Yun Sik Hong

An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest: a propensity-matched study

IntroductionProlonged conventional cardiopulmonary resuscitation (CCPR) is associated with a poor prognosis in out-of-hospital cardiac arrest (OHCA) patients. Alternative methods can be needed to improve the outcome in patients with prolonged CCPR and extracorporeal cardiopulmonary resuscitation (ECPR) can be considered as an alternative method. The objectives of this study were to estimate the optimal duration of CPR to consider ECPR as an alternative resuscitation method in patients with CCPR, and to find the indications for predicting good neurologic outcome in OHCA patients who received ECPR.MethodsThis study is a retrospective analysis based on a prospective cohort. We included patients ≥18 years of age without suspected or confirmed trauma and who experienced an OHCA from May 2006 to December 2013. First, we determined the appropriate cut-off duration for CPR based on the discrimination of good and poor neurological outcomes in the patients who received only CCPR, and then we compared the outcome between the CCPR group and ECPR group by using propensity score matching. Second, we compared CPR related data according to the neurologic outcome in matched ECPR group.ResultsOf 499 patients suitable for inclusion, 444 and 55 patients were enrolled in the CCPR and ECPR group, respectively. The predicted duration for a favorable neurologic outcome (CPC1, 2) is < 21 minutes of CPR in only CCPR patients. The matched ECPR group with ≥21 minutes of CPR duration had a more favorable neurological outcome than the matched CCPR group at 3 months post-arrest. In matched ECPR group, younger age, witnessed arrest without initial asystole rhythm, early achievement of mean arterial pressure ≥60 mmHg, low rate of ECPR-related complications, and therapeutic hypothermia were significant factors for expecting good neurologic outcome.ConclusionsECPR should be considered as an alternative method for attaining good neurological outcomes in OHCA patients who required prolonged CPR, especially of ≥21 minutes. Younger or witnessed arrest patients without initial asystole were good candidates for ECPR. After implantation of ECPR, early hemodynamic stabilization, prevention of ECPR-related complications, and application of therapeutic hypothermia may improve the neurological outcome.

Concordance of End-Tidal Carbon Dioxide and Arterial Carbon Dioxide in Severe Traumatic Brain injury

OBJECTIVE It is important for preventing hyperventilation so as to improve the outcomes of patients with severe traumatic brain injuries. End-tidal CO2 (Petco2) reflects arterial CO2 (Paco2), noninvasively and continuously. The aim of this study is to examine the concordance between Paco2 and Petco2 among adults presenting to the emergency department with severe traumatic brain injury and to elucidate the patient groups who had discordance. METHODS From July 1, 2006 to December 31, 2007, 77 patients who presented in the emergency department of the hospital after severe brain injury were enrolled. Glasgow Coma Scale, blood pressure, heart rate, respiration rate, body temperature, arterial blood gas variables, and serum lactate levels were measured under the mechanical ventilation support. Finally, Injury Severity Score and Abbreviated Injury Scale of head and chest were recorded. The concordance between Petco2 and Paco2 was analyzed using Bland-Altman plot. We defined that normal gap of Paco2 and Petco2 [P(a-et)co2] is -5 mm Hg to 5 mm Hg, and compared the normal and high P(a-et)co2 groups to find the factors affecting the P(a-et)co2. RESULTS Sixty-six patients after exception of 11 patients with nontraumatic brain injury were analyzed. Ten patients (15.2%) were below 30 mm Hg of Paco2. Pearsons correlation coefficient between Paco2 and Petco2 was 0.666 (p < 0.001) and the concordance between Paco2 and Petco2 was 77.3%. The patients with high P(a-et)co2 showed significantly higher Injury Severity Score, lower systolic blood pressure, lower arterial pH, lower base deficit, and higher serum lactate levels than patients with normal P(a-et)co2. Patients with severe chest trauma, hypotension, and metabolic acidosis increased the risk of the discordance between Paco2 and Petco2. Twenty-eight patients who had no hypotension, no metabolic acidosis, and no severe chest trauma showed concordance rate of 100.0% between Paco2 and Petco2. CONCLUSIONS Severe chest trauma and hemodynamic and tissue perfusion state should be considered when attempting to monitor the hyperventilation in severe brain injury patients using Petco2.

Anticholinesterase therapy for patients with ophthalmoplegia following snake bites: Report of two cases

Although ophthalmoplegia following snake bites is not indicative of a serious neurotoxic complication, symptoms of diplopia, dizziness and ocular discomfort can be emotionally devastating for patients. The authors experienced two cases of ophthalmoplegia following snake bites in Korea. The patients complained of diplopia that had developed several hours after the snake bites. The diplopia did not improve with antivenom treatment, but resolved completely after several injections of neostigmine.

Effect of hypertonic saline on apoptosis of polymorphonuclear cells

BACKGROUND The function of polymorphonuclear (PMN) cells can be influenced by the choice of resuscitation fluids in hemorrhagic shock. Widespread interest in the use of hypertonic solutions for resuscitation has led to extensive investigation of their immune-modulating properties. Hypertonic saline (HTS) is known to modulate immune reactions, preventing the multiorgan failure mediated by immune reactions in trauma and hemorrhagic shock. PMN cells play a key role in such immune-mediated inflammatory processes, and HTS is believed to affect these PMN cells. However, how these events influence the actual event of apoptosis has not yet been described. Thus, in the present study, we aimed to investigate the differences in the apoptosis of PMN cells when exposed to isotonic and hypertonic environments and the temporal relations between the interval of administration of HTS after the stimulation of PMN cells. METHODS Whole blood was sampled from healthy volunteers, and the PMN cells were isolated. The isolated layer of PMN cells was washed twice with phosphate-buffered saline to yield the PMN cells. The number of cells was kept uniform, and an overall survival rate greater than 95% was maintained. After stimulation of the isolated PMN cells with N-formyl-methionyl-leucyl-phenylalanine, the PMN cells were allocated into 3 study groups (i.e., 1 isotonic group and 2 hypertonic groups with an osmolarity of 160 mM and 180 mM each). The extent of apoptosis was investigated in each group after culturing the PMN cells for 0, 1, 3, 6, 12, 15, 18, and 24 h. Depending on whether the PMN cells were stimulated with N-formyl-methionyl-leucyl-phenylalanine, they were also divided into stimulated and nonstimulated groups. In the stimulated group, the hypertonic environment was fostered immediately (HTS 0 h) and 6 h (HTS 6 h) after stimulation, which was accomplished after allocating the cells into an isotonic group (140 mM) and a hypertonic group (180 mM), according to the concentration of the culture medium. The PMN cells were then cultured at 37°C for 15 h with 5% carbon dioxide incubation. Each PMN suspension was labeled with Annexin V-fluorescein isothiocyanate and propidium iodide. Each sample underwent immediate flow cytometric analysis. PMN cells with high propidium iodide uptake were considered nonviable (necrotic). Among the viable PMN cells, those with no Annexin V uptake were considered normal and those with Annexin V uptake were considered apoptotic. RESULTS Decreased apoptosis was observed in the PMN cells stimulated with N-formyl-methionyl-leucyl-phenylalanine. Increased apoptosis was observed in the stimulated PMN cells incubated in hypertonic condition compared with the cells incubated in isotonic condition. Early HTS administration demonstrated increased apoptosis compared with late administration. CONCLUSIONS HTS treatment resulted in increased PMN apoptosis and an anti-inflammatory effect. Decreased apoptosis (prolonged lifespan) has been implicated in neutrophil-mediated tissue damage. HTS, by increasing the apoptosis of PMN cells, attenuates the postinjury inflammatory response. Also, early treatment with HTS was more efficient than delayed treatment.

Gastric emphysema after methyl ethyl ketone peroxide ingestion.

A 53-year-old male visited our emergency department after ingesting an unknown amount of methyl ethyl ketone peroxide. At presentation, he was hypotensive with reduced conscious level. Despite resuscitation, he died about 6 h after admission. On simple radiography, it was found that the patient had diffused gastric emphysema. We assumed that the unique radiologic findings were derived from the increased upper gastrointestinal tract pressure that occurred during bag–valve–mask ventilation with the patient having severely damaged gastric mucosa.

Initial Low Oxygen Extraction Ratio Is Related to Severe Organ Dysfunction and High In-Hospital Mortality in Severe Sepsis and Septic Shock Patients

BACKGROUND In severe sepsis and septic shock, global tissue hypoxia is a key development preceding multi-organ failure and death. OBJECTIVE Our aim was to find whether the initial low oxygen extraction ratio (OER) is related to the severity of organ dysfunction and to predict the in-hospital mortality in severe sepsis or septic shock patients. METHODS This was a secondary analysis of 169 patients with severe sepsis or septic shock in an emergency department. We calculated OER with 1- central venous oxygen saturation (ScvO2)/arterial oxygen saturation and compared the data according to the level of OER (high > 0.3, 0.2 ≤ normal ≤ 0.3, lower < 0.2). RESULTS A total 133 patients were selected for analysis. OER was inversely proportional to ScvO2 (r(2) = 0.878; p < 0.001). The sepsis-related organ failure assessment score and in-hospital mortality of each group were 6.2 ± 3.7 and 37.0% for high OER, 5.7 ± 3.0 and 11.8% for normal OER, and 7.7 ± 3.9 and 41.7% for low OER, respectively (p = 0.034; p = 0.003). In patients with initial ScvO2 of >70%, in-hospital mortality of patients with low OER was significantly higher than patients with normal OER. CONCLUSIONS Initial low OER was associated with severe organ dysfunction that resulted in high mortality with severe sepsis and septic shock. When patients had initial ScvO2 of > 70% but abnormally low OER, their in-hospital mortality was higher than in normal OER patients. Therefore, the OER should be considered when attempting to predict the outcome of septic patients using ScvO2 at an early stage of management for sepsis.

Gastric pneumatosis and acute massive gastric dilatation without specific cause.

A 53-year-old man presented to the Emergency Department (ED) with a chief complaint of 15 h of abdominal distension and vomiting. He had a history of hypertension but had not undergone any surgeries. On presentation he was alert with the following vital signs: blood pressure, 140/100 mm Hg; heart rate, 100 beats/ min; respiratory rate, 20 breaths/min; and body temperature, 36 C. Bowel sounds were absent and no tenderness was noted. Blood sampling results were as follows: white blood cells, 23.4 10/mm; hemoglobin, 15.2 g/dL; normal platelet count; normal electrolyte levels; and serum creatinine, 1.6 mg/dL. Urine analysis was positive for glucosuria and hematuria. Massive gastric dilatation was observed on a plain abdominal film (Figure 1). Intravenous fluid replacement was initiated and a nasogastric tube was inserted, which drained 1500 cc of dark-brown fluid in 5 h. Vital signs after drainage were: blood pressure, 180/100 mm Hg; heart rate, 140 beats/min; and respiratory rate, 26 breaths/ min. No abdominal pain or fever was observed. The patient’s symptoms had not improved, and further diagnostic modalities were ordered. An abdominal computed tomography (CT) scan revealed gastric pneumatosis (GP), along with diffuse gas in the hepatoportal, splenic, and intrahepatic portal vein,

Acute traumatic coagulopathy decreased actual survival rate when compared with predicted survival rate in severe trauma

Objective To determine whether acute traumatic coagulopathy (ATC) should be combined with the trauma and injury severity score (TRISS) to predict outcome in severe trauma patients and investigate effects of the change in coagulation state during early resuscitation on the actual survival rate. Methods This was a retrospective study. Significant variables that affected 28-day mortality were analysed using multivariate logistic regression. Study patients were classified into three groups: no coagulopathy, mild coagulopathy or severe coagulopathy. Concordance between actual and predicted survival rates were compared for each group. The predicted survival rate was calculated using the TRISS method. The study also determined whether changes in the coagulation state during inhospital resuscitation affected the relationship between actual and predicted survival in patients who had rechecked coagulation profile within 12 h after presentation. Results Data from a total of 336 patients were analysed. At presentation, 20.8% of the study patients had mild coagulopathy, whereas 7.7% had severe coagulopathy. Age, injury severity score, revised trauma score and presence of ATC at presentation were independently associated with 28-day mortality. Actual survival was significantly lower than predicted survival in the mild and severe coagulopathy groups. Aggravation of coagulation state from normal or mild to severe coagulopathy or persistent severe coagulopathy during inhospital resuscitation mainly contributed to the discrepancy between actual and predicted survival. Conclusions ATC decreased actual survival more than expected. ATC should be combined with TRISS to predict trauma outcome in severely injured patients. Improvement in coagulopathy during resuscitation may reduce the incidence of preventable death after trauma.

Effects of atmospheric temperature and humidity on outbreak of diseases

Objective:  The present study aimed to determine the plausibility of forecasting the outbreak of diseases based on the weather by analysing the impact of atmospheric temperature and humidity on the occurrence of different diseases.

Radiological misinterpretations by emergency physicians in discharged minor trauma patients

Introduction Unerring radiological interpretation is essential in discharged minor trauma patients without follow-up visits based on the rapid decision of emergency physicians (EPs). Misinterpretation may raise issues concerning patient care, reimbursement and lawsuits. The authors investigated the discrepancies and associated factors in radiological interpretation for discharged trauma patients between EPs and radiologists. Methods The authors included trauma patients who visited the emergency department, from 1 August 2009 to 31 July 2010, and searched for cases showing discrepancy using the ‘modified quality assurance model for radiological interpretation’. The overall/clinically significant discrepancy (CSD)/clinically insignificant discrepancy (CinSD) rates were calculated. The authors also looked at the relationship between discrepancies and several factors including age and time of visit. Results 10 243 cases were related to minor trauma, in which the radiological images were interpreted as normal by EPs. The overall discrepancy, the CSD and CinSD rates were 0.77% (n=79), 0.47% (n=48) and 0.3% (n=31), respectively. No discrepancy was shown to be related to the day or time of visit. The discrepancy rate turned out to be relatively higher with increasing age, and for injuries of the extremities. No associated factors were found between the CSD and CinSD groups. Conclusions Despite a relatively low CSD rate, careful interpretation is recommended considering age and body areas imaged. A modified model would be needed as a supportive tool for training and improving the quality of care. A further development of the modified system for efficient use of resources will be needed to focus on quality improvement and education in each hospital.