Temporal Bone Fracture and Labyrinthine Concussion as Ataxic Gait in 21-Months-Old Child

Blunt head injury can concuss the membranous labyrinth against the otic capsule. This results in acute hypofunction of some portion of the vestibular neural substrate within the affected labyrinth. Both labyrinthine concussions and transverse temporal bone fractures produce acute unilateral vestibular hypofunction. We describe a 21-months-old child who presented with a ataxic gait for two days. It is difficult to make diagnosis of labyrinthine concussions and temporal bone fractures in children, for we can not know the exact history of trauma and can not perform complete neurologic examination in children. When child present with ataxic gait, the emergency physician should consider labyrinthine concussion and temporal bone fracture in the differential diagnosis and take temporal bone CT.ope

Reliability and Validity of the Modified Emergency Severity Index-2 as a Triage Tool)

Purpose: We measured the inter-rater reliability and validity of the modified Emergency Severity Index-2 (mESI-2) as a triage tool in the emergency department (ED). Methods: We applied mESI-2 to 2,724 patients who visited three EDs. In each ED, emergency medicine residents, interns, and nurses independently evaluated the severity of the patient with mESI-2. Data on the triage result, the patient disposition, and the length of stay in the ED were collected prospectively. For patients who were admitted or who stayed more than 24 hours in the ED, the APACHE Ⅱ score was calculated. Results: The weighted kappa value was 0.602 between residents and interns, 0.541 between residents and nurses, and 0.451 between interns and nurses. Hospitalization (ED death, admission, transfer) rates were 100% in category 1 and 82.4%, 53.8%, 17.2%, 6.2% in categories 2 through 5, respectively. The mean length of stay was longest in category 3 (687 min) and shortest in category 5 (150 min). The mean APACHE Ⅱ score was highest in category 1 (10.8) and 8.6, 6.2, 5.2, 2.9 in categories 2 through 5, respectively. Conclusion: The mESI-2 demonstrated good to fair interrater reliability among residents, interns, and nurses, and the resultant categories were related with the hospitalization rates, the length of stay in the ED, and the APACHE Ⅱ score. With further modification and refinement, mESI-2 can be a reliable and a valid triage tool in the ED.ope

The efficacy of optimal doses of intramuscular ketamine and midazolam injections for procedural sedation in laceration repair of children

Purpose: We reported previously that intramuscular ketamine with adjunctive midazolam is more effective than ketamine alone in pediatric procedural sedation, but with limited satisfactory sedation by suboptimal ketamine dose. The optimal dose of intramuscular ketamine in children has never been studied in Korea. In this study, we investigated the effectiveness and adverse events of ketamine 4mg/kg with adjunctive midazolam in pediatric laceration repair. Methods: From Jan. 2005 to July 2005, we enrolled 60 children, aged 3 months-7 years, who needed laceration repair under sedation. After verbal consent from parents, patients were randomly assigned to KMA group(IM ketamine 4 mg/kg+atropine 0.01 mg/kg+intramuscular midazolam 0.05 mg/kg) or KA group(without midazolam). We compared both groups with the induction time, recovery time, total sedation time, efficacy of sedation, adverse effects, and the satisfaction score of treating physicians. Results: Potentially confounding variables, age, weight, injury site and anxiety score, were similar between groups. The induction time, recovery time and total sedation time were not different statistically. In KMA group, 90.9 percent of patients showed satisfactory sedation compared to 66.7 percent of KA group(P=0.02) and the occurrence rate of significant adverse effect was 0.0 percent and 37.0 percent respectively. Conclusion: We found adjunctive midazolam with ketamine doses of 4 mg/kg IM produced more effective, satisfactory sedation and less adverse effect than without midazolam in pediatric laceration repair. The emergence phenomenon(agitation during recovery) only occurred in 9 KA group patients. In spite of adverse effect, all patients recovered, were discharged and there were no reported delayed events.ope

Retroperitoneal Hematoma and Renal Cortical Injury: A Rare Complication of Cerebral Angiography -A Case Report-

Cerebral angiography is an invasive technique and can induce various complications, such as neurologic complications. We describe two cases of retroperitoneal hematoma and renal injury, a rare complication of cerebral angiography. A 65-year-old male and 56-year-old male underwant cerebral angiography for stem cell implantation at a general hospital. The diagnoses of retroperitoneal hematoma and renal injury were delayed. On abdominal-pelvic CT, renal injury was demonstrated with a pseudoaneurysm and a retroperitoneal hematoma in the perirenal space. Interventional angiography was performed. Renal angiography showed that the contrast was extravasated with a pseudoaneurysm in the lower pole of right kidney. The feeding artery of the pseudoaneurysm was successfully embolized. Emergency physicians must consider a retroperitoneal hematoma and renal cortical injury after angiography, especially when patients present with hypotension and abdominal distention.ope

Effect of Cardiac Arrest Team Training Using Script on the Quality of Simulated Resuscitation

Background: The purpose of this study was to compare the quality of simulated resuscitation between the conventional simulation training group and the script based training group. Methods: This was a retrospective analysis of video clips from a previous study of cardiopulmonary resuscitation (CPR) team simulation training. A total of eighty-four video clips were analyzed. Each video clip belonged to either the conventional group or the script group, of either pre-training or post-training. One of the authors analyzed all the video clips. The qualities of resuscitation team plays were compared in terms of the hands-on compression time, the interval to meaningful measures and the number of utterances of the team leader and members. Results: The hands-on time of the conventional group improved after training whereas that of the script group deteriorated (22.2 vs －7.0 sec, p = 0.009). The time to defibrillation also improved in the conventional group whereas that of the script group deteriorated (－24.0 vs 33.0 sec, p = 0.002). There were no differences in the utterances of team leaders and members between groups and between pre- and post-training. Conclusions: This study suggested that the effect of script-based training on quality of CPR was less useful than that of conventional training using simulation and debriefing. Therefore, CPR team training using a script alone should not be recommended.ope

Assessment and Training of Teamwork and Leadership for Critical Care Nurses: A Pilot Study

Background: Teamwork and leadership training have been shown to improve subsequent resuscitation performance in a variety of clinical situations. Critical care nurses, in addition to those who may be part of resuscitation team leaders and members, have also the need for such training. This study examines the teamwork and leadership skills of critical care nurses and their perceptions of the need for teamwork and leadership training. Methods: We developed a pilot, interactive 3-hour teamwork, and the leadership training program based on the objectives and teaching methods of the Advanced Life Support (ACLS) course. Participants completed a 1-hour lecture, and discussion for team roles and obstacles, 30 min of script-based role play in resuscitation team training, and finally, a 2-hour simulation-based team training program. Before the completion of the course, participants were anonymously surveyed on the perceived educational value of the teamwork and leadership program. Expert raters reviewed videos of simulated resuscitation events in the course, and scored each video by two existing checklist for the team dynamic. Results: Fifty-one nurses voluntarily participated and six videotaped simulation were rated by an expert rater. Most of the students believed the course was delivered at an appropriate level for them, and that it is a necessary training in their continuing professional education. The video rated average scores were from 68.5 to 72.9 according to the checklists. Conclusions: Critical care nurses can learn teamwork and leadership skills from appropriately designed programs, and believe it is a necessity in their training.ope

A Diagnostic Utility of Fitz-Hugh-Curtis Syndrome by Using contrast Enhanced Abdominopelvic Computerized Tomography

Purpose: Fitz-Hugh-Curtis (FHC) syndrome is characterized by right upper quadrant pain due to perihepatitis with pelvic inflammatory disease (PID). It is diagnosed by using its typical symptoms, but final diagnosis is made by confirmation of the presence of laparoscopically visualized perihepatic violin string like adhesions. However, laparoscopy is difficult to perform in the emergency department. Recently, on computerized tomography (CT) a linear enhancement of the liver capsule was detected in a patient with FHC syndrome. We present a review of a series of 11 cases in female of FHC syndrome diagnosed by CT. Methods: We reviewed the medical records and the CT findings of 11 cases of FHC syndrome diagnosed during 7 months in the emergency department. The clinico radiologic criteria of our hospital is as follows: First, right upper quadrant pain. Second, linear enhancement of the liver capsule in the contrast enhancement phase of CT. Third, no pathologic findings for the liver, the gallbladder and the biliary tract in CT. Results: Eleven patients were diagnosed during 7 months by using criteria. The mean age was 30.2 (range: 16~46) years. Seven patients had a history of PID within 6 months. Seven of the 9 patients who take a pelvic examination were positive in C. trachomatis PCR (polymerase chain reaction), and another patient had a positive N. gonorrhoeae cervix culture. One patient who showed negative in both the C. trachomatis PCR and the N. gonorrhoeae cervix culture had cultured E. coli in urine and blood culture. Conclusion: CT makes easy the previously difficult diagnosis of FHC syndrome in female patients capable of pregnancy with right upper quadrant abdominal pain.ope

Acetaminophen Poisoning

Acetaminophen (AAP) overdose can result in potentially serious hepatotoxicity. The ingested dose and time from ingestion to presentation are important prognostic factors. Toxic dose in adult is thought to be at least 10 g or 200 mg/kg. However, early management of acute overdose should be guided by the plasma AAP concentration. The antidote for AAP poisoning is N-acetylcysteine (NAC). It provides complete protection against hepatotoxicity if given within 8 h of acute overdose. If the concentration is above the possible toxicity line as predicted by the Rumack-Matthew nomogram, either the 72-hr oral or the 20-hr intravenous NAC regimen should be administered. NAC is also effective if started late in patients with established hepatic failure. This article summarizes the current consensus of clinical assessment and management for acute AAP overdose.ope

Validation of Termination Guidelines for Out of Hospital Cardiac Arrest in Korea

PURPOSE: There have been no studies on the termination of resuscitation (TOR) in Korea. We retrospectively applied TOR rules to OHCA patient data in order to validate the BLS and ALS TOR rules for Korea. METHODS: We collected OHCA (out-of-hospital cardiac arrest) data from 3 hospitals for the period January 1 to December 31, 2009. We then retrospectively applied BLS and ALS TOR rules to this data. We measured both the specificity and positive predictive value for each BLS and ALS TOR rule. RESULTS: The overall rate of survival until hospital discharge was 14.5%. Out of 102 patients who met BLS criteria TOR rules, 8 patients survived until hospital discharge. Out of 52 patients who met ALS criteria TOR rules, 4 patients survived until hospital discharge. The BLS rule had a specificity of 0.57 and a positive predictive value of 0.92. The ALS rule had a specificity of 0.78 and a positive predictive value of 0.92. CONCLUSION: In this study, the BLS and ALS TOR rules had relatively low positive predictive value and were not applicable to patients with low survival probability in Korea.ope

Prognosis of Patients Admitted to ICU after Cardiopulmonary Resuscitation in Emergency Room

BACKGROUND: The prognosis of patients admitted to intensive care unit (ICU) after cardiopulmonary resuscitation (CPR) is poor. Although the number of these patients is increasing as a consequence of emergency medical service improvements, we had no information conceiving the survival rates of patients admitted to ICU after CPR in Korea. The aim of this study was to determine the outcome of these patients. METHODS: We retrospectively evaluated all patients admitted to an ICU after CPR at an emergency room of a teaching hospital during the 24 month period from July, 2002 to July, 2004. The demographic and clinical information of each patient were recorded. These included primary diagnosis, total resuscitation time, APACHE II score (acute physiology and chronic health evaluation II score) at admission to ICU, ICU days, and hospital days. We analyzed all variables in the database and compared the data of patients who died in hospital with that of those who were discharged. RESULTS: Thirty-seven patients were admitted to the ICU after CPR in the emergency room, and 14 were discharged alive. APACHE II scores were significantly lower and Glasgow coma scales were significantly higher in survivors. CONCLUSIONS: 38% of patients who admitted to ICU after CPR in the emergency room were discharged from hospital alive. We evaluated that the severity scores of patients who receive CPR before ICU admission are important predictors of survival.ope