PURPOSE: The purpose of this study is to review the evidence comparing the efficacy and safety between L-carnitine and extracorporeal elimination therapy in the management of acute valproic acid L-carnitine vs Extracorporeal Elimination for Acute Valproic acid Intoxication METHODS: PubMed, Embase, Cochrane library, Web of Science, KoreaMed, KMbase, and KISS were searched, using the terms carnitine and valproic acid. All studies, regardless of design, reporting efficacy or safety endpoints were included. Reference citations from identified publications were reviewed. Both English and Korean languages were included. Two authors extracted primary data elements including poisoning severity, presenting features, clinical management, and outcomes. RESULTS: Thirty two articles including 33 cases were identified. Poisoning severity was classified as 3 mild, 11 moderate, and 19 severe cases. Nine cases were treated with L-carnitine while 24 cases received extracorporeal therapy without L-carnitine. All patients except one expired patient treated with hemodialysis recovered clinically and no adverse effects were noted. A case report comparing two patients who ingested the same amount of valproic acid showed increased ICU stay (3 vs 11 days) in case of delayed extracorporeal therapy. CONCLUSION: Published evidence comparing L-carnitine with extracorporeal therapy is limited. Based on the available evidence, it is reasonable to consider L-carnitine for patients with acute valproic acid overdose. In case of severe poisoning, extracorporeal therapy would also be considered in the early phase of treatment.
Carnitine* ; Humans ; Poisoning ; Renal Dialysis ; Valproic Acid*

Phentermine has been widely used as an appetite suppressant since 2004 in Korea. The authors experienced two cases of acute phentermine overdose and report with the literature review. A 36-year-old man and a 24-year-old woman presented together to the emergency department with taking 13 tablets (390 mg) of phentermine 16 hours ago. They had tachycardia, hypertension and complained visual symptoms, nausea, insomnia and anxiety. These symptoms were resolved by conservative management.
Adult ; Anxiety ; Appetite ; Drug Overdose ; Emergency Service, Hospital ; Female ; Humans ; Hypertension ; Korea ; Nausea ; Phentermine* ; Sleep Initiation and Maintenance Disorders ; Tablets ; Tachycardia ; Young Adult

PURPOSE: The purpose of this systematic review was to evaluate the evidence regarding injury and poisoning associated with the clinical mercury thermometer. METHODS: Electronic literature searches were conducted for identification of relevant studies and case reports of injury and poisoning associated with the clinical mercury thermometer. The search outcomes were limited to literature with English and Korean languages published from 1966. Studies related to occupational mercury exposure, or mercury exposure from sphygmomanometer, barometer, and fluorescent light were excluded. RESULTS: A total of 60 reports, including 59 case reports, were finally included. Of those, nine cases pertained to an intact thermometer as a foreign body, 25 injuries were related to a thermometer, and 26 cases involved exposures to mercury from a broken thermometer. Case reports were classified according to severity into 16 mild, 41 moderate, and two severe cases. Two cases of mortality were reported, one was deliberate intravenous injection of mercury and the other was acute vapor inhalation of mercury from broken thermometers. CONCLUSION: Findings of this systematic review suggested that the mercury thermometer could cause various forms of poisoning and injury. In particular, inhalation of mercury vapor from a broken thermometer can lead to systemic toxicity requiring chelating therapy.
Foreign Bodies ; Inhalation ; Injections, Intravenous ; Mortality ; Poisoning* ; Sphygmomanometers ; Thermometers*

Phentermine has been widely used as an appetite suppressant since 2004 in Korea. The authors experienced two cases of acute phentermine overdose and report with the literature review. A 36-year-old man and a 24-year-old woman presented together to the emergency department with taking 13 tablets (390 mg) of phentermine 16 hours ago. They had tachycardia, hypertension and complained visual symptoms, nausea, insomnia and anxiety. These symptoms were resolved by conservative management.
Adult ; Anxiety ; Appetite ; Drug Overdose ; Emergency Service, Hospital ; Female ; Humans ; Hypertension ; Korea ; Nausea ; Phentermine* ; Sleep Initiation and Maintenance Disorders ; Tablets ; Tachycardia ; Young Adult

PURPOSE: The purpose of this systematic review was to evaluate the evidence regarding injury and poisoning associated with the clinical mercury thermometer. METHODS: Electronic literature searches were conducted for identification of relevant studies and case reports of injury and poisoning associated with the clinical mercury thermometer. The search outcomes were limited to literature with English and Korean languages published from 1966. Studies related to occupational mercury exposure, or mercury exposure from sphygmomanometer, barometer, and fluorescent light were excluded. RESULTS: A total of 60 reports, including 59 case reports, were finally included. Of those, nine cases pertained to an intact thermometer as a foreign body, 25 injuries were related to a thermometer, and 26 cases involved exposures to mercury from a broken thermometer. Case reports were classified according to severity into 16 mild, 41 moderate, and two severe cases. Two cases of mortality were reported, one was deliberate intravenous injection of mercury and the other was acute vapor inhalation of mercury from broken thermometers. CONCLUSION: Findings of this systematic review suggested that the mercury thermometer could cause various forms of poisoning and injury. In particular, inhalation of mercury vapor from a broken thermometer can lead to systemic toxicity requiring chelating therapy.
Foreign Bodies ; Inhalation ; Injections, Intravenous ; Mortality ; Poisoning* ; Sphygmomanometers ; Thermometers*

PURPOSE: Severe hyperkalemia leads to significant morbidity and mortality if it is not immediately recognized and treated. The concentration of potassium (K+) in the serum increases along with deteriorating renal function. The use of point-of-care K+ (POC-K+) in chronic kidney disease (CKD) could reduce the time for an accurate diagnosis and treatment, saving lives. We hypothesized that POC-K+ would accurately report K+ serum level without significant differences compared to reference testing, regardless of the renal function of the patient. MATERIALS AND METHODS: The retrospective study was performed between January 2008 and September 2011 at an urban hospital in Seoul. The screening program using POC was conducted as a critical pathway for rapid evaluation and treatment of hyperkalemia since 2008. When a patient with CKD had at least one warning symptom or sign of hyperkalemia, both POC-K+ and routine laboratory tests were simultaneously ordered. The reliability of the two assays for serum-creatinine was assessed by intra-class correlation coefficient (ICC) analysis using absolute agreement of two-way mixed model. RESULTS: High levels of reliability were found between POC and the laboratory reference tests for K+ (ICC=0.913, 95% CI 0.903-0.922) and between two tests for K+ according to changes in the serum-creatinine levels in CKD patients. CONCLUSION: The results of POC-K+ correlate well with values obtained from reference laboratory tests and coincide with changes in serum-creatinine of patients with CKD.
Blood Chemical Analysis/methods ; Emergency Service, Hospital ; Humans ; Hyperkalemia/*diagnosis ; Point-of-Care Systems ; Potassium/*blood ; Renal Insufficiency, Chronic/*blood ; Reproducibility of Results ; Retrospective Studies ; Sensitivity and Specificity

PURPOSE: Cardiopulmonary resuscitation (CPR) is commonly performed in high-risk, high intensity situations and is therefore a good procedure around which to develop and implement safety culture strategies in the hospital. The purpose of this study was to evaluate the impact of a hospital-wide quality improvement program on the management of sudden cardiac arrests by assessing healthcare providers' attitudes towards patient safety. MATERIALS AND METHODS: This study was designed as a prospective cohort study at a single academic medical center. The comprehensive hospital-based safety program included steps to identify areas of hazard, partner units with the Resuscitation Committee, and to conduct a Safety Attitudes Questionnaire (SAQ). The SAQ evaluated 35 questions in seven domains to assess changes in patient safety culture by comparing the results before and after the hospital-wide high risk patient care improvement program. RESULTS: The response rates of the pre- and post-SAQ survey were 489 out of 1121 (43.6%) and 575 out of 1270 (45.3%), respectively. SAQ survey responses revealed significant improvement in all seven domains of the questionnaire (p-values of 0.006 and lower). In a subgroup analysis, doctors and nurses showed improvement in five domains. Both doctors and nurses did not show improvement in the "sharing information" domain. CONCLUSION: A hospital-wide quality improvement program for high-risk, high reliability patient care involving CPR care was shown to be associated with a change in healthcare providers' attitudes towards patient safety. Through an immersive and active program on CPR care, change in healthcare providers' attitudes towards patient safety was initiated.
Academic Medical Centers ; Cardiopulmonary Resuscitation ; Cohort Studies ; Death, Sudden, Cardiac ; Delivery of Health Care* ; Health Personnel* ; Humans ; Methods ; Patient Care* ; Patient Safety ; Prospective Studies ; Quality Improvement ; Questionnaires ; Resuscitation

PURPOSE: The severity of a stroke cannot be described by widely used prehospital stroke scales. We investigated the usefulness of the Kurashiki Prehospital Stroke Scale (KPSS) for assessing the severity of stroke, compared to the National Institutes of Health Stroke Scale (NIHSS), in candidate patients for intravenous or intra-arterial thrombolysis who arrived at the hospital within 6 hours of symptom onset. MATERIALS AND METHODS: We retrospectively analyzed a prospective registry database of consecutive patients included in the Emergency Stroke Therapy program. In the emergency department, the KPSS was assessed by emergency medical technicians. A cutoff KPSS score was estimated for candidates of thrombolysis by comparing KPSS and NIHSS scores, as well as for patients who actually received thrombolytic therapy. Clinical outcomes were compared between patients around the estimated cut-off. The independent predictors of outcomes were determined using multivariate logistic regression analysis. RESULTS: Excellent correlations were demonstrated between KPSS and NIHSS within 6 hours (R=0.869) and 3 hours (R=0.879) of hospital admission. The optimal threshold value was a score of 3 on the KPSS in patients within 3 hours and 6 hours by Youden's methods. Significant associations with a KPSS score > or =3 were revealed for actual intravenous administration of tissue plasminogen activator (IV-tPA) usage [odds ratio (OR) 125.598; 95% confidence interval (CI) 16.443-959.368, p<0.0001] and actual IV-tPA or intra-arterial urokinase (IA-UK) usage (OR 58.733; 95% CI 17.272-199.721, p<0.0001). CONCLUSION: The KPSS is an effective prehospital stroke scale for identifying candidates for IV-tPA and IA-UK, as indicated by excellent correlation with the NIHSS, in the assessment of stroke severity in acute ischemic stroke.
Administration, Intravenous ; Confidence Intervals ; Emergencies ; Emergency Medical Services ; Emergency Medical Technicians ; Emergency Service, Hospital ; Humans ; Logistic Models ; Methods ; National Institutes of Health (U.S.) ; Prospective Studies ; Retrospective Studies ; Stroke* ; Thrombolytic Therapy ; Tissue Plasminogen Activator ; Urokinase-Type Plasminogen Activator ; Weights and Measures

PURPOSE: Until now, there has been no standardized method for insertion of the introducer needle in ultrasound-guided internal jugular venous catheterization (IJVC). The needle insertion site and angle have been determined by the performer's experiences. In an effort to improve first attempt success rates and reduce complications, we designed a new standardized approach (called the 45degrees set square method) for determination of the site and angle of needle insertion during ultrasound-guided IJVC. This study investigated that the clinical usefulness of the novel 45degrees set square method for ultrasound-guided IJVC in the emergency department. METHODS: We conducted a prospective study in the emergency department (ED) of a tertiary teaching hospital. Forty one patients requiring central venous catheterization were enrolled in the study. They were randomized to either the conventional ultrasound guidance group or the 45degrees set square group. The primary outcome measure was success rate within three attempts and secondary measures were the number of trials, first-attempt success, puncture time, complications, and technical difficulty score. RESULTS: All 41 participants completed this study successfully. Twenty one consecutive patients were enrolled in the 45degrees set square group and 20 were enrolled in the conventional group. The 45degrees set square group (100%) was superior to the conventional group (60%) in overall success rate within three attempts (p=0.001) and the number of attempts (p<0.001). Significant differences in puncture time (p=0.004), hematoma (p=0.048), and technical difficulty score (p<0.001) were observed between the groups. CONCLUSION: The 45degrees set square method is an effective and safe method for ultrasound-guided internal jugular venous catheterization.
Catheterization ; Catheterization, Central Venous ; Catheters ; Central Venous Catheters ; Emergencies ; Hematoma ; Hospitals, Teaching ; Humans ; Needles ; Outcome Assessment (Health Care) ; Prospective Studies ; Punctures

PURPOSE: The accuracy of the automated external defibrillator (AED) is susceptible to environmental factors such as vibration, motion artifacts, and electromagnetic interference (EMI). The purpose of this study was to evaluate whether the EMI produced by an electric mattress can affect the performance of AEDs. METHODS: Four commercially available AEDs were evaluated under four ECG rhythm settings (normal sinus rhythm, asystole, ventricular fibrillation, and ventricular tachycardia) with or without an electric mattress. The sensitivity, specificity, positive predictable value, negative predictable value, and accuracy of AEDs were calculated to differentiate shockable from nonshockable rhythms. Times required to interpret the ECGs were checked with and without an electric mattress. RESULTS: A total of 320 tests were recorded, and each AED was tested a total of 80 times. Depending on the AED model used on an electric mattress, sensitivity ranged from 55% to 90% with a specificity of 100%, and accuracy ranged from 77.5% to 95%. For some AEDs, sensitivity was reduced compared to the control. Although there was no significant difference in times required to interpret ECG signals with or without an electric mattress, some AEDs detected a relatively small interference as motion artifacts when an electric mattress was used. All recorded ECG rhythms on an electric mattress showed baseline artifacts and these artifacts lessened with increasing distance from an electric mattress. CONCLUSION: This study suggests that an electric mattress could affect the shockable rhythm performance of some AEDs. Electromagnetic interference generated by an electric mattress could interfere with the ability of some commercial AEDs to correctly interpret stimulated ECG rhythms and provide appropriate defibrillation.
Artifacts ; Defibrillators* ; Electrocardiography ; Heart Arrest ; Magnetic Fields ; Magnets ; Sensitivity and Specificity ; Ventricular Fibrillation ; Vibration