Purpose: In most areas of the world, transfers between emergency centers are performed through direct communication between physicians of transferring and receiving hospitals. The emergency medical information center “1339” (or 1339, for short), which had mediated inter-hospital transfers for about 10 years, was recently discontinued. This study aimed to survey the stance of physicians at transferring and receiving hospitals on the importance of 1339 functions. Methods: In May 2012, before the discontinuation of 1339 as a mediator, a questionnaire was distributed to emergency- related physicians at several hospitals on the level of emergency care in Busan. Results: There were 202 answers. Physicians of high level emergency centers had a higher tendency to transfer patients without pre-contact for transfer (p=0.019). The physicians at each level of care thought that direct communication between physicians was more accurate (69.9%), but mediation through 1339 was more convenient (53.6%). Mediation through 1339 was the most frequent resource used for pre-contact of inter-hospital transfers (58.1%). Conclusion: Physicians at each level of care tended to find pre-contact between physicians more accurate for inter-hospital transfers; however, they also thought mediation through 1339 was more convenient and it was the most frequently used resource for pre-contact of inter-hospital transfers.

Purpose: Spontaneous intracranial hemorrhage (ICH) is not an uncommon cause of cardiac arrest. The purpose of this study was to identify the prognosis of patients with ICH for Out-of-Hospital Cardiac arrest (OHCA). Methods: From January 2008 to December 2010, a total of 214 patients were checked brain computed tomography (CT) in OHCA. The majority of patients were male (136, 63.8%), and the median age was 55.0 (±16.7). We included all patients who were checked through brain CT for nontraumatic OHCA. Data were collected from electronic medical records and pre-hospital records. Demographic, clinical and laboratory data were compared between the ICH and non-ICH group. Results: The detection of ICH by clinical manifestations and laboratory data was difficult. Out of 214 patients, 21 (9.8%) patients were positive for ICH and 193(90.2%) patients had a normal brain CT. In demographic and clinical data, the neurological outcome (CPC score, p=0.009) and 30-day survival rate (p<0.001) were statistically different between the two groups. Using the Cox proportional hazards model, the ICH group had a 3.54 hazard ratio compared with non-ICH group. In addition, pH (p=0.033), lactate (p=0.023) in ABGA, potassium (p=0.008), glucose (p=0.026), and S-100 (p=0.047) showed significant results. Conclusion: The prognosis of ICH patients in OHCA is poor; further studies are needed to improve the prognosis of ICH patients after ROSC in OHCA.

Purpose: In cardiopulmonary resuscitation (CPR) there are different opinions on the compression rate that should be applied. The aim of this study was to compare the total number of adequate compressions delivered during a fiveminute period among four groups of lay persons (≥139 min-1, 129-138, 114-128, and <114). Methods: This study represents a secondary data analysis from our previous research about the influence of age on fatigue during CPR. Participants were asked to perform chest compressions (without rescue breaths) at a rate of >100 times/minute and a depth of >5 cm for five minutes. A total of 86 participants were then divided into four groups based on their mean compression rate. Age, sex, and body mass index were analyzed as factors affecting the compression rates. Results: The group delivering a compression rate above 139 compressions min-1 performed better than those delivering below 114 compressions min-1 (p=0.03). There was no significant difference in the mean compression depth (p=0.13), percentage of incomplete chest recoil (p=0.277), or the percentage of incorrect hand positioning (p=0.091). All participants (except five) performed chest compressions at a rate above 100 compressions min-1. Conclusion: Our results suggest that a chest compression rate above 139 compressions min-1 does not deteriorate the quality of compressions compared to a lower chest compression rate (below 114 min-1) during a five-minute period. Most untrained lay people performed chest compressions well, within a range of 100~150 min-1.

Purpose: Serum creatinine is a late marker of acute kidney injury (AKI). We assessed the diagnostic value of plasma neutrophil gelatinase-associated lipocalin (NGAL) for predicting acute kidney injury in emergency department patients with sepsis. Methods: This was a prospective observational study of adult sepsis patients. Plasma NGAL levels were measured upon admission to the hospital, and clinical data and serum creatinine were collected daily during the hospital stay. The primary outcome measure was the occurrence of AKI based on criteria from the Acute Kidney Injury Network (AKIN). Results: A total of 178 patients were included, with 13 patients (7.3%) that developed AKI during their hospital stay; 9 and 4 were classified as AKIN stage 1 and 2, respectively. Six patients out of the 13 with AKI died. Mean plasma NGAL levels were 277 ng/mL in patients without AKI and 852 ng/mL in patients with AKI. The area under the receiver operating characteristic curve was 0.883 (95% confidence interval 0.803 to 0.964), the sensitivity was 91.7%, and the specificity was 80.5% for the prediction of AKI (using a cut-off value of 353.5 ng/mL). Conclusion: Plasma NGAL is a useful early marker that predicts the development of AKI in adult sepsis patients.

Purpose: Delayed neuropsychiatric sequelae (DNS) encompass a broad spectrum of neurological deficits, cognitive impairments, and affective disorders which commonly occur after a recovery from acute carbon monoxide (CO) poisoning. The early identification of patients with a high risk of DNS might improve their quality of care. Thus, we studied the role of magnetic resonance imaging (MRI) for the prediction of DNS. Methods: This retrospective study included 41 patients with CO poisoning from January 2009 to June 2012. Magnetic resonance imaging (MRI) was performed within seven days after CO poisoning. Positive MRI findings were defined as focal or diffuse signals in fluid-attenuated inversion recovery (FLAIR), diffusion weighted imaging (DWI), and T2 weighted imaging (T2WI). DNS was considered present when patients had clinical symptoms and signs of DNS within 3 months after CO poisoning. Clinical and biohumoral data were collected; univariate and multivariate statistical analyses were performed to identify the predictive role of MRI for DNS. Results: DNS occurred at a rate of 58.5%, with abnormal MRI findings associated with the development of DNS in the multivariate analysis. The sensitivity of MRI to DNS was 82.6%. In contrast, a normal MRI was seen in eighteen patients (43.9%). MRI revealed abnormalities in the deep white matter (41.5%), globus pallidus (34.1%), cerebral cortex (12.2%), medial temporal lobe (MTL)/hippocampus (7.3%), and cerebellum (4.9%). Among the MRI abnormalities revealed, lesions in the deep white matter were significantly associated with DNS development. Abnormal findings of the globus pallidus, cerebral cortex, MTL/hippocampus, and cerebellum were not associated with DNS development. Conclusion: This study demonstrates the utility of early MRI for the prediction of DNS. Future studies will be required to ascertain the prevention of DNS with hyperbaric treatment in CO poisoning.

Purpose: The primary prevention and proper initial treatment of childhood injuries is important, as it encompasses a bigger social and economic burden than cancer and ischemic heart disease. The Pediatric Risk of Mortality III (PRISM III) scoring system, used to evaluate the severity or mortality of pediatric patients in critical condition, was investigated for children with injuries in an emergency department (ED). Methods: A retrospective analysis included data on 293 injured children (age<16) who visited the ED in two hospitals from March 2010 to February 2012. Physiologic and laboratory data were collected to calculate the PRISM III score and the Injury Severity Score (ISS). The correlation was analyzed between PRISM III scores, the Revised Trauma Scale (RTS), and ISS. The PRISM III score and ISS were assessed for their ability to predict mortality by comparing their receiver operating characteristic (ROC) curves. Results: The median PRISM III score was 5.0 (Interquartile Range, 5.0-9.0) and correlated with RTS and ISS (the Spearman`s rho were -0.19 (p=0.001) and 0.20 (p=0.001), respectively. Five children did not survive after ED admission. The area under the ROC (AUC) was 1.00 for PRISM III (95% confidence interval [CI], 0.99-1.00), and the cutoff value was placed over 20 to predict mortality. The AUC of ISS and RTS was 0.99 (95% CI, 0.98-1.00) and 0.99 (95% CI, 0.98-1.00), respectively. Conclusion: The PRISM III score excellently predicts the mortality of injured children in the ED, and can be used to sort minor pediatric trauma patients in the ED. However, the PRISM III score had no great difference or advantage compared with RTS. The development of other tools for effective prognosis is needed to efficiently predict mortality and severity in the ED.

Purpose: The delta neutrophil index (DNI) corresponds to the calculated immature granulocyte counts and the severity of sepsis. The aim of this study was to investigate the diagnostic value of DNI as a predictable laboratory marker for septic shock in patients with severe community-acquired pneumonia in emergency department. Methods: The present study was a retrospective analysis of patients with pathologically confirmed communityacquired pneumonia from December 2011 to February 2012 at a hospital. The DNI was automatically calculated as a subset of routine complete blood count test. The diagnostic performance of DNI for septic shock in patients with community-acquired pneumonia was evaluated. Results: During the study period, 105 patients were enrolled. Among them, 27 patients (25.7%) were confirmed as having septic shock according to predetermined criteria. The initial value of DNI was significantly higher in septic shock group than in non-shock group (8.7% vs 2.3%, p=0.008). The peak value of DNI was also significantly higher in septic shock group (18.6% vs 4%, p<0.001). The sensitivity and specificity of the initial and peak DNI values for predicting septic shock in patients with communityacquired pneumonia were 48.2%, 96.2%, 74.1%, and 87.2%, respectively, at initial and peak cutoff levels of 11.2% and 8.7% with an area under the curve (AUC) of 0.72 and 0.81 on the Receiver Operating Characteristic (ROC) curve. The AUC to predict septic shock was 0.74 for the CURB-65 scale. The AUC was significantly increased when peak DNI was added to CURB-65 scale (p=0.007). Conclusion: This study suggested that the DNI is associated with septic shock in patients with community-acquired pneumonia. Clinically, the peak value of DNI added to CURB-65 scale could improve predictable performance of septic shock in patients with community-acquired pneumonia.

Purpose: Indoxacarb insecticide poisoning causes methemoglobinemia, which is occasionally life-threatening. However, there is limited data on indoxacarb effects after human ingestion. The purpose of this study was to examine the clinical features, complications, management, and medical outcome of patients with indoxacarb insecticide poisoning. Methods: We retrospectively reviewed the medical records of 10 patients with indoxacarb insecticide poisoning who had visited our emergency centers from January 2008 to December 2011. We collected data on the general characteristics of the patients, their clinical symptoms and signs, laboratory data, management of their condition, and clinical results. Results: Among the 10 patients, 8 were diagnosed with methemoglobinemia. The clinical manifestations of indoxacarb insecticide poisoning were hypotension (3 patients), altered mentality (5 patients), cyanosis (5 patients), dyspnea (2 patients), seizure (3 patients), and cardiac arrest (2 patients). Four patients had a poisoning severity score of 3 and 2 patients had a poisoning severity score of 2. Four patients were treated with methylene blue for methemoglobinemia and one patient was treated with a high dose (150 mg/kg) of ascorbic acid. The serum methemoglobin saturation of five patients who were treated with methylene blue or a high dose of ascorbic acid was nearly normalized. Four patients experienced rhabdomyolysis, pneumonia, hemolytic anemia, acute pancreatitis, and heart failure as a complication of indoxacarb insecticide poisoning. Conclusion: We observed a variety of clinical features, complications, management, medical outcome, and clinical course of patients with indoxacarb insecticide poisoning. We could also ascertain the efficacy of methylene blue and high dose ascorbic acid for indoxacarb-induced metheglo-binemia.

Purpose: We aimed to investigate whether a trained layperson could perform high quality Cardiopulmonary Resuscitation (CPR) after conventional training and a selflearning program using the “CPR Anytime” kit. Methods: Traditional CPR training for a lay rescuer was conducted two weeks before a CPR contest for high school students. “CPR Anytime” training kits were distributed to the students for their practical training at home or in school. The students were tested in pairs for two-person CPR with rescuer breaths and an automated external defibrillator. The quantitative and qualitative data regarding the quality of CPR, including chest compression and rescuer breaths, were collected using a standardized checklist and a skill reporter. Results: A total of 161 teams with 322 students, including 116 males and 206 females, participated in the CPR contest in pairs. The mean depth and rate for the chest compression were 49.0±8.2 mm and 110.2±10.2 /min, respectively. The mean tidal volume for the rescue breaths was 604.8±208.7 ml. The percentage of participants satisfying the correct chest compression rate of 100/min and depth of 50 mm was 87.3% and 52.2%, respectively. Only 25.2% of the participants satisfied an optimal tidal volume (between 500 ml and 600 ml). Shallow compression (57.5%) and under-ventilation (44.4%) were the major causes of incorrect compression and ventilation, respectively. Conclusion: The quality of CPR with rescuer breaths in the trained lay rescuer was not adequate, especially for mouthto- mouth rescue breathing. Therefore, the development of teaching methods to improve rescue breathing or omit mouth-to-mouth ventilation in training should be considered.

Purpose: As an emergency medical system provider, cardiopulmonary resuscitation (CPR) quality for first responder is an important determinant of cardiac arrest outcome. However, feedback on their CPR performance is often lacking. In this simulation study, we analyzed their CPR variables after CPR training based on high-quality CPR requirements highlighted by the 2010 American Heart Association updated guidelines. Furthermore, we aimed to compare the CPR quality between first responders and emergency medical technicians. Methods: Firefighters employed at Seoul metropolitan fire and disaster headquarters in 2011 and 2012 were included in the study. The data were collected from a PC Skill reporting System? (Laerdal, Norway) 5 hours after CPR training. Outcomes included compression variables (depth, rate, hand position, full release, delivered per minute, duty cycle), ventilation variables (volume, flow rate) and hands-off time variables (hands-off fraction, time for airway and breathing, automated external defibrillator (AED)). Results: Sixty-one members to the emergency medical technician group and 66 members to the first responder group were recruited and were tested after CPR training. Results of the first responder group were as follows: for average compression variables, depth 57.6 mm, rate 108.3 numbers/ min, correct hand position 90.0%, full release 100.0%, and duty cycle 40.8%. For average ventilation variables, volume 526.2 ml and flow rate 316.8 ml/sec. These values were same for both groups and showed no statistical significance. The number of compressions performed per minute was better in the emergency medical technician group (74.4 versus 70.6, p<0.002), as was total hands-off time (65.5 sec versus 73.2 sec, p<0.000) and hand-off fraction (32.0% versus 35.2%, p<0.000). Time for operating AED was found to be same for both groups but time for airway and breathing management was shorter in the emergency medical technician group (41.0 sec versus 48.0 sec, p<0.000) Conclusion: The first responder group showed that through short-term CPR training, overall measured quality of CPR was in compliance with international consensus guidelines. But total hands-off time was longer in the first responder group and the time spent for airway and breathing management rather than operating AED was significantly different between the two groups. Appropriate training programs for first responder`s airway and breathing skills are required to minimize interruption time.