Out-of-hospital cardiac arrest: incidence, patient characteristics, outcomes, and trends over time between 2012 and 2018 in an urban city

Objective@#This study aimed to determine the incidence, characteristics, and outcomes of out-of-hospital cardiac arrests (OHCA) and to investigate the trends for the same in Changwon city, South Korea between 2012 and 2018. @*Methods@#We analyzed a list of adult cardiac arrest cases occurring between 2012 and 2018 from the OHCA surveillance registry and the Changwon Fire Department’s emergency medical services database. The trends in the incidence and resuscitation-related characteristics were assessed using nonparametric tests for trends across ordered groups. The predictors of the primary outcome were investigated using multivariable logistic regression. The primary outcome was a good neurological outcome at hospital discharge. @*Results@#A total of 2,951 OHCAs were attended by the emergency medical services and of these, 2,834 were included in this study. Overall, the proportion of patients discharged with a good neurologic outcome was 4.7% (133/2,834). Both OHCA survival and good neurologic outcomes improved significantly over time, from 4.9% and 2.1%, respectively, in 2012 to 10.3% and 7.4% in 2018 (P<0.001). The Utstein comparator (bystander-witnessed arrests presenting with initial shockable rhythm) increased over the study period (P-for-trend<0.001). Age, response time, scene time, in-hospital cardiopulmonary resuscitation (CPR) time, witness presence, cardiac origin, and shockable rhythm were associated with good neurologic outcomes. @*Conclusion@#With the gradual increase in the proportion of patients with witnessed cardiac arrests, bystander CPR, and initial shockable rhythm, the rate of survival and a good neurologic outcome at discharge also increased annually.

Pediatric out-of-hospital cardiac arrest: incidence and outcomes in an urban city

Objective@#The aim of this study was to examine the incidence and outcomes of pediatric out-of-hospital cardiac arrests (OHCA) in Changwon city, South Korea. @*Methods@#From the Out-of-Hospital Cardiac Arrest Surveillance registry and the Changwon Fire Department’s Emergency Medical Services data, we obtained a list of 119 assessed pediatric OHCAs occurred between January 2012 and December 2018. We analyzed basic demographic variables, the location of cardiac arrest, witnessed status, bystander cardiopulmonary resuscitation (CPR), time variables for CPR, dispatcher-assisted CPR, initial cardiac rhythm, automated defibrillator use, and clinical outcomes at hospital discharge. @*Results@#A total of 2,954 OHCAs occurred during the study period, of which 72 were pediatric OHCAs. The rate of witnessed cardiac arrest was 30.6% (22/72), and bystander CPR was performed in 29 patients (40.3%). The rate of cardiac arrest occurring in public places was 16.7% (12/72). The rate of shockable rhythm in the initial electrocardiogram rhythm was 8.3% (6/72). Twelve patients (16.7%) survived to admission. The proportion of survivors discharged was 4.3% (3/70), and the rate of discharge with a good prognosis was 2.8% (2/70). @*Conclusion@#The incidence rate of pediatric OHCA was low in Changwon city. The survival rate was also low. Thus, studies with larger sample sizes and continuous monitoring in the community are needed.

Association between Cardiac Arrest Time and Favorable Neurological Outcomes in Witnessed Out-of-Hospital Cardiac Arrest Patients Treated with Targeted Temperature Management

Background@#Patients who achieve a return of spontaneous circulation (ROSC) with prolonged cardiac arrest have been recognized to have a poor prognosis. This might lead to reluctance in the provision of post-resuscitation care. Hence, we evaluated the impact of cardiac arrest time on neurologic outcomes in out-of-hospital cardiac arrest (OHCA) patients. @*Methods@#This cross-sectional study used a hospital-based nationwide registry of OHCAs in Korea between 2012 and 2016. All witnessed OHCA patients aged ≥ 15 years and treated with targeted temperature management were included. We collected the time from collapse to sustained ROSC, which was defined as the downtime. The primary outcome was a favorable neurological outcome at hospital discharge. A multiple logistic regression analysis was conducted to determine independent factors for primary outcome in patients with downtime > 30 minutes. @*Results@#Overall, neurologically favorable outcome rates were 30.5% in 1,963 patients. When the downtime was stratified into categories of 0–10, 11–20, 21–30, 31–40, 41–50, 51–60, and > 60 minutes according to 10-minute intervals, neurologically favorable outcome rates were 58.2%, 52.3%, 37.3%, 24.6%, 14.1%, 17.4%, and 16.7%, respectively (P 30 minutes, age 51–70 years (odds ratio [OR], 5.35; 95% confidence interval [CI], 2.50–11.49), age ≤ 50 years (OR, 13.16; 95% CI, 6.06–28.57), shockable rhythm (OR, 3.92; 95% CI, 2.71–5.68), bystander resuscitation (OR, 1.80; 95% CI, 1.27–2.55), cardiac cause (OR, 3.50; 95% CI, 1.69–7.25), percutaneous coronary intervention (OR, 1.82; 95% CI, 1.18–2.81), and downtime ≤ 40 minutes (OR, 2.02; 95% CI, 1.42–2.88) were associated with favorable neurological outcomes. @*Conclusion@#In patients with prolonged downtime, predicting favorable neurologic outcome may be multifactorial. The cutoff value for downtime is not the only determining factor to provide post-resuscitation care.

Utility of white matter to gray matter signal intensity ratio in comatose patients treated by targeted temperature management after cardiac arrest: a preliminary study

OBJECTIVE: This study examined the efficacy of the white matter (WM) to gray matter (GM) signal intensity ratio (SIR) in predicting the clinical prognosis of cardiac arrest patients. METHODS: Thirty-one patients who were resuscitated from cardiac arrest and underwent brain magnetic resonance imaging (MRI) were investigated retrospectively. Thirty one subjects with normal brain MRI findings served as the controls. The signal intensities (SI) were measured on T2-weighted image (T2WI). The circular regions of measurement (2–10 mm²) were placed over the regions of interest, and the average signals in GM and WM were recorded in the caudate nucleus (CN), putamen, anterior limb of the internal capsule, corpus callosum (CC), and in the cortex and WM of the frontal lobe. Cerebral performance category (CPC) 1–2 were classified as a good prognosis, and CPC 3–5 were classified as a poor prognosis. RESULTS: Most combinations of the SIR of WM to GM and most SIs of GM, except the frontal cortex, were significantly different between the two groups. On the other hand, the SI of WM was insignificant between both groups. In receiver operating characteristic (ROC) curve analysis, the SIR of the CC to CN had an area under the ROC curve (AUROC) of 1.00 for a cut-off value of 1.59 (sensitivity, 100%; specificity, 100%), the SIR of the CC to putamen had also an AUROC of 1.00 for a cut-off value of 1.43 (sensitivity, 100%; specificity, 100%). CONCLUSION: The SIR of WM to GM measured on a T2WI is related to the neurological outcome after a cardiac arrest.

Clinical Analysis of Flumazenil Administration in the Single Emergency Department for Unconscious Patients, Suspected Benzodiazepine Overdose

PURPOSE: Flumazenil is an effective benzodiazepine antagonist. However, serious adverse effects, including seizures, cardiac arrhythmias, and even death, have been reported in patients treated with flumazenil. These adverse effects are commonly associated with co-ingested tricyclic antidepressants and benzodiazepine withdrawal. Herein, we examined the safety, effectiveness, and risk of using flumazenil to treat suspected benzodiazepine overdose in the emergency department (ED). METHODS: This is a retrospective observational study of adult patients administered with flumazenil for a known or suspected benzodiazepine overdose in the ED between July 2010 and January 2016. The outcomes included mental status improvement, incidence of seizures, and intubation rate after flumazenil administration. RESULTS: Seventy-six patients were included in the analysis. Thirty-eight (50%) patients experienced clinically significant mental status improvement. One patient had a seizure (1.3%), despite 17 reported proconvulsant coingestants. No patient required endotracheal intubation, and no patient had arrhythmias after flumazenil administration. Flumazenil was given intravenously bolus in all cases, and the average dose was 0.44mg. There were no significant changes in the vital signs after flumazenil administration. CONCLUSION: Flumazenil was effective and associated with a low frequency of seizure. However, patients with contraindications may develop seizures. The benefits with respect to risk of adverse effects should be considered carefully in all patients.

The Factors Associated with the Hypotension Development in Acute Glyphosate-surfactant Herbicide Poisoning

PURPOSE: Recently, glyphosate-surfactant herbicide has been used increasingly because it is known for its low toxicity in mammals. However, some cases presented severe clinical complications including hypotension. Previous studies have shown that hypotension is a predictor of poor outcome and mortality. Therefore, we aimed to identify factors that may be related to hypotension in glyphosate intoxication. METHODS: This retrospective study targeted patients with glyphosate intoxication who were admitted to the emergency department of a single hospital from January 1st, 2004 to November 2014. The data were collected retrospectively from clinical records and laboratory files. Using multivariate logistic analysis, data were analyzed retrospectively for association with hypotension. RESULTS: Of the 245 patients, 63 patients (25.7%) had hypotension. The results of this study showed statistically significant differences in old age, underlying disease, amount of ingestion, GCS (Glasgow coma scale), White blood cell, hemoglobin, total bilirubin, glucose level, pH, bicarbonate, base excess, lactate level, AST (aspartate aminotransferase), creatinine level, saturation, Chest X-ray abnormality, and prolonged QTc (corrected QT interval) between hypotension group and non-hypotension group. By multivariate logistic analysis, GCS, creatinine level, chest X-ray abnormality, and prolonged QTc interval were associated with the cases presenting with hypotension. CONCLUSION: GCS, creatinine level, chest X-ray abnormality, and prolonged QTc interval were significant factors associated with hypotension in patients with glyphosate intoxication.

Differences in Hands-off Time According to the Position of a Second Rescuer When Switching Compression in Pre-hospital Cardiopulmonary Resuscitation Provided by Two Bystanders: A Randomized, Controlled, Parallel Study

The change of compressing personnel will inevitably accompany hands off time when cardiopulmonary resuscitation (CPR) is performed by two or more rescuers. The present study assessed whether changing compression by a second rescuer located on the opposite side (OS) of the first rescuer can reduce hands-off time compared to CPR on the same side (SS) when CPR is performed by two rescuers. The scenario of this randomized, controlled, parallel simulation study was compression-only CPR by two laypersons in a pre-hospital situation. Considering sex ratio, 64 participants were matched up in 32 teams equally divided into two gender groups, i.e. , homogenous or heterogeneous. Each team was finally allocated to one of two study groups according to the position of changing compression (SS or OS). Every team performed chest compression for 8 min and 10 sec, with chest compression changed every 2 min. The primary endpoint was cumulative hands-off time. Cumulative hands-off time of the SS group was about 2 sec longer than the OS group, and was significant (6.6 +/- 2.6 sec vs. 4.5 +/- 1.5 sec, P = 0.005). The range of hands off time of the SS group was wider than for the OS group. The mean hands-off times of each rescuer turn significantly shortened with increasing number of turns (P = 0.005). A subgroup analysis in which cumulative hands-off time was divided into three subgroups in 5-sec intervals revealed that about 70% of the SS group was included in subgroups with delayed hands-off time > or = 5 sec, with only 25% of the OS group included in these subgroups (P = 0.033). Changing compression at the OS of each rescuer reduced hands-off time compared to the SS in prehospital hands-only CPR provided by two bystanders.

Intracranial Hemorrhage Identified in the Early Stage after Applying Extracorporeal Membrane Oxygenation to Support Cardiopulmonary Resuscitation / 대한구급학회지

Extracorporeal membrane oxygenation support can extend the duration of cardiopulmonary resuscitation, but neurologic complications may develop. Cardiac arrest is a fairly common complication following severe intracranial hemorrhage; this complication is encountered both out-of-hospital and in-hospital with variable frequency. To prevent cerebral complications, to detect the cause of cardiac arrest, and to guide further treatment, early neuroimaging study is needed. Herein, we report a case of intracranial hemorrhage identified after extracorporeal cardiopulmonary resuscitation, in which the cause of the hemorrhage was not clear.

A Comparison of Compression Rates on the Quality of Cardiopulmonary Resuscitation

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 five-minute period among four groups of lay persons (> or =139 min-1, 129-138, 114-128, and 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.

The Status of the Korea Blood Inventory Monitoring System, 2009~2012 / 대한수혈학회지

BACKGROUND: In the Republic of Korea, due to the low birth rate, blood donation is expected to decrease. However, the demand for blood is increasing as the proportion of elderly has increased. Korea Centers for Disease Control and Prevention operate the Korea Blood Inventory Monitoring System (KBIMs) for detection and response to the shortage of blood. The aim of this study was to show the trend of blood supply monitored by KBIMs. METHODS: This study analyzed the red blood cell inventory ratio, average daily usage, time-lag from blood donation to transfusion and from receipt to transfusion in blood banks monitored by KBIMs from 2009 to 2012. RESULTS: A total of 25 hospitals have participated in KBIMs since 2009. The average inventory ratio of blood banks was 5.3 days. By month, the inventory ratio was highest between November and February; and by week, highest on Fridays. Daily amount of RBC utilized in hospitals peaked on Thursday by week. Time-lag from blood donation to transfusion and from receipt to transfusion in blood banks was 12.2 and 6.4 days, respectively. The inventory ratio of type-A RBC was the lowest, because of the highest level of demand. In addition, time-lags from blood donation to transfusion and from receipt to transfusion were shortest in type-A RBC. CONCLUSION: The inventory ratio in blood banks monitored by KBIMs was stable throughout the years. However, due to higher level of demand, there is a risk of shortage of type-A RBC.

The Superiority of the Laryngeal Mask Airway to the Pentax(R)AirwayScope Used by an Unskilled Pre-hospital Rescuer: A Randomized, Controlled, Crossover Mannequin Study

INTRODUCTION: Recent studies have highlighted the use of a video laryngoscope, a promising airway device that enables faster intubation than a Macintosh laryngoscope without the cessation of chest compressions. The aim of this study was to compare the performance of a Pentax AirwayScope (AWS) with that of a laryngeal mask airway (LMA) when utilized by unskilled personnel in a mannequin model while performing chest compressions. METHODS: We conducted a randomized controlled crossover trial to compare the effects of these two airway devices. A total of 36 participants performed intubation on a mannequin, with each device in both common and moderate level of difficulty airway scenarios. The time to successful ventilation, rate of ventilation success, and subjective difficulty in manipulating the devices were compared. RESULTS: In a scenario with airways of common difficulty, the LMA had a shorter time interval to successful ventilation than the AWS (13.6 vs. 25.2 seconds, respectively, p<0.001). In a scenario with moderately difficult airways, the LMA was also shorter than the AWS (14.5 vs. 26.9 seconds, respectively, p<0.001). For every level of difficulty for the airway, the LMA showed a higher successful ventilation rate and a lower extent of difficulty in device operation than the AWS (p<0.05). CONCLUSION: In the pre-hospital setting, using the LMA could enable an unskilled rescuer to establish airway patency more rapidly. LMA might also be safer and easier for operation than the AWS.

Invasive Cribriform Carcinoma Arising in Malignant Phyllodes Tumor of Breast: A Case Report

Phyllodes tumor is an uncommon fibroepithelial neoplasm of the breast. And it is characterized by expanded stroma with increased cellularity and elongated epithelium-lined clefts. Mammary carcinomas within phyllodes tumors have been rarely reported. To date, however, no reports have described the invasive cribriform carcinoma arising in malignant phyllodes tumor. Here, we report a 62-year-old woman who presented with a large breast mass. Microscopically, the mass was a typical malignant phyllodes tumor showing well developed leaf-like architecture and stromal overgrowth with high cellularity and nuclear pleomorphism. In a portion of the tumor, however, the epithelial component showed a cribriform pattern of proliferation in the absence of myoepithelial cells, suggestive of the invasive cribriform carcinoma. To our knowledge, this is rare and it is difficult to make a differential diagnosis of it. Here, we report our case with a review of literatures.

A Case of Erdheim-Chester Disease with Asymptomatic Renal Involvement / Journal of the Korean Cancer Association, 대한암학회지

Erdheim-Chester disease is a rare non-Langerhans-cell histiocytosis involving bones and multiple organs. Its clinical course can vary, from an asymptomatic state to a fatal disease, with renal involvement being a common cause of death. A 41-year-old man presented with a 10-month history of bilateral lower limb pain. Left perirenal soft-tissue infiltration had been found incidentally two years earlier. No progression of the lesion or deterioration of renal function was observed for a period of two years. At admission, plain radiography and magnetic resonance imaging of the patient's lower limbs showed patchy osteosclerosis. Biopsy of the tibia revealed histiocytic infiltration, which was found to be positive for CD68 and negative for CD1a. This report describes an unusual case of Erdheim-Chester disease involving a stationary course of disease with no specific treatment for a long period of time.