Young Min Oh

The usefulness of the semiquantitative procalcitonin test kit as a guideline for starting antibiotic administration.

OBJECTIVES The Surviving Sepsis Campaign has recommended that antibiotic therapy should be started within the first hour of recognizing severe sepsis. Procalcitonin has recently been proposed as a biomarker of bacterial infection, although the quantitative procalcitonin assay is often time consuming, and it is not always available in many emergency departments (EDs). Our aim is to evaluate usefulness of the semiquantitative procalcitonin fast kit as a guideline for starting antibiotic administration for patients with severe sepsis or septic shock that requires prompt antibiotic therapy in the ED. METHODS We include those patients who were admitted to the ED and who were suspected of having infection. The procalcitonin concentration was determined by semiquantitative PCT-Q strips, and the points of the severity scoring system were calculated. The receiver operating characteristic curve was used to assess the diagnostic value of the PCT-Q strips to predict severe sepsis or septic shock. RESULTS Of the 80 recruited patients, 33 patients were categorized as having severe sepsis or septic shock according to the definition. At a procalcitonin cutoff level of 2 ng/mL or greater, the sensitivity of the PCT-Q for detecting severe sepsis or septic shock was 93.94% and the specificity was 87.23. The receiver operating characteristic curve for PCT-Q to predict severe sepsis or septic shock had an area under the curve of 0.916. CONCLUSION PCT-Q is probably a fast, useful method for detecting severe sepsis in the ED, and it can be used as a guideline for antibiotic treatment.

GlideScope video laryngoscopy versus direct laryngoscopy in the emergency department: a propensity score-matched analysis

Objective To evaluate whether the use of a GlideScope video laryngoscope (GVL) improves first-attempt intubation success compared with the Macintosh laryngoscope (MAC) in the emergency department (ED). Design A propensity score-matched analysis of data from a prospective multicentre ED airway registry—the Korean Emergency Airway Management Registry (KEAMR). Setting 4 academic EDs located in a metropolitan city and a province in South Korea. Participants A total of 4041 adult patients without cardiac arrest who underwent emergency intubation from January 2007 to December 2010. Outcome measures The primary and secondary outcomes were successful first intubation attempt and intubation failure, respectively. To reduce the selection bias and potential confounding effects, we rigorously adjusted for the baseline differences between two groups using a propensity score matching. Results Of the 4041 eligible patients, a GVL was initially used in 540 patients (13.4%). Using 1:2 propensity score matching, 363 and 726 patients were assigned to the GVL and MAC groups, respectively. The adjusted relative risks (95% CIs) for the first-attempt success rates with a GVL compared with a MAC were 0.76 (0.56 to 1.04; p=0.084) and the respective intubation failure rates 1.03(0.99 to 1.07; p=0.157). Regarding the subgroups, the first-attempt success of the senior residents and attending physicians was lower with the GVL (0.47 (0.23 to 0.98), p=0.043). In the patients with slight intubation difficulty, the first-attempt success was lower (0.60 (0.41 to 0.88), p=0.008) and the intubation failure was higher with the GVL (1.07 (1.02 to 1.13), p=0.008). Conclusions In this propensity score-matched analysis of data from a prospective multicentre ED airway registry, the overall first-attempt intubation success and failure rates did not differ significantly between GVL and MAC in the ED setting. Further randomised controlled trials are needed to confirm our findings.

A Randomized Comparison Simulating Face to Face Endotracheal Intubation of Pentax Airway Scope, C-MAC Video Laryngoscope, Glidescope Video Laryngoscope, and Macintosh Laryngoscope.

Objectives. Early airway management is very important for severely ill patients. This study aimed to investigate the efficacy of face to face intubation in four different types of laryngoscopes (Macintosh laryngoscope, Pentax airway scope (AWS), Glidescope video laryngoscope (GVL), and C-MAC video laryngoscope (C-MAC)). Method. Ninety-five nurses and emergency medical technicians were trained to use the AWS, C-MAC, GVL and Macintosh laryngoscope with standard airway trainer manikin and face to face intubation. We compared VCET (vocal cord exposure time), tube pass time, 1st ventilation time, VCET to tube pass time, tube pass time to 1st ventilation time, and POGO (percentage of glottis opening) score. In addition, we compared success rate according to the number of attempts and complications. Result. VCET was similar among all laryngoscopes and POGO score was higher in AWS. AWS and Macintosh blade were faster than GVL and C-MAC in total intubation time. Face to face intubation success rate was lower in GVL than other laryngoscopes. Conclusion. AWS and Macintosh were favorable laryngoscopes in face to face intubation. GVL had disadvantage performing face to face intubation.

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...

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.

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.

Predicting long-term outcomes after cardiac arrest by using serum neutrophil gelatinase-associated lipocalin

Objectives: Neutrophil gelatinase‐associated lipocalin (NGAL) is secreted by various tissues in pathologic states. Previous studies reported that post‐cardiac arrest serum NGAL levels correlate with short‐term neurologic outcomes and survival. The aim of this study was to examine the associations between NGAL levels post‐cardiac arrest and long‐term outcomes and survival. Methods: This prospective observational study and retrospective review included adult out‐of‐hospital cardiac arrest survivors who were treated by hypothermia‐targeted temperature management. Serum NGAL was assessed at 0, 24, 48, and 72 h after return of spontaneous circulation. The primary outcome was poor outcome at six months after cardiac arrest, defined as cerebral performance category score of 3–5. The secondary outcome was six‐month mortality. Results: In total, 76 patients were analyzed. The patients with poor outcomes showed significantly higher NGAL levels at 24, 48 and 72 h after cardiac arrest than the patients with good outcomes. Long‐term survival rates were significantly lower in the high‐NGAL group than in the low‐NGAL group at each time point. Subgroup analysis of patients who survived 72 h showed that only serum NGAL 72 h after cardiac arrest had prognostic value for long‐term outcomes (area under the receiver operating characteristic curve = 0.72; p = 0.02). Conclusions: Post‐cardiac arrest serum NGAL is associated with long‐term outcomes and survival; particularly, three days post‐cardiac arrest is the optimal time point for predicting long‐term outcomes. However, the predictive power of NGAL is unsatisfactory, and it should be regarded as an additional prognostic modality.

Comparison of Different Thawing Methods on Cryopreserved Rabbit Aorta

ABSTRACT The studies on cryopreserved arterial allografts have been focused on cooling methods, pre-treatment, cryoprotectant agents, and preservation temperature. But recently, several studies have reported that thawing methods also play an important role in the occurrence of macroscopic and microscopic cracks. This study was designed to investigate the expression of apoptosis after thawing, using a rabbit model to clarify the effect of thawing methods on cryopreserved arteries. Segments of the rabbit aorta were obtained and divided into 3 groups (n=60) according to whether the specimens were fresh (control, n=20), cryopreserved and rapidly thawed (RT) at 37°C (n=20), or cryopreserved and subjected to controlled, automated slow thawing (ST) (n=20). Cell damage was established using the TUNEL method and the morphological and microstructural changes were also evaluated. In the group that was rapidly thawed, the expression of TUNEL (+) cells increased significantly more than in the slowly thawed group. In addition, the endothelial denudation, microvesicles and edema were significant in the rapidly thawed group compared with the microstructural changes in the slowly thawed group. Our study suggests that the rapidly thawing method may be the major cause of cellular damage and delayed rupture in cryopreserved arterial allografts. The expression of TUNEL (+) cells and structural changes were significantly lower in the slowly thawed group, which might have contributed to the improvement of graft failure after transplantation.