Objective Myocardial rupture is a fatal complication of acute myocardial infarction (AMI). Early diagnosis of myocardial rupture is feasible when emergency physicians (EPs) perform emergency transthoracic echocardiography (TTE). The purpose of this study was to report the echocardiographic features of myocardial rupture on emergency TTE performed by EPs in the emergency department (ED).
Methods This was a retrospective and observational study involving consecutive adult patients presenting with AMI who underwent TTE performed by EPs in the ED of a single academic medical center from March 2008 to December 2019.
Results Fifteen patients with myocardial rupture, including eight (53.3%) with free wall rupture (FWR), five (33.3%) with ventricular septal rupture (VSR), and two (13.3%) with FWR and VSR, were identified. Fourteen of the 15 patients (93.3%) were diagnosed on TTE performed by EPs. Diagnostic echocardiographic features were found in 100% of the patients with myocardial rupture, including pericardial effusion for FWR and a visible shunt on the interventricular septum for VSR. Additional echocardiographic features indicating myocardial rupture were thinning or aneurysmal dilatation in 10 patients (66.7%), undermined myocardium in six patients (40.0%), abnormal regional motions in six patients (40.0%), and pericardial hematoma in six patients (40.0%).
Conclusion Early diagnosis of myocardial rupture after AMI is possible using echocardiographic features on emergency TTE performed by EPs.
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Objective Carbon monoxide (CO) poisoning causes brain injury by hypoxia and inflammatory mechanisms. Hypoxic conditions result in increased serum phosphate concentration due to loss of polarity of the cell membrane, changes in membrane fluidity, and consequent destruction of phospholipids in the cell membrane. This study aimed to evaluate whether serum phosphate measured in the emergency department (ED) can serve as an early predictor of neurocognitive sequelae 1 month after acute CO poisoning.
Methods We included patients ≥16 years with acute CO poisoning from a cohort who were treated at a single tertiary academic hospital in Wonju, Korea, between January 2006 and May 2021. Neurocognitive outcome was assessed using the Global Deterioration Scale score; patients were classified into favorable (1–3 points) or poor (4–7 points) neurocognitive outcome groups based on this score. These two groups were compared before and after propensity score matching.
Results Data from 888 patients were analyzed. Seven hundred seventy-one patients (86.8%) were assigned to the favorable outcome group and 117 patients (13.2%) to the poor outcome group. Patients with a poor outcome had a higher mean serum phosphate level than those with a favorable outcome (3.9 mg/dL vs. 3.5 mg/dL, P=0.001). Propensity score matching yielded 85 matched patient pairs. After matching, serum phosphate level in the ED was not significantly different between the favorable and poor outcome groups (3.9 vs. 3.7 mg/dL, P=0.349).
Conclusion Serum phosphate level measured in the ED did not predict poor neurocognitive outcomes 1 month after CO poisoning.
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Long-term mortality of adult patients with carbon monoxide poisoning presenting to the emergency department in Korea: a population-based cohort study Sang Hwan Lee, Soo Rack Ryu, Kyung Hun Yoo, Juncheol Lee, Yongil Cho, Tae Ho Lim, Hyunggoo Kang, Jaehoon Oh, Byuk Sung Ko Acute and Critical Care.2024; 39(4): 526. CrossRef
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Objective Carbon monoxide (CO) activates intravascular neutrophils through platelet-neutrophil aggregates, which cause neutrophil degranulation. This process causes the release of myeloperoxidase (MPO), proteases, and reactive oxygen species. The MPO index (MPXI) is a newly reported inflammatory marker that reflects the MPO level within neutrophils. The MPXI in conditions associated with neutrophil activation depends on the net effect of azurophil degranulation. This study aimed to determine whether the MPXI can predict neurocognitive prognosis 1 month after acute CO poisoning.
Methods We included patients aged ≥16 years with acute CO poisoning from a cohort at a single tertiary academic hospital in Wonju, Korea, between January 2010 and May 2021. Data from 699 patients were analyzed. The neurocognitive outcome was assessed using Global Deterioration Scale scores and classified as favorable (score, 1–3 points) or poor (score, 4–7 points). The MPXI was determined within 1 hour of arrival to the emergency department.
Results Among the 699 patients, 52 (7.4%) showed poor outcomes. The median MPXI of the patients in the poor outcome group was higher than that of the favorable outcome group (0.85 vs. 0.2, P=0.189). However, a significant difference was not found between the favorable and poor outcome groups, and MPXI was not a significant variable in multivariate logistic regression.
Conclusion The MPXI evaluated in the emergency department did not differ based on neurocognitive outcome at 1 month after acute CO poisoning.
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Some cases of plaster ingestion include the occurrence of gastrointestinal obstruction that requires surgery. To date, there are no reports on the treatment of plaster lesions in the mouth. A 50-year-old woman was referred to the emergency department after intentionally drinking a solution of approximately 100 g of plaster powder in 250 mL of water, 3 hours earlier. On arrival, the patient was alert but unable to speak because the plaster had hardened in her mouth. Hardened plaster was also found in her stomach. There was no evidence of acute gastrointestinal obstruction on abdominal computed tomography; we therefore decided to perform surgical observation. The intraoral plaster lesions were successfully removed using forceps, and the plaster bezoar was successfully eliminated without surgical treatment. The present case shows that not all patients with plaster poisoning require surgery; the patient’s conditions, such as gastrointestinal obstruction, should indicate the course of treatment.
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Central retinal artery occlusion (CRAO) is considered an ophthalmologic emergency. The prognosis of this disease is very poor. Currently, there is no generally effective therapy available to treat CRAO. Hyperbaric oxygen therapy (HBOT) can increase the volume of oxygen delivered to the ischemic retinal tissue until spontaneous or assisted reperfusion occurs. We report the case of a patient who experienced sudden visual loss due to CRAO that was treated with HBOT. The patient was an 81-year-old woman who presented with CRAO in her right eye (OD). She exhibited “hand motion” visual acuity before treatment. She underwent three sessions of HBOT at a pressure of 2.8 atmospheres absolute, performed over 3 days. After 4 days in hospital, her visual acuity improved to 0.4 (OD) for far vision and 0.5 (OD) for near vision. Her vision was stable without the supply of oxygen; therefore, she was discharged.
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Objective We conducted a study to validate the effectiveness of the Korean criteria for trauma team activation (TTA) and compared its results with a two-tiered system.
Methods This observational study was based on data from the Korean Trauma Data Bank. Within the study period, 1,628 trauma patients visited our emergency department, and 739 satisfied the criteria for TTA. The rates of overtriage and undertriage in the Korean one-tiered system were compared with the two-tiered system recommended by the American College of Surgery-Committee on Trauma.
Results Most of the patient’s physiologic factors reflected trauma severity levels, but anatomical factors and mechanism of injury did not show consistent results. In addition, while the rate of overtriage (64.4%) was above the recommended range according to the Korean criteria, the rate of undertriage (4.0%) was within the recommended range. In the simulated two-tiered system, the rate of overtriage was reduced by 5.5%, while undertriage was increased by 1.8% compared to the Korean activation system.
Conclusion The Korean criteria for TTA showed higher rates of overtriage and similar undertriage rates compared to the simulated two-tier system. Modification of the current criteria to a two-tier system with special considerations would be more effective for providing optimum patient care and medical resource utilization.
Objective In severe organophosphate (OP) poisoning, administration of atropine via continuous intravenous infusion is typically considered. To date, there have been no studies on predicting successful atropine discontinuation through plasma cholinesterase (PChE) and serum lactate levels, which are monitored during critical care in severe acute OP poisoning. Therefore, we retrospectively evaluated the usefulness of serum lactate and PChE as predictors of successful discontinuation of atropine infusion.
Methods This retrospective observational study was performed on consecutive adult patients treated for severe acute OP poisoning between March 2011 and December 2016. We sequentially evaluated serum lactate and PChE levels on emergency department arrival and before a discontinuation trial of atropine infusion. Discontinuation of atropine intravenous infusion was attempted in patients after clearance of respiratory secretions and cessation of bronchoconstriction. Discontinuation of atropine infusion attempts were divided into successful and failed trials.
Results A total of 95 trials were conducted in 62 patients. Serum lactate levels before trials were significantly different between patients with successful and failed trials. The area under the curve for prediction of successful atropine discontinuation using serum lactate levels before trial discontinuation were 0.742 (95% confidence interval, 0.638 to 0.846). PChE level was not significantly different between two groups.
Conclusion Serum lactate levels before the discontinuation trial of atropine infusion served to predict successful discontinuation in severe acute OP poisoning.
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Objective Clinically, consumptive coagulopathy, such as disseminated intravascular coagulopathy (DIC), is the most important among the common venomous snakebite complications owing to the serious hemorrhage risk associated with this condition. We evaluated the predictive value of the delta neutrophil index (DNI)—a new indicator for immature granulocytes—for DIC diagnosis.
Methods This retrospective observational study consecutively assessed adult patients with venomous snakebites for over 51 months. Patients were categorized into the no DIC and DIC groups. DNI values were measured within 24 hours after snakebite.
Results Thirty patients (26.3%) developed DIC. The DIC group had significantly higher median initial DNI than the no DIC group (0% vs. 0.2%, P<0.001). When the DIC group was divided into early and late groups (within and over 24 hours after snakebite, respectively), the DNI of the former was significantly higher than that of the latter and no DIC group. The late DIC group had significantly higher DNI than the no DIC group. Furthermore, DNI positively correlated with the DIC score (r=0.548, P<0.001). The initial DNI (odds ratio, 4.449; 95% confidence interval, 1.738 to 11.388; P=0.002) was an early DIC predictor. The area under the curve based on the initial DNI’s receiver operating characteristic curve was 0.724.
Conclusion DNI values were significantly higher in the DIC group. Additionally, DNI was an early predictor of DIC development in patients with venomous snakebites in the emergency department.
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Objective When managing patients with acute meningitis in an emergency department (ED), early diagnosis of the type of infection (bacterial or viral) considerably affects the clinical course and treatment because of the high mortality and morbidity associated with bacterial meningitis (BM). The serum delta neutrophil index (DNI), a new inflammatory marker, reflects the fraction of circulating immature granulocytes and is elevated in cases of bacterial infection. The objective of this study was to evaluate whether serum DNI can be used to differentiate between BM and viral meningitis (VM) in the ED.
Methods This retrospective, observational study included 104 consecutive patients (aged >18 years) diagnosed with acute meningitis from January 2012 to November 2014 in a regional emergency center. White blood cell and neutrophil counts, C-reactive protein level, and DNI were evaluated regarding their usefulness for differentiating BM and VM.
Results Serum DNI was not significantly higher in the BM group (n=12) than in the VM group (n=92) (0 [interquartile range, 0% to 2.73%] vs. 0 [interquartile range, 0 to 0%], P=0.057). However, the white blood cell count and C-reactive protein level were statistically higher in the BM group (P=0.034 and P=0.026, respectively). Serum DNI was not found to be a statistically useful differential diagnostic parameter (area under the curve, 0.628; 95% confidence interval, 0.438 to 0.818).
Conclusion Currently, there is no evidence that the serum DNI aids in differentiating acute BM from acute VM in the ED.
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Objective Adverse cardiovascular events (ACVEs) account for a large proportion of the morbidities and mortalities associated with drug overdose emergencies. However, there are no published reports regarding outcomes of ACVEs associated with acute dapsone poisoning. Here, the authors retrospectively analyzed ACVEs reported within 48 hours of treatment in patients with acute dapsone poisoning and assessed the significance of ACVEs as early predictors of mortality.
Methods Sixty-one consecutive cases of acute dapsone poisoning that were diagnosed and treated at a regional emergency center between 2006 and 2014 were included in the study. An ACVE was defined as myocardial injury, shock, ventricular dysrhythmia, cardiac arrest, or any combination of these occurring within the first 48 hours of treatment for acute dapsone poisoning.
Results Nineteen patients (31.1%) had evidence of myocardial injury (elevation of serum troponin-I level or electrocardiography signs of ischemia) after dapsone overdose, and there were a total of 19 ACVEs (31.1%), including one case of shock (1.6%). Fourteen patients (23.0%) died from pneumonia or multiple organ failure, and the incidence of ACVEs was significantly higher among non-survivors than among survivors (64.3% vs. 21.3%, P=0.006). ACVE was a significant predictor of mortality (odds ratio, 5.690; 95% confidence interval, 1.428 to 22.675; P=0.014).
Conclusion The incidence of ACVE was significantly higher among patients who died after acute dapsone poisoning. ACVE is a significant predictor of mortality after dapsone overdose, and evidence of ACVE should be carefully sought in these patients.
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