Jae Chol Yoon

Modified early warning score with rapid lactate level in critically ill medical patients: the ViEWS-L score

Objectives To examine whether the predictive value of the early warning score (EWS) could be improved by including rapid lactate levels, and to compare the modified EWS with the pre-existing risk scoring systems. Design Retrospective observational study in South Korea. Setting An urban, academic, tertiary hospital. Participants Consecutive adult patients who were admitted to the medical intensive care unit via the emergency department (ED). Outcome measures A newly developed EWS—the VitalPAC EWS (ViEWS), was used in the present study. Lactate level, ViEWS and HOTEL score were obtained from patients at presentation to the ED, and APACHE II, SAPS II and SAPS III scores were obtained after admission. The area under curve of each risk scoring system for in-hospital, 1-week, 2-week and 4-week mortality was compared. Results 151 patients were enrolled and the mortality was 42.4%. The ViEWS-L score was calculated as follows: ViEWS-L score=ViEWS+lactate (mmol/l) according to the regression coefficient. The mean ViEWS-L score was 11.6±7.3. The ViEWS-L score had a better predictive value than the ViEWS score for hospital mortality (0.802 vs 0.742, p=0.009), 1-week mortality (0.842 vs 0.707, p<0.001), 2-week mortality (0.827 vs 0.729, p<0.001) and 4-week mortality (0.803 vs 0.732, p=0.003). The ViEWS-L score also had a better predictive value than the HOTEL and APACHE II scores. The predictive value of ViEWS-L was comparable with SAPS II and SAPS III. Conclusions The ViEWS-L score performed as well as or better than the pre-existing risk scoring systems in predicting mortality in critically ill medical patients who were admitted to the medical intensive care unit via the ED.

Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department.

Objectives Emergency tracheal intubation has achieved high success and low complication rates in the emergency department (ED). The objective of this study was to evaluate the incidence of post-intubation CA and determine the clinical factors associated with this complication. Methods A matched case-control study with a case to control ratio of 1∶3 was conducted at an urban tertiary care center between January 2007 and December 2011. Critically ill adult patients requiring emergency airway management in the ED were included. The primary endpoint was post-intubation CA, defined as CA within 10 minutes after tracheal intubation. Clinical variables were compared between patients with post-intubation CA and patients without CA who were individually matched based on age, sex, and pre-existing comorbidities. Results Of 2,403 patients who underwent emergency tracheal intubation, 41 patients (1.7%) had a post-intubation CA within 10 minutes of the procedure. The most common initial rhythm was pulseless electrical activity (78.1%). Patients experiencing CA had higher in-hospital mortality than patients without CA (61.0% vs. 30.1%; p<0.001). Systolic hypotension prior to intubation, defined as a systolic blood pressure ≤90 mmHg, was independently associated with post-intubation CA (OR, 3.67 [95% CI, 1.58–8.55], p = 0.01). Conclusion Early post-intubation CA occurred with an approximate 2% frequency in the ED. Systolic hypotension before intubation is associated with this complication, which has potentially significant implications for clinicians at the time of intubation.

Advanced radiology utilization in a tertiary care emergency department from 2001 to 2010.

Objective To evaluate the utilization trends of advanced radiology, i.e. computed tomography (CT) and magnetic resonance imaging (MRI), examination in an emergency department (ED) of an academic medical center from 2001 to 2010. Patients and Methods We assessed the overall CT and MRI utilization, and the ED patient encounters. Each examination was evaluated according to the patient’s age and anatomically relevant regions. Results During the study period, 737,760 patient visited the ED, and 156,287 CT and 35,018 MRI examinations were performed. The number of annual ED patients increased from 63,770 in 2001 to 94,609 in 2010 (P = 0.018). The rate of CT utilization increased from 105.5 per 1000 patient visits in 2001 to 289.2 in 2010 (P<0.001), and the rate of MRI utilization increased from 8.1 per 1000 patient visits in 2001 to 74.6 in 2010 (P<0.001). In all of the patient age groups, the overall CT and MRI utilization increased. The greater the patient age, the more likely the use of advanced radiology [CT: 87.1 per 1000 patients in age <20 vs. 293.9 per 1000 in age>60 (P<0.001); MRI: 5.1 per 1000 patients in age <20 vs. 108.7 per 1000 in age>60 (P<0.001)]. Abdomen-pelvis (40.2%) and the head (35.7%) comprised the majority of CT scans, while the head (86.4%) comprised the majority of MRI examinations. The rates of advanced radiology use increased across all anatomical regions, with the highest increase being in chest CT (5.9 per 1000 to 49.2) and head MRI (7.2 per 1000 to 61.9). Conclusion We report a three-fold and nine-fold increase in the use of CT and MRI, respectively, during the study period. Additional studies will be required to understand the causes of this change and to determine the effect of advanced radiology utilization on the patient outcome.

Optimal insertion depth of central venous catheters—Is a formula required? A prospective cohort study

INTRODUCTION To determine the optimal length for initial insertion of central venous catheters (CVCs) and to evaluate whether a recommended depth predicted optimal positioning of CVCs. MATERIALS AND METHODS All patients who were CVC-cannulated and who underwent chest computed tomography (CT) during a 10-month period were included. We measured the distance from catheter insertion to the superior vena cava/right atrium (SVC/RA) junction and calculated a recommended insertion depth. We compared the accuracy of the recommended depth with that suggested by the formula of Peres for predicting optimal positioning of a CVC. RESULTS Of the 1238 patients who were CVC-cannulated over 10 months, 106 underwent chest CT. Based on the mean distance from the CVC insertion point to the distal SVC, we determined that the recommended depth of insertion should be 14 cm for the right subclavian vein, 15 cm for the right internal jugular vein, 17 cm for the left subclavian vein and 18 cm for left internal jugular vein. Using these guidelines, initial placement of a CVC in the distal SVC was more accurate than when the Peres formula was used (91.5% vs. 77.4%, p<0.05). CONCLUSIONS For Asian populations, we found that these guidelines are more accurate than those derived from the Peres formulae and more simple to use, thus increasing the likelihood of optimal tip location within the SVC on the first attempt and eliminating the need for later repositioning.

Reversible Splenial Lesion Syndrome (RESLES) Following Glufosinate Ammonium Poisoning

Isolated and reversible lesion restricted to the splenium of the corpus callosum, known as reversible splenial lesion syndrome, have been reported in patients with infection, high‐altitude cerebral edema, seizures, antiepileptic drug withdrawal, or metabolic disturbances. Here, we report a 39‐year‐old female patient with glufosinate ammonium (GLA) poisoning who presented with confusion and amnesia. Diffusion‐weighted magnetic resonance imaging of the brain revealed cytotoxic edema of the splenium of the corpus callosum. The lesion was not present on follow‐up MR imaging performed 9 months later. We postulate that a GLA‐induced excitotoxic mechanism was the cause of this reversible splenial lesion.

What should we consider when applying termination of resuscitation rules

Historically, following full resuscitative efforts by emergency medical services (EMS), out-of-hospital cardiac arrest (OHCA) patients are transported to the hospital for continued resuscitation efforts at the emergency department. However, in patients in whom the chance of survival is deemed negligible, terminating resuscitation efforts in the field may be considered. In East Asia, EMS personnel are not legally permitted to terminate resuscitation, but field termination occurs in 40–60% and up to 40% of patients in Europe and the United States, respectively (1-4). The adoption of termination-of-resuscitation (TOR) rules may decrease the unnecessary consumption of valuable resources and number accidents during emergency transport (5).

Serial evaluation of SOFA and APACHE II scores to predict neurologic outcomes of out-of-hospital cardiac arrest survivors with targeted temperature management

Objective This study was aimed at a serial evaluation and comparison of the prognostic values of Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores for neurologic outcomes in comatose, out-of-hospital cardiac arrest (OHCA) survivors, treated with targeted temperature management (TTM). Methods We analysed a prospective cohort of comatose OHCA patients, with TTM, admitted to an emergency intensive care unit (ICU), between January 2010 and December 2015. SOFA and APACHE II scores were calculated initially, and then at day 1, 2, 3, 5, and 7 after ICU admission. Primary and secondary outcomes were the 28-day neurologic outcome and the 28-day mortality, respectively. Prognostic value of the SOFA and APACHE II scores was analysed using the receiver operating characteristic curve. Results Of the 143 selected patients, 62 survived and 34 had good neurologic outcomes at day 28. There was no significant difference in the SOFA and extracerebral SOFA scores between the good and poor neurologic outcome groups. However, the APACHE II scores were significantly higher in the good outcome group; they displayed good discriminatory power in predicting poor outcomes, unlike the SOFA scores. The APACHE II score at day 3 had the highest prognostic value for predicting poor neurologic outcomes with an area under the cure of 0.793, and with a cut-off value of 20, the APACHE II score predicted poor neurologic outcomes with a sensitivity of 43.75%, a specificity of 94.12%, a positive predictive value of 94.59%, and a negative predictive value of 41.56%. Conclusions Identifying APACHE II score might assist as one piece of multimodal prognostic approach for the assessment of neurologic outcomes in OHCA survivors treated with TTM.

Fitz-Hugh-Curtis syndrome in a male patient due to urinary tract infection

Fitz-Hugh-Curtis syndrome (FHCS) is inflammation of the liver capsule usually associated with pelvic inflammatory disease. FHCS has been rarely reported in male patients, and hematogenous and lymphatic spread to the liver is thought to be the underlying mechanism. Although a confirmatory diagnosis was made by laparoscopy, contrast-enhanced computed tomography scan is considered the first-line imaging tool in clinical diagnosis of FHCS. We report a case of FHCS that developed in a young male patient with a urinary tract infection.

ST elevation measurements differ in patients with inferior myocardial infarction and right ventricular infarction

PURPOSE Few studies specify the methods used to measure ST-segment elevation (STE). We therefore assessed differences in electrocardiography results depending on STE measurement methods for patients with inferior acute myocardial infarction (MI) and right ventricular infarction. METHODS This study was a retrospective analysis. The STE group consisted of 88 patients consecutively admitted to the emergency department with inferior ST elevation MI associated with occlusion of right coronary artery or left circumflex coronary artery who underwent primary percutaneous coronary intervention. The control group consisted of 109 patients with non-ST elevation MI who had occlusion of right coronary artery or left circumflex coronary artery and underwent percutaneous coronary intervention. Measurements were performed at the J point and 60 milliseconds later for limb lead and right precordial V(4) lead (V4R). The criterion of at least 1-mm STE in 2 consecutive leads was applied, and the diagnostic accuracy of V4R was calculated. RESULTS In the STE group, the measurements 60 milliseconds after the J point were significantly higher than measurements at the J point at the II, III, aVF, and V4R leads. In the control group, only the measurements at lead I differed significantly. There was a 5% difference in diagnostic sensitivity depending on the measuring points in the STE group, a 1% to 3% difference in the control group, and a 10% to 11% difference at the V4R lead. CONCLUSION In patients with inferior MI, STE depends on the method of measurement, indicating a need for the standardization of measurements.

Respiratory arrest caused by accidental rapid pralidoxime infusion

PAM infusion at a rate of 200 mg/min for 2 min resulted in cardiac arrest in a previous case. 4 Here, we report a case of respiratory arrest following accidental rapid infusion of high-dose PAM. A 41-year-old previously healthy man was brought to our emergency department (ED) 1.5 h after ingestion of approximately 250 ml of diethoxy organophosphate pesticide (34% diazinon emulsion). On arrival, he was alert and had no cholinergic symptoms. Gastric lavage and charcoal instillation were performed. Despite the absence of cholinergic symptoms, PAM therapy was started according to our institute ’ s policy that PAM infusion should be commenced and maintained at least 1 – 2 days in all OPP-poisoned patients due to the risk of delayed cholinergic manifestations and the general safety of PAM. Continuous infusion of PAM was started at a rate of 21 ml per hour using an infusion pump (12 g of PAM diluted with 500 ml of 5% dextrose) after a 2-g intravenous infusion of PAM diluted with 150 ml of 0.9% saline over 30 min as a loading dose. His vital signs were closely monitored. Laboratory results received after the incident showed that the initial serum pseudocholinesterase level was 688 U/L (reference range: 3,400 – 14,200 U/L) and returned to the normal range (3,767 U/L) on the second hospital day. He was stable until the third hospital day (approximately 36 h after admission) and was prepared for discharge. At this time, the ED nurse removed the infusion pump while the roller clamp of the intravenous tube was fully open. Consequently, approximately 150 – 200 ml of the remaining PAM solution (approximately 4 – 5 g of PAM) was rapidly infused over 10 – 20 min. He complained of blurred vision, rigidity of the extremities, and of being unable to open his eyes. Although the patient was not fully cooperative, neurologic examination showed lateral gaze palsy at this time. His blood pressure increased to 190/110 mmHg and tachycardia (116 bpm) was observed. Respiratory arrest and rigidity of whole extremities developed. He was intubated and received mechanical ventilation with sedation. The results of a portable electroencephalography were normal. One day after the beginning of ventilator support, he became alert and extubation was performed. The remainder of his course was uneventful, and on hospital day 5 he was discharged. In an animal study, high-dose PAM caused an anti-cholinesterase effect and induced fasciculation and neuromuscular block. 5,6