Seong Chun Kim

Comparison of clinical performance of cranial computed tomography rules in patients with minor head injury: a multicenter prospective study.

OBJECTIVES The objective was to compare the predictive performance of three previously derived cranial computed tomography (CT) rules, the Canadian CT Head Rule (CCHR), the New Orleans Criteria (NOC), and National Emergency X-Ray Utilization Study (NEXUS)-II, for detecting clinically important traumatic brain injury (TBI) and the need for neurosurgical intervention in patients with blunt head trauma. METHODS This was a prospective, multicenter, observational cohort study of patients with blunt head trauma from June 2008 to May 2009. The historical and physical examination components of the CCHR, NOC, and NEXUS-II were documented on a data collection form and the performance of each of the three rules was compared. Patient eligibility for each specific rule was defined exactly as previously described for each specific rule. To compare the three decision rules in terms of sensitivity and specificity, an intersection cohort satisfying inclusion criteria of all three decision rules was derived. The primary outcome was clinically important TBI, and the secondary outcome was neurosurgical intervention. The sensitivity and specificity of each rule were calculated with 95% confidence intervals (95% CIs). We also calculated the potential reduction rate in cranial CT scan utilization realized by theoretical implementation of these rules. RESULTS A total of 7,131 patients were prospectively enrolled, including 692 (9.7%) with clinical TBI. Among the enrolled population, patients eligible for CCHR, NOC, and NEXUS-II totaled 696, 677, and 2,951, respectively. The sensitivity and specificity for clinically important brain injury were as follows: CCHR, 112 of 144 (79.2%, 95% CI = 70.8% to 86.0%) and 228 of 552 (41.3%, 95% CI = 37.3% to 45.5%); NOC, 91 of 99 (91.9%, 95% CI = 84.7% to 96.5%) and 125 of 558 (22.4%, 95% CI = 19.0% to 26.1%); and NEXUS-II, 511 of 576 (88.7%, 95% CI = 85.8% to 91.2%) and 1,104 of 2,375 (46.5%, 95% CI = 44.5% to 48.5%). The sensitivity and specificity for neurosurgical intervention were as follows: CCHR, 100% (95% CI = 59.0% to 100.0%) and 38.3% (95% CI = 34.5% to 41.9%); NOC, 100% (95% CI = 54.1% to 100.0%) and 20.4% (95% CI = 17.4% to 23.7%); and NEXUS-II, 95.1% (95% CI = 90.1% to 98.0%) and 41.4% (95% CI = 39.5% to 43.2%). Among the enrolled population, intersection patients of CCHR, NOC, and NEXUS-II totaled 588. The sensitivity and specificity for clinically important brain injury were as follows: CCHR, 73 of 98 (74.5%, 95% CI = 64.7% to 82.8%) and 201 of 490 (41.0%, 95% CI = 36.6% to 45.5%); NOC, 89 of 98 (90.8%, 95% CI = 83.3% to 95.7%) and 112 of 490 (22.9%, 95% CI = 19.2% to 26.8%); and NEXUS-II, 82 of 98 (83.7%, 95% CI = 74.8% to 90.4%) and 172 of 490 (35.1%, 95% CI = 30.9% to 39.5%). The potential reduction in emergency CT scans by using these decision rules would have been higher with the NEXUS-II rule (39.6%, 95% CI = 37.8% to 41.4%) than with the CCHR rule (27.0%, 95% CI = 23.7% to 30.3%) or NOC rule (20.2%, 95% CI = 17.2% to 23.3%). CONCLUSIONS For clinically important TBI, the three cranial CT decision rules had much lower sensitivities in this population than the original published studies, while the specificities were comparable to those studies. The sensitivities for neurosurgical intervention, however, were comparable to the original studies. The NEXUS-II rule showed the highest reduction rate for CT scans compared to other rules, but failed to identify all undergoing neurosurgical intervention for their original inclusion cohort.

A point-of-care chemistry test for reduction of turnaround and clinical decision time

PURPOSE Our study compared clinical decision time between patients managed with a point-of-care chemistry test (POCT) and patients managed with the traditional central laboratory test (CLT). BASIC PROCEDURE This was a randomized controlled multicenter trial in the emergency departments (EDs) of 5 academic teaching hospitals. We randomly assigned patients to POCT or CLT stratified by the Emergency Severity Index. A POCT chemistry analyzer (Piccolo; Abaxis, Inc, Union City, Calif), which is able to test liver panel, renal panel, pancreas enzymes, lipid panel, electrolytes, and blood gases, was set up in each ED. Primary and secondary end point was turnaround time and door-to-clinical-decision time. MAIN FINDINGS The total 2323 patients were randomly assigned to the POCT group (n = 1167) or to the CLT group (n = 1156). All of the basic characteristics were similar in the 2 groups. The turnaround time (median, interquartile range [IQR]) of the POCT group was shorter than that of the CLT group (14, 12-19 versus 55, 45-69 minutes; P < .0001). The median (IQR) door-to-clinical-decision time was also shorter in the POCT compared with the CLT group (46, 33-61 versus 86, 68-107 minutes; P < .0001). The proportion of patients who had new decisions within 60 minutes was 72.8% for the POCT group and 12.5% for the CLT group (P < .0001). CONCLUSIONS A POCT chemistry analyzer in the ED shortens the test turnaround and ED clinical decision times compared with CLT.

Absolute lymphocyte count as a predictor of mortality in emergency department patients with paraquat poisoning.

Background Paraquat (PQ) is a potent, highly toxic and widely used herbicide. The major medical problems associated with PQ are accidental or suicidal ingestion. There are several prognostic markers of PQ poisoning, with the serum PQ concentration considered to be the best indicator of outcome. However, the measurement of such markers is limited in many hospitals. Objective The present study was conducted to investigate the association of absolute lymphocyte count (ALC) and the 30-day mortality rate in patients with PQ poisoning. Methods We performed a retrospective analysis of patients admitted to the emergency department after paraquat poisoning between January 2010 and April 2013. Independent risk factors including ALC for 30-day mortality were determined. The ALC was categorized in quartiles as ≤1700, 1700 to 3200, 3200 to 5000, and >5000. Univariate and multivariate Cox proportional hazard analysis were performed to determine the independent risk factors for mortality. Results A total of 136 patients were included in the study, and the 30-day mortality was 73.5%. ALC was significantly higher in nonsurvivors than in survivors. The highest ALC quartile (ALC>5000; hazard ratio, 2.58; 95% CI, 1.08–6.21) was associated with increased mortality in multivariate analysis. In addition, old age, lower arterial PaCO2, increased peripheral neutrophil count, and high serum levels of creatinine were associated with mortality. Conclusion The absolute lymphocyte count is associated with the 30-day mortality rate in patients with paraquat poisoning.

Clinical Evaluation of BacT/Alert FA Plus and FN Plus Bottles Compared with Standard Bottles

ABSTRACT The performance of the BacT/Alert FA Plus and FN Plus resin bottles was evaluated in comparison with that of standard aerobic (SA) and standard anaerobic (SN) bottles. Twenty milliliters of blood from adult patients was equally distributed into four types of bottles: FA Plus, FN Plus, SA, and SN. The detection of clinically significant organisms and the time to detection (TTD) were monitored for each bottle. Among the 3,103 blood culture sets that were requested, the blood volume of each bottle was over 4 ml in 1,481 sets (47.7%). Among these 1,481 sets, 158 cultures grew in the FA Plus and SA bottles, and 136 grew in the FN Plus and SN bottles. Growth in only one type of bottle was more commonly observed for the FA Plus (n = 38) than for the SA (n = 14) (P = 0.001) bottles and for the FN Plus (n = 27) than for the SN (n = 10) (P = 0.008) bottles. Gram-negative bacilli were more frequently isolated in the resin bottles (P < 0.05). The skin contamination rate was 1.2% in the resin bottles and the standard bottles. The mean TTD was 11.1 h in the FA Plus bottles versus 13.1 h in the SA bottles (P < 0.001) and 12.0 h in the FN Plus bottles versus 12.8 h in the SN bottles (P = 0.083). Clinically significant bacteria, including Gram-negative bacilli, were isolated more frequently from the resin bottles than from the standard bottles. Clinically significant bacteria were detected faster using the aerobic resin bottles than using the standard aerobic bottles. This finding might not be applicable to the standard-practice 10-ml protocol for each bottle because the results from using a smaller volume (5 ml) might be less pronounced.

Epidemiology of Traumatic Head Injury in Korean Children

The aim of this study was to elucidate the epidemiology of traumatic head injury (THI) among Korean children. A prospective, in-depth trauma survey was conducted in five teaching hospitals. Data from all of the children who attended the emergency department (ED) were analyzed. From June 2008 to May 2009, 2,856 children with THI visited the 5 EDs. The average age of the subjects was 5.6 (SD ± 4.9) yr old, and 1,585 (55.5%) were 0-4 yr old. The male-to-female ratio was 2.3 to 1 (1,979 vs 877). Consciousness levels of the subjects were classified according to the Glasgow Coma Scale (GCS), and 99.1%, 0.6%, and 0.4% were determined as mild, moderate, or severe injury, respectively, according to the GCS categorization. Most injuries occurred at home (51.3%), and the most common mechanism of injury was collision (43.2%). With regard to outcome, 2,682 (93.9%) patients were sent home, and 35 (1.2%) were transferred to another hospital. A total of 133 (4.7%) patients were hospitalized, and 38 (1.3%) underwent surgery. The incidence and characteristics of pediatric THI in Korea are affected by sex, location and injury mechanism.

Changes in arterial blood gases after use of high-flow nasal cannula therapy in the ED

INTRODUCTION A high-flow nasal cannula (HFNC) has been used to treat patients with dyspnea. We identified changes in arterial blood gas (ABG) of patients visiting the emergency department (ED) with hypercapnic and nonhypercapnic respiratory failure after use of an HFNC. METHODS This study was a retrospective chart review of patients with respiratory failure who visited the hospital and used an HFNC in the ED. The study period was July 1, 2011, to December 31, 2013. Patients with Paco2 greater than 45 mm Hg before the HFNC ABG analyses were included in the hypercapnia group; others comprised the nonhypercapnia group. Primary outcomes were the changes in ABG before and after use of an HFNC in the hypercapnia and nonhypercapnia groups. Progression to noninvasive or invasive ventilation and mortality rates were also assessed. RESULTS A total of 173 patients were included after exclusion of 92 according to exclusion criteria. Eighty-one patients (hypercapnia group, 46, and nonhypercapnia group, 35) were included. Paco2 significantly decreased among all patients after use of HFNC (from 54.7±26.4 mm Hg to 51.3±25.8 mm Hg; P=.02), but the reduction was significant only in the hypercapnia group (from 73.2±20.0 to 67.2±23.4; P=.02). Progression to noninvasive or invasive ventilation and mortality rates were similar between the groups. CONCLUSIONS Use of an HFNC in patients with hypercapnia could show a significant trend of decrease in Paco2. Progression to noninvasive or invasive ventilation and mortality rates were similar in patients with and without hypercapnia.

The uniform chest compression depth of 50 mm or greater recommended by current guidelines is not appropriate for all adults

OBJECTIVE This study was conducted to evaluate the appropriateness of the chest compression (CC) depth recommended in the current guidelines and simulated external CCs, and to characterize the optimal CC depth for an adult by body mass index (BMI). METHODS Adult patients who underwent chest computed tomography as a screening test for latent pulmonary diseases in the health care center were enrolled in this study. We calculated the internal anteroposterior (AP) diameter (IAPD) and external AP diameter (EAPD) of the chest across BMIs (<18.50, 18.50-24.99, 25.00-29.99, and ≥30.00 kg/m(2)) for simulated CC depth. We also calculated the residual chest depths less than 20 mm for simulated CC depth. RESULTS There was a statistically significant difference in the chest EAPD and IAPD measured at the lower half of the sternum for each BMI groups (EAPD: R(2) = 0.638, P < .001; IAPD: R(2) = 0.297, P < .001). For one-half external AP CC, 100% of the patients, regardless of BMI, had a calculated residual internal chest depth less than 20 mm. For one-fourth external AP CC, no patients had a calculated residual internal chest depth less than 20 mm. For one-third external AP CC, only 6.48% of the patients had a calculated residual internal chest depth less than 20 mm. CONCLUSIONS It is not appropriate that the current CC depth (≥50 mm), expressed only as absolute measurement without a fraction of the depth of the chest, is applied uniformly in all adults. In addition, in terms of safety and efficacy, simulated CC targeting approximately between one-third and one-fourth EAPD CC depth might be appropriate.

Red cell distribution width as a predictor of mortality in organophosphate insecticide poisoning

OBJECTIVE Suicide by organophosphate insecticide (OPI) poisoning is a major clinical concern (predominantly in developing countries), and 200000 deaths occur annually worldwide. Red cell distribution width (RDW) has been used to predict outcome in several clinical conditions. Here, we aimed to investigate the relationship between the RDW and 30-day mortality during OPI poisoning. METHODS This retrospective analysis was performed between January 2008 and July 2013 in patients admitted to the emergency department after OPI poisoning. A Kaplan-Meier 30-day survival curve was analyzed in patients stratified according to the optimal cut-off point of RDW defined using a receiver operating characteristic (ROC) curve. Multivariate Cox proportional hazards analyses were conducted to determine the independent prognostic factors for 30-day mortality. RESULTS Among 102 patients, 21 died, yielding a mortality of 20.6%. Elevated RDW was significantly associated with early mortality in patients with OPI poisoning. Levels of RDW that exceeded 13.5% (hazard ratio, 2.64; 95% confidence interval [CI], 1.05-6.60) were associated with increased mortality in the multivariate analysis. The area under the ROC curve of RDW was 0.675 (95% CI, 0.522-0.829). CONCLUSIONS This study showed that RDW is an independent predictor of 30-day mortality in patients with OPI poisoning.

A risk stratification model of acute pyelonephritis to indicate hospital admission from the ED

OBJECTIVES There are no guidelines regarding the hospitalization of female patients with acute pyelonephritis (APN); therefore, we performed a retrospective analysis to construct a clinical prediction model for hospital admission. METHODS We conducted a retrospective analysis of a prospective database of women diagnosed as having APN in the emergency department between January 2006 and June 2012. Independent risk factors for admission were determined by multivariable logistic regression analysis in half of the patients in this database. The risk of admission was categorized into 5 groups. The internal and external validations were conducted using the remaining half of the patients and 192 independent patients, respectively. RESULTS Independent risk factors for admission were age of 65 years or greater (odds ratio [OR], 2.62; 1 point), chill (OR, 2.40; 1 point), and the levels of segmented neutrophils greater than 90% (OR, 2.00; 1 point), serum creatinine greater than 1.5 mg/dL (OR, 2.41; 1 point), C-reactive protein greater than 10 mg/dL (OR, 2.37; 1 point), and serum albumin less than 3.3 g/dL (OR, 7.36; 2 points). The admission risk scores consisted of 5 categories, which were very low (0 points; 5.9%), low (1 point; 10.7%), intermediate (2 points; 20.7%), high (3-4 points; 51.9%), and very high (5-7 points; 82.8%) risk, showing an area under the curve of 0.770. The areas under the curve of the internal and external validation cohorts were 0.743 and 0.725, respectively. CONCLUSION This model can provide a guideline to determine the admission of women with APN in the emergency department.

The effects of intravenous lipid emulsion on prolongation of survival in a rat model of calcium channel blocker toxicity

Abstract Context. Intravenous lipid emulsion (ILE) has been shown to ameliorate the toxicity of lipid-soluble agents in animal studies and clinical cases. Objectives. To investigate the therapeutic effects of ILE in a rat model of toxicity from calcium channel blockers (CCBs), including diltiazem and nicardipine. Methods. Two sets of experiments of CCB poisoning were conducted. In the first set, 14 male Sprague-Dawley rats were sedated and treated with ILE or normal saline (NS), followed by continuous intravenous infusion of diltiazem (20 mg/kg/h). In the second experiment, the study protocol was the same except the infusion of nicardipine (20 mg/kg/h). The total dose of infused drug and the duration of survival were measured. In addition, mean arterial pressure and heart rate were monitored. Results. Survival was prolonged in the ILE group (48.4 ± 11.3 vs. 25.0 ± 3.7 min; p = 0.002). Furthermore, the cumulative mean lethal dose of diltiazem was higher in the ILE group (16.1 ± 3.8 mg/kg) than in the NS group (8.3 ± 1.1 mg/kg) (p = 0.002). With nicardipine poisoning, survival was also prolonged in the ILE group (71.0 ± 8.3 min vs. 30.6 ± 6.1 min; p = 0.002). The cumulative mean lethal dose was higher in the ILE group than in the NS group (23.7 ± 2.8 mg/kg vs. 10.2 ± 2.0 mg/kg; p = 0.002). Conclusions. ILE pretreatment prolonged survival and increased the lethal dose in a rat model of CCB poisoning using diltiazem and nicardipine.