Daun Jeong, Minyoung Choi, Seung Jin Maeng, Hanbeom Yoon, Jong Eun Park, Gun Tak Lee, Sung Yeon Hwang, Tae Gun Shin, Sung Phil Chung, Tae Ho Lim, on behalf of the Korean Shock Society
In Press, Received October 15, 2025 Accepted December 29, 2025 Available online January 14, 2026
Objective Sepsis remains a major clinical challenge because of its complex, heterogeneous, and multidimensional clustering patterns. This study aimed to investigate the association between vasopressor administration and machine learning–derived clusters based on initial vital signs and lactate measurements obtained in emergency department (ED) and intensive care unit (ICU) settings.
Methods A retrospective cohort analysis was performed using data from the Korean Shock Society Septic Shock (KOSS) Registry (septic shock in the ED) and the Marketplace for Medical Information in Intensive Care (MIMIC)-IV database (ICU patients with suspected infection). To derive clusters, k-means clustering was applied to six initial vital signs and serum lactate measurements. The primary outcome was vasopressor administration. Secondary outcomes included second vasopressor administration and 28-day mortality.
Results A total of 17,500 patients were included in the analysis (KOSS cohort, n=7,130; MIMIC-IV cohort, n=10,370). K-means clustering identified three distinct clusters in each cohort. In the KOSS cohort, Cluster 3 was characterized by the lowest mean arterial pressure (MAP) (62 mmHg [IQR, 53–71]) and the highest diastolic shock index (DSI) (2.6 [2.3–3.0]). This cluster was associated with the highest rates of vasopressor administration (93.9%), second vasopressor administration (33.5%), and 28-day mortality (25.3%) (all p<0.001). Comparable physiological and clinical patterns were observed in the MIMIC-IV cohort, in which Cluster 3 likewise demonstrated the lowest MAP (68 mmHg [60–76]) and highest DSI (2.0 [1.8–2.3]). This group similarly exhibited the poorest outcomes, including vasopressor administration (41.0%), second vasopressor administration (16.7%), and 28-day mortality (29.0%).
Conclusion Machine learning–derived clusters based on initial vital signs and serum lactate levels demonstrated different patterns of vasopressor use and mortality. The clinical utility of this approach for guiding timely or targeted vasopressor therapy requires prospective validation.
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Objective Based on the development of artificial intelligence (AI), an emerging number of methods have achieved outstanding performances in the diagnosis of acute myocardial infarction (AMI) using an electrocardiogram (ECG). However, AI-ECG analysis using a multicenter prospective design for detecting AMI has yet to be conducted. This prospective multicenter observational study aims to validate an AI-ECG model for detecting AMI in patients visiting the emergency department.
Methods Approximately 9,000 adult patients with chest pain and/or equivalent symptoms of AMI will be enrolled in 18 emergency medical centers in Korea. The AI-ECG analysis algorithm we developed and validated will be used in this study. The primary endpoint is the diagnosis of AMI on the day of visiting the emergency center, and the secondary endpoint is a 30-day major adverse cardiac event. From March 2022, patient registration has begun at centers approved by the institutional review board.
Discussion This is the first prospective study designed to identify the efficacy of an AI-based 12-lead ECG analysis algorithm for diagnosing AMI in emergency departments across multiple centers. This study may provide insights into the utility of deep learning in detecting AMI on electrocardiograms in emergency departments.
Trial registration ClinicalTrials.gov identifier: NCT05435391. Registered on June 28, 2022.
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Objective This study analyzed trends in emergency department (ED) visits in South Korea using the National Emergency Department Information System (NEDIS) data from 2018 to 2022.
Methods This was a retrospective observational study using data from the NEDIS database from 2018 to 2022. Age- and sex-standardized ED visits per 100,000 population, as well as age- and sex-standardized rates for mortality, admission, and transfer, were calculated.
Results The standardized ED visits per 100,000 population was approximately 20,000 from 2018 to 2019 and decreased to about 18,000 in 2022. The standardized mortality rate ranged from 1.4% to 1.7%. The admission rate (18.4%–19.4%) and the transfer rates (1.6%–1.8%) were similar during the study period. Approximately 5.5% of patients were triaged as Korean Triage and Acuity Scale score 1 or 2. About 91% of patients visited the ED directly and 21.7% of patients visited the ED with an ambulance. The ED length of stay was less than 6 hours in 90.3% of patients and the ED mortality rate was 0.6%. Acute gastroenteritis was the most common diagnosis. Respiratory virus symptoms, such as fever and sore throat, were also common chief complaints.
Conclusion ED visits decreased during the 5-year period, while admission, transfer, and death rates remained relatively stable.
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Objective We evaluated the performance of diastolic shock index (DSI) and lactate in predicting vasopressor requirement among hypotensive patients with suspected infection in an emergency department.
Methods This was a single-center, retrospective observational study for adult patients with suspected infection and hypotension in the emergency department from 2018 to 2019. The study population was split into derivation and validation cohorts (70/30). We derived a simple risk score to predict vasopressor requirement using DSI and lactate cutoff values determined by Youden index. We tested the score by the area under the receiver operating characteristic curve (AUC). We performed a multivariable regression analysis to evaluate the association between the timing of vasopressor treatment and 28-day mortality.
Results A total of 1,917 patients were included. We developed a score, assigning 1 point each for the high DSI (≥2.0) and high lactate (≥2.5 mmol/L) criteria. The AUCs of the score were 0.741 (95% confidence interval [CI], 0.715–0.768) at hypotension and 0.736 (95% CI, 0.708–0.763) after initial fluid challenge in the derivation cohort and 0.676 (95% CI, 0.631–0.719) at hypotension and 0.688 (95% CI, 0.642–0.733) after initial fluid challenge in the validation cohort, respectively. In patients with scores of 2 points, early vasopressor therapy initiation was significantly associated with decreased 28-day mortality (adjusted odds ratio, 0.37; 95% CI, 0.14–0.94).
Conclusion A prediction model with DSI and lactate levels might be useful to identify patients who are more likely to need vasopressor administration among hypotensive patients with suspected infection.
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Objective Steroids are used in cases of sepsis, especially in patients experiencing septic shock. However, clinical trials to date have reported contradictory results. Different patient endotypes and variations in the type and dose of steroid may be at fault for this discrepancy, and further investigation is warranted. In this paper, we propose a new DEXA-SEPSIS study design.
Methods We plan to conduct a multicenter, double-blinded randomized pilot study (DEXA-SEPSIS) investigating the feasibility and safety of early use of dexamethasone in sepsis. Participants will be high-risk septic patients presenting to the emergency department with a systolic blood pressure of <90 mmHg or serum lactate level of >2 mmol/L. Participants will be randomized to the following three groups: control, 0.1 mg/kg of dexamethasone, or 0.2 mg/kg of dexamethasone per day for 1 to 2 days. The primary outcome will be 28-day mortality. Secondary outcomes will include time to septic shock, shock reversal, additional steroid administration, number of ventilator-free days, use of continuous renal-replacement therapy, length of stay in the intensive care unit and/or hospital, delta Sequential Organ Failure Assessment score on days 3 and 7, superinfection, gastrointestinal bleeding, hypernatremia, and hyperglycemia.
Discussion The DEXA-SEPSIS study will provide insight regarding the feasibility and safety of early use of dexamethasone in high-risk sepsis. The results could provide data to design a future phase III study.
Trial registration ClinicalTrials.gov Identifier: NCT05136560
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High expression of L-GILZ transcript variant 1 (GILZ TV 1) is associated with increased 30-day sepsis mortality, and a high expression ratio possibly contraindicates hydrocortisone administration Stefan Rusev, Patrick Thon, Birte Dyck, Dominik Ziehe, Tim Rahmel, Britta Marko, Lars Palmowski, Hartmuth Nowak, Björn Ellger, Ulrich Limper, Elke Schwier, Dietrich Henzler, Stefan Felix Ehrentraut, Lars Bergmann, Matthias Unterberg, Michael Adamzik, Björ Critical Care.2024;[Epub] CrossRef
Heesu Park, Tae Gun Shin, Won Young Kim, You Hwan Jo, Yoon Jung Hwang, Sung-Hyuk Choi, Tae Ho Lim, Kap Su Han, Jonghwan Shin, Gil Joon Suh, Gu Hyun Kang, Kyung Su Kim, Korean Shock Society investigators
Clin Exp Emerg Med 2022;9(2):84-92. Published online June 30, 2022
Objective We investigated the effects of a quick Sequential Organ Failure Assessment (qSOFA)–negative result (qSOFA score <2 points) at triage on the compliance with sepsis bundles among patients with sepsis who presented to the emergency department (ED).
Methods Prospective sepsis registry data from 11 urban tertiary hospital EDs between October 2015 and April 2018 were retrospectively reviewed. Patients who met the Third International Consensus Definitions for Sepsis and Septic Shock criteria were included. Primary exposure was defined as a qSOFA score ≥2 points at ED triage. The primary outcome was defined as 3-hour bundle compliance, including lactate measurement, blood culture, broad-spectrum antibiotics administration, and 30 mL/kg crystalloid administration. Multivariate logistic regression analysis to predict 3-hour bundle compliance was performed.
Results Among the 2,250 patients enrolled in the registry, 2,087 fulfilled the sepsis criteria. Only 31.4% (656/2,087) of the sepsis patients had qSOFA scores ≥2 points at triage. Patients with qSOFA scores <2 points had lower lactate levels, lower SOFA scores, and a lower 28-day mortality rate. Rates of compliance with lactate measurement (adjusted odds ratio [aOR], 0.47; 95% confidence interval [CI], 0.29–0.75), antibiotics administration (aOR, 0.64; 95% CI, 0.52–0.78), and 30 mL/kg crystalloid administration (aOR, 0.62; 95% CI, 0.49–0.77) within 3 hours from triage were significantly lower in patients with qSOFA scores <2 points. However, the rate of compliance with blood culture within 3 hours from triage (aOR, 1.66; 95% CI, 1.33–2.08) was higher in patients with qSOFA scores <2 points.
Conclusion A qSOFA-negative result at ED triage is associated with low compliance with lactate measurement, broad-spectrum antibiotics administration, and 30 mL/kg crystalloid administration within 3 hours in sepsis patients.
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Clin Exp Emerg Med 2022;9(1):1-9. Published online March 31, 2022
Objective Coronavirus disease 2019 (COVID-19) has notably altered the emergency department isolation protocol, imposing stricter requirements on probable infectious disease patients that enter the department. This has caused adverse effects, such as an increased rate of leave without being seen (LWBS). This study describes the effect of fever/respiratory symptoms as the main cause of isolation regarding LWBS after the COVID-19 pandemic.
Methods We retrospectively analyzed emergency department visits before (March to July 2019) and after (March to July 2020) the COVID-19 pandemic. Patients were grouped based on existing fever or respiratory symptoms, with the LWBS rate as the primary outcome. Logistic regression analysis was used to identify the risk factors of LWBS. Logistic regression was performed using interaction terminology (fever/respiratory symptom patient [FRP]×post–COVID-19) to determine the interaction between patients with FRPs and the COVID-19 pandemic period.
Results A total of 60,290 patients were included (34,492 in the pre–COVID-19, and 25,298 in the post–COVID-19 group). The proportion of FRPs decreased significantly after the pandemic (P<0.001), while the LWBS rate in FRPs significantly increased from 2.8% to 19.2% (P<0.001). Both FRPs (odds ratio, 1.76; 95% confidence interval, 1.59–1.84 (P<0.001) and the COVID-19 period (odds ratio, 2.29; 95% confidence interval, 2.15–2.44; P<0.001) were significantly associated with increased LWBS. Additionally, there was a significant interaction between the incidence of LWBS in FRPs and the COVID-19 pandemic period (P<0.001).
Conclusion The LWBS rate has increased in FRPs after the COVID-19 pandemic; additionally, the effect observed was disproportionate compared with that of nonfever/respiratory symptom patients.
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Objective This study aimed to confirm the accuracy of a machine-learning-based model in predicting the 30-day mortality of patients with pneumonia and evaluating whether they were required to be admitted to the intensive care unit (ICU).
Methods The study conducted a retrospective analysis of pneumonia patients at an emergency department (ED) in Seoul, Korea, from January 1, 2016 to December 31, 2017. Patients aged 18 years or older with a pneumonia registry designation on their electronic medical record were enrolled. We collected their demographic information, mental status, and laboratory findings. Three models were used: the pre-existing CURB-65 model, and the CURB-RF and Extensive CURB-RF models, which were machine-learning models that used a random forest algorithm. The primary outcomes were ICU admission from the ED or 30-day mortality. Receiver operating characteristic curves were constructed for the models, and the areas under these curves were compared.
Results Out of the 1,974 pneumonia patients, 1,732 patients were eligible to be included in the study; from these, 473 patients died within 30 days or were initially admitted to the ICU from the ED. The area under receiver operating characteristic curves of CURB-65, CURB-RF, and extensive-CURB-RF were 0.615 (0.614–0.616), 0.701 (0.700–0.702), and 0.844 (0.843–0.845), respectively.
Conclusion The proposed machine-learning models could predict the mortality of patients with pneumonia more accurately than the pre-existing CURB-65 model and can help decide whether the patient should be admitted to the ICU.
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Objective While the effect of typhoons on emergency medicine has been evaluated, data are scarce on their effects on the emergency medical service (EMS). This study evaluated the effect of typhoons on EMS patients and performance.
Methods The study period was January 2010 to December 2012. Meteorological data regarding typhoons were provided by the Korean Meteorological Administration. EMS data were retrieved from the EMS database of the national emergency management agency. The database includes ambulance run sheets, which contain clinical and operational data. In this case-crossover study, the cases and controls were EMS calls on the day of typhoon warnings and calls one week prior to the typhoon warnings, respectively.
Results During the study period, 11 typhoons affected Korea. A total of 14,521 cases were selected for analysis. Overall, there were no obvious differences between the case and control groups. However, there were statistically significant differences in age, place, and time requests. There were fewer patients between 0 and 15 years of age (P=0.01) and more unconscious patients (P=0.01) in the case group. The EMS operational performance, as measured by the times elapsed between call to start, call to field, and call to hospital did not differ significantly. There was also no significant difference in the time from hospital arrival between the cases (28.67, standard deviation 16.37) and controls (28.97, standard deviation 28.91) (P=0.39).
Conclusion Typhoons did not significantly affect the EMS system in this study. Further study is necessary to understand the reasons for this finding.
Tae Gun Shin, Sung Yeon Hwang, Gu Hyun Kang, Won Young Kim, Seung Mok Ryoo, Kyuseok Kim, You Hwan Jo, Sung Phil Chung, Young Seon Joo, Jin Ho Beom, Sung-Hyuk Choi, Young Hoon Yoon, Woon Yong Kwon, Tae Ho Lim, Kap Su Han, Han Sung Choi, Gil Joon Suh
Clin Exp Emerg Med 2017;4(3):146-153. Published online September 30, 2017
Objective To evaluate the clinical characteristics, therapeutic interventions, and outcomes of patients with septic shock admitted to the emergency department (ED). Methods This study was a preliminary, descriptive analysis of a prospective, multi-center, observational registry of the EDs of 10 hospitals participating in the Korean Shock Society. Patients aged 19 years or older who had a suspected or confirmed infection and evidence of refractory hypotension or hypoperfusion were included. Results A total of 468 patients were enrolled (median age, 71.3 years; male, 55.1%; refractory hypotension, 82.9%; hyperlactatemia without hypotension, 17.1%). Respiratory infection was the most common source of infection (31.0%). The median Sepsis-related Organ Failure Assessment score was 7.5. The sepsis bundle compliance was 91.2% for lactate measurement, 70.3% for blood culture, 68.4% for antibiotic administration, 80.3% for fluid resuscitation, 97.8% for vasopressor application, 68.0% for central venous pressure measurement, 22.0% for central venous oxygen saturation measurement, and 59.2% for repeated lactate measurement. Among patients who underwent interventions for source control (n=117, 25.1%), 43 (36.8%) received interventions within 12 hours of ED arrival. The in-hospital, 28-day, and 90-day mortality rates were 22.9%, 21.8%, and 27.1%, respectively. The median ED and hospital lengths of stay were 6.8 hours and 12 days, respectively. Conclusion This preliminary report revealed a mortality of over 20% in patients with septic shock, which suggests that there are areas for improvement in terms of the quality of initial resuscitation and outcomes of septic shock patients in the ED.
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