Kyoung-Soo Lim

An Increase in Initial Shock Index Is Associated With the Requirement for Massive Transfusion in Emergency Department Patients With Primary Postpartum Hemorrhage

ABSTRACT The aim of this study was to determine whether initial shock index (SI) was independently associated with the requirement for massive transfusion (MT) in emergency department (ED) patients with primary postpartum hemorrhage (PPH). A retrospective cohort study of ED patients with primary PPH was performed at a university-affiliated, tertiary referral center between January 2004 and May 2012. Patients were classified to two groups: MT group (patients who received ≥10 U of packed red blood cells within 24 h of ED admission) and non-MT group (patients who received <10 U). Variables of the two groups were compared using univariate and multivariate analyses. A total of 126 patients were included in this study. Of these patients, 26 (20.6%) were included in MT group and 100 (79.4%) in non-MT group. Patients in MT group had significantly lower blood pressure and higher heart rate compared with patients in non-MT group (P < 0.01). Initial SI was significantly higher in MT group than in non-MT group (1.3 vs 0.8, P < 0.01). In multivariate logistic regression analysis, initial SI and heart rate were the only variables associated with the requirement for MT, with an odds ratio of 9.47 (95% confidence interval, 1.75–51.28; P < 0.01) and 1.06 (95% confidence interval, 1.02–1.09; P < 0.01), respectively. In conclusion, initial SI was independently associated with the requirement for MT in ED patients with primary PPH. Routine calculation of initial SI can help clinicians to identify patients who may benefit from timely and appropriate use of MT to improve clinical outcomes.

Intracardiac thrombus formation induced by carbon monoxide poisoning

Introduction: Carbon monoxide (CO) is one of the leading causes of poisoning; it inhibits oxygen delivery, subsequently causing ischemic changes and ultimately death by multiorgan failure. Furthermore, thromboembolic episodes due to CO poisoning have been reported. However, intracardiac thrombus formation following exposure to CO has been very rarely described. Here, a case of right atrial large thrombus formation after CO poisoning is presented. Case presentation: A previously healthy 24-year-old woman was referred for CO poisoning. She has attempted suicide, and her initial mental status was drowsy with focal memory loss. Her initial CO fraction was 16%, and initial laboratory data showed creatinine kinase-myocardial bound of 90.6 ng/mL (upper limit 5 ng/mL) and troponin I of 1.899 ng/mL (upper limit 1.5 ng/mL). A transthoracic echocardiography was performed 24 h after the accident, revealing a 30 × 15 mm nodular echogenic mass in the right atrium. Anticoagulation with low-molecular-weight heparin was started along with hyperbaric oxygen therapy. After 7 days of heparinization, the large thrombus in right atrium had resolved. Conclusion: This report describes an intracardiac thrombus formation induced by CO poisoning. Because intracardiac thrombus can result in pulmonary embolism and cerebral embolic infarction, its consideration following CO poisoning is important.

A case of severe methemoglobinemia caused by hair dye poisoning

Context: Hair dyes are widely used and very popular xenobiotics. Most of these products contain paraphenylenediamine (PPD) that can cause methemoglobinemia. We here report a case of severe methemoglobinemia that we treated using large amounts of methylene blue. Case details: A 30-year-old man visited a regional hospital with cyanosis. He was congenitally blind and had autism. For several weeks, he had mistaken hair dye for toothpaste. When he arrived at a regional hospital, he was drowsy with cyanosis and his initial serum methemoglobin (MetHb) level was 59.5%. After being treated with 2 mg/kg methylene blue (1 mg/kg × 2 administrations), he was transferred to a tertiary university hospital. Upon presentation at the Emergency Department in the tertiary hospital, his MetHb level was found to be 49.4% and his oxygen saturation was 80%. He was then admitted to the intensive care unit. After treatment with 4 mg/kg methylene blue (1 mg/kg × 4 administrations), he successfully recovered. Discussion: Because PPD can result in serious methemoglobinemia, clinicians should test it in cyanotic patients who have been exposed to hair dye for an extended period.

Life-threatening methemoglobinemia after unintentional ingestion of antifreeze admixtures containing sodium nitrite in the construction sites

Context. Construction workers are exposed to a wide variety of health hazards such as poisoning at the construction sites. Various forms of poisoning incidents in construction workers have been reported. However, studies on methemoglobinemia caused by unintentional ingestion of antifreeze admixtures containing sodium nitrite at the construction sites have not been reported yet. Objective. The aim of this study was to evaluate life-threatening methemoglobinemia after unintentional ingestion of antifreeze admixtures containing sodium nitrite at the construction sites and describe similar incidents involving ingestion of antifreeze admixtures in Korea. Materials and methods. Retrospective observational case series study on patients with methemoglobinemia after unintentional ingestion of antifreeze admixtures containing sodium nitrite admitted to the emergency department (ED) from January 1, 2010 to December 31, 2012 and cases reported to the Korea Occupational Safety and Health Agency (KOSHA) was performed. Results. Six victims were admitted to our ED. They had methemoglobin levels ranging from 32.4% to 71.5% and all of them recovered after receiving one (2 mg/kg) or two doses infusion of methylene blue. From the data of the KOSHA, six incidents that caused 27 victims were identified. Of 27 victims, five were included in the ED cases. For all incidents, antifreeze admixtures were not contained in their original containers and all new containers did not have a new label. All workers mistook antifreeze admixtures for water. Among the 28 victims included in this study, four died. Conclusion. Unintentional ingestion of antifreeze admixtures containing sodium nitrite at the construction sites can cause life-threatening methemoglobinemia. There is a need to store and label potentially hazardous materials properly to avoid unintentional ingestion at the construction sites.

Disseminated Intravascular Coagulation in Emergency Department Patients with Primary Postpartum Hemorrhage

ABSTRACT The aim of this study was to evaluate the prevalence of disseminated intravascular coagulation and to determine whether the presence of disseminated intravascular coagulation is associated with major adverse events in patients with primary post-partum hemorrhage (PPH) who present to the emergency department. This retrospective case-control study was conducted in the emergency department of a university-affiliated, tertiary referral center between January 1, 2004 and December 31, 2013. Patients were classified into disseminated intravascular coagulation (disseminated intravascular coagulation score ≥ 5) and non-disseminated intravascular coagulation groups. The two groups were compared in terms of clinical characteristics and the occurrence of major adverse events, defined as massive transfusion (≥ 10 units of packed red blood cells within 24 h of emergency department admission), invasive intervention (uterine artery embolization or emergency hysterectomy), hospital days, ventilator-free days, intensive care unit admission, intensive care unit-free days, and in-hospital mortality. Among 255 patients with primary PPH, 57 patients (22.4%) had overt disseminated intravascular coagulation. The disseminated intravascular coagulation group had significantly lower hemoglobin, hematocrit, platelet counts, and fibrinogen levels than the non-disseminated intravascular coagulation group; in addition, they had higher prothrombin times, and D-dimer levels (P < 0.01). The occurrence of major adverse events was greater in the disseminated intravascular coagulation group than in the non-disseminated intravascular coagulation group (96.5% vs. 44.4%, P < 0.01). In conclusion, disseminated intravascular coagulation was frequently found in combination with primary PPH, and the outcome was worse in these patients than in those without disseminated intravascular coagulation.

Value of cardiac troponin I for predicting in-hospital occurrence of hypotension in stable patients with acute pulmonary embolism.

ABSTRACT Although cardiac troponin I (cTnI) elevations during acute pulmonary embolism (PE) are predictive of in-hospital death, it is not clear whether cTnI measurements at emergency department (ED) admission are predictive of the occurrence of hypotension. The study subjects included all consecutive patients with acute PE (diagnosed by chest computed tomography angiography) in the ED between January 2006 and December 2011. All underwent cTnI tests at ED admission and were divided into two groups based on the occurrence of hypotension within 24 h. Of 457 stable patients with acute PE who were admitted to the ED during the study period, 301 patients were included. Within 24 h of hospitalization, 27 (9.0%) developed hypotension. The patients who developed hypotension had a significantly higher mean cTnI concentration than did the remaining patients (1.01 vs. 0.14 ng/mL, P < 0.00). They were also more likely to be treated with thrombolytic therapy and had higher 28-day and 6-month mortality rates. Cardiac TnI elevation (>0.05 ng/mL) at ED admission was a strong predictor of the development of hypotension within 24 h (odds ratio, 8.2; 95% confidence interval, 2.6–26.1; P = 0.00). The sensitivity, specificity, positive predictive value, and negative predictive value of elevated cTnI were 85%, 66%, 20%, and 98%, respectively. This study suggests that a normal cTnI nearly rules out subsequent development of hypotension within 24 h. This may help to select those patients who would benefit most from intensive clinical surveillance and escalated treatment.

Trends in the incidence and outcomes of bicycle-related injury in the emergency department: A nationwide population-based study in South Korea, 2012-2014

Objective This study aimed to examine trends in the incidence and outcomes of bicycle-related injuries in emergency departments (ED) in South Korea. Methods We analysed data from the National Emergency Department Information System database for adult patients (≥20 years) with bicycle-related injuries presenting to EDs in South Korea between January 2012 and December 2014. Riders and bicycle passengers whose injuries were associated with bicycle use were included. Serious outcomes were defined as death at the ED, need for emergency operation, or intensive care unit admission. Results The number of people who commute to work by bicycle increased by 36% from 205,100 in 2005 to 279,544 in 2015. Of 529,278 traffic-related trauma cases, 58,352 (11.0%) were bicycle-related, which increased from 7,894 (10.2%) in the first half of 2012 to 12,882 (12.2%) in the second half of 2014 (p < 0.001). However, the proportion of serious outcomes decreased from 5.0% to 4.2% during the study period (p < 0.001). Serious outcomes were most frequent in the elderly (65–74 years) and older elderly (≥75 years) groups and decreased for all but the elderly age group from 10.3% to 9.8% (p = 0.204). The helmet use rate increased from 14.2% to 20.3% (p < 0.001) but was the lowest in the older elderly group (3.6%) without change during the study period (from 4.7% to 3.7%, p = 0.656). A lack of helmet use was significantly associated with serious outcomes (odds ratio, 1.811; 95% confidence interval, 1.576–2.082). Conclusions Although the incidence of bicycle-related injuries increased, the proportion of serious outcomes decreased, possibly due to increased helmet use. Public education on safety equipment use is required, especially in elderly populations.

Characteristics of computed tomography in hemodynamically unstable blunt trauma patients: Experience at a tertiary care center

Abstract Emergent exploratory laparotomy is recommended for hemodynamically unstable blunt trauma patients suspected of having hemoperitoneum. However, given the unreliability of ultrasonography and rapid scan speed of computed tomography (CT), CT might help clinicians provide accurate information even in hemodynamically unstable trauma patients. This observational study aimed to describe the bleeding site and hospital course of severe blunt trauma patients with hemoperitoneum diagnosed by CT scan. We enrolled all consecutive adult blunt trauma patients (≥18 years old) who underwent whole-body CT before operation between February 2012 and October 2016. Patients with hemoperitoneum on CT images were included and categorized into hemodynamically stable and unstable (persistent hypotension despite fluid resuscitation) groups. Among 1723 severe blunt trauma patients, 136 patients with hemoperitoneum were included. Of these, 98 (72.1%) patients had documented intraperitoneal injury, and the liver (60.2%) was most frequently damaged site, followed by spleen (23.5%) and mesentery (23.5%). The rate of intraperitoneal organ injury did not differ between hemodynamically stable (n = 107) and unstable (n = 29) groups (69.2% vs 82.8%, P = .15), while the documented active internal bleeding was high in the unstable group (29.9% vs 69.0%, P < .001). In the unstable group, 14 (48.3%) patients underwent emergent operation, while 3 patients underwent embolization, and the others were treated in a conservative manner. Even in hemodynamically unstable hemoperitoneum patients, 17.2% had no documented intraperitoneal injury and over half of the patients were treated without emergent operation.

Blood lactate concentration and shock index associated with massive transfusion in emergency department patients with primary postpartum haemorrhage

Background We hypothesised that lactate concentrations are independently associated with massive transfusion in patients with primary postpartum haemorrhage. Moreover, combining lactate concentrations with the shock index, defined as the ratio of heart rate to systolic arterial blood pressure, can improve the predictive performance for massive transfusion. Methods We retrospectively analysed patients with primary postpartum haemorrhage in the emergency department of a tertiary referral centre in Korea between January 1, 2004 and December 31, 2015. Results Of the 302 patients, 101 (33.4%) patients required massive transfusion. Lactate concentration was independently associated with the requirement for massive transfusion [odds ratio, 1.56; 95% confidence interval (CI), 1.31–1.87; P<0.01]. The area under the receiver operating characteristic curve of lactate concentration and shock index for massive transfusion was 0.788 (95% CI: 0.736–0.840; P<0.01) and 0.776 (95% CI: 0.717–0.836; P<0.01), respectively. Lactate elevation (>4.0 mM L−1) was associated with 86.1% specificity and 67.8% positive predictive value for massive transfusion. When combining elevated lactate concentrations (>4.0 mM L−1) with a shock index >1.0, the specificity and positive predictive value increased to 95.5% and 82.4%, respectively. Conclusions Point‐of‐care testing of lactate concentrations in the emergency department may be useful to predict massive transfusion requirements in primary postpartum haemorrhage. Combining initial lactate concentrations with the shock index improves the predictive performance for massive transfusion requirements and may contribute to rapid risk stratification of patients with primary postpartum haemorrhage in need of transfusion and further focus on early interventions to control bleeding.