use despite the known effects on pregnant laboratory animals and on DNA adduct formation in the absence of human data are a cause of concern. Future research into antidotes needs to tailor the requirement for high neuro- logical penetration to achieve reversal of intoxication.

Ritesh Agarwal MD, DM Rajagopala Srinivas MBBS, MD Department of Pulmonary Medicine

Postgraduate Institute of Medical Education and Research

Sector-12, Chandigarh 160012, India E-mail addresses: [email protected]

[email protected]

doi:10.1016/j.ajem.2006.11.044

References

1. Huang NC, Lin SL, Chou CH, et al. Fatal ventricular fibrillation in a PiCCO monitoring accuracy in low body te”>patient with acute Imidacloprid poisoning. Am J Emerg Med 2006;7: 883 - 5.
2. Wu IW, Lin JL, Cheng ET. Acute poisoning with the neonicotinoid insecticide imidacloprid in N-methyl pyrrolidone. J Toxicol Clin Toxicol 2001;39:617 - 21.
3. Ecobichon DJ. Toxic effects of pesticides. In: Klaassen CD, editor. Casarett and Doull’s toxicology. New York7 McGraw Hill; 2001.

p. 763 - 811.

1. Cox C. Insecticide factsheet/imidacloprid, Northwest Coalition for Alternatives to Pesticides (NCAP). J Pestic Reform 2001;21: 15 - 21.

PiCCO monitoring accuracy in low body temperature

To the Editor,

transpulmonary thermodilution assumes that the tem- perature within the artery is stable during the measurement period. This condition may not be achieved in clinical practice because of temperature changes that are not solely produced by the thermal indicator; such temperature changes constitute bthermal noise.Q Thermal noise, includ- ing hypothermia and short-term variations in body temper- ature, has been reported to influence the accuracy and reproducibility of thermodilution measurements.

We report the case of a 45-year-old man received from the emergency department (ED) for severe hypothermia after brain trauma, with a body temperature = 248C. The first examination revealed the following: arterial pressure, 70/50 mm Hg; heart rate = 45 beats per minute; coma (Glasgow coma scale 8). He received mechanical ventilation and progressive internal warming. The PiCCO monitoring (Pulsion Medical Systems, Munich, Germany) (triplicate measures) revealed a low cardiac index = 2. 27 L/(min m²), extravascular lung water = 6.1 mL/kg, and intrathoracic blood volume = 740 mL/m². Afterward, we realized new triplicate measures at each 18 increase in body temperature.

Fig. 1 The COV: b10%, good; 10% V COV V 15%, acceptable. CI indicates cardiac index; ITBVI, intrathoracic blood volume; EVLW, extravascular lung water.

Internal warming increased the body temperature up to 358C in 12 hours. Reproducibility of the PiCCO parameters was assessed by the coefficient of variation (COV= 100% x SD / mean) [1]. According to usual practice, a COV of b10% was considered bgood,Q a COV of 10% to 15% was considered bacceptable,Q and a COV N15% was considered bpoorQ [2]. A total of 36 measurements (12 triplicate measurements) were realized. The COV for cardiac index, intrathoracic blood volume, and extravascular lung water varied, respec- tively, from 17% to 2.4%, 20.4% to 2%, and 15.7% to 3.4%. We noticed that the COV value decreased, whereas the body temperature increased. This may suggest the poor reproduc- ibility of PiCCO thermodilution measurements at low body temperature because of thermal noise (Fig. 1).

Thermal noise was first described with pulmonary arterial catheter [3,4]. Latson et al [5] have concluded that Respiratory variations in pulmonary artery blood tempera- ture are transiently increased in many patients after cardiopulmonary bypass and that this increased thermal noise may cause significant errors in thermodilution cardiac output measurements [5]. Subsequent model calculations demonstrated that the magnitude of potential error in thermodilution cardiac output measurements is dependent on both the amplitude of the respiratory variations in pulmonary artery blood temperature and the baseline cardiac output. On the basis of these thermal area calculations, potential errors of 15% to 50% could be caused by respiratory variations in pulmonary artery blood temperature [5].

With PiCCO monitoring, there are few data. Holm et al

[2] have demonstrated in patients with burn shock and Mild hypothermia a clinically sufficient reproducibility. Martinez- Simon et al [6] reported an erroneous measurement of hemodynamic parameters by PiCCO in a critically ill patient with renal replacement therapy. In our case, the accuracy of PiCCO parameters seems to be worse at low body temperature (b338C).

Conclusion

PiCCO monitoring is a simple device for hemodynamic monitoring, but its parameters’ accuracy seems to be affected by body temperature variation (thermal noise).

Alaya Sami MD Abdellatif Sami MD Nasri Rochdil MD Ksouri Hatem MD Ben Lakhal Salah Pr Medical Intensive Care

Rabta Hospital Tunis, 1007 Tunisia

doi:10.1016/j.ajem.2006.11.046

References

1. Jansen JRC, Schreuder JJ, Punt KD, et al. Mean cardiac output thermodilution with single controlled injection. Crit Care Med 2001;29: 1868 - 73.
2. Holm C, Mayr M, Horbrand F, et al. Reproducibility of transpulmonary thermodilution measurements in patients with burn shock and hypothermia. J Burn Care Rehabil 2005;26:260 - 5.
3. Johnson RW, Normann RA. Central venous blood temperature and thermodilution signal in dogs. Ann Biomed Eng 1989;17:657 - 69.
4. Johnson RW, Normann RA. Central venous blood temperature fluctuation and thermodilution signal processing in dogs. Ann Biomed Eng 1989;17:657 - 69.
5. Latson TW, Whitten CW, O’Flaherty D. Ventilation, thermal noise, and error in cardiac output measurements after cardiopulmonary bypass. Anesthesiology 1993;79:1233 - 43.
6. Martinez-Simon A, Monedero P, Ccho-Asenjo E. Erroneous measure- ment of haemodynamic parameters by PICCO monitor in a critically ill patient with renal replacement therapy: case report. Crit Care 2006;10:410.

The current status of the emergency medical system in Korea

To the Editor,

The Republic of Korea is a country of 48 million people and one of the most densely populated countries in the world. South Korea is situated at the southern end of the Korean peninsula and surrounded by the Yellow Sea, the East Sea, and the 38th parallel. Two thirds of the population live in an urban area and a quarter of the population live in Seoul, the capital city of Korea. Life expectancy for Korean men is 72 years, and that for Korean women is 78 years.

Demand for emergency care is increasing in Korea along with economic growth, urbanization, and crowding. The growing elderly population has resulted in an increased need for proper emergency care [1]. In Korea, persons aged older than 60 years make up more than a quarter of the total population, and the percentage of the elderly population is rapidly increasing. As in other developing and developed countries, cardiovascular diseases have become a leading cause of death in Korea. Trauma is another serious issue in emergency care. In 1999, more than 400000 persons were injured and more than 10000 persons were killed in traffic accidents in Korea. These statistics have alerted the people of Korea to the necessity for an efficient prehospital emergency care system [2].

Emergency medicine is one of the medical specialties that have rapidly developed in the Republic of Korea in the past decade [1]. A universal emergency call number was introduced in the Seoul area in 1982, and since then, b119Q has been designated as the national emergency number. During this initial implementation of prehospital services, it was customary that fire departments responded to 119 calls by dispatching to the scene an ambulance, usually without any medical personnel. In 1987, there was an event that brought nationwide attention to the need to develop an emergency medical service system (EMSS). A young man with multiple injuries from a motor vehicle collision died without proper emergency treatment, although he had been seen at 7 different hospitals. This event caused a public outcry for the urgent need for a proper EMSS. In response to this incident, the Korean president promised to establish a functional EMSS within 5 years. Because of the public response, an academic emergency foundation was founded in 1989 by a small group of pioneering physicians who recognized this national emergency. Since that time the Korean Society of Emergency Medicine began to galvanize a growing demand for emergency medicine by generating resident training programs and developing a functional EMS system. Currently, there are approximately 400 active members in the Korean Society of Emergency Medicine. In 1991, the Ministry of Health and Welfare established emergency information call centers and divided the country into 11 emergency medical service areas. Wireless commu- nication between information centers and hospitals began to be established. However, the status of EMS has not improved because the emergency information centers suffer from unresolved shortages in funding and the Ministry of Health and Welfare is not able to control the fire depart- ments that take charge of prehospital care [3]. Several episodes of man-made disasters such as the collapse of the Sampoong department store and an aircraft crash served as wake-up calls for the development of the national EMSS. In 1994, the Korean government established a federal mandate to better define an EMSS in South Korea. This law focused on prehospital care and transportation, communication systems and medical information centers, classification and role definitions for emergency facilities, and the duties of emergency medical personnel. The EMS law was amended last year by the Ministry of Government Admin- istration and Home Affairs.

Currently in Korea, prehospital EMS is operated by the fire department, which is within the jurisdiction of the Ministry of Government Administration and Home Affairs. For fire and emergency, the universal number is 119, which is free of charge for Korean citizens. A dispatch center in the fire department receives all 119 emergency calls and then allocates them to an appropriate ambulance, a firefighter squad, or emergency medical technician (EMT) services. The Ministry of Health and Welfare operates medical information centers, which gather and provide hospitals and fire depart- ments with hospital information such as availability of