Yuri Choi

Background: The utilization of renal replacement therapy (RRT) is crucial for the management of patients with acute kidney injury (AKI) in emergency departments (EDs). The prompt initiation of RRT, encompassing both intermittent hemodialysis (HD) and continuous renal replacement therapy (CRRT), is acknowledged as beneficial for critically ill patients. The purpose of this study is to investigate the implementation of RRT within EDs and its impact on ED length of stay (EDLOS) in South Korea. Methods: This retrospective study utilized data from the National Emergency Department Information System (NEDIS) for the year 2019 to assess the utilization of RRT in emergency medical centers (EMCs) across South Korea. The analysis focused on RRT, which includes intermittent HD and CRRT, as identified through insurance billing codes for patients treated during ED visits and subsequent admissions. EMCs were categorized into three groups based on the frequency of RRT sessions, and the median EDLOS was evaluated. Results: Among 5,937,569 ED visits to Level I and II emergency medical centers (EMCs), 40,130 cases (0.68%) received RRT. Of the 162 EMCs, 58 centers (35.8%) did not perform intermittent HD in the ED and 106 centers (65.4%) did not perform CRRT in the ED during the study period. Centers that frequently performed CRRT in the ED showed significantly longer EDLOS compared with centers that seldom or never performed CRRT (588 min [IQR 286–767] vs. 270 min [IQR 147–337] and 205 min [IQR 149–363], respectively; p = 0.01). Regional disparities in the availability of ED-based RRT were also observed across South Korea. Conclusions: The frequency of RRT administration in EMCs in South Korea varied by region and facility. ED-based RRT utilization was associated with longer EDLOS, particularly in centers frequently performing CRRT. These findings suggest that patient acuity, institutional characteristics, and RRT-related resource utilization should be considered when evaluating EMC performance based on EDLOS.

Phosphine (PH3) is a highly toxic gas used as a fumigant and rodenticide, and inhalational exposure can cause severe systemic toxicity. In Korea, aluminum phosphide and related compounds are strictly regulated, and PH3 poisoning has been rarely reported, with no published cases since 2012. We report a case of PH3 inhalation that occurred during post-fire cleanup at a waste treatment facility. PH3 gas was detected at the scene by the fire investigation unit, which enabled rapid diagnosis and management. The patient presented with persistent hypotension, myocardial depression, and metabolic abnormalities, which improved after norepinephrine infusion and supportive care. N-acetylcysteine was administered to reduce oxidative stress. This case illustrates the clinical features of rare PH3 inhalation poisoning in Korea and highlights the importance of on-site gas detection by firefighters. Rapid field identification may help distinguish PH3 exposure from poisoning by other toxic gases, such as cyanide, and support timely diagnosis and treatment.

Clinical and Experimental Emergency Medicine

When comparing mortality, the severity of illness or injury should be considered; therefore, scoring systems that represent severity have been developed and used. Given that diagnosis codes in the International Classification of Disease (ICD) and vital signs are part of routine data used in medical care, a severity scoring system based on these routine data would allow for the comparison of severity-adjusted treatment outcomes without substantial additional efforts. This study was based on the National Emergency Department Information System database of the Republic of Korea. Patients aged 15 years or older were included. Data from between 2016 and 2018 were used to develop the scoring system, and data from 2019 were used for testing. We calculated the products of the number of disease-specific survival probabilities (DSPs) to reflect the severity of the patients with multiple diagnoses. A logistic regression model was developed using DSPs, age, and physiological parameters to develop a more accurate mortality prediction model. The newly developed model showed predictive ability, as indicated by an area under the receiver-operating characteristic curve of 0.975 (95% CI: 0.974–0.977). When a threshold value of -5.869 was used for determining mortality, the overall accuracy was 0.958 (0.958–0.958). We developed a scoring system based on ICD codes, age, and vital signs to predict the in-hospital mortality of emergency patients, and it achieved good performance. The scoring system would be useful for standardizing the severity of emergency patients and comparing treatment results.

Background. In the Republic of Korea, a trauma care system was not created until 2012, at which point regional trauma centers (RTCs) were established nationwide. In accordance with the national emergency care system and legislation, regional and local emergency medical centers (EMCs) also treat patients presenting with trauma. The aim of the present study was to assess whether treatment in RTCs is truly associated with better patient outcomes than that in EMCs by means of propensity score-matched comparisons and to identify populations that would benefit from treatment in RTCs. Methods. This study analyzed the data of patients with consecutive emergency visits between January 1, 2018, and December 31, 2018, collected in the National Emergency Department Information System registry. Data from RTCs, designated regional EMCs, or local EMCs were included; data from smaller emergency departments were excluded because, in Korea, dedicated RTCs are established only in hospitals with regional or local EMCs. Propensity scores for treatment in RTCs or EMCs were estimated by logistic regression using linear terms. Mortality rates in RTCs and EMCs were compared between the matched samples. Results. The in-hospital mortality rates in the matched cases treated in RTCs and EMCs were 1.4 and 1.6, respectively. The odds ratio for in-hospital mortality in RTCs over EMCs was 0.984 (95 confidence interval: 0.8131.191). Among the subgroups evaluated, the subgroup of patients with injuries involving the chest or lower limbs showed a significant difference in the in-hospital mortality rate. Conclusion. There was no significant difference in the overall severity-adjusted mortality rate between patients treated in RTCs and EMCs. Treatment in an RTC might benefit those with injuries involving the chest or lower limbs.

The early prediction of significant coronary artery lesion, including coronary vasospasm, have yet to be studied. It is essential to discern the disorders with significant coronary lesions (SCDs) requiring coronary angiography from mimicking disease. We aimed to determine which of all clinical variables were more important using conventional logistic regression (cLR) and machine learning (ML). Of 3382 patients with chest pain/discomfort or dyspnea in whom CAG was performed, 1893 were included. All clinical data were divided as follows (i): Demographics, history, and physical examination; (ii): (i) plus electrocardiography; and (iii): (ii) plus echocardiography, and analyzed by cLR and ML. In multivariable analysis via cLR, the AUC and accuracy of the model using the final 20 variables were 0.795 and 72.62%, respectively. In multivariable analysis via ML, the best AUCs in the internal validation were 0.8 with (i), 0.81 with (ii), 0.83 with (iii), and in external validation, the best AUCs were 0.71 with (i), 0.74 with (ii), and 0.79 with (iii). The best AUCs and accuracy of the fittest model including 21 importance variables by ML were 0.81 and 72.48% in internal validation; and 0.75 and 70.5% in external validation, respectively. The importance variables in ML and cLR were similar, but slightly different and the additional discriminators via ML were found. The assessment using the fittest importance variables can assist physicians in differentiating mimicking diseases in which coronary angiography may not be required in patients suspected of having acute coronary syndrome in emergency department.

Objective. This study aimed to elucidate whether direct transport of out-of-hospital cardiac arrest (OHCA) patients to higher-level emergency medical centres (EMCs) would result in better survival compared to resuscitation in smaller local emergency departments (EDs) and subsequent transfer. Methods. This study was a retrospective population-based analysis of cases registered in the national database of 2019. This study investigated the immediate results of cardiopulmonary resuscitation for OHCA compared between EMCs and EDs and the results of therapeutic temperature management (TTM) compared between the patients directly transported from the field and those transferred from other hospitals. In-hospital mortality was compared using multivariate logistic regression. Results. From the population dataset, 11,493 OHCA patients were extracted. (8,912 in the EMC group vs. 2,581 in the ED group). Multivariate logistic regression revealed that the odds for ED mortality were lower with treatment in EDs than with treatment in EMCs. (odds ratio 0.712 (95% confidence interval (CI): 0.638–0.796)). From the study dataset, 1,798 patients who received TTM were extracted. (1,164 in the direct visit group vs. 634 in the transferred group). Multivariate regression analysis showed that the odds ratio for overall mortality was 1.411 (95% CI: 0.809–2.446) in the transferred group. ( ). Conclusion. The immediate outcome of OHCA patients who were transported to EDs was not inferior to that of EMCs. Therefore, it would be acceptable to transport OHCA patients to the nearest emergency facilities rather than to the specialized centres in distant areas.

Extracorporeal removal of organophosphate from blood has been proposed, but the efficacy of hemodialysis and hemoperfusion has not been established. We report a case of organophosphate poisoning in which continuous renal replacement therapy (CRRT) was applied with conventional indications and was found to increase plasma cholinesterase levels by hemodiafiltration. A 73-year-old male was found unconscious at home and was brought to the emergency department by ambulance. An empty bottle of Supracide insecticide, of which the active ingredient is methidathion, was found beside him. CRRT was initiated because he showed signs of oliguria and acidosis with an unstable hemodynamic condition. Although his condition improved temporarily after CRRT initiation, it subsequently deteriorated, and he died despite maximal supportive effort. His prefilter plasma cholinesterase levels remained at <200 U/L for 3 days, while his postfilter levels were 358 U/L 1 hour after CRRT initiation and they were 689 U/L 18 hours later. Our case suggests that CRRT might play a role in treating organophosphate poisoning by possibly eliminating organophosphate.

Objective. A nationwide strike that took place from August 21 to September 7, 2020, which was led by young doctors represented by residents and interns, resulted in shortages of manpower at almost all university and training hospitals. This study aimed to identify differences in the process and outcomes of emergency department (ED) patient care by comparing the performance over about 2 weeks of the strike with that during the usual ED operations. Methods. This retrospective observational study evaluated ED flow and performance during the junior doctors’ strike and compared it with the usual period in a single tertiary-care academic hospital. The outcome variables were defined as ED length of stay, crude mortality, and hospital mortality and adjusted for demographic and clinical parameters. The effect of the doctors’ strike on hospital mortality adjusted for demographic and clinical variables was investigated using logistic regression. Results. A total of 1,121 and 1,496 patients visited the ED during the strike and control periods (both 17 days), respectively. The care usually provided by four or six physicians, including one specialist, was replaced with that by one or two specialists at any one time. During the trainee doctors’ strike, EM specialists managed patients with fewer consultations. However, the proportion of patients who underwent laboratory and radiologic tests did not change significantly. The median ED length of stay significantly decreased from 359 minutes (interquartile range, IQR: 147–391) in the control period to 326 minutes (IQR: 123–318) during the strike period . The doctors’ strike was not found to have a significant effect on mortality after adjustments with other variables. Conclusion. During the junior doctors’ strike in 2020 in Korea, EM specialists efficiently managed the care of emergency patients with higher levels of acuity without compromising the survival rate, through fewer consultations and faster disposition.