Expert opinion on evidence after the 2020 Korean Cardiopulmonary Resuscitation Guidelines: a secondary publication.

Considerable evidence has been published since the 2020 Korean Cardiopulmonary Resuscitation Guidelines were reported. The International Liaison Committee on Resuscitation (ILCOR) also publishes the Consensus on CPR and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR) summary annually. This review provides expert opinions by reviewing the recent evidence on CPR and ILCOR treatment recommendations. The authors reviewed the CoSTR summary published by ILCOR in 2021 and 2022. PICO (patient, intervention, comparison, outcome) questions for each topic were reviewed using a systemic or scoping review methodology. Two experts were appointed for each question and reviewed the topic independently. Topics suggested by the reviewers for revision or additional description of the guidelines were discussed at a consensus conference. Forty-three questions were reviewed, including 15 on basic life support, seven on advanced life support, two on pediatric life support, 11 on neonatal life support, six on education and teams, one on first aid, and one related to COVID-19. Finally, the current Korean CPR Guideline was maintained for 28 questions, and expert opinions were suggested for 15 questions.

Role of point-of-care ultrasound in critical care and emergency medicine: update and future perspective.

Point-of-care ultrasound (POCUS) is a rapidly developing technology that has the potential to revolutionize emergency and critical care medicine. The use of POCUS can improve patient care by providing real-time clinical information. However, appropriate usage and proper training are crucial to ensure patient safety and reliability. This article discusses the various applications of POCUS in emergency and critical care medicine, the importance of training and education, and the future of POCUS in medicine.

The interaction effect of bystander cardiopulmonary resuscitation (CPR) and dispatcher CPR on outcomes after out-of-hospital cardiac arrest.

This study aimed to evaluate the effects of bystander cardiopulmonary resuscitation (CPR) and dispatcher-assisted CPR (DA-CPR) on outcomes after out-of-hospital cardiac arrest (OHCA). We conducted a prospective observational study using the Korean Cardiac Arrest Research Consortium registry database and enrolled adults aged > 20 years who sustained OHCA. The study population comprised 13,864 patients from October 1, 2015, to June 30, 2021. All enrolled patients were transported to the emergency room and resuscitated by the emergency medical personnel. Patients with terminal illnesses, pregnancy, "do not resuscitate" cards, and insufficient recorded information were excluded. Good neurologic outcomes were noted in 6.5%, 9.9%, and 9.6% of patients in the "no bystander", "standard bystander", and "compression-only bystander" CPR groups, respectively, and differed significantly (p < 0.001). Survival to discharge differed significantly (p < 0.001) between groups at 10.8%, 13.1%, and 13.2%, respectively. In a multivariable model, the interaction between "compression-only" and DA-CPR showed a positive effect on good neurological outcomes and survival to discharge with an odds ratio of 1.93 (Confidence interval, CI 1.28-2.91, p = 0.002) and 1.74 (CI 1.24-2.44, p = 0.001), respectively. In conclusion, the interaction between compression-only CPR and DA-CPR is significantly associated with good neurological and survival outcomes after OHCA. Education for bystanders and dispatchers should adhere to the current guidelines to improve outcomes among OHCA victims.

Association between hourly call volume in the emergency medical dispatch center and dispatcher-assisted cardiopulmonary resuscitation instruction time in out-of-hospital cardiac arrest.

OBJECTIVES: Cardiac arrest recognition, ambulance dispatch and dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) by emergency medical dispatch (EMD) are crucial for an optimal outcome of out-of-hospital cardiac arrest (OHCA). In EMD, crowding is caused by a mismatch between the number of emergency calls and the number of dispatchers available per shift. Crowding in the emergency department has been shown to decrease performance and outcomes; however, little is known about the effect of crowding in EMD. We aimed to evaluate the incidence of crowding in the EMD and the effect of emergency call crowding on dispatcher-assisted CPR instruction performance in OHCA calls. METHODS: We used a nationwide OHCA database from 2013 to 2016 consisting of patients with the presumed cardiac origin who were dispatched by Seoul EMD. The main exposure was an hourly number of total incoming emergency calls to EMD. The number of hourly calls was categorized into quartiles (≤40 calls, 41-51 calls, 52-61 calls and ≥62 calls). The primary outcome was successful DA-CPR instruction provision within 120 s. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were estimated to evaluate the association between EMD crowding and outcomes in the multivariable logistic regression model. RESULTS: Of a total of 12,722 patients, the proportion of successful DA instruction was highest in the least-crowded quartile and lowest in the most-crowded quartile (22.7% vs. 15.0%, p < 0.01). The adjusted odds ratio was 0.85 (95% CI 0.74-0.98) in the most-crowded EMD quartile, with a lower proportion of DA instruction within 120 s. Crowding in quartile 4 and quartile 3 was associated with a less favorable neurological outcome in the multivariable logistic regression model (AOR (95% CI) 0.78 (0.60-0.99) and 0.70 (0.54-0.91), respectively). CONCLUSION: Crowding in emergency medicine dispatch caused by increased hourly call volume was associated with delayed dispatcher-assisted CPR instruction provision. Medical directors might consider a strategic approach to addressing crowding in EMD according to the crowding distribution.

Application of point-of-care ultrasound for different types of esophageal foreign bodies: three case reports: A CARE-compliant article.

RATIONALE: Esophageal point-of-care ultrasound (POCUS) has recently been reported as a useful, quick, safe, and simple technique to detect esophageal foreign bodies (FBs). However, case series to detect esophageal FB using POCUS have been rarely reported. Chicken bones and pills, especially, have not yet been reported as esophageal FBs. The objective of this case series was to describe the POCUS findings of 3 different materials-food, pill, and chicken bone. PATIENT CONCERNS: Case 1, a 75-year-old woman with odynophagia and neck pain occurring 30 min after eating chicken porridge; Case 2, a 32-year-old woman with neck discomfort occurring 2 h after taking a pill; Case 3, a 29-year-old woman reporting FB sensation in the neck that occurred 1 h after eating sausage and rice soup. DIAGNOSIS: Case 1. Cervical esophageal FB (chicken bone), Case 2. Cervical esophageal FB (oral pill), Case 3. Cervical esophageal FB (food). INTERVENTIONS: Case 1. POCUS, urgent esophagogastroduodenoscopy (EGD) with alligator forceps. POCUS findings; hyperechoic material (suspected FB) that did not disappear by swallowing and esophageal dilatation with pooling of secretions. Case 2. POCUS. POCUS findings; hypoechoic material (suspected FB) that did not disappear by swallowing, and esophageal bulging above the FB, especially observed in the longitudinal view. Case 3. POCUS. POCUS findings; hyperechoic material (suspected FB) with reverberation artifact that did not disappear with swallowing efforts. Prior FB esophageal bulging with persistent air-fluid level was especially observed in the longitudinal view. OUTCOMES: Case 1. FB was removed by EGD with alligator forceps. Case 2. Symptoms disappeared under observation without EGD. Follow-up POCUS revealed normalized bulging esophagus. Case 3. These symptoms improved after vomiting a large piece of food material. Three patients were discharged without complications. LESSONS: In this case series, the impacted materials were chicken bone, pill, and food. However, POCUS findings were similar (esophageal dilation, hyperechoic or hypoechoic lesion with mixed echogenic contents in food or secretion, and no change with swallowing efforts). A longitudinal view was useful to assume the presence of cervical esophageal FB in all three cases. Thus, POCUS findings could be indirect signs of a FB in the esophagus.

Neurological outcomes after an out-of-hospital cardiac arrest among people living in high-rise buildings in South Korea.

OBJECTIVE: Living in high-rise buildings may cause delays in reaching a hospital after an out-of-hospital cardiac arrest. This study aimed to compare neurological outcomes in people who had had an out-of-hospital cardiac arrest, according to their floor of residence. METHODS: We conducted a retrospective study of 1541 patients aged ≥20 years who had out-of-hospital cardiac arrest between 1 October 2015 and 30 June 2018, using data from a central registry. We compared the outcomes of patients living on the first (ground) or second floor and those living on the third floor or above, using multiple logistic regression. RESULTS: Those living on higher floors were more likely to have been at home (88.1% vs. 58.0%); to have had bystander cardiopulmonary resuscitation (57.9% vs. 45.2%); and experienced a significantly longer emergency medical service response time [median interquartile range (IQR): 7 min (6-10 min) vs. 7 min (5-9 min), P = 0.001] and on-scene time [median (IQR): 16 min (11-23 min) vs. 12 min (8-19 min), P < 0.001]. The strongest predictors of a good neurological outcome were younger age [odds ratio (OR): 0.96, 95% confidence interval (CI): 0.94-0.97], being on a lower floor at the time of the cardiac arrest (OR: 1.82, 95% CI: 1.09-3.12) and having a shockable rhythm (OR: 21.97, 95% CI: 12.81-39.47). CONCLUSION: People living on higher floors have poorer outcomes after an out-of-hospital cardiac arrest. Further studies are required to assess factors causing a delay in the emergency medical service response time, and placement of automated external defibrillators in high-rise buildings.

Interrater reliability of emergency physician-performed ultrasonography for diagnosing femoral, popliteal, and great saphenous vein thromboses compared to the criterion standard study by radiology.

PURPOSE: To assess the interrater reliability and test characteristics of lower limb sonographic examination for the diagnosis of deep venous and proximal great saphenous vein thrombosis when performed by Emergency Physicians (EPs) as compared to that by the Department of Radiology (Radiology). The secondary objective was to assess the effects of patient body mass index and EP satisfaction with bedside ultrasound on sensitivity and specificity. METHODS: A prospective study was conducted for patients with clinical suspicion for lower extremity thrombus. EPs evaluated for venous thrombosis in the common femoral vein, femoral vein of the thigh, popliteal vein, and proximal great saphenous vein. Subsequently, all patients received ultrasounds by Radiology, the criterion standard. RESULTS: One hundred ninety-seven patients (257 individual legs) were evaluated. There was 90-95% agreement between EP and Radiology, moderate kappa agreement for common femoral vein, and femoral vein of the thigh and fair kappa agreement for great saphenous vein and popliteal vein. The sensitivity and specificity of EP ultrasounds compared with criterion standard were lower than previously reported. There was no trend in patient body mass index or provider satisfaction influencing the test characteristics. CONCLUSIONS: Our study suggests that point-of-care sonography should not replace Radiology-performed scans. The required amount of training for EPs to be competent in this examination needs further investigation. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:360-367, 2016.

Sonographic finding of a pulled elbow: the "hook sign".

Point-of-care ultrasound has become a useful clinical adjunct, especially in emergency medicine, because it is noninvasive, repeatable, and nonradiating. In cases of pulled elbow also known as nursemaid's elbow or radial head subluxation, diagnosis is usually performed clinically. However, there is the potential for a failed reduction or misdiagnosis. We introduce a potentially useful diagnostic finding for pulled elbow ("Hook sign") using point-of-care ultrasound in the emergency department.

Na+/HCO3- cotransporter immunoreactivity changes in neurons and expresses in astrocytes in the gerbil hippocampal CA1 region after ischemia/reperfusion.

The maintenance of intracellular pH is important in neuronal function. Na(+)/HCO(3)(-) cotransporter (NBC), a bicarbonate-dependent acid-base transport protein, may contribute to cellular acid-base homeostasis in pathophysiological processes. We examined the alterations of NBC immunoreactivity and its protein levels in the hippocampal CA1 region after transient cerebral ischemia in gerbils. In the sham-operated group, moderate NBC immunoreactivity was detected in CA1 pyramidal neurons, and, 12 h after I/R, the immunoreactivity in the pyramidal neurons was markedly increased over controls. Three days after I/R, NBC immunoreactivity nearly disappeared in the CA1 pyramidal neurons. However, NBC immunoreactivity was detected in the non-pyramidal neurons of the ischemic CA1 region at 3 days after I/R. From double immunofluorescence study with glial markers, NBC immunoreactivity was detected in astrocytes, not in microglia, at 4 days after I/R. NBC protein level in the CA1 region was significantly increased at 12 h post-ischemia and significantly decreased at 2 days post-ischemia. Thereafter, NBC protein level was again increased and returned to the level of the sham-operated group at 4 days post-ischemia. On the other hand, treatment with 4,4'-diisothiocyanatostilbene-2,2'-disulfonate (DIDS), an inorganic anion exchanger blocker including Cl-bicarbonate exchanger, protected CA1 pyramidal neurons from I/R injury at 4 days post-ischemia. These results indicate that changes in NBC expressions may play an important role in neuronal damage and astrocytosis induced by transient cerebral ischemia.

Ischemia-induced changes in glucagon-like peptide-1 receptor and neuroprotective effect of its agonist, exendin-4, in experimental transient cerebral ischemia.

Glucagon-like peptide-1 receptor (GLP-1R) protects against neuronal damages in the brain. In the present study, ischemia-induced changes in GLP-1R immunoreactivity in the gerbil hippocampal CA1 region were evaluated after transient cerebral ischemia; in addition, the neuroprotective effect of the GLP-1R agonist exendin-4 (EX-4) against ischemic damage was studied. GLP-1R immunoreactivity and its protein levels in the ischemic CA1 region were highest at 1 day after ischemia/reperfusion (I/R). At 4 days after I/R, GLP-1R immunoreactivity was hardly detected in CA1 pyramidal neurons, and its protein level was lowest. GLP-1R protein level was increased again at 10 days after I/R, and GLP-1R immunoreactivity was found in astrocytes and GABAergic interneurons. In addition, EX-4 treatment attenuated ischemia-induced hyperactivity, neuronal damage, and microglial activation in the ischemic CA1 region in a dose-dependent manner. EX-4 treatment also induced the elevation of GLP-1R immunoreactivity and protein levels in the ischemic CA1 region. These results indicate that GLP-1R is altered in the ischemic region after an ischemic insult and that EX-4 protects against ischemia-induced neuronal death possibly by increasing GLP-1R expression and attenuating microglial activation against transient cerebral ischemic damage.

Changes in corticosteroid hormone receptors in the ischemic gerbil hippocampal CA1 region following repeated restraint stress.

Restraint stress produces physiological changes including suppression of long-term potentiation in the brain. We observed the effects of repeated stress on ischemic damage associated with corticosteroid hormone receptors in gerbils. Animals were placed into restrainers for 5 h (between 09:30 h and 14:30 h) for 21 consecutive days prior to induction of transient cerebral ischemia. The animals were divided into 4 groups; (1) sham-operated-control-group (sham-group), (2) ischemia-operated-control-group (ischemia-group), (3) sham-operated-stress-group (stressed-sham-group), and (4) ischemia-operated-stress-group (stressed-ischemia-group). We found that serum corticosterone level in the ischemia-group was highest (374% of the sham-group) 12 h after ischemia/reperfusion and its level in the stressed-ischemia-group was significantly lower than the ischemia-group. Locomotor activity in the ischemia-group was significantly increased (295% of the sham-group) at 1 day post-ischemia; however, the locomotor activity in the stressed-ischemia-group was less increased compared to the ischemia-group. Cresyl violet positive (CV(+)) cells were significantly decreased in the stratum pyramidale (SP) of the hippocampal CA1 region (CA1) of the 4 days post-ischemia-group, while 79.4% of CV(+) cells were detected in the CA1 of the stressed-ischemia-group. Also, a few NeuN (neuron-specific soluble nuclear antigen)(+) cells were detected in the SP of the 4 days post-ischemia-group; however, in the 4 days stressed-post-ischemia-group, 77.2% of NeuN(+) neurons were found in the SP. Glial fibrillary acidic protein(+) astrocytes in the CA1 in the stressed-ischemia-groups were similar to those in the ischemia-groups; however, ionized calcium-binding adapter molecule 1(+) microglia in the stressed-ischemia-groups were less activated compared to the ischemia-groups. Mineralocorticoid receptor (MCR) and glucocorticoid receptor (GR) immunoreactivity in the SP of the stressed-ischemia-group were higher than the ischemia-group; at 4 days post-ischemia, MCR and GR immunoreactivity were expressed in non-pyramidal cells. In brief, our results indicate that repeated restraint stress significantly increase levels of corticosteroid hormone receptors and attenuates neuronal damage in the ischemic hippocampal CA1 region.

Long-term changes in neuronal degeneration and microglial activation in the hippocampal CA1 region after experimental transient cerebral ischemic damage.

Delayed neuronal death following transient cerebral ischemia is mixed with apoptosis and necrosis, and the activation of microglia are activated after the ischemic insult. In the present study, we examined the long-term changes in neuronal degeneration and microglial activation in the gerbil hippocampal CA1 region after 5min of transient cerebral ischemia using specific markers for neuronal damage and microliosis. Transient ischemia-induced neuronal death was shown in CA1 pyramidal cells 4days after ischemia/reperfusion (I/R). However, neuronal degeneration of the pyramidal cells were observed up to 45days in the CA1 region after I/R. Microglial activation was also observed in the CA1 region after I/R. Isolectin B4- (IB4) immunoreactive ((+)) microglia appeared in the CA1 region 4days after I/R. On the other hand, ionized calcium-binding adapter molecule 1 (Iba-1)(+) microglia was markedly increased after I/R, and peaked at 15days after I/R. Thereafter, Iba-1 immunoreactivity was decreased with time-dependant manner in the ischemic CA1 region. These results indicate that neuronal degeneration of CA1 pyramidal cells may last about 45days in the CA1 region after ischemic damage, and microglial activation may be diverse according to their function, such as phagocytosis, after I/R.

Rosiglitazone, an agonist of peroxisome proliferator-activated receptor gamma, decreases immunoreactivity of markers for cell proliferation and neuronal differentiation in the mouse hippocampus.

In the present study, we investigated the regulating effects of rosiglitazone (RSG), a synthetic agonist of peroxisome proliferator-activated receptor gamma, treatment for 28days on the cell proliferation and neuronal differentiation in the mouse hippocampal dentate gyrus by 5-bromo-2'-deoxyuridine (BrdU), Ki67 and doublecortin (DCX) immunohistochemistry. These markers were detected in the subgranular zone (SGZ) of the dentate gyrus in vehicle- and RSG-treated groups. In the RSG-treated group, the number of BrdU-, Ki67- and DCX-immunoreactive cells was significantly decreased compared to those in the vehicle-treated group. In addition, brain-derived neurotrophic factor and glial cell line-derived neurotrophic factor levels were significantly decreased in the dentate gyrus of the RSG-treated groups compared to the vehicle-treated group. These results indicate that RSG treatment decreases immunoreactivities of markers for cell proliferation and neuronal differentiation and levels of neurotrophic factors in the SGZ of the hippocampal dentate gyrus.