Jungeun Kim

Clinical experiences with spontaneous intracranial hypotension: A proposal of a diagnostic approach and treatment

OBJECTIVEnWe analyzed our clinical experience with patients with intracranial hypotension and developed a strategic model for the diagnosis mainly using Radioisotope (RI) cisternography and treatment of spontaneous intracranial hypotension (SIH).nnnMETHODS AND MATERIALSnWe retrospectively analyzed our clinical experiences with 30 cases of SIH from January 2000 through December 2006. All patients had confirmed by magnetic resonance image (MRI). RI cisternography or computed-tomography (CT) myelography was done for disclosing a cerebrospinal fluid leakage point. Initially patients were treated with medication. When patients complained of persistent headache, we performed epidural blood patch (EBP) administration. We performed subdural hematoma evacuation when it grew or worsened neurological status.nnnRESULTSnTwenty-one women (70%) and 9 men (30%) were enrolled. The mean age was 40 years (range: 30-58 years). After initial diagnosis with MRI, RI cisternography and CT myelography were helpful in pinpointing the exact leakage site. Four patients were treated only with the medication and 24 patients were treated with the epidural blood patch (EBP). Half of them achieved dramatic relief of symptoms after the initial EBP. A blind EBP was performed in 15 patients. Six patients experienced recurrence of symptoms. Hematoma evacuation was performed in 8 patients. None of diagnostic tools or treatment methods showed distinct superiority in predicting a favorable clinical outcome.nnnCONCLUSIONnClinicians should be systematic in their approach to plan a treatment regimen for patients with SIH. We suggest the use of a flow diagram when determining how to best approach and treat patients with SIH.

Ambient air pollution and out-of-hospital cardiac arrest

BACKGROUNDnSudden cardiac arrest is a leading cause of cardiovascular death. This study aimed at investigating the impact of short-term exposure to air pollutants on the incidence of OHCA.nnnMETHODSnWe identified OHCA cases that occurred in Seoul between 2006 and 2013 from the nationwide emergency medical service database. The association of the daily incidence of OHCA with air pollutants including PM2.5 (particles ≤ 2.5 μm in aerodynamic diameter), PM10, CO, O3, NO2, and SO2 was analyzed with the use of time-series and case-crossover analyses.nnnRESULTSnA total of 21,509 OHCAs of presumed cardiac origin were identified. An elevation in PM2.5 by 10 μg/m(3) at a moving average of lag 1 and 2 days was shown to increase the risk of OHCA by 1.30% (95% confidence intervals, 0.20-2.41%). An exposure-response relationship was present: the risk of OHCA increased significantly with even a mild elevation of PM2.5 (10-15 μg/m(3)) and further increased with higher levels. While PM10, NO2, CO, and SO2 also showed significant associations with OHCA in single-pollutant models, only PM2.5 remained significant after adjustment for other pollutants. Subgroup analyses showed male sex, advanced age, hypertension, diabetes, heart disease, and history of stroke were risk factors for OHCA in response to elevations in PM2.5.nnnCONCLUSIONSnThis study showed that increased ambient levels of PM2.5 were significantly associated with increased risk of OHCA within 1 to 2 days of exposure, which had a dose-response relationship. Subjects with conventional cardiovascular risk factors were more susceptible to harm of PM2.5.

Heat, heat waves, and out-of-hospital cardiac arrest

OBJECTIVEnCardiac arrest is one of the common presentations of cardiovascular disorders and a leading cause of death. There are limited data on the relationship between out-of-hospital cardiac arrest (OHCA) and ambient temperatures, specifically extreme heat. This study investigated how heat and heat waves affect the occurrence of OHCA.nnnMETHODSnSeven major cities in Korea with more than 1 million residents were included in this study. A heat wave was defined as a daily mean temperature above the 98th percentile of the yearly distribution for at least two consecutive days.nnnRESULTSnA total of 50,318 OHCAs of presumed cardiac origin were identified from the nationwide emergency medical service database between 2006 and 2013. Ambient temperature and OHCA had a J-shaped relationship with a trough at 28°C. Heat waves were shown to be associated with a 14-% increase in the risk of OHCA. Adverse effects were apparent from the beginning of each heat wave period and slightly increased during its continuation. Excess OHCA events during heat waves occurred between 3PM and 5PM. Subgroup analysis showed that those 65years or older were significantly more susceptible to heat waves.nnnCONCLUSIONSnAmbient temperature and OHCA had a J-shaped relationship. The risk of OHCA was significantly increased with heat waves. Excess OHCA events primarily occurred during the afternoon when the temperature was high. We found that the elderly were more susceptible to the deleterious effects of heat waves.

Epidemiology of emergency medical services-assessed mass casualty incidents according to causes

To effectively mitigate and reduce the burden of mass casualty incidents (MCIs), preparedness measures should be based on MCIs’ epidemiological characteristics. This study aimed to describe the epidemiological characteristics and outcomes of emergency medical services (EMS)-assessed MCIs from multiple areas according to cause. Therefore, we extracted the records of all MCIs that involved ≥ 6 patients from an EMS database. All patients involved in EMS-assessed MCIs from six areas were eligible for this study, and their prehospital and hospital records were reviewed for a 1-year period. The EMS-assessed MCIs were categorized as being caused by fire accidents (FAs), road traffic accidents (RTAs), chemical and biological agents (CBs), and other mechanical causes (MECHs). A total of 362 EMS-assessed MCIs were identified, with a crude incidence rate of 0.6–5.0/100,000 population. Among these MCIs, 322 were caused by RTAs. The MCIs involved 2,578 patients, and 54.3% of these patients were women. We observed that the most common mechanism of injury varied according to MCI cause, and that a higher number of patients per incident was associated with a longer prehospital time. The highest hospital admission rate was observed for CBs (16 patients, 55.2%), and most patients in RTAs and MECHs experienced non-severe injuries. The total number of deaths was 32 (1.2%). An EMS-assessed MCI database was established using the EMS database and medical records review. Our findings indicate that RTA MCIs create a burden on EMS and emergency department resources, although CB MCIs create a burden on hospitals’ resources.

Age effects on case fatality rates of injury patients by mechanism

BACKGROUNDnCase fatality from injury increases exponentially with age. The objective of this study is to identify age effects on case fatality of injury patients by injury mechanism.nnnMETHODSnThis is an observational study using the Emergency Department-based Injury In-depth Surveillance data from 2007 to 2012. Eligibility was all injured patients, excluding those with unknown information for age, disposition after emergency department or admission, or injury mechanism. End point of this study was inhospital mortality. Injury mechanism was categorized into road transport injury (RTI), fall, collision, cut/pierce, burn, poisoning, and miscellaneous. Case fatality ratio was calculated to evaluate age effects on case fatality by injury mechanism and gender.nnnRESULTnAmong 927011 injury patients, a total of 924755 patients were analyzed. Total case fatality rate was 0.9%, and rates by injury mechanisms were 4.4% in poisoning, 2.1% in RTI, and 0.8% in fall. By age and gender, the highest crude case fatality rate was 19.74% observed in older than 80-year-old men with poisoning. Case fatality ratios in both genders increased by age from 60- to 69-, 70- to 79-, to older than 80-year-old patients; ratios by injury mechanisms were 13.71, 20.76, and 22.29 (male) and 7.21, 11.18, and 13.05 (female) in poisoning; 5.46, 9.30, and 14.13 (male) and 3.90, 7.96, and 12.08 (female) in RTI; 1.22, 1.52, and 2.02 (male) and 1.14, 2.15, and 6.42 (female) in burn.nnnCONCLUSIONSnCase fatality rates of injury increased with age; however, the trends in increase differed by injury mechanisms and gender. Strategies for injury prevention and decreasing mortality should consider the age effects on case fatality of different injury mechanisms.

Does Prehospital Time Influence Clinical Outcomes in Severe Trauma Patients?: A Cross Sectional Study

Abstract Objective: Prehospital time potentially impacts clinical outcomes in severely injured trauma patients. The importance of individual components, including scene and response time, however, is controversial. Our objective was to determine the impact of prehospital times on survival in severely injured patients. Methods: We reviewed injured trauma patients enrolled in a Korean EMS trauma registry during 2012. Severe trauma patients were defined as having either a “V” or lower in the AVPU system, a systolic blood pressure ≤90mmHg, or respiratory rate <10 or >29. Patients with Injury Severity Scores(ISS) < 9 were excluded. Patients were categorized by scene time into 4 groups as follows: <3 minutes, 3–6 minutes, 6–9 minutes, and ≥9 minutes and by prehospital time as follows: <16 minutes, 16–24 minutes, 24–32 minutes, and ≥32 minutes. The primary outcome was in-hospital mortality. Multiple linear regression analysis was used to adjust for possible confounders. Results: A total of 2,257 eligible patients were analyzed. Scene time was <3 minutes in 220 (9.7%), 3–6 in 865 (38.3%), 6–9 in 587 (26.0%), and ≥9 in 585 (25.9%). In-hospital mortality was 396 (17.5%). Compared to a scene time 6 to 9 minutes, mortality was higher as the scene time decreased: odds ratio (OR) = 1.3(3 to <6), OR = 1.9(0 to <3). Mortality was slightly decreased as prehospital time increased, OR = 1.0(16 to <24), OR = 0.9(24 to <32), OR = 0.7(≥32). Conclusion: Longer prehospital times did not increase mortality in severely injured trauma patients in Korea. Furthermore, longer scene times were associated with lower mortality.

Epidemiologic Characteristics of Injured School-age Patients Transported via Emergency Medical Services in Korea

Background The purpose of this study was to identify the characteristics of injuries of school-aged children transported via emergency medical services (EMS) that occurred in schools by comparing with injuries that occurred outside of school. Methods Data from the 119 EMS from 2012 to 2014 were analyzed. School and non-school injuries were analyzed in children 6 to 17 years of age. The epidemiologic characteristics were assessed according to school-age groups; low-grade primary (6–8 years), high-grade primary (9–13 years), middle (13–15 years) and high (15–17 years) school. Gender-stratified multivariable logistic regression analysis was conducted to estimate the risks of school injury in each age group. Results During the study period, a total of 167,104 children with injury were transported via 119 ambulances. Of these injuries, 13.3% occurred at schools. Boys accounted for 76.9% of school injuries and middle school children accounted for a significantly greater proportion (39.6%) of school injuries (P < 0.001). The most frequent mechanisms of injury at school were falls (43.8%). The peak times for school injury occurrence were lunch time (13:00–13:59) in all age groups. Multivariate regression identified the risky age groups as high-grade primary (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.09–1.20) and middle school-aged boys (OR, 1.82; 95% CI, 1.74–1.90) and middle school-aged girls (OR, 1.30; 95% CI, 1.21–1.40). Conclusion Notable epidemiologic differences exist between in- and out-of-school injuries. The age groups at risk for school injuries differ by gender.

Trend in Disability-Adjusted Life Years (DALYs) for Injuries in Korea: 2004–2012

Background Injury is a major public health problem and accounts for 10% of the global burden of disease. This study intends to present the temporal trend in the injury burden in Korea and to compare the burden size by injury mechanism and age group. Methods This study was a nationwide population-based observational study. We used two data sets, the death certificates statistics and the Korean National Hospital Discharge Survey data (2004–2012). We calculated age-standardized disability-adjusted life year (DALY) from years of life lost (YLL) and years lived with disability (YLD) and trend analysis. Results The DALYs of road injury decreased (P = 0.002), falls did not exhibit a trend (P = 0.108), and self-harm increased overall (P = 0.045). In the road injury, the YLLs decreased across all 4 age groups (0–14, 15–49, 50–79, ≥ 80) and the YLDs decreased in the 0–14-year-old group. In total, the DALYs of road injuries decreased in the 0–14-year-old group. In the fall injury, although the YLLs decreased in the over 80-year-old group, the YLDs increased in the 50–79-year-old group and the over 80-year-old group. The burden of self-harm injury was high in the age group 15 years and over, especially in the 15–49-year-old group. Conclusion The leading causes of the injury burden were road injuries, falls, and self-harm. The burden of road injury and self-harm have recently shown a gradual decreasing tendency. On the other hands, that of fall injuries are continually high in the age group over 50 years of age.

Prehospital Response Time Delays for Emergency Patients in Events of Concurrent Mass Casualty Incidents

OBJECTIVEnWe investigated the extent of delays in the response time of emergency medical services (EMS) as an impact of mass casualty incidences (MCIs) in the same area.nnnMETHODSnWe defined an MCI case as an event that resulted in 6 or more patients being transported by EMS, and prehospital response time as the time from the call to arrival at the scene. We matched patients before and after MCIs by dividing them into categories of 3 hours before, 0-1 hour after, 1-2 hours after, and 2-3 hours after the MCIs. We compared prehospital response times using multiple linear regression.nnnRESULTSnA total of 33,276 EMS-treated patients were matched. The prehospital response time for the category of 3 hours before the MCIs was 8.8 minutes (SD: 8.2), treated as the reference, whereas that for the category of 0-1 hour after the MCI was 11.3 minutes (P<0.01). The multiple linear regression analysis revealed that prehospital response time increased by 2.5 minutes (95% CI: 2.3-2.8) during the first hour and by 0.3 minutes (95% CI: 0.1-0.6) during the second hour after MCIs.nnnCONCLUSIONnThere were significant delays in the prehospital response time for emergency patients after MCIs, and it lasted for 2 hours as the spillover effect. (Disaster Med Public Health Preparedness. 2018;12:94-100).