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Acute brain lesions on diffusion-weighted-magnetic resonance imaging (MRI) after acute carbon monoxide (CO) poisoning were associated with delayed neurological sequelae. This study was conducted to identify the risk factors associated with acute brain lesions on MRI after acute CO poisoning and to help select patients who need acute-phase brain MRI after acute CO poisoning in the emergency department (ED).This retrospective observational study included 103 adult patients who were hospitalized at a tertiary-care hospital between November 2016 and September 2019 and underwent brain MRI because of acute CO poisoning. Multivariable logistic regression analysis was applied to identify predictive factors for acute brain lesions on MRI after acute CO poisoning.Multivariable logistic regression analysis showed that Glasgow Coma Scale (GCS) score of9 at ED presentation (odds ratio [OR] 17.749, 95% confidence interval [CI] 3.098-101.690, P = 0.001) and the initial troponin-I level at presentation in the ED (OR 13.657, 95% CI 1.415-131.834, P = 0.024) were predictive factors for acute brain lesions on MRI in acute CO poisoning. The receiver operating characteristics curve for initial troponin-I showed an area under the curve of 0.761 (95% CI 0.638-0.883, P 0.001) and the optimal cutoff value was 0.105 ng/mL.Acute-phase brain MRI in acute CO poisoning can be considered for patients who present at the ED with a GCS score9 or troponin-I level0.105 ng/mL.

Background: Increasing antimicrobial resistance in uropathogens is a clinical challenge to emergency physicians as antibiotics should be selected before an infecting pathogen or its antibiotic resistance profile is confirmed. This single-center retrospective study evaluated patients diagnosed with upper urinary tract infection (UTI) in the emergency department (ED) between January 2020 and June 2021 to develop a predictive model for antibiotic resistance of uropathogens, using machine learning (ML) algorithmsResults: Forty variables were used to train the model for predicting resistance to ciprofloxacin and the presence of ESBL of urinary pathogens. Model performance with the XGBoost Gradient-Boosted Decision Tree (GBDT) was compared with that of empirical treatment (ET) according to effectiveness of antibiotic selected and appropriateness of selection with respect to antibiotic stewardship. Two prediction models using different decision thresholds were developed. The probability of using ineffective antibiotics in the ED was significantly lowered by 13.3% in the GDBT 0.25 using a decision threshold of 0.25 than in the ET model. Further, the rate of appropriate use of narrow-spectrum antibiotics was higher by 7.4 times in the GBDT 0.44 model than in the ET model, while the ineffectiveness level was maintained.Conclusions: An ML model is potentially useful for predicting antibiotic resistance, improving the effectiveness and appropriateness of empirical antimicrobial treatment in patients with upper UTI in the ED. The model could be a point-of-care decision support tool to guide clinicians towards individualized antibiotic prescription.

The use of airplanes is becoming increasingly frequent worldwide. However, although the number of flight passengers is steadily increasing, there is no comprehensive database that accurately reflects the frequency of emergency medical events that occur in airports. We evaluated the characteristics and treatment outcomes of patients who had emergency medical events at an airport. We retrospectively reviewed cases of patients who had emergency medical events at International Airport between May 2013 and April 2018. A comparative analysis was conducted on gender, age, disease, temperament, and average length of stay between patients visiting the airport and the general population visiting the emergency room (ED). Among the 258,823 patients who visited our ED during the study period. A total of 846 patients (0.3%) were transferred from the airport; the proportion of men was 59.3%, the mean age of the subjects was 43.7 ± 20.1 years. The admission and mortality rates of the patients in the airport group were relatively higher (35.1% and 2.6%, respectively) than that of those in the direct ED visit group (21.6% and 0.5%, respectively). Abdominal disease was the most common medical problem, and the most common causes of death were sudden cardiac arrest and acute myocardial infarction. Future prospective studies are necessary to affirm its findings.

Background/Aims. Febrile neutropenia is considered as one of the most important and potentially life-threatening oncologic emergencies, which requires prompt medical assessment and treatment with antibiotics. This was a single-center retrospective study that investigated the prognostic factors predicting poor outcome in patients with cancer who presented with febrile neutropenia at the emergency department (ED). Methods. The medical records of patients diagnosed with febrile neutropenia in the ED from January 2014 to December 2017 were reviewed. Patients aged >18 years who were diagnosed with a malignancy were included in the analysis. Febrile neutropenia was defined as an absolute neutrophil count < 1,000/mm3 with a temperature greater than 38°C. Patients were divided into two groups: those who were admitted at the intensive care unit (ICU) or those who died in the hospital (case group) and those who were admitted at general wards and were discharged (control group). The two groups were compared to determine the factors associated with poor prognosis. Results. We identified 104 patients (25 and 79 from the case and control groups, respectively) with cancer who presented with febrile neutropenia at the ED during the study period. Lower blood pressure, platelet count, and HCO3- level, higher CRP and creatinine level, and the presence of bacteremia were more commonly observed in the case group than in the control group. In the multiple logistic regression analysis, the following independent predictors significantly correlated with ICU admission and in-hospital mortality: quick sequential (sepsis-related) organ failure assessment (qSOFA) score (odds ratio [OR]: 4.62; 95% confidence interval [CI]: 1.17–18.22; p=0.285), hemoglobin level (OR: 0.51; 95% CI: 0.33–0.78; p=0.002), total bilirubin level (OR: 7.69; 95% CI: 1.29–45.8; p=0.025), and respiratory tract infection (OR: 29.65; 95% CI: 3.81–230.7; p=0.0012). Conclusions. The qSOFA can be a useful bedside tool for patients with cancer who present with febrile neutropenia at the ED. Moreover, it can help emergency physicians in identifying patients at risk of poor prognosis and in initiating prompt empirical antimicrobial therapy. Further studies must be conducted to validate the efficacy of the qSOFA in these patients in the ED.

Objectives Recently, there has been an emerging clinical data suggesting that intravenous propacetamol may cause iatrogenic hypotension. The primary objective of this study was to evaluate hemodynamic changes after propacetamol infusion in the emergency department (ED) with the patients of influenza A. Secondary objective was to assess the incidence of propacetamol-induced significant hypotension and to evaluate factors associated with this adverse effect by comparing two groups of patients with or without a significant reduction in blood pressure (BP). Methods We retrospectively reviewed the medical records of the patients with laboratory-confirmed influenza A who received intravenous propacetamol for the control of fever in the ED during the 2015–16 influenza season. Results 101 patients of influenza A were included in this study. Overall, all the vital signs including BP, pulse rate and body temperature recorded after propacetamol administration were lower than the pre-infusion values. A significant reduction in BP was observed in 30 (29.7%) patients and 6 (20%) of them required crystalloid infusion. Interestingly, pre-infusion BPs were higher in the group of propacetamol-induced significant hypotension, yet there was no difference in post-infusion BPs between the groups. Discussion To our knowledge this is the first study on the effect of intravenous propacetamol in the ED patients with influenza A infection. We hypothesized that the group with a significant reduction in BP could have higher sympathetic tone, consequently showing higher pre-infusion BPs and pulse rate. And there was no difference in post-infusion BPs because baroreflex homeostasis could compensate further decrease in BPs.

We present a patient with scrub typhus complicated with a splenic infarction. A 40-year-old man visited the emergency medical center complaining of fever for the previous week. He had no past medical history, but reported engaging in outdoor activities. Examination revealed a maculopapular rash on his trunk and an eschar on his epigastrium. Abdominal computed tomography was performed to examine the cause of the tenderness on the left upper quadrant of his abdomen, which revealed a splenic infarct. The patient was diagnosed with scrub typhus based on the results of blood polymerase chain reaction testing, and genetic sequencing confirmed the presence of Orientia tsutsugamushi Boryong. His symptoms improved following doxycycline treatment.

SummaryWe report a patient with a clinical picture of suggestive for adult-onset Still's Disease (ASOD) due to Bartonella infection. A 42-year-old immunocompetent man was admitted with fever, rash, arthralgia and sore throat. As his clinical picture suggested ASOD except unusual skin manifestation, we treated him on steroid and ibuprofen. His fever and constitutional symptoms responded immediately within 24hrs of commencing therapy, yet rash and leukocytosis remained. Meanwhile, Bartonella infection was proved by culture of bone marrow. Minocyclin treatment started combined with hydroxychloroquine sulfate and the patient discharged with overall improvement.

Objectives The incidence of urinary tract infection (UTI) due to extended-spectrum β-lactamase (ESBL)-producing Escherichia coli has increased over recent years. Initial empirical therapy is often ineffective for these resistant isolates resulting in prolonged hospitalization and increased mortality. This study was conducted to determine the risk factors of UTI caused by ESBL E. coli in the emergency department (ED). Methods This is a retrospective case-control study at a university hospital in Korea with UTI patients who visited ED between June 2015 and December 2016. We compared case patients with ESBL E. coli UTI (n = 50) to control patients with non-ESBL-producing E. coli UTI (n = 100), which were matched for age and sex. Multivariate logistic regression analysis was used to explore risk factors. Results Our study showed that hospital-acquired infection (OR = 3.86; 95% CI = 1.26–11.8; p = .017), prior UTI within 1 year (OR = 3.26; 95% CI = 1.32–8.05; p = .010), and underlying cerebrovascular disease (OR = 3.24; 95% CI = 1.45–7.25; p = .004) were independent risk factors for acquisition of ESBL-producing E. coli. Notably, 35 (70%) out of 50 case patients had community-acquired infection, and 68% and 54% of ESBL E. coli were resistance to ciprofloxacin and trimethoprim-sulfamethoxazole, respectively. On the contrary, 98% of ESBL E. coli was susceptible to amikacin. Conclusion The main risk factors identified in our study should be considered when treating UTI patients in ED. Amikacin may improve the outcome of empirical treatment without increasing carbapenem utilization.

Spontaneous non-aneurysmal aortic rupture is a rare and life threatening clinical entity. A 23-year-old female patient who visited a nearby hospital due to intractable seizure was transferred to our hospital with the impression of hypotension and decreased level of haemoglobin. She had a history of seizure attacks once a month. However, in the 2 weeks before presentation, the frequency of seizure attacks had increased to 2 to 3 times a day. An abdominal-pelvic computed tomogram scan showed extravasation of contrast from the abdominal aorta at L3 level. An emergency laparotomy revealed a 0.3 cm diameter tear in the posterior wall of the aorta, superior to the iliac bifurcation. We discuss the mechanism of spontaneous aortic rupture and the possibility of aortic rupture related to seizure attacks. (Hong Kong j.emerg.med. 2014;21:103-106)

Introduction The aim of this study was to determine the degree and nature of bacterial contamination of computer equipment in three Korean emergency departments (ED). Methods Hand hygiene practices of ED doctors and nurses were observed before contact with computer equipment. Microbiological swab samples were obtained from 112 multiple-user computer keyboards and electronic mice in the ED of three teaching hospitals. Isolated organisms were identified by a clinical microbiologist using Gram stain, colony morphology, and susceptibility test. Results Of the 112 samples, 103 (92.0%) showed growth of organisms on culture. Thirty-eight (33.9%) pieces of computer equipment yielded multiple bacterial species. Coagulase-negative Staphylococcus was the most common microorganism isolated (85.7%). Methicillin-resistant Staphylococcus aureus was obtained from two keyboards in two hospitals (1.8%). Hand hygiene compliance was observed on 29.9% occasions. Hand hygiene compliance after patient contact (38.0%) was higher than after other environmental contact (20.7%). Conclusions Multiple user computer equipment in the ED may serve as reservoirs for nosocomial infection. Hand hygiene should be performed before and after using all ED equipment, including computer equipment. (Hong Kong j.emerg.med. 2012;19:387-393)

Influenza epidemics occur annually with variations in size and severity. Hospital-based Influenza Morbidity & Mortality was established to monitor influenza epidemics and their severity, which is composed of two surveillance systems: emergency room-based and inpatient-based surveillance. Regarding emergency room-based surveillance, influenza-like illness index (influenza-like illness cases per 1,000 emergency room-visiting subjects), number of laboratory-confirmed cases and the distribution of influenza types were estimated weekly. Inpatient-based surveillance included monitoring for hospitalization, complications, and mortality. The emergency room influenza-like illness index correlated well with the number of laboratory-confirmed influenza cases, and showed a bimodal peak at Week 4 (179.2/1,000 emergency room visits) and Weeks 13-14 (169.6/1,000 emergency room visits) of 2012. Influenza A was the predominant strain during the first epidemic peak, while influenza B was isolated exclusively during the second peak. In 2011-2012 season, the mean admission rate of emergency room-visiting patients with influenza-like illness was 16.3% without any increase over the epidemic period. Among the hospitalized patients with influenza, 33.6% (41 out of 122 patients) were accompanied by complications, and pneumonia (28.7%, 35 out of 122 patients) was the most common. Most fatal cases were caused by influenza A (96.2%) after the first epidemic peak. In conclusion, Hospital-based Influenza Morbidity & Mortality was effective for monitoring the trends in circulating influenza activity concurrently with its severity. In the 2011-2012 season, the influenza epidemic persisted for a ≥ 5-month period, with a bimodal peak of influenza A and B in sequence. Overall, influenza A was more severe than influenza B.

The objective of this study was to assess the epidemiology and clinical data of patients observed by the Korean Disaster Relief Team, during its deployment in Myanmar, from 6 to 12 June 2008. A cross-sectional, medical record-based study in the Korean Disaster Relief Team clinic, established a month after the cyclone Nargis devastated Myanmar. Data collected included demographic variables, and whether or not the problem was acute or chronic, and traumatic or medical. We included 2641 patients in the study. Of those, 57.6% presented with an acute condition, and the rest had chronic conditions. Approximately 5% of the patients presented with trauma/injury; and in 29% of the trauma cases, the problem was directly related to the cyclone. The most common diagnostic category was musculoskeletal problems (21.5%), followed by respiratory (15.3%), and digestive (14.6%) abnormalities. A little over 5% of patients had posttraumatic stress disorder, and the odds ratio was 2.62 (95% confidence interval 1.63-4.21) for women to have posttraumatic stress disorder. Most of the patients (97.5%) had minor problems and were sent home. In conclusion, a huge unmet medical need in at-risk populations and a relatively large proportion of chronic medical conditions should be considered in any future planning of a similar type of disaster.

This study aimed to report the survival of a rare case of complete tracheal transection followed by blunt neck trauma. A 66-year-old man was presented in the emergency room after a motorcycle accident in which a rope was wrapped around his neck. Although alert, he was in respiratory distress. A computed tomographic scan showed transection of the cervical trachea. Emergency neck exploration revealed that the tracheal laceration had been cut from the tracheal anterior third ring to the posterior first ring and the anterior esophageal wall had ruptured. Laryngectomy, tracheostomy, and esophagopharyngeal anastomosis were performed. Prompt airway management and immediate neck exploration is important for survival in these cases.

After being lost for 16 hr, a 7-yr-old boy was admitted to the emergency Department (ED) in a severe hypothermic condition of 23.3 degrees C with cardiac arrest. Active rewarming was conducted with cardiopulmonary resuscitation (CPR). Sixty minutes after admission, return of spontaneous circulation was confirmed. Fever developed 14 hr after admission and continued for 9 days due to frostbite wound of both feet. This case report demonstrates successful resuscitation in severe hypothermic cardiac arrest with complete neurologic recovery in a 7-yr-old boy.

Fever is the most common complaint among children brought into the emergency department (ED). 'Fever phobia' is a descriptive term for an unrealistic concern about the consequences of fever. 'Fever phobia' is prevalent among parents and even healthcare providers, worldwide. The aim of this study was to determine the implications of fever-phobic ideas in Korean caregivers. A prospective, multi-center survey was conducted on Korean caregivers who visited the EDs with febrile children. In total, 746 caregivers were enrolled. The mean age of the subjects was 34.7 yr (SD±5.0). Three hundred sixty respondents (48.3%) believed that the body temperature of febrile children can reach higher than 42.0℃. Unrealistic concerns about the improbable complications of fever, such as brain damage, unconsciousness, and loss of hearing/vision were believed by 295 (39.5%), 66 (8.8%), and 58 (7.8%) caregivers, respectively. Four hundred ninety-four (66.2%) guardians woke children to give antipyretics. These findings suggest that fever phobia is a substantial burden for Korean caregivers.

Objective Procedural sedation and analgesia (PSA) in children has become a standard tool in emergency settings, but no national PSA guidelines have been developed for the emergency department (ED) in Korea. Therefore, we investigated the practice of PSA and the level of adherence to institutional PSA guidelines in EDs of teaching hospitals. Methods This study was a cross-sectional, web-based survey. The study subjects were the faculty of EDs from 96 teaching hospitals. The questionnaire was posted on an internet site, and the participants were requested that the questionnaire be answered by email and telephone in May 2009. Results The questionnaires were completed by 67.7% of the participants. Only 20% of EDs had institutional PSA guidelines, 21.5% of those had discharge criteria and 13.8% of EDs had a discharge instruction form. Residents were administered PSA at 76.9% of EDs. The airway rescue equipment was near the area where PSA was performed in 76.9% of EDs. The most commonly used medication for both diagnostic imaging and painful procedure was oral chloral hydrate (87.7%, 61.5%). In 64.6% of EDs, patients were monitored. In only 21 cases, EDs (50.0%) monitored the patients to recovery after PSA or discharge. Conclusions Current PSA for paediatric patients have not been appropriately applied in Korea. Unified PSA guidelines were rare in the hospitals surveyed, and many patients were not monitored over an appropriate duration, nor did they receive adequate medications for sedation by the best trained personnel. Therefore, the national PSA guidelines must be developed and implemented as early as possible.

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder that has three major features: multiple neural tumors, cafe-au-lait spots, and pigmented iris hamartomas (Lisch nodules). The purpose of this case report is to advise physicians of the danger associated with the progression of fast-onset massive hemorrhage to hemodynamic instability, which mandates rapid treatment to prevent the development of a life-threatening condition. A 64-yr-old woman with NF-1 was admitted to the Emergency Department (ED) because of a rapidly growing, 10 x 5 x 3 cm-sized mass on the left back area. She had previously undergone surgery for a large subcutaneous hematoma, which had developed on her right back area 30 yr before. She became hemodynamically unstable with hypotension during the next 3 hr after admission to ED. Resuscitation and blood transfusion were done, and the hematoma was surgically removed. The mass presented as a subcutaneous, massive hematoma with pathologic findings of neurofibroma. We report a case of NF-1 that presented as recurrent, massive, subcutaneous hemorrhage on the back region combined with hypovolemic shock.

Intussusception is relatively rare in adults and differs from the childhood form in its etiology, presentation and treatment. Unlike childhood intussusception, adult intussusception is usually due to underlying pathologic lead points, most probably neoplasms. The main clinical presentation of intussusception in the adult is chronic abdominal pain, and acute adult intussusception is uncommon. Here, we describe an uncommon case of acute ileocecal intussusception due to ileal lymphoid hyperplasia in a 46-year-old woman. Lymphoid hyperplasia of the intestines is a benign reactive process. Intestinal lymphoid hyperplasia has been reported in association with infections and as an allergic response to various foods. In adults, it has been reported to occur in association with immune deficiencies. There were no obvious causes for this patient's ileal lymphoid hyperplasia. We conclude that physicians need to consider intussusception, due to intestinal lymphoid hyperplasia, as a possible cause of acute abdominal pain in adults, even in the absence of any specific medical history.

Angioedema due to acquired C1 esterase deficiency is a rare condition and a non-inflammatory disease characterized by episodes of edema of the mucosa of the upper airway or gastrointestinal tract. The purpose of this case report is to heighten awareness among emergency physicians of a peritonitis-like condition that can develop into angioedema due to acquired C1 esterase inhibitor deficiency, and thereby help to prevent false diagnosis resulting in unnecessary surgical intervention. We report the case of a 21-year-old man who presented to the Emergency Department (ED) with abdominal pain. He was later diagnosed with angioedema of the gastrointestinal tract due to acquired C1 esterase deficiency that was initially suspected as peritonitis. Careful evaluation of the acute abdomen in acquired C1 esterase deficiency is very important in the ED to distinguish between medical and surgical causes of an acute abdomen.

Emphysematous pyelonephritis is an acute gas forming necrotizing infection of the renal parenchyma with high mortality, which shows non-specific clinical findings. Elderly patients with altered mentality and shock require careful monitoring and abdominal computed tomography scanning is thought to be beneficial in prompt detection of infection focus and management. We report on a patient with altered mentality who showed emphysematous pyelonephritis on abdominal computed tomography and provide a review of the literature.

Paraganglioma is a tumor originating from the extra-adrenal chromaffin cells, and functional paraganglioma causes paroxysmal hypertension, headache and tachycardia, due to excess excretion of catecholamine. However, rarely, ARDS, acute myocardial infarction, heart failure, arrhythmia, and pulmonary edema are also seen in patients with paraganglioma and clinical manifestations are depending on the patient’s intravascular volume status. Seventy one-years-old male was presented with hypotension and pulmonary edema after intravenous midazolam injection during colonoscopy under conscious sedation. The patient was initially suspected with anaphylactic shock, due to midazolam injection. However, later, he was diagnosed with paraganglioma, and blood pressure was successfully controlled with alpha adrenergic blockade. We suggest that when we encounter heart failure, pulmonary edema and shock of unknown origin, pheochromocytoma must be taken into consideration.

Infection-associated plasmacytosis is not uncommon; however, marked plasmacytosis in both peripheral blood and bone marrow that mimicks plasma cell leukemia is a very rare condition. We encountered a case of extreme plasmacytosis associated with Klebsiella pneumoniae sepsis in an aplastic anemia patient. A 42-year-old man presented with high fever of 5 days' duration. Hematological analysis revealed severe neutropenia and thrombocytopenia; his white blood cell count was 900/mm(3), with 26% of plasma and plasmacytoid cells in peripheral blood. Bone marrow biopsy and aspiration showed 25% cellularity with marked plasmacytosis (80%), highly suggestive of plasma cell leukemia. On the eighth hospital day, K. pneumoniae was identified in blood and sputum cultures. Fever improved after switching antibiotics, although his hematological condition worsened. His bone marrow cellularity (plasma cell proportion) progressively decreased: the values were 25% (80%), 10% (26%), 10% (11%), and < 10% (< 4%) on the 8th, 30th, 60th, and 90th hospital day, respectively. His plasmacytosis was extremely severe but was confirmed to be reactive with polyclonality. The present case represents the first report of strong suspicion of K. pneumoniae sepsis-associated marked plasmacytosis in an aplastic anemia patient.

Purpose: We designed this study to evaluate the feasibility of using mangafodipir trisodium enhanced functional liver imaging (MT-FLI) for assessing the viable fraction of hepatocytes (VFH) in the liver. Materials and Methods: We evaluated the change of VFH with using MT-FLI before and after inducing acute hepatic necrosis (AHN) with CCl4 in the liver of 15 beagle dogs. The MR imaging was performed on a 1.5T MRI unit with using the EFGRE-3D sequence (TR/TE=4.7/1.1 msec; flip angle: 20.0°). We evaluated the linear dependence of the density of viable hepatocytes in AHN on the MR images as compared to that in the corresponding normal livers (DAHN/DN) on the VFH in their pathologic specimens, and the change of the VFH from the MT-FLI on that of the laboratory findings (AST, ALT, albumin, bilirubin, PT, ICG-R15) before and after AHN induction. Results: The mean±SD of the VFH from the MT-FLI in AHN was 61.2±10.7% of that of the normal ones. The DAHN/DN showed strong positive linear dependence on the VFH in their pathologic specimens (β=.769, p.938, p

Purpose:Pneumonia is one of the most common infections in children who visit emergency departments(ED), but standard clinical guidelines for children with pneumonia in Korea have not been studied. This study was performed to collect and evaluate a data-base of children with pneumonia for establishing clinical guidelines in ED. Methods:This study reviewed 304 children who were diagnosed and treated for pneumonia in the ED at one tertiary hospital between January 2003 and December 2003 retrospectively by reviewing the charts and analyzing the clinical characteristics, laboratory findings, and radiologic findings between an admission group and a discharge group. Results:The 2 year-5 year age group was the top of age distribution and the peak incidence of monthly distribution was December. Two hundred forty seven(81.3 percent) children were hospitalized(admission group), and the mean length of hospitalization was 7.24±3.24 days. The most common indications of admission were fever, tachypnea and an age of less than three months. There was statistical differences in the outpatient department follow-up between the two groups(85.8 percent in admission group vs 35.1 percent in discharge group). Conclusion:More prospective studies are needed to establish clinical standard guidelines for children with pneumonia. This will be helpful in ED management and will aid the prevention of pneumonia