Patients With Refractory Out-of-Cardiac Arrest and Sustained Ventricular Fibrillation as Candidates for Extracorporeal Cardiopulmonary Resuscitation　- Prospective Multi-Center Observational Study.

BACKGROUND: We investigated whether patients with out-of-hospital cardiac arrest (OHCA) and sustained ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) or conversion to pulseless electrical activity/asystole (PEA/asystole) benefit more from extracorporeal cardiopulmonary resuscitation (ECPR). Methods and Results: We analyzed data from the Study of Advanced Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan, which was a prospective, multicenter, observational study with 22 institutions in the ECPR group and 17 institutions in the conventional CPR (CCPR) group. Patients were divided into 4 groups by cardiac rhythm and CPR group. The primary endpoint was favorable neurological outcome, defined as Cerebral Performance Category 1 or 2 at 6 months. A total of 407 patients had refractory OHCA with VF/pVT on initial electrocardiogram. The proportion of ECPR patients with favorable neurological outcome was significantly higher in the sustained VF/pVT group than in the conversion to PEA/asystole group (20%, 25/126 vs. 3%, 4/122, P<0.001). Stratifying by cardiac rhythm, on multivariable mixed logistic regression analysis an ECPR strategy significantly increased the proportion of patients with favorable neurological outcome at 6 months in the patients with sustained VF/pVT (OR, 7.35; 95% CI: 1.58-34.09), but these associations were not observed in patients with conversion to PEA/asystole. CONCLUSIONS: OHCA patients with sustained VF/pVT may be the most promising ECPR candidates (UMIN000001403).

Perineal laceration treated with negative pressure wound therapy following colostomy.

A male in his early 30s was transported to the emergency room after being hit by a vehicle while inebriated and lying in the street. His general condition was stable; however, he had a perineal laceration that extended to the coccyx. Due to the proximity of the wound margin to the anus, we were concerned regarding the potential contamination and opted not to suture it. Therefore, we refrained from suturing the wound and kept the wound open after irrigation and debridement. Additionally, we performed a transverse colostomy. On day 4, we initiated negative pressure wound therapy for 40 days, during which sufficient wound granulation occurred. The patient was discharged, and the colostomy was closed approximately 4 months after the injury. Our case illustrates the effectiveness of negative pressure wound therapy in managing perineal lacerations.

Effective use of fibrinogen concentrate in a pediatric splenic injury requiring transcatheter arterial embolization.

Correction of coagulation is a crucial aspect of trauma care. While there are reports highlighting the effectiveness of fibrinogen concentrate in severe trauma cases with coagulopathic complications, literature on its use in pediatric cases remains limited. This paper discusses the case of a 5-year-old male presenting with a splenic injury and associated coagulopathy. We administered fibrinogen concentrate to enhance his coagulability prior to performing transcatheter arterial embolization utilizing gelatin sponges, aiming for optimal hemostasis. Post-administration, the patient's fibrinogen levels improved significantly, leading to successful hemostasis and a positive clinical outcome.

Non-1st seizure was less severe than 1st seizure with non-urgent level among suspected seizures transferred by ambulance.

BACKGROUND: To prioritize emergency medical calls for ambulance transport for patients with suspected seizures, information about whether the event is their 1st or non-1st seizure is important. However, little is known about the difference between 1st and non-1st seizures in terms of severity. We hypothesized that patients transferred multiple times (≥2 times) would represent a milder scenario than patients on their first transfer. The purpose of this study was to compare patients with suspected seizures on 1st transfer by ambulance and patients who had been transferred ≥2 times. METHODS: We statistically compared severity of suspected seizures between two groups of patients with suspected seizures transferred between December 2014 and November 2019 (before the coronavirus disease 2019 pandemic) to our facility by ambulance for either the first time (1st Group) or at least the second time (Non-1st Group). Severity categories were defined as: Level 1 = life-threatening; Level 2 = emergent, needing admission to the intensive care unit; Level 3 = urgent, needing admission to a hospital general ward; Level 4 = less urgent, needing intervention but not hospitalization; and Level 5 = non-urgent, not needing intervention. RESULTS: Among 5996 patients with suspected seizures conveyed to the emergency department by ambulance a total of 14,263 times during the study period, 1222 times (8.6%) and 636 patients (11%) met the criteria. Severity grade of suspected seizures ranged from 1 to 5 (median, 4; interquartile range, 3-4) for the 1st Group and from 1 to 5 (median, 5; interquartile range, 4-5) for the Non-1st Group. Most severe grade ranged from 1 to 5 (median, 4; interquartile range, 4-5) for the Non-1st Group. Severity grade differed significantly between groups (p < 0.001, Mann-Whitney U-test). Uni- and multivariate logistic regression tests also suggested a significant difference (p < 0.001) in severity grades. CONCLUSION: In direct comparisons, grade of suspected seizure severity was lower in the Non-1st Group than in the 1st Group.

Long-term prognostic significance of gasping in out-of-hospital cardiac arrest patients undergoing extracorporeal cardiopulmonary resuscitation: a post hoc analysis of a multi-center prospective cohort study.

BACKGROUND: Gasping during resuscitation has been reported as a favorable factor for out-of-hospital cardiac arrest. We examined whether gasping during resuscitation is independently associated with favorable neurological outcomes in patients with refractory ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) undergoing extracorporeal cardiopulmonary resuscitation ECPR. METHODS: Data from a 2014 study on advanced cardiac life support for ventricular fibrillation with extracorporeal circulation in Japan (SAVE-J), which examined the efficacy of ECPR for refractory VF/pVT, were analyzed. The primary endpoint was survival with a 6-month favorable neurological outcome in patients who underwent ECPR with or without gasping during resuscitation. Multivariate logistic regression analysis was performed to evaluate the association between gasping and outcomes. RESULTS: Of the 454 patients included in the SAVE-J study, data from 212 patients were analyzed in this study after excluding those with missing information and those who did not undergo ECPR. Gasping has been observed in 47 patients during resuscitation; 11 (23.4%) had a favorable neurological outcome at 6 months. Multivariate logistic regression analysis showed that gasping during resuscitation was independently associated with a favorable neurological outcome (odds ratio [OR], 10.58 [95% confidence interval (CI) 3.22-34.74]). The adjusted OR for gasping during emergency medical service transport and on arrival at the hospital was 27.44 (95% CI 5.65-133.41). CONCLUSIONS: Gasping during resuscitation is a favorable factor in patients with refractory VF/pVT. Patients with refractory VF/pVT with continuously preserved gasping during EMS transportation to the hospital are expected to have more favorable outcomes.

Acute aortic dissection with highly compressed true lumen: unanticipated pitfall of point-of-care ultrasonography.

A 46-year-old man presented with sudden onset of chest pain. He was in cardiogenic shock at arrival. Based on the results of ECG and echocardiogram, he was diagnosed with ST-segment elevation myocardial infarction. Point-of-care ultrasonography (POCUS) did not reveal acute aortic dissection (AAD). During an emergency coronary angiography, aortic dissection was detected and computed tomographic angiography (CTA) revealed Stanford type A AAD with a highly compressed true lumen. Because of this form of aortic dissection, the enlarged false lumen could be potentially misidentified as a normal aorta in POCUS. Although POCUS is useful when AAD is suspected, we should not overestimate its findings and lower the threshold for CTA.

Cluster Randomized Trial of Duration of Cooling in Targeted Temperature Management After Resuscitation for Cardiac Arrest.

Background: The 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care recommend that comatose patients with return of spontaneous circulation after cardiac arrest have targeted temperature management (TTM). However, the duration of TTM remains to be elucidated. Methods and Results: We conducted a cluster randomized trial in 10 hospitals to compare 12-24 vs. 36 h of cooling in patients with cardiac arrest who received TTM. The primary outcome was the incidence, within 1 month, of complications including bleeding requiring transfusion, infection, arrhythmias, decreasing blood pressure, shivering, convulsions, and major adverse cardiovascular events. Secondary outcomes were mortality and favorable neurological outcome (Cerebral Performance Categories 1-2) at 3 months. Random-effects models with clustered effects were used to calculate risk ratios (RR). Data of 185 patients were analyzed (12- to 24-h group, n=100 in 5 hospitals; 36-h group, n=85 in 5 hospitals). The incidence of complications within 1 month did not differ between the 2 groups (40% vs. 34%; RR 1.04, 95% confidence interval [CI] 0.67-1.61, P=0.860). Favorable neurological outcomes at 3 months were comparable between the 2 groups (64% vs. 62%; RR 0.91, 95% CI 0.72-1.14, P=0.387). Conclusions: TTM at 34℃ for 12-24 h did not significantly reduce the incidence of complications. This study did not show superiority of TTM at 34℃ for 12-24 h for neurologic outcomes.

Validation of extravascular lung water measurement by single transpulmonary thermodilution: human autopsy study.

INTRODUCTION: Gravimetric validation of single-indicator extravascular lung water (EVLW) and normal EVLW values has not been well studied in humans thus far. The aims of this study were (1) to validate the accuracy of EVLW measurement by single transpulmonary thermodilution with postmortem lung weight measurement in humans and (2) to define the statistically normal EVLW values. METHODS: We evaluated the correlation between pre-mortem EVLW value by single transpulmonary thermodilution and post-mortem lung weight from 30 consecutive autopsies completed within 48 hours following the final thermodilution measurement. A linear regression equation for the correlation was calculated. In order to clarify the normal lung weight value by statistical analysis, we conducted a literature search and obtained the normal reference ranges for post-mortem lung weight. These values were substituted into the equation for the correlation between EVLW and lung weight to estimate the normal EVLW values. RESULTS: EVLW determined using transpulmonary single thermodilution correlated closely with post-mortem lung weight (r = 0.904, P < 0.001). A linear regression equation was calculated: EVLW (mL) = 0.56 × lung weight (g) - 58.0. The normal EVLW values indexed by predicted body weight were approximately 7.4 ± 3.3 mL/kg (7.5 ± 3.3 mL/kg for males and 7.3 ± 3.3 mL/kg for females). CONCLUSIONS: A definite correlation exists between EVLW measured by the single-indicator transpulmonary thermodilution technique and post-mortem lung weight in humans. The normal EVLW value is approximately 7.4 ± 3.3 mL/kg. TRIAL REGISTRATION: UMIN000002780.

Incentive spirometry to prevent pulmonary complications after chest trauma: a retrospective observational study.

AIM: Pulmonary complications (PCs) are a major cause of poor prognosis in chest trauma. Evidence on the effectiveness of incentive spirometry (IS) in trauma is scarce. This study investigated the effectiveness of IS in preventing PCs in patients with chest trauma with rib fractures. METHODS: This retrospective observational study analyzed the data obtained from the electronic medical records of patients with chest trauma with rib fractures admitted between 2011 and 2019. We included patients 18 years of age or older with risk of worsening respiratory failure. Early IS was the primary exposure and PCs (pulmonary infection or respiratory failure requiring escalating oxygen therapy) were the primary outcomes. Secondary outcomes were length of hospital stay, duration of oxygenation therapy, and adverse events of IS. Logistic regression analysis with a propensity score was used. RESULTS: We extracted 514 patients from the electronic medical records; 299 patients were included. The early IS group had a higher proportion of hypoxemia at admission, opioid analgesia use, invasive positive pressure ventilation, and respiratory physiotherapy. The severity of trauma was higher in the early IS group. There was no significant difference in the occurrence of the PCs between groups (adjusted odds ratio 0.71; 95% confidence interval, 0.24-2.16). No statistical differences were seen in the secondary outcomes. CONCLUSION: For patients with chest trauma with rib fractures at risk of worsening respiratory failure, IS early after injury did not reduce the rate of PCs. No adverse event of IS was observed and IS was shown to be safe.

Cost-effectiveness of extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: A multi-centre prospective cohort study.

AIM: Extracorporeal cardiopulmonary resuscitation (ECPR) is an evolving resuscitative method for refractory cardiopulmonary arrests. However, considering the substantial healthcare costs and resources involved, there is an urgent need for a full economic evaluation. We therefore assessed the cost-effectiveness of ECPR for refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). METHODS: We developed a decision model to estimate lifetime costs and outcomes for out-of-hospital cardiac arrest patients with VF/pVT who received either ECPR or conventional cardiopulmonary resuscitation. Quality-adjusted life-years (QALY) was used as the main outcome measure. This model was a combination of a decision tree model for the acute phase based on a prospective observational study (SAVE-J study), together with a Markov model for long-term follow-up periods extrapolated from published data. To evaluate the robustness of this model, we conducted a comprehensive deterministic sensitivity analysis (DSA) and a probabilistic sensitivity analysis (PSA). RESULTS: ECPR was cost-effective, with an incremental cost of ¥3,521,189 (Є30,227), an incremental effectiveness of 1.34 QALY, and an incremental cost-effectiveness ratio of ¥2,619,692 (Є22,489) per QALY gained. DSA revealed that the present model was most sensitive to probability of Cerebral Performance Category 1 after ECPR (¥2,153,977/QALY to ¥3,186,475/QALY), patient age (¥2,170,112/QALY to ¥3,334,252/QALY), and long-term medical cost for modified Rankin Scale 0 (¥2,280,352/QALY to ¥2,855,330/QALY). PSA indicated ECPR to be cost-effective and below the willingness-to-pay threshold of ¥5,000,000 with an 86.7 % possibility. CONCLUSIONS: ECPR was an economically acceptable resuscitative strategy, and the results of the present study were robust even when considering the uncertainty of all parameters.

The profile of Japanese Association for Acute Medicine - out-of-hospital cardiac arrest registry in 2014-2015.

AIM: To describe the registry design of the Japanese Association for Acute Medicine - out-of-hospital cardiac arrest (JAAM-OHCA) Registry as well as its profile on hospital information, patient and emergency medical service characteristics, and in-hospital procedures and outcomes among patients with OHCA who were transported to the participating institutions. METHODS: The special committee aiming to improve the survival after OHCA by providing evidence-based therapeutic strategies and emergency medical systems from the JAAM has launched a multicenter, prospective registry that enrolled OHCA patients who were transported to critical care medical centers or hospitals with an emergency care department. The primary outcome was a favorable neurological status 1 month after OHCA. RESULTS: Between June 2014 and December 2015, a total of 12,024 eligible patients with OHCA were registered in 73 participating institutions. The mean age of the patients was 69.2 years, and 61.0% of them were male. The first documented shockable rhythm on arrival of emergency medical services was 9.0%. After hospital arrival, 9.4% underwent defibrillation, 68.9% tracheal intubation, 3.7% extracorporeal cardiopulmonary resuscitation, 3.0% intra-aortic balloon pumping, 6.4% coronary angiography, 3.0% percutaneous coronary intervention, 6.4% targeted temperature management, and 81.1% adrenaline administration. The proportion of cerebral performance category 1 or 2 at 1 month after OHCA was 3.9% among adult patients and 5.5% among pediatric patients. CONCLUSIONS: The special committee of the JAAM launched the JAAM-OHCA Registry in June 2014 and continuously gathers data on OHCA patients. This registry can provide valuable information to establish appropriate therapeutic strategies for OHCA patients in the near future.

Significance of magnetic resonance imaging in the diagnosis of vertebral artery injury associated with blunt cervical spine trauma.

Vertebral artery injury associated with non-penetrating cervical trauma is rare. We report 11 cases of vertebral artery injury diagnosed with magnetic resonance imaging (MRI) after blunt trauma to the cervical spine and discuss about the importance of MRI in the diagnosis of this injury. Seven cases were caused by motor vehicle accidents, three by diving accidents, and one by static compression of the neck. All of the patients had documented cervical spine fractures and dislocations. In three patients, the diagnosis of complete occlusion of the vertebral artery was made on the basis of MRI and digital subtraction angiography (DSA). In the other patients, mural injuries of the vertebral artery were demonstrated with DSA. These 11 patients presented with acute, nonspecific changes in neurological status. Two had infarctions of the cerebellum and brainstem. None were treated with anticoagulants. All of them survived and were discharged to other hospitals for physical and occupational therapy. Although DSA remains the gold standard for diagnosing vertebral artery injuries, MRI is a newer modality for assessing cervical cord injury, and it may be useful for evaluating the presence of vertebral injury after blunt cervical spine trauma.

Cerebral endothelial injury in elderly patients with severe head injury measured by serum thrombomodulin and von Willebrand factor.

Elevated serum levels of thrombomodulin (TM) and von Willebrand factor (vWf) are good indicators of injury and activation of cerebral endothelium in patients with severe simple head injury. The present study evaluated cerebral endothelial injury or activation as the serum levels of TM and vWf in elderly and younger patients with similar brain trauma, to evaluate the primary parenchymal injury of the brain. Patients with head injury were classified into the young group (16-30 years), the middle-aged group (31-65 years), and the elderly group (over 66 years). There was no difference in Glasgow Coma Scale on admission between the three groups. The serum levels of TM and vWf at 2 hours after injury were significantly higher in the elderly group than in the other groups. However, the serum levels of TM and vWf were not significantly different at 3 and 7 days after injury. Cerebral endothelial activation and injury were significantly higher in elderly patients just after head injury than in younger patients, which suggests that greater sensitivity to endothelial injury and activation may be important in the worse outcome after head injury in elderly patients compared with younger patients.

[Case of carbon monoxide poisoning with the lesions demonstrated as abnormal intensity in the basal part of the left temporal lobe by MR image in acute phase].

A 46-year-old male patient was found unconscious in his room. There were remnants of burned-out charcoal briquettes. On arrival to our ER, the concentration of carbon monoxide (CO) hemoglobin was detected in 16.2%, and he was diagnosed with CO poisoning based on both his circumstantial evidence and laboratory results. Brain CT obtained on Day 1 revealed low density area in the basal part of the left temporal lobe, and T2-weighted MR images of the brain on Day 8 showed hyperintensity in the same region. MR images on Day 15 showed findings caused by white matter encephalopathy, and signal intensity in the left temporal lobe was decreased. To our best knowledge, it is very rare to see abnormal signal changes in the temporal lobe on radiological imaging of the patients who is suspected CO poisoning in acute phase because it has been reported that white matter encephalopathy after CO poisoning is commonly seen in delayed timing.

Concomitant fat embolism syndrome and pulmonary embolism in a patient with a femoral shaft fracture.

Case: A 22-year-old man was injured in a traffic accident and developed respiratory distress on his first day of admission. On postadmission day 3, he developed serious respiratory distress with a suddenly altered mental status. Chest computed tomography revealed a pulmonary embolism that had not been evident when he was admitted. The patient was intubated and a continuous heparin infusion was started to treat the pulmonary embolism. Palpebral conjunctival petechiae were noticed the following day, at which point the patient fulfilled Gurd's criteria for fat embolism syndrome. Within a few days, his respiratory status was improved. Brain magnetic resonance imaging also provided evidence of fat embolism syndrome. His femoral shaft fracture was repaired on day 20. Outcome: The patient was discharged home on postadmission day 63. Conclusion: Concomitant fat embolism syndrome and pulmonary embolism, although very rare, should be considered when a trauma patient's respiratory status worsens.

Refractory paroxysmal sympathetic hyperactivity following brain injury in a pregnant woman that dramatically improved after delivery.

Case: A 16-year-old primiparous girl in the 11th week of gestation presented to our hospital with a traumatic brain injury suffered during a motorcycle accident. She was comatose on arrival to the hospital and was admitted to the intensive care unit. From day 2, she developed intermittent episodes of tachycardia with tachypnea, fever, profuse sweating, and extensor posturing. She was diagnosed with paroxysmal sympathetic hyperactivity (PSH) and treated with morphine. However, paroxysmal sympathetic hyperactivity could not be controlled and her general condition deteriorated. Intrauterine fetal death was confirmed in the 16th week of gestation, on day 37 of hospitalization. P paroxysmal sympathetic hyperactivity increased each day until delivery and dramatically improved after delivery. Outcome: The patient gradually regained consciousness and was discharged to a rehabilitation hospital on day 117 after hospitalization. Conclusion: Pregnancy is a risk factor for paroxysmal sympathetic hyperactivity exacerbation, and delivery can result in resolution of the condition.

Reduction in gastrointestinal bleeding by development and implementation of a protocol for stress ulcer prophylaxis: a before-after study.

BACKGROUND: The implementation of a protocol has been associated with improvements in the processes of care in clinical settings. Although stress ulcer prophylaxis is recommended for critically ill patients at high risk, there is currently no consensus on its use. Therefore, we herein developed a protocol for stress ulcer prophylaxis, and evaluated therapeutic outcomes in a before-after study. METHODS: The protocol was developed by considering the effectiveness, disadvantages (including adverse events) and cost of each agent based on previous findings. Patients who were admitted to the 8-bed emergency intensive care unit (ICU) of our hospital for more than 24 h during the year before and after implementation of the study were eligible. Each investigation item was evaluated retrospectively. RESULTS: There were 211 and 238 study patients before and after implementation of the protocol, respectively. The baseline characteristics of patients on/during ICU admission were similar in the two groups. The proportion of medicated patients was 79.6 % before and 84.5 % after protocol implementation. Before implementation of the protocol, 4.3 % of patients developed clinically important gastrointestinal bleeding, and this incidence decreased significantly to 0.8 % after its implementation (P = 0.019). The frequency at which medication was discontinued due to adverse events was slightly lower after implementation of the protocol. No significant differences were observed in the costs of stress ulcer prophylactic agents or mortality in the ICU. CONCLUSIONS: The results of the present study indicated that the development and implementation of a protocol for stress ulcer prophylaxis, for which there are currently no criteria, improved a main outcome, clinically important gastrointestinal bleeding.