Je Sung You

The usefulness of CT for patients with carpal bone fractures in the emergency department.

Objective: The wrist is the most commonly injured joint in the body. However, wrist injuries are often missed in the emergency department (ED). If the fracture is not diagnosed and remains untreated, the patient runs a considerable risk of chronic disability. The utility of CT as an aid in the diagnosis of carpal bone fracture was investigated. Materials and methods: A retrospective analysis was performed of patients who underwent CT and plain radiography for wrist injury in the ED between March 2003 and February 2006. Plain radiograph interpretations were classified into three groups: (1) the definite fracture group, (2) the no fracture group, and (3) the ambiguous fracture group. The CT results were analysed in relation to the classification of the plain radiograph interpretation. The final diagnoses reviewed from the medical records were used as the reference standard. Results: 36 carpal fractures in 33 patients were identified from 45 patients who underwent plain radiography and CT. The interpretations of plain radiographs were classified into definite fractures (n = 10), ambiguous fractures (n = 15) and no fractures (n = 20). When both the definite fracture and ambiguous fracture groups were considered positive, the sensitivity and specificity were 69.7% and 83.3%, respectively. The sensitivity and specificity of CT scans were both 100%. Conclusion: Emergency physicians should consider CT of the wrist after plain radiography when patients with suspected carpal fracture show normal radiographic findings.

A higher chest compression rate may be necessary for metronome-guided cardiopulmonary resuscitation

OBJECTIVES Metronome guidance is a simple and economical feedback system for guiding cardiopulmonary resuscitation (CPR). However, a recent study showed that metronome guidance reduced the depth of chest compression. The results of previous studies suggest that a higher chest compression rate is associated with a better CPR outcome as compared with a lower chest compression rate, irrespective of metronome use. Based on this finding, we hypothesized that a lower chest compression rate promotes a reduction in chest compression depth in the recent study rather than metronome use itself. METHODS One minute of chest compression-only CPR was performed following the metronome sound played at 1 of 4 different rates: 80, 100, 120, and 140 ticks/min. Average compression depths (ACDs) and duty cycles were compared using repeated measures analysis of variance, and the values in the absence and presence of metronome guidance were compared. RESULTS Both the ACD and duty cycle increased when the metronome rate increased (P = .017, <.001). Average compression depths for the CPR procedures following the metronome rates of 80 and 100 ticks/min were significantly lower than those for the procedures without metronome guidance. CONCLUSIONS The ACD and duty cyle for chest compression increase as the metronome rate increases during metronome-guided CPR. A higher rate of chest compression is necessary for metronome-guided CPR to prevent suboptimal quality of chest compression.

Delta Neutrophil Index as a Promising Prognostic Marker in Out of Hospital Cardiac Arrest

Background The post-resuscitation phase after out-of-hospital cardiac arrest (OHCA) is characterised by a systemic inflammatory response (e.g., severe sepsis), for which the immature granulocyte count is a diagnostic marker. In this study we evaluated the prognostic significance of the delta neutrophil index (DNI), which is the difference in leukocyte subfractions as assessed by an automated blood cell analyser, for early mortality after OHCA. Materials and Methods OHCA records from the emergency department cardiac arrest registry were retrospectively analysed. Patients who survived at least 24 h after return of spontaneous circulation were included in the analysis. We evaluated mortality and cerebral performance category scores at 30 days. Results A total of 83 patients with OHCA were included in the study. Our results showed that DNI >8.4% on day 1 (hazard ratio [HR], 3.227; 95% CI, 1.485–6.967; p = 0.001) and DNI >10.5% on day 2 (HR, 3.292; 95% CI, 1.662–6.519; p<0.001) were associated with increased 30-day mortality in patients with OHCA. Additionally, DNI >8.4% on day 1 (HR, 2.718; 95% CI, 1.508–4.899; p<0.001) and DNI >10.5% on day 2 (HR, 1.709; 95% CI, 1.051–2.778; p = 0.02) were associated with worse neurologic outcomes 30 days after OHCA. Conclusion A higher DNI is a promising prognostic marker for 30-day mortality and neurologic outcomes after OHCA. Our findings indicate that patients with elevated DNI values after OHCA might be closely monitored so that appropriate treatment strategies can be implemented.

Predictive value of the Cincinnati Prehospital Stroke Scale for identifying thrombolytic candidates in acute ischemic stroke

BACKGROUND Despite the usefulness of the Cincinnati Prehospital Stroke Scale (CPSS) for rapid recognition of acute stroke, its ability to assess stroke severity is unclear. We investigated the usefulness of CPSS for assessment of stroke severity by comparing CPSS and National Institutes of Health Stroke Scale (NIHSS) scores in patients who were candidates for thrombolytic therapy at hospital admission within 6 hours of symptom onset. METHODS We conducted a retrospective analysis of a prospective registry database of consecutive patients included in the brain salvage through emergency stroke therapy program. In the emergency department, CPSS score was determined by emergency medical technicians. A CPSS cut-off score was estimated for candidates of thrombolytic therapy by comparing CPSS and NIHSS scores of patients who actually received thrombolytic therapy. Clinical outcomes were compared among patients with scores near the cut-off. Independent predictors of outcome were evaluated by multivariate logistic regression analysis. RESULTS Strong correlations were observed between CPSS and NIHSS scores within 3 hours (R = 0.778) and 6 hours (R = 0.769) of symptom onset. The optimal cut-off score was 2 for CPSS was associated with actual usage of intravenous tissue plasminogen activator (odds ratio [OR] 34.455; 95% confidence interval [CI] 7.924-149.817, P < .0001) and actual usage of thrombolytic therapy overall (intravenous tissue plasminogen activator or intra-arterial urokinase) (OR 36.310; 95% CI 10.826-121.782, P < .0001). CONCLUSION The CPSS is an effective prehospital stroke scale for the determination of stroke severity and identification of candidates for thrombolytic therapy.

Use of Bedside Sonography for Diagnosing Acute Epiglottitis in the Emergency Department A Preliminary Study

The purpose of this study was to investigate the ability of sonography to identify acute epiglottitis in the emergency department.

Newly designed delta neutrophil index–to–serum albumin ratio prognosis of early mortality in severe sepsis☆

PURPOSE We evaluated the ratio of delta neutrophil index (DNI) to albumin (A) in patients receiving early goal-directed therapy (EGDT) to determine the prognostic significance of the DNI/A ratio as a marker of early mortality in critically ill patients with suspected sepsis. METHODS We retrospectively analyzed records from a prospective EGDT registry in an emergency department (ED) and screened eligible adult patients who were admitted to the ED with severe sepsis and/or septic shock. The new DNI/A ratio was calculated as the DNI value on each hospital day divided by the initial albumin level on ED admission. The clinical outcome was mortality after 28 days. RESULTS A total of 120 patients receiving EGDT were included in this study. Multivariate Cox proportional-hazard models revealed that higher DNI/A ratios on day 1 (hazard ratio [HR], 1.068; 95% confidence interval [CI], 1.01-1.13; P = .0209) and the peak day (HR, 1.057; 95% CI, 1.001-1.116; P = .0456) were independent risk factors for mortality at 28 days. Our study demonstrated that the increased trend toward 28-day mortality was associated with a DNI/A ratio greater than 8.4 on day 1 (HR, 2.513; 95% CI, 0.950-6.64; P = .0528) and a higher DNI/A ratio (>6.4) on the peak day (average, 4.2 days; HR, 2.953; 95% CI, 1.033-8.441; P < .001) in patients with severe sepsis receiving EGDT. CONCLUSION The ratio of DNI to serum albumin on ED admission is a promising prognostic marker of 28-day mortality in patients with severe sepsis receiving EGDT.

Induction of a shorter compression phase is correlated with a deeper chest compression during metronome-guided cardiopulmonary resuscitation: a manikin study

Objectives Recent studies have shown that there may be an interaction between duty cycle and other factors related to the quality of chest compression. Duty cycle represents the fraction of compression phase. We aimed to investigate the effect of shorter compression phase on average chest compression depth during metronome-guided cardiopulmonary resuscitation. Methods Senior medical students performed 12 sets of chest compressions following the guiding sounds, with three down-stroke patterns (normal, fast and very fast) and four rates (80, 100, 120 and 140 compressions/min) in random sequence. Repeated-measures analysis of variance was used to compare the average chest compression depth and duty cycle among the trials. Results The average chest compression depth increased and the duty cycle decreased in a linear fashion as the down-stroke pattern shifted from normal to very fast (p<0.001 for both). Linear increase of average chest compression depth following the increase of the rate of chest compression was observed only with normal down-stroke pattern (p=0.004). Conclusions Induction of a shorter compression phase is correlated with a deeper chest compression during metronome-guided cardiopulmonary resuscitation.

The usefulness of rapid point-of-care creatinine testing for the prevention of contrast-induced nephropathy in the emergency department.

Background Renal dysfunction is the most important factor to consider when predicting a patients risk of developing contrast-induced nephropathy (CIN). Measurement of creatinine (Cr) via rapid point-of-care blood urea nitrogen/creatinine testing (POCT-BUN/Cr) to determine CIN risk could potentially reduce the time required to achieve an accurate diagnosis and to initiate and complete treatment in the emergency department (ED). The aim of our study was to compare the results of POCT-BUN/Cr and reference laboratory tests for BUN and serum Cr. Materials and methods A retrospective analysis of suspected stroke patients who presented between November 2009 and November 2010, and had BUN and Cr levels measured by POCT-BUN/Cr, and the reference laboratory tests performed with the blood sample which was transferred to the central laboratory by an air-shoot system. Two assays were conducted on the whole blood (POCT) and serum (reference) by trained technicians. The time interval from arrival at the ED to reporting of the results was assessed for both assays via a computerised physician order entry system. Results The mean standard deviation (SD) interval from arrival at the ED to reporting of the results was 11.4 (4.9) min for POCT-BUN/Cr and 46.8 (38.5) min for the serum reference laboratory tests (p<0.001). Intra-class correlation coefficient (ICC) analysis demonstrated a high level of agreement (the consistency agreement) between POCT and the serum reference tests for both BUN (ICC=0.914) and Cr (ICC=0.980). Conclusions This study suggests that POCT-BUN/Cr results correlate well with those of serum reference tests in terms of BUN and Cr levels and, in turn, predicting CIN. POCT-BUN/Cr is easily performed with a rapid turnaround time, suggesting its use in the ED may have substantial clinical benefit.

Clinical Features of Fitz-Hugh-Curtis Syndrome in the Emergency Department

Purpose Fitz-Hugh-Curtis Syndrome (FHCS) is a clinical entity characterized by inflammation of the liver capsule associated with genital tract infection. The aim of this study is to provide physicians with clinical suggestions for diagnostic approaches based on a series of patients who were diagnosed with FHCS. Materials and Methods We conducted a retrospective study of patients who were diagnosed with FHCS after presenting to the emergency department (ED). The symptoms, physical examinations, laboratory findings, radiological findings, and progress of the patients were reviewed. Results During the four-year study period, a total of 82 female patients received a final diagnosis of FHCS in the ED. Chlamydia trachomatis was identified as a pathogen in 89% of the patients. Their clinical characteristics and laboratory findings were described. Fifty-two patients (63.4%) were admitted to the hospital. All of the admitted patients improved after treatment combining antibiotic therapy with conservative care. Conclusion FHCS should be considered as a differential diagnosis for female patients of childbearing age with right upper abdominal pain. Timely diagnosis using biphasic computed tomography (CT) with arterial and portal phases may help ensure adequate medical treatment as well as avoid invasive procedures.

Quality of chest compressions performed by inexperienced rescuers in simulated cardiac arrest associated with pregnancy

OBJECTIVE We aimed to compare the quality of chest compressions performed by inexperienced rescuers in different positions, notably supine and at a 30° inclined lateral position, to ascertain whether high-quality chest compression is feasible on a pregnant subject in cardiac arrest. SUBJECTS AND METHODS We performed a prospective, randomised crossover design study. Each participant performed 2-min chest compressions in two different positions on a mannequin: a supine position and a 30° left inclined lateral position. After 2 min of chest compression in one position, the participant took a rest for 10 min to minimise rescuer fatigue and then performed chest compression in the second position. Data on chest compression rate, mean chest compression depth, correct compression depth rate, correct recoil rate, and correct hand position rate were collected. To measure the angle between the rescuers arm and the victims chest surface, chest compressions were recorded with a video recorder. After each practice session, participants were asked to report the subjective difficulty of performing chest compressions using a visual analogue scale. RESULTS All 32 participants successfully completed the study. The mean compression rate and depth were 121.0 per minute and 53.3 mm in the supine position and 118.8 per minute and 52.0 mm in the inclined lateral position, respectively (p=0.978 and p=0.260, respectively). Also, there were no differences in the correct compression depth rate, the correct hand position rate, or the correct recoil rate (p=0.426, p=0.467, and p=0.260, respectively). However, the lowest and highest angles and the subjective difficulty of chest compression differed significantly (p<0.001, p<0.001, and p=0.007, respectively). CONCLUSIONS Inexperienced rescuers appear to be capable of performing high-quality chest compressions in a 30° inclined lateral position on pregnant women in a simulated cardiac arrest state.