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The prognostic implication of cardiac troponin I (cTnI) values for the determination of the magnitude or duration of cause-specific death risk is limited. We included consecutive patients with maximal cTnI values within 24 h of their emergency department visits. Multivariate analyses using variables selected by the Bayesian information criterion were performed to investigate the impact of cTnI on the event rate, time-dependent risk, and dose-dependent risk of cardiovascular or non-cardiovascular death within 360 days. There were 5472 (14.9%) all-cause deaths including 881 (2.4%) cardiovascular deaths and 4591 (12.5%) non-cardiovascular deaths. In patients with positive cTnI, defined as the ≥ 99th percentile of the upper normal limit, the cumulative risk of cardiac and non-cardiac death was 4.4- and 1.4-fold higher, respectively, than that of negative cTnI, respectively. In the competing risk analysis, positive cTnI was linked to 2.4- and 1.2-fold higher risks of cardiovascular and non-cardiovascular death, respectively. The cTnI value showed a positive relationship with the risk of both cardiovascular and non-cardiovascular deaths. In the time-dependent risk analysis, the excess risk of cardiovascular death was mostly evident in the first few weeks. Higher cTnI value was associated with an increased risk of both cardiovascular and non-cardiovascular death, especially which was in the early period.

We evaluated the relationship between hyperkalemia and wide QRS complex in patients with pulseless electrical activity (PEA) cardiac arrest.This was a single-center, retrospective observational study of patients over the age of 18 treated for cardiac arrest at a tertiary referral hospital whose initial electrocardiogram rhythm was PEA from February 2010 to December 2019. Wide QRS PEA was defined as a QRS interval of 120 ms or more. Hyperkalemia was defined as serum potassium level 5.5 mmol/L. The primary outcome was hyperkalemia. Multivariable logistic regression analysis was used to evaluate the relationship between wide QRS and hyperkalemia.Among 617 patients, we analyzed 111 episodes in the wide QRS group and 506 episodes in the narrow QRS group. The potassium level in the wide QRS group was significantly higher than in the narrow QRS group (5.4 mmol/L, IQR 4.4-6.7 vs. 4.6 mmol/L, IQR 4.0-5.6, P 0.001). Among all patients, 49.6% (n = 55/111) in the wide QRS group had hyperkalemia, which was significantly higher than the 26.7% (n = 135/506) in the narrow QRS group (P 0.001). In multivariable logistic regression analysis, wide QRS PEA was significantly associated with hyperkalemia (odds ratio = 2.86, 95% confidence interval: 1.80-4.53, P 0.001).Wide QRS PEA as an initial cardiac rhythm was significantly associated with hyperkalemia in cardiac arrest patients.

Background The prognostic ability of cardiac troponin I (TnI) has been demonstrated in general populations and among cardiovascular disease patients, but it has not been evaluated in cancer patients. Hypothesis This study assumes to have the prognostic ability of cardiac troponin in cancer patients visiting the emergency department. Methods Cancer patients visiting the emergency department were enrolled in this retrospective cohort study. Patients with previously known coronary artery disease or clinically indicated coronary angiography were not included. The maximal value from Siemens ADVIA Centaur troponin I Ultra assay within 24 hours was assessed. The primary endpoint was 180‐day all‐cause death, including cardiovascular and noncardiovascular death. Results A total of 9135 cancer patients (mean age: 63 years, male gender: 60%) were enrolled. Lowest (0.006 ng/mL), assay‐specific

Objective This study aimed to confirm the accuracy of a machine-learning-based model in predicting the 30-day mortality of patients with pneumonia and evaluating whether they were required to be admitted to the intensive care unit (ICU). Methods The study conducted a retrospective analysis of pneumonia patients at an emergency department (ED) in Seoul, Korea, from January 1, 2016 to December 31, 2017. Patients aged 18 years or older with a pneumonia registry designation on their electronic medical record were enrolled. We collected their demographic information, mental status, and laboratory findings. Three models were used: the pre-existing CURB-65 model, and the CURB-RF and Extensive CURB-RF models, which were machine-learning models that used a random forest algorithm. The primary outcomes were ICU admission from the ED or 30-day mortality. Receiver operating characteristic curves were constructed for the models, and the areas under these curves were compared. Results Out of the 1,974 pneumonia patients, 1,732 patients were eligible to be included in the study; from these, 473 patients died within 30 days or were initially admitted to the ICU from the ED. The area under receiver operating characteristic curves of CURB-65, CURB-RF, and extensive-CURB-RF were 0.615 (0.614-0.616), 0.701 (0.700-0.702), and 0.844 (0.843-0.845), respectively. Conclusion The proposed machine-learning models could predict the mortality of patients with pneumonia more accurately than the pre-existing CURB-65 model and can help decide whether the patient should be admitted to the ICU.

Background N95 filtering facepiece respirators (N95 respirators) may not provide adequate protection against respiratory infections during chest compression due to inappropriate fitting. Methods This was a single-center simulation study performed from December 1, 2016, to December 31, 2016. Each participant underwent quantitative fit test (QNFT) of N95 respirators according to the Occupational Safety and Health Administration protocol. Adequacy of respirator fit was represented by the fit factor (FF), which is calculated as the number of ambient particles divided by the number inside the respirator. We divided all participants into the group that passed the overall fit test but failed at least one individual exercise (partially passed group [PPG]) and the group that passed all exercises (all passed group [APG]). Then, the participants performed three sessions of continuous chest compressions, each with a duration of 2 min, while undergoing real-time fit testing. The primary outcome was any failure (FF

Background and Objectives: This retrospective study evaluated the clinical impact of enhanced personal protective equipment (PPE) on the clinical outcomes in patients with out-of-hospital cardiac arrest. Moreover, by focusing on the use of a powered air-purifying respirator (PAPR), we investigated the medical personnel’s perceptions of wearing PAPR during cardiopulmonary resuscitation. Materials and Methods: According to the arrival time at the emergency department, the patients were categorized into a conventional PPE group (1 August 2019 to 20 January 2020) and an enhanced PPE group (21 January 2020, to 31 August 2020). The primary outcomes of this analysis were the return of spontaneous circulation (ROSC) rate. Additionally, subjective perception of the medical staff regarding the effect of wearing enhanced PPE during cardiopulmonary resuscitation (CPR) was evaluated by conducting a survey. Results: This study included 130 out-of-hospital cardiac arrest (OHCA) patients, with 73 and 57 patients in the conventional and enhanced PPE groups, respectively. The median time intervals to first intubation and to report the first arterial blood gas analysis results were longer in the enhanced PPE group than in the conventional PPE group (3 min vs. 2 min; p = 0.020 and 8 min vs. 3 min; p < 0.001, respectively). However, there were no significant differences in the ROSC rate (odds ratio (OR) = 0.79, 95% confidence interval (CI): 0.38–1.67; p = 0.542) and 1 month survival (OR 0.38, 95% CI: 0.07–2.10; p = 0.266) between the two groups. In total, 67 emergent department (ED) professionals responded to the questionnaire. Although a significant number of respondents experienced inconveniences with PAPR use, they agreed that PAPR was necessary during the CPR procedure for protection and reduction of infection transmission. Conclusion: The use of enhanced PPE, including PAPR, affected the performance of CPR to some extent but did not alter patient outcomes. PAPR use during the resuscitation of OHCA patients might positively impact the psychological stability of the medical staff.

This study was designed to evaluate the hemodynamic effect of norepinephrine (NE) on the peak systolic velocity (PSV), diameter, and blood flow of the common carotid artery (CCA) using the point-of-care ultrasound (POCUS) in patients with septic shock. The study involved patients above 18 years old with septic shock. Arterial monitoring, carotid ultrasonography, and transthoracic echocardiography were performed before NE administration (T0). When the mean arterial pressure exceeded 65 mmHg after NE administration (T1), the measurement was repeated. Twenty-four patients (median age 67 [interquartile range: 54–77] years; 42% female) with septic shock were examined in this study. Before (T0) and after (T1) NE administration, the PSV (mean, standard deviation [SD]) changed from 85.3 (21.1) cm/s to 83.5 (23.5) cm/s (p = 0.417); this change was not significant. However, the diameter and blood flow of the CCA increased significantly from 0.6 (0.09) cm and 0.75 (0.27) L/min to 0.66 (0.09) cm and 0.85 (0.27) L/min, respectively (p

Background An accurate disease severity score that can quickly predict the prognosis of patients with sepsis in the emergency department (ED) can aid clinicians in distributing resources appropriately or making decisions for active resuscitation measures. This study aimed to compare the prognostic performance of quick sequential organ failure assessment (qSOFA) with that of other disease severity scores in patients with septic shock presenting to an ED. Methods We performed a prospective, observational, registry-based study. The discriminative ability of each disease severity score to predict 28-day mortality was evaluated in the overall cohort (which included patients who fulfilled previously defined criteria for septic shock), the newly defined sepsis subgroup, and the newly defined septic shock subgroup. Results A total of 991 patients were included. All disease severity scores had poor discriminative ability for 28-day mortality. The sequential organ failure assessment and acute physiology and chronic health evaluation II scores had the highest area under the receiver-operating characteristic curve (AUC) values, which were significantly higher than the AUC values of other disease severity scores in the overall cohort and the sepsis and septic shock subgroups. The discriminative ability of each disease severity score decreased as the mortality rate of each subgroup increased. Conclusions All disease severity scores, including qSOFA, did not display good discrimination for 28-day mortality in patients with serious infection and refractory hypotension or hypoperfusion; additionally, none of the included scoring tools in this study could consistently predict 28-day mortality in the newly defined sepsis and septic shock subgroups.

Purpose In late 2012, South Korea revised the Pharmaceutical Affairs Act to make selected medications including acetaminophen, ibuprofen, and cold medications available in nonpharmacy outlets, including the 24-hour convenient stores (CVS). The objective of this study was to identify whether the characteristics and trend of self-poisonings associated with these medications were altered after the legislative change. Methods A retrospective study was performed using national data from the Emergency Department (ED)-based Injury In-depth Surveillance database. The patients diagnosed with poisoning were sorted from 2011 to 2016 and included in the study. As the Act was implemented from 2013, the demographic characteristics and clinical outcomes were compared before and after January 2013. A piecewise regression analysis was performed to determine the association between the monthly use of acetaminophen, medication for cold, and nonsteroidal anti-inflammatory drugs (NSAIDs) and the incidence of total poisonings before and after the January 2013. Results Among 1 536 277 patients included in the database, 17 523 patients diagnosed with poisoning were enrolled. After the legislative change, the etiology of poisoning did not change, although the frequency of hospitalization from ED was significantly increased. The monthly trend for poisoning due to acetaminophen, cold medications, and NSAIDs showed no significant slope change between before and after the legislative change. The proportional use of acetaminophen and cold medications was significantly decreased, while that of NSAIDs was unchanged before and after the legislative change. Conclusions The change in the Pharmaceutical Affairs Act was not associated with any change in the monthly frequency of medication-related poisoning.

Objective While the effect of typhoons on emergency medicine has been evaluated, data are scarce on their effects on the emergency medical service (EMS). This study evaluated the effect of typhoons on EMS patients and performance. Methods The study period was January 2010 to December 2012. Meteorological data regarding typhoons were provided by the Korean Meteorological Administration. EMS data were retrieved from the EMS database of the national emergency management agency. The database includes ambulance run sheets, which contain clinical and operational data. In this case-crossover study, the cases and controls were EMS calls on the day of typhoon warnings and calls one week prior to the typhoon warnings, respectively. Results During the study period, 11 typhoons affected Korea. A total of 14,521 cases were selected for analysis. Overall, there were no obvious differences between the case and control groups. However, there were statistically significant differences in age, place, and time requests. There were fewer patients between 0 and 15 years of age (P=0.01) and more unconscious patients (P=0.01) in the case group. The EMS operational performance, as measured by the times elapsed between call to start, call to field, and call to hospital did not differ significantly. There was also no significant difference in the time from hospital arrival between the cases (28.67, standard deviation 16.37) and controls (28.97, standard deviation 28.91) (P=0.39). Conclusion Typhoons did not significantly affect the EMS system in this study. Further study is necessary to understand the reasons for this finding.

Background Ear-loop-type Korean Filter 94 masks (KF94 masks, equivalent to the N95 and FFP2) are broadly used in health care settings in Korea for the coronavirus disease 2019 pandemic. Methods A prospective randomized open-label study was designed to identify differences in the fitting performance between mask wearing methods in three different types of KF94 mask with ear loops between January to March 2021. General-fitting involved wearing an ear-loop-type KF94 mask, and tight-fitting involved wearing a mask aided by a clip connecting the ear loops. Each of the 30 participants wore three types of masks according to a randomly assigned order in both methods and performed a total of six quantitative fit tests (QNFTs) according to the occupational safety and health administration protocol. Results All fit factors (FFs) measured by the QNFT were significantly higher for tight-fitting method with the clip in all KF94 masks (P < 0.001). However, the total FFs were very low, with a median (interquartile range) of 6 (3–23) and 29 (9–116) for general-fitting and tight-fitting, respectively. When wearing tightly, the horizontal 3-fold type mask with adjustable ear-loop length had the highest FF, with a median of 125, and the QNFT pass rate (FF ≥ 100) increased significantly from 4 (13%) to 18 (60%). Conclusion Even with sufficient filter efficiency, ear-loop-type-KF94 masks do not provide adequate protection. However, in relatively low-risk environments, wearing a face-seal adjustable KF94 mask and tight wearing with a clip can improve respiratory protection for healthcare workers. Trial Registration ClinicalTrials.gov Identifier: NCT04794556, Graphical Abstract

Background: Nighttime hospital admission is often associated with increased mortality risk in various diseases. Following sepsis campaign implementation, this study investigated compliance rates with the Surviving Sepsis Campaign 3-h bundle for daytime and nighttime emergency department (ED) admissions and the clinical impact of compliance on mortality. Methods: We conducted an observational study using data from a prospective, multicenter registry for septic shock provided by the Korean Shock Society from 11 institutions from November 2015 to December 2017. The outcome was the compliance rate with the complete 3-hour treatment bundle according to the time of arrival in the ED. Mediation analysis was conducted to evaluate the proportion of the total effect that could be explained by hospital admission times.Results: A total of 2,247 patients were enrolled. Compared with daytime admission, nighttime admission was associated with higher compliance for the administration of antibiotics within 3-h (adjusted odds ratio (AOR), 1.276; 95% confidence interval (95% CI), 1.050–1.550, p=0.014), vasopressor within 3-h (AOR, 1.235; 95% CI, 1.009–1.512; P=0.031) and for the administration of the complete 3-h bundle (AOR, 1.231; 95% CI, 1.004–1.501; P=0.046), likely as a result of the increased volume of patients admitted during daytime hours. Consequently, daytime hospital admission adversely affected in-hospital and 28-day mortality rates, mediated by decreased compliance with the complete 3-h bundle. Conclusions: Septic shock patients admitted to the ED during the daytime exhibited lower sepsis bundle compliance than those admitted at night. Despite sepsis campaign implementation, factors that decrease bundle compliance should be reconsidered in patients with septic shock.

Background Cardiovascular disease is the leading cause of death worldwide. Early recognition, diagnosis, and reperfusion are the key elements of treatment for ST-segment elevation myocardial infarction. The absence of a prehospital 12-lead electrocardiogram (P12ECG) can cause definitive treatment delay and repeated transfer. Although guidelines highly recommend the measurement and transmission of P12ECG data, P12ECG use has not been widely established. Objective The aim of this study was to verify the time-efficiency and feasibility of the use of a patchy-type 12-lead ECG measuring and transmitting device (P-ECG) by an emergency medical technician (EMT) in an ambulance during patient transport. Methods This was a simulation-based prospective randomized crossover-controlled study that included EMTs. The participants were randomly assigned to one of two groups. Group A began the experiment with a conventional 12-lead ECG (C-ECG) device and then switched to the intervention device (P-ECG), whereas group B began the experiment with the P-ECG and then switched to the C-ECG. All simulations were performed inside an ambulance driving at 30 km/h. The time interval was measured from the beginning of ECG application to completion of sending the results. After the simulation, participants were administered the System Usability Scale questionnaire about usability of the P-ECG. Results A total of 18 EMTs were recruited for this study with a median age of 35 years. The overall interval time for the C-ECG was 254 seconds (IQR 247-270), whereas the overall interval time for the P-ECG was 130 seconds (IQR 112-150), with a significant difference (P Conclusions Performance of 12-lead ECG examination and transmission of the results using P-ECG are faster than those of C-ECG during ambulance transport. With the additional time afforded, EMTs can provide more care to patients and transport patients more rapidly, which may help reduce the symptoms-to-balloon time for patients with acute coronary syndrome. Trial Registration ClinicalTrials.gov NCT04114760; https://www.clinicaltrials.gov/ct2/show/NCT04114760

BACKGROUND Out-of-hospital cardiac arrest (OHCA) is a serious public health issue and predicting the prognosis of OHCA patients would be helpful for clinicians to make decisions on the treatment of patients or use of hospital resources. OBJECTIVE This study aimed to develop a time-adaptive conditional prediction model (TACOM) for predicting clinical outcomes every minute. METHODS We performed a retrospective observational study using data from the Korea OHCA Registry in South Korea. In this study, we excluded patients with trauma, those who experienced return of spontaneous circulation before arriving in the emergency departments (ED), and those who did not receive cardiopulmonary resuscitation (CPR) in the ED. We selected patients who received CPR in the ED. To develop the time-adaptive prediction model, we organized the training dataset as ongoing CPR patients by the minute. We used LightGBM as the machine-learning method. Model performance was quantified using the prediction probability of the model, area under the receiver operating characteristic curve (AUROC), and area under the precision recall curve. RESULTS From 0 to 30 min, the AUROC of TACOM for predicting good neurologic outcomes ranged from 0.910 (0.910–0.911) to 0.869 [0.865–0.871], whereas that for survival to hospital discharge was 0.800 (0.797–0.800) to 0.734 (0.736–0.740). The prediction probability of TACOM showed similar flow with cohort data, based on a comparison with the conventional model’s prediction probability. CONCLUSIONS TACOM predicted the clinical outcome of patients with OHCA every minute. This model for predicting patient outcomes by minute can be expected to help clinicians make rational decisions for OHCA patients.

Various types and levels of personal protective equipment (PPE) are currently available to protect health-care workers against infectious diseases. However, wearing cumbersome PPE may negatively affect their performance in life-saving procedures. This study aimed to evaluate the impact of wearing extensive PPE, including a powered air-purifying respirator with a loose-fitting hood or an N95 filtering facepiece respirator, on the first-pass success (FPS) rate of endotracheal intubation (ETI) in the emergency department (ED). This study was a single-center, observational before-and-after study of 934 adult (≥18 years old) patients who underwent ETI in the academic ED. The study period was divided into a control period (from 20 January 2019, to 30 September 2019, and from 20 January 2018, to 30 September 2018) and an intervention period (from 20 January 2020, to 30 September 2020). Extensive PPE was not donned during the control period (control group, n = 687) but was donned during the intervention period (PPE group, n = 247). The primary outcome was the FPS rate. We used propensity score matching between the PPE and control groups to reduce potential confounding. Propensity score matching identified 247 cases in the PPE group and 492 cases in the control group. In the matched cohort, no significant difference was found in the FPS rate between the PPE and control groups (83.8% (n = 207) vs. 81.9% (n = 403), p = 0.522). In multivariable analysis, wearing PPE was not associated with the FPS rate (adjusted odds ratio, 0.90, 95% confidence interval, 0.57–1.40, p = 0.629) after adjusting for the level of the intubator (junior resident, senior resident, or emergency medicine (EM) specialist). In conclusion, the FPS rate is not significantly affected by wearing extensive PPE in the ED.

Background Point-of-care ultrasound (POCUS) is an essential tool in emergency medicine (EM). We aimed to investigate the current status and perception of POCUS use in emergency medical centers in Korea. Methods A cross-sectional, nationwide survey was conducted using a mobile survey of physicians at emergency medical centers in Korea. The first message was sent on November 27, 2020, and the second message was sent on December 3, 2020 to the non-responders. The questionnaire comprised 6 categories and 24 questionnaires on demographics, current practice, education, perception, and barriers to the use of POCUS. Results A total of 467 physicians participated in the survey (a response rate of 32% among 1,458 target physicians), of which 43% were residents and 57% were EM specialists. Most of the respondents (96%) answered that they use POCUS, of which 89% reported using it at least once a week. The most frequently used types of POCUS were focused assessment with sonography for trauma (68%) and echocardiography (66%). Musculoskeletal, male genital, and pediatric scans were rarely performed tests but ranked as of the scans physicians most wanted to learn. About 73% of the respondents received ultrasound education, and 41% received ultrasound education at their own institutions. Nevertheless, education-related barriers are still the biggest deterrent to POCUS use (60%). In addition, multivariate multinomial logistic regression analysis revealed that the greater the number of ultrasound devices and the total number of physicians in the emergency center, the more likely they were to use POCUS every day. Conclusion This study found that most physicians currently working in emergency medical centers in Korea more frequently perform various types of ultrasound scans compared to those 10 years prior. To further promote the use of POCUS, it is important to have an appropriate number of ultrasound devices and physicians in the emergency center along with systematic POCUS education., Graphical Abstract

Background and objectives: As in adults, the survival rates and neurological outcomes after infant Cardiopulmonary resuscitation (CPR) are closely related to the quality of resuscitation. This study aimed to demonstrate that using a smartwatch as a haptic feedback device increases the quality of infant CPR performed by medical professionals. Materials and methods: We designed a prospective, randomized, case-crossover simulation study. The participants (n = 36) were randomly allocated to two groups: control first group and smartwatch first group. Each CPR session consisted of 2 min of chest compressions (CCs) using the two-finger technique (TFT), 2 min of rest, and 2 min of CCs using the two-thumb encircling hands technique (TTHT). Results: The primary outcome was the variation in the “proportion of optimal chest compression duration” and “compression rate” between the smartwatch-assisted and non-smartwatch-assisted groups. The secondary outcome was the variation in the “compression depth” between two groups. The proportion of optimal CC duration was significantly higher in the smartwatch-assisted group than in the non-smartwatch-assisted group. The absolute difference from 220 was much smaller in the smartwatch-assisted group (218.02) than in the non-smartwatch-assisted group (226.59) (p-Value = 0.018). Conclusion: This study demonstrated the haptic feedback system using a smartwatch improves the quality of infant CPR by maintaining proper speed and depth regardless of the compression method used.

This study aimed to address the impact of 1-hr bundle achievement on outcomes in septic shock patients. Secondary analysis of multicenter prospectively collected data on septic shock patients who had undergone protocolized resuscitation bundle therapy at emergency departments was conducted. In-hospital mortality according to 1-h bundle achievement was compared using multivariable logistic regression analysis. Patients were also divided into 3 groups according to the time of bundle achievement and outcomes were compared to examine the difference in outcome for each group over time: group 1 (≤1 h reference), group 2 (1–3 h) and group 3 (3–6 h). In total, 1612 patients with septic shock were included. The 1-h bundle was achieved in 461 (28.6%) patients. The group that achieved the 1-h bundle did not show a significant difference in in-hospital mortality compared to the group that did not achieve the 1-h bundle on multivariable logistic regression analysis (&lt, 1 vs. &gt, 1 h) (odds ratio = 0.74, p = 0.091). However, 3- and 6- h bundle achievements showed significantly lower odds ratios of in-hospital mortality compared to the group that did not achieve the bundle (&lt, 3 vs. &gt, 3 h, &lt, 6 vs. &gt, 6 h, odds ratio = 0.604 and 0.458, respectively). There was no significant difference in in-hospital mortality over time for group 2 and 3 compared to that of group 1. One-hour bundle achievement was not associated with improved outcomes in septic shock patients. These data suggest that further investigation into the clinical implications of 1-h bundle achievement in patients with septic shock is warranted.

Background We aimed to investigate the association between initial fluid resuscitation in septic shock patients with isolated hyperlactatemia and outcomes. Methods This multicenter prospective study was conducted using the data from the Korean Shock Society registry. Patients diagnosed with isolated hyperlactatemia between October 2015 and December 2018 were included and divided into those who received 30 mL/kg of fluid within 3 or 6 h and those who did not receive. The primary outcome was in-hospital mortality; the secondary outcomes were intensive care unit (ICU) admission, length of ICU stay, mechanical ventilation, and renal replacement therapy (RRT). Results A total of 608 patients were included in our analysis. The administration of 30 mL/kg crystalloid within 3 or 6 h was not significantly associated with in-hospital mortality in multivariable logistic regression analysis ([OR, 0.8; 95% CI, 0.52–1.23, p = 0.31], [OR, 0.96; 95% CI, 0.59–1.57, p = 0.88], respectively). The administration of 30 mL/kg crystalloid within 3-h was not significantly associated with mechanical ventilation and RRT ([OR, 1.19; 95% CI, 0.77–1.84, p = 0.44], [OR, 1.2; 95% CI, 0.7–2.04, p = 0.5], respectively). However, the administration of 30 mL/kg crystalloid within 6 h was associated with higher ICU admission and RRT ([OR, 1.57; 95% CI, 1.07–2.28, p = 0.02], [OR, 2.08; 95% CI, 1.19–3.66, p = 0.01], respectively). Conclusions Initial fluid resuscitation of 30 mL/kg within 3 or 6 h was neither associated with an increased or decreased in-hospital mortality in septic shock patients with isolated hyperlactatemia.

Objectives: Many patients with massive hemorrhage, respiratory failure due to trauma admit the emergency department, and further that the experience can fall into shock, inducing to sepsis, multiple organ failure due to hyperinflammation or immunosuppression. In the these patients, the low oxygen flow with immunosuppression is believed to play a significant role. Hence, oxygen supply and medicines is essential in severe trauma patients. Therefore, this study aims to investigate the effects of oxygen and variable medicines in hypoxic condition. Methods: T cells and macrophages were plated into trans-well plate for co-culture for 30 minutes in hypoxia. After that, the cells were stimulated with lipopolysaccharide (LPS) followed by variable medicines by normoxia or oxygen supply for 2 hrs and cells were inculated overnight under normoxic conditions. The T cell viability was measured by MTT, and the expression of interleukin-2 (IL-2), interleukin-8 (IL-8) and macrophage migration inhibitory factor (MIF) were measured by western blots using the T cells with co-culture with inflammatory maccrophages. Also, the concentration of MIF was analyzed by ELISA. Results: The T cells viability was decreased in hypoxia with LPS stimulation, however, pentoxifylline (PTX) effectively restored cell viability regardless of oxygen state (p < 0.05). Besides, PTX in oxygen supply status restored the decreases in IL-2 expression of T cells and the increases MIF in the LPS stimulation with hypoxia (p < 0.05). Conclusions: PTX has more effectively restored the T cells immunosuppression in hypoxia during oxygen supply, and has an immunomodulation effect by controlling hyperinflammation.

We aimed to describe the clinical manifestations of patients with sepsis who had the hollow adrenal gland sign (HAGS) during the acute phase of resuscitation and evaluated its value in predicting in-hospital mortality.We performed a single-center, retrospective study of patients with sepsis who visited the emergency department (ED) from November 2015 to December 2018. The patients were categorized into the positive HAGS (pHAGS) and negative HAGS (nHAGS) groups, based on its presence in initial dual-phase contrast-enhanced abdominal computed tomography (CT). The primary outcome was in-hospital mortality. A multiple logistic regression model was developed to assess variables related to in-hospital mortality.In all, 156 patients were included, and 36.5% (n = 57) was assigned to the pHAGS group. Both the maximal Sequential Organ Failure Assessment score within 24 h after ED arrival (10, interquartile range [IQR] 7-13 vs. 8, IQR 6-10, p 0.01) and APACHE II score (24, IQR 20-31 vs. 20, IQR 17-25, p 0.01) were significantly higher in the pHAGS than in the nHAGS group; the former group received significantly more interventions including vasopressors, renal replacement therapy, mechanical ventilation, and transfusions; in-hospital mortality was significantly higher in the former than in the latter group (29.8% vs. 10.1%, p 0.01). pHAGS was an independent predictor of in-hospital mortality (adjusted odds ratio, 2.89; 95% confidence interval, 1.08-7.78; p = 0.04).Patients with sepsis who showed the HAGS had more severe illness than those who did not, and had an increased need for organ-supportive interventions. Presence of the HAGS was independently associated with in-hospital mortality.

The aim of the study was to investigate the diagnostic accuracy of initial and post-fluid resuscitation lactate levels in predicting 28 day mortality.We retrospectively analyzed a multi-center registry of suspected septic shock cases that was prospectively collected between October 2015 and December 2018 from 11 Emergency Departments. The primary outcome was 28 day mortality. The diagnostic performance of the initial and post-fluid resuscitation lactate levels as a predictor for 28 day mortality was assessed.A total of 2568 patients were included in the final analysis. The overall 28 day mortality rate was 23%. The area under the receiver operating characteristic curve (AUROC) of initial lactate for predicting 28 day mortality was 0.66 (95% CI, 0.64-0.69) and that of after fluid administration lactate was 0.70 (95% CI, 0.67-0.72), and there was a significant difference (p 0.001). The optimal cutoff point of lactate after fluid administration was 4.4 mmol/L. Compared with this, the Sepsis-3 definition with a lactate level of 2 mmol/L or more was relatively more sensitive and less specific for predicting 28 day mortality.The post-fluid resuscitation lactate level was more accurate than the initial lactate level in predicting 28 day mortality in patients with suspected septic shock.

Background The application of appropriate personal protective equipment for respiratory protection to health care workers is a cornerstone for providing safe healthcare in emergency departments. We investigated the protective effect and usefulness of loose-fitting powered air-purifying respirators (PAPRs) during chest compression. Methods This was a single-center simulation study performed from May 2019 to July 2019 in a tertiary hospital. We measured the concentrations of ambient aerosol and particles inside the loose-fitting PAPR during chest compression, and this ratio was set as the simulated workplace protecting factor (SWPF). According to the National Institute for Occupational Safety and Health regulations, the assigned protection factor (APF) of loose-fitting PAPRs is 25. Thus, the loose-fitting PAPRs were assumed to have a protective effect when the SWPF were ≥ 250 (APF × 10). We measured the SWPF of PAPR in real time during chest compression and also investigated the problems encountered during its use. Results Ninety-one participants (median age 29 [interquartile range (IQR): 26–32] years; 74% female) completed the simulation. None of the participants failed with SWPF below 250 during three sessions of chest compression. The median (IQR) values of SWPF at three cycles were 17,063 (10,145-26,373), 15,683 (9477-32,394), and 16,960 (7695-27,279). There was no disconnection of equipment or mechanical failures during chest compression. In addition, most participants (83%) replied that they rarely or never experienced difficulty in verbal communication and felt that the loose-fitting PAPR was comfortable. Conclusions The loose-fitting PAPRs provided sufficient respiratory protection without disturbances during chest compression.

Background and objectives: We aimed to compare the accuracy of positive quick sequential organ failure assessment (qSOFA) scores and the RED sign in predicting critical care requirements (CCRs) in patients with suspected infection who presented to the emergency department (ED). Materials and Methods: In this retrospective observational study, we examined adult patients with suspected infection in the ED from June 2018 to September 2018. A positive qSOFA (qSOFA+) was defined as the presence of &ge, 2 of the following criteria: altered mental status (AMS), systolic blood pressure (SBP) &lt, 100 mmHg, and respiratory rate (RR) &ge, 22 breaths/min. A positive RED sign (RED sign+) was defined as the presence of at least one of the RED sign criteria: AMS, skin mottling, SBP &lt, 90 mmHg, heart rate &gt, 130 beats/min, or RR &gt, 30 breaths/min. A qSOFA/RED+ was defined as the presence of qSOFA+ or RED+. We applied these tools twice using the initial values upon ED arrival and all values within 2 h after ED arrival. The accuracy of qSOFA+, RED+, and qSOFA/RED+ in predicting CCR was assessed. Results: Data from 5353 patients with suspected infection were analyzed. The area under the receiver operating characteristic curve (AUC) of RED+ (0.67, 95% confidence interval [CI]: 0.65&ndash, 0.70) and that of qSOFA/RED+ (0.68, 95% CI: 0.66&ndash, 0.70, p &lt, 0.01) were higher than the AUC of qSOFA+ (0.59, 95% CI: 0.57&ndash, 0.60) in predicting CCR on ED arrival. The qSOFA/RED+ within 2 h showed the highest accuracy (AUC 0.72, 95% CI: 0.70&ndash, 0.75, p &lt, 0.001). Conclusions: The accuracy of the RED sign in predicting CCR in patients with suspected infection who presented at ED was better than that of qSOFA. The combined use of the RED sign and qSOFA (positive qSOFA or RED sign) showed the highest accuracy.

Sepsis is a common cause of delirium in the intensive care unit (ICU). Recently, vitamin C and thiamine administration has been gaining interest as a potential adjunct therapy for sepsis. We investigated the impact of early vitamin C and thiamine administration on ICU delirium-free days among critically ill patients in septic shock. We performed a single-center, retrospective study of patients who visited the emergency department (ED) from January 2017 to July 2018. We categorized patients into a treatment (received vitamin C and thiamine) and control group. We compared delirium-free days within 14 days after ICU admission using propensity score matching. Of 435 patients with septic shock, we assigned 89 propensity score-matched pairs to the treatment and control groups. The median delirium-free days did not differ between treatment (11, interquartile range [IQR] 5&ndash, 14 days) and control (12, IQR 6&ndash, 14 days) groups (p = 0.894). Secondary outcomes were not different between the two groups, including delirium incidence and 28-day mortality. These findings were consistent after subgroup analysis for patients who met the sepsis-3 definition of septic shock. Vitamin C and thiamine administration showed no association with ICU delirium-free days among patients in septic shock.

ObjectiveThe increasing frequency of bicycle-related injuries is due to the growing elderly population and their increasing physical activity. This study aimed to compare the protective effects of helmets on bicycle-related injuries in elderly individuals compared with those in younger adults.MethodsData from the Korean emergency department–based Injury In-depth Surveillance database from eight emergency departments during 2011–2016 were retrospectively analysed. The subjects sustained injuries while riding bicycles. Cases with unknown clinical outcomes were excluded. Covariates included mechanism, place and time of injury. The primary outcome was traumatic brain injury (TBI) incidence, and the secondary outcomes were in-hospital mortality and severe trauma. The effects of helmets on these outcomes were analysed and differences in effects were determined using logistic regression analysis. Subsequently, the differences in the effects of helmets use between age groups were examined by using interaction analysisResultsOf 7181 adults, 1253 were aged >65 years. The injury incidents showed a bimodal pattern with peaks around ages 20 and 50 years. Meanwhile, the helmet-wearing rate showed a unimodal pattern with its peak at age 35–40 years; it decreased consistently with age. By multivariate analysis, helmet-wearing was associated with a reduced TBI incidence (OR 0.76; 95% CI 0.57 to 0.99) and severe trauma (OR 0.78; 95% CI 0.65 to 0.93). The effects of helmets increased in elderly individuals (TBI (p=0.022) and severe trauma (p=0.024)).ConclusionThe protective effects of helmets on bicycle-related injuries are greater for elderly individuals, thus reducing TBI incidence.

Objective To evaluate the clinical characteristics, therapeutic interventions, and outcomes of patients with septic shock admitted to the emergency department (ED). Methods This study was a preliminary, descriptive analysis of a prospective, multi-center, observational registry of the EDs of 10 hospitals participating in the Korean Shock Society. Patients aged 19 years or older who had a suspected or confirmed infection and evidence of refractory hypotension or hypoperfusion were included. Results A total of 468 patients were enrolled (median age, 71.3 years; male, 55.1%; refractory hypotension, 82.9%; hyperlactatemia without hypotension, 17.1%). Respiratory infection was the most common source of infection (31.0%). The median Sepsis-related Organ Failure Assessment score was 7.5. The sepsis bundle compliance was 91.2% for lactate measurement, 70.3% for blood culture, 68.4% for antibiotic administration, 80.3% for fluid resuscitation, 97.8% for vasopressor application, 68.0% for central venous pressure measurement, 22.0% for central venous oxygen saturation measurement, and 59.2% for repeated lactate measurement. Among patients who underwent interventions for source control (n=117, 25.1%), 43 (36.8%) received interventions within 12 hours of ED arrival. The in-hospital, 28-day, and 90-day mortality rates were 22.9%, 21.8%, and 27.1%, respectively. The median ED and hospital lengths of stay were 6.8 hours and 12 days, respectively. Conclusion This preliminary report revealed a mortality of over 20% in patients with septic shock, which suggests that there are areas for improvement in terms of the quality of initial resuscitation and outcomes of septic shock patients in the ED.

Objective Many studies have described constructing a prediction model for bacteremia in community-acquired pneumonia (CAP), but these studies were not validated in external heterogeneous groups. The objective of this study was to test the generalizability of a previous bacteremia prediction model for CAP by external validation. Methods This multicenter retrospective cohort analysis was performed in eight tertiary urban hospital emergency departments (ED). We reviewed adult patients who were hospitalized after presentation to the ED with CAP. We categorized the enrolled patients into three groups according to the bacteremia prediction model score and calculated the number of patients with or without a blood culture-positive result. We performed a multivariable analysis to identify significant predictors for bacteremia. Results Among the enrolled 2,001 patients, 1,592 (79.6%), 371 (18.5%), and 38 (1.9%) were stratified to a low, moderate, and high-risk group, respectively, and this proportion was similar with previous study. Each group had a bacteremia-positive rate as follows: 1.2% for the low-risk group, 7.2% for the moderate-risk group, and 31.5% for the high-risk group. The area under the receiver operating characteristic curve for the bacteremia model in the external validation cohort was 0.81, and there was no significant difference with that of the previous internal validation cohort (p = 0.246). Assuming that blood cultures were not performed in the low-risk patients, the sensitivity and specificity of this model were 0.68 and 0.81, respectively. Additionally, the positive predictive value and negative predictive value were 9.54% and 98.87%, respectively. A platelet count less than 130,000 cell/μL, albumin less than 3.3 mg/dL, and C-reactive protein (CRP) greater than 17 mg/dL were identified as significant predictors with a sensitivity and specificity of, 0.70 and 0.83, respectively. Conclusion The bacteremia prediction model was well validated in the general population and could help physicians make the decision to reduce the number of blood cultures in patients with CAP. This article is protected by copyright. All rights reserved.

Objective We aimed to evaluate the knowledge and attitudes of emergency medical service (EMS) personnel pertaining to sepsis. We also compared EMS personnel's knowledge of sepsis and their intention to engage in prehospital sepsis management. Methods The survey was conducted during education conferences for EMS personnel in December 2013 and January 2015 in Seoul, Korea. The questionnaire composed of 10 questions relevant to sepsis, was distributed on-scene, and was retrieved by investigators after the conference. We classified subjects into active and passive groups based on intent to participate in prehospital sepsis care. Results A total of 271 questionnaires were distributed; 255 EMS personnel (94%) completed the survey, 126 (49%) of whom were first-degree emergency medical technicians (EMTs). Less than 75% of subjects provided clinically relevant responses to questions about the definitions of sepsis, tachycardia, tachypnea, hypotension, hypothermia, fluid resuscitation, and vasopressor. Only 15% of participants had suspected that a patient had sepsis, and 9% reported that they could identify patients with sepsis during transportation. Overall, first-degree EMTs showed higher levels of knowledge and a positive attitude to sepsis compared with non-first-degree EMTs. Sixty percent of the participants reported that they were actively involved in prehospital sepsis care. The active group showed significantly higher levels of knowledge and more positive responses to the clinical impact of prehospital sepsis care. Conclusion Our study showed that is a substantial portion of EMS personnel lacks appropriate level of knowledge on sepsis care. We also found that the intention to engage in sepsis management was associated with appropriate knowledge of sepsis.

We evaluated the associations between the neutrophil-to-lymphocyte ratio (NLR) or changes in NLR and outcomes in septic patients.Patients who met the criteria for severe sepsis or septic shock were categorized into five groups according to the quintile of initial NLR value. We defined two risk groups according to NLR value and changes in NLR during the first two days (defined as the persistently low NLR group and the persistently high NLR group). The primary outcome was 28-day mortality.A total of 1395 patients were included. The median initial NLR values from Quintile 1 to Quintile 5 were as follows: 0.2 (IQR [interquartile range], 0.1-0.7), 3.4 (IQR, 2.6-4.7), 8.6 (IQR, 7.1-9.9), 15.4 (IQR, 13.3-17.8), and 31.0 (IQR, 24.6-46.8), respectively. The 28-day mortality values for the same groups were as follows: 24.4%, 12.2%, 11.1%, 11.8%, and 16.1% (P.01). Cox regression analysis showed that inclusion in Quintile 1 or Quintile 5 was a significant risk factor predicting 28-day mortality compared to Quintile 3 (adjusted hazard ratio [HR]: 1.79 (95% confidence interval [CI], 1.15-2.78) in Quintile 1; 1.67 (95% CI, 1.04-2.66) in Quintile 5). The analysis indicated that persistently low NLR (adjusted HR: 2.25, 95% CI, 1.63-3.11) and persistently high NLR (adjusted HR: 2.65, 95% CI, 1.64-4.29) were significant risk factors.In summary, the initial NLR measured at ED admission was independently associated with 28-day mortality in patients with severe sepsis and septic shock. In addition, change in NLR may prove to be a valuable prognostic marker.

ObjectivesHyperchloraemia is associated with poor clinical outcomes in sepsis patients; however, this association is not well studied for hypochloraemia. We investigated the prevalence of chloride imbalance and the association between hypochloraemia and 28-day mortality in ED patients with septic shock.MethodsA retrospective analysis of data from 11 multicentre EDs in the Republic of Korea prospectively collected from October 2015 to April 2018 was performed. Initial chloride levels were categorised as hypochloraemia, normochloraemia and hyperchloraemia, according to sodium chloride difference adjusted criteria. The primary outcome was 28-day mortality. A multivariate logistic regression model adjusting for age, sex, comorbidities, acid-base state, sepsis-related organ failure assessment (SOFA) score, lactate and albumin level was used to test the association between the three chloride categories and 28-day mortality.ResultsAmong 2037 enrolled patients, 394 (19.3%), 1582 (77.7%) and 61 (3.0%) patients had hypochloraemia, normochloraemia and hyperchloraemia, respectively. The unadjusted 28-day mortality rate in patients with hypochloraemia was 27.4% (95% CI, 23.1% to 32.1%), which was higher than in patients with normochloraemia (19.7%; 95% CI, 17.8% to 21.8%). Hypochloraemia was associated with an increase in the risk of 28-day mortality (adjusted OR (aOR), 1.36, 95% CI, 1.00 to 1.83) after adjusting for confounders. However, hyperchloraemia was not associated with 28-day mortality (aOR 1.35, 95% CI, 0.82 to 2.24).ConclusionHypochloraemia was more frequently observed than hyperchloraemia in ED patients with septic shock and it was associated with 28-day mortality.

Background This study described and analysed the features of powered mobility device (PMD)-related injuries and compared elderly and younger adult injuries. Methods Data from Korea Emergency Department-based Injury In-depth Surveillance (EDIIS) database involving eight emergency departments in 2011–2016 were analysed. The inclusion criteria were injuries sustained during the use of PMDs. The variables were compared between adults aged ≥ 65 years and younger adults. Primary and secondary outcomes were severe trauma and poor clinical course accordingly. The logistic regression analysis was used to identify risk factors for study outcomes. Results A total of 231 adults were enrolled, of whom 150 were ≥ 65 years of age. The total number of PMD-related injuries and the proportion of elderly injured patients increased annually, and most injuries occurred on the roadway and did not involve crash opponents. By multivariate analysis, patients aged ≥ 65 years had a higher injury severity score (adjusted odds ratio [AOR], 2.78; 95% confidence interval [CI], 1.50–5.40) and had a higher incidence of intensive care unit admissions, surgery, and death (AOR, 2.42; 95% CI, 1.16–5.28). Conclusion Given the higher number and severity of injuries sustained among elderly adults ≥ 65 years of age shown in this study, we recommend that safety educations, such as the use of protective equipment and the safe driving on the roadway, are considered for PMD users ≥ 65 years of age., Graphical Abstract

Background and Objectives: Ultrasonography is useful in evaluating patients with renal colic and it has high sensitivity and specificity for diagnosing ureter stones by revealing hydronephrosis. We evaluated the efficacy of point-of-care ultrasonography protocol in managing patients with acute renal colic who visited the emergency department (ED). Materials and Methods: Between March 2019 and July 2019, patients who visited the ED because of renal colic were randomly assigned by date of visit either to the conventional group (CG), who underwent routine diagnostic work-up without ultrasonography, or to the ultrasonography group (UG), who underwent bedside ultrasonography as an initial diagnostic testing. When hydronephrosis was detected in the UG group, a confirmatory non-contrast abdomen computed tomography scan was promptly performed. The ED length of stay, complications, and missed or delayed high-risk diagnosis were evaluated. Results: In total, 128 of 147 analyzed patients were confirmed to have ureter stones. The ED length of stay was significantly lower in the UG group than in the CG group (mean 172 min, 95% confidence interval (CI): 151&ndash, 194 min vs. mean 234 min, 95% CI: 216&ndash, 252 min). The medical cost was also remarkably lower in the UG group than in the CG group (259 USD vs. 319 USD, p &lt, 0.001). The incidence of complications within 30 days after visiting ED and missed or delayed high-risk diagnosis were not significantly different between the two groups. Conclusions: We found that protocolized point-of-care ultrasonography in patients with acute renal colic who visited the ED can more effectively reduce the length of stay and medical cost without 30-day complication than usual clinical practice.

Objective The utilization of emergency medical services (EMS) varies widely among communities. In this study, we aimed to evaluate the relationship between the use of EMS by patients with ST-elevation myocardial infarction (STEMI) and the individual and neighborhood characteristics of these patients. Methods We performed a secondary analysis of data from the Cardiovascular Disease Surveillance project, which included patients diagnosed with STEMI at 29 emergency centers in South Korea. Our analysis included only patients living in Seoul, and the primary outcome measured was the use of EMS. While the clinical variables of the patients were collected from the Cardiovascular Disease Surveillance registry, the 2010 National Census data was used to identify neighborhood variables such as population density, income, age, and residence type. We used a 3-level hierarchical logistic regression to estimate the effects of neighborhood-level factors on EMS use by individual patients. Results We evaluated 1,634 patients with STEMI from 2007 to 2012. The neighborhoods were grouped into 25 counties. The regional rates of EMS use varied from 18.3% to 46.5%. The final adjusted logistic model revealed that the use of EMS was significantly associated with the average number of households (neighborhood level factor) and symptoms of syncope, cardiac arrest, and history of cardiovascular disease (individual level factors). Conclusion The individual levels factors had a greater influence on the use of EMS compared to the neighborhood-level factors.

Objectives The aim of this study was to test the applicability of haptic feedback using a smartwatch to the delivery of cardiac compression (CC) by professional healthcare providers. Methods A prospective, randomized, controlled, case-crossover, standardized simulation study of 20 medical professionals was conducted. The participants were randomly assigned into haptic-first and non-haptic-first groups. The primary outcome was an adequate rate of 100-120/min of CC. The secondary outcome was a comparison of CC rate and adequate duration between the good and bad performance groups. Results The mean interval between CCs and the number of haptic and non-haptic feedback-assisted CCs with an adequate duration were insignificant. In the subgroup analysis, both the good and bad performance groups showed a significant difference in the mean CC interval between the haptic and non-haptic feedback-assisted CC groups-good: haptic feedback-assisted (0.57-0.06) vs. non-haptic feedback-assisted (0.54-0.03), p < 0.001; bad: haptic feedback-assisted (0.57-0.07) vs. non-haptic feedback-assisted (0.58-0.18), p = 0.005-and the adequate chest compression number showed significant differences- good: haptic feedback-assisted (1,597/75.1%) vs. non-haptic feedback-assisted (1,951/92.2%), p < 0.001; bad: haptic feedbackassisted (1,341/63.5%) vs. non-haptic feedback-assisted (523/25.4%), p < 0.001. Conclusions A smartwatch cardiopulmonary resuscitation feedback system could not improve rescuers' CC rate. According to our subgroup analysis, participants might be aided by the device to increase the percentage of adequate compressions after one minute.

Background Septic shock is a life-threatening condition with underlying circulatory and cellular/metabolic abnormalities. Vitamin C and thiamine are potential candidates for adjunctive therapy; they are expected to improve outcomes based on recent experimental and clinical research. The aim of the Ascorbic Acid and Thiamine Effect in Septic Shock (ATESS) trial is to evaluate the effects of early combination therapy with intravenous vitamin C and thiamine on recovery from organ failure in patients with septic shock. Methods This study is a randomized, double-blind, placebo-controlled, multicentre trial in adult patients with septic shock recruited from six emergency departments in South Korea. Patients will be randomly allocated into the treatment or control group (1:1 ratio), and we will recruit 116 septic shock patients (58 per group). For the treatment group, vitamin C (50 mg/kg) and thiamine (200 mg) will be mixed in 50 ml of 0.9% saline and administered intravenously every 12 h for a total of 48 h. For the placebo group, an identical volume of 0.9% saline will be administered in the same manner. The primary outcome is the delta Sequential Organ Failure Assessment (SOFA) score (ΔSOFA = initial SOFA at enrolment – follow-up SOFA after 72 h). Discussion This trial will provide valuable evidence about the effectiveness of vitamin C and thiamine therapy for septic shock. If effective, this therapy might improve survival and become one of the main therapeutic adjuncts for patients with septic shock. Trial registration ClinicalTrials.gov, NCT03756220. Registered on 5 December 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3542-x) contains supplementary material, which is available to authorized users.

BACKGROUND: We aimed to investigate the association between average mean arterial pressure (a-MAP) and mortality in critically ill sepsis patients according to the presence of hypertension and previously measured blood pressure (BP). METHODS: From August 2008 to September 2014, patients with severe sepsis or septic shock presenting to the ED were categorized into four groups according to a-MAP during the initial 24 hours (group 0, a-MAP 85 mmHg. The primary outcome was 28-day mortality. RESULTS: A total of 1,395 patients were included. The 28-day mortality rates were 15.1% in patients overall, 39.7% in group 0, 18.3% in group 1, 10.1% in group 2, and 13.4% in group 3. In the regression analyses, mortality in group 2 was significantly lower compared with group 1 [odds ratio (OR), 0.33] or group 3 (OR, 0.31) in patients with hypertension. In the low previous BP group, there was greater mortality in group 3 compared to group 1 (OR, 2.42) and group 2 (OR, 3.88). In the high previous BP group, mortality was lower in group 2 compared with group 1 (OR, 0.32). CONCLUSIONS: In critically ill sepsis patients, there were different trends in mortality according to a-MAP depending on the presence of hypertension or previous BP.

Background and objectives: To compare the first pass success (FPS) rate of the C-MAC video laryngoscope (C-MAC) and conventional Macintosh-type direct laryngoscopy (DL) during cardiopulmonary resuscitation (CPR) in the emergency department (ED). Materials and Methods: This study was a single-center, retrospective study conducted from April 2014 to July 2018. Patients were categorized into either the C-MAC or DL group, according to the device used on the first endotracheal intubation (ETI) attempt. The primary outcome was the FPS rate. A multiple logistic regression model was developed to identify factors related to the FPS. Results: A total of 573 ETIs were performed. Of the eligible cases, 263 and 310 patients were assigned to the C-MAC and DL group, respectively. The overall FPS rate was 75% (n = 431/573). The FPS rate was higher in the C-MAC group than in the DL group, but there was no statistically significant difference (total n = 431, 79% compared to 72%, p = 0.075). In the multiple logistic regression analysis, the C-MAC use had higher FPS rate (adjusted odds ratio: 1.80, 95% CI, 1.17&ndash, 2.77, p = 0.007) than that of the DL use. Conclusions: The C-MAC use on the first ETI attempt during cardiopulmonary resuscitation in the emergency department had a higher FPS rate than that of the DL use.

The objective of this study was to evaluate the prognostic value of C-reactive protein (CRP), procalcitonin (PCT), and their combination for mortality in patients with septic shock. This multicenter, prospective, observational study was conducted between November 2015 and December 2017. A total of 1,772 septic shock patients were included, and the overall 28-day mortality was 20.7%. Although both CRP and PCT were elevated in the non-survivor group, only CRP had statistical significance (11.9 mg/dL vs. 14.7 mg/dL, p = 0.003, 6.4 ng/mL vs. 8.2 ng/mL, p = 0.508). Multivariate analysis showed that CRP and PCT were not independent prognostic markers. In the subgroup analysis of the CRP and PCT combination matrix using their optimal cut-off values (CRP 14.0 mg/dL, PCT 17.0 ng/dL), both CRP and PCT elevated showed significantly higher mortality (Odds ratio 1.552 [95% Confidence intervals 1.184–2.035]) than both CRP and PCT not elevated (p = 0.001) and only PCT elevated (p = 0.007). However, both CRP and PCT elevated was also not an independent predictor in multivariate analysis. Initial levels of CRP and PCT alone and their combinations in septic shock patients had a limitation to predict 28-day mortality. Future research is needed to determine new biomarkers for early prognostication in patients with septic shock.

Current guidelines recommend that rapid source control should be adopted in patients not6-12 h after sepsis is diagnosed. However, evidence level of this guideline is not specified, and there is no previous study on patients with septic shock visiting the emergency department (ED). Therefore, we aimed to assess the impact of rapid source control in patients with septic shock visiting the ED.In a prospective, observational, multicenter, registry-based study in 11 EDs, Cox proportional hazards model was used to assess the independent effect of source control and time to source control on 28-day mortality.Cox proportional hazard models revealed that 28-day mortality was significantly lower in patients who underwent source control (HR 0.538 (0.389-0.744), p .001). However, no significant association between the performance of source control after 6 h or 12 h from enrollment and 28-day mortality was noted.Patients with septic shock visiting the ED who underwent source control showed better outcomes than those who did not. We failed to demonstrate the performance of rapid source control reduced the 28-day mortality in septic shock patients. Further studies are required to determine the impact of rapid source control in sepsis and septic shock.

This study evaluated the prognostic ability of lactate normalization achieved within 6 and 24 h from septic shock recognition. Data from a septic shock registry from October 2015 to February 2017 were reviewed. The study included 2,102 eligible septic shock patients to analyze the prognostic ability of lactate normalization, defined as a follow-up lactate level

(1) Background: Cardiac magnetic resonance (CMR) imaging is an emerging tool for investigating nonischemic cardiomyopathies and cardiac systemic disease. However, data on the cardiac arrest population are limited. This study aimed to evaluate the usefulness of CMR imaging in out-of-hospital cardiac arrest (OHCA) survivors treated with targeted temperature management (TTM). (2) Methods: We conducted the retrospective observational study using a multicenter registry of adult non-traumatic comatose OHCA survivors who underwent TTM between January 2010 and December 2019. Of the 949 patients, 389 with OHCA of non-cardiac cause, 145 with significant lesions in the coronary artery, 151 who died during TTM, 81 without further evaluation due to anticipated poor neurological outcome, and 51 whose etiology is underlying disease were excluded. In 36 of the 132 remaining patients, the etiologies included variant angina, long QT syndrome, and complete atrioventricular block in ancillary studies. Fifty-six patients were diagnosed idiopathic ventricular fibrillation without CMR. (3) Results: CMR imaging was performed in the remaining 40 patients with cardiac arrest of unknown cause. The median time from cardiac arrest to CMR imaging was 10.1 days. The CMR finding was normal in 23 patients, non-diagnostic in 12, and abnormal in 5, which suggested non-ischemic cardiomyopathy but did not support the final diagnosis. (4) Conclusions: CMR imaging may not be useful for identifying unknown causes of cardiac arrest in OHCA survivors treated with targeted temperature management without definitive diagnosis even after coronary angiography, echocardiography, and electrophysiology studies. However, further large-scale studies will be needed to confirm these findings.

OBJECTIVES We evaluated central venous oxygen saturation (Scvo2) and lactate levels as a combination measure to predict mortality in patients with severe sepsis or septic shock. METHODS We included patients older than 18 years of age who presented to a single tertiary emergency center with septic shock or severe sepsis and received early goal-directed therapy. We classified the sample into four groups according to lactate (cut-off: 4 mmol/L) and Scvo2 (cut-off: 70%) levels at the time of initial resuscitation: Group 1, high-Scvo2, and low-lactate; Group 2, low-Scvo2, and low-lactate; Group 3, high-Scvo2, and high-lactate; Group 4, low-Scvo2, and high-lactate. The primary outcome was 28-day mortality determined by multivariable Cox-regression analysis. RESULTS A total of 880 patients were included in this study. The 28-day mortality was 6.7% in Group 1, 15.7% in Group 2, 26.7% in Group 3, and 25.5% in Group 4 (P

Current sepsis guidelines recommend administration of antibiotics within 1 hour of emergency department (ED) triage. However, the quality of the supporting evidence is moderate, and studies have shown mixed results regarding the association between antibiotic administration timing and outcomes in septic shock. We investigated to evaluate the association between antibiotic administration timing and in-hospital mortality in septic shock patients in the ED, using propensity score analysis.An observational study using a prospective, multicenter registry of septic shock, comprising data collected from 10 EDs, was conducted. Septic shock patients were included, and patients were divided into 4 groups by the interval from triage to first antibiotic administration: group 1 (≤1 hour; reference), 2 (1-2 hours), 3 (2-3 hours), and 4 (3 hours). The primary endpoint was in-hospital mortality. After inverse probability of treatment weighting, the outcomes of the groups were compared.A total of 2250 septic shock patients were included, and the median time to first antibiotic administration was 2.29 hours. The in-hospital mortality of groups 2 and 4 were significantly higher than those of group 1 (odds ratio [OR] 1.248; 95% confidence interval [CI], 1.053-1.478; P = .011; OR 1.419; 95% CI, 1.203-1.675; P.001, respectively), but those of group 3 was not (OR 1.186; 95% CI, 0.999-1.408; P = .052). Subgroup analyses of patients (n = 2043) with appropriate antibiotics presented similar results.In patients with septic shock, rapid administration of antibiotics was generally associated with a decrease in in-hospital mortality, but no "every hour delay" was seen.

BackgroundThe task of monitoring and managing the entire emergency department (ED) is becoming more important due to increasing pressure on the ED. Recently, dashboards have received the spotlight as health information technology to support these tasks. ObjectiveThis study aimed to describe the development of a real-time autonomous dashboard for the ED and to evaluate perspectives of clinical staff on its usability. MethodsWe developed a dashboard based on three principles—“anytime, anywhere, at a glance;” “minimal interruption to workflow;” and “protect patient privacy”—and 3 design features—“geographical layout,” “patient-level alert,” and “real-time summary data.” Items to evaluate the dashboard were selected based on the throughput factor of the conceptual model of ED crowding. Moreover, ED physicians and nurses were surveyed using the system usability scale (SUS) and situation awareness index as well as a questionnaire we created on the basis of the construct of the Situation Awareness Rating Technique. ResultsThe first version of the ED dashboard was successfully launched in 2013, and it has undergone 3 major revisions since then because of geographical changes in ED and modifications to improve usability. A total of 52 ED staff members participated in the survey. The average SUS score of the dashboard was 67.6 points, which indicates “OK-to-Good” usability. The participants also reported that the dashboard provided efficient “concentration support” (4.15 points), “complexity representation” (4.02 points), “variability representation” (3.96 points), “information quality” (3.94 points), and “familiarity” (3.94 points). However, the “division of attention” was rated at 2.25 points. ConclusionsWe developed a real-time autonomous ED dashboard and successfully used it for 5 years with good evaluation from users.

Postintubation hypotension (PIH) is an adverse event associated with poor outcomes in emergency department (ED) endotracheal intubation. This study aimed to evaluate the association between sedative dose adjustment and PIH during emergency airway management. We also investigated the impact of patient and procedural factors on the incidence of PIH.This was a single-center, retrospective study that used a prospectively collected registry of airway management performed at the ED from April 2014 to February 2017. Adult patients who received emergency endotracheal intubation were included. Multivariable logistic regression models were used to evaluate the association of PIH with sedative dose, patient variables, and procedural variables.Overall, 689 patients were included, and 233 (33.8%) patients developed PIH. In the patients overall, multivariable logistic regression demonstrated that age 70 years, shock index0.8, arterial acidosis (pH 7.2), intubation indication, and use of non-depolarizing neuromuscular blocking agent were significantly related to PIH. In patients overall, the sedative dose was not related to PIH (overdose; OR: 1.09, 95%CI: 0.57-2.06), (reduction; OR: 0.93, 95%CI: 0.61-1.42), (none used; OR: 1.28, 95%CI: 0.64-2.53). In subgroup analysis, ketamine dose was not related to PIH (overdose; OR: 0.81, 95%CI: 0.27-2.38, reduction; OR: 1.41, 95%CI: 0.78-2.54). Reduction of etomidate dose was significantly associated with decreased PIH (reduction; OR: 0.46, 95%CI: 0.22-0.98, overdose; OR: 1.77, 95%CI: 0.79-3.93).PIH was mainly related to predisposing patient-related factors. Only adjustment of etomidate dose was associated with the incidence of PIH.

The aim of this study was to evaluate the clinical utility of the lactate/albumin (L/A) ratio as a predictive factor of 28-day mortality in critically ill sepsis patients.This is a retrospective observational study from a prospectively collected multicenter registry of 10 emergency departments (EDs) in teaching hospitals that participated in the Korean Shock Society. It enrolled patients who were 19 years of age or older who had a suspected or confirmed infection and evidence of refractory hypotension or hypoperfusion. The prognostic performance of the L/A ratio and lactate level for predicting 28-day mortality was assessed. Lactate and albumin levels were measured immediately after ED arrival.A total of 946 patients were included, with 22.5% overall 28-day mortality. The area under the receiver operating characteristic curve (AUROC) value of the L/A ratio (0.69, 95% confidence interval [CI] 0.64-0.73, P 0.01) was higher than that of lactate (0.65, 95% CI 0.61-0.70, P 0.01) for predicting 28-day mortality. The optimal cutoff of the L/A ratio was 1.32. The AUROC value of the L/A ratio was better than that of lactate regardless of lactate level (normal [2.0 mmol/L]: 0.68 vs. 0.55; intermediate [≥2.0, 4.0 mmol/L]: 0.65 vs. 0.50; high [≥4.0 mmol/L]: 0.66 vs. 0.62). In the subgroup with decreased lactate elimination, the AUROC value of the L/A ratio was also significantly higher than that of lactate (hepatic dysfunction: 0.70 vs. 0.66; renal dysfunction: 0.71 vs. 0.67). The L/A ratio cut-off and hypoalbminemia showed further discriminative value for 28-day mortality even in patients with normal or intermediate lactate levels.The prognostic performance of the L/A ratio was superior to that of a single lactate measurement for predicting 28-day mortality of critically ill sepsis patients. L/A ratio can be a useful prognostic factor regardless of initial lactate level and the presence of hepatic or renal dysfunction.

Background Septic shock can be defined both by the presence of hyperlactatemia and need of vasopressors. Lactate levels should be measured after volume resuscitation (as per the Sepsis-3 definition). However, currently, no studies have evaluated patients who have been excluded by the new criteria for septic shock. The aim of this study was to determine the clinical characteristics and prognosis of these patients, based on their lactate levels after initial fluid resuscitation. Methods This observational study was performed using a prospective, multi-center registry of septic shock, with the participation of 10 hospitals in the Korean Shock Society, between October 2015 and February 2017. We compared the 28-day mortality between patients who were excluded from the new definition (defined as lactate level

Background: We compared the clinical characteristics and outcomes between the new definition of sepsis-3 septic shock and the definition previously used from 1991 until recently. Methods: We conducted an observational study using a prospective, multi-center registry of septic shock from October 2015 to February 2017. Registry data were collected by 10 emergency departments (EDs) in tertiary hospitals that are members of the Korean Shock Society. Data on septic shock patients who met the previous septic shock definition were collected. The patients were divided into a sepsis-3 defined septic shock group, made up of those who met the new criteria for refractory hypotension with hyperlactatemia, and a group of those who met only the 1991 definition for septic shock. The primary outcome was 90-day mortality, and secondary outcomes were 28-day mortality and in-hospital mortality. Results: Of all 1,028 included patients, 574 (55.8%) met the septic shock criteria for sepsis-3, leaving 454 patients who met only the previous definition. Those who met the sepsis-3 criteria demonstrated higher comorbidity than those who met the previous definition (83.1% vs . 75.3%, P vs . 5.0±2.9, 9.3±3.8 vs . 6.6±3.4, and 20.0 (15.0–26.0) vs . 15.0 (10.0–20.3), respectively; P vs . 23.3%; P vs . 17.1% and 25.1% vs . 16.5%, respectively; P Conclusions: The new definition of septic shock successfully selected patients with greater severities and worse outcomes.

Background Suicide in young people is one of most common cause of death; and deliberate self-harm (DSH) is important indicator of suicide. It is currently unclear how old the rate begins to increase or when it reaches to the same level with adults. The purpose of this study was to find beginning age of DSH and compare their characteristics with adults. Methods This study retrospectively reviewed 5 years of nationwide prospective registry named Emergency Department-based Injury In-depth Surveillance (EDIIS) registry composed of all injured patients who were admitted to twenty tertiary university hospital emergency departments. Injured patients aged 29 years or younger from January 1, 2011 to December 31, 2015 were included. Incidence rate of DSH in all age was described. Patients were stratified by age: early teenage (11–15 years), late teenage (16–19 years), and early adulthood (20–29 years). Data of early teenage group were compared to those of other groups for examining their characteristics. Results Among 588,549 injury patients, 8,400 patients reported DSH. The rate began to rise at age 11 and reach at age 16 which was equivalent to that of age 20 to 29. Early teenage had significantly higher excess mortality ratio based injury severity score (EMR-ISS) and had almost same level without significant difference in operation incidence or mortality compared to late teenage and early adulthood. Conclusion DSH rate began to rise at age 11, reaching adulthood level at age 16 in Korea., Graphical Abstract