Purpose: A high anion gap (AG) is known to be a significant risk factor for serious acid-base imbalances and death in acute poisoning cases. The strong ion difference (SID), or strong ion gap (SIG), has recently been used to predict in-hospital mortality or acute kidney injury (AKI) in patients with systemic inflammatory response syndrome. This study presents a comprehensive acidbase analysis in order to identify the predictive value of the SIG for disease severity in severe poisoning. Methods: A cross-sectional observational study was conducted on acute poisoning patients treated in the emergency intensive care unit (ICU) between December 2015 and November 2020. Initial serum electrolytes, base deficit (BD), AG, SIG, and laboratory parameters were concurrently measured upon hospital arrival and were subsequently used along with Stewart’s approach to acid-base analysis to predict AKI development and in-hospital death. The area under the receiver operating characteristic curve (AUC) and logistic regression analysis were used as statistical tests. Results: Overall, 343 patients who were treated in the intensive care unit were enrolled. The initial levels of lactate, AG, and BD were significantly higher in the AKI group (n=62). Both effective SID [SIDe] (20.3 vs. 26.4 mEq/L, p<0.001) and SIG (20.2 vs. 16.5 mEq/L, p<0.001) were significantly higher in the AKI group; however, the AUC of serum SIDe was 0.842 (95% confidence interval [CI]=0.799-0.879). Serum SIDe had a higher predictive capacity for AKI than initial creatinine (AUC=0.796, 95% CI=0.749-0.837), BD (AUC=0.761, 95% CI=0.712-0.805), and AG (AUC=0.660, 95% CI=0.607-0.711). Multivariate logistic regression analyses revealed that diabetes, lactic acidosis, high SIG, and low SIDe were significant risk factors for in-hospital mortality. Conclusion Initial SIDe and SIG were identified as useful predictors of AKI and in-hospital mortality in intoxicated patients who were critically ill. Further research is necessary to evaluate the physiological nature of the toxicant or unmeasured anions in such patients.

In a prehospital setting, the narrow therapeutic window of epinephrine necessitates its cautious administration to avoid anaphylaxis. In this case, a 46-year-old man presented severe anaphylactic symptoms. Following the standard protocol, the emergency medical technician (EMT) administered intramuscular epinephrine; however, symptoms persisted. Under the oversight of the emergency medical services (EMS) medical director, an additional intravenous bolus of epinephrine was administered, unfortunately leading to atrial fibrillation. This case underscores the potential risks of intravenous epinephrine, which is not typically recommended for anaphylaxis without continuous monitoring. Since 2019, Korea has initiated a pilot program to expand the EMT scope of practice, which gives them the authority to administer epinephrine for anaphylaxis. The ultimate decision regarding epinephrine use for anaphylaxis, emphasizing patient safety, rests with the EMS medical director. Proper training for EMTs, coupled with the EMS medical director’s comprehensive knowledge and meticulous protocol adherence, can ensure patient safety and optimal outcomes.

In a prehospital setting, the narrow therapeutic window of epinephrine necessitates its cautious administration to avoid anaphylaxis. In this case, a 46-year-old man presented severe anaphylactic symptoms. Following the standard protocol, the emergency medical technician (EMT) administered intramuscular epinephrine; however, symptoms persisted. Under the oversight of the emergency medical services (EMS) medical director, an additional intravenous bolus of epinephrine was administered, unfortunately leading to atrial fibrillation. This case underscores the potential risks of intravenous epinephrine, which is not typically recommended for anaphylaxis without continuous monitoring. Since 2019, Korea has initiated a pilot program to expand the EMT scope of practice, which gives them the authority to administer epinephrine for anaphylaxis. The ultimate decision regarding epinephrine use for anaphylaxis, emphasizing patient safety, rests with the EMS medical director. Proper training for EMTs, coupled with the EMS medical director’s comprehensive knowledge and meticulous protocol adherence, can ensure patient safety and optimal outcomes.

In a prehospital setting, the narrow therapeutic window of epinephrine necessitates its cautious administration to avoid anaphylaxis. In this case, a 46-year-old man presented severe anaphylactic symptoms. Following the standard protocol, the emergency medical technician (EMT) administered intramuscular epinephrine; however, symptoms persisted. Under the oversight of the emergency medical services (EMS) medical director, an additional intravenous bolus of epinephrine was administered, unfortunately leading to atrial fibrillation. This case underscores the potential risks of intravenous epinephrine, which is not typically recommended for anaphylaxis without continuous monitoring. Since 2019, Korea has initiated a pilot program to expand the EMT scope of practice, which gives them the authority to administer epinephrine for anaphylaxis. The ultimate decision regarding epinephrine use for anaphylaxis, emphasizing patient safety, rests with the EMS medical director. Proper training for EMTs, coupled with the EMS medical director’s comprehensive knowledge and meticulous protocol adherence, can ensure patient safety and optimal outcomes.

BACKGROUND: Electrocardiogram (ECG) rhythms, particularly shockable rhythms, are crucial for planning cardiac arrest treatment. There are varying opinions regarding treatment guidelines depending on ECG rhythm types and documentation times within pre-hospital settings or after hospital arrivals. We aimed to determine survival and neurologic outcomes based on ECG rhythm types and documentation times. METHODS: This prospective observational study of 64 emergency medical centers was performed using non-traumatic out-of-hospital cardiac arrest registry data between October 2015 and June 2017. From among 4,608 adult participants, 4,219 patients with pre-hospital and hospital ECG rhythm data were enrolled. Patients were divided into 3 groups: those with initial-shockable, converted-shockable, and never-shockable rhythms. Patient characteristics and survival outcomes were compared between groups. Further, termination of resuscitation (TOR) validation was performed for 6 combinations of TOR criteria confirmed in previous studies, including 2 rules developed in the present study. RESULTS: Total survival to discharge after cardiac arrest was 11.7%, and discharge with good neurologic outcomes was 7.9%. Survival to discharge rates and favorable neurologic outcome rates for the initial-shockable group were the highest at 35.3% and 30.2%, respectively. There were no differences in survival to discharge rates and favorable neurologic outcome rates between the converted-shockable (4.2% and 2.0%, respectively) and never-shockable groups (5.7% and 1.9%, respectively). Irrespective of rhythm changes before and after hospital arrival, TOR criteria inclusive of unwitnessed events, no pre-hospital return of spontaneous circulation, and asystole in the emergency department best predicted poor neurologic outcomes (area under the receiver operating characteristic curve of 0.911) with no patients classified as Cerebral Performance Category 1 or 2 (specificity = 1.000). CONCLUSION: Survival outcomes and TOR predictions varied depending on ECG rhythm types and documentation times within pre-hospital filed or emergency department and should, in the future, be considered in treatment algorithms and prognostications of patients with out-of-hospital cardiac arrest. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03222999
Adult ; Cardiopulmonary Resuscitation ; Electrocardiography ; Emergencies ; Emergency Service, Hospital ; Heart Arrest ; Humans ; Observational Study ; Out-of-Hospital Cardiac Arrest ; Prospective Studies ; Resuscitation ; ROC Curve

Objective: This study aimed to determine the factors that affect successful esophageal foreign body (FB) removal using a Foley catheter and to identify methods to increase the success rate. Methods: In this retrospective, cross-sectional study, we included pediatric patients who presented with esophageal FB impaction that was removed using a Foley catheter in the emergency departments of tertiary care and academic hospitals. We analyzed the effect of the patients’ age, sex, and symptoms; FB type, size, and location; Foley catheter size; complications during FB removal; duration between FB ingestion and removal; operator’s years of training; sedation; success rate of FB removal; endoscopy; and patient’s posture during FB removal on the success of Foley catheter-based FB removal. Results: Of the 43 patients we enrolled, Foley catheter-based FB removal was successful in 81.4% (35/43) but failed in 18.6% (8/43) of patients; no FB-removal-related complications were reported. There was no significant association between the success rate of Foley catheter-based FB removal and any study variable. A higher number of years in training tended to increase the success rate of Foley catheter-based FB removal, although statistical significance was not achieved. Conclusion Children’s esophageal FB removal is a practical challenge in the emergency rooms, and using a Foley catheter is associated with a high success rate of the removal and low occurrence of complications. In this study, no single variable was found correlated with the success rate of Foley catheter-based esophageal FB removal in pediatric patients, which may indicate multiple variables interacting with one another to affect the success rate.

Objective: This study aimed at analyzing the clinical characteristics of patients visiting the emergency department (ED) and pre-triage clinic during the coronavirus disease 2019 (COVID-19) pandemic era in Daegu, South Korea. Methods: We conducted a retrospective observational study by using the medical records of patients who visited the ED and pre-triage clinic from February 22 to March 31, 2020 and comparing them with the corresponding period in 2019. Results: The number of patients visiting the ED per day decreased from 122 (115-138) to 77 (66-93). The percentage of patients with respiratory infection increased from 6.6% to 15.4% (P<0.001). The length of the ED stay increased from 269 (150-562) to 559 (293-941) minutes, especially in patients with fever (P<0.001). The rate of injured and less urgent patients decreased from 24.7 to 13.2 and 53.4% to 50.2%, respectively (P<0.001). Sixty-one-point nine percent of patients visiting the ED were triaged and discharged at the pre-triage clinic without entering the ED. Conclusion In the COVID-19 pandemic era, there was an increase in the proportion of patients with fever and respiratory symptoms and a decrease in the proportion of injured patients. At the pre-triage clinic, a significant number of patients with suspected COVID-19 or less urgent conditions were treated and discharged without their having to enter the ED.

Objective: This study aimed to determine the factors that affect successful esophageal foreign body (FB) removal using a Foley catheter and to identify methods to increase the success rate. Methods: In this retrospective, cross-sectional study, we included pediatric patients who presented with esophageal FB impaction that was removed using a Foley catheter in the emergency departments of tertiary care and academic hospitals. We analyzed the effect of the patients’ age, sex, and symptoms; FB type, size, and location; Foley catheter size; complications during FB removal; duration between FB ingestion and removal; operator’s years of training; sedation; success rate of FB removal; endoscopy; and patient’s posture during FB removal on the success of Foley catheter-based FB removal. Results: Of the 43 patients we enrolled, Foley catheter-based FB removal was successful in 81.4% (35/43) but failed in 18.6% (8/43) of patients; no FB-removal-related complications were reported. There was no significant association between the success rate of Foley catheter-based FB removal and any study variable. A higher number of years in training tended to increase the success rate of Foley catheter-based FB removal, although statistical significance was not achieved. Conclusion Children’s esophageal FB removal is a practical challenge in the emergency rooms, and using a Foley catheter is associated with a high success rate of the removal and low occurrence of complications. In this study, no single variable was found correlated with the success rate of Foley catheter-based esophageal FB removal in pediatric patients, which may indicate multiple variables interacting with one another to affect the success rate.

Objective: The incidences of prehospital advanced airway management by emergency medical technicians in South Korea are increasing; however, whether this procedure improves the survival outcomes of patients experiencing out-of-hospital cardiac arrest remains unclear. The present study aimed to investigate the association between prehospital advanced airway management and neurologic outcomes according to a transport time interval (TTI) using the Korean Cardiac Arrest Research Consortium database. Methods: We retrospectively analyzed the favorable database entries that were prospectively collected between October 2015 and December 2016. Patients aged 18 years or older who experienced cardiac arrest that was presumed to be of a medical etiology and that occurred prior to the arrival of emergency medical service personnel were included. The exposure variable was the type of prehospital airway management provided by emergency medical technicians. The primary endpoint was a favorable neurologic outcome. Results: Of 1,871 patients who experienced out-of-hospital cardiac arrest, 785 (42.0%), 121 (6.5%), and 965 (51.6%) were managed with bag-valve-mask ventilation, endotracheal intubation (ETI), and supraglottic airway (SGA) devices, respectively. SGAs and ETI provided no advantage in terms of favorable neurologic outcome in patients with TTIs ≥12 minutes (odds ratio [OR], 1.37; confidence interval [CI], 0.65–2.87 for SGAs; OR, 1.31; CI, 0.30–5.81 for ETI) or in patients with TTI <12 minutes (OR, 0.57; CI, 0.31–1.07 for SGAs; OR, 0.63; CI, 0.12–3.26 for ETI). Conclusion Neither the prehospital use of SGA nor administration of ETI was associated with superior neurologic outcomes compared with bag-valve-mask ventilation.

Objective: This study aimed to analyze types and rates of symptoms according to vaccine type and to identify the characteristics of patients who visited emergency departments (EDs) with adverse reactions after coronavirus disease 2019 (COVID-19) vaccination. Methods: The medical records of 1,020 patients who visited the EDs of five participating tertiary hospitals from February 26, 2021 to July 31, 2021, and reported adverse reactions after vaccination with a COVID-19 vaccine to the Korean Disease Control and Prevention Agency or diagnosed with a disease code U129 at time of ED discharge were retrospectively analyzed. Symptoms, examinations, treatments received at EDs, and hospital outcomes were compared with respect to vaccine type. Results: Of the 1,020 study subjects, 559 received the ChAdOx1-S vaccine, 52 the Ad.26.COV2.S vaccine, 331 the BNT162b2 vaccine, and 77 the mRNA-1273 vaccine. The adenovirus-vectored vaccines (ChAdOx1-S and Ad.26.COV2.S) had the highest myalgia and headache complaint rates during the 24 hours following vaccination. However, the mRNA vaccines (BNT162b2 and mRNA-1273) had the highest chest pain and fever complaint rates at 7 days post-vaccination. Furthermore, 4.7% of the study subjects required hospitalization, and three died during hospitalization. Conclusion Patients who visited EDs with adverse reactions after COVID-19 vaccination had various ages and experienced symptoms that depended on vaccine type. Most patients were discharged following ED symptom management, but caution should be exercised as several patients experienced potentially serious adverse events.