Objective: This study aimed to determine the clinical factors associated with positive brain magnetic resonance imaging (MRI) findings in patients presenting to the emergency department (ED) with acute altered mental status (AMS). Methods: Patients with acute AMS who presented to the ED were retrospectively analyzed from September 2019 to March 2020. Non-traumatic patients with abnormal alert, verbal, pain, unresponsive (AVPU) scale scores and exhibiting acute change in mental status were included in the study. We evaluated the clinical characteristics of patients with acute AMS according to the results of their brain MRI. A multivariable logistic regression model was used to determine the clinical factors associated with positive brain MRI findings. Results: During the study period, 138 patients underwent brain MRI in the ED, with 36 (26.1%) positive results. A majority of patients with positive brain MRI findings had underlying malignancies, cerebrovascular disease, higher serum total bicarbonate (TCO2) levels, TCO2≥22 mmol/L, lower blood urea nitrogen levels, abnormal findings on brain computed tomography and abnormal findings on neurologic examination. In the multivariable analysis, serum TCO2≥22 mmol/L (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.09-4.12) and the presence of cranial nerve abnormalities (OR, 3.88; 95% CI, 1.55-9.68) and extremity abnormalities (OR, 2.76; 95% CI, 1.11-6.88) were significantly associated with positive brain MRI results. Conclusion Serum TCO2 level and the presence of cranial nerve and extremity abnormalities in the neurologic examinations were significantly associated with positive brain MRI results in patients with acute AMS.

Objective: We investigated the factors that affect the time from the onset of acute stroke symptoms to arrival at the emergency department (ED). Methods: Between July 2019 and February 2020, patients with acute stroke symptoms who visited a public hospital were evaluated by retrospective analysis using a prospective survey. The data for this study was gathered from baseline interviews with patients enrolled in stroke surveys. The primary outcome was time to arrival at the ED, evaluated as a binary variable with a value of 4.5 hours. Results: Overall, 205 patients were included in the final analysis. Among them, 47% (n=96) of patients with acute stroke symptoms arrived at the ED later than 4.5 hours from the time of onset of acute stroke symptoms. After multivariable logistic regression analyses, it was found that patients with higher National Institutes of Health Stroke Scale (NIHSS) scores, patients who did not live with their family members, and patients who were found by a passerby were associated with early ED arrival post onset of acute stroke symptoms. Among patients diagnosed with acute stroke, those with higher NIHSS scores or underlying malignant diseases were found to present earlier at the ED. Conclusion Approximately half of the patients (47%) with acute stroke symptoms presented to the ED within 4.5 hours. Higher NIHSS scores and the presence of underlying malignancy were identified as the key factors that were associated with an early presentation at the ED from the time of onset of acute stroke.

Background: The preventable trauma death rate survey is a basic tool for the quality management of trauma treatment because it is a method that can intuitively evaluate the level of national trauma treatment. We conducted this study as a national biennial follow-up survey project and report the results of the review of the 2019 trauma death data in Korea. Methods: From January 1, 2019 to December 31, 2019, of a total of 8,482 trauma deaths throughout the country, 1,692 were sampled from 279 emergency medical institutions in Korea. All cases were evaluated for preventability of death and opportunities for improvement using a multidisciplinary panel review approach. Results: The preventable trauma death rate was estimated to be 15.7%. Of these, 3.1% were judged definitive preventable deaths, and 12.7% were potentially preventable deaths. The odds ratio for preventable traumatic death was 2.56 times higher in transferred patients compared to that of patients who visited the final hospital directly. The group that died 1 hour after the accident had a statistically significantly higher probability of preventable death than that of the group that died within 1 hour after the accident. Conclusion The preventable trauma death rate for trauma deaths in 2019 was 15.7%, which was 4.2%p lower than that in 2017. To improve the quality of trauma treatment, the transfer of severe trauma patients to trauma centers should be more focused.

Objective: The sensitivity of ultrasonography is poor in pregnant women with suspected appendicitis. Additional magnetic resonance imaging (MRI) is usually required, which can delay the diagnosis and surgical intervention. We hypothesized that the use of MRI as the first diagnostic tool could increase the detection rate and reduce the time for diagnosis. Therefore, we sought to investigate the diagnostic yield of ultrasonography vs. MRI and the emergency department length of stay (ED-LOS) of pregnant women with suspected appendicitis. Methods: This was a retrospective, observational study in the ED of a single tertiary teaching hospital from January 2010 to December 2017. Patients who underwent ultrasonography or MRI or both were enrolled. The primary outcome was the diagnostic yield of acute appendicitis and the ED-LOS. The secondary outcome was the proportion of complicated appendicitis cases. Results: A total of 145 pregnant women were enrolled (ultrasonography only, n=73; MRI only, n=26; both ultrasonography and MRI, n=46). The diagnostic yield was 23.5% (28/119) by ultrasonography and 79.2% (57/72) by MRI. The diagnostic yield of ultrasonography was significantly lower than that of MRI, especially in the second and third trimesters. The ED-LOS was significantly longer in the ultrasonography plus MRI group than that in the MRI-only group (9 hours vs. 6 hours, P=0.002). Conclusion In this study, MRI had a higher diagnostic yield than ultrasonography and can reduce the time to diagnosis. Thus, MRI should be considered as the first diagnostic tool for suspected acute appendicitis in pregnant women.

Objective: The sensitivity of ultrasonography is poor in pregnant women with suspected appendicitis. Additional magnetic resonance imaging (MRI) is usually required, which can delay the diagnosis and surgical intervention. We hypothesized that the use of MRI as the first diagnostic tool could increase the detection rate and reduce the time for diagnosis. Therefore, we sought to investigate the diagnostic yield of ultrasonography vs. MRI and the emergency department length of stay (ED-LOS) of pregnant women with suspected appendicitis. Methods: This was a retrospective, observational study in the ED of a single tertiary teaching hospital from January 2010 to December 2017. Patients who underwent ultrasonography or MRI or both were enrolled. The primary outcome was the diagnostic yield of acute appendicitis and the ED-LOS. The secondary outcome was the proportion of complicated appendicitis cases. Results: A total of 145 pregnant women were enrolled (ultrasonography only, n=73; MRI only, n=26; both ultrasonography and MRI, n=46). The diagnostic yield was 23.5% (28/119) by ultrasonography and 79.2% (57/72) by MRI. The diagnostic yield of ultrasonography was significantly lower than that of MRI, especially in the second and third trimesters. The ED-LOS was significantly longer in the ultrasonography plus MRI group than that in the MRI-only group (9 hours vs. 6 hours, P=0.002). Conclusion In this study, MRI had a higher diagnostic yield than ultrasonography and can reduce the time to diagnosis. Thus, MRI should be considered as the first diagnostic tool for suspected acute appendicitis in pregnant women.

PURPOSE: This study was designed to provide a basis for building a master plan for a regional trauma system by analyzing the distribution of trauma deaths in the most populous province in Korea.MATERIALS AND METHODS: We investigated the time distribution to death for trauma patients who died between January and December 2017. The time distribution to death was categorized into four groups (within a day, within a week, within a month, and over a month). Additionally, the distribution of deaths within 24 hours was further analyzed. We also reviewed the distribution of deaths according to the cause of death and mechanism of injury.RESULTS: Of the 1546 trauma deaths, 328 cases were included in the final study population. Patients who died within a day were the most prevalent (40.9%). Of those who died within a day, the cases within an hour accounted for 40.3% of the highest proportion. The majority of trauma deaths within 4 hours were caused by traffic-related accidents (60.4%). The deaths caused by bleeding and central nervous system injuries accounted for most (70.1%) of the early deaths, whereas multi-organ dysfunction syndrome/sepsis had the highest ratio (69.7%) in the late deaths. Statistically significant differences were found in time distribution according to the mechanism of injury and cause of death (p<0.001).CONCLUSION: The distribution of overall timing of death was shown to follow a bimodal pattern rather than a trimodal model in Korea. Based on our findings, a suitable and modified trauma system must be developed.
Cause of Death ; Central Nervous System ; Hemorrhage ; Humans ; Korea ; Wounds and Injuries

Objective: Practice guidelines for diverticulitis have been developed in countries where left-colon diverticulitis is dominant,but there is limited information on right-colon diverticulitis. This study examined the clinical characteristics and riskfactors of clinically severe right-colon diverticulitis. Methods: A retrospective chart review of patients diagnosed with diverticulitis in an emergency department in Koreabetween 2013 and 2017 was performed. Clinically severe diverticulitis was defined as any cause of death, intensive careunit admission, surgery, or invasive intervention due to diverticulitis, and admission for seven or more hospital days.Multivariable logistic regression was used to identify the risk factors for clinically severe diverticulitis. Results: This study analyzed 302 patients. Patients with older age (odds ratio [OR], 1.044; 95% confidence interval [CI],1.009-1.080; P=0.013), complications observed on computed tomography (CT) (OR, 6.906; 95% CI, 2.514-18.968;P<0.001), rebound tenderness on a physical examination (OR, 2.542; 95% CI, 1.041-6.218; P=0.041), high alkalinephosphatase (ALP) levels (OR, 1.014; 95% CI, 1.002-1.026; P=0.026), and high C-reactive protein (CRP) levels (OR,1.095; 95% CI, 1.017-1.178; P=0.013) were at higher risk of clinically severe diverticulitis. Conclusion Among patients diagnosed with right-colon diverticulitis in the emergency department, those of older age,distinct complications on CT, rebound tenderness on physical examination, high ALP, and high CRP levels are related toclinically severe disease.

Objective: High-quality intensive care, including targeted temperature management (TTM) for patients with postcardiac arrest syndrome, is a key element for improving outcomes after out-of-hospital cardiac arrest (OHCA). We aimed to assess the status of postcardiac arrest syndrome care, including TTM and 6-month survival with neurologically favorable outcomes, after adult OHCA patients were treated with TTM, using data from the Korean Hypothermia Network prospective registry. Methods: We used the Korean Hypothermia Network prospective registry, a web-based multicenter registry that includes data from 22 participating hospitals throughout the Republic of Korea. Adult comatose OHCA survivors treated with TTM between October 2015 and December 2018 were included. The primary outcome was neurological outcome at 6 months. Results: Of the 1,354 registered OHCA survivors treated with TTM, 550 (40.6%) survived 6 months, and 413 (30.5%) had good neurological outcomes. We identified 839 (62.0%) patients with preClinsumed cardiac etiology. A total of 937 (69.2%) collapses were witnessed, shockable rhythms were demonstrated in 482 (35.6%) patients, and 421 (31.1%) patients arrived at the emergency department with prehospital return of spontaneous circulation. The most common target temperature was 33°C, and the most common target duration was 24 hours. Conclusion The survival and good neurologic outcome rates of this prospective registry show great improvements compared with those of an earlier registry. While the optimal target temperature and duration are still unknown, the most common target temperature was 33°C, and the most common target duration was 24 hours.

OBJECTIVE: To test the hypothesis that the quick Sepsis-related Organ Failure Assessment (qSOFA) score, derived from vital signs taken during triage and recommended by current sepsis guidelines for screening patients with infections for organ dysfunction, is not sensitive enough to predict the risk of mortality in emergency department (ED) sepsis patients.METHODS: Patients diagnosed with severe sepsis and septic shock using the old definition between May 2014 and April 2015 were retrospectively reviewed in three urban tertiary hospital EDs. The sensitivities of systemic inflammatory response syndrome (SIRS) criteria, qSOFA, and Sequential Organ Failure Assessment (SOFA) scores ≥2 were compared using McNemar’s test. Diagnostic performances were evaluated using specificity, positive predictive value, and negative predictive value.RESULTS: Among the 928 patients diagnosed with severe sepsis or septic shock using the old definition, 231 (24.9%) died within 28 days. More than half of the sepsis patients (493/928, 53.1%) and more than one-third of the mortality cases (88/231, 38.1%) had a qSOFA score <2. The sensitivity of a qSOFA score ≥2 was 61.9%, which was significantly lower than the sensitivity of SIRS ≥2 (82.7%, P<0.001) and SOFA ≥2 (99.1%, P<0.001). The specificity, positive predictive value, and negative predictive value of a qSOFA score ≥2 for 28-day mortality were 58.1%, 32.9%, and 82.2%, respectively.CONCLUSION: The current clinical criteria of the qSOFA are less sensitive than the SIRS assessment and SOFA to predict 28-day mortality in ED patients with sepsis.
Emergencies ; Emergency Service, Hospital ; Humans ; Mass Screening ; Mortality ; Prognosis ; Retrospective Studies ; Sensitivity and Specificity ; Sepsis ; Shock, Septic ; Systemic Inflammatory Response Syndrome ; Tertiary Care Centers ; Triage ; Vital Signs

PURPOSE: Traumatic diaphragmatic rupture resulting from blunt trauma is usually severe. However, it is often overlooked during initial evaluation because there are no characteristic signs and symptoms. Thus, this study aimed to determine the clinical characteristics of diaphragmatic rupture caused by blunt trauma and investigate the diagnostic usefulness of diaphragmatic height index (DHI) measured using chest radiographs. METHODS: The cohort comprised patients who were admitted due to diaphragmatic rupture from blunt trauma. Patients were divided into 2 groups; the control group comprised patients with blunt trauma who were matched for age, sex, and Injury Severity Score, while the DHI group comprised patients with diaphragmatic rupture from blunt trauma. Receiver operating characteristic curve was used to determine the cutoff value of DHI for diaphragmatic injury. The sensitivity, specificity, predictability, accuracy, and likelihood ratio of the cutoff were then determined. RESULTS: A total of 60 patients were confirmed to have diaphragmatic rupture. The mean DHI in patients with diaphragmatic rupture on the right and left side were both significantly different compared to that in the control group. A DHI cutoff value of >1.31 showed 71% sensitivity and 87% specificity for diagnosing right diaphragmatic rupture, while a cutoff value of <0.43 showed 87% sensitivity and 76% specificity for diagnosing left diaphragmatic rupture. CONCLUSION: DHI can be useful in the diagnosis of diaphragmatic rupture. DHI as determined using chest radiographs in patients with blunt abdominal trauma, particularly in those ineligible for diagnostic work-up, may help in the diagnosis of diaphragmatic rupture.
Abdominal Injuries ; Cohort Studies ; Diagnosis ; Diaphragm ; Humans ; Injury Severity Score ; Multiple Trauma ; Radiography, Thoracic ; ROC Curve ; Rupture ; Sensitivity and Specificity