Soo Hoon Lee

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.

Low apparent diffusion coefficient cluster-based analysis of diffusion-weighted MRI for prognostication of out-of-hospital cardiac arrest survivors

OBJECTIVE Recent studies suggested quantitative analysis of diffusion-weighted magnetic resonance imaging as a promising tool for early prognostication of cardiac arrest patients. However, most of their methods involve significant manual image handling often subjective and difficult to reproduce. Therefore developing a computerized analysis method using easy-to-define characteristics would be useful. METHODS Comatose out-of-hospital cardiac arrest (OHCA) patients who underwent brain MRI between January 2008 and July 2012 were identified from an OHCA registry. Apparent diffusion coefficient (ADC) axial images were analyzed using a program to detect and characterize clusters of low ADC pixels from six brain regions including frontal, occipital, parietal, rolandic and temporal and basal ganglia region. Identified clusters were ranked according to size, mean ADC and minimum ADC to assess the regional maximum cluster size (MCS), lowest mean ADC (LMEAN) and lowest minimum ADC (LMIN). Their power to predict poor outcome, defined as 6-month CPC 3 or higher, was assessed by contingency table analyses. RESULTS 51 OHCA patients were eligible during the study period. The sensitivities of MCS, LMEAN and LMIN to detect poor outcome varied according to brain region from 62.5 to 90.0%, 50.0 to 72.5% and 42.5 to 82.5% with their specificities set to 100%, respectively. The MCS of occipital region showed most favorable test profile (sensitivity 90%, specificity 100%; AUROC 0.940, 95% confidence interval 0.874-1.000). CONCLUSION The cluster-based computerized image analysis might be a simple but useful method for prediction of poor neurologic outcome. Future studies validating its prognostic performance are required.

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.

Does the quality of chest compressions deteriorate when the chest compression rate is above 120/min?

Objectives The quality of chest compressions along with defibrillation is the cornerstone of cardiopulmonary resuscitation (CPR), which is known to improve the outcome of cardiac arrest. We aimed to investigate the relationship between the compression rate and other CPR quality parameters including compression depth and recoil. Methods A conventional CPR training for lay rescuers was performed 2 weeks before the ‘CPR contest’. CPR anytime training kits were distributed to respective participants for self-training on their own in their own time. The participants were tested for two-person CPR in pairs. The quantitative and qualitative data regarding the quality of CPR were collected from a standardised check list and SkillReporter, and compared by the compression rate. Results A total of 161 teams consisting of 322 students, which includes 116 men and 206 women, participated in the CPR contest. The mean depth and rate for chest compression were 49.0±8.2 mm and 110.2±10.2/min. Significantly deeper chest compression depths were noted at rates over 120/min than those at any other rates (47.0±7.4, 48.8±8.4, 52.3±6.7, p=0.008). Chest compression depth was proportional to chest compression rate (r=0.206, p<0.001), but there were significantly more incomplete chest recoils at the rate of over 120/min than at any other rates (9.8%, 6.3%, 25.6%, p=0.011). Conclusions The study showed conflicting results in the quality of chest compression including chest compression depth and chest recoil by chest compression rate. Further evaluation regarding the upper limit of the chest compression rate is needed to ensure complete full chest wall recoil while maintaining an adequate chest compression depth.

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.

Implementation of clinical practices to reduce return visits within 72 h to a paediatric emergency department

Objective Return visits to the paediatric emergency department (PED) are an important measure of quality of healthcare and are associated with patients’ and parents’/guardians’ satisfaction. Previous studies have been limited to describing characteristics and factors related to return visits. The objectives of this study were to develop new clinical practices to reduce return visits to the PED and to see whether implementation of these practices had the desired effect. Patients and methods This was a controlled before-and-after study. New clinical practices were developed by analysing data for patients visiting in 2011 (before) and by surveying emergency physicians and nurses in the PED. New clinical practices were implemented between 16 July and 4 November 2012 (after). The rate of return visits and admission rates after return visits were compared between matched periods in 2011 and 2012. We also investigated return visits at three independent hospitals to overcome the limitation of the intervention application to a single hospital. Results The new clinical practices included five protocols: set orders for common symptoms; management plans for patients at high risk of a return visit; a daily physician feedback system; protocolised discharge instructions; early planned visits to clinics. After implementation, the rate of return visits was reduced significantly, from 4.4% to 2.6% (p<0.01). The admission rate for return visits was also reduced, but not significantly so, from 22.3% to 17.5% (p=0.37). Return visits at the other hospitals were similar or significantly increased in 2012 compared with 2011. Conclusions The development and implementation of clinical practices were effective in reducing return visits of paediatric patients to the ED.

Awareness and knowledge of sepsis in the general Korean population: comparison with the awareness and knowledge of acute myocardial infarction and stroke

Objective Patients with severe sepsis or septic shock require timely, aggressive management to improve their outcomes, and early presentation of patients to the hospital may also be important. Thus, public awareness about sepsis may be important for improved outcomes. However, there are no studies regarding the public awareness of sepsis in the general Korean population. Therefore, the objective of this survey was to gain insight into the public awareness of sepsis. Methods Prospective paper-based and web-based surveys were issued between May and June 2013 to adults aged ≥18 years. Results A total of 1,081 participants responded to the survey (394 paper-based and 687 web-based). Mean age was 38.7±11.4 years, and 541 participants (50%) were men. Of the 1,081 participants, 831 (76.9%) had heard of the term “sepsis.” Of these participants, only 295 (35%) responded correctly regarding the definition of sepsis. However, 1,019 participants (94.3%) had heard of acute myocardial infarction, and 817 of these (80%) correctly defined acute myocardial infarction. Regarding stroke, 1,047 (96.9%) had heard of stroke, and 975 of these responded (93.1%) correctly to the definition of stroke. Conclusion There is poor public awareness about sepsis compared with that of acute myocardial infarction and stroke. This may limit the timely management of severe sepsis and septic shock.