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Background Various methods have been used to control body temperature in targeted temperature management (TTM), but few studies have compared specific subtypes of surface cooling systems. The aim of this study was to compare the efficiencies and neurological outcomes between hydrogels pad and water-circulating blanket cooling methods. Methods We conducted a multicentre, prospective, registry-based study of out-of-hospital cardiac arrest patients treated with TTM between 2015 and 2018. We compared the neurological outcomes, efficacies for cooling, and adverse events between patients who received TTM using a hydrogel pad and water-circulating blanket cooling. Patients were one-to-one matched using propensity scores to adjust for differences in the baseline characteristics of each cooling method. The primary outcome was a favourable neurological outcome at 6 months. Results We included 1,132 patients in the analysis, 870 of whom underwent hydrogel pad cooling, and the remaining 262 underwent water-circulating blanket cooling. In the unmatched cohort, a greater number of adverse events occurred in the water-circulating blanket group. The favourable neurologic outcome rates at 6 months were similar between the hydrogel pad group and the water circulating blanket group (30.2% vs. 29.8%, p = 0.939). In the propensity-matched cohort, which included 184 pairs, the rates of adverse events between the two groups were similar. The similarity of favourable neurologic outcome rates at 6 months between the two groups persisted (28.8% vs. 29.9%, p = 0.819). Conclusion Neurological outcomes and adverse events between the hydrogel pad cooling and water-circulating blanket cooling groups were similar.

Seismocardiography measures the vibrations produced by the beating heart using an accelerometer sensor placed on the chest. We evaluated the ability of smartphone seismocardiography to distinguish between the presence and absence of spontaneous circulation.Seismocardiography signals were obtained using a smartphone placed on the sternum in a convenience sample of 60 adult patients (30 comatose patients with spontaneous circulation and 30 deceased patients). The maximum, minimum, and standard deviation (SD) of acceleration values for head-to-foot, right-to-left, and dorsoventral axes and the three axis-root mean square (RMS) of the acceleration signals were calculated. Blinded observers (n = 156) were each asked to determine the presence or absence of spontaneous circulation based on seismocardiography video clips for each of the 60 patients.The seismocardiography revealed periodic large positive peaks in the patients with spontaneous circulation, which were absent in the patients without spontaneous circulation. For each of the four output measurements (three independent axes plus the three-axis RMS), the acceleration maxima and SD were significantly higher and the minima significantly lower in the patients with spontaneous circulation than in those without spontaneous circulation (all P 0.001 except the minimum of three axis-RMS results [P = 0.009]). The observers accurately identified the seismocardiography signals from patients without spontaneous circulation, with a sensitivity of 97.6% (95% confidence interval, 97.0%-98.2%) and a specificity of 98.4% (95% confidence interval, 97.8%-99.0%).In conclusion, blinded observers accurately distinguished between seismocardiography signals from patients with and without spontaneous circulation.

Rearrest occurs commonly after initial resuscitation following out-of-hospital cardiac arrest (OHCA). We determined (1) the predictors of rearrest during hospitalisation that can be identified in the hours immediately after OHCA, (2) the association between rearrest and favourable long-term outcomes, and (3) the predictors of favourable long-term outcomes in rearrest patients.Conditional multivariable logistic regression analyses were performed using the Korean Hypothermia Network prospective registry data, which included details of adult OHCA patients treated with targeted temperature management at 22 teaching hospitals in South Korea.Among the 1,233 patients, 260 (21.1%) experienced rearrest. Of the 192 patients resuscitated from first rearrest, 33 (17.2%) achieved 6-month favourable outcomes. Arrhythmia, heart failure, ST-segment elevation, lower initial Glasgow coma scale (GCS) motor score, higher initial lactate level, and antiarrhythmic drug use within 1 h were independently associated with rearrest. Higher lactate level and antiarrhythmic drug use were associated with shockable first rearrest, while arrhythmia, heart failure, ST-segment elevation, and lower GCS motor score were associated with non-shockable first rearrest. Rearrest was independently associated with a lower likelihood of 6-month favourable outcomes (P = 0.003). Initial shockable rhythm after OHCA, absence of diabetes, shorter cumulative time to restoration of spontaneous circulation, coronary angiography, and hypophosphataemia within 7 d were independently associated with 6-month favourable outcomes in the patients resuscitated from first rearrest.Rearrest during hospitalisation after OHCA was inversely associated with 6-month favourable outcomes. We identified several risk factors for rearrest and prognostic factors for patients resuscitated from first rearrest.

Thrombocytopenia is common and associated with mortality in critically ill patients. However, the time course of platelet counts and its association with the neurologic outcome after out-of-hospital cardiac arrest (OHCA) are not well known. The purpose of this study is to describe the time course of platelet counts in relation to the neurologic outcome in patients undergoing targeted temperature management (TTM) after CA.Review of consecutive patients receiving TTM after out-of-hospital CA between 2009 and 2016. The blood sample was collected daily until 7 days. The primary outcome was poor neurologic outcome at 6 months after CA defined as Cerebral Performance Category of 3-5 and secondary outcome was mortality at 6 months.A total of 261 consecutive patients treated with TTM after OHCA between 2009 and 2016. One hundred seventy-five patients (67.0%) had poor neurologic outcomes 6 months after CA. The changes in the platelet counts over time between the good and poor outcome groups were statistically significant (p 0.001). The platelet counts declined during TTM in both groups. The platelet counts recovered to the normal range at the end of the first week in the good neurologic outcome group. However, the platelet counts remained low in the poor outcome group. Low platelet counts on the 7th day were associated with poor neurologic outcomes (aOR 0.975, 95% CI, 0.961-0.989) and mortality at 6 months (aOR 0.986, 95% CI, 0.975-0.997) after adjusting for covariates.The changes in platelet counts in OHCA patients have a biphasic pattern that is significantly different in patients with good neurologic outcomes and those with poor neurologic outcomes at 6 months. A low platelet count 7 days after CA was associated with a poor neurologic outcome and mortality at 6 months.

Several studies reported that disturbances in cellular ion homeostasis occur following ischaemia, the magnitude of which was proportional to illness severity. The changes in serum electrolyte levels following ischaemia were minor compared with the changes in ion concentrations in the extracellular fluid. To amplify the serum electrolyte changes, we devised a new index (ion shift index), which could be calculated using commonly measured serum electrolyte levels, and explored its prognostic value in adult cardiac arrest patients.This retrospective observational study included adult cardiac arrest survivors treated at a tertiary university hospital between January 2014 and December 2017. Using the first available serum electrolyte levels, the ion shift index was calculated as follows: ion shift index = (potassium + phosphate + magnesium) / calcium. The primary outcome was poor outcome at hospital discharge (cerebral performance categories 3-5).The area under the receiver operating characteristic curve (AUC) of ion shift index for predicting poor outcome was 0.878 (95% confidence interval [CI], 0.849-0.907). The AUC of ion shift index was greater than those of individual electrolytes (all p 0.001). In multivariate analysis, higher ion shift index levels were independently associated with poor outcome (odds ratio, 2.916; 95% CI, 1.798-4.730; p 0.001). The AUC of multivariate model including ion shift index was greater than that of multivariate model after excluding ion shift index (p = 0.007).Our results suggest that the ion shift index can be helpful in the early prognostication of adult cardiac arrest patients.

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.

We examined the association between variability in body temperature (BT) and water temperature (WT) during the maintenance period of targeted temperature management (TTM) and neurologic outcomes in out-of-hospital cardiac arrest (OHCA) survivors. Adult (≥18 years), comatose OHCA survivors who underwent TTM at 33°C between October 2015 and December 2019 were included. We collected data on BT and WT recorded every minute during the TTM maintenance period. Temperature variability was measured as the standard deviation of BT and WT during the 33°C maintenance period. The primary outcome was a poor neurologic outcome, defined as a cerebral performance category scale 3-5 at 6 months. Of the 154 included patients, 96 (62.3%) had poor outcomes. The BT variability in the poor outcome group was lower than that in the good outcome group (0.16°C [0.13-0.27°C] vs. 0.13°C [0.11-0.18°C]). In addition, the WT variability during the maintenance period in the poor outcome group was lower than that in the good outcome group (2.24°C [1.80-3.96°C] vs. 1.77°C [1.26-2.32°C]). In the multivariate analysis, WT variability (odds ratio 0.508; 95% confidence interval, 0.295-0.874

Aim To examine the association between heat index (HI) during the induction, maintenance, and rewarming periods of targeted temperature management (TTM) and neurologic outcome in out-of-hospital cardiac arrest (OHCA) survivors. Methods Adult (≥18 years) comatose OHCA survivors who underwent TTM at 33 °C between 2016 and 2018 were included. We collected data on water temperature (WT) recorded every minute during TTM. We calculated HI during induction as the inverse of the average WT × induction time (h) × 100 and HI of maintenance and rewarming as the inverse of the average WT × 100. The primary outcome was a poor neurologic outcome, based on Cerebral Performance Category 3–5 after 6 months. Results Of the 118 included patients, 78 (66.1%) had poor outcome. Poor outcome group had lower HI during each of three periods than good outcome group. The areas under the curves for poor outcome of HI during the induction, maintenance, and rewarming periods were 0.819 (95% confidence interval [CI], 0.737–0.883), 0.781 (95% CI, 0.696–0.852), and 0.844 (95% CI, 0.765–0.904), respectively. Induction time (odds ratio [OR], 0.991; 95% CI, 0.983–0.999) and HI during induction (OR, 0.916; 95% CI, 0.854–0.983), maintenance (OR, 0.082; 95% CI, 0.011–0.589), and rewarming (OR, 0.009; 95% CI, 0.000–0.285) were associated with poor outcome. Conclusions Heat generation was independently associated with neurologic outcome in OHCA survivors who underwent TTM at 33 °C. The performance of HI was higher in the rewarming period than in the induction or maintenance period in association with poor neurologic outcomes.

Aim of the study Brain swelling after cardiac arrest may affect the ventricles. We aimed to investigate the prognostic performance of ventricular characteristics on brain computed tomography (CT) in cardiac arrest survivors who underwent targeted temperature management (TTM). Methods This retrospective cohort study included adult comatose cardiac arrest survivors who underwent brain CT scan within 24 h after resuscitation and underwent TTM from 2014 to 2016. The ventricular areas (lateral, third, and fourth ventricle), distances between the anterior horns of the lateral ventricle (LV) and the posterior horns of the LV, and maximal internal diameter of the skull were measured. Grey-to-white matter ratio (GWR), Evans’ index, and relative LV area were calculated. The primary outcome was a 6-month neurologic outcome. Results Of 258 patients, 176 (68.2%) had an unfavourable neurologic outcome. GWR, LV area, third ventricle area, distance between the anterior horns of the LV, distance between the posterior horns of the LV, Evans’ index, and relative LV area were different between neurologic outcome groups. Evans’ index (0.683; 95% confidence interval [CI], 0.623–0.739) and relative LV area (0.670; 95% CI, 0.609–0.727) had higher value of area under the curve than the other ventricular characteristics and showed prognostic performance comparable with GWR (0.600; 95% CI, 0.538–0.661). All ventricular characteristics and GWR were not independently associated with neurologic outcome after adjusting for covariates. Conclusion Ventricular characteristics on brain CT were associated with 6 months neurologic outcome in cardiac arrest survivors. Ventricular characteristics were objective measures that had comparable prognostic performance with GWR.

Aim of the study Previous studies on the relationship between age and outcomes after cardiac arrest were performed in settings where the majority of patients died after the withdrawal of life support (WLS). We examined the association between age and outcomes of comatose cardiac arrest survivors in a setting where WLS was not performed. Methods This single-centre retrospective observational study included adult comatose cardiac arrest survivors treated with targeted temperature management. In Korea, WLS is not permitted unless the patient is pronounced brain-dead. The primary outcome was poor neurologic outcome at hospital discharge, defined as Cerebral Performance Categories scores of 3–5. The secondary outcomes were in-hospital and six-month mortalities. Results A total of 534 patients were analysed. In multivariate analysis, age was not associated with in-hospital mortality (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.99–1.02), but it was independently associated with neurologic outcome at hospital discharge (OR, 1.03; 95% CI, 1.02–1.05) and six-month mortality (OR, 1.05; 95% CI, 1.03–1.07). When age was categorised into 10-year intervals, age groups less than 61–70 years had significantly lower OR for poor neurologic outcome compared with the reference group (61–70 years), while the OR for poor neurologic outcome in age groups greater than 70 years did not differ from that in the reference group. Conclusion In a setting where WLS is not performed, we found that age was not associated with in-hospital mortality but was independently associated with neurologic outcome at hospital discharge and six-month mortality.

Background Lipid profiles are known to be a risk factor for development of cardiovascular disease. However, the relationship between lipid profiles and outcome in out-of-hospital cardiac arrest (OHCA) survivors remains unclear. We aimed to examine the association between lipid profiles and neurologic outcome in OHCA survivors. Methods This retrospective observational study included adult (≥18 years) OHCA survivors between January 2016 and December 2018. We measured patients’ lipid profiles after return of spontaneous circulation (ROSC) including total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglyceride. The primary outcome was neurologic outcome at hospital discharge. Good neurologic outcome was defined cerebral performance categories 1 and 2. Results A total of 182 patients were included. Of them, 57 (31.3%) were discharged with good neurologic outcomes. Median serum levels of total cholesterol (178.0 vs. 123.0 mg/dL), HDL (44.0 vs. 31.0 mg/dL), and LDL (104.0 vs. 75.0 mg/dL) were significantly higher in patients with good neurologic outcome. The area under the curves of total cholesterol, HDL, LDL, and triglyceride were 0.742 (95% confidence interval [CI], 0.672–0.803), 0.729 (95% CI, 0.658–0.792), 0.683 (95% CI, 0.610–0.750), and 0.572 (95% CI, 0.497–0.645), respectively. Total cholesterol (odds ratio [OR], 1.013; 95% CI, 1.000–1.025; p = 0.043) and HDL (OR, 1.071; 95% CI, 1.021–1.123; p = 0.005) levels were associated with good neurologic outcomes. Conclusions The levels of total cholesterol and HDL after ROSC were associated with good neurologic outcomes in patients with OHCA, without considering the effect of other lipid profiles simultaneously.

The association between long duration of resuscitation efforts in out-of-hospital cardiac arrest (OHCA) and neurologic outcome is unclear and understudied with advancements in post-cardiac arrest care and high-quality cardiopulmonary resuscitation. We investigated how downtime, defined as the interval from collapse-to-return of spontaneous circulation (ROSC), impacts on neurologic outcome in OHCA patients treated with targeted temperature management (TTM).A multicenter, registry-based, retrospective cohort study was conducted using cases from 24 hospitals across South Korea. Of the 930 adults (≥18 years) non-traumatic OHCA patients treated with TTM between January 2007 and December 2012 at these hospitals, we included 858 patients who had sufficient data for calculating downtime. Good neurologic outcome was defined as a cerebral performance category score of 1 or 2.Median downtime was 30.0 (22.0-41.0min) and 242 patients (28.2%) had good neurologic outcome. When downtime was divided by 10-min intervals (≤10min, 11-20min, 21-30min, 31-40min, 41-50min, 51-60min, and60min), their neurologically intact survival rate were 48.2%, 51.6%, 29.2%, 22.1%, 16.1%, 14.8%, and 7.1%, respectively (p=0.01). Although downtime was associated with poor neurologic outcome [odds ratio 1.06 (1.05-1.08), p0.01], the area under the receiver operating characteristic curve of downtime for outcome was only 0.67, 95% CI (0.63-0.71). Furthermore, even with downtime20min, 22.2% (150/526) patients still had a good neurologic outcome, and this percentage increased to 50.3% (93/185) in patients with an initial shockable rhythm, and 31.1% (134/431) with age65 years.We found that neurologically intact survival can occur at prolonged downtimes and were unable to identify a downtime for which survivability was clearly futile. These data suggest that downtime should not be considered as a factor in determining whether to provide aggressive post-arrest care, especially in patients with young patients or those with an initially shockable rhythm.

Ischemic contracture compromises the hemodynamic effectiveness of cardiopulmonary resuscitation (CPR) and resuscitability from cardiac arrest. In a pig model of cardiac arrest, 2,3-butanedione monoxime (BDM) attenuated ischemic contracture. We investigated the effects of different doses of BDM to determine whether increasing the dose of BDM could improve the hemodynamic effectiveness of CPR further, thus ultimately improving resuscitability.After 16minutes of untreated ventricular fibrillation and 8minutes of basic life support, 36 pigs were divided randomly into 3 groups that received 50mg/kg (low-dose group) of BDM, 100mg/kg (high-dose group) of BDM, or an equivalent volume of saline (control group) during advanced cardiovascular life support.During advanced cardiovascular life support, the control group showed an increase in left ventricular (LV) wall thickness and a decrease in LV chamber area. In contrast, the BDM-treated groups showed a decrease in the LV wall thickness and an increase in the LV chamber area in a dose-dependent fashion. Mixed-model analyses of the LV wall thickness and LV chamber area revealed significant group effects and group-time interactions. Central venous oxygen saturation at 3minutes after the drug administration was 21.6% (18.4-31.9), 39.2% (28.8-53.7), and 54.0% (47.5-69.4) in the control, low-dose, and high-dose groups, respectively (P.001). Sustained restoration of spontaneous circulation was attained in 7 (58.3%), 10 (83.3%), and 12 animals (100%) in the control, low-dose, and high-dose groups, respectively (P=.046).2,3-Butanedione monoxime administered during CPR attenuated ischemic contracture and improved the resuscitability in a dose-dependent fashion.

The present study aimed to analyze and compare the prognostic performances of the Japanese Ministry of Health and Welfare (JMHW) score, the Korean Society on Thrombosis and Hemostasis (KSTH) score, the International Society on Thrombosis and Haemostasis (ISTH) score, the Japanese Association for Acute Medicine (JAAM) score, and the revised JAAM (rJAAM) score, for 28-day mortality in severe trauma. This retrospective observational study included patients admitted for severe trauma between 2012 and 2015. Receiver operating characteristics analysis was performed to examine the prognostic performance of the 5 different DIC score systems. The primary outcome was 28-day mortality following an injury. Of the 1266 patients included in the study, 28-day mortality rate was 19.7% (n = 249). The area under the curves (AUCs) of JMHW, KSTH, ISTH, JAAM, and rJAAM scores for 28-day mortality were 0.751 [95% confidence interval (95% CI), 0.726–0.775], 0.726 (95% CI, 0.701–0.750), 0.700 (95% CI, 0.674–0.725), 0.673 (95% CI, 0.646–0.699), and 0.676 (95% CI, 0.649–0.701), respectively. The AUC of JMHW score was significantly different from those of the other score systems. Fibrinogen levels ≤1.0 g/L [odds ratio (OR), 1.824; 95% CI, 1.029–3.232] and 1.0 to 1.5 g/L (OR, 1.697; 95% CI, 1.058–2.724) were independently associated with 28-day mortality compared with fibrinogen level above 1.5 g/L. JMHW score has the highest prognostic performance for 28-day mortality among DIC score systems in severe trauma. Fibrinogen level seemed to have a role in greater discrimination of JMHW scores than the other DIC score systems.

Aim of the study Ischaemic contracture compromises the haemodynamic effectiveness of cardiopulmonary resuscitation and resuscitability. 2,3-Butanedione monoxime (BDM) reduced ischaemic contracture by inhibiting actin-myosin crossbridge formation in an isolated heart model. We investigated the effects of BDM on ischaemic contracture and resuscitation outcomes in a pig model of out-of-hospital cardiac arrest (OHCA). Methods After 15min of untreated ventricular fibrillation, followed by 8min of basic life support, 16 pigs were randomised to receive either 2mlkg −1 of BDM solution (25gl −1 ) or 2mlkg −1 of saline during advanced cardiac life support (ACLS). Results During the ACLS, the control group showed an increase in left ventricular (LV) wall thickness from 10.0mm (10.0–10.8) to 13.0mm (13.0–13.0) and a decrease in LV chamber area from 8.13cm 2 (7.59–9.29) to 7.47cm 2 (5.84–8.43). In contrast, the BDM group showed a decrease in the LV wall thickness from 10mm (9.0–10.8) to 8.5mm (7.0–9.8) and an increase in the LV chamber area from 9.86cm 2 (7.22–12.39) to 12.15 cm 2 (8.02–14.40). Mixed model analyses of the LV wall thickness and LV chamber area revealed significant group effects and group-time interactions. Spontaneous circulation was restored in four (50%) animals in the control group and in eight (100%) animals in the BDM group ( p =0.077). All the resuscitated animals survived during an intensive care period of 4h. Conclusion BDM administered during cardiopulmonary resuscitation reversed ischaemic contracture in a pig model of OHCA.

Introduction Predicting neurologic outcomes after cardiac arrest (CA) is challenging. This study tested the hypothesis that a quantitative analysis of diffusion weighted imaging (DWI) using the FMRIB Software Library (FSL) can predict neurologic outcomes after CA and can clarify the optimal apparent diffusion coefficient (ADC) thresholds for predicting poor neurologic outcomes. Methods Out-of-hospital CA patients treated with targeted temperature management (TTM) who underwent DWI were included in this study. Voxel-based analysis was performed to calculate the mean ADC value. ADC thresholds (750, 700, 650, 600, 550, 500, 450 and 400) and brain volumes below each threshold were also analyzed for their correlation with outcomes. The patients were divided into early (within 48 h after return of spontaneous circulation (ROSC)) and late group (between 48 h and 7 days after ROSC) according to the DWI scan time. The primary outcome was a poor neurologic outcome at 6 months after CA, defined as a cerebral performance category (CPC) of 3–5. Results One hundred ten DWIs were analyzed. The mean ADC values were 789.0 (761.5–826.5) × 10−6 mm2/s for the good neurologic outcome group and 715.2 (663.1–778.4) × 10−6 mm2/s for the poor neurologic outcome group (p 2.5% ADC threshold of 400 × 10−6 mm2/s) in the early group and 79.2% (cutoff value; >1.66% ADC threshold of 400 × 10−6 mm2/s) in the late group. Conclusions Voxel-based analysis using FSL software can predict neurologic outcomes after CA. The ADC threshold of 400 × 10−6 mm2/s had the highest OR for predicting a poor neurologic outcome.

Purpose We aimed to examine the serial changes in coagulofibrinolytic markers that occurred after the restoration of spontaneous circulation (ROSC) in cardiac arrest patients, who were treated with targeted temperature management (TTM). We also evaluated the association between the disseminated intravascular coagulation (DIC) score and clinical outcomes. Methods This was a single-centre, retrospective observational study that included cardiac arrest patients who were treated with TTM from May 2012 to December 2015. The prothrombin time (PT) and partial thromboplastin time (PTT), along with the levels of fibrinogen, fibrin degradation products (FDP), and D-dimer were obtained after ROSC and on day 1, 2, and 3. The DIC score was calculated after ROSC. The primary outcome was the neurologic outcome at discharge and the secondary outcome was the 6-month mortality. Results This study included 317 patients. Of these, 222 (70.0%) and 194 (61.2%) patients had a poor neurologic outcome at discharge and 6-month mortality, respectively. The PT, PTT, and fibrinogen level significantly increased over time, while the FDP and D-dimer levels decreased during first three days after ROSC. Multivariate logistic analyses revealed that the DIC score remained a significant predictor for poor neurologic outcome (odds ratio [OR], 1.800; 95% confidence interval [CI], 1.323–2.451) and 6-month mortality (OR, 1.773; 95% CI, 1.307–2.405). Conclusion The activity of coagulation and fibrinolysis decreased over time. An increased DIC score was an independent prognostic factor for poor neurologic outcome and 6-month mortality.

Purpose A step stool is an ordinary device to improve the quality of chest compression (CC) during in-hospital cardiopulmonary resuscitation (CPR). We investigated the effect of an inclined step stool on the quality of CC during CPR on a hospital bed. Methods We conducted a randomized crossover study of simulation using a manikin. Two different methods of CC were performed and compared: CC using a flat stool and CC using an inclined (20°) stool. Each session of CC was performed for 2 minutes using a metronome at a rate of 110 beats per minute. The primary outcome was the depth of CC. The adequate CC rate, duty cycle, rate of incomplete recoil, and the angle between the arm of the participants and the bed were also measured. Results The median value of the mean depth of CC was 50.5 mm (45.0-57.0 mm) in the flat stool group and 54.5 mm (47.0-58.3 mm) in the inclined stool group ( P = .014). The adequate CC rate was significantly higher in the inclined stool group (84.2% [37.6%-99.1%] vs 57.0% [15.2%-95.0%]; P = .016). The duty cycle and the rate of incomplete recoil were comparable between the 2 groups. The angles between the arm of the participants and the bed were more vertical in the inclined stool group (84.0° ± 5.2° vs 81.0° ± 4.8°; P = .014). Conclusion Using an inclined stool resulted in an improvement in the depth of CC and the adequate CC rate without increasing the rate of incomplete chest recoil.

Objectives Several studies in patients who underwent open heart surgery found that myocardial ischemic damage was reduced by potassium cardioplegia combined with lidocaine infusion. The authors evaluated the effects of potassium/lidocaine-induced cardiac standstill during conventional cardiopulmonary resuscitation (CPR) on myocardial injury and left ventricular dysfunction after resuscitation from prolonged ventricular fibrillation (VF) cardiac arrest in a pig model. Methods Ventricular fibrillation was induced in 16 pigs, and circulatory arrest was maintained for 14 minutes. Animals were then resuscitated by standard CPR. Animals were randomized at the start of CPR to receive 20 mL of saline (control group) or 0.9 mEq/kg potassium chloride and 1.2 mg/kg lidocaine diluted to 20 mL (K-lido group). Results Seven animals in each group achieved return of spontaneous circulation (ROSC; p = 1.000). Four of the K-lido group animals (50%) achieved ROSC without countershock. Resuscitated animals in the K-lido group required fewer countershocks (p = 0.004), smaller doses of epinephrine (p = 0.009), and shorter durations of CPR (p = 0.004) than did the control group. The uncorrected troponin-I at 4 hours after ROSC was lower in the K-lido group compared with the control group (2.82 ng/mL, 95% confidence interval [CI] = 1.07 to 3.38 ng/mL vs. 6.55 ng/mL, 95% CI = 4.84 to 13.30 ng/mL; p = 0.025), although the difference was not significant after Bonferroni correction. The magnitude of reduction in left ventricular ejection fraction (LVEF) between baseline and 1 hour after ROSC was significantly lower in the K-lido group (26.5%, SD ± 6.1% vs. 39.1%, SD ± 6.8%; p = 0.004). Conclusions In a pig model of untreated VF cardiac arrest for 14 minutes, resuscitation with potassium/lidocaine-induced cardiac standstill during conventional CPR tended to reduce myocardial injury and decreased the severity of postresuscitation myocardial dysfunction significantly. Resumen Objetivos Varios estudios en pacientes en los que se llevo a cabo una cirugia a corazon abierto documentaron que el dano isquemico del miocardio se redujo por la infusion cardioplejica de potasio combinada con lidocaina. Se evaluaron los efectos de la lidocaina y el potasio en la parada cardiaca inducida, durante la resucitacion cardiopulmonar (RCP) convencional (RCP), en la lesion miocardica y la disfuncion ventricular izquierda tras la RCP de la parada cardiaca por fibrilacion ventricular (FV) prolongada en un modelo de cerdo. Metodologia Se indujo fibrilacion ventricular en dieciseis cerdos, y se mantuvo la parada cardiorrespiratoria durante 14 minutos. Los animales fueron entonces resucitados mediante RCP convencional. Los animales se aleatorizaron a recibir 20 mL de salino (grupo control) o 0,9 mEq/kg de potasio clorhidrico y 1,2 mg/kg de lidocaina diluidos a 20 mL (grupo Lido-K), al inicio de la RCP. Resultados Siete animales en cada grupo consiguieron la recuperacion de la circulacion espontanea (RCE) (p = 1,000). Cuatro de los animales del grupo Lido-K (50%) alcanzaron la RCE sin choques electricos. Los animales resucitados del grupo Lido-K requirieron menor numero de choques electricos (p = 0,004), menor dosis de adrenalina (p = 0,009), y menor duracion de la RCP (p = 0,004) que el grupo control. La troponina-I a las 4 horas tras RCE fue menor en el grupo Lido-K en comparacion con el grupo control (2,82 ng/mL [IC 95% = 1,07 a 3,38 ng/mL] frente 6,55 ng/mL [IC 95% = 4,84 a 13,30 ng/mL] p = 0,025), aunque la diferencia no fue significativa tras la correccion de Bonferroni. La magnitud de la reduccion en la fraccion de eyeccion del ventriculo izquierdo entre el momento inicial y una hora tras la RCE fue significativamente menor en el grupo Lido-K (26,5% [DE ±6,1%] vs. 39,1% [DE ±6,8%]; p = 0,004). Conclusiones En un modelo cerdo de parada cardiaca por FV en cerdos no tratada durante 14 minutos, el uso de lidocaina y potasio durante la RCP convencional tendio a reducir la lesion miocardica y disminuyo la gravedad de la disfuncion miocardica tras la RCP de forma significativa.

We sought to assess the reliability of the method using the pressure measured at the intraosseous (IO) cannula while squeezing the involved limb (P(squeezing)) in determining the position of the IO needle and to compare its performance with that of the traditional confirmation method.Eighty limbs of twenty domestic swine were assigned to one of three conditions regarding the position of the IO needle; correct placement (n=40), incorrect placement in which the IO needle was placed into the subcutaneous space without entering the bone (incorrect-subcutaneous placement, n=20), or incorrect placement in which the IO needle passed entirely through the bone (incorrect-penetrating placement, n=20). A blinded investigator randomly identified the position of the needle by the traditional method or test method using P(squeezing). If P(squeezing) was 80 mmHg or higher, the IO cannula was regarded as incorrectly placed.P(squeezing) was higher in incorrect placements (176.0 mmHg (130.0-195.0)) compared with that in correct placements (27.0 mmHg (20.0-34.0)) (p0.001). The test method correctly identified all 40 placements, but the traditional method was incorrect for one (5%) of 20 correct placements (p=1.000) and 7 (35%) of 20 incorrect placements (p=0.008). In incorrect placements, false positive results occurred mainly in incorrect-penetrating placements.We suggest that the method using the pressure measured at the IO cannula can be used when there is uncertainty about the position of the IO cannula after determination using traditional methods.

Aim of the study We determined whether combining the grey-to-white matter ratio (GWR) on brain computed tomography (CT) and serum neuron specific enolase (NSE) improves the prognostic performance when compared to either alone in cardiac arrest patients treated with therapeutic hypothermia (TH). Methods We performed a retrospective study of a cohort of cardiac arrest patients treated with TH. The Hounsfield unit was measured in the caudate nucleus (CN), putamen (P), posterior limb of internal capsule (PIC) and corpus callosum (CC); GWR was calculated as CN/PIC and P/CC. The NSE value was obtained at 0, 24, and 48 h after restoration of spontaneous circulation (ROSC). We analysed the prognostic performance of GWR and NSE, singly and in combination, in predicting poor neurologic outcome (cerebral performance category 3–5). Results Of the 224 included patients, 82 showed good neurologic outcome at hospital discharge, while 142 showed poor neurologic outcome. The P/CC (area under receiver operating characteristics (AUROC) 0.864, sensitivity/specificity 52.9%/100%) showed better prognostic performance than did the CN/PIC (AUROC 0.721, sensitivity/specificity 19.8%/100%). The NSE value at 48 h after ROSC (AUROC 0.895, sensitivity/specificity 60.2%/100%) showed the highest prognostic value among the three NSE time points. Analysis of 119 patients undergoing both brain CT and NSE at 48 h indicated that combining P/CC and NSE improved the sensitivity (78.6%) compared to either alone (48.6%, 62.9%). Conclusion Combining brain CT and serum NSE improves the prognostic performance when compared to either alone in predicting poor neurologic outcome in cardiac arrest patients treated with TH.

Aim of the study Potassium-based cardioplegia has been the gold standard for cardioprotection during cardiac surgery. We sought to evaluate the feasibility and the effects of potassium-induced cardiac standstill during conventional cardiopulmonary resuscitation (CPR) in a pig model of prolonged ventricular fibrillation (VF). Methods VF was induced in 20 pigs, and circulatory arrest was maintained for 14 min. Animals were then resuscitated by standard CPR. Coincident with the start of CPR, 20 ml of saline (control group) or 0.9 mequiv. kg −1 of potassium chloride diluted to 20 ml (potassium group) was administered into right atrium. Results Administration of potassium resulted in asystole lasting for 1.0 min (0.2) in the potassium group animals. VF reappeared in all but one animal, in which wide QRS complex bradycardia followed. Restoration of spontaneous circulation (ROSC) was attained in two animals (20%) in the control group and in seven animals (70%) in the potassium group ( p = 0.070). Resuscitated animals in the potassium group required fewer countershocks (3, 4 vs. 2 (1–2)), smaller doses of adrenaline (1.84, 1.84 vs. 0.94 (0.90–1.00) mg), and shorter duration of CPR (8, 10 vs. 4.0 (4.0–4.0) min) than did the control group. Potassium concentrations normalised rapidly after ROSC in both groups, and the potassium concentrations at 5 min (5.5, 6.6 vs. 6.8 (6.5–7.8) mequiv. l −1 ) and 4 h (4.9, 5.4 vs. 5.9 (5.1–6.4) mequiv. l −1 ) after ROSC were similar in the both groups. Conclusion In a pig model of untreated VF cardiac arrest for 14 min, resuscitation with potassium-induced cardiac standstill during conventional CPR was found to be feasible.

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.

Purpose Obesity is a well-known risk factor in various health conditions. We analyzed the association between obesity and clinical outcomes, and its effect on targeted temperature management (TTM) practice for cardiac arrest survivors by calculating and classifying their body mass indexes (BMIs). Methods We conducted a retrospective data analysis of adult comatose cardiac arrest survivors treated with TTM from 2008 to 2015. BMI was calculated and the cohort was divided into four categories based on the cut-off values of 18.5, 23.0, and 27.5kgm −2 . The primary outcome was six-month mortality and the secondary outcomes were neurologic outcome at hospital discharge, cooling rate, and rewarming rate. Results The study included 468 patients. Poor neurologic outcome at discharge and six-month mortality were reported in 311 (66.5%) and 271 (57.9%) patients, respectively. A multivariate logistic analysis showed that an overweight compared to normal BMI was associated with lower probability of six-month mortality (odds ratio [OR], 0.481; 95% confidence interval [CI], 0.274–0.846; p =0.011) and poor neurologic outcome at discharge (OR, 0.482; 95% CI, 0.258–0.903; p =0.023). BMI correlated with cooling rate (B, −0.073; 95% CI, −0.108 to −0.039; p p =0.058). Conclusion Overweight BMI compared to normal BMI classification was found to be associated with lower six-month mortality and poor neurologic outcome at discharge in cardiac arrest survivors treated with TTM. Higher BMI correlated with a slower induction rate.

Aim of the study Studies examining associations between time to target temperature and outcomes in cardiac arrest patients who underwent targeted temperature management (TTM) have shown inconsistent results. We examined these associations separately for time from restoration of spontaneous circulation to TTM initiation (pre-induction time) and time from TTM initiation to target temperature (induction time). Furthermore, we examined whether critical time thresholds exist if there is an association. Methods This was a single-centre retrospective observational study including adult cardiac arrest patients treated with TTM from 2008 to 2015. We tested the associations of pre-induction time and induction time with outcomes at hospital discharge using multivariate logistic regression analysis. We then performed additional multivariate analyses, each with the significant timing variable at different binary cutoffs. Results A total of 515 patients were analysed. At hospital discharge, 357 patients (69.3%) were alive, of whom 161 (31.3%) had a favourable neurologic outcome. In multivariate analysis, a shorter pre-induction time was independently associated with a favourable neurologic outcome (odds ratio [OR], 1.110; 95% confidence interval [CI], 1.025–1.202), whereas the induction time was not (OR, 0.954; 95% CI, 0.852–1.067). We found two pre-induction time thresholds (120 and 360 min) that were associated with neurologic outcome. Conclusion We found that a shorter pre-induction time was independently associated with a favorable neurologic outcome at hospital discharge, whereas induction time was not. We also found two time thresholds at 120 and 360 min, after which initiation of cooling was associated with a worse neurologic outcome.

Intractable hypotension is a major cause of death after glyphosate-surfactant herbicide poisoning. However, there is no specific treatment besides conservative care. Herein, we report a patient poisoned by glyphosate-surfactant herbicide experiencing cardiac arrest but was successfully resuscitated and treated with continuous venovenous haemodiafiltration (CVVHDF). The 60-year-old patient was brought to our emergency department after ingesting glyphosate-surfactant herbicide. He developed pulmonary oedema, severe metabolic acidosis (pH 6.960), and hyperkalaemia (serum potassium 8.8 mmol/L). Although he experienced cardiac arrest for about 12 minutes, the use of CVVHDF improved the metabolic acidosis and hyperkalaemia, and finally stabilised his vital signs. He regained an alert mental state after therapeutic hypothermia. CVVHDF, which is a better tolerated renal replacement therapy than haemodialysis in haemodynamically unstable patients, should be considered in glyphosate-surfactant poisoned patients of intractable hypotension with severe metabolic acidosis or hyperkalaemia.

Aim of the study The available data suggest that automated external defibrillators (AED) can be safely used in vibration-like moving conditions such as rigid inflatable boats and aircraft environments. However, little literature exists examining their performance in a moving ambulance. The present study was undertaken to determine whether an AED is able to analyse the heart rhythm correctly during ambulance transport. Methods An ambulance was driven on paved (20–100km/h) and unpaved (10km/h) roads. The performance of two AED devices (CU ER 2, CU Medical Systems Inc., Korea, and Heartstart MRx, Phillips, USA) was determined in a moving ambulance using manikins. Vibration intensity was measured simultaneously with a digital vibrometer. AED performance was then evaluated again on manikins and on a swine model under simulated vibration intensities (0.5–5m/s 2 ) measured by the vibrometer in the previous phase of the investigation. Results The vibration intensity increased with increasing speeds on paved roads (1.98±0.44m/s 2 at 100km/h). While driving on unpaved roads, it increased to 6.40±1.06m/s 2 . Both AED algorithms analysed the heart rhythm correctly under resting state. When tested on pigs, both algorithms showed substantially degraded performances, even at low vibration intensities of 0.5–1m/s 2 , which corresponded to vibration intensities while driving on paved roads at 20–60km/h. This study also showed that electrocardiograms generated on manikins were more resistant to motion artifacts than were the pig electrocardiograms. Conclusion Ambulance personnel should consider the possibility of misinterpretation by an AED when this device is used while transporting a patient.

Summary Purpose The present study was undertaken to determine whether flushing the carotid artery with normal saline at 4 °C (hypothermic carotid arterial flush, HCAF) during cardiac arrest can achieve selective cerebral hypothermia rapidly during cardiac arrest and improve cerebral outcome. Methods Ventricular fibrillation (VF) was induced in fourteen dogs and circulatory arrest was maintained for 9 min. Dogs were then resuscitated by cardiopulmonary resuscitation. The dogs were divided into two groups; a control group ( n = 7), which underwent precisely the same procedure as the experimental group but not HCAF, and an experimental group (HCAF group; n = 7), which received HCAF from 8 min after the onset of VF. Results Two dogs in the control group and in the HCAF group died within 72 h after the recovery of spontaneous circulation (ROSC) due to extracerebral complications. The remaining 10 dogs survived to final evaluation at 72 h post-ROSC. In the HCAF group, tympanic temperature decreased from 37.7 °C (37.5–37.8) to 34 °C in 1 min (1–1.5) from the start of HCAF and was maintained below 34 °C until 6.5 min (3–12) after the start of HCAF, whereas oesophageal and rectal temperatures were maintained above 35 °C. Neurological deficit scores (0–100%) at 72 h post-ROSC were 42.4% (27.0–80.6) in the control group and 18.4% (14.0–36.0) in the HCAF group ( p Conclusion HCAF induced selective cerebral hypothermia rapidly during cardiac arrest and improved neurological deficit scores after 9 min of no blood flow in the described canine cardiac arrest model.

Purpose This study evaluated the prognostic performance of the gray to white matter ratio (GWR) on brain computed tomography (CT) in out-of-hospital cardiac arrest (OHCA) survivors with a noncardiac etiology and compared the prognostic performance of GWR between hypoxic and nonhypoxic etiologies. Methods Using a multicenter retrospective registry of adult OHCA patients treated with targeted temperature management, we identified those with a noncardiac etiology who underwent brain CT within 24 hours after restoration of spontaneous circulation. Attenuation of the gray matter and white matter (at the level of the basal ganglia, centrum semiovale, and high convexity) were measured and GWRs were calculated. The primary outcome was neurologic outcome. Results Of 164 patients, 145 (88.4%) were discharged with a poor neurologic outcome. Lower GWR was associated with a poor neurologic outcome. The sensitivities of this marker were markedly low (9.7%-43.5%) at cutoff values, with 100% sensitivity. The cutoff values of the GWR for hypoxic arrest showed higher sensitivities than those for nonhypoxic arrest. The area under the curve (AUC) values of the GWR for the caudate nucleus/posterior limb of the internal capsule, putamen/corpus callosum, and basal ganglia were significant in the hypoxic group, whereas the AUC of the putamen/corpus callosum was the only significant GWR in the nonhypoxic group. Conclusion A low GWR is associated with poor neurologic outcome in noncardiac etiology OHCA patients treated with targeted temperature management. Gray to white matter ratio can help to predict the neurologic outcome in a cardiac arrest with hypoxic etiology rather than a nonhypoxic etiology.

Central diabetes insipidus (CDI) is a marker of severe brain injury. Here we aimed to investigate the prevalence and risk factors of CDI in cardiac arrest survivors treated with targeted temperature management (TTM).This retrospective observational study included consecutive adult cardiac arrest survivors treated with TTM between 2008 and 2014. Central diabetes insipidus was confirmed if all of the following criteria were met: urine volume50 cc kg(-1) d(-1), serum osmolarity300 mmol/L, urine osmolarity300 mmol/L, and serum sodium145 mEq/L. The primary outcome was the incidence of CDI.Of the 385 included patients, 45 (11.7%) had confirmed central CDI. Univariate analysis showed that younger age, nonwitness of collapse, nonshockable rhythm, a high incidence of asphyxia arrest, longer downtime, and lower initial core temperature were associated with CDI development. Patients with CDI had a higher incidence of poor neurologic outcomes at discharge and higher in-hospital mortality rate (20/45 vs 76/340, P= .001) as well as 180-day mortality (44/45 vs 174/340, P.001). Multivariate analysis revealed that age (odds ratio [OR], 0.963; 95% confidence interval [CI], 0.942-0.984), shockable rhythm (OR, 0.077; 95% CI, 0.009-0.662), downtime (OR, 1.025; 95% CI, 1.006-1.044), and asphyxia etiology (OR, 6.815; 95% CI, 2.457-18.899) were independently associated with CDI development.Central diabetes insipidus developed in 12% of cardiac arrest survivors treated with TTM, and those with CDI showed poor neurologic outcomes and high mortality rates. Younger age, nonshockable rhythm, long downtime, and asphyxia arrest were significant risk factors for development of CDI.

Aim of the study Previous studies found that the gray matter to white matter ratio (GWR) on brain computed tomography (CT) could be used to predict poor outcomes in cardiac arrest survivors. However, these studies have included cardiac arrests of both cardiac and non-cardiac etiologies. We sought to evaluate if the GWR on brain CT can help to predict poor outcomes after out-of-hospital cardiac arrest (OHCA) of cardiac etiology. Methods Using a multicenter retrospective registry of adult cardiac arrest survivors treated with therapeutic hypothermia, we identified survivors of OHCA of cardiac etiology who underwent brain CT within 24 h after successful resuscitation. Gray and white matter attenuations were measured, and the GWRs were calculated as in previous studies. The prognostic values of the GWRs were analyzed, and a logistic regression analysis was performed to determine the contribution of the GWR in predicting poor outcomes (Cerebral Performance Category 3–5). Results of 283 included patients, 140 had good outcomes and 143 had poor outcomes. Although the GWRs could predict poor outcomes with statistical significance, the sensitivities were remarkably low (3.5% to 5.6%) at cutoff values with 100% specificity. No significant difference in predictive performance was found between the primary predictive model, containing independent poor outcome predictors, and the primary predictive model combined with the GWR. Conclusion In a cohort of comatose adults after OHCA of cardiac etiology, the GWR demonstrated poor predictive performance and was not helpful in predicting poor outcomes.

Central venous oxygen saturation has been shown to reflect the adequacy of tissue oxygenation during cardiopulmonary resuscitation (CPR), thereby enabling the assessment of CPR quality and the prediction of restoration of spontaneous circulation (ROSC). The femoral vein can be easily accessed during CPR. We determined if femoral venous oxygen saturation (SFVO2) values obtained during CPR could reliably predict ROSC in a pig model.After 15 minutes of untreated ventricular fibrillation followed by 8 minutes of basic life support, 19 pigs underwent advanced cardiovascular life support. During advanced cardiovascular life support, femoral venous blood samples were obtained at 4-minute intervals. The abilities of SFVO2 and coronary perfusion pressure (CPP) to predict ROSC were evaluated by calculating the areas under receiver operating characteristic curves (AUCs).Eight pigs (42.1%) achieved ROSC. The resuscitated animals had significantly higher CPP (P.001) and SFVO2 (P.001) values than the nonresuscitated animals, and there was a significant correlation between SFVO2 and CPP values (r = 0.684; P.001). The CPPs of the resuscitated and nonresuscitated animals overlapped considerably; however, there was minimal overlap between the 2 groups for SFVO2. Femoral venous oxygen saturation significantly predicted ROSC with an AUC of 0.997 (95% confidence interval, 0.911-1.000; P.001), and it had a larger AUC than CPP (AUC, 0.964; 95% confidence interval, 0.855-0.997; P.001). The AUC difference, however, was not statistically significant (P = .157).In this study, SFVO2 values obtained during CPR exhibited a significant correlation with CPP and reliably predicted ROSC.

Purpose We investigated the use of blood color brightness and blood gas variables for discriminating arterial from venous puncture during cardiopulmonary resuscitation (CPR). The study's aims were to determine if discrimination using Po 2 is superior to using blood color brightness, and if blood color brightness, Po 2 , and acid-base variables derived from blood gas analysis accurately discriminate arterial from venous blood during CPR. Methods Fifteen pigs underwent ventricular fibrillation followed by CPR. During CPR, paired femoral arterial and venous blood samples were obtained, and 2 blinded observers were asked to identify the blood's origin. Blood color brightness was measured using a blood brightness scale (BBS). The discriminatory performances of the BBS and blood gas variables were evaluated by calculating the area under receiver operating characteristic curves (AUC). Results The observers accurately discriminated arterial from venous blood with a sensitivity of 97.0% (84.7%-99.5%) and specificity of 84.9% (69.1%-93.4%). The BBS (AUC = 0.983) and Po 2 (AUC = 0.981) methods both showed comparable and excellent discriminatory performances. pH, Pco 2 , and HCO 3 − all discriminated arterial from venous blood (AUC = 0.831, 0.971, and 0.652, respectively). The AUC for Pco 2 was comparable to that for Po 2 but significantly larger than that for pH ( P = .002) or HCO 3 − ( P Conclusion The BBS and Po 2 methods showed comparable and excellent discrimination performances. Using pH, Pco 2 , and HCO 3 − levels also discriminated arterial from venous blood during CPR with statistical significance.

To improve the quality of chest compression (CC), we developed the assistant-push method, whereby the second rescuer pushes the back of the chest compressor during CC. We investigated the effectiveness and feasibility of assistant push in achieving and maintaining the CC quality.This was a randomized crossover trial in which 41 subjects randomly performed both of standard CC (single-rescuer group) and CC with instructor-driven assistant push (assistant-push group) in different order. Each session of CC was performed for 2 minutes using a manikin. Subjects were also assigned to both roles of chest compressor and assistant and together performed CC with subject-driven assistant push. Depth of CC, compression to recoil ratio, duty cycle, and rate of incomplete recoil were quantified.The mean depth of CC (57.0 [56.0-59.0] vs 55.0 [49.5-57.5], P.001) was significantly deeper, and the compression force (33.8 [29.3-36.4] vs 23.3 [20.4-25.3], P.001) was stronger in the assistant-push group. The ratio of compression to recoil, duty cycle, and rate of incomplete chest recoil were comparable between the 2 groups. The CC depth in the single-rescuer group decreased significantly every 30 seconds, whereas in the assistant-push group, it was comparable at 60- and 90-second time points (P = .004). The subject assistant-push group performed CCs at a depth comparable with that of the instructor assistant-push group.The assistant-push method improved the depth of CC and attenuated its decline, eventually helping maintain adequate CC depth over time. Subjects were able to feasibly learn assistant push and performed effectively.

Purpose This study aimed to determine the effect of case volume on targeted temperature management (TTM) performance, incidence of adverse events, and neurologic outcome in comatose out-of-hospital cardiac arrest (OHCA) survivors treated with TTM. Methods We used a Web-based, multicenter registry (Korean Hypothermia Network registry), to which 24 hospitals throughout the Republic of Korea participated to study adult (≥ 18 years) comatose out-of-hospital cardiac arrest patients treated with TTM between 2007 and 2012. The primary outcome was neurologic outcome at hospital discharge. The secondary outcomes were inhospital mortality, TTM performance, and adverse events. We extracted propensity-matched cohorts to control for bias. Multivariate logistic regression analysis was performed to assess independent risk factors for neurologic outcome. Results A total of 901 patients were included in this study; 544 (60.4%) survived to hospital discharge, and 248 (27.5%) were discharged with good neurologic outcome. The high-volume hospitals initiated TTM significantly earlier and had lower rates of hyperglycemia, bleeding, hypotension, and rebound hyperthermia. However, neurologic outcome and inhospital mortality were comparable between high-volume (27.7% and 44.6%, respectively) and low-volume hospitals (21.1% and 40.5%) in the propensity-matched cohorts. The adjusted odds ratio for the high-volume hospitals compared with low-volume hospitals was 1.506 (95% confidence interval, 0.875-2.592) for poor neurologic outcome. Conclusions Higher TTM case volume was significantly associated with early initiation of TTM and lower incidence of adverse events. However, case volume had no association with neurologic outcome and inhospital mortality.

Objectives: This study was undertaken to determine how rapidly refrigerated fluids gain heat during bolus infusion and to determine whether the refrigerated fluids could be kept cold by a simple cold-insulation method. Methods: One liter of refrigerated fluid was run through either a 16-gauge catheter (16G(–) and 16G(+) groups) or an 18-gauge catheter (18G(–) and 18G(+) groups) while monitoring the temperature in the fluid bag and the outflow site. In the 16G(+) and the 18G(+) groups, the fluid bag was placed with an ice pack inside an insulating sleeve during the fluid run. Results: In the 16G(–) and the 18G(–) groups, the outflow temperature increased to 10–12°C during the fluid run. Meanwhile, outflow temperatures in the 16G(+) and the 18G(+) groups remained below 4.6 and 6.8°C, respectively. The temperatures differed significantly between the 16G(–) and the 16G(+) groups (p

We report two cases of bowel perforation that presented to the ED after ingesting multiple magnets as diagnosed with exploratory laparotomy. Foreign body ingestion is a common occurrence in the paediatric population. Diagnosis is often delayed because it is difficult to obtain a precise history of foreign body ingestion. Fortunately, in many cases, ingested foreign bodies pass spontaneously without complications. However, surgical intervention is required for about one percent of foreign body ingestions. Multiple magnet ingestion produces bowel injuries, including bowel obstruction, ischaemia, necrosis, perforation and fistula formation, finally requiring surgical intervention. The incidence, which is rare, of magnet ingestion with complications has increased as a result of the popularity of magnetic toys. This case report highlights the complications that might occur with multiple magnet ingestion. We aim to alert physicians that multiple magnet ingestion can be a serious matter.

Objectives The aim of this study was to analyze the outcomes of patients with hanging-induced cardiac arrest who underwent therapeutic hypothermia (TH). Method In this multicenter, retrospective registry-based study, discharged patients after out-of-hospital cardiac arrest and treatment with TH were enrolled between June 2007 and March 2013. Several prehospital and hospital variables were examined for an outcome analysis with multivariable logistic regression. Results A total of 964 patients who had cardiac arrest were enrolled in this study. All patients underwent TH during post-cardiac arrest care after return of spontaneous circulation (ROSC). Of all patients, 105 were assigned to the hanging group and 859 to the non-hanging group. Six patients (6%) with good neurologic outcomes (Cerebral Performance Category 1 or 2) in the hanging group at the time of discharge were found. A shorter time interval between witnessed arrest and ROSC and a Glasgow Coma Scale over 4 after ROSC are statistically significant variables of good neurologic outcomes after hanging-induced cardiac arrest treated with TH. Conclusion A small number of patients who underwent TH after a hanging-induced cardiac arrest provided good neurologic outcomes, and some variables influenced these outcomes.

Purpose Studies suggest that the current therapeutic hypothermia (TH) protocol does not improve outcomes in adult asphyxial arrest survivors. We sought to compare the effect of 24-hour cooling at 33°C vs that of 72-hour cooling at 32°C on outcomes and the incidence of adverse events in unconscious asphyxial arrest survivors. Methods Retrospectively collected data on 79 consecutive asphyxial arrest patients treated with TH from January 2006 to March 2013 were analyzed. Forty-one patients who presented between January 2006 and January 2011 formed the 33°C-24 h group, whereas 38 patients who presented between February 2011 and March 2013 formed the 32°C-72 h group. The primary outcome was neurologic outcome at 30 days following arrest. The secondary outcomes were all-cause mortality at 30 days following arrest and the incidence of adverse events. Results The Kaplan-Meier curve showed no significant difference in survival over time during the 30 days after arrest between the 2 groups ( P = .608). Good neurologic outcome was achieved in only 2 patients (2.5%) of the overall cohort, despite TH. One of the 32°C-72 h group (2.6%; 95% confidence interval, 4.7%-13.5%) had a good neurologic outcome, as did one of the 33°C-24 h group (2.4%; 95% confidence interval, 4.3%-12.6%) ( P = 1.000). There were no significant differences in the rates of adverse events between the 2 groups. Conclusion The present study did not demonstrate an advantage of 72-hour cooling at 32°C in unconscious asphyxial arrest patients compared with 24-hour cooling at 33°C.

Background Studies investigating the relationship between blood gas tension and outcome in cardiac arrest survivors have reported conflicting results. This might have resulted from the use of a blood gas value at a single time point and the difference in the proportion of patients treated with therapeutic hypothermia (TH). We investigated the association of the mean blood gas tensions calculated from blood gas values obtained between restoration of spontaneous circulation and end of TH with the outcome in cardiac arrest patients treated with TH. Methods This was a retrospective observational study including 213 adult cardiac arrest patients. The cohort was divided into four categories based on the distribution of the mean Pao 2 data using quartiles as cut-off values between categories. According to the mean Paco 2 , the cohort was divided into hypocarbia, normocarbia, and hypercarbia. The primary outcome was in-hospital mortality. Results In multivariate analysis, the mean Pao 2 quartile was not associated with in-hospital mortality, but hypocarbia was significantly associated with increased risk of in-hospital mortality (odds ratio 2.522; 95% confidence interval 1.184-5.372; P = .016). We found a V-shaped independent association between the mean Pao 2 and poor neurologic outcome at hospital discharge, with the risk of poor neurologic outcome increasing with a descending and ascending Pao 2 ranges. Conclusion Mean Pao 2 had no independent association with in-hospital mortality whereas hypocarbia was independently associated with in-hospital mortality. We also found a V-shaped independent association between the mean Pao 2 and poor neurologic outcome at hospital discharge.

Catheter-related right atrial thrombus (RAT) is an uncommon life-threatening complication. Few cases of endovascular cooling catheter–related complications have been reported. We report the first case of endovascular cooling catheter–related RAT. A 17-year-old adolescent boy was treated with therapeutic hypothermia using an endovascular cooling catheter following ventricular fibrillation cardiac arrest. He became alert, but RAT was found 3 days after the placement of the cooling catheter. Anticoagulation with enoxaparin for 2 weeks completely resolved the RAT, and he was consequently treated with radiofrequency ablation and received an implanted cardiac defibrillator. This case report highlights the occurrence of endovascular cooling catheter–related RAT early after the placement of a catheter. Physicians should monitor whether RAT occurs during and following therapeutic hypothermia with a cooling catheter.

A tight mask seal is frequently difficult to obtain and maintain during single-rescuer bag-valve-mask (BVM) ventilation. The ResMed mask (Bella Vista, NSW, Australia) is a continuous-positive-airway-pressure mask (CM) designed for noninvasive ventilation.In this study, we compared the ventilation performances of a standard mask (SM) and a ResMed CM using a simulation manikin in an out-of-hospital single-rescuer BVM ventilation scenario.Thirty emergency medical technicians (EMTs) performed two 2-minute attempts to ventilate a simulation manikin using BVM ventilation, alternatively, with the SM or the ResMed CM in a randomized order. Ventilation parameters including tidal volume and peak airway pressure were measured using computer analysis software connected to the simulation manikin. Successful volume delivery was defined as delivery of 440-540 mL of tidal volume in accord with present cardiopulmonary resuscitation guidelines.BVM ventilation using the ResMed CM produced higher mean (± standard deviation) tidal volumes (452 ± 50 mL vs. 394 ± 113 mL, p = 0.014) and had a higher proportion of successful volume deliveries (65.3% vs. 26.7%, p0.001) than that using the SM. Peak airway pressure was higher in BVM ventilation using the ResMed CM (p = 0.035). Stomach insufflation did not occur during either method. Twenty-nine of the participants (96.7%) preferred BVM ventilation using the ResMed CM.BVM ventilations using ResMed CM resulted in a significantly higher proportion of successful volume deliveries meeting the currently recommended range of tidal volume. Clinical studies are needed to determine the value of the ResMed CM for BVM ventilation.

Endovascular cooling using the femoral cooling catheter is widely practiced. Central venous pressure (CVP) monitoring in patients undergoing femoral endovascular cooling may require the placement of another catheter near the right atrium (RA). We sought to estimate the agreement between the CVP recorded from catheters placed in the superior vena caval pressure (SVCP) and the inferior vena caval pressure (IVCP) recorded from the femoral cooling catheter in patients undergoing femoral endovascular cooling.We enrolled adult cardiac arrest survivors undergoing femoral endovascular cooling. A commercially available central venous catheter was placed in the SVC (superior vena cava) near the RA via subclavian venous access. Both SVCP and IVCP were recorded every 4 hours during therapeutic hypothermia. Arterial pressure, heart rate, peak inspiratory pressure (PIP), and positive end expiratory pressure (PEEP) at the time of vena caval pressure measurements were obtained.A total of 323 pairs of SVCP and IVCP measurements were collected. The correlation coefficient between SVCP and IVCP was 0.965 (P.001). The mean difference between SVCP and IVCP was -0.45 mm Hg (SD, 1.27; 95% confidence interval, -0.59 to -0.31 mm Hg). The limits of agreement were -2.94 to 2.05 mm Hg. Vena caval pressures were significantly correlated with airway pressures (peak inspiratory pressure and positive end expiratory pressure), whereas the difference between SVCP and IVCP did not correlate with airway pressures.Inferior vena caval pressure measured via the femoral cooling catheter showed excellent agreement with CVP recorded from catheters placed in the SVC, which indicates that the femoral cooling catheter can be used for monitoring CVP.

Background Hanging has been increasingly used to commit suicide. There is no specific treatment besides general intensive care after near-hanging. Therapeutic hypothermia (TH) has been used in unconscious patients after near-hanging. Objective To describe the outcomes in unconscious patients after near-hanging in order to determine whether TH improves the outcome of near-hanging injury. Methods Medical charts were reviewed of unconscious patients after near-hanging who presented to Chonnam National University Hospital between January 2006 and December 2010 and who were considered to be eligible for TH. According to local policy, unconscious survivors after near-hanging, whether or not they experienced cardiac arrest at the scene, were treated with TH if this was agreed by next-of-kin. Results There were 16 survivors of asphyxial cardiac arrest after near-hanging, of whom 13 received TH. Among them, only one (7.7%, 95% CI 1.4% to 33.3%) attained Cerebral Performance Category (CPC) 1; the other 15 patients had poor neurological outcomes (CPC 5 in seven patients and CPC 4 in eight patients). Nine of the patients did not experience cardiac arrest at the scene and of these, four received TH and five received normothermic treatment. All patients who did not have cardiac arrest recovered and were discharged with CPC 1. Conclusion In this study, outcomes in unconscious near-hanging patients with cardiac arrest were poor despite treatment with TH. Before recommending TH in near-hanging patients, a prospective, randomised controlled study is required.