Min Joung Kim

Chest injury following cardiopulmonary resuscitation: A prospective computed tomography evaluation

INTRODUCTIONnTraumatic chest injuries may occur following cardiopulmonary resuscitation (CPR). The aim of this study was to address the frequency of injuries, especially rib and sternal fractures, and also to identify factors that contribute to post-CPR trauma.nnnMETHODSnThis study was a prospective cross-sectional study conducted in the emergency departments (ED) of eight academic tertiary care centers. To evaluate injuries secondary to CPR, we performed chest computed tomography (CT) in patients who were successfully resuscitated from cardiac arrest. Contributing factors that might be related to injuries were also investigated.nnnRESULTSnWe enrolled 71 patients between 1 January 2011 and 30 June 2011. Rib and sternal fractures were diagnosed in 22 and 3 patients, respectively. Females were more susceptible to rib fracture (p=0.036). When non-physicians participated as chest compressors in the ED, more ribs were fractured (p=0.048). The duration of CPR and number of compressors were not contributing factors to trauma secondary to CPR. There was a wide variation in the frequency of rib fractures from hospital to hospital (0-83.3%). In high-risk hospitals (in which more than 50% of patients had rib fractures), the average age of the patients was higher, and non-physicians took part in ED CPR more often than they did at low-risk hospitals.nnnCONCLUSIONnThe incidence of rib fracture following CPR was different in various hospitals. The presence of non-physician chest compressors in the ED was one of the contributing factors to rib fracture. Further studies on the influence of resuscitators and relation between quality of chest compression and CPR-induced injuries are warranted to reduce complications following CPR.

Efficacy of VeinViewer in pediatric peripheral intravenous access: a randomized controlled trial

Peripheral venous access in infants and children is technically challenging, because their veins are small and located deep in subcutaneous tissue, which makes them difficult to palpate or visualize. The VeinViewer® (Luminetx Corporation, Memphis, TN, USA) is a near-infrared light device that delineates the running course of subcutaneous veins. In this study, we investigated whether the use of the VeinViewer® in infants and children facilitated peripheral venous access, especially in difficult cases. This study was a randomized, controlled trial of a convenience sample of pediatric patients between the ages of 1xa0month and 16xa0years who required peripheral venous access in the pediatric ward. Prior to randomization, difficult intravenous access (DIVA) score, a four-variable clinical prediction rule for first-attempt success, was estimated. We compared the first-attempt success rates and procedural times between the VeinViewer® group and a control group. We evaluated 111 patients: 54 in the VeinViewer® group and 57 in the control group. Patient demographics and factors related to the success of vein access were similar for both groups. The overall first-attempt success rate was 69.4%: i.e., 77/111 in the VeinViewer® group and 38/57 in the control group, a difference that was not statistically significant. However, the first-attempt success rate increased from 5/20 in the control group to 14/24 in the VeinViewer® group for difficult veins with a DIVA score greater than 4 (pu2009=u20090.026). There were no significant differences in procedural time between the two groups. Conclusion: The VeinViewer® facilitated peripheral venous access for pediatric patients with difficult veins, which enhanced first-attempt success rates.

Estimation of anatomical structures underneath the chest compression landmarks in children by using computed tomography

OBJECTIVEnThere has been little investigation on the appropriateness of the hand position suggested by various guidelines in paediatric cardiopulmonary resuscitation (CPR). We aimed to identify anatomical structures underneath the chest compression landmarks and tried to find the proper hand position using computed tomography (CT) images for more effective paediatric CPR.nnnPATIENTS AND METHODSnThis study included a total of 181 paediatric patients who were admitted to Severance Hospital and underwent CTs of chest. We studied structures located under the inter-nipple line and under the lower third of the sternum. The distances from the xiphoid process to the level of the left ventricular outflow tract (LVOT) were measured to find the ceiling on the proper hand position.nnnRESULTSnThe LVOT (42.0%) and the root of the aorta (21.5%) were more frequently located than the left ventricle under the inter-nipple line, and the liver was located under the lower third of the sternum in a significant number of patients (28.7%). The LVOT was placed 6.8±13.9 mm below the nipple level, but there was no significant difference in the distance from the nipple level to the LVOT among the age groups (p=0.517).nnnCONCLUSIONSnThe hand position at the inter-nipple line might be too high and that at the lower third of the sternum might be too low as it can compress the liver. Further studies are needed to find the proper hand position for more effective chest compression during paediatric CPR.

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.

Neurologic outcome of comatose survivors after hanging: a retrospective multicenter study

PURPOSEnThe aim of this study is to identify the neurologic outcome of hanging patients and prognostic factors.nnnMATERIALS AND METHODSnWe retrospectively investigated comatose hanging patients who arrived at the emergency departments (EDs) of twelve academic tertiary care centers during a period of seven years (2006-2012). Patients were analyzed separately according to whether out-of-hospital cardiac arrest (OHCA) occurred or not. The neurologic outcome was evaluated using the Cerebral Performance Category (CPC) at the time of hospital discharge.nnnRESULTSnA total of 1118 patients were admitted to the ED after hanging attempts. There were 159 comatose patients who did not experience OHCA. Twelve (7.5%) of 159 patients were discharged from the hospital with a poor neurologic outcome (CPC 3-5). These 12 patients received only conservative management without therapeutic hypothermia. On multivariate logistic regression analysis, mental state upon ED arrival and arterial pH were predicting factors for poor prognosis. One hundred twenty-one patients suffered OHCA and experienced restored spontaneous circulation after cardiopulmonary resuscitation. Among them, only five (4.1%) patients recovered consciousness to the level of CPC 1-2. The initial arterial pH and HCO3(-) were prognostic factors in hanging patients with OHCA.nnnCONCLUSIONSnEven though cardiac arrest did not occur after hanging injuries, 7.5% of patients could not recover consciousness. Therapeutic hypothermia should be considered for such patients. If OHCA occurred after the hanging injury, the proportion of patients with good neurologic outcome was very low at 4.1%.

Comparison of GlideScope ® versus Macintosh laryngoscope for the removal of a hypopharyngeal foreign body: A randomized cross-over cadaver study

OBJECTIVEnThis study aimed to evaluate whether GlideScope(®) is an effective and acceptable method for the removal of a hypopharyngeal foreign body.nnnMETHODSnThis was a prospective study conducted in 28 first year emergency residents with little prior airway management experience. Participants extracted hypopharyngeal foreign bodies using a Macintosh laryngoscope and GlideScope(®) with Magill and Sponge forceps. The primary endpoints were extraction time and success rate with each device. Participant preferences were also assessed.nnnRESULTSnThe cumulative success rate in relation to time to extraction was significantly higher with the Macintosh laryngoscope than with the GlideScope(®) (p<0.001) regardless of the extraction device. Significantly fewer attempts were required for the first successful extraction with the Macintosh laryngoscope versus GlideScope(®) with Magill forceps (p=<0.001) and Sponge forceps (p=<0.001). The time for successful foreign body extraction using GlideScope(®) was significantly lower when using Magill (median 46 s, IQR 28-75 s) forceps than Sponge forceps (median 79 s, IQR 41-88 s).nnnCONCLUSIONSnIn this cadaver model, the Macintosh laryngoscope appeared to be more efficient and preferred than GlideScope(®) for extracting hypopharyngeal airway foreign bodies that are associated with fatal asphyxiation.

Effects of a short text message reminder system on emergency department length of stay

PURPOSEnSpecialty consultations and waiting for admission to a hospital bed are major contributors to increased length of stay and overcrowding in the emergency department. We implemented a computerized short messaging service to inform care providers of patient delay in order to reduce length of stay. The purpose of this study was to evaluate the effects of this strategy on length of stay in the emergency department.nnnMETHODSnThis was a before-and-after observational study. Prior to this study, we registered the mobile phone numbers of all board certified specialists into a computerized physician order entry database and developed an auto-sending short messaging program linked to consultation orders. The short message was transmitted at 2 and 4h after consultation, when a disposition was not yet established, and at 8h after the admission order if the patient was still waiting. The length of stay of consulted patients and intervals such as consultation time (registration-consultation), disposition time (consultation-admission decision), and boarding time (admission decision-hospitalization) of admitted patients were compared between the pre-implementation (September 2009) and post-implementation period (November 2009). Subgroup analyses of disposition time were performed according to time of consultation and the number of consultations.nnnRESULTSnA total of 7518 patients visited the emergency department during the pre-periods and post-periods. Among them, 3335 patients required specialty consultations. The median length of stay of consulted patients decreased significantly after implementation of the messaging system (pre-207 min vs. post-193 min, p<0.001). Among admitted patients, the median length of stay decreased by 36 min from 294 min to 258 min (p<0.001). In the subgroup analysis, times for establishing patient dispositions decreased significantly when the consultation was performed at night and when there was only one department consulted. The numbers of patients with disposition times within 2 and 4h and boarding times within 8h were all increased after implementation of the short message service program.nnnCONCLUSIONSnThis study suggested that the computerized physician order entry-based short messaging service program, used to inform decision-makers of patient delay, could reduce the length of stay for consulted patients in the emergency department.

Investigation of complications secondary to chest compressions before and after the 2010 cardiopulmonary resuscitation guideline changes by using multi-detector computed tomography: a retrospective study

BackgroundThe purpose of this study was to identify the relationship between the deeper and faster chest compressions suggested by the 2010 cardiopulmonary resuscitation guidelines and complications arising from chest compressions, using multi-detector computed tomography.MethodsWe performed a retrospective analysis of prospective registry data. This study was conducted with in- and out-of-hospital cardiac arrest patients who underwent successful resuscitation in the emergency departments of two academic tertiary care centres from October 2006 to September 2010 (pre-2010 group) and from October 2011 to September 2015 (post-2010 group). We examined chest injuries related to chest compressions, classified as follows: rib fracture, sternal fracture, and other uncommon complications.ResultsWe enrolled 185 patients in this study. The most frequent complication to occur in both groups was rib fracture: 27 (62.8%) and 112 (78.9%) patients in the pre-2010 and post-2010 groups, respectively (p = 0.03). However, we observed no statistical differences in sternum fracture, the second most common complication (p = 0.80). Retrosternal and mediastinal haematoma were not reported in the pre-2010 group but 13 patients (9.1%) in the post-2010 group were reported to have haematoma (p = 0.04). Nine serious, life-threatening complications occurred, all in the post-2010 group. Among the younger group (less than 65 years old), 8 (38.1%) patients in the pre-2010 group and 40 (64.5%) in the post-2010 group sustained rib fractures.DiscussionThe deeper and faster chest compressions for enhancing ROSC are associated with increased occurrence of complications. Additional studies are needed to compensate for the limitations of our study design.ConclusionsThis study found that the 2010 guidelines, recommending deeper and faster chest compressions, led to an increased proportion of rib fractures and retrosternal and mediastinal haematoma.

Optimal chest compression technique for paediatric cardiac arrest victims

BackgroundThe aim of this study was to assess the quality of chest compressions performed by inexperienced rescuers using three different techniques: two-hand, right one-hand, and left one-hand.MethodsWe performed a prospective, randomised, crossover study in a simulated 6-year-old paediatric manikin model. Each participant performed 2-minute continuous chest compressions, using three different techniques. Chest compression quality data, including compression rate, compression depth, and residual leaning was recorded by a Q-CPR™ compression sensor connected to HeartStart MRx (Philips Healthcare, Andover, MA, USA). To examine trends in chest compression performance over time, each 2-minute period was divided into six consecutive 20-second epochs.ResultsThe 36 participants completed 108 two-minute trials, consisting of a total of 25,030 compressions. The mean compression rates [95% confidence interval] were as follows: two-hand, 116.8 [111.7–121.9]; left one-hand, 115.0 [109.9–120.1]; and right one-hand, 115.5 [110.4–120.6] (pu2009=u20090.565). The mean compression depth for two-hand was 38.7 mm (37.1–40.2), which was higher than for left one-hand (36.3 mm [34.8–37.9]) or right one-hand (35.4 mm [33.9-37.0]) (pu2009<u20090.001). Chest compression depth declined over time, regardless of the technique (pu2009<u20090.001). The pattern of compression depth change over time was similar for all techniques (pu2009>u20090.999). The residual leaning rate was higher with two-hand (40.7 [27.9–53.5]) than that for left one-hand (29.2 [16.4–42.0]) or right one-hand (25.8 [13.0–38.6]) (pu2009=u20090.021).ConclusionsFor paediatric cardiopulmonary resuscitation by inexperienced rescuers, the two-hand technique has the advantage of producing deeper compressions than the one-hand technique, but it is accompanied by more frequent residual leaning. For the one-hand techniques, the right and left hand produced chest compressions of similar quality.

Outcomes before and after the Implementation of a Critical Pathway for Patients with Acute Aortic Disease

Purpose Acute aortic diseases, such as aortic dissection and aortic aneurysm, can be life-threatening vascular conditions. In this study, we compared outcomes before and after the implementation of a critical pathway (CP) for patients with acute aortic disease at the emergency department (ED). Materials and Methods This was a retrospective observational cohort study. The CP was composed of two phases: PRE-AORTA for early diagnosis and AORTA for prompt treatment. We compared patients who were diagnosed with acute aortic disease between pre-period (January 2010 to December 2011) and post-period (July 2012 to June 2014). Results Ninety-four and 104 patients were diagnosed with acute aortic disease in the pre- and post-periods, respectively. After the implementation of the CP, 38.7% of acute aortic disease cases were diagnosed via PRE-AORTA. The door-to-CT time was reduced more in PRE-AORTA-activated patients [71.0 (61.0, 115.0) min vs. 113.0 (56.0, 170.5) min; p=0.026]. During the post-period, more patients received emergency intervention than during the pre-period (22.3% vs. 36.5%; p=0.029). Time until emergency intervention was reduced in patients, who visited the ED directly, from 378.0 (302.0, 489.0) min in the pre-period to 200.0 (170.0, 299.0) min in the post-period (p=0.001). The number of patients who died in the ED declined from 11 to 4 from the pre-period to the post-period. Hospital mortality decreased from 26.6% to 14.4% in the post-period (p=0.033). Conclusion After the implementation of a CP for patients with acute aortic disease, more patients received emergency intervention within a shorter time, resulting in improved hospital mortality.