Appropriateness of recommended chest compression depths for cardiopulmonary resuscitation based on chest computed tomography parameters among Thai population: A multicenter retrospective study.

Aim: We evaluated the appropriateness of various chest compression (CC) depths among Thai population by comparing the calculated heart compression fraction (HCF) using mathematical methods based on chest computed tomography (CT) measurements. Methods: This multicenter retrospective cross-sectional study was conducted from September 2014 to December 2020. Chest parameters included external anteroposterior diameter (EAPD), internal anteroposterior diameter (IAPD), heart anteroposterior diameter (HAPD), and non-cardiac soft tissue measured at the level of maximum left ventricular diameter (LVmax). We compared the HCFs as calculated from CT parameters using different CC depths at 5 cm, 6 cm, 1/4 of EAPD, and 1/3 of EAPD, with further subgroup analysis stratified by sex and BMI. Results: A total of 2927 eligible adult patients with contrast-enhanced chest CT were included. The study group had mean age of 60.1 ± 14.7 years, mean BMI of 22 ± 4.4 kg/m2, and were 57% males. The mean HCFs were 41.5%, 53.5%, 42.4%, and 62.6%, for CC depths of 50 mm, 60 mm, 1/4 of EAPD, and 1/3 of EAPD respectively. HCF was significantly lower in male patients for all CC depths. Advanced age and higher BMI showed significant correlation with lower HCF for CC depths of 50 mm and 60 mm. Conclusion: The CC depth measure of 50-60 mm demonstrated efficacy in maintaining HCF and coronary perfusion in the general population except for geriatric and obese individuals. Adjusting CC depth to 1/4-1/3 of the EAPD yielded better outcomes. Future research should prioritize determining individualized CC depths based on EAPD proportion.

Optimal chest compression position for cardiopulmonary resuscitation determined by computed tomography image: retrospective cross-sectional analysis.

The objective of this study was to determine the height of optimal hand position for chest compression during adult cardiopulmonary resuscitation (CPR) from the tip of the sternal xiphoid process (TOX) along with the relative heights of the left ventricular outflow tract (LVOT) and abdominal organs among the Thai population. The retrospective cross-sectional study was conducted through a review of medical records and contrast-enhanced chest computed tomography. The total of 204 Thai patients without obvious chest deformity at Ramathibodi Hospital from January to June 2018 was included as part of a multi-regional study. The heights of the level of maximal LV width (LVmax), LOVT, top of liver and stomach with respect to TOX were measured on midline sagittal image. Mean age and body mass index (BMI) were 59.5 years and 23.9 kg/m2, respectively. One hundred and one subjects (49.5%) had pulmonary diseases. Mean height of the LVmax from TOX was 37.7 mm, corresponding to 20% of the sternal length (SL) in the inspiration arm raised position (IAR). The adjusted height of LVmax from TOX in the expiration arm-down position (EAD) was 89.7 mm (48% of SL). The inter-nipple line was at 84.5 mm (45.1% of SL) from TOX on IAR. Among 178 and 109 subjects whose uppermost part of the liver and stomach were above TOX, 80.4% and 94.5% were located within the lower half of the sternum, respectively. The adjusted optimal hand position for chest compression during CPR was at approximately 89.7 mm from TOX in EAD (48% of SL). The hand position at the upper part of the lower half of the sternum is closest to the adjusted LVmax and has a better chance to avoid compression of intraabdominal organs.Trial registration This trial was retrospectively registered on 2 February 2023 in the Thai Clinical Trial Registry, identification number TCTR 20230202006.

Cost-effectiveness analysis of isolation strategies for asymptomatic and mild symptom COVID-19 patients.

BACKGROUND: Management of COVID-19 patients with mild and moderate symptoms could be isolated at home isolation (HI), community isolation (CI) or hospitel. However, it was still unclear which strategy was more cost-effective. Therefore, this study was conducted to evaluate this. METHODS: This study used data from patients who initially stayed at HI, CI, and hospitel under supervision of Ramathibodi Hospital between April and October 2021. Outcomes of interest were hospitalisation and mortality. An incremental cost-effectiveness ratios (ICER) was calculated based on hospital perspective using home isolation as the reference. RESULTS: From 7,077 patients, 4,349 2,356, and 372 were admitted at hospitel, HI, and CI, respectively. Most patients were females (57.04%) and the mean age was 40.42 (SD = 16.15). Average durations of stay were 4.47, 3.35, and 3.91 days for HI, CI, and hospitel, respectively. The average cost per day for staying in these corresponding places were 24.22, 63.69, and 65.23 US$. For hospitalisation, the ICER for hospitel was at 41.93 US$ to avoid one hospitalisation in 1,000 patients when compared to HI, while CI had more cost, but less cases avoided. The ICER for hospitel and CI were at 46.21 and 866.17 US$ to avoid one death in 1,000 patients. CONCLUSIONS: HI may be cost-effective isolated strategy for preventing hospitalisation and death in developing countries with limited resources.

Comparing Ultrasonography and Surface Landmark-Guided Lumbar Puncture in Patients with Obesity and Difficult Anatomy; a Randomized Controlled Trial.

Introduction: Previous studies have shown higher lumbar puncture (LP) success rates when using ultrasound guidance. This study aimed to compare the first-attempt success rate of ultrasound-guided LP with blind technique of needle insertion using the palpable spinal surface landmark in patients with obesity or a difficult anatomy. Methods: This prospective randomized controlled study was performed at the emergency department of Ramathibodi Hospital, an academic tertiary university hospital, from August 2015 to July 2016. Results: 40 patients were enrolled (20 surface landmark-guided and 20 ultrasound-guided LPs). 52.5% of the patients were male with the mean age of 60.33 ± 4.24 years. The first-attempt success rate in the ultrasound-guided LP group was significantly higher than the landmark-guided LP group (80% vs. 35%, respectively), with risk difference (RD) of 45.00% (95% confidence interval (CI): 17.72%, 72.28%). This indicated absolute risk reduction and number needed to treat of 45.00% and 2.22, respectively. The median procedural duration required to achieve successful LP in the ultrasound-guided LP group was significantly shorter than the surface landmark-guided LP group (5 [IQR: 3-18] minutes vs. 13.5 [IQR: 5-30] minutes, respectively). Traumatic puncture as a complication occurred less frequently in the ultrasound-guided LP group than the surface landmark-guided LP group with risk ratio (RR) = 0.33 (95% CI: 0.08, 1.46) and RD = -20.00% (95% CI: -44.00%, 4.00%). This indicated absolute risk reduction and number needed to harm of 20.00% and 5.00, respectively. However, the difference was not significant. Conclusion: Using ultrasound to help localize the insertion point before LP increased the first-attempt success rate and improved other LP outcomes in Thai patients with obesity or a difficult anatomy. It also shortened the procedural duration and reduced the incidence of traumatic tap.

The impact of the three-level collaboration exercise on collaboration and leadership during scenario-based hospital evacuation exercises using flexible surge capacity concept: a mixed method cross-sectional study.

BACKGROUND: Hospitals play a crucial role in responding to disasters and public health emergencies. However, they are also vulnerable to threats such as fire or flooding and can fail to respond or evacuate adequately due to unpreparedness and lack of evacuation measures. The United Nations Office for Disaster Risk Reduction has emphasised the importance of partnerships and capacity building in disaster response. One effective way to improve and develop disaster response is through exercises that focus on collaboration and leadership. This study aimed to examine the effectiveness of using the 3-level collaboration (3LC) exercise in developing collaboration and leadership in districts in Thailand, using the concept of flexible surge capacity (FSC) and its collaborative tool during a hospital evacuation simulation. METHODS: A mixed-method cross-sectional study was conducted with 40 participants recruited from disaster-response organisations and communities. The data from several scenario-based simulations were collected according to the collaborative elements (Command and control, Safety, Communication, Assessment, Triage, Treatment, Transport), in the disaster response education, "Major Incident Medical Management and Support" using self-evaluation survey pre- and post-exercises, and direct observation. RESULTS: The 3LC exercise effectively facilitated participants to gain a mutual understanding of collaboration, leadership, and individual and organisational flexibility. The exercise also identified gaps in communication and the utilisation of available resources. Additionally, the importance of early community engagement was highlighted to build up a flexible surge capacity during hospital evacuation preparedness. CONCLUSIONS: the 3LC exercise is valuable for improving leadership skills and multiagency collaboration by incorporating the collaborative factors of Flexible Surge Capacity concept in hospital evacuation preparedness.

Using computed tomography to evaluate proper chest compression depth for cardiopulmonary resuscitation in Thai population: A retrospective cross-sectional study.

INTRODUCTION: The effectiveness of cardiopulmonary resuscitation is determined by appropriate chest compression depth and rate. The American Heart Association recommended CC depth at 5-6 cm to indicate proper cardiac output during cardiac arrest. However, many studies showed the differences in the body builds between Caucasians and Asians. Therefore, this study aimed to determine heart compression fraction (HCF) in the Thai population by using contrast-enhanced computed tomography (CT) scan of the chest and a mathematical model. MATERIALS AND METHODS: Consecutive contrast-enhanced CT scans of the chest performed at Ramathibodi Hospital were retrospectively reviewed from January to March 2018 by two independent radiologists. Patients' characteristics, including gender, age, weight, height, and pre-existing diseases, were recorded, and the chest parameters were measured from a CT scan. The heart compression fraction (HCF) was subsequently calculated. RESULTS: Of 306 subjects, there were 139 (45.4%) males, 148 (47.4%) lung diseases and 10 (3.3%) heart diseases. Mean age and BMI were 60.4 years old and 23.8 kg/m2, respectively. Chest diameter, heart diameter, and non-cardiac soft tissue were significantly smaller in females compared to males. Mean (SD) HCF proportional with 50 mm and 60 mm depth were 38.3% (13.3%) and 50% (14.3%), respectively. There were significant differences of HCF proportional by 50 mm and 60 mm depth between men and women (33.2% vs 42.6% and 44% vs 54.9%, respectively (P<0.001)). In addition, a decrease in HCF was significantly observed among higher BMI groups. CONCLUSION: The CT scan and mathematical model showed that 38% and 50% HCF proportions were generated by 50 mm and 60 mm CC depth. HCF proportions were significantly different between genders and among BMI groups. The recommended depth of 5-6 cm is likely to provide sufficient CC depth in the population of Thailand.

Characteristics and outcomes of out-of-hospital cardiac arrest patients before and during the COVID-19 pandemic in Thailand.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) remains one of the leading causes of death worldwide, and bystander CPR with public-access defibrillation improves OHCA survival outcomes. The COVID-19 pandemic has posed many challenges for emergency medical services (EMS), including the suggestion of compression-only resuscitation and recommendations for complete personal protective equipment, which have created operational difficulties and prolonged response time. However, the risk factors affecting OHCA outcomes during the pandemic are poorly defined. This study aimed to assess the characteristics and outcomes of OHCA patients before and during the COVID-19 pandemic in Thailand. METHODS: This single-center, retrospective cohort study used data from electronic medical records and EMS paper records. All OHCA patients who visited Ramathibodi Hospital's emergency department before COVID-19 (March 2018 to December 2019) and during COVID-19 (March 2020-December 2021) were identified, and the number of emergency department returns of spontaneous circulation (ED-ROSC) and characteristics in OHCA patients before and during the COVID-19 pandemic in Thailand were collected. RESULTS: A total of 136 patients were included (78 men [59.1%]; mean [SD] age, 67.9 [18] years); 60 of these were during the COVID-19 period (beginning March 2020), and 76 were before the COVID-19 period. The overall baseline characteristics that differed significantly between the two groups were bystander witness and mode of chest compression (p-values < 0.001 and < 0.001, respectively). The ED ROSC during the COVID-19 period was significantly lower than before the COVID-19 period (26.67% vs. 46.05%, adjusted OR 0.21, p-value < 0.001). There were significant differences in survival to admission between the COVID-19 period and before (25.00% and 40.79%, adjusted OR 0.26, p-value 0.005). However, 30-day survivals were not significantly different (3.3% during the COVID-19 period and 10.53% before the COVID-19 period). CONCLUSIONS: During the COVID-19 pandemic in Thailand, ED ROSC and survival to admission in out-of-hospital cardiac arrest patients were significantly reduced. Additionally, the witness responses and mode of chest compression were very different between the two groups. TRIAL REGISTRATION: This trial was retrospectively registered on 7 December 2021 in the Thai Clinical Trial Registry, identification number TCTR20211207006.

Comparison of chest compression quality between 2-minute switch and rescuer fatigue switch: A randomized controlled trial.

Background: Rescuers performing chest compressions (CCs) should be rotated every 2 min or sooner if rescuers become fatigued. Is it preferable to switch rescuers when they become fatigued in such cases? This study was performed to compare the quality of CCs between two scenarios in hospitalized patients with cardiac arrest: 2-minute rescuer switch and rescuer fatigue switch. Methods: This randomized controlled trial involved 144 health-care providers, randomized to switch CC on the manikin model with 2-minute or rescuer fatigue. We recorded the CC quality for 20 min. Results: There were no significant differences in the percentage of target compressions, mean depth of compressions, or mean compression rate between the two groups. However, the rescuer fatigue switch group showed a significantly lower frequency of interruptions (4 vs. 9 times, P < 0.001) and a longer duration of each compression cycle (237 vs. 117 sec, P < 0.001). The change in the respiratory rate from before to after performing compressions was significantly greater in the 2-minute switch group (12 vs. 8 bpm, P = 0.036). Conclusion: The use of a rescuer fatigue switch CC approach resulted in no decrease in the quality of CC, suggesting that it may be used as an alternate strategy for managing in-hospital cardiac arrest.

Prehospital time of suspected stroke patients treated by emergency medical service: a nationwide study in Thailand.

BACKGROUND: This work was to study the prehospital time among suspected stroke patients who were transported by an emergency medical service (EMS) system using a national database. METHODS: National EMS database of suspected stroke patients who were treated by EMS system across 77 provinces of Thailand between January 1, 2015, and December 31, 2018, was retrospectively analyzed. Demographic data (i.e., regions, shifts, levels of ambulance, and distance to the scene) and prehospital time (i.e., dispatch, activation, response, scene, and transportation time) were extracted. Time parameters were also categorized according to the guidelines. RESULTS: Total 53,536 subjects were included in the analysis. Most of the subjects were transported during 06.00-18.00 (77.5%) and were 10 km from the ambulance parking (80.2%). Half of the subjects (50.1%) were served by advanced life support (ALS) ambulance. Median total time was 29 min (IQR 21, 39). There was a significant difference of median total time among ALS (30 min), basic (27 min), and first responder (28 min) ambulances, Holm P = 0.009. Although 91.7% and 88.3% of the subjects had dispatch time ≤ 1 min and activation time ≤ 2 min, only 48.3% had RT ≤ 8 min. However, 95% of the services were at the scene ≤ 15 min. CONCLUSION: Prehospital time from EMS call to hospital was approximately 30 min which was mainly utilized for traveling from the ambulance parking to the scene and transporting patients from the scene to hospitals. Even though only 48% of the services had RT ≤ 8 min, 95% of them had the scene time ≤ 15 min.

Comparison of Accuracy and Speed in Computer-Assisted Versus Conventional Methods for Pediatric Drug Dose Calculation: A Scenario-Based Randomized Controlled Trial.

Pediatric emergency care is prone to medication errors in many aspects including prescriptions, administrations, and monitoring. This study was designed to assess the effects of computer-assisted calculation on reducing error rates and time to prescription of specific emergency drugs. We conducted a randomized crossover experimental study involving emergency medicine residents and paramedics in the Department of Emergency Medicine at Ramathibodi Hospital. Participants calculated and prescribed medications using both the conventional method and a computer-assisted method. Medication names, dosages, routes of administration, and time to prescription were collected and analyzed using logistic and quantile regression analysis. Of 562 prescriptions, we found significant differences between computer-assisted calculation and the conventional method in the calculation accuracy of overall medications, pediatric advanced life support (PALS) drugs, and sedative drugs (91.17% vs 67.26%, 86.54% vs 46.15%, and 89.29% vs 57.86%, respectively, P < .001). Moreover, there were significant differences in calculation time for overall medications, PALS drugs and sedative drugs (25 vs 47 seconds, P < .001), and computer-assisted calculation significantly decreased the gap in medication errors between doctors and paramedics (P < .001). We conclude that computer-assisted prescription calculation provides benefits over the conventional method in accuracy of all medication dosages and in time required for calculation, while enhancing the drug prescription ability of paramedics.

Characteristics of Pediatric Emergency and Risk Factors for Life-saving Interventions.

Pediatric emergency patients are vulnerable population and require special care or interventions. Nevertheless, there is limited data on the prevalence and risk factors for life-saving interventions. This study is a retrospective analytical study. The inclusion criteria were children aged 15 years or under who were triaged as level 1 or 2 and treated at the resuscitation room. Factors associated with LSI were executed by logistic regression analysis. During the study period, there were 22 759 ER visits by 14 066 pediatric patients. Of those, 346 patients (2.46%) met the study criteria. Triage level 1 accounted for 16.18% (56 patients) with 29 patients (8.38%) with LSI. Trauma was an independent factor for LSI with adjusted odds ratio (95% CI) of 4.37 (1.49, 12.76). In conclusion, approximately 8.38% of these patients required LSI. Trauma cause was an independent predictor for LSI.

Prehospital prediction of severe injury in road traffic injuries: A multicenter cross-sectional study.

BACKGROUND: To develop and validate a risk stratification model of severe injury (SI) and death to identify and prioritize road traffic injury (RTI) patients for transportation to an appropriate trauma center (TC). METHODS: A 2-phase multicenter-cross-sectional study with prospective data collection was collaboratively conducted using 9 dispatch centers (DC) across Thailand. Among the 9 included DC, 7 and 2 DCs were used for development and validation, respectively. RTI patients who were treated and transported to hospitals by advanced life support (ALS) response units were enrolled. Multiple logistic regression was used to derive risk prediction score of death in 48 h and SI (new injury severity score ≥ 16). Calibration/discrimination performances were explored. RESULTS: A total of 5359 and 2097 RTIs were used for development and external validation, respectively. Seven and 9 predictors among demographic data, mechanism of injury, physic data, EMS operation, and prehospital managements were significant predictors of death and SI, respectively. Risk prediction models fitted well with the developed data (O/E ratios of 1.00 (IQR: 0.69, 1.01) and 0.99 (IQR: 0.95, 1.05) for death and SI, respectively); and the C statistics of 0.966 (0.961, 0.972) and 0.913 (0.905, 0.922). The risk scores were further stratified as low, moderate and high risk. The derive models did not fit well with external data but they were improved after recalibrating the intercepts. However, the model was externally good/excellent discriminated with C statistics from 0.896 (0.871, 0.922) to 0.981 (0.971, 0.991). CONCLUSION: Risk prediction models of death and SI were developed with good calibration and excellent discrimination. The model should be useful for ALS response units in proper allocation of patients.

Assessment of nationwide emergency systems in Thailand, a middle-income country setting with UHC.

BACKGROUND: Evidence has been limited regarding broader emergency systems assessment in low- and middle-income countries. The aim of the present study was to provide the empirical evidence of Thai emergency department (ED) workforce vis-à-vis workload on a national scale, the availability of services for selected high-priority health burdens, and the governance obstacles in addressing the workforce management. METHOD: One hundred thirty public Thai EDs that provide 24-hour emergency medical care were identified across Thailand as meeting the inclusion criteria. The mailed questionnaires were administered to collect data related to the objectives of the research study. RESULT: Responses were received from 91 of 130 (70%) hospitals. The median number of patients visiting hospital EDs was 51 221 per year with 32.8% considered nonurgent (ESI levels 4-5). University hospital EDs were staffed with a higher number of ER professionals than EDs of service-based secondary care and tertiary care hospitals under Ministry of Public Health (MOPH). Almost all hospitals expressed concerns about the deficiency of doctors and nurses especially emergency physician (EP) and emergency nurses. The percentage of hospitals reporting the availability of coronary artery catheterization (34%) and thrombolytic infusion for acute thrombotic stroke (24%) was limited. The governance obstacles to manage emergency systems were considered. CONCLUSION: ED staffing seems to positively correlate with workloads except university hospitals, in our study, which may suggest the influence of teaching status on the allocation of the human resource. Among the governance obstacles in ED management, a better response to nonurgent patients requires flexibility for hospitals to set financial disincentives or mobilization and management of human resources.

Closing the Equity Gap of Access to Emergency Departments of Private Hospitals in Thailand.

BACKGROUND: Previous policy implementation in 2012 to incentivize private hospitals in Thailand, a country with universal health coverage, to provide free-of-charge emergency care using DRG-based payment resulted in an equity gap of access and copayment. To bridge the gap, strategic policies involving financial and legal interventions were implemented in 2017. This study aims to assess whether this new approach would be able to fill the gap. METHODS: We analyzed an administrative dataset of over 20,206 patients visiting private hospital EDs from April 2017 to October 2017 requested for the preauthorization of access to emergency care in the first 72 hours free of charge. The association between types of insurance and the approval status was explored using logistic regression equation adjusting for age, modes of access, systolic blood pressure, respiratory rate, and Glasgow coma scores. RESULTS AND DISCUSSION: The strategic policies implementation resulted in reversing ED payer mix from the most privileged scheme, having the major share of ED visit, to the least privileged scheme. The data showed an increasing trend of ED visits to private hospitals indicates the acceptance of the financial incentive. Obvious differences in degrees of urgency between authorized and unauthorized patients suggested the role of preauthorization as a barrier to the noncritical patient visiting the ED. Furthermore, our study depicted the gender disparity between authorized and unauthorized patients which might indicate a delay in care seeking among critical female patients. Lessons learned for policymakers in low-and-middle income countries attempting to close the equity gap of access to private hospital EDs are discussed.

Payment Reforms for Prehospital Care Services in a Middle Income Country: Assessing Implementation and Patient Outcomes Using a Mixed-Methods Approach.

INTRODUCTION: Financing health systems constitutes a key element of well-functioning healthcare system. Prior to 2015, two new financial arrangements (direct-pay and E-claim systems) were introduced on a voluntary basis which aimed to pool more financial resources and improve cash flow of prehospital care systems. The aims of this study were to (1) assess the effects of direct-pay system in terms of (a) timeliness of reimbursement to EMS agencies, (b) changes in clinical care processes, and (c) the outcomes of patient care as compared to previous system; (2) identify the reasons for or against EMS agencies to participate in direct-pay system mechanisms; (3) identify the emerging issues with potential to significantly further the advancement of EMS systems. Using a mixed-methods approach, retrospective datasets of 3,769,399 individual records of call responses from 2015 to 2017 were analyzed which compared EMS units with the direct-pay system against those without in terms of time flow of claim data and patient outcomes. For qualitative data, in-depth interviews were conducted. RESULTS: EMS units participating in both systems had the highest percentages of financial claim being made in time as compared to those not participating in any (p=0.012). However, there were not any practically meaningful differences between EMS units participating and not participating in either of the payment systems in terms of patient care such as appropriateness of response time, airway management, and outcome of treatment. Analysis of data from focus-group and individual interviews ended up with a causal loop diagram demonstrating potential explanatory mechanisms for those findings. CONCLUSION: It is evident that progress has been made in terms of mobilising more financial inputs and improving financial information flow. However, there is no evidence of any changes in patient outcomes and quality of care. Furthermore, whether the progress is meaningful in filling the gaps of financial demands of the prehospital care systems is still questionable. Room for future improvement of prehospital care systems was discussed with implications for other countries.

Clinical characteristics of zinc phosphide poisoning in Thailand.

OBJECTIVE: The objectives of this study were to describe the clinical characteristics and outcomes of poisoning by zinc phosphide, a common rodenticide in Thailand, and to evaluate whether these outcomes can be prognosticated by the clinical presentation. MATERIALS AND METHODS: A 3-year retrospective cohort study was performed using data from the Ramathibodi Poison Center Toxic Exposure Surveillance System. RESULTS: In total, 455 poisonings were identified. Most were males (60.5%) and from the central region of Thailand (71.0%). The mean age was 39.91±19.15 years. The most common route of exposure was oral (99.3%). Most patients showed normal vital signs, oxygen saturation, and consciousness at the first presentation. The three most common clinical presentations were gastrointestinal (GI; 68.8%), cardiovascular (22.0%), and respiratory (13.8%) signs and symptoms. Most patients had normal blood chemistry laboratory results and chest X-ray findings at presentation. The median hospital stay was 2 days, and the mortality rate was 7%. Approximately 70% of patients underwent GI decontamination, including gastric lavage and a single dose of activated charcoal. In all, 31 patients were intubated and required ventilator support. Inotropic drugs were given to 4.2% of patients. Four moribund patients also received hyperinsulinemia-euglycemia therapy and intravenous hydrocortisone; however, all died. Patients who survived and died showed significant differences in age, duration from taking zinc phosphide to hospital presentation, abnormal vital signs at presentation (tachycardia, low blood pressure, and tachypnea), acidosis, hypernatremia, hyperkalemia, in-hospital acute kidney injury, in-hospital hypoglycemia, endotracheal tube intubation, and inotropic requirement during hospitalization (P<0.05). CONCLUSION: Zinc phosphide poisoning causes fatalities. Most patients have mild symptoms, and GI symptoms are the most common. Patients who present with abnormal vital signs or electrolytes might have more severe poisoning and should be closely monitored and aggressively treated. All patients should be observed in the hospital for 2 days and followed up for cardiovascular and respiratory symptoms, electrolyte balances, kidney function, and blood glucose.

Effects of prehospital adrenaline administration on out-of-hospital cardiac arrest outcomes: a systematic review and meta-analysis.

INTRODUCTION: The aim of this study was to conduct a systematic review and meta-analysis for determining the effects of prehospital adrenaline administration on return of spontaneous circulation, hospital admission, survival to discharge and discharge with cerebral performance category 1 or 2 in out-of-hospital cardiac arrest patients. METHODS: MEDLINE and Scopus databases were searched to identify studies reported to March 2014. Study selection and data extraction were independently completed by two reviewers (PA and SR). The baseline characteristics of each study and number of events were extracted. Risk ratios (RR) and 95% confidence interval (CI) were estimated. Heterogeneity and publication bias were also explored. RESULTS: In total 15 studies were eligible and included in the study. Of 13 adult observational studies, four to eight studies were pooled for each outcome. These yielded a total sample size that ranged from 2,381 to 421,459. A random effects model suggested that patients receiving prehospital adrenaline were 2.89 times (95% CI: 2.36, 3.54) more likely to achieve prehospital return of spontaneous circulation than those not administered adrenaline. However, there were no significant effects on overall return of spontaneous circulation (RR = 0.93, 95% CI: 0.5, 1.74), admission (RR = 1.05, 95% CI: 0.80, 1.38) and survival to discharge (RR = 0.69, 95% CI: 0.48, 1.00). CONCLUSIONS: Prehospital adrenaline administration may increase prehospital return of spontaneous circulation, but it does not improve overall rates of return of spontaneous circulation, hospital admission and survival to discharge.