Yong Won Kim

Pyrethroid poisoning: features and predictors of atypical presentations

Background Although pyrethroids are known for low toxicity to humans, clinical systemic characteristics of pyrethroid poisoning remain undefined. We investigated atypical presentations of pyrethroid poisoning and the predictors, among those readily assessed in the emergency department. Methods 59 pyrethroid poisoning cases that were diagnosed and treated at the emergency department of Wonju Severance Christian Hospital from September 2004 to December 2012 were retrospectively reviewed. Results Atypical presentations were seen in 22 patients (39.3%). Atypical presentations after pyrethroid poisoning included respiratory failure requiring ventilator care (10 patients, 17.9%), hypotension (systolic blood pressure <90 mm Hg) (6 patients, 10.7%), pneumonia (4 patients, 7.1%), acute kidney injury (6 patients, 10.7%), Glasgow Coma Scale (GCS) <15 (19 patients, 33.9%), seizure (2 patients, 3.6%) and death (2 patients, 3.6%). There were differences between atypical versus typical groups in terms of age (62.1±3.7 vs 51.0±2.9, p=0.020), ingested amounts (300 (IQR 100–338) cc vs 100 (IQR 50–300) cc, p=0.002), and bicarbonate and serum lactate (17.4±1.1 vs 20.5±0.4, p=0.011; and 4.42 (IQR 3.60–7.91) mmol/L vs 3.01 (IQR 2.16–4.73) mmol/L, p=0.010, respectively) in initial arterial blood gas analysis. Predictors of the atypical presentations were ingested amount and serum lactate ((OR 1.004, 95% CI 1.001 to 1.008, p=0.013) and (OR 1.387, CI 1.074 to 1.791, p=0.012), respectively). The optimal points were 250 cc and 3.5 mmol/dL. Conclusions 39.3% of pyrethroid poisoned patients had atypical presentations with the most common being respiratory failure requiring ventilator care. Predictors of atypical presentation were ingested amount >250 cc and serum lactate >3.5 mmol/L.

Shock Duration after Resuscitation Is Associated with Occurrence of Post-Cardiac Arrest Acute Kidney Injury

This retrospective observational study investigated the clinical course and predisposing factors of acute kidney injury (AKI) developed after cardiac arrest and resuscitation. Eighty-two patients aged over 18 yr who survived more than 24 hr after cardiac arrest were divided into AKI and non-AKI groups according to the diagnostic criteria of the Kidney Disease/Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for AKI. Among 82 patients resuscitated from cardiac arrest, AKI was developed in 66 (80.5%) patients (AKI group) leaving 16 (19.5%) patients in the non-AKI group. Nineteen (28.8%) patients of the AKI group had stage 3 AKI and 7 (10.6%) patients received renal replacement therapy during admission. The duration of shock developed within 24 hr after resuscitation was shorter in the non-AKI group than in the AKI group (OR 1.02, 95% CI 1.01-1.04, P < 0.05). On Multiple logistic regression analysis, the only predisposing factor of post-cardiac arrest AKI was the duration of shock. In conclusion, occurrence and severity of post-cardiac arrest AKI is associated with the duration of shock after resuscitation. Renal replacement therapy is required for patients with severe degree (stage 3) post-cardiac arrest AKI.

Parenchymal lung injuries related to standard cardiopulmonary resuscitation

Objectives: We analyzed chest computed tomographic scan to evaluate parenchymal lung injury and its clinical significance in patients who received standard cardiopulmonary resuscitation and were resuscitated from cardiac arrest. Methods: We enrolled nontraumatic out‐of‐hospital cardiac arrest patients older than 19 years who had been admitted to the emergency department in cardiac arrest and successfully resuscitated after cardiopulmonary resuscitation. Chest computed tomography was obtained immediately after return of spontaneous circulation (ROSC). To allocate the area of lung contusion, we divided both hemithoraces into 3 regions longitudinally, and each part was subdivided into 4 segments except the lower part of the left lung. To stratify the severity of lung contusion, each segment was scored depending on the area of lung contusion. Oxygen index (OI) was measured at the time of ROSC, 24, 48, and 72 hours and 1 week after cardiac arrest. Results: Lung contusion was developed in 37 (41%) patients and median lung contusion score (LCS) was 17 (12‐26). Lung contusion was not associated with hospital mortality (P = .924) or length of intensive care unit stay (P = .446). The OI at the time of ROSC was lower in patients with LCS greater than 23 than that in patients with LCS less than or equal to 23 (126 [93‐224] vs 278 [202‐367]; P = .008); however, the OI at the other timelines was not different between patients with LCS greater than 23 and patients with LCS less than or equal to 23. Conclusion: Extensive lung contusion is associated with a lower oxygenation index at the time of ROSC, but did not affect the resuscitation outcome.

Evaluation of usefulness of myeloperoxidase index (MPXI) for differential diagnosis of systemic inflammatory response syndrome (SIRS) in the emergency department

Background The myeloperoxidase index (MPXI) is elevated in infection. We ascertained whether MPXI might be useful in differentiation of sepsis versus non-infectious systemic inflammatory response syndrome (SIRS) in emergency department (ED). Methods After exclusion of patients with an age of <18 years, trauma, haematological disease and on anticancer chemotherapy, 444 consecutive cases with SIRS (sepsis: 224, 50.3%; and non-infectious SIRS: 220, 49.7%) diagnosed and treated at the ED of The Wonju Severance Christian Hospital from May 2012 to June 2012 were retrospectively reviewed. Results Median MPXI was higher in sepsis versus non-infectious SIRS (0.1 (IQR: −3.1 to 2.5) vs −1.2 (−4.1 to 1.6), respectively, p=0.020). Median white cell count, neutrophil percentage, C reactive protein level and δ neutrophil index were also higher. However, MPXI resulted as not statistically useful for differential diagnostic parameter in analysis. Conclusions MPXI is higher in sepsis than in non-infectious SIRS. However, there is currently no evidence that the MPXI adds any additional benefit to differentiate sepsis from non-infectious SIRS in the ED. Therefore, further study will be needed.

The gradient between arterial and end-tidal carbon dioxide predicts in-hospital mortality in post-cardiac arrest patient

Purpose: We investigated the predictive value of the gradient between arterial carbon dioxide (PaCO2) and end‐tidal carbon dioxide (ETCO2) (Pa‐ETCO2) in post‐cardiac arrest patients for in‐hospital mortality. Methods: This retrospective observational study evaluated cardiac arrest patients admitted to the emergency department of a tertiary university hospital. The PaCO2 and ETCO2 values at 6, 12, and 24 h after return of spontaneous circulation (ROSC) were obtained from medical records and Pa‐ETCO2 gap was calculated as the difference between PaCO2 and ETCO2 at each time point. Multivariate logistic regression analysis was performed to verify the relationship between Pa‐ETCO2 gap and clinical variables. Receiver operating characteristic (ROC) curve analysis was performed to determine the cutoff value of Pa‐ETCO2 for predicting in‐hospital mortality. Results: The final analysis included 58 patients. In univariate analysis, Pa‐ETCO2 gaps were significantly lower in survivors than in non‐survivors at 12 h [12.2 (6.5–14.8) vs. 13.9 (12.1–19.6) mmHg, p = 0.040] and 24 h [9.1 (6.3–10.5) vs. 17.1 (13.1–23.2) mmHg, p < 0.001)] after ROSC. In multivariate analysis, Pa‐ETCO2 gap at 24 h after ROSC was related to in‐hospital mortality [odds ratio (95% confidence interval): 1.30 (1.07–1.59), p = 0.0101]. In ROC curve analysis, the optimal cut‐off value of Pa‐ETCO2 gap at 24 h after ROSC was 10.6 mmHg (area under the curve, 0.843), with 77.8% sensitivity and 85.7% specificity. Conclusion: The Pa‐ETCO2 gap at 24 h after ROSC was associated with in‐hospital mortality in post‐cardiac arrest patients.

Comparison Between 30:1 and 30:2 Compression-to-ventilation Ratios for Cardiopulmonary Resuscitation: Are Two Ventilations Necessary?

OBJECTIVES Controversy is continuing over the need for ventilation and the optimal compression-ventilation (CV) ratio during cardiopulmonary resuscitation (CPR). The aim of this study was to comparatively elucidate the effect on hemodynamics and arterial oxygen saturation of a single ventilation relative to two consecutive ventilations during CPR in a dog model of cardiac arrest. METHODS Twenty mongrel dogs were divided into two groups. After 3 minutes of ventricular fibrillation (VF), the single-ventilation group received CPR with a 30:1 CV ratio, and the two-ventilation group received CPR with a 30:2 CV ratio, all with room air for 7 minutes. Thereafter, continuous chest compressions and intermittent ventilation at rate of 10 per minute were followed for both groups for 10 minutes. Hemodynamic parameters, arterial blood gas profiles, and variables from CPR were compared at baseline and at 5, 10, 15, and 20 minutes after induction of VF. RESULTS Hemodynamic parameters including aortic systolic and diastolic pressures, right atrial systolic and diastolic pressures, coronary perfusion pressure, end-tidal carbon dioxide tension, and arterial blood gas profiles including arterial oxygen tension, arterial oxygen saturation, and arterial carbon dioxide tension were not different between two groups during CPR. In the 30:1 group, the period of compression interruption was shorter and chest compression fraction was higher than that in the 30:2 group (6 sec/min vs. 10.9 sec/min, p < 0.001; 90.0% vs. 81.8%, p < 0.001). CONCLUSIONS CPR with a 30:1 CV ratio, compared to CPR with a 30:2 CV ratio, results in comparable arterial oxygenation saturation and hemodynamics.