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ABSTRACT: INTRODUCTION: The purpose of this study was to examine the prognostic value of continuous amplitude-integrated electroencephalogram (aEEG) applied immediately after return of spontaneous circulation (ROSC) in therapeutic hypothermia (TH)-treated cardiac arrest patients. METHODS: From September 2010 to August 2011, we prospectively studied comatose patients treated with TH after cardiac arrest who were monitored with aEEG. Monitoring at the forehead was applied as soon as possible after ROSC in the emergency department and continued until recovery of consciousness, death, or 72h after ROSC. Neurological outcome was assessed with the Cerebral Performance Category (CPC) scale at hospital discharge, and good neurological outcome was defined as a CPC score of 1 or 2. RESULTS: A total of 55 TH-treated patients were included. Monitoring started at a median of 96min after ROSC (interquartile range, 49-174). At discharge, 28 patients had a CPC of 1-2, and 27 patients had a CPC of 3-5. Seventeen patients had a continuous normal voltage (CNV) trace at the start of monitoring, and this voltage was strongly associated with a good outcome (16/17 [94.1%]; sensitivity and specificity of 57.1 and 96.3%, respectively). No development of a CNV trace within the recorded period accurately predicted a poor outcome (21/21 [100%]; sensitivity and specificity of 77.8 and 100%, respectively). CONCLUSIONS: An initial CNV trace in aEEG applied to forehead immediately after ROSC is a good early predictor of a good outcome in TH-treated cardiac arrest patients. Conversely, no development of a CNV trace within 72h is an accurate and reliable predictor of a poor outcome with a false-positive rate of 0%.
Resuscitation 09/2012; · 3.60 Impact Factor
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Medical Teacher 01/2012; 34(6):510. · 1.22 Impact Factor
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ABSTRACT: The early use of reperfusion therapy has a significant effect on the prognosis of patients with ST-segment elevation myocardial infarction (STEMI), and it is recommended that emergency department (ED) physicians activate the cardiac catheterization laboratory (CCL) as soon as possible to treat these patients. The aim of this study was to examine the appropriateness of emergency physician activation of the CCL for patients with suspected STEMI. Inappropriate activations (i.e., false positive activations) were identified according to a variety of criteria.
All patients with emergency physician CCL activations between August 2009 and April 2011 were included in the study. False positive cases were defined according to ECG criteria and cardiologists' reviews of patients' initial clinical information.
ED physicians used a STEMI page to activate the CCL 117 times. According to reviews by cardiologists, this activation was appropriate 89.8% of the time (in 105/117 cases). Truly unnecessary activation (i.e., cases in which STEMI was not identified by the cardiologists, no clear culprit coronary artery was present, no significant coronary artery disease and cardiac biomarkers were negative) occurred 5.1% of the time (in 6/117 cases).
CCL activation was appropriate for most patients and was unnecessary in a relatively small percentage of cases. This result supports the current recommendation for CCL activation by emergency physicians. Such early activation is a key strategy in the reduction of door-to-balloon time.
Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 09/2011; 19:50. · 1.85 Impact Factor
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ABSTRACT: The benefit of therapeutic hypothermia (TH) for comatose adult patients with return of spontaneous circulation after cardiac arrest (CA) with non-shockable initial rhythms is uncertain. We evaluated whether TH reduces mortality and improves neurological outcome in comatose adults resuscitated from non-shockable CA.
We searched PubMed, EMBASE, CENTRAL, and BIOSIS through March 2010, to identify studies using TH after non-shockable CA. Randomized and non-randomized studies (RS and NRS) comparing survival or neurological outcome in TH and standard care or normothermia were selected. We corresponded with authors to clarify data missing from published articles. Individual and pooled statistics were calculated as risk ratios (RRs) with 95% confidence interval (CI). Both fixed- and random-effects models were used for both meta-analyses.
Two RS and twelve NRS were included in the meta-analysis and separately analyzed. The pooled RR for 6-month mortality of two RS was 0.85 (95% CI 0.65-1.11). The pooled RR for in-hospital mortality for 10 NRS was 0.84 (95% CI 0.78-0.92) and for poor neurological outcome on discharge was 0.95 (95% CI 0.90-1.01) in random-effects model. In subgroup analysis for the NRS with out-of-hospital CA, the pooled RR for in-hospital mortality was 0.86 (95% CI 0.76-0.99) and for the poor neurological outcome on discharge was 0.96 (95% CI 0.90-1.02). For the prospective NRS, the pooled RR for in-hospital mortality was 0.76 (95% CI 0.65-0.89) and for the poor neurological outcome on discharge was 0.96 (95% CI 0.90-1.02). Most of studies had substantial risks of bias and overall quality of evidence was very low.
TH is associated with reduced in-hospital mortality for adults patients resuscitated from non-shockable CA. However, most of the studies had substantial risks of bias and quality of evidence was very low. Further high quality randomized clinical trials would confirm the actual benefit of TH in this population.
Resuscitation 08/2011; 83(2):188-96. · 3.60 Impact Factor
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ABSTRACT: The aim of the study was to compare the time taken for intubation (TTI) using the Macintosh and 2 video laryngoscopes (VLs) (GlideScope [GVL]; Saturn Biomedical System, Burnaby, British Columbia, Canada, and Airway Scope [AWS]; Pentax, Tokyo, Japan) with and without chest compressions by experienced intubators in a mannequin model.
This was a randomized crossover study. Twenty-two experienced physicians who have limited experience in the VLs participated in the study. The TTI using 3 laryngoscopes with and without compressions were compared.
Median TTI difference between 2 conditions was only significant in the AWS (1.64 seconds; P = .01). There were no significant differences in the TTI between the Macintosh and the GVL or the AWS during compressions.
In a mannequin model, the Macintosh or the GVL was not affected by chest compressions. The TTI using the AWS was delayed by compressions but not clinically significant. Considering the lack of experience, 2 VLs may be useful adjuncts for intubation by experienced intubators during chest compressions.
The American journal of emergency medicine 07/2011; 29(6):682-6. · 1.54 Impact Factor
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ABSTRACT: It is often difficult to diagnose acute myocardial infarction (AMI) in patients who resuscitated after out-of-hospital cardiac arrest (OHCA) and had a delayed elevation in cardiac marker. This study explored whether elevations in cardiac marker were due to coronary artery occlusion or resulted from other causes.
The study included 19 non-ST-segment elevation patients who resuscitated after OHCA and underwent delayed coronary angiography. We checked patients' serial creatine kinase-myocardial band (CK-MB) and troponin I (cTnI) levels on arrival and 6, 12, 24, 48, 72, and 96 hours postarrest. Based on the association of elevated cTnI and the results of their delayed angiographies, the patients were retrospectively divided into 2 groups: an AMI group (n=5) and a non-AMI group (n=14). We then analyzed the serial cardiac marker measurements in each group.
Peak marker levels were significantly higher in the AMI group than in the non-AMI group (CK-MB, 177.0±112.7 vs 66.4±85.2 ng/mL; P=.033 and cTnI, 40.4±14.5 vs 10.6±13.5 ng/mL; P=.005). After adjusting for covariates, the peak and 6-, 12-, and 24-hour cTnI and 6-hour CK-MB were significantly different between the 2 groups (P=.005, P=.004, P=.005, P=.020, and P=.007). In the non-AMI group, 3 patients had cTnI values that were within the reference range at all of the evaluated times. Most patients had only low cTnI elevations that rapidly fell back to normal.
The resuscitation of patients who experience sudden OHCA but do not have an AMI may lead to elevations of cardiac markers. However, these elevations are low and normalize early.
The American journal of emergency medicine 02/2011; 30(3):464-71. · 1.54 Impact Factor
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The American journal of emergency medicine 10/2010; · 1.54 Impact Factor
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ABSTRACT: To evaluate whether chest compressions affect the time taken for intubation (TTI) using the Macintosh laryngoscope and two portable video laryngoscopes (VLs) (GlideScope Ranger and Airway Scope) when used by novice prehospital caregivers, and to compare the TTIs and rates of successful intubation among the three laryngoscopes with and without chest compressions in a manikin model.
This was a pilot randomized crossover study. Twenty paramedic students and paramedics who had no clinical experience with tracheal intubation and had never used any of two VLs participated in the study. After a one-hour training session for the VLs, participants performed intubations on a Laerdal Resusci Anne Simulator placed on the floor. Each paramedic used all three laryngoscopes, with the order of usage being randomly assigned. The TTIs and rates of successful intubation among the three laryngoscopes, with and without ongoing chest compressions, were compared.
The difference between the TTIs using each laryngoscope with and without chest compressions was not significant (Macintosh: 2.99 sec, p = 0.06; GlideScope Ranger: 2.04 sec, p = 0.11; and Airway Scope: 0.91 sec, p = 0.10). The median TTI using the Airway Scope (15.46 sec) was significantly shorter than those for the Macintosh (24.14 sec) and the GlideScope Ranger (24.12 sec) during chest compressions (p = 0.028 and p = 0.004, respectively). There were no significant differences in the rates of successful intubation among the three laryngoscopes on each condition (without chest compressions, p = 0.15; with chest compressions, p = 0.27), but the cumulative success rates related to the TTI were significantly greater with the Airway Scope than with the other devices in both conditions.
In this pilot study, chest compressions did not significantly affect the TTI using the Macintosh laryngoscope and two portable VLs when used by novice prehospital caregivers in the manikin model on the floor. Considering the fairly short training time, two portable VLs may be potentially useful adjuncts for tracheal intubation during chest compressions for novice prehospital caregivers. Further studies are required to validate whether these findings are clinically relevant.
Prehospital Emergency Care 10/2010; 15(1):98-103. · 1.78 Impact Factor
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ABSTRACT: This study compared the Airway scope (AWS) to the Macintosh laryngoscope (ML) during chest compressions on a fresh cadaver.
This was a prospective crossover study. The participants who had experiences with AWS were excluded. The participants intubated with randomly assigned AWS or ML on a fresh cadaver during chest compressions. Primary outcome were as follows: time to intubation, ease of intubation (rated by using the visual analog scale [VAS]), and intubation success rate.
Twenty-five were enrolled. Median time of intubation was similar between the AWS and ML (AWS, 18.5 seconds vs ML, 18.3 seconds; P = .112). The median VAS of AWS and ML were 3.0 and 2.0, respectively (P = .023). There was no failure of intubation. However, participants replied that the AWS was more difficult to use than the ML.
Considering the lack of experience with the AWS, AWS could be an alternative intubation device during chest compressions after practices with AWS.
The American journal of emergency medicine 07/2010; 28(6):741-4. · 1.54 Impact Factor
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ABSTRACT: To investigate the use and success rates of the GlideScope (GVL) by emergency physicians (EPs) during the initial two years after its introduction.
We performed an observational study using registry data of five emergency departments. The success rates in adult patients were evaluated and compared with those of conventional laryngoscope (CL).
The GVL was used in 345 (10.7%) of 3233 intubation attempts by EPs. The overall success rate of the GVL was not higher than a CL (79.1% vs 77.6%, p=0.538). The success rate for the patients with difficult airway was higher in the GVL than a CL (80.0% vs 50.4%, p<0.001).
The GVL was not used frequently by EPs during the initial two years after its introduction. Although the GVL provides a better glottic view, the overall success rates were similar to a CL. The GVL may be useful in patients with difficult airway.
Emergency Medicine Journal 05/2010; 27(5):380-2. · 1.44 Impact Factor
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ABSTRACT: The Surviving Sepsis Campaign has recommended that antibiotic therapy should be started within the first hour of recognizing severe sepsis. Procalcitonin has recently been proposed as a biomarker of bacterial infection, although the quantitative procalcitonin assay is often time consuming, and it is not always available in many emergency departments (EDs). Our aim is to evaluate usefulness of the semiquantitative procalcitonin fast kit as a guideline for starting antibiotic administration for patients with severe sepsis or septic shock that requires prompt antibiotic therapy in the ED.
We include those patients who were admitted to the ED and who were suspected of having infection. The procalcitonin concentration was determined by semiquantitative PCT-Q strips, and the points of the severity scoring system were calculated. The receiver operating characteristic curve was used to assess the diagnostic value of the PCT-Q strips to predict severe sepsis or septic shock.
Of the 80 recruited patients, 33 patients were categorized as having severe sepsis or septic shock according to the definition. At a procalcitonin cutoff level of 2 ng/mL or greater, the sensitivity of the PCT-Q for detecting severe sepsis or septic shock was 93.94% and the specificity was 87.23. The receiver operating characteristic curve for PCT-Q to predict severe sepsis or septic shock had an area under the curve of 0.916.
PCT-Q is probably a fast, useful method for detecting severe sepsis in the ED, and it can be used as a guideline for antibiotic treatment.
The American journal of emergency medicine 10/2009; 27(7):859-63. · 1.54 Impact Factor
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Resuscitation 08/2009; 80(7):836. · 3.60 Impact Factor
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ABSTRACT: We report a case in which mild hypothermia was induced successfully using a cold intravenous fluid infusion in a 12-year-old boy who was comatose following 21 min of cardiac arrest caused by a lightning strike.
Resuscitation 10/2008; 79(2):336-8. · 3.60 Impact Factor
