits (RVs) to ED between the “before” period (March 1, 2015 to February 28, 2016) and the “after” period (March 1, 2016 to February 28, 2017) were compared. Piecewise regression was used to assess trend differences of LOS and RVs between the periods. A total of 16,942 and 16,287 patients were included in the before and after periods of education, respectively. During the study periods, 966 (6%) and 2801 (18%) POCUS were ordered, respectively (rate difference  =  12%; P < .001). Before the education, the median LOS was 6.55 (interquartile rage [IQR]: 6.2–6.75) and the trend slope of LOS was −0.01. After the education, the median LOS was 5.25 (IQR: 4.85–5.45) and the trend slope (the change of which was considered significant, at a P value of .012) was −0.15. Before the education, the median RV rate was 6.4% (IQR: 6.15–6.65) and the trend slope of RVs was −0.01. After the education, the median RVs was 5.25% (IQR: 4.95–5.35) and the trend slope of RVs was also significant, at −0.11. The education of POCUS-PE in ED successfully increased use of POCUS, and reduced the LOS and RV rate in ED.

Effectiveness of a radiation reduction campaign targeting children with gastrointestinal symptoms in a pediatric emergency department.

Abstract Children feature more active cellular division and a smaller body area, which leads to a greater radiation dosage accumulation. We tried to reduce radiation hazards by reducing unnecessary radiological studies in a pediatric emergency department (PED) through the radiation reduction campaign. Our campaign involved a reduction from 2 (erect and supine) to 1 ordered abdominal plain radiograph (erect). This quasi-experimental, uncontrolled before-and-after study aimed to evaluate the campaign effect. We compared simple radiograph orders, length of stay (LOS) in PED, and return visit (RV) to PED between the before period (June 1, 2011–May 30, 2014) and the after period (June 1, 2014–May 30, 2015). Piecewise regression was used to assess rate differences between the periods. A total of 10,729 and 3515 patients were included before and after the campaign, respectively. During study periods, 9647 (90%) and 2710 (77%) total abdominal radiographs were ordered, respectively (rate difference = 13%; P < 0.001), and the slopes of rate changes were 0.03 and −0.71, respectively (P = 0.056). The total abdominal erect and supine film rate slope decreased from −0.19 to −2.86 (P = 0.004). The RV rate did not change (220 [2%] vs 56 [2%], respectively; P = 0.104). The slope of total RV rate changed from −0.01 to −0.05 (P = 0.132), and the slope of LOS changed from 0.001 to −0.352 (P = 0.243). The campaign to reduce abdominal radiograph orders in pediatric patients successfully reduced the abdominal plain film X-ray rate without on the RV rate and the LOS.

The effectiveness of a newly developed reduction method of anterior shoulder dislocations; Sool's method ☆ ☆☆ ☆☆☆ ★ ★★

OBJECTIVE Nearly a dozen reduction methods for the treatment of anterior shoulder dislocation have been reported, but the majority are painful and require patients to be in the supine or prone position. METHODS This retrospective cohort study was conducted in a university-affiliated emergency department (ED). Sools method and traditional shoulder reduction methods (TSRMs) were performed for the patient with anterior shoulder dislocation. Fifty-nine eligible patients were recruited; 35 were treated with TSRMs, wherease 24 were treated with Sools method. RESULTS The rate of successful reduction was 80% (26/35) in the TSRM group and 75% (18/24) in the Sools method group (P=.75). The length of stay in the ED was 72.3minutes in the Sools method group and 98.4minutes in the TSRM group (P=.037). No significant difference was observed between the neurovascular deficit before and after reduction in either group. The procedural time of successfully reduced cases in patients treated by Sools method was shorter than that of the failed cases (P=.015). CONCLUSIONS Sools method was as successful as other methods at reducing shoulder dislocation and has demonstrated encouraging results, including significant reduction in length of stay in the ED and unnecessary use of sedation. Sools method is technically easy and requires only a place to sit and a single operator.

Where is the left ventricle during cardiopulmonary resuscitation based on chest computed tomography in the expiration with arms down position

Objective Patients usually receive cardiopulmonary resuscitation during ventilatory expiration and with their arms down, which does not reflect the normal imaging position. This study used scout images from low-dose chest computed tomography to compare the locations of the left ventricle (LV) in the expiration with arms down position (EAD) and in the full inspirational with arms raised position (IAR). Methods This cross-sectional study used a convenience sample and evaluated scout images that were obtained during screening with the participants in the EAD and IAR positions. The effective compression point was defined as being on the sternum above the longest anteroposterior diameter (APD) of the LV (using axial computed tomography images). The sternum was divided into three parts and the heart’s position was evaluated on the EAD and the IAR images, and the distance from the xiphoid process to the LV’s sternum landmark (XLVD) was measured. We also examined the compressible organs during CPR based on the EAD and IAR images. Results We enrolled 127 participants. The LVs were located in the middle of the sternum at EAD for 117 participants (92%) and in the lower half of the sternum at IAR for 107 participants (84%). The mean XLVD was significantly different between the EAD and IAR positions (mean: 85 ± 21 mm vs. 33 ± 17 mm, respectively). The liver’s left lobe was located in the lower half of the sternum at EAD for 118 participants (93%). Conclusions These findings indicate that the location of the LV during cardiopulmonary resuscitation might be in the middle of the sternum if the patient is treated in the EAD position.

N-terminal pro-brain natriuretic peptide and prediction of coronary artery dilatation in hyperacute phase of Kawasaki disease

Background Coronary artery dilatation (CAD) is a great concern with Kawasaki disease (KD). This study aimed to investigate the relationship between serum N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) levels and CAD in patients with the hyperacute phase (≤4 days of fever) of KD. Methods Serum NT‐proBNP levels were compared between patients with and those without CAD, who underwent transthoracic echocardiography (TTE) within 24 h of the hyperacute phase of KD in the pediatric emergency department (PED). Electronic medical records of patients aged 1 month to 15 years who visited the PED were retrospectively assessed from January 2010 to December 31, 2014. Results One hundred nine patients were enrolled in the study. Twenty‐three of those patients had CAD within 24 h of TTE. Median serum NT‐proBNP levels were significantly higher in patients with CAD (824.1 pg/ml; interquartile range [IQR], 515.4–1570.0184.8–767.8 pg/ml) than in patients without CAD (396.4 pg/ml; IQR, 184.8–767.8 pg/ml) (p ≤ 0.001). The cutoff value of serum NT‐proBNP, which predicted CAD during the hyperacute phase of KD, was 515.4 pg/ml, which yielded sensitivity of 78.26% and specificity of 61.63%. The area under the curve for NT‐proBNP for predicting CAD during hyperacute KD was 0.749 (95% CI, 0.642–0.856). Conclusion Serum NT‐proBNP might be an additional laboratory marker for detecting early CAD during the hyperacute phase of KD in the PED.

A Practice Guideline for Postreduction Management of Intussusception of Children in the Emergency Department.

Objectives The aim of this study was to evaluate the effects of a practice guideline of postreduction management of intussusception in children on the length of stay (LOS) from reduction in the pediatric emergency department (PED) and on the incidence of recurrence. Methods We developed a practice guideline of postreduction management of intussusception in the PED. The practice guideline involved feeding 2 hours after reduction and discharge 2 hours after successful feeding. The guideline was implemented on October 1, 2012. Retrospective quasi-experimental study was conducted for evaluation of the difference in LOS in the PED after reduction of intussusceptions, and the recurrence rate of intussusceptions between the preimplementation and postimplementation periods. Piecewise regression was performed to determine the differences between groups. Results In total, 45 and 52 patients were included in the preimplementation and postimplementation periods, respectively. The median LOS in the postimplementation period was significantly shorter than that in the preimplementation period (289 vs 532 minutes, respectively; P = 0.001). The slope of the LOS changed from 0.68 to −0.29. The slope decreased by 0.97 after practice guideline implementation. This difference was not statistically significant (P = 0.123), but it changed from a positive to negative gradient. The recurrence rate was not significantly different between the 2 periods (P = 0.605). Conclusions Implementation of a practice guideline involving early feeding and discharge after reduction of intussusception resulted in a reduced LOS from reduction of intussusception in the PED and was not associated with recurrence of intussusception.

Effectiveness of finger-marker for maintaining the correct compression point during paediatric resuscitation: A simulation study

Objective: High‐quality cardiopulmonary resuscitation is a significant factor for increasing the survival rate of paediatric patients. This study is to investigate the effectiveness of finger‐marker stickers for maintaining the correct compression point during simulated infant cardiopulmonary resuscitation (CPR). Methods: This crossover simulation study was conducted with 40 emergency physicians and paramedics at emergency departments of 2 tertiary hospitals. We used a remodeled infant CPR manikin developed to measure CPR quality indicators. After random coupling of participants (20 pairs), the pre‐group (10 pairs) performed conventional 2‐rescuer infant manikin CPR, then performed sticker‐applied CPR after 1 month. The post‐group (10 pairs) performed the process in the opposite order. The participants placed finger‐marker stickers to indicate the appropriate compression point before starting CPR. We compared accurate finger placement rates and other CPR quality indicators (compression depth, rate, complete chest recoil, and hands‐off time) with and without the finger‐marker sticker. Results: All finger‐marker stickers were correctly attached within 5 s (4.88 ± 1.28 s) of approaching the model. There were significant differences in the rate of correct finger compression position between conventional and sticker‐applied CPR (25.4% [IQRs 7.6–69.8] vs. 88.2% [IQRs 69.6–95.5], P < 0.001). Results did not differ according to sex, career, and job of the participants. There were no significant differences in mean compression rate, depth, hands‐off times, and rate of fully recoiled compression between the 2 groups. Conclusion: Finger‐marker stickers can be used to maintain correct finger positioning during 2‐rescuer infant manikin CPR.

Validation of the mid-arm-based weight estimation formula (the Cattermole formula) for Korean children

BACKGROUND A mid-arm circumference-based weight estimation formula has recently been proposed. The Cattermole formula, which is suggested for children aged 1-11 years, is calculated as (mid-arm circumference in cm - 10) × 3 kg. The objective of this study was to externally validate the Cattermole formula using a Korean national survey database. METHODS The data collected from a national survey conducted in 2005 by the Korean Pediatric Society included body weight, height, age and mid-arm circumference. To determine whether the Cattermole formula accurately predicted the actual weights of Korean children, we compared the performance of the Cattermole formula with those of other age-based and height-based weight estimation methods. RESULTS A total of 91,147 children aged 1-11 years were assessed for eligibility. The mean age was 5.3 years, and 52.6% of the children were boys. The mean measured weight was 22.4 kg, and the mean mid-arm circumference was 17.9 cm. The Cattermole formula resulted in a mean difference of 1.35 kg and a mean percentage error of 11.5% with 95% limits of agreement of -8.1 to +10.8. A total of 37.9% of the estimates were within 10% of the measured weights. CONCLUSION Across all ages, the Cattermole formula was not more accurate than the other methods. However, in children older than 6 years, the Cattermole formula results were more accurate than those of the age-based formulae with the exception of the Broselow tape. CLINICAL TRIAL REGISTRATION None.

Early detection of cerebral infarction with middle cerebral artery occlusion with functional near-infrared spectroscopy: a pilot study

Background: NIRSIT, a functional near-infrared spectroscopy (fNIRS) device with 204 channels, can measure oxyhemoglobin (HbO2) and deoxyhemoglobin (HbR) in non-pulsatile blood flow non-invasively using the absorption difference between HbO2 and HbR at a wavelength of 700–1,000 nm and can display the perfusion status in real time. Objective: We applied NIRSIT to patients with stroke to evaluate the usefulness of NIRSIT as an fNIRS device for the early detection of stroke. Methods: We performed a prospective pilot study in an emergency department (ED). Adult patients who had suspected symptoms and signs of stroke within 12 h of the first abnormal time and who underwent intravenous thrombolysis (IVT) or intra-arterial thrombectomy with acute middle cerebral artery (MCA) or internal carotid artery (ICA) infarction were enrolled. NIRSIT was applied to the patients before the imaging study, and the perfusion status of the brain was displayed in real time at the bedside. We compared the NIRSIT results with the mean transit time (MTT) map from perfusion computed tomography (PCT) and the time-to-peak (TTP) map from perfusion-weighted magnetic resonance imaging (PWI). Results: Six male and three female patients were enrolled, and the median age was 74 years. The most common symptom was unilateral extremity weakness (77.8%), followed by dysarthria (33.3%) and aphasia (11.1%). The median National Institutes of Health Stroke Scale (NIHSS) score was 17. All cases of MCA infarction showed different cerebral oxygen saturation values between bilateral lobes of the brain in fNIRS imaging, and these values matched the PCT and PWI results. Conclusions: The brain hemisphere with low oxygen saturation on fNIRS showed hypoperfusion on PCT or PWI. The fNIRS device could be useful in assessing the perfusion status of the brain and detecting MCA or ICA infarction in real time at the bedside.

New decision formulas for predicting endotracheal tube depth in children: analysis of neck CT images

Introduction The purpose of this study was to construct a prediction model for endotracheal tube depth using neck CT images. Methods A retrospective image review was conducted that included patients who had undergone neck CT. Using sagittal neck CT images, we calculated the length between upper incisor and mid-trachea and then derived the model via regression analysis. The model was validated externally using chest radiographs of patients who had undergone endotracheal intubation. We compared performance of our model with that of other methods (Broselow tape and APLS formula) via Bland-Altman analysis and the percentage of estimations within 10% of the measured values. Results A total of 1111 children were included in this study. The tube depth obtained from CT images was linearly related to body weight (tube depth (cm)=5.5+0.5×body wt (kg)) in children younger than 1 year and to height (tube depth (cm)=3+0.1×height (cm)) in children older than 1 year. External validation demonstrated that our new model showed better agreement with the desired tube depth than Broselow tape and APLS formula. The mean differences in children younger than 1 year were 0.61 cm and −1.24 cm for our formula and Broselow tape, respectively. The mean differences in children older than 1 year were −0.43 cm, −1.98 and −1.64 cm for our formula, Broselow tape and APLS formula, respectively. The percentages of estimates within 10% of the measured values were 52.7% and 35.8% for our formula and Broselow tape in children younger than 1 year, respectively, and 54.3%, 33.8% and 37.2% for our formula, Broselow tape and APLS formula in children older than 1 year, respectively (P<0.01). Conclusion Our new formula is useful and more accurate than the currently available methods.