Variability in the effects of prehospital advanced airway management on outcomes of patients with out-of-hospital cardiac arrest

Objective@#To investigate variations in the effects of prehospital advanced airway management (AAM) on outcomes of out-of-hospital cardiac arrest (OHCA) patients according to regional emergency medical service (EMS) systems in four Asian cities. @*Methods@#We enrolled adult patients with EMS-treated OHCA of presumed cardiac origin between 2012 and 2014 from Osaka (Japan), Seoul (Republic of Korea), Singapore (Singapore), and Taipei (Taiwan). The main exposure variable was prehospital AAM. The primary endpoint was neurological recovery. We compared outcomes between the prehospital AAM and non-AAM groups using multivariable logistic regression with an interaction term between prehospital AAM and the four Asian cities. @*Results@#A total of 16,510 patients were included in the final analyses. The rates of prehospital AAM varied among Osaka, Seoul, Singapore, and Taipei (65.0%, 19.2%, 84.9%, and 34.1%, respectively). The non-AAM group showed better outcomes than the AAM group (adjusted odds ratio [aOR] for neurological recovery 0.30; 95% confidence interval [CI], 0.24–0.38]). In the interaction model for neurological recovery, the aORs for AAM in Osaka and Singapore were 0.12 (95% CI, 0.06–0.26) and 0.21 (95% CI, 0.16–0.28), respectively. In Seoul and Taipei, the association between prehospital AAM and neurological recovery was not significant (aOR 0.58 [95% CI, 0.31–1.10] and 0.79 [95% CI, 0.52–1.20], respectively). The interaction between prehospital AAM and region was significant (P=0.01). @*Conclusion@#The effects of prehospital AAM on outcomes of OHCA patients differed according to regional variability in the EMS systems.

Paediatric middle aortic syndrome with endovascular treatment in East Malaysia

Middle-aortic syndrome is a surgically curable cause ofchildhood hypertension. Open surgery is traditionallyoffered but with the advance of medical technology,endovascular approached is available in many country.Failure to control BP in open surgery is as low as 4.1%compares to 13% in endovascular approaches. However,mortality is 4% in open surgery almost 2 times higher than2.3% in endovascular approach. This article presents a caseof 10 years old child treated successfully withoutcomplication with endovascular balloon dilatation, as a firstcase of such disease in East Malaysia.

Management of concurrent thoracic and abdominal aortic aneurysms

Concurrent thoracic and abdominal aortic aneurysm is uncommon. It remains a formidable surgical challenge to vascular surgeons, as decision to treat in staged or simultaneous setting still debatable. We present, here, a case of a 62-year-old-man with asymptomatic concurrent thoracic and abdominal aortic aneurysms, which was successfully treated with two-stage hybrid endovascular repair. The aim of this case report is to discuss the treatment options available, possible associated complications and measures to prevent them.

Therapeutic temperature management (TTM): post-resuscitation care for adult cardiac arrest, with recommendations from the National TTM Workgroup

Therapeutic temperature management (TTM) was strongly recommended by the 2015 International Liaison Committee on Resuscitation as a component of post-resuscitation care. It has been known to be effective in improving the survival rate and neurologic functional outcome of patients after cardiac arrest. In an effort to increase local adoption of TTM as a standard of post-resuscitation care, this paper discusses and makes recommendations on the treatment for local providers.

Advanced Cardiac Life Support: 2016 Singapore Guidelines

The main areas of emphasis in the Advanced Cardiac Life Support (ACLS) guidelines are: early recognition of cardiac arrest and call for help; good-quality chest compressions; early defibrillation when applicable; early administration of drugs; appropriate airway management ensuring normoventilation; and delivery of appropriate post-resuscitation care to enhance survival. Of note, it is important to monitor the quality of the various care procedures. The resuscitation team needs to reduce unnecessary interruptions to chest compressions in order to maintain adequate coronary perfusion pressure during the ACLS drill. In addition, the team needs to continually look out for reversible causes of the cardiac arrest.

The role of dispatch in resuscitation

The role of the dispatch centre has increasingly become a focus of attention in cardiac arrest resuscitation. The dispatch centre is part of the first link in the chain of survival because without the initiation of early access, the rest of the chain is irrelevant. The influence of dispatch can also extend to the initiation of bystander cardiopulmonary resuscitation, early defibrillation and the rapid dispatch of emergency ambulances. The new International Liaison Committee on Resuscitation, the American Heart Association and, especially, the European Resuscitation Council 2015 guidelines have been increasing their emphasis on dispatch as the key to improving out-of-hospital cardiac arrest survival.

Prompt use of mechanical cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the MECCA study report

<p><b>INTRODUCTION</b>Early use of mechanical cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) may improve survival outcomes. Current evidence for such devices uses outcomes from an intention-to-treat (ITT) perspective. We aimed to determine whether early use of mechanical CPR using a LUCAS 2 device results in better outcomes.</p><p><b>METHODS</b>A prospective, randomised, multicentre study was conducted over one year with LUCAS 2 devices in 14 ambulances and manual CPR in 32 ambulances to manage OHCA. The primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes were survival at 24 hours, discharge from hospital and 30 days.</p><p><b>RESULTS</b>Of the 1,274 patients recruited, 1,191 were eligible for analysis. 889 had manual CPR and 302 had LUCAS CPR. From an ITT perspective, outcomes for manual and LUCAS CPR were: ROSC 29.2% and 31.1% (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.82-1.45; p = 0.537); 24-hour survival 11.2% and 13.2% (OR 1.20, 95% CI 0.81-1.78; p = 0.352); survival to discharge 3.6% and 4.3% (OR 1.20, 95% CI 0.62-2.33; p = 0.579); and 30-day survival 3.0% and 4.0% (OR 1.32, 95% CI 0.66-2.64; p = 0.430), respectively. By as-treated analysis, outcomes for manual, early LUCAS and late LUCAS CPR were: ROSC 28.0%, 36.9% and 24.5%; 24-hour survival 10.6%, 15.5% and 8.2%; survival to discharge 2.9%, 5.8% and 2.0%; and 30-day survival 2.4%, 5.8% and 0.0%, respectively. Adjusted OR for survival with early LUCAS vs. manual CPR was 1.47 after adjustment for other variables (p = 0.026).</p><p><b>CONCLUSION</b>This study showed a survival benefit with LUCAS CPR as compared to manual CPR only, when the device was applied early on-site.</p>

Popliteal artery pseudoaneurysm successfully treated with amplatzer vascular plug

Popliteal artery pseudoaneurysm is uncommon. They usually result from penetrating or blunt trauma, arterial reconstructive surgery, invasive diagnostic or surgical orthopedic procedures. They can cause arterial thrombosis and limb ischeamia. We report a 53 year old Chinese gentleman with popliteal artery pseudoaneurysm who presented with right lower limb numbness and paralysis in toes extension. He gave a history of acupuncture treatment around the popliteal fossa of the affected limb. Clinical examination revealed a pulsatile mass in the popliteal fossa. Computed tomography angiography showed a large, 5 cm, pseudoaneurysm arising from the popliteal artery. A diagnostic angiogram was performed and revealed that there is no run off from the popliteal artery and the tibial vessels were reconstructed from collaterals. Endovascular intervention was carried out with an Amplatzer Vascular Plug to embolise the pseudoaneurysm. The pseudoaneurysm was successfully excluded and post-op follow up revealed no more pulsatile mass and improving lower limb function. To the best of our knowledge this is first reported case of pseudoaneurysm of the popliteal artery secondary to acupuncture in Malaysia.

Effect of location of out-of-hospital cardiac arrest on survival outcomes

<p><b>INTRODUCTION</b>This study aims to study how the effect of the location of patient collapses from cardiac arrest, in the residential and non-residential areas within Singapore, relates to certain survival outcomes.</p><p><b>MATERIALS AND METHODS</b>A retrospective cohort study of data were done from the Cardiac Arrest and Resuscitation Epidemiology (CARE) project. Out-of- hospital cardiac arrest (OHCA) data from October 2001 to October 2004 (CARE) were used. All patients with OHCA as confirmed by the absence of a pulse, unresponsiveness and apnoea were included. All events had occurred in Singapore. Analysis was performed and expressed in terms of the odds ratio (OR) and the corresponding 95% confidence interval (CI).</p><p><b>RESULTS</b>A total of 2375 cases were used for this analysis. Outcomes for OHCA in residential areas were poorer than in non-residential areas-1638 (68.9%) patients collapsed in residential areas, and 14 (0.9%) survived to discharge. This was significantly less than the 2.7% of patients who survived after collapsing in a non-residential area (OR 0.31 [0.16 - 0.62]). Multivariate logistic regression analysis showed that location alone had no independent effect on survival (adjusted OR 1.13 [0.32 - 4.05]); instead, underlying factors such as bystander CPR (OR 3.67 [1.13 - 11.97]) and initial shockable rhythms (OR 6.78 [1.95 - 23.53]) gave rise to better outcomes.</p><p><b>CONCLUSION</b>Efforts to improve survival from OHCA in residential areas should include increasing CPR by family members, and reducing ambulance response times.</p>