Serotonin syndrome is a drug-induced clinical syndrome caused by increased serotonin activity in the central nervous system. It occurs when starting a serotonergic drug, increasing its dose (including overdoses) or using a serotonergic drug in combination with other drugs. It manifests along a broad spectrum, ranging from mild side effects to life-threatening conditions. This condition should be suspected if patients have altered mental states, autonomic dysfunction, or neuromuscular symptoms such as clonus and tremor after using serotonergic drugs. Although the Hunter criteria have been widely used, new diagnostic criteria have recently been proposed to screen severe serotonin toxicity. It is necessary to differentiate it from neuroleptic malignant syndrome, which is associated with taking antipsychotic drugs that exert dopamine-antagonistic effects. If serotonin syndrome is suspected, the relevant drug should be stopped, and the patient should be treated with benzodiazepines. Severely ill patients with hyperthermia or neuromuscular symptoms require aggressive treatment. Serotonin receptor antagonists such as cyproheptadine or chlorpromazine have been tried as antidotes, but the level of evidence for their therapeutic effectiveness is very low.

Serotonin syndrome is a drug-induced clinical syndrome caused by increased serotonin activity in the central nervous system. It occurs when starting a serotonergic drug, increasing its dose (including overdoses) or using a serotonergic drug in combination with other drugs. It manifests along a broad spectrum, ranging from mild side effects to life-threatening conditions. This condition should be suspected if patients have altered mental states, autonomic dysfunction, or neuromuscular symptoms such as clonus and tremor after using serotonergic drugs. Although the Hunter criteria have been widely used, new diagnostic criteria have recently been proposed to screen severe serotonin toxicity. It is necessary to differentiate it from neuroleptic malignant syndrome, which is associated with taking antipsychotic drugs that exert dopamine-antagonistic effects. If serotonin syndrome is suspected, the relevant drug should be stopped, and the patient should be treated with benzodiazepines. Severely ill patients with hyperthermia or neuromuscular symptoms require aggressive treatment. Serotonin receptor antagonists such as cyproheptadine or chlorpromazine have been tried as antidotes, but the level of evidence for their therapeutic effectiveness is very low.

Serotonin syndrome is a drug-induced clinical syndrome caused by increased serotonin activity in the central nervous system. It occurs when starting a serotonergic drug, increasing its dose (including overdoses) or using a serotonergic drug in combination with other drugs. It manifests along a broad spectrum, ranging from mild side effects to life-threatening conditions. This condition should be suspected if patients have altered mental states, autonomic dysfunction, or neuromuscular symptoms such as clonus and tremor after using serotonergic drugs. Although the Hunter criteria have been widely used, new diagnostic criteria have recently been proposed to screen severe serotonin toxicity. It is necessary to differentiate it from neuroleptic malignant syndrome, which is associated with taking antipsychotic drugs that exert dopamine-antagonistic effects. If serotonin syndrome is suspected, the relevant drug should be stopped, and the patient should be treated with benzodiazepines. Severely ill patients with hyperthermia or neuromuscular symptoms require aggressive treatment. Serotonin receptor antagonists such as cyproheptadine or chlorpromazine have been tried as antidotes, but the level of evidence for their therapeutic effectiveness is very low.

Objective: This study verifies the practicality of the delta neutrophil index to lymphocyte ratio for the prognostic evaluation of sepsis patients. Methods: Records of 2,233 patients diagnosed with sepsis were reviewed; 1,042 patients were included in the final analysis. Receiver operating characteristic (ROC) curve studies were used to calculate the area under the curve (AUC) to determine the neutrophil-to-lymphocyte ratio (NLR) and the delta neutrophil-to-lymphocyte ratio (Delta-NLR). To adjust for skewed distributions, the NLR and Delta-NLR were analyzed after natural logarithm transformations. Multivariate logistic regression was applied to determine potential predictors for mortality. Results: To predict 30-day mortality, AUCs were performed using the values of days 0, 1, and 2 (0.604, P<0.0001; 0.648, P<0.0001; and 0.684, P<0.0001, respectively). The NLR results were 0.504 (P=0.8624), 0.553 (P=0.0191), and 0.598 (P<0.0001), respectively. The AUC increased significantly when the Delta-NLR at day 0 was combined with age, hemoglobin levels, and lactate levels. Further subgroup analysis was performed by dividing patients into an upper respiratory infection (URI) group, a gastrointestinal tract infection (GI) (including hepatobiliary infection) group, and a urinary tract infection (UTI) group. The predictive ability of the GI group was determined to be much higher than the other two groups. Conclusion Increase in the Delta-NLR of sepsis patients was found to be an independent predictor of mortality within 30 days.

Objective: Early prediction of the multiple organ dysfunction syndrome (MODS) and providing early innovative treatment may improve outcomes in patients with severe trauma. Lactate and serum albumin levels, which are widely used markers predicting the severity of critically ill patients, tend to diverge during clinical deterioration. This study aimed to evaluate the clinical utility of the lactate/albumin ratio (LAR) as a predictive factor for MODS and 30-day mortality in patients with severe trauma. Methods: This retrospective, observational cohort study was performed with patients prospectively integrated into a critical pathway for trauma. We analyzed severe trauma patients (Injury Severity Score≥16) admitted to the emergency department (ED), between January 1, 2011, and May 31, 2017. The outcomes were the development of MODS and 30-day mortality. Results: In total, 348 patients were enrolled, of which 18 (5.2%) died within 96 hours of ED admission, and the remaining 330 patients (94.8%) were evaluated for the development of MODS. An increase in the LAR at admission (odds ratio, 1.618; P=0.028) was an independent predictor of MODS development. The area under the receiver operating characteristic curve (0.755) and Harrell's C-index (0.783) showed that LAR could predict MODS and 30-day mortality. Conclusion Initial LAR is an independent predictor of MODS development in patients with severe trauma. Our study results suggest that an elevated LAR can be a useful prognostic marker in patients with severe trauma.

Purpose: A pilot project using epinephrine at the scene under medical control is currently underway in Korea. This study aimed to determine whether prehospital epinephrine administration is associated with improved survival and neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients who received epinephrine during cardiopulmonary resuscitation (CPR) in the emergency department. Materials and Methods: This retrospective observational study used a nationwide multicenter OHCA registry. Patients were classified into two groups according to whether they received epinephrine at the scene or not. The associations between prehospital epinephrine use and outcomes were assessed using propensity score (PS)-matched analysis. Multivariable logistic regression analysis was performed using PS matching. The same analysis was repeated for the subgroup of patients with non-shockable rhythm. Results: PS matching was performed for 1084 patients in each group. Survival to discharge was significantly decreased in the patients who received prehospital epinephrine [odds ratio (OR) 0.415, 95% confidence interval (CI) 0.250–0.670, p<0.001]. However, no statistical significance was observed for good neurological outcome (OR 0.548, 95% CI 0.258–1.123, p=0.105). For the patient subgroup with non-shockable rhythm, prehospital epinephrine was also associated with lower survival to discharge (OR 0.514, 95% CI 0.306–0.844, p=0.010), but not with neurological outcome (OR 0.709, 95% CI 0.323–1.529, p=0.382). Conclusion Prehospital epinephrine administration was associated with decreased survival rates in OHCA patients but not statistically associated with neurological outcome in this PS-matched analysis. Further research is required to investigate the reason for the detrimental effect of epinephrine administered at the scene.

Objective: Biliary decompression through bile drainage is a key treatment for common bile duct obstruction with cholangitis. However, the effectiveness of early interventions has not been studied sufficiently in Korea. This study investigated the effectiveness of fast-track biliary decompression. Methods: A group of patients diagnosed with common bile duct obstruction with cholangitis between January 1, 2014, and December 31, 2019, was reviewed retrospectively. We divided them into two groups: before and after the implementation of fast-track biliary decompression. The following items were analyzed in the two groups: time to intervention, number of hospital days, length of stay in the emergency department, and intensive care unit (ICU) admission. Results: Between January 1, 2014, and December 31, 2019, 418 patients were admitted for common bile duct obstruction, and a total of 369 patients were included in this study. Of these, 168 patients visited the hospital prior to implementation of the treatment, and 201 patients visited after implementation. The time to intervention was 6.1 (4.2-11.0) hours in the fast-track group, which was about 9 hours shorter than the other group (P<0.001). There was no statistical difference in the number of hospital days, emergency department length of stay, and ICU admissions (P=0.535, P=0.034, P=0.322). Conclusion The time to intervention was shortened significantly in the fast-track group. However, we did not observe a significant improvement in patient prognosis. It may be possible that the procedure time may need to be shortened for a better prognosis. This should be investigated in future studies.

Purpose: Given the morphological characteristics of schistocytes, thrombotic microangiopathy (TMA) score can be beneficial as it can be automatically and accurately measured. This study aimed to investigate whether serial TMA scores until 48 h post admission are associated with clinical outcomes in patients undergoing targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA). Materials and Methods: We retrospectively evaluated a cohort of 185 patients using a prospective registry. We analyzed TMA scores at admission and after 12, 24, and 48 hours. The primary outcome measures were poor neurological outcome at discharge and 30-day mortality. Results: Increased TMA scores at all measured time points were independent predictors of poor neurological outcomes and 30-day mortality, with TMA score at time-12 showing the strongest correlation [odds ratio (OR), 3.008; 95% confidence interval (CI), 1.707–5.300; p<0.001 and hazard ratio (HR), 1.517; 95% CI, 1.196–1.925; p<0.001]. Specifically, a TMA score ≥2 at time-12 was closely associated with an increased predictability of poor neurological outcomes (OR, 6.302; 95% CI, 2.841–13.976; p<0.001) and 30-day mortality (HR, 2.656; 95% CI, 1.675–4.211; p<0.001). Conclusion Increased TMA scores predicted neurological outcomes and 30-day mortality in patients undergoing TTM after OHCA. In addition to the benefit of being serially measured using an automated hematology analyzer, TMA score may be a helpful tool for rapid risk stratification and identification of the need for intensive care in patients with return of spontaneous circulation after OHCA.

Objective: Aneurysmal subarachnoid hemorrhage (SAH) is a common emergency condition, resulting in high morbidity and mortality. The delta neutrophil index (DNI), which reflects the fraction of circulating immature granulocytes, is significantly associated with systemic inflammation after infection or sterile injury. Aneurysmal SAH also leads to systemic inflammation after a brain injury. This study aimed to evaluate the relationship between the DNI and poor neurologic outcomes in patients with aneurysmal SAH. Methods: We retrospectively identified patients (>18 years old) with aneurysmal SAH consecutively admitted to the emergency department (ED) between January 1, 2011, and November 30, 2018. The diagnosis of aneurysmal SAH was confirmed using clinical and radiological findings. DNI was determined at 0, 24, 48, and 72 hours after ED admission. The primary result was a poor neurologic outcome using the modified Rankin scale. Results: A total of 352 patients with aneurysmal SAH were included in this study. A multivariable logistic regression model revealed that a high value of DNI at 24 hours after ED admission was a strong independent predictor of poor neurologic outcome upon discharge (odds ratio [OR], 1.471; 95% confidence interval [CI], 1.081-2.001; P=0.014). Among patients with aneurysmal SAH, DNI >1.0% at 24 hours was significantly associated with poor neurologic outcomes upon discharge (OR, 5.037; 95% CI, 3.153-8.044; P<0.001). Conclusion DNI can be determined easily and rapidly after ED admission without any additional cost or time burden. A high DNI value at 24 hours after ED admission is significantly associated with a poor neurologic outcome upon discharge among patients with aneurysmal SAH.

Objective: Aneurysmal subarachnoid hemorrhage (SAH) is a common emergency condition, resulting in high morbidity and mortality. The delta neutrophil index (DNI), which reflects the fraction of circulating immature granulocytes, is significantly associated with systemic inflammation after infection or sterile injury. Aneurysmal SAH also leads to systemic inflammation after a brain injury. This study aimed to evaluate the relationship between the DNI and poor neurologic outcomes in patients with aneurysmal SAH. Methods: We retrospectively identified patients (>18 years old) with aneurysmal SAH consecutively admitted to the emergency department (ED) between January 1, 2011, and November 30, 2018. The diagnosis of aneurysmal SAH was confirmed using clinical and radiological findings. DNI was determined at 0, 24, 48, and 72 hours after ED admission. The primary result was a poor neurologic outcome using the modified Rankin scale. Results: A total of 352 patients with aneurysmal SAH were included in this study. A multivariable logistic regression model revealed that a high value of DNI at 24 hours after ED admission was a strong independent predictor of poor neurologic outcome upon discharge (odds ratio [OR], 1.471; 95% confidence interval [CI], 1.081-2.001; P=0.014). Among patients with aneurysmal SAH, DNI >1.0% at 24 hours was significantly associated with poor neurologic outcomes upon discharge (OR, 5.037; 95% CI, 3.153-8.044; P<0.001). Conclusion DNI can be determined easily and rapidly after ED admission without any additional cost or time burden. A high DNI value at 24 hours after ED admission is significantly associated with a poor neurologic outcome upon discharge among patients with aneurysmal SAH.