Comparison of the Macintosh Laryngoscope and the GlideScope Video Laryngoscope in a Cadaver Model of Foreign Body Airway Obstruction

Purpose: The GlideScope video laryngoscope (GL) has been known to help inexperienced health care providers become able to manage even difficult airways. The purpose of this study was to compare foreign body removal efficacies between the Macintosh laryngoscope (ML) and the GL in a setting of airway obstruction. Methods: Participants were asked to remove the simulated foreign body (2×2 cm rice cake) from the supraglottic area of a freshly embalmed cadaver. This simulated a normal airway and a difficult airway with cervical spine immobilization. Participants performed the removal maneuver 4 times in random order using a Magill forceps with both the ML and the GL. We measured the time to removal (sec) and preference of the participant (5-point scale) and compared results according to the type of laryngoscope. Successful removal was defined as a removal time that was less than 120 sec. Results: Forty participants were enrolled in this simulation experiment. The success rate, time to removal and provider preference were not significantly different betweeh the two types of laryngoscope. In subgroup analysis for experienced providers, the time to removal was significantly shorter shorter in the ML group than the GL group (14 vs 20 sec, p<0.05). The preference of experienced provider was also significantly higher for ML than GL. Conclusion: This study suggests that ML has comparable efficacy for foreign body removal to GL and is acceptable to experienced providersope

Healthcare Process Pattern Analysis with Triage in the Emergency Department

Emergency room process is very important in the whole hospital processes because it is first diagnosis for patient. Above all, triage is important activity which quickly diagnose the status of emergency patient and sets the priority for treatment. This paper analyzes the treatment process pattern by triage type. The results show that the treatment process after triage such as residence time, diagnosis and checkup type, and joint treatment are dependent on triage types. We can use these analysis results for improving the current triage system and developing the new triage system considering a domestic emergency medical service environment.ope

Predicting the Airway Patency using the Parameters of Soft-tissue Lateral Neck Radiography in Adult Patients with Acute Epiglottitis

Purpose: We wanted to predict the high risk group that requires urgent airway intervention by using the parameters of the soft-tissue lateral neck radiographs of adult acute epiglottitis patients. Methods: This retrospective study was conducted in two teaching hospitals. The patients who were diagnosed with acute epiglottitis from June, 2007 to May, 2009 were enrolled and their medical records and x-ray films were reviewed. The width of the epiglottis at the widest point (EW), the width of the arytenoid at the widest point (AW), the prevertebral soft tissue distance at the third cervical spine (PSTD), the shortest distance from the epiglottis to the hypopharyngeal wall (EHD) and the shortest distance from the epiglottic root to the arytenoids` tip (EAD) were investigated and we performed regression analyses of these parameters of the patients in the high risk group that required urgent airway intervention. Results: A total of 42 patients were enrolled. Dyspnea and hoarseness were more frequent in the high risk group that required urgent airway intervention (p=0.008, 0.040, respectively). The EW was significantly longer (p=0.001) in the high risk group. The EHD and EAD were significantly shorter (p=0.012, <0.001, respectively) in the high risk group. Only the EAD showed significant correlation with the percent of airway patency on linear regression analysis (p=0.003) and the EAD was the only significant predictor for the high risk group on multivariate logistic regression analysis (p=0.043). The receiver operating characteristics curve of the EW/EAD for the high risk group was obtained and it showed the best predictive power (AUC: 0.977, p<0.001). Conclusion: The EAD noted on soft-tissue lateral neck radiography is an important predictor of high risk patients who require urgent airway intervention. The cut-off value of the EW/EAD for the predicting the high risk group is 2.44 (sensitivity 100%, specificity 85.7%).ope

The Effect of Symptom Recognition on Pre-hospital Delay in Patients with Acute Coronary Syndrome

Purpose: This study was performed to determine the association of symptom recognition with pre-hospital delay in patients with acute coronary syndrome (ACS), and to determine the factors influencing symptom recognition. Methods: A prospective study from June 1, 2009 to July 31, 2009 was performed. The pre-hospital delay was calculated by subtraction of the hospital-arrival time from the symptom-onset time. The pre-hospital delay of the patients that recognized the symptoms as cardiovascular in origin was compared to the patients that did not recognize the symptoms as cardiac in origin. In addition, the socioeconomic indexes and risk factors were evaluated. Results: Eighty three subjects were enrolled from a total of 205 patients suspected of having an ACS during the study period. No statistical differences were identified in the comparison of the pre-hospital delay by socioeconomic and risk factors of ischemic heart disease. The median pre-hospital delay of the patients that recognized the symptoms as cardiac was 2.9 hours compared to 11.9 hours among the patients that did not recognize the symptoms as cardiac; this difference was statistically significant (p=0.003). There were statistically significant differences in symptom recognition between the patients that had a history of cardiovascular disease and those that did not (p=0.037), and between the patients that took aspirin and those that did not (p=0.014). In addition, the severity of symptoms differed between the patients that recognized their symptoms and those that did not; this difference was statistically significant (p=0.019). Only the severity of symptoms was statistically significant by the logistic regression analysis (p=0.018). Conclusion: The pre-hospital delay was shorter, if patients that recognized the symptoms as cardiac in origin. A history of cardiovascular disease, taking aspirin and severity of symptoms were factors influencing the recognition of symptomsope

Assessment of Severity Scoring Systems for Predicting the Prognosis of Early Goal Directed Therapy (EGDT) Enrolled Patients

Purpose: Mortality in emergency department sepsis (MEDS), sepsis-related organ failure assessment (SOFA), multiple organ dysfunction score (MODS), and serum lactate levels have shown their efficacy in the early detection of patients with a bad prognosis. However, those studies did not consider differences in treatment protocols and could not rule out the interference of these differences in treatment modalities. Hence, we aimed to assess the performance of MEDS, MODS, SOFA, and serum lactate levels for predicting a bad prognosis in patients scheduled for identical, standardized treatment protocols, EGDT. Methods: Medical records of patients who visited a tertiary level teaching hospital and were enrolled in an EGDT program between October 2009 and May 2010, were retrospectively reviewed. MEDS, SOFA, and MODS scores were calculated and recorded along with serum lactate levels. Receiver operating characteristics (ROC) curves of those predictors of mortality were plotted, Bivariate correlation analyses with overall lengths of admission and ICU lengths of stay were done for surviving patients. Results: None of the diagnostic methods (serum lactate level, MEDS, SOFA, MODS) showed a significant difference difference on ROC analysis (p=0.819, 0.506, 0.811, 0.873, respectively). Bivariate correlation analyses of MEDS, SOFA, MODS and overall lengths of admission showed significant results (p=0.048, 0.018, and 0.003, respectively. Pearson correlation coefficients were, 0.263, 0.312, and 0.381). Only MEDS showed a significant correlation with intensive care unit (ICU) length of stay (p=0.032, Pearson correlation coefficient = 0.332). Conclusion: Neither MEDS, SOFA, MODS, nor serum lactate level can predict mortality in EGDT-enrolled patients. MEDS may be correlated with ICU length of stayope

Usefulness of Tip-to-Carina Distance as a Marker for Detecting Right Atrium Positioning of a Central Venous Catheter on Chest X-Ray

Purpose: Our goal was to check the effect of physique on tip-to-carina (TC) distance for detecting the right atrium (RA) position of a central venous catheter tip, and to determine the optimal cut-off value for TC distance. Methods: We did a retrospective review of patients who were given chest computed tomography within 12 hours after central venous catheterization (CVC) between September 2005 and February 2009. We used electronic medical records (EMR) and a picture archiving communication system (PACS). TC/height ratio and TC/thoracic width ratio were used as height and thoracic width corrected TC distances. We developed receiver operating characteristic (ROC) curves for TC distance, TC/height and TC/thoracic width, and compared the area under curves (AUCs) of each. An optimal cut-off value for TC distance was obtained using ROC curves. Results: A total of 88 patients were enrolled in our study to determine the optimal cut-off value for TC distance. Of the 88, records for 64 included height, which was required for comparing TC with height and thoracic width corrected TC. AUCs of TC, TC/height, and TC/thoracic width were, respectively, 0.966, 0.962, 0.970. There was no statistically significant differences between them. The cut-off value for TC distance for detecting RA positioning of a CVC is 30 mm (Sensitivity=100%, Specificity=85.1%). Conclusion: TC distance is a useful marker for detecting RA positioning of a CVC regardless of the patient`s height and thoracic width. We suggest 30 mm as the optimal cutoff value for TC distance.ope

Optimal Chest Compression Depth for Children Determined by Chest Computed Tomography

Purpose: The recommended compression depth for basic life support of pediatric patients is one third to one half the anterior-posterior diameter of the chest. This study was designed to evaluate, using chest computed tomography (CT), whether the recommended compression depth is appropriate. Methods: Data for pediatric patients who underwent chest computed tomography were collected. Axial images containing both nipples were selected. We measured external chest thickness, internal thickness from sternum to vertebral body, and residual thickness; the latter was defined as internal thickness minus one third or one half of external thickness. We assumed potential injury would occur from chest compression if residual thickness was less than 10 mm. Results: Chest CT images from 164 children were analyzed. The compression depth was 62.4±6.9 mm if one half of the chest thickness was compressed, which was deeper than the high margin of compression depth recommended for adults. No potential injury was assumed when compressing one third of external chest thickness, while 96.3% of patients were assumed to sustain an injury when receiving compressions as deep as one half of chest thickness. Conclusion: One half the anterior-posterior diameter of the chest, the compression depth for pediatric CPR recommended in the current guidelines, is deeper than the 4~5 cm depth recommended for adult chest compression, and will result in less than 10 mm of residual thickness in most cases. This may cause internal organ injuryope

일과적 전뇌허혈 후의 지연된 신경세포사멸에 대한 지방기원 중간엽줄기세포 투여와 치료적 저체온 유도의 효과

Dept. of Medicine/박사Background: Global cerebral ischemia is the most important cause of poor prognosis after successful resuscitation from cardiac arrest. Therapeutic induction of hypothermia (maintenance of core body temperature between 32℃ and 34℃ for 12 to 24 hr, TH) has shown its efficacy in reduction of the neurologic damage from global cerebral ischemia through various laboratory and clinical researches, and it is recommended as one of the standard post-resuscitation managements. However, alternatives or complements for TH are necessary due to its technical difficulty in induction of recommended temperature and keeping recommended rate of rewarming, which limits the application of TH. We aimed to show the effect of stem cell on the neurologic recovery after transient global cerebral ischemia including the comparison with that of current standard therapy, TH.Materials and methods: Rats were subjected to 7 min of transient global cerebral ischemia and randomized into 4 intervention groups: placebo control, TH, human mesenchymal stem cell (MSC), and combined TH and MSC, along with 4 sham operation groups with same intervention. Hippocampal neuronal death was evaluated at 7 days after ischemia by Fluoro Jade B staining. Activated microglia and infiltrating macrophages were evaluated at 7 days after ischemia by immunostaining for CD11b. IgG immunostaining was performed to detect blood brain barrier (BBB) disruption, and myeloperoxidase (MPO) immunostaining was done to detect neutrophil infiltration in the hippocampus. 4HNE immunostaining was performed to detect oxidative injury. The time until the animal removed adhesive tapes on their both forepaws was measured to test the behavioral function, a week after the insult.Results: No degenerating neuron was detected by Fluoro-Jade B staining in any of the sham operation groups. Analysis of variance (ANOVA) showed significant differences in degenerating neuron count among 4 ischemia induced groups at CA1, CA3, and hilus region (p= <0.001, 0.004, and 0.033, respectively). Post hoc analysis revealed significant differences: between control and TH, between control and MSC, and between control and TH/MSC in CA1; between control and MSC, and between control and TH/MSC in CA3; between control and MSC in hilus. Significant difference in microglial activation was found among 8 sham operation and ischemia groups through ANOVA (p<0.001). Post hoc analysis showed: no significant difference among 4 sham operation groups (control, TH, MSC, and TH/MSC with sham operation); significant differences between sham groups and control, between sham groups and TH, between sham MSC and MSC, between control and TH, between control and MSC, between control and TH/MSC, between TH and MSC, and between TH and TH/MSC. ANOVA showed a significant difference in IgG leakage among 8 sham operation and ischemia groups (p<0.001). Post hoc analysis revealed: no significant difference among 4 sham operation groups; significant differences between sham groups and control, between control and TH, between control and MSC, and between control and TH/MSC. ANOVA failed to show a significant difference in MPO(+) cell count among 8 sham operation and ischemia groups (p=0.052). Significant difference in 4HNE intensity was found among 8 sham operation and ischemia groups through ANOVA (p<0.001). Post hoc analysis showed: no significant difference among 4 sham operation groups; significant differences between sham groups and control, between sham groups and TH, between control and TH, between control and MSC, between control and TH/MSC, between TH and MSC, and between TH and TH/MSC. Significant difference of the time spent to detach the adhesive tapes on forepaws among 5 normal and ischemia groups was found through ANOVA (p<0.001), and post hoc analysis showed the differences between placebo controlled ischemia group and other groups.Conclusions: Administration of MSC after transient global cerebral ischemia has a prominent protective effect on delayed hippocampal neuron death comparing with TH, current standard treatment option. The present results also suggest combined treatment of MSC and hypothermia warrants a potential therapeutic strategy for intervention of global cerebral ischemia after cardiac arrest.ope

Application of Mortality in Emergency Department Sepsis (MEDS) scoring

의학과/석사[한글]패혈증은 병원내 사망의 주요 원인으로 조기에 진단하여 적절히 치료되지 않을 경우 30-50%의 높은 사망률을 보이는 치명적인 질환이다. 이에 최근의 치료 지침은 질환의 조기 인지의 필요성을 특히 강조하고 있는데 이를 위해서는 환자의 상태를 실시간으로 객관적, 정량적으로 평가할 수 있는 도구가 필요하다. 기존에 쓰이던 도구들의 경우 중환자실 환자를 대상으로 개발 및 유효성 평가가 이뤄진 것으로 패혈증 환자의 조기인지가 주로 필요한 응급 진료 단계에서의 적용을 위해 MEDS 점수 체계가 개발되었다. MEDS 점수 체계는 한번의 후향적인 연구를 통해 개발 및 유효성 평가가 이뤄진 도구로 추가적인 유효성 평가나 기존에 쓰이던 평가 도구들과의 객관적인 비교가 없었던 점에 착안하여 전향적인 점수 체계의 평가 및 기존의 도구 중 유효성이 입증된 MODS, SOFA 점수 체계와의 비교 연구를 기획하게 되었다.전신 감염증이 의심되는 288명의 환자를 대상으로 응급실 내원시 MEDS, MODS, SOFA 점수를 계산하였고 6개월 후 의무 기록 검토를 통해 진료 경과를 확인하였다.MEDS, MODS, SOFA 점수 체계 모두 로지스틱 분석에서 유의한 사망 예측을 보여주었고, 프로빗 분석 결과 점수대에 따라 유의하게 사망률이 차이가 남을 확인할 수 있었으며, 각 점수 체계의 사망 예측력이 동일한 수준임을 알 수 있었다. MEDS 점수 체계의 경우 점수 체계에 제시된 임상적 기준값을 이용하여 사망 위험도에 따라 군을 나눌 수 있었으며 생존 환자 대상의 로지스틱 분석에서도 응급실 이후 입원 여부에 대해 유의한 예측력을 보였다.본 연구에서 MEDS, MODS, SOFA 점수 체계가 모두 응급실에 내원한 패혈증이 의심되는 환자에서 사망 관련 예후를 예측하는데 적합하고 예측 정도도 유사함을 알 수 있었다. 또한 MEDS 점수 체계는 다른 두 가지에 비해 점수 계산이 용이하고 사망 위험도별로 구분이 가능하며 생존 환자의 예후에도 영향을 미칠 수 있기에 응급진료 단계에서 패혈증 의심 환자의 예후를 조기에 예측함에 있어 상당한 유용성을 가짐을 알 수 있었다. [영문]Sepsis is one of the most important causes of hospital death. Unless diagnosed and treated early it is related to high mortality rate. The recent guideline for sepsis treatment emphasizes the early recognition of the disease. Therefore, an objective tool which can assess sepsis-suspected patients in real time is needed. Conventional assessment tools for sepsis was designed and validated only with intensive care unit (ICU) patients and the need for early recognition of sepsis in emergency department resulted in development of MEDS scoring system. But there has been no prospective validation or comparison study of MEDS with other scoring systems until now. Therefore we prospectively validated the MEDS scoring system and compared it with Multiple Organ Dysfunction Score (MODS) and Sepsis-related Organ Failure Assessment (SOFA) scoring systems. MEDS, MODS, SOFA scores of 288 patients who were suspected of systemic infection were calculated at the time of their emergency department visit and clinical data of the patients were reviewed after 6 month.MEDS, MODS, and SOFA scoring systems were all valid in the prediction of mortality by logistic regression analysis. The result of probit analysis showed significant and direct relation between the score and the mortality rate, and proved the parallelism of the mortality prediction of three scoring systems. The cut-off values provided with MEDS scoring systems successfully divided subjects into five groups according to their risk for death and also MEDS score predicted the admission of surviving patients.This study proved that MEDS, MODS, SOFA score all predict the prognosis of the sepsis suspected patients well and three scoring systems had same degree of predictive power. But MEDS scoring system was easy to calculate and had definite clinical cut-off value which was useful in the decision of treatment options and also was related to the prognosis of surviving patients. So we believe it to be the most useful and appropriate clinical prediction tool for sepsis suspected patient who visits the emergency department.ope

The utility of the HeartSaver Sticker for maintaining correct hand position during chest compressions

BACKGROUND: The importance of attaining correct hand position in cardiopulmonary resuscitation (CPR) instruction has not been emphasized as much as the significance of the compression performance. Study Objectives: This pilot study was performed to investigate the utility of a HeartSaver Sticker for maintaining correct hand position during chest compressions. METHODS: Fifty-one sophomore college students, training to become emergency medical technicians, were recruited. The students, having no previous experience using HeartSaver stickers, participated in this prospective, randomized simulation-based controlled study, which consisted of two groups: 1) with sticker (n=26), 2) without sticker (n=25). The 4×4-cm HeartSaver sticker marked with both vertical and horizontal center lines was used in this study. Proper sticker placement was such that the vertical line coincided with the mid-sternum of the chest, and the horizontal line aligned with the nipples. Participants performed adult basic life support by single rescuer according to the 2005 American Heart Association resuscitation guidelines. Skill assessment was also performed by these guidelines. RESULTS: Group 1 participants placed the HeartSaver sticker on the correct landmark within 10 s of approaching the model. The compression rate and depth were not significantly different between the two groups. However, significant improvement in correct hand position was noticed when using the HeartSaver sticker. Correct hand position was 97.1% ± 7.4% in group 1 and 85.9% ± 21.5% in group 2 (p=0.002). CONCLUSION: The HeartSaver sticker was useful in maintaining correct hand position during the single-rescuer CPR scenario because it provided easy recognition of that position when compressing after ventilations.ope