Benefit of Extracorporeal Membrane Oxygenation before Revascularization in Patients with Acute Myocardial Infarction Complicated by Profound Cardiogenic Shock after Resuscitated Cardiac Arrest

Background and Objectives@#The study sought to investigate the impact of early extracorporeal membrane oxygenation (ECMO) support before revascularization in patients with acute myocardial infarction (AMI) complicated by profound cardiogenic shock after resuscitated cardiac arrest. It is difficult to determine optimal timing of ECMO in patients with AMI complicated by profound cardiogenic shock after resuscitated cardiac arrest. @*Methods@#Among 116,374 patients experiencing out-of-hospital cardiac arrest in South Korea, a total of 184 resuscitated patients with AMI complicated by profound cardiogenic shock, and who were treated successfully with percutaneous coronary intervention (PCI) and ECMO, were enrolled. Patients were divided into 2 groups according to the timing of ECMO: pre-PCI ECMO (n=117) and post-PCI ECMO (n=67). We compared 30-day mortality between the 2 groups. @*Results@#In-hospital mortality was 78.8% in the entire study population and significantly lower in the pre-PCI ECMO group (73.5% vs. 88.1%, p=0.020). Thirty-day mortality was also lower in the pre-PCI ECMO group compared to the post-PCI ECMO group (74.4% vs.91.0%; adjusted hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.47–0.93; p=0.017). Shockable rhythm at the emergency room (HR, 0.57; 95% CI, 0.36–0.91; p=0.019) and successful therapeutic hypothermia (HR, 0.40; 95% CI, 0.23–0.69; p=0.001) were also associated with improved 30-day survival. @*Conclusions@#ECMO support before revascularization was associated with an improved short-term survival rate compared to ECMO after revascularization in patients with AMI complicated by profound cardiogenic shock after resuscitated cardiac arrest.

Benefit of Extracorporeal Membrane Oxygenation before Revascularization in Patients with Acute Myocardial Infarction Complicated by Profound Cardiogenic Shock after Resuscitated Cardiac Arrest

Background and Objectives@#The study sought to investigate the impact of early extracorporeal membrane oxygenation (ECMO) support before revascularization in patients with acute myocardial infarction (AMI) complicated by profound cardiogenic shock after resuscitated cardiac arrest. It is difficult to determine optimal timing of ECMO in patients with AMI complicated by profound cardiogenic shock after resuscitated cardiac arrest. @*Methods@#Among 116,374 patients experiencing out-of-hospital cardiac arrest in South Korea, a total of 184 resuscitated patients with AMI complicated by profound cardiogenic shock, and who were treated successfully with percutaneous coronary intervention (PCI) and ECMO, were enrolled. Patients were divided into 2 groups according to the timing of ECMO: pre-PCI ECMO (n=117) and post-PCI ECMO (n=67). We compared 30-day mortality between the 2 groups. @*Results@#In-hospital mortality was 78.8% in the entire study population and significantly lower in the pre-PCI ECMO group (73.5% vs. 88.1%, p=0.020). Thirty-day mortality was also lower in the pre-PCI ECMO group compared to the post-PCI ECMO group (74.4% vs.91.0%; adjusted hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.47–0.93; p=0.017). Shockable rhythm at the emergency room (HR, 0.57; 95% CI, 0.36–0.91; p=0.019) and successful therapeutic hypothermia (HR, 0.40; 95% CI, 0.23–0.69; p=0.001) were also associated with improved 30-day survival. @*Conclusions@#ECMO support before revascularization was associated with an improved short-term survival rate compared to ECMO after revascularization in patients with AMI complicated by profound cardiogenic shock after resuscitated cardiac arrest.

Performance of four different tools for predicting mortality in elderly patients with severe trauma

Objective@#The present study aimed to analyze and compare the prognostic performances of Revised Trauma Score (RTS), Injury Severity Score (ISS), shock index (SI), and modified Early Warning Score (MEWS) for in-hospital mortality in severe trauma. @*Methods@#This retrospective observational study included elderly (≥65 years) patients admitted for severe trauma between January 2018 and December 2018. Receiver operating characteristics analysis was performed to examine the prognostic performance of the four different tools. The primary outcome was in-hospital mortality following an injury. @*Results@#Of the 279 patients included in the study, in-hospital mortality was 20.1% (n=56). In multivariate analysis, age (odds ratio [OR], 1.055; 95% confidence interval [CI], 1.004-1.109), ISS (OR, 1.080; 95% CI, 1.008-1.157), Glasgow Coma Scale (OR, 0.842; 95% CI, 0.785-0.904), and respiratory rate (OR, 1.261; 95% CI, 1.071-1.486) were independently associated with in-hospital mortality. The area under the curves (AUCs) of MEWS, RTS, ISS, and SI were 0.851 (95% CI, 0.763-0.857), 0.733 (0.677-0.784), 0.664 (0.606-0.720), and 0.567 (0.506-0.626), respectively. The AUC of MEWS was significantly different from those of RTS (P=0.034), ISS (P=0.001), and SI (P<0.001). @*Conclusion@#MEWS has the highest prognostic performance for in-hospital mortality among four different tools in elderly patients with severe trauma.

Use of amplitude-integrated electroencephalography in decision-making for extracorporeal membrane oxygenation in comatose cardiac arrest patients whose eventual neurologic recovery is uncertain

Comatose cardiac arrest patients frequently experience cardiogenic shock or recurrent arrest. Extracorporeal membrane oxygenation (ECMO) can be used to salvage patients with cardiogenic shock or cardiac arrest refractory to conventional therapies. However, in comatose cardiac arrest patients whose neurologic recovery is uncertain, the use of ECMO is restricted because it requires considerable financial and human resources. Amplitude-integrated electroencephalography is an easily applicable, real-time electroencephalography monitoring tool that has been increasingly used to monitor brain activity in comatose cardiac arrest patients. We describe our experience of using amplitude-integrated electroencephalography in decision-making to place ECMO for comatose cardiac arrest patients whose eventual neurologic recovery appeared uncertain at the time of ECMO placement.

Effect of pralidoxime on coronary perfusion pressure during cardiopulmonary resuscitation in a pig model

OBJECTIVE: Pralidoxime is widely used for the treatment of organophosphate poisoning. Multiple studies have reported its vasoconstrictive property, which may facilitate the restoration of spontaneous circulation (ROSC) after cardiac arrest by increasing the coronary perfusion pressure (CPP). 2,3-Butanedione monoxime, which belongs to the same oxime family, has been shown to facilitate ROSC by reducing left ventricular ischemic contracture. Because pralidoxime and 2,3-butanedione monoxime have several common mechanisms of action, both drugs may have similar effects on ischemic contracture. Thus, we investigated the effects of pralidoxime administration during cardiopulmonary resuscitation in a pig model with a focus on ischemic contracture and CPP.METHODS: After 14 minutes of untreated ventricular fibrillation, followed by 8 minutes of basic life support, 16 pigs randomly received either 80 mg/kg of pralidoxime (pralidoxime group) or an equivalent volume of saline (control group) during advanced cardiovascular life support (ACLS).RESULTS: Mixed-model analyses of left ventricular wall thickness and chamber area during ACLS revealed no significant group effects or group-time interactions, whereas a mixed-model analysis of the CPP during ACLS revealed a significant group effect (P=0.038) and group-time interaction (P<0.001). Post-hoc analyses revealed significant increases in CPP in the pralidoxime group, starting at 5 minutes after pralidoxime administration. No animal, except one in the pralidoxime group, achieved ROSC; thus, the rate of ROSC did not differ between the two groups.CONCLUSION: In a pig model of cardiac arrest, pralidoxime administered during cardiopulmonary resuscitation did not reduce ischemic contracture; however, it significantly improved CPP.

Five-year Experience of Extracorporeal Life Support in Emergency Physicians / 대한구급학회지

BACKGROUND: This study aimed to present our 5-year experience of extracorporeal cardiopulmonary resuscitation (ECPR) performed by emergency physicians. METHODS: We retrospectively analyzed 58 patients who underwent ECPR between January 2010 and December 2014. The primary parameter analyzed was survival to hospital discharge. The secondary parameters analyzed were neurologic outcome at hospital discharge, cannulation time, and ECPR-related complications. RESULTS: Thirty-one patients (53.4%) were successfully weaned from extracorporeal membrane oxygenation, and 18 (31.0%) survived to hospital discharge. Twelve patients (20.7%) were discharged with good neurologic outcomes. The median cannulation time was 25.0 min (interquartile range 20.0-31.0 min). Nineteen patients (32.8%) had ECPR-related complications, the most frequent being distal limb ischemia. Regarding the initial presentation, 52 patients (83.9%) collapsed due to a cardiac etiology, and acute myocardial infarction (33/62, 53.2%) was the most common cause of cardiac arrest. CONCLUSIONS: The survival to hospital discharge rate for cardiac arrest patients who underwent ECPR conducted by an emergency physician was within the acceptable limits. The cannulation time and complications following ECPR were comparable to those found in previous studies.

Association between lactate clearance during post-resuscitation care and neurologic outcome in cardiac arrest survivors treated with targeted temperature management

OBJECTIVE: We investigated the association between lactate clearance or serum lactate levels and neurologic outcomes or in-hospital mortality in cardiac arrest survivors who were treated with targeted temperature management (TTM). METHODS: A retrospective analysis of data from cardiac arrest survivors treated with TTM between 2012 and 2015 was conducted. Serum lactate levels were measured on admission and at 12, 24, and 48 hours following admission. Lactate clearance at 12, 24, and 48 hours was also calculated. The primary outcome was neurologic outcome at discharge. The secondary outcome was in-hospital mortality. RESULTS: The study included 282 patients; 184 (65.2%) were discharged with a poor neurologic outcome, and 62 (22.0%) died. Higher serum lactate levels at 12 hours (odds ratio [OR], 1.157; 95% confidence interval [CI], 1.006 to 1.331), 24 hours (OR, 1.320; 95% CI, 1.084 to 1.607), and 48 hours (OR, 2.474; 95% CI, 1.459 to 4.195) after admission were associated with a poor neurologic outcome. Furthermore, a higher serum lactate level at 48 hours (OR, 1.459; 95% CI, 1.181 to 1.803) following admission was associated with in-hospital mortality. Lactate clearance was not associated with neurologic outcome or in-hospital mortality at any time point after adjusting for confounders. CONCLUSION: Increased serum lactate levels after admission are associated with a poor neurologic outcome at discharge and in-hospital mortality in cardiac arrest survivors treated with TTM. Conversely, lactate clearance is not a robust surrogate marker of neurologic outcome or in-hospital mortality.

Five-year Experience of Extracorporeal Life Support in Emergency Physicians / 대한중환자의학회지

BACKGROUND: This study aimed to present our 5-year experience of extracorporeal cardiopulmonary resuscitation (ECPR) performed by emergency physicians. METHODS: We retrospectively analyzed 58 patients who underwent ECPR between January 2010 and December 2014. The primary parameter analyzed was survival to hospital discharge. The secondary parameters analyzed were neurologic outcome at hospital discharge, cannulation time, and ECPR-related complications. RESULTS: Thirty-one patients (53.4%) were successfully weaned from extracorporeal membrane oxygenation, and 18 (31.0%) survived to hospital discharge. Twelve patients (20.7%) were discharged with good neurologic outcomes. The median cannulation time was 25.0 min (interquartile range 20.0-31.0 min). Nineteen patients (32.8%) had ECPR-related complications, the most frequent being distal limb ischemia. Regarding the initial presentation, 52 patients (83.9%) collapsed due to a cardiac etiology, and acute myocardial infarction (33/62, 53.2%) was the most common cause of cardiac arrest. CONCLUSIONS: The survival to hospital discharge rate for cardiac arrest patients who underwent ECPR conducted by an emergency physician was within the acceptable limits. The cannulation time and complications following ECPR were comparable to those found in previous studies.

The Association between Dyscarbia and Outcome in Out-of-hospital Cardiac Arrest Survivors Treated with Therapeutic Hypothermia

PURPOSE: There is a lack of clinical evidence in terms of the association between carbon dioxide tension and outcomes in cardiac arrest survivors treated with therapeutic hypothermia (TH). We investigated the association of time-weighted mean carbon dioxide tension (TWMCO2) and outcomes in out-of-hospital cardiac arrest (OHCA) survivors treated with TH. METHODS: This was a retrospective cohort study including 177 OHCA survivors. The patients were divided into three groups according to the values of TWMCO2 (normocarbia, 35~45 mmHg; hypocarbia, 45 mmHg). The primary outcome was in-hospital mortality and the secondary outcome was neurologic outcome at discharge. We assessed neurologic outcome at hospital discharge using the Cerebral Performance Categories (CPC). Neurologic outcome was dichotomized as either good neurologic outcome (CPC1 and CPC2) or poor neurologic outcome (CPC 3 to 5). The odds ratio with 95% confidence interval (CI) was estimated. RESULTS: The median value of PaCO2 was 38.2 (33.9-43.3) mmHg. Among a total of 1,239 PaCO2 values, normocarbia, hypocarbia, and hypercarbia were 618 (49.8%), 380 (30.7%), and 241 (19.5%), respectively. Results of univariate logistic regression analysis showed that hypocarbia had a significantly high odds ratio for in-hospital mortality (2.474 (95% CI, 1.129-5.424), p=0.024) compared with normocarbia. Results of multivariate logistic regression analysis showed that hypocarbia (2.926; 95% CI, 1.212-7.066; p=0.017) and hypercarbia (4.673; 95% CI, 1.348-16.205; p=0.015) had a significantly high odds ratio for in-hospital mortality compared with normocarbia. CONCLUSION: In OHCA survivors treated with TH, dyscarbia (hypocarbia and hypercarbia) was frequent and dyscarbia showed an association with in-hospital mortality.

The Relation between Time-weighted Mean Oxygen Tension and Outcome in Out-of-hospital Cardiac Arrest Survivors Treated with Therapeutic Hypothermia

PURPOSE: Studies to determine the relation between oxygen tension and outcome in cardiac arrest survivors treated with therapeutic hypothermia (TH) are lacking. We investigated the relation of time-weighted mean oxygen tension (TWMO2) and outcome in cardiac arrest survivors treated with TH. METHODS: This was a retrospective observational study including 177 out-of-hospital cardiac arrest (OHCA) survivors. The patients were divided into four categories according to quartile values of TWMO2. The primary outcome was neurologic outcome at discharge and the secondary outcome was all cause in-hospital mortality. We assessed neurologic outcome using the Cerebral Performance Categories (CPC) at hospital discharge. Neurologic outcome was dichotomised as either good neurologic outcome (CPC1 and CPC2) or poor neurologic outcome (CPC 3 to 5). The odds ratio with 95% confidence interval (CI) was estimated. RESULTS: The median value of PaO2 was 139(104.5-170.0) mmHg. Among a total of 1,239 PaO2 values, 22(1.8%) values were hypoxia (300 mmHg). Results of univariate logistic regression analysis showed a significantly low odds ratio for poor neurologic outcome [0.353(95% CI, 0.133-0.938) and 0.321(95% CI, 0.121-0.850), respectively] and for in-hospital mortality [0.338(95% CI, 0.132-0.870) and 0.387(95% CI, 0.154-0.975), respectively] for the third quartile and the fourth quartile. However, results of multivariate logistic regression analysis showed no significant relation between TWMO2 and outcomes. CONCLUSION: In OHCA survivors treated with TH, time-weighted oxygen tension did not show an association with neurologic outcome and in-hospital mortality.

Current Duty Hours of Emergency Resident Physicians in Korea: Multicenter Cross-sectional Study

PURPOSE: This study was conducted in order to determine the current status of duty hours of emergency resident physicians in Korea. METHODS: The training committee of the Korean Society of Emergency Medicine surveyed using a questionnaire on resident training status, which contained the total number of duty hours during four weeks of July (first to 28th day) according to the grades of the resident physician. The proportions of both irregular working hours and independent working hours without supervision of a board certified physician were also evaluated. RESULTS: Responses from 80 hospitals out of 97 training hospitals were analyzed. The average number of duty hours of emergency resident physicians was 63.7+/-10.7 hours/week. The proportion of hospitals for which the average number of duty hours exceeded 80 hours/week was 16.1%. Irregular working hours consisted of 63.9%. Residents in 15(18.7%) hospitals worked 3.7~73.5% of their duty hours without supervision of a board certified physician. The higher grade resident had fewer working hours (p<0.001). No statistical difference was observed in the rate of both irregular work and unsupervised work according to the grade. CONCLUSION: Results of this study showed that nine(11.3%) hospitals had average duty hours above 80 hours/week. In Korea, training hospitals should prepare to minimize the impact of duty hour restriction in the near future, as well as to improve training quality.

Blood Gases during Cardiopulmonary Resuscitation in Predicting Arrest Cause between Primary Cardiac Arrest and Asphyxial Arrest / 대한구급학회지

BACKGROUND: If acid-base status and electrolytes on blood gases during cardiopulmonary resuscitation (CPR) differ between the arrest causes, this difference may aid in differentiating the arrest cause. We sought to assess the ability of blood gases during CPR to predict the arrest cause between primary cardiac arrest and asphyxial arrest. METHODS: A retrospective study was conducted on adult out-of-hospital cardiac arrest patients for whom blood gas analysis was performed during CPR on emergency department arrival. Patients were divided into two groups according to the arrest cause: a primary cardiac arrest group and an asphyxial arrest group. Acid-base status and electrolytes during CPR were compared between the two groups. RESULTS: Presumed arterial samples showed higher potassium in the asphyxial arrest group (p < 0.001). On the other hand, presumed venous samples showed higher potassium (p = 0.001) and PCO2 (p < 0.001) and lower pH (p = 0.008) and oxygen saturation (p = 0.01) in the asphyxial arrest group. Multiple logistic regression analyses revealed that arterial potassium (OR 5.207, 95% CI 1.430-18.964, p = 0.012) and venous PCO2 (OR 1.049, 95% CI 1.021-1.078, p < 0.001) were independent predictors of asphyxial arrest. Receiver operating characteristic curve analyses indicated an optimal cut-off value for arterial potassium of 6.1 mEq/L (sensitivity 100% and specificity 86.4%) and for venous PCO2 of 70.9 mmHg (sensitivity 84.6% and specificity 65.9%). CONCLUSIONS: The present study indicates that blood gases during CPR can be used to predict the arrest cause. These findings should be confirmed through further studies.

Initial Laboratory Parameters and its Correlation to Intermediate Syndrome in Patients with Acute Organophosphate Poisoning

PURPOSE: The association of serial serum cholinesterase (SChE) activity and the occurrence of intermediate syndrome (IMS) in patients orally poisoned with organophosphate (OP) were investigated. In addition, other clinical and laboratory factors were assessed for their ability to predict the subsequent development of IMS. METHODS: A total of 114 patients presented to our emergency department with acute OP ingestion between 2007 and 2012 were enrolled in this prospective study. Of these patients, 67 who needed mechanical ventilation (MV) over five days were divided into the IMS group. The 47 patients weaned from MV within four days after admission, or who did not receive the assistance of MV, were placed in the non-IMS group. The level of SChE at admission, 48 hours, and 96 hours, at discharge after admission were checked. The APACHE II (Acute Physiology, Age, Chronic Health Evaluation II) score, the amount ingested, exposure route, gender, age, and the laboratory test results were collected. All statistical analyses were performed using the Statistical Package for the Social Sciences (version 20.0). RESULTS: The mean age of total enrolled patients was 53.7+/-17.9 years and 73 patients (64.0% of total patients) were male. There were 102(89.5%) patients who intentionally ingested the OP and the mean amount ingested was 102.5+/-64.9 mL. The mean time after patients sought medical care was 5.4+/-10.5 hours after ingestion. The level of SChE at admission was 1,586+/-796 U/L and the APACHE II score was 28.81+/-19.7. The arterial pH, bicarbonate and carbon dioxide pressure, and serum protein and albumin were significantly lower in the IMS group than the non-IMS group (p<0.001). In contrast, the serum amylase, lipase, and glucose were higher in the IMS group. The APACHE II score, serum albumin and amylase, arterial bicarbonate, and the SChE at 48 and 96 hours after ingestion were independent factors that predicted the occurrence of IMS in patients with OP poisoning. The rate of recovery was 86.6% in the IMS group and 100% in the non-IMS group (p<0.001). CONCLUSION: Patients with a higher APACHE II score and levels of serum amylase, and lower levels of serum albumin and arterial bicarbonate, may be associated with the occurrence of IMS. Furthermore, when SChE levels after 48 hours and 96 hours did not increase, compared with the level of SChE at admission, patients tended to show IMS.

Initial Laboratory Parameters and its Correlation to Intermediate Syndrome in Patients with Acute Organophosphate Poisoning

PURPOSE: The association of serial serum cholinesterase (SChE) activity and the occurrence of intermediate syndrome (IMS) in patients orally poisoned with organophosphate (OP) were investigated. In addition, other clinical and laboratory factors were assessed for their ability to predict the subsequent development of IMS. METHODS: A total of 114 patients presented to our emergency department with acute OP ingestion between 2007 and 2012 were enrolled in this prospective study. Of these patients, 67 who needed mechanical ventilation (MV) over five days were divided into the IMS group. The 47 patients weaned from MV within four days after admission, or who did not receive the assistance of MV, were placed in the non-IMS group. The level of SChE at admission, 48 hours, and 96 hours, at discharge after admission were checked. The APACHE II (Acute Physiology, Age, Chronic Health Evaluation II) score, the amount ingested, exposure route, gender, age, and the laboratory test results were collected. All statistical analyses were performed using the Statistical Package for the Social Sciences (version 20.0). RESULTS: The mean age of total enrolled patients was 53.7+/-17.9 years and 73 patients (64.0% of total patients) were male. There were 102(89.5%) patients who intentionally ingested the OP and the mean amount ingested was 102.5+/-64.9 mL. The mean time after patients sought medical care was 5.4+/-10.5 hours after ingestion. The level of SChE at admission was 1,586+/-796 U/L and the APACHE II score was 28.81+/-19.7. The arterial pH, bicarbonate and carbon dioxide pressure, and serum protein and albumin were significantly lower in the IMS group than the non-IMS group (p<0.001). In contrast, the serum amylase, lipase, and glucose were higher in the IMS group. The APACHE II score, serum albumin and amylase, arterial bicarbonate, and the SChE at 48 and 96 hours after ingestion were independent factors that predicted the occurrence of IMS in patients with OP poisoning. The rate of recovery was 86.6% in the IMS group and 100% in the non-IMS group (p<0.001). CONCLUSION: Patients with a higher APACHE II score and levels of serum amylase, and lower levels of serum albumin and arterial bicarbonate, may be associated with the occurrence of IMS. Furthermore, when SChE levels after 48 hours and 96 hours did not increase, compared with the level of SChE at admission, patients tended to show IMS.

Effect of the Community Education Program on the Attitude on the Emergency Medical Service and Safety in a Rural Emergency Medical Service System

PURPOSE: Compared to urban areas, access to emergency medical services in rural areas is relatively restricted both in quality and quantity. However, based on the aged population model, the need for such services is greater in rural areas, due to accidents and underlying disease. We set out to investigate whether education for emergency medical services would be helpful for utilization of poor resources for emergency medical services in rural areas and how efficient it might be. METHODS: Goheung (n=796) and Haenam (n=819), which appeared to be similar in terms of area, population composition, and quality and quantity of emergency medical services, were selected. While one area received Life Helper for the Village, one of the educational programs for emergency medical services, the other did not. A questionnaire containing items on recognition of emergency medical services and roles of the primary responder was administered. RESULTS: Significant differences were observed in the recognition of emergency medical services and safety awareness in Goheung, to which education for emergency medical services was provided. However, we did not find a relationship between injury or accident development and education for the rural emergency medical service system in two areas. CONCLUSION: Thus, provision of education is needed for development of common residents into primary responders in alienated rural and fishing villages, offering them ongoing and repeating education in order to increase their recognition of emergency medical services and safety awareness, and expand such education to areas that are in a similar situation.

Neuron Specific Enolase as a Biomarker Predicting Neurological Outcome after Cardiac Arrest in Patients Treated by Therapeutic Hypothermia

PURPOSE: Neurological outcome prediction is an important aspect of post-resuscitation care in cardiac arrest survivors. The appearance of high serum neuron specific enolase (NSE) is known to be associated with ischemic brain injury and poor neurological outcome. The application of therapeutic hypothermia to cardiac arrest survivors has been shown to improve neurological outcomes. As such, we investigated the predictive value of serial serum NSE levels in patients who were resuscitated from cardiac arrest. METHODS: This study included 123 cardiac arrest survivors who were treated by therapeutic hypothermia from January 2008 to June 2011. Blood samples used for evaluating NSE were collected at return of spontaneous circulation (ROSC) at 6, 24 and 48 hours after initiation of therapeutic hypothermia. Neurological outcome was graded as 'good' or 'poor' at discharge and assessed according to the Cerebral Performance Category scale (CPC). A poor outcome was defined as a CPC value of 3-5. RESULTS: Receiver operating characteristic (ROC) analysis revealed NSE cut-off values of 53.9 microg/L (sensitivity 14.6%), 48.5 microg/L (sensitivity 30.6%), 80.0 microg/L (sensitivity 40.0%), and 52.7 microg/L (sensitivity 55.5%) for poor outcomes with a specificity of 100%, measured at ROSC of 6, 24 and 48 hours after initiation of therapeutic hypothermia, respectively. The poor outcome group showed significant change in NSE concentration over time (p=0.002), while the good outcome group did not. CONCLUSION: Detection of NSE at the cut-off value, 48 hr after initiation of therapeutic hypothermia was a specific but moderately sensitive marker of poor outcome at discharge. Single measurements of NSE should be cautiously interpreted, but NSE change over time was helpful in predicting the neurologic outcome.

Neuron Specific Enolase as a Biomarker Predicting Neurological Outcome after Cardiac Arrest in Patients Treated by Therapeutic Hypothermia

PURPOSE: Neurological outcome prediction is an important aspect of post-resuscitation care in cardiac arrest survivors. The appearance of high serum neuron specific enolase (NSE) is known to be associated with ischemic brain injury and poor neurological outcome. The application of therapeutic hypothermia to cardiac arrest survivors has been shown to improve neurological outcomes. As such, we investigated the predictive value of serial serum NSE levels in patients who were resuscitated from cardiac arrest. METHODS: This study included 123 cardiac arrest survivors who were treated by therapeutic hypothermia from January 2008 to June 2011. Blood samples used for evaluating NSE were collected at return of spontaneous circulation (ROSC) at 6, 24 and 48 hours after initiation of therapeutic hypothermia. Neurological outcome was graded as 'good' or 'poor' at discharge and assessed according to the Cerebral Performance Category scale (CPC). A poor outcome was defined as a CPC value of 3-5. RESULTS: Receiver operating characteristic (ROC) analysis revealed NSE cut-off values of 53.9 microg/L (sensitivity 14.6%), 48.5 microg/L (sensitivity 30.6%), 80.0 microg/L (sensitivity 40.0%), and 52.7 microg/L (sensitivity 55.5%) for poor outcomes with a specificity of 100%, measured at ROSC of 6, 24 and 48 hours after initiation of therapeutic hypothermia, respectively. The poor outcome group showed significant change in NSE concentration over time (p=0.002), while the good outcome group did not. CONCLUSION: Detection of NSE at the cut-off value, 48 hr after initiation of therapeutic hypothermia was a specific but moderately sensitive marker of poor outcome at discharge. Single measurements of NSE should be cautiously interpreted, but NSE change over time was helpful in predicting the neurologic outcome.

The Changing Pattern of Blood Glucose Levels and Its Association with In-hospital Mortality in the Out-of-hospital Cardiac Arrest Survivors Treated with Therapeutic Hypothermia / 대한구급학회지

BACKGROUND: The aim of this study was to analyze the dynamics of blood glucose during therapeutic hypothermia (TH) and the association between in-hospital mortality and blood glucose in out-of-hospital cardiac arrest survivors (OHCA) treated with TH. METHODS: The OHCA treated with TH between 2008 and 2011 were identified and analyzed. Blood glucose values were measured every hour during TH and collected. Mean blood glucose and standard deviation (SD) were calculated using blood glucose values during the entire TH period and during each phase of TH. The primary outcome was in-hospital mortality. RESULTS: One hundred twenty patients were analyzed. The non-shockable rhythm (OR = 8.263, 95% CI 1.622-42.094, p = 0.011) and mean glucose value during induction (OR = 1.010, 95% CI 1.003-1.016, p = 0.003) were independent predictors of in-hospital mortality. The blood glucose values decreased with time, and median glucose values were 161.0 (116.0-228.0) mg/dl, 128.0 (102.0-165.0) mg/dl, and 105.0 (87.5-129.3) mg/dl during the induction, maintenance, and rewarming phase, respectively. The 241 (180-309) mg/dl of the median blood glucose value before TH was significantly lower than 183 (133-242) mg/dl of the maximal median blood glucose value during the cooling phase (p < 0.001). CONCLUSIONS: High blood glucose was associated with in-hospital mortality in OHCA treated with TH. Therefore, hyperglycaemia during TH should be monitored and managed. The blood glucose decreased by time during TH. However, it is unclear whether TH itself, insulin treatment or fluid resuscitation with glucose-free solutions affects hypoglycaemia.

Gray/White Matter Ratio as an Outcome Predictor for Cardiac Arrest Patients Treated by Therapeutic Hypothermia

PURPOSE: Ischemic brain injury following cardiac arrest presents as cerebral edema. Cerebral edema can be diagnosed using computed tomography (CT) by evidence of difference in the ratio between gray and white matter density. The prognostic value of CT scan use in determining neurologic outcomes remains unclear for cardiac arrest survivors treated with therapeutic hypothermia. We investigated the density of gray and white matter and found that their ratio was associated with neurologic outcome. METHODS: Our study data included 93 cardiac arrest survivors treated with therapeutic hypothermia from January 2008 to June 2011. Cranial CT was performed after the return of spontaneous circulation. Circular regions of CT measurement (9.4 mm2) evaluated locations of interest including the caudate nucleus, putamen, posterior limb of the internal capsule, and the corpus callosum. The average attenuation in Hounsfield Units (HU) for each region was recorded. Neurological outcome was ranked as good or poor at discharge with neurological outcome assessed according to the Cerebral Performance Category scale (CPC) with a poor outcome defined as a CPC of 3-5. RESULTS: Gray matter attenuation was found to be significantly different between the good and poor outcome cases while white matter attenuation was insignificant. All types of gray/white matter ratio were significantly different between two groups. Receiver operating characteristics analysis determined a cut-off value of gray/white matter ratio at less than 1.11 (sensitivity 29.8%) which results in a poor outcome with a specificity of 100%. CONCLUSION: A low gray/white matter ratio (<1.11), as evaluated by CT scan, is associated with poor outcome after cardiac arrest and therapeutic hypothermia. However, the results of a CT scan should be interpreted with caution as the gray/white matter ratio is a low sensitivity marker.

Delayed Splenic Rupture Following Minor Trauma in a Patient with Underlying Liver Cirrhosis

The spleen is the most frequently injured organ following blunt abdominal trauma. However, delayed splenic rupture is rare. As the technical improvement of computed tomography has proceeded, the diagnosis of splenic injury has become easier than before. However, the diagnosis of delayed splenic rupture could be challenging if the trauma is minor and remote. We present a case of delayed splenic rupture in a patient with underlying liver cirrhosis. A 42-year-old male visited our emergency department with pain in the lower left chest following minor blunt trauma. Initial physical exam and abdominal sonography revealed only liver cirrhosis without traumatic injury. On the sixth day after trauma, he complained of abdominal pain and diarrhea after eating snacks. The patient was misdiagnosed as having acute gastroenteritis until he presented with symptoms of shock. Abdominal sonography and computed tomography revealed the splenic rupture. The patient underwent a splenectomy and then underwent a second operation due to postoperative bleeding 20 hours after the first operation. The patient was discharged uneventfully 30 days after trauma. In the present case, the thrombocytopenia and splenomegaly due to liver cirrhosis are suspected of being risk factors for the development of delayed splenic rupture. The physician should keep in mind the possibility of delayed splenic rupture following blunt abdominal or chest trauma.