Jin Hui Paik

Value of plasma neutrophil gelatinase-associated lipocalin in predicting the mortality of patients with sepsis at the emergency department.

BACKGROUND Sepsis is a major cause of morbidity and mortality in the emergency department. This study aimed to evaluate the assessment of severity of sepsis by and prognostic value of plasma neutrophil gelatinase-associated lipocalin (NGAL) compared with other widely used biological markers of inflammation in patients with sepsis. METHODS NGAL, procalcitonin, and C-reactive protein values were measured in 470 patients with suspected sepsis, and the Mortality in Emergency Department Sepsis (MEDS) score was obtained for all enrolled subjects, who were followed for up to 28days. RESULTS The median plasma NGAL value was increased with sepsis severity according to the MEDS score. The plasma NGAL value was higher in nonsurvivors than in survivors. The area under the receiver operating characteristic curve of NGAL (0.797) was greater than that of procalcitonin (0.599) and MEDS score (0.774) in predicting 28-day hospital mortality. Multivariable logistic regression found that the plasma NGAL value was an independent predictor for hospital mortality in patients with sepsis. The plasma NGAL values were positively correlated with C-reactive protein and procalcitonin levels, and MEDS scores. CONCLUSIONS Plasma NGAL is a valuable biological marker in the assessment of severity and prediction of prognosis of patients with sepsis in the emergency department.

Complete cervical tracheal transection caused by blunt neck trauma: case report.

This study aimed to report the survival of a rare case of complete tracheal transection followed by blunt neck trauma. A 66-year-old man was presented in the emergency room after a motorcycle accident in which a rope was wrapped around his neck. Although alert, he was in respiratory distress. A computed tomographic scan showed transection of the cervical trachea. Emergency neck exploration revealed that the tracheal laceration had been cut from the tracheal anterior third ring to the posterior first ring and the anterior esophageal wall had ruptured. Laryngectomy, tracheostomy, and esophagopharyngeal anastomosis were performed. Prompt airway management and immediate neck exploration is important for survival in these cases.

Application of high-flow nasal cannula in the ED for patients with solid malignancy.

Age, y 71.6 ± 10.6 Male sex 4 (36.3%) Body mass index, kg/m 20.3 ± 5.4 Mode of arrival, ambulance 8 (72.7%) Triage, red 10 (90.9%) Location of primary cancer Lung 4 (36.3%) Gastrointestinal tract 4 (36.3%) Hepatobiliary tract 2 (18.1%) Disease status Active 8 (72.7%) No evidence of disease 3 (27.2%) Metastasis to lungs 5 (45.4%) Chemotherapy in the last 30 d 3 (27.2%) Comorbid conditions Diabetes mellitus 3 (27.2%) Heart diseases 2 (18.1%) Neurodegenerative diseases 2 (18.1%) Chronic lung diseases 1 (9.0%) APACHE II 23.3 ± 4.0 Reasons for acute respiratory failure Pneumonia 8 (72.7%) Cardiogenic 1 (9.0%) Nephrogenic 1 (9.0%) Other 1 (9.0%) Do-not-intubate order 4 (36.3%) Vital signs on presentation Systolic blood pressure, mm Hg 136.8 ± 39.9 Diastolic blood pressure, mm Hg 76.4 ± 20.1 Heart rate, beats/min 112.9 ± 27.7 Respiratory rate, breaths/min 32.1 ± 6.2 Body temperature, °C 36.7 ± 0.8 Saturation, % 79.1 ± 8.9 Bilateral pulmonary infiltrates on chest radiograph 9 (81.8%) Arterial blood gas on presentation pH 7.3 ± 0.1 PCO2, mm Hg 37.4 ± 13.0 PO2, mm Hg 48.1 ± 12.2 HCO3, mmol/L 19.4 ± 5.0 SpO2 76.3 ± 16.9 Neutropenia 1 (9.0%) CRP, mg/dL 12.3 ± 11.2 Use of vasopressor 2 (18.1%) Hopeless discharge 2 (18.1%) Death 4 (36.3%)

Prognostic Factors Predicting Poor Outcome in Cancer Patients with Febrile Neutropenia in the Emergency Department: Usefulness of qSOFA

Background/Aims Febrile neutropenia is considered as one of the most important and potentially life-threatening oncologic emergencies, which requires prompt medical assessment and treatment with antibiotics. This was a single-center retrospective study that investigated the prognostic factors predicting poor outcome in patients with cancer who presented with febrile neutropenia at the emergency department (ED). Methods The medical records of patients diagnosed with febrile neutropenia in the ED from January 2014 to December 2017 were reviewed. Patients aged >18 years who were diagnosed with a malignancy were included in the analysis. Febrile neutropenia was defined as an absolute neutrophil count < 1,000/mm3 with a temperature greater than 38°C. Patients were divided into two groups: those who were admitted at the intensive care unit (ICU) or those who died in the hospital (case group) and those who were admitted at general wards and were discharged (control group). The two groups were compared to determine the factors associated with poor prognosis. Results We identified 104 patients (25 and 79 from the case and control groups, respectively) with cancer who presented with febrile neutropenia at the ED during the study period. Lower blood pressure, platelet count, and HCO3− level, higher CRP and creatinine level, and the presence of bacteremia were more commonly observed in the case group than in the control group. In the multiple logistic regression analysis, the following independent predictors significantly correlated with ICU admission and in-hospital mortality: quick sequential (sepsis-related) organ failure assessment (qSOFA) score (odds ratio [OR]: 4.62; 95% confidence interval [CI]: 1.17–18.22; p=0.285), hemoglobin level (OR: 0.51; 95% CI: 0.33–0.78; p=0.002), total bilirubin level (OR: 7.69; 95% CI: 1.29–45.8; p=0.025), and respiratory tract infection (OR: 29.65; 95% CI: 3.81–230.7; p=0.0012). Conclusions The qSOFA can be a useful bedside tool for patients with cancer who present with febrile neutropenia at the ED. Moreover, it can help emergency physicians in identifying patients at risk of poor prognosis and in initiating prompt empirical antimicrobial therapy. Further studies must be conducted to validate the efficacy of the qSOFA in these patients in the ED.

Clinical Predictors of Pseudomonas aeruginosa Bacteremia in Emergency Department

Objectives Pseudomonas aeruginosa shows higher mortality rate compared to other bacterial infections and is susceptible to a limited number of antimicrobial agents. Considering inadequate empirical treatment of Pseudomonas bacteremia has been associated with increased mortality, it is important for emergency physicians to identify infections by P. aeruginosa. Methods This was a single-center retrospective case-control study to investigate the clinical predictors of patients diagnosed as Pseudomonas bacteremia in the emergency department (ED) from June 2012 to December 2016. Patients with blood culture positive for Escherichia coli in the same period were chosen as the control group, and type of infection was matched for each patient. Results A total of 54 cases with Pseudomonas bacteremia and 108 controls with E. coli bacteremia were included. In the case group, 76% was community-acquired infection, 44% received inappropriate empirical treatment in the ED, and in-hospital mortality was 30%. Multiple logistic regression showed that respiratory tract infection was an independent risk factor for Pseudomonas bacteremia (OR 6.56, 95% CI 1.78-23.06; p = 0.004), whereas underlying diabetes mellitus (OR 0.22, 95% CI 0.07-0.61; p = 0.004) and presentation as urinary tract infection (OR 0.06, 95% CI 0.02-0.18; p < 0.001) were negative clinical predictors. Conclusions We suggest that antipseudomonal antibiotics should be considered beyond simple coverage of Gram-negative bacteria in the ED, especially if the patient is likely to have pneumonia. Having diabetes or presenting with urinary tract infection could be clinical factors unfavorable to use of antipseudomonal antibiotics.

A case report of bittern intoxication.

Bittern is made from marine water after extraction of salt, and its major components include magnesium chloride, magnesium sulfate, potassium chloride, sodium chloride and magnesium bromide. For a long time, it has been used as the main ingredient of tofu coagulant and chemical weapons. A 73-year-old woman arrived to the emergency department after a suicide attempt by drinking an unknown amount bittern. She complained of dizziness, general weakness, and altered mental state (Glasgow Coma Scale (GCS) 13/15). The brain computed tomography (CT) and magnetic resonance imaging (MRI) showed no abnormality. But blood chemistry showed hypermagnesemia ([Mg2+] 7.8 mEq/L) and hypernatremia ([Na+] 149 mEq/L). Electrocardiograph showed QT prolongation of 0.482 s. Electrolyte imbalances were corrected following adequate fluid therapy and injection of calcium gluconate. The patient recovered/was subsequently discharged without any complications. Electrolyte imbalances are a common presentation following bittern poisoning. Severe side effects like respiratory depression, hypotension, arrhythmia, bradycardia, and cardiac arrest can also occur. Patients will require immediate fluid therapy and correction of electrolyte imbalances. The symptoms vary depending on the electrolyte levels. It is mandatory to closely monitor the electrolyte levels and electrocardiograph in these patients.

Cervical spinal cord injury without bone injuries in an alcohol-intoxicated patient with atlantoaxial osteoarthritis

Dear Editor, High-level cervical spinal cord injury (CSI) without bony injuries cannot be easily considered in the initial diagnoses for an acutely alcohol-intoxicated patient with an altered mental status. The authors encountered a relatively rare and diagnostically diffi cult case of CSI at the C1-C2 level without any bony injury, which was caused by atlantoaxial osteoarthritis in an obtunded, alcohol-intoxicated patient after minor blunt trauma.