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Objective We compared training using a voice advisory manikin (VAM) with an instructor-led (IL) course in terms of acquisition of initial cardiopulmonary resuscitation (CPR) skills, as defined by the 2010 resuscitation guidelines. Methods This study was a randomized, controlled, blinded, parallel-group trial. We recruited 82 first-year emergency medical technician students and distributed them randomly into two groups: the IL group (n=41) and the VAM group (n=37). In the IL-group, participants were trained in "single-rescuer, adult CPR" according to the American Heart Association's Basic Life Support course for healthcare providers. In the VAM group, all subjects received a 20-minute lesson about CPR. After the lesson, each student trained individually with the VAM for 1 hour, receiving real-time feedback. After the training, all subjects were evaluated as they performed basic CPR (30 compressions, 2 ventilations) for 4 minutes. Results The proportion of participants with a mean compression depth ≥50 mm was 34.1% in the IL group and 27.0% in the VAM group, and the proportion with a mean compression depth ≥40 mm had increased significantly in both groups compared with ≥50 mm (IL group, 82.9%; VAM group, 86.5%). However, no significant differences were detected between the groups in this regard. The proportion of ventilations of the appropriate volume was relatively low in both groups (IL group, 26.4%; VAM group, 12.5%; P=0.396). Conclusion Both methods, the IL training using a practice-while-watching video and the VAM training, facilitated initial CPR skill acquisition, especially in terms of correct chest compression.

Coronary artery dissection and intramural hematoma after blunt chest trauma are rare, but life-threatening, complications. Coronary intramural hematoma extension is even rarer. A 31-year-old man was transferred to our hospital for worsening left chest pain during while he was admitted at a nearby hospital due to blunt chest trauma. Bedside echocardiography showed akinesis of the left ventricular apex and anterior wall as well as hypokinesis of the mid-to-basal anteroseptal wall and mid-to-basal lateral and posterior walls of the left ventricle. Computed tomography coronary angiography revealed intramural hematoma in the left main (LM) coronary and proximal left anterior descending (LAD) arteries. Percutaneous coronary intervention, with bare metal stent implantation from the LM coronary artery to the proximal LAD artery, was performed to treat the occlusion caused by the hematoma. After stenting, the hematoma that compressed the LM coronary artery shifted the left circumflex (LCX) artery, and the intramural hematoma developed and extended to the LCX artery. To resolve this occlusion, a drug-eluting stent was successfully implanted in the LCX artery. The patient was discharged without complications. At 2-month follow-up, he remained asymptomatic, with no recurrence of cardiovascular symptoms. Delayed chest pain after trauma should be suspected during coronary dissection, and on treatment, care must be taken to extend the hematoma.

Background: Cardiac enzymes such as creatine kinase-MB, troponin I, and brain natriuretic peptide (BNP) are thought to be useful prognostic factors in patients with acute ischemic stroke. This study investigated the efficacy of cardiac biomarkers as prognostic factors. Methods: We reviewed patients with acute ischemic stroke whose cardiac biomarkers had been measured and who were admitted to our hospital between January 2012 and December 2013. The cardiac biomarkers were measured within 24 hours after admission to the emergency room. We evaluated the clinical characteristics and compared the outcomes of the patients based on their cardiac biomarkers. Results: The following cardiac biomarkers were measured in 219 patients with acute ischemic stroke: creatine kinase-MB (n=218), troponin I (n=219), and BNP (n=143). Statistically significant differences were observed in older age (68.77±12.42 vs. 74.59±6.68, p

Ulcerative colitis (UC) is a chronic and debilitating disorder, characterized by inflammation of the colonic mucosa. UC can be considered a systemic disorder but UC-related manifestations in the central nervous system (CNS) are quite rare. A 29-year-old man was admitted to the emergency department with repeated generalized tonic-clonic (GTC) type seizures. Based on brain CT, brain metastasis or hemorrhagic infarct was suspected. Diffusion-weighted image of brain MRI showed high signal in the left thalamus and heterogenous enhancement in the right parietal and left frontal lobes. This image indicated a cerebral infarct, but could not completely rule out cerebral metastasis and vasculitis, or any other pathology. However, the brain biopsy revealed multiple thromboemboli with acute inflammation and necrosis. Thus, the patient was diagnosed with multiple cerebral infarcts with cerebral vasculitis, occurring as a complication of UC. In conclusion, CNS manifestations of UC are rare. However, clinicians should consider uncommon diagnoses like vasculitis and thromboembolism in patients with UC presenting with seizures.

OBJECTIVE We aimed to evaluate the factors influencing treatment option selection among urologists for patients with ureteral stones, according to the stone diameter and location. METHODS We retrospectively reviewed the records of 360 consecutive patients who, between January 2009 and June 2014, presented to the emergency department with renal colic and were eventually diagnosed with urinary stones via computed tomography. The maximal horizontal and longitudinal diameter and location of the stones were investigated. We compared parameters between patients who received urological intervention (group 1) and those who received medical treatment (group 2). RESULTS Among the 360 patients, 179 (49.7%) had stones in the upper ureter and 181 (50.3%) had stones in the lower ureter. Urologic intervention was frequently performed in cases of upper ureteral stones (P

Objectives The hydraulic height control systems of hospital beds provide convenience and shock absorption. However, movements in a hydraulic bed may reduce the effectiveness of chest compressions. This study investigated the effects of hydraulic bed movement on chest compressions. Materials and methods Twenty-eight participants were recruited for this study. All participants performed chest compressions for 2 min on a manikin and three surfaces: the floor (Day 1), a firm plywood bed (Day 2), and a hydraulic bed (Day 3). We considered 28 participants of Day 1 as control and each 28 participants of Day 2 and Day 3 as study subjects. The compression rates, depths, and good compression ratios (> 5-cm compressions/all compressions) were compared between the three surfaces. Results When we compared the three surfaces, we did not detect a significant difference in the speed of chest compressions (p = 0.582). However, significantly lower values were observed on the hydraulic bed in terms of compression depth (p = 0.001) and the good compression ratio (p = 0.003) compared to floor compressions. When we compared the plywood and hydraulic beds, we did not detect significant differences in compression depth (p = 0.351) and the good compression ratio (p = 0.391). Conclusions These results indicate that the movements in our hydraulic bed were associated with a non-statistically significant trend towards lower-quality chest compressions.

Objective To assess whether ultrasonographic examination compared to chest radiography (CXR) is effective for evaluating complications after central venous catheterization. Methods We performed a prospective observational study. Immediately after central venous catheter insertion, we asked the radiologic department to perform a portable CXR scan. A junior and senior medical resident each performed ultrasonographic evaluation of the position of the catheter tip and complications such as pneumothorax and pleural effusion (hemothorax). We estimated the time required for ultrasound (US) and CXR. Results Compared to CXR, US could equivalently identify the catheter tip in the internal jugular or subclavian veins (P=1.000). Compared with CXR, US examinations conducted by junior residents could equivalently evaluate pneumothorax (P=1.000), while US examinations conducted by senior residents could also equivalently evaluate pneumothorax (P=0.557) and pleural effusion (P=0.337). The required time for US was shorter than that for CXR (Pl0.001). Conclusion Compared to CXR, US could equivalently and more quickly identify complications such as pneumothorax or pleural effusion.

The purpose of this study was to evaluate the prognostic significance of classification of patients with septic shock into different critical illness-related corticosteroid insufficiency subgroups. A retrospective observational study was conducted in patients with septic shock who underwent a short corticotropin stimulation test within 72 h of the onset of shock. Patients were classified into normal adrenal function (NOM), low basal cortisol (LBC) (basal cortisol

Purpose The Simplified Acute Physiology Score (SAPS) 3 was recently proposed to reflect contemporary changes in intensive care practices. SAPS 3 features customized equations for the prediction of mortality in different geographic regions. However, the usefulness of SAPS 3 and its customized equation (Australasia SAPS 3) have never been externally validated in Korea. This study was designed to validate SAPS 3 and Australasia SAPS 3 for mortality prediction in Korea. Materials and methods A retrospective analysis of the prospective intensive care unit (ICU) registry was conducted in the medical ICU of Samsung Medical Center. Calibration and discrimination were determined by the Hosmer-Lemeshow test and area under the receiver operating characteristic (aROC) curve from 633 patients. Results The mortalities (%) predicted by SAPS 3, Australasia SAPS 3, and SAPS II were 42 ± 28, 39 ± 27 and 37 ± 31, respectively. The calibration of SAPS II was poor (p = 0.003). SAPS 3 and Australasia SAPS 3 were appropriate (p > 0.05). The discriminative power of all models yielded aROC values less than 0.8. Conclusion In Korea, mortality rates predicted using general SAPS 3 and Australasia SAPS 3 exhibited good calibration and modest discrimination. However, Australasia SAPS 3 did not improve the mortality prediction. To better predict mortality in Korean ICUs, a new equation may be needed specifically for Korea.

Objectives When performing cardiopulmonary resuscitation (CPR), the 2010 American Heart Association guidelines recommend a chest compression rate of at least 100 min, whereas the 2010 European Resuscitation Council guidelines recommend a rate of between 100 and 120 min. The aim of this study was to examine the rate of chest compression that fulfilled various quality indicators, thereby determining the optimal rate of compression. Methods Thirty-two trainee emergency medical technicians and six paramedics were enrolled in this study. All participants had been trained in basic life support. Each participant performed 2 min of continuous compressions on a skill reporter manikin, while listening to a metronome sound at rates of 100, 120, 140, and 160 beats/min, in a random order. Mean compression depth, incomplete chest recoil, and the proportion of correctly performed chest compressions during the 2 min were measured and recorded. Results The rate of incomplete chest recoil was lower at compression rates of 100 and 120 min compared with that at 160 min (P=0.001). The numbers of compressions that fulfilled the criteria for high-quality CPR at a rate of 120 min were significantly higher than those at 100 min (P=0.016). Conclusion The number of high-quality CPR compressions was the highest at a compression rate of 120 min, and increased incomplete recoil occurred with increasing compression rate. However, further studies are needed to confirm the results.

Objectives In an attempt to begin ST-segment elevation myocardial infarction (STEMI) treatment more quickly (referred to as door-to-balloon [DTB] time) by minimizing preventable delays in electrocardiogram (ECG) interpretation, cardiac catheterization laboratory (CCL) activation was changed from activation by the emergency physician (code heart I) to activation by a single page if the ECG is interpreted as STEMI by the ECG machine (ECG machine auto-interpretation) (code heart II). We sought to determine the impact of ECG machine auto-interpretation on CCL activation. Methods The study period was from June 2010 to May 2012 (from June to November 2011, code heart I; from December 2011 to May 2012, code heart II). All patients aged 18 years or older who were diagnosed with STEMI were evaluated for enrolment. Patients who experienced the code heart system were also included. Door-to-balloon time before and after code heart system were compared with a retrospective chart review. In addition, to determine the appropriateness of the activation, we compared coronary angiography performance rate and percentage of STEMI between code heart I and II. Results After the code heart system, the mean DTB time was significantly decreased (before, 96.51 ± 65.60 minutes; after, 65.40 ± 26.40 minutes; P = .043). The STEMI diagnosis and the coronary angiography performance rates were significantly lower in the code heart II group than in the code heart I group without difference in DTB time. Conclusion Cardiac catheterization laboratory activation by ECG machine auto-interpretation does not reduce DTB time and often unnecessarily activates the code heart system compared with emergency physician–initiated activation. This system therefore decreases the appropriateness of CCL activation.

Introduction In critically ill patients with hematologic malignancies, acute kidney injury (AKI) usually occurs in the context of multiple organ failure due to various etiologies and is associated with poor prognosis. The objective of the present study was to identify the prognostic factors associated with intensive care unit (ICU) mortality in patients with hematologic malignancies and AKI requiring renal replacement therapy (RRT). Methods We retrospectively evaluated 94 patients with hematologic malignancies and AKI who received RRT in the ICU of Samsung Medical Center, Seoul, Korea, between January 2004 and December 2007. Results The study sample included 65 men and 29 women with a median age of 49 years (interquartile range [IQR], 36-61 years). The median Simplified Acute Physiology Score II and Sequential Organ Failure Assessment (SOFA) scores at ICU admission were 64 (IQR, 46-79) and 13 (IQR, 9-16), respectively. The RRT for AKI was initiated at a median time of 1 day (IQR, 0-4 day) after ICU admission. Seventy-two (77%) patients died in the ICU after a median time of 4 days (IQR, 2-20 days) after the initiation of RRT. Among the 22 patients who survived, 5 (23%) required RRT after ICU discharge. Intensive care unit mortality was associated with an etiology of AKI, Simplified Acute Physiology Score II score, and SOFA score. Modified SOFA (mSOFA) score (defined as the sum of the 5 nonrenal components of the SOFA score) at the initiation of RRT was lower in survivors than in nonsurvivors. In a multiple logistic regression analysis, ICU mortality was independently associated with mSOFA score (odds ratio, 1.83 per mSOFA score increase; 95% confidence interval, 1.38-2.42) at the initiation of RRT. The estimated area under the curve for mSOFA score was 0.902 (95% confidence interval, 0.831-0.972). Conclusion The severity of organ failure, excluding renal failure, at initiation of RRT was independently associated with ICU mortality in patients with hematologic malignancies and AKI requiring RRT.

Hypoglycemia is caused by poor oral intake, excessive exercise, alcohol abuse and inaccurate use of a hypoglycemic agent or insulin in patients that have history of diabetes mellitus (DM), especially in the elderly. Severe hypoglycemia has a variety of different symptoms or signs from focal neurologic deficits to severe coma, or death. It can be difficult to differentiate hypoglycemia-induced symptoms or signs, and stroke or cardiovascular disease in acute setting. Transient hypoglycemic hemiparesis is an infrequent case in the emergency department (ED), which is frequently misdiagnosed for stroke. When patients with decreased mental status or hemiparesis are admitted to the ED, a routine blood sugar test is essential. Hypoglycemic hemiparesis if unrecognized can result in permanent neurological damage. Therefore, it is important to detect hypoglycemia early and treat it appropriately.

Background: There are only inadequate studies on the characteristics of severe pneumonia in the patients who have solid cancer and who are treated with cytotoxic chemotherapy and also on the usefulness of the various severity index scores. Methods: We retrospectively reviewed 31 patients who were treated with cytotoxic chemotherapy because of solid cancer and who were admitted to the medical ICU at Samsung Medical Center from April 2007 to August 2008. Results: The median age of the 31 patients was 64 years old (34−79). The types of solid cancer were lung cancer (19, 61.3%), gastroesophageal cancer (4, 12.9%), breast cancer (2, 6.5%), liver cancer (1, 3.2%), ovarian cancer (1, 3.2%) and other types of cancer (4, 12.9%). The hospital mortality rate was 64.5%. We were able to determine the pathogen of 19 (61.3%) patients; S. pneumoniae (6), S. aureus (3), Candida species (3), P. aeruginosa (2), K. pneumoniae (1), Pneumocystis jiroveci (1) and others (3). There were no statistically differences of the laboratory data and severity index scores (PSI, CURB-65, APACHE II, SOFA, SAPS 3) between the survivors and nonsurvivors, except the P/F ratio. Conclusions: The hospital mortality rate of severe pneumonia in patients who had solid cancer and who received cytotoxic chemotherapy was high. The major pathogen was S. pneumoniae. The severity indexes for general pneumonia were not useful to these patients.

Background: Acute lung injury (ALI) and acute respiratory distress syndrom e (ARDS) are the leading causes of death after lungresection. Neutrophil elastase is thought to be an important mediator in the pathogenesis of ALI. Sivelestat is a new neutrophil elastase inhibitor which may improve the outcome in patients with ALI/ARDS after lung resection. The objective of this study was to determine whether or not sivelestat can reduce mortality in pa- tients with ALI after pulmonary resection for lung cancer. Methods: This study was a retrospective case-control study of twenty three patients who developed ALI/ARDS within seven days of lung resection for lung cancer. The control group (n = 12) received standard care, while the sivelestat group (n = 11) received a continuous infusion of siv elestat (0.2 mg/kg/hr) for seven days in addition to standard care. Results: There was no significant difference in the baseline characteristics between the control and sivelestat groups, except for heart rate. Six of twelve patients (50%) in the control group survived, while seven of twelve pa- tients (64%) survived in the sivelestat group (p = 0.34). There was also no significant difference between the two groups in the progression to ARDS. In the sivelelestat group, survivors had lower APACHE II and SOFA scores than the patients in the control group. Conclusions: There was no additional effect of a neutrophil elastase inhibitor in the treatment of ALI after pul- monary resection for lung cancer.

Background: The role of glucocorticoids for treating persistent acute respiratory distress syndrome (ARDS) is matter of debate. In the previous studies, the side effects of moderate doses of glucocorticoids might have negated positive effects of glucocorticoids. This study aimed at determining the feasibility of administering “low-dose” glucocorticoid to treat the patients who suffer with persistent ARDS. Methods: We retrospectively reviewed the medical records of twelve patients with ARDS of at least seven days’ duration and who were treated with “low-dose” glucocorticoid (starting dose of 1 mg/kg) between June 2007 to December 2008. The patients were divided by whether or not they were successfully weaned from the ventilator after glucocorticoid therapy. The baseline characteristics and physiologic parameters were recorded for up to 7 days after starting glucocorticoid therapy. Results: Five patients (42%) were included in the weaned group. There was no significant difference in the clinical characteristics and the physiologic parameters between the two groups on the day of ARDS. Yet the weaned group had a significantly lower Sequential Organ Failure Assess ment (SOFA) score, as compared to that of the failed group [3 (3−6) vs 8 (5− 12), p = 0.009)] at start of glucocorticoid treatment. After 3 days of glucocorticoid therapy, there was significant improvement in the PEEP, the PaO2/FIO2 ratio, the PCO2 , the SOFA score and the Murray Lung Injury Score of the weaned group, as compared to th at of the failed group. There were no major neuromuscular side effects from the therapy. Conclusions: This study suggests that the “low-dose” glucocorticoid therapy is feasible and that the SOFA score and the physiologic parameters may assist in determining whether or not to initiate and to continue glucocorticoid therapy for the patients who are suffering with persistent ARDS.