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1 Flight of Idea As an Emergency Physician Kyuseok Kim, MD. Department of Emergency Medicine Seoul National University Bundang Hospital

2 Agenda Appendicitis Pneumonia Acute Pyelonephritis Cardiac arrest Chest pain Laboratory studies

4 History of NEJM 순조홍경래의난 ( )

5 Factors for Successful Publish Good Luck! 삐딱 : 학문 Do it by the book, But be the author!!! -P.Safar- Being prepared! Have an Impossible Dream! 있는그대로 : 사람 Cooperation!

6 Factors for Successful Publish 2000 CT for appendicitis: Blame Pubmed : 수도병원 2004: Retrospective study 2005: Prospective study 2006: Another Prospective study 2007: Small RCT 2009: Big RCT

11 CT reading at that time Probably appendicitis Probably not appendicitis Possibly appendicitis Can not rule out appendicitis Maybe appendicitis Equivocal appendicitis Rec) Clinical correlation No evidence of appendicitis Appendicitis Rec) Operation

12 Grading System Clinical Grading Gr V: % Gr IV: 60-80% Gr III: 40-60% Gr II: 20-40% Gr I: 0-20% CT Grading: Discuss with Dr Lee Gr V: % Gr IV: 60-80% Gr III: 40-60% Gr II: 20-40% Gr I: 0-20%

Pain Control in Suspicious Appendicitis CJEM, 2015 2006-2010 SNUBH Idea: Pain control in suspicious appendicitis Taboo??? Randomized Controlled trial Pain control vs.

14 Pain Control in Suspicious Appendicitis CJEM, SNUBH Idea: Pain control in suspicious appendicitis Taboo??? Randomized Controlled trial Pain control vs. no pain control Primary outcome: Diagnostic performance Sensitivity Compared ROC curve of clinical probability Specificity ROC area of Placebo : ROC area of Morphine : Reference Pr =0.8060

15 Pneumonia

16 학문 ( 일 ) 은삐딱하게 폐렴입원 ( 이전 ) 그날그날달라요주치의따라달라요혈액배양은무조건! 폐렴 ( 현재 ) 치료지침에따라입원 혈액배양은선택적으로

21 Bacteremia prediction model: External Validation, Multi-center Blood culture guideline No evidence right now! USA: 30-40% In Korea: 90% 10 hospitals 서울대 ( 연건, 보라매, 분당 ) 삼성, 아산, 연세대 ( 신촌, 강남 ), 고려대 ( 안암, 구로 ), 서울성모, 아주대 Retrospective: external validation & new model development RCTs

22 Laboratory findings (n=2001) WBC count, X10 3 /mm ± 8.4 Hematocrit, % 36.3 ± 6.3 Platelet count, X10 3 /mm ± Glucose, mg/dl 150 ± 75 Albumin, mg/dl 3.5 ± 0.6 BUN, mg/dl 21.9 ± 17.4 Creatinine, mg/dl 1.2 ± 1.4 Sodium, mmol/dl ± 8.1 C-reactive protein, mg/dl 12.7 ± 10.1 Bacteremia 57 (2.8)

25 Acute Pyelonephritis

26 학문 ( 일 ) 은삐딱하게 급성신우신염 ( 이전 ) 65 세이상입원 당뇨환자입원 혈액배양에서뭐가자라면입원 급성신우신염 ( 현재 ) 나이무시당뇨무시혈액배양무시

27 Acute pyelonephritis Previously DM, Old age, bacteremia admission with IV antibiotics

32 Chest Compression Position

35 심정지환자연구

36 심폐소생술은언제까지? 심폐소생술을얼마동안해야하나? 15분? 20분? 30분? 1시간? 지침이없음환자따라다를수밖에젊은환자, 기저질환 (-), 쓰러지자마자소생술시작노인, 암말기, 쓰러진채로발견

41 CPR: Prognostication

43 Prognostic Factor 1. Underlying conditions or injury severity 2. CPR procedures 3. Neurological Assessment 4. EEG: Maybe helpful without HT (Class IIb, LOE B) 5. Evoked Potential 6. Neuroimaging 7. Biomarker 8. Etc

44 Underlying conditions or injury severity Resuscitation 2012

45 Underlying conditions or injury severity Resuscitation 2013

46 Underlying conditions or injury severity

47 CPR Procedures Resuscitation 2014

Poor Prognosis Functional study: Function(-) Imaging study: Lesion(+) Functional

48 Neuroimaging Cannot be recommended alone as prognostic factor yet MRI, CT Timing: 48h(?) Globally, No extensive studies yet! Poor Prognosis Functional study: Function(-) Imaging study: Lesion(+) Functional study: Fx(-) might be (+) Imaging study: Lesion(+) Lesion(-)(?), more useful? E.g. Functionally R. side weakness(+) Same prognosis?

49 Neurocrit Care 2012

50 Resuscitation 2013

51 Resuscitation 2013

52 Resuscitation 2013

53 Resuscitation 2016

55 How about combination? MRI & NSE NSE 78.9 ADC 615 Neurocrit Care 2012

56 Chest pain

57 급성심근경색증 (STEMI) 수련의 응급의학과전공 의 내과전공의 심장내과 전임의 심장내과교수

61 Ischemia/Reperfusion

62 Ischemia/Reperfusion Injury Local I/R injury Acute myocardial infarction Stroke Intestinal: SMA obstruction Transplantation Systemic I/R injury Hemorrhagic shock Cardiac arrest

66 ROS 감소

67 J Trauma 2014

72 Stepwise Resuscitation J Surg Res 2016

Methods Male, cross breed, domestic pigs weighing 35-40 kg Sedation

inhalation (dose was not changed throughout the experiment) Temp.

73 Methods Male, cross breed, domestic pigs weighing kg Sedation atropine (0.05mg/kg) I.M. zoletil (5 mg/kg) + xylazine (4 mg/kg) I.M. Intubation & MV apply FiO , PEEP 10 cm H 2 O, TV 8 ml/kg. RR 10 12/min apco 2 taget mm General anesthesia 1-2% sevoflurane inhalation (dose was not changed throughout the experiment) Temp. taget: C Monitoring ECG, capnography, oximeter, rectal temperature probe

74 Methods BP monitor Masterflex Rt. Femoral artery 6-Fr catheter for BP monitoring Rt. Femoral vein balloon-tipped thermodilution catheter To measure CVP, MPAP, PAOP, SmvO 2 and CO Lt. Femoral artery 6-Fr catheter insertion for blood withdrawal and infusion

77 혼자하는것은가치가낮다 신약개발 서울대약대 L교수님서울대공대 H교수님 KAIST G교수님 KAIST P교수님 UNIST K교수님 바이오마커개발 서울대약대 K교수님한국화학연구소 S교수님 의료기기개발 KAIST O교수님 KAIST B교수님 KAIST P교수님

78 나눔의법칙 You!!!

79 마지막슬라이드 여러분에게도행운이가득하길 경청해주셔서감사합니다!!!

김범수

김범수 Analysis of Outcomes after Resection of Sarcomatous Hepatocellular Carcinoma Purpose: Sarcomatous hepatocellular carcinoma (HCC) is rare. Therefore, the clinicopathologic characteristics and prognosis