Effect of Prehospital Epinephrine on Outcomes of Out-of-Hospital Cardiac Arrest: A Bayesian Network Approach.

BACKGROUND: The benefit of prehospital epinephrine in out-of-hospital cardiac arrest (OHCA) was shown in a recent large placebo-controlled trial. However, placebo-controlled studies cannot identify the nonpharmacologic influences on concurrent or downstream events that might modify the main effect positively or negatively. We sought to identify the real-world effect of epinephrine from a clinical registry using Bayesian network with time-sequence constraints. METHODS: We analyzed a prospective regional registry of OHCA where a prehospital advanced life support (ALS) protocol named "Smart ALS (SALS)" was gradually implemented from July 2015 to December 2016. Using Bayesian network, a causal structure was estimated. The effect of epinephrine and SALS program was modelled based on the structure using extended Cox-regression and logistic regression, respectively. RESULTS: Among 4324 patients, SALS was applied to 2351 (54.4%) and epinephrine was administered in 1644 (38.0%). Epinephrine was associated with faster ROSC rate in nonshockable rhythm (HR: 2.02, 6.94, and 7.43; 95% CI: 1.08-3.78, 4.15-11.61, and 2.92-18.91, respectively, for 1-10, 11-20, and >20 minutes) while it was associated with slower rate up to 20 minutes in shockable rhythm (HR: 0.40, 0.50, and 2.20; 95% CI: 0.21-0.76, 0.32-0.77, and 0.76-6.33). SALS was associated with increased prehospital ROSC and neurologic recovery in noncardiac etiology (HR: 5.36 and 2.05; 95% CI: 3.48-8.24 and 1.40-3.01, respectively, for nonshockable and shockable rhythm). CONCLUSIONS: Epinephrine was associated with faster ROSC rate in nonshockable rhythm but slower rate in shockable rhythm up to 20 minutes. SALS was associated with improved prehospital ROSC and neurologic recovery in noncardiac etiology.

Can We Predict Good Survival Outcomes by Classifying Initial and Re-Arrest Rhythm Change Patterns in Out-of-Hospital Cardiac Arrest Settings?

Objective The purpose of this study was to investigate whether a change in prehospital arrest rhythms could allow medical personnel to predict survival outcomes in patients who achieved a return of spontaneous circulation (ROSC) in the setting of out-of-hospital cardiac arrest (OHCA). Methods The design of this study was retrospective, multi-regional, observational, and cross-sectional with a determining period between August 2015 and July 2016. Cardiac arrest rhythms were defined as a shockable rhythm (S), which refers to ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT), and non-shockable rhythm (NS), which refers to pulseless electrical activity or asystole. Survival to admission, survival to discharge, and good cerebral performance category (CPC) (CPC 1 or 2) were defined as good survival outcomes. Results A total of 163 subjects were classified into four groups according to the rhythm change pattern: NS→NS (98), S→S (27), S→NS (23), and NS→S (15). NS→NS pattern was used as the reference in logistic regression analysis. In the case of survival to hospital admission, the odds ratio (OR) (95% CI) of the S→S pattern was the highest [12.63 (3.56-44.85), p: <0.001 by no correction] and [7.29 (1.96-27.10), p = 0.003 with adjusting]. In the case of survival to hospital discharge, the OR (95% CI) of the S→S pattern was the highest [37.14 (11.71-117.78), p: <0.001 by no correction] and [13.85 (3.69-51.97), p: <0.001 with adjusting]. In the case of good CPC (CPC 1 or 2) at discharge, the OR (95% CI) of the S→S pattern was the highest [96 (19.14-481.60), p: <0.001 by no correction] and [149.69 (19.51-1148.48), p: <0.001 with adjusting]. Conclusions The S→S group showed the highest correlation with survival to hospital admission, survival to hospital discharge, and good CPC (CPC 1 or 2) at discharge compared to the NS→NS group. Verifying changes in initial cardiac arrest rhythm and prehospital re-arrest (RA) rhythm patterns after prehospital ROSC can help us predict good survival outcomes in the OHCA setting.

Outcome and status of postcardiac arrest care in Korea: results from the Korean Hypothermia Network prospective registry.

OBJECTIVE: High-quality intensive care, including targeted temperature management (TTM) for patients with postcardiac arrest syndrome, is a key element for improving outcomes after out-of-hospital cardiac arrest (OHCA). We aimed to assess the status of postcardiac arrest syndrome care, including TTM and 6-month survival with neurologically favorable outcomes, after adult OHCA patients were treated with TTM, using data from the Korean Hypothermia Network prospective registry. METHODS: We used the Korean Hypothermia Network prospective registry, a web-based multicenter registry that includes data from 22 participating hospitals throughout the Republic of Korea. Adult comatose OHCA survivors treated with TTM between October 2015 and December 2018 were included. The primary outcome was neurological outcome at 6 months. RESULTS: Of the 1,354 registered OHCA survivors treated with TTM, 550 (40.6%) survived 6 months, and 413 (30.5%) had good neurological outcomes. We identified 839 (62.0%) patients with preClinsumed cardiac etiology. A total of 937 (69.2%) collapses were witnessed, shockable rhythms were demonstrated in 482 (35.6%) patients, and 421 (31.1%) patients arrived at the emergency department with prehospital return of spontaneous circulation. The most common target temperature was 33°C, and the most common target duration was 24 hours. CONCLUSION: The survival and good neurologic outcome rates of this prospective registry show great improvements compared with those of an earlier registry. While the optimal target temperature and duration are still unknown, the most common target temperature was 33°C, and the most common target duration was 24 hours.

Prehospital advanced cardiac life support by EMT with a smartphone-based direct medical control for nursing home cardiac arrest.

OBJECTIVE: To compare the survival to discharge between nursing home (NH) cardiac arrest patients receiving smartphone-based advanced cardiac life support (SALS) and basic life support (BLS). METHODS: The SALS registry includes data on cardiac arrest from 7 urban and suburban areas in Korea between July 2015 and December 2016. We include adult patients (>18) with out-of-hospital cardiac arrest (OHCA) of medical causes and EMS attended and dispatched in. SALS is an advanced field resuscitation including drug administration by paramedics with video communication-based direct medical direction. Prehospital resuscitation method was key exposure (SALS, BLS). The primary outcome was survival to discharge. RESULTS: A total of 616 consecutive out-of-hospital cardiopulmonary resuscitation cases in NHs were recorded, and 199 (32.3%) underwent SALS. Among the NH arrest patients, the survival discharge rate was a little higher in the SALS group than the BLS group (4.0% vs 1.7%), but the difference was not significant (P = 0.078). Survival discharge with good neurologic outcome rates was 0.5% in the SALS group and 1.0% in the BLS group (P = 0.119). On the other hand, in the non-NH group, all outcome measures significantly improved when SALS was performed compared to BLS alone (survival discharge rate: 10.0% vs 7.3%, P = 0.001; good neurologic outcome: 6.8% vs 3.3%, P < 0.001). CONCLUSIONS: As a result of providing prehospital ACLS with direct medical intervention through remote video calls to paramedics, the survival to discharge rate and that with good neurologic outcome (CPC 1, 2) of non-NH patients significantly improved, however those of NH patients were not significantly increased.

The Anion Gap is a Predictive Clinical Marker for Death in Patients with Acute Pesticide Intoxication.

Pesticide formulation includes solvents (methanol and xylene) and antifreeze (ethylene glycol) whose metabolites are anions such as formic acid, hippuric acid, and oxalate. However, the effect of the anion gap on clinical outcome in acute pesticide intoxication requires clarification. In this prospective study, we compared the anion gap and other parameters between surviving versus deceased patients with acute pesticide intoxication. The following parameters were assessed in 1,058 patients with acute pesticide intoxication: blood chemistry (blood urea nitrogen, creatinine, glucose, lactic acid, liver enzymes, albumin, globulin, and urate), urinalysis (ketone bodies), arterial blood gas analysis, electrolytes (Na(+), K(+), Cl(-) HCO3 (-), Ca(++)), pesticide field of use, class, and ingestion amount, clinical outcome (death rate, length of hospital stay, length of intensive care unit stay, and seriousness of toxic symptoms), and the calculated anion gap. Among the 481 patients with a high anion gap, 52.2% had a blood pH in the physiologic range, 35.8% had metabolic acidosis, and 12.1% had acidemia. Age, anion gap, pesticide field of use, pesticide class, seriousness of symptoms (all P < 0.001), and time lag after ingestion (P = 0.048) were significant risk factors for death in univariate analyses. Among these, age, anion gap, and pesticide class were significant risk factors for death in a multiple logistic regression analysis (P < 0.001). In conclusions, high anion gap is a significant risk factor for death, regardless of the accompanying acid-base balance status in patients with acute pesticide intoxication.

Common Pesticides Used in Suicide Attempts Following the 2012 Paraquat Ban in Korea.

To determine the change in pesticides used during suicide attempts after the 2012 paraquat (PQ) ban, we evaluated the annual number of suicide attempts by pesticide ingestion between 2011 and 2014. We extracted demographic, clinical outcome, and pesticide class data from the medical records of 1,331 patients that attempted suicide by pesticide ingestion. Pesticides were sorted into 5 groups: herbicides, insecticides, fungicides, other pesticides, and combined pesticides. Each group was subdivided into various classes based on publications by the respective Resistance Action Committees. The chi-square test for trends was used to compare the annual incidence of categorical variables. The total number of suicide attempts decreased each year, from 399 in 2011 to 245 in 2014. Simultaneously, PQ ingestion decreased from 253 patients in 2011 to 60 in 2014. The proportion of PQ to pesticides also decreased from 63.4% in 2011 to 24.5% in 2014. Furthermore, the rate of decrease in the proportion of PQ to all herbicide categories increased by calendar year. In conclusion, there is a significant trend in increased annual number of suicides and proportion of suicides using glyphosates and glufosinates versus total herbicides. However, the number of suicide attempts using glyphosate and glufosinate is lower than that using PQ. The ratio of persons completing suicide to those attempting suicide after pesticide ingestion has decreased every year after the PQ ban.