Yeon Young Kyong

An observational study of surface versus endovascular cooling techniques in cardiac arrest patients: a propensity-matched analysis

IntroductionVarious methods and devices have been described for cooling after cardiac arrest, but the ideal cooling method remains unclear. The aim of this study was to compare the neurological outcomes, efficacies and adverse events of surface and endovascular cooling techniques in cardiac arrest patients.MethodsWe performed a multicenter, retrospective, registry-based study of adult cardiac arrest patients treated with therapeutic hypothermia presenting to 24 hospitals across South Korea from 2007 to 2012. We included patients who received therapeutic hypothermia using overall surface or endovascular cooling devices and compared the neurological outcomes, efficacies and adverse events of both cooling techniques. To adjust for differences in the baseline characteristics of each cooling method, we performed one-to-one matching by the propensity score.ResultsIn total, 803 patients were included in the analysis. Of these patients, 559 underwent surface cooling, and the remaining 244 patients underwent endovascular cooling. In the unmatched cohort, a greater number of adverse events occurred in the surface cooling group. Surface cooling was significantly associated with a poor neurological outcome (cerebral performance category 3–5) at hospital discharge (p = 0.01). After propensity score matching, surface cooling was not associated with poor neurological outcome and hospital mortality [odds ratio (OR): 1.26, 95% confidence interval (CI): 0.81-1.96, p = 0.31 and OR: 0.85, 95% CI: 0.55-1.30, p = 0.44, respectively]. Although surface cooling was associated with an increased incidence of adverse events (such as overcooling, rebound hyperthermia, rewarming related hypoglycemia and hypotension) compared with endovascular cooling, these complications were not associated with surface cooling using hydrogel pads.ConclusionsIn the overall matched cohort, no significant difference in neurological outcomes and hospital morality was observed between the surface and endovascular cooling methods.

Current practices for paediatric procedural sedation and analgesia in emergency departments: results of a nationwide survey in Korea

Objective Procedural sedation and analgesia (PSA) in children has become a standard tool in emergency settings, but no national PSA guidelines have been developed for the emergency department (ED) in Korea. Therefore, we investigated the practice of PSA and the level of adherence to institutional PSA guidelines in EDs of teaching hospitals. Methods This study was a cross-sectional, web-based survey. The study subjects were the faculty of EDs from 96 teaching hospitals. The questionnaire was posted on an internet site, and the participants were requested that the questionnaire be answered by email and telephone in May 2009. Results The questionnaires were completed by 67.7% of the participants. Only 20% of EDs had institutional PSA guidelines, 21.5% of those had discharge criteria and 13.8% of EDs had a discharge instruction form. Residents were administered PSA at 76.9% of EDs. The airway rescue equipment was near the area where PSA was performed in 76.9% of EDs. The most commonly used medication for both diagnostic imaging and painful procedure was oral chloral hydrate (87.7%, 61.5%). In 64.6% of EDs, patients were monitored. In only 21 cases, EDs (50.0%) monitored the patients to recovery after PSA or discharge. Conclusions Current PSA for paediatric patients have not been appropriately applied in Korea. Unified PSA guidelines were rare in the hospitals surveyed, and many patients were not monitored over an appropriate duration, nor did they receive adequate medications for sedation by the best trained personnel. Therefore, the national PSA guidelines must be developed and implemented as early as possible.

Combination treatment with 17β-estradiol and therapeutic hypothermia for transient global cerebral ischemia in rats

OBJECTIVE Therapeutic hypothermia is now regarded as the only effective treatment of global ischemic injury after cardiac arrest. Numerous studies of the neuroprotective effects of 17β-estradiol have yielded conflicting results depending on administration route and dose. Herein, we investigated the neuroprotective effect of postischemic 17β-estradiol administration combined with therapeutic hypothermia. METHODS Twenty-one rats were randomly divided into 4 groups: control (group I), therapeutic hypothermia (group II), 17β-estradiol treatment (group III), and therapeutic hypothermia combined with 17β-estradiol treatment (group IV). One rat was assigned to a sham operation group. With the exception of the sham-operated rat, all animals underwent transient global cerebral ischemia for 20 minutes by the 4-vessel occlusion method. Hypothermia was maintained at 33°C for 2 hours in groups II and IV, and 17β-estradiol (10 μg/kg) was intraperitoneally administered to rats in groups III and IV. Neurologic deficit scores and hippocampal cornu ammonis 1 neuronal injury were assessed 72 hours postischemia. RESULTS The neurologic deficit score was not significantly different among the groups. The percentage of normal neurons in the hippocampal cornu ammonis 1 was 7.32% ± 0.88% in group I, 53.65% ± 2.52% in group II, 51.6% ± 3.44% in group III, and 79.79% ± 1.6% in group IV. The neuroprotective effect in the combined treatment group was markedly greater than in the single treatment groups, which suggests that hypothermia and 17β-estradiol work synergistically to exert neuroprotection. CONCLUSION Postischemic administration of low-dose 17β-estradiol appears to be neuroprotective after transient global ischemia, and its effect is potentiated by therapeutic hypothermia.

“Hyperammonemia following glufosinate-containing herbicide poisoning: A potential marker of severe neurotoxicity” by Yan-Chido Mao et al., Clin Toxicol (Phila) 2011; 49:48–52

To the Editor:We read the article by Mao et al. on hyperammonemia following glufosinate-containing herbicide poisoning with interest.1 We wish to report a further 13 cases of poisoning with the amm...

Physician and nurse knowledge about patient radiation exposure in the emergency department

BACKGROUND Imaging methods that use ionizing radiation in emergency departments (EDs) have increased with advances in radiological diagnostic methods. Physician and nurse awareness of the radiation dose in the ED and the associated cancer risks to which the patients are exposed were surveyed with a questionnaire. METHODS A total of 191 subjects in six EDs participated in this study. ED physicians and ED nurses were asked about the risks and the radiation doses of imaging methods ordered in the ED. The differences between the two groups were compared using Students t-test for continuous variables. A Fishers exact and Chi-squared tests were used for categorical variables. RESULTS A total of 82 ED physicians and 109 ED nurses completed the questionnaire; 38 (46.3%) physicians and 8 (7.3%) nurses correctly answered the question about the chest X-ray radiation dose. A question about the number of chest X-rays that is equivalent to the dose of a pelvic X-ray was answered correctly by 5 (6.1%) physicians and 9 (8.3%) nurses (P = 0.571). Questions regarding abdominal computed tomography (CT), chest CT, brain CT, abdominal ultrasonography, and brain magnetic resonance imaging were answered correctly more frequently by the physician group than the nurse group (P < 0.05). The risk of developing cancer over a lifetime due to a brain CT was correctly answered by 21 (25.6%) physicians and 30 (27.5%) nurses (P = 0.170). A similar question regarding abdominal CT was correctly answered by 21 (25.6%) physicians and 42 (38.5%) nurses (P = 0.127). CONCLUSIONS Knowledge of the radiation exposure of radiology examinations was lower in nurses than physicians, but knowledge was poor in both groups. ED physicians and nurses should be educated about radiation exposure and cancer risks associated with various diagnostic radiological methods.

Therapeutic hypothermia complicated by spontaneous brain stem hemorrhage

Hypothermia increases clotting time, which is known as hypothermic coagulopathy. However, prothrombin time and activated partial thromboplastin time prolongation associated with therapeutic hypothermia is usually mild and thus, hypothermic coagulopathy is not considered to cause clinically significant bleeding. On the other hand, PT and aPTT do not seem to reflect the severity of hypothermic coagulopathy. Serious bleeding complications of therapeutic hypothermia has not been reported previously. Herein, we introduce a case of spontaneous brain stem hemorrhage as a complication of therapeutic hypothermia-induced coagulopathy.

Serial monitoring of sedation scores in benzodiazepine overdose

Benzodiazepines are widely used for many diseases, and benzodiazepine overdose is globally increasing in proportion to its prescriptions. Although most benzodiazepine overdoses are known to be safe and nonfatal without coingestions, morbidity or mortality after benzodiazepine overdose is closely related with the duration of unconsciousness or depth of compromised airway. Proper use of flumazenil, a potent antidote of benzodiazepine, seems to accelerate the recovery from the toxicity after benzodiazepine overdose.However, as the case we present demonstrates, careful attention and repetitive evaluations before and after use of flumazenil may be needed in benzodiazepine overdose because resedation occurs in approximately 30% of total flumazenil-treated cases, which suggests that the risk of aspiration or incidental death after administrating flumazenil might be significant without careful monitoring.

Acinetobacter bacteremia following Agkistrodon envenoming.

Dear Editor, We report the case of Acinetobacter bacteremia following Agkistrodon envenoming. Proper administrations of antivenin successfully decrease the snakebiterelated morbidity and mortality. However, we suggest that clinicians must be alert for the occurrence of systemic infection after snakebite, although it is rare, which is clearly related with poor clinical outcome. A 51-year-old woman with no medical history was transferred to our hospital 5 days after snakebite. Immediately after she was bitten by a snake while working on the yard, she visited the primary hospital, where she received four vials of antivenin (Antivenin for Agkistrodon halys, 6000 IU/vial) daily for the progressive swelling and pain on the extremity. On arrival at our ED, she complained of severe abdominal pain. Vital signs were blood pressure of 100/60 mm Hg, heart rate of 100/min, respiratory rate of 26 breaths/min and temperature of 36.5°C. The affected extremity was painful and swelling, which extended to the inguinal area. The diffuse petechia and 0.5 cm-sized bulla without necrosis were found at the bite site. ABGA showed the following: pH, 7.42; PCO2, 23.1 mm Hg; Po2, 73 mm Hg; and HCO3−, 14.6 mmol/L. After blood samples were taken for routine laboratory test and blood culture, she received broad spectrum antibiotics, coagulation factors and platelet concentrations (Table 1). Microbiology laboratory reported Acinetobacter baumanni hemolyticus, sensitive to cefuroxime, was isolated and cultured from the patient’s blood. At the 19th day after the bite, the patient was discharged with good medical condition after the negative conversion of Acinetobacter bacteremia. Among the 14 species of snakes inhabited in Korea, only four species are venomous (three Agkistrodon species and one Rhabdophis species). The patient saw the snake crawl away. By showing the patient an illustrated animal book, causative snake species was identified as a viper snake (Agkistrodon brevicadus). Our patient showed extensive local injury, coagulopathy that had no response to antivenin therapy and Acinetobacter bacteremia following Agkistrodon envenoming. Coagulopathy is a common and unique systemic toxicity after Agkistrodon envenomations. Venominduced coagulopathy resembles intravascular haemolysis of other causes, but it can be characterised by

Severe systemic intoxication following triclopyr-TEA ingestion.

We report a case of triclopyr ingestion, a herbicide that acts via the auxin system in plants. It is classified as low-toxicity herbicide. The patient ingested this product and developed metabolic acidosis and coma with cardiovascular impairment. Echocardiography and elevated Troponin T and CK MB with prolongation of QTc suggested direct myocardial toxicity. The patient was extubated 57 h after ingestion, and he recovered completely. This case illustrates the potential acute toxicity of this agent in humans.

Suicidal hanging patient with complete tracheal rupture

In attempted suicide, laryngotracheal rupture caused by hanging leads to rapid death at the scene or before arrival at hospital. The case presented here describes a patient with complete tracheal rupture from an attempted suicidal hanging who was successfully resuscitated. Pre-hospital providers transferred the patient to hospital without being aware of the possibility of airway damage. Cardiac arrest occurred shortly after arrival at hospital. During the cardiopulmonary resuscitation, endotracheal intubation was performed, and fortunately, the tracheal tube was located just below the ruptured trachea and thus enabled ventilation. For patients suspected of having airway damage at the pre-hospital stage, awareness of the patient’s condition and adequate airway management are important. The management of laryngotracheal rupture which suggests that for patients not adequately ventilated, immediate treatment with flexible fiberoptic intubation or tracheostomy is needed to secure the airway. Equipment and personnel at the receiving hospital need to be prepared for immediate treatment.