Cardiopulmonary Resuscitation Without Aortic Valve Compression Increases the Chances of Return of Spontaneous Circulation in Out-of-Hospital Cardiac Arrest: A Prospective Observational Cohort Study.

OBJECTIVES: Following current cardiopulmonary resuscitation (CPR) guidelines, which recommend chest compressions at "the center of the chest," ~50% of patients experiencing out-of-hospital cardiac arrest (OHCA) undergo aortic valve (AV) compression, obstructing blood flow. We used resuscitative transesophageal echocardiography (TEE) to elucidate the impact of uncompressed vs. compressed AV on outcomes of adult patients experiencing OHCA. DESIGN: Prospective observational cohort study. SETTING: Single center. PATIENTS: This study included adult OHCA patients undergoing resuscitative TEE in the emergency department. Patients were categorized into AV uncompressed or AV compressed groups based on TEE findings. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was sustained return of spontaneous circulation (ROSC). The secondary outcomes included end-tidal co2 (Etco2) during CPR, any ROSC, survival to ICU and hospital discharge, post-resuscitation withdrawal, and favorable neurologic outcomes at discharge. Additional analyses on intra-arrest arterial blood pressure (ABP) were also conducted. The sample size was pre-estimated at 37 patients/group. From October 2020 to January 2023, 76 patients were enrolled, 39 and 37 in the AV uncompressed and AV compressed groups, respectively. Intergroup baseline characteristics were similar. Compared with the AV compressed group, the AV uncompressed group had a higher probability of sustained ROSC (53.8% vs. 24.3%; adjusted odds ratio [aOR], 4.72; p = 0.010), any ROSC (56.4% vs. 32.4%; aOR, 3.30; p = 0.033), and survival to ICU (33.3% vs. 8.1%; aOR, 6.74; p = 0.010), and recorded higher initial diastolic ABP (33.4 vs. 11.5 mm Hg; p = 0.002) and a larger proportion achieving diastolic ABP greater than 20 mm Hg during CPR (93.8% vs. 33.3%; p < 0.001). The Etco2, post-resuscitation withdrawal, and survival to discharge revealed no significant intergroup differences. No patients were discharged with favorable neurologic outcomes. Uncompressed AV seemed critical for sustained ROSC across all subgroups. CONCLUSIONS: Absence of AV compression during OHCA resuscitation is associated with an increased chance of ROSC and survival to ICU. However, its effect on long-term outcomes remains unclear.

The hypoxia-age-shock index at triage to predict the outcomes of Covid-19 patients.

STUDY OBJECTIVE: The coronavirus disease 2019 (COVID-19) outbreak has caused a severe burden on medical professionals, as the rapid disposition of patients is important. Therefore, we aimed to develop a new clinical assessment tool based on the shock index (SI) and age-shock index (ASI). We proposed the hypoxia-age-shock index (HASI) and determined the usability of triage for COVID-19 infected patients in the first scene. METHODS: The predictive power for three indexes on mortality, intensive care unit (ICU) admission, and endotracheal intubation rate was evaluated using the receiver operating curve (ROC). We used DeLong's method for comparing the ROCs. RESULTS: The area under the curve (AUC) for ROC on mortality for SI, ASI, and HASI were 0.546, 0.771, and 0.773, respectively. The AUC on ICU admission mortality for SI, ASI, and HASI were 0.581, 0.700, and 0.743, respectively. The AUC for intubation for SI, ASI, and HASI were 0.592, 0.708, and 0.757, respectively. The AUC differences between HASI and SI showed statistically significant (P = 0.001) results on mortality, ICU admission, and intubation. Additionally, statistically significant results were found for the AUC difference between the HASI and ASI on ICU admission and intubation (P = 0.001 and P = 0.004, respectively). CONCLUSION: HASI can provide a better prediction compared to ASI on ICU admission and endotracheal intubation. HASI was more sensitive in mortality, ICU admission, and intubation prediction than the ASI.

Compared with physician overread, computer is less accurate but helpful in interpretation of electrocardiography for ST-segment elevation myocardial infarction.

INTRODUCTION: Previous studies have demonstrated varying sensitivity and specificity of computer-interpreted electrocardiography (CIE) in identifying ST-segment elevation myocardial infarction (STEMI). This study aims to evaluate the accuracy of contemporary computer software in recognizing electrocardiography (ECG) signs characteristic of STEMI compared to emergency physician overread in clinical practice. MATERIAL AND METHODS: In this retrospective observational single-center study, we reviewed the records of patients in the emergency department (ED) who underwent ECGs and troponin tests. Both the Philips DXL 16-Lead ECG. Algorithm and on-duty emergency physicians interpreted each standard 12­lead ECG. The sensitivity and specificity of computer interpretation and physician overread ECGs for the definite diagnosis of STEMI were calculated and compared. RESULTS: Among the 9340 patients included in the final analysis, 133 were definitively diagnosed with STEMI. When "computer-reported infarct or injury" was used as the indicator, the sensitivity was 87.2% (95% CI 80.3% to 92.4%) and the specificity was 86.2% (95% CI 85.5% to 86.9%). When "physician-overread STEMI" was used as the indicator, the sensitivity was 88.0% (95% CI 81.2% to 93.0%) and the specificity was 99.9% (95% CI 99.8% to 99.9%). The area under the receiver operating characteristic curve for physician-overread STEMI and computer-reported infarct or injury were 0.939 (95% CI 0.907 to 0.972) and 0.867 (95% CI 0.834 to 0.900), respectively. CONCLUSIONS: This study reveals that while the sensitivity of the computer in recognizing ECG signs of STEMI is similar to that of physicians, physician overread of ECGs is more specific and, therefore, more accurate than CIE.

Contrast Agent Pooling (C.A.P.) sign and imminent cardiac arrest: a retrospective study.

BACKGROUND: The sign of contrast agent pooling (C.A.P.) in dependent part of the venous system were reported in some case reports, which happened in the patients before sudden cardiac arrest. Until now, there is no solid evidence enough to address the importance of the sign. This study aimed to assess the accuracy of the C.A.P. sign in predicting imminent cardiac arrest and the association of the C.A.P. sign with patient's survival. METHODS: This is a retrospective cohort study. The study included all patients who visited the emergency department, who received contrast computed tomography (CT) scan and then experienced cardiac arrest at the emergency department (from January 1, 2016 to December 31, 2018). We evaluated the occurrence of the C.A.P. sign on the chest or abdominal CT scan, patients with ECMO were excluded. With positive C.A.P. sign, the primary outcome is whether in-hospital cardiac arrest happens within an hour; the accuracy of C.A.P. sign was calculated. The secondary outcome is survival to discharge. RESULTS: In the study, 128 patients were included. 8.6% (N = 11) patients had positive C.A.P. sign and 91.4% (N = 117) patients did not. The accuracy of C.A.P. sign in predicting cardiac arrest within 1 h was 85.94%. The C.A.P. sign had a positive association with IHCA within 1 h after the CT scan (adjusted odds ratio 7.35, 95% confidence interval [CI] 1.27 - 42.69). The relative risk (RR) of survival to discharge was 0.90 with positive C.A.P. sign (95% CI 0.85 - 0.96). CONCLUSIONS: The C.A.P. sign can be considered as an alarm for imminent cardiac arrest and poor prognosis. The patients with positive C.A.P. sign were more likely to experience imminent cardiac arrest; in contrast, less likely to survive. TRIAL REGISTRATION: IRB No.108107-E.

Hiccups as the Presenting Manifestation of Cardiac Tamponade: A Case Report.

BACKGROUND: Cardiac tamponade is a life-threatening disease with a high mortality rate. Its clinical manifestations depend on the length of time over which pericardial effusion accumulates. Among those, hiccups are rarely reported. CASE REPORT: We present a 48-year-old man who came in with a chief complaint of persistent hiccups and later had hypotension and dyspnea at the emergency department. Electrocardiogram revealed diffuse ST elevation with mildly elevated cardiac enzymes. Echocardiography showed massive pericardial effusion, implying cardiac tamponade. Catheter pericardiocentesis was performed and massive pericardial effusion was drained. Hiccups subsided after the procedure and the patient recovered uneventfully. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To the best of our knowledge, this is the first case of cardiac tamponade with the presenting manifestation of persistent hiccups. Emergency physicians should stay vigilant when approaching those patients with unexplainable prolonged hiccups.

An alternative tool for triaging patients with possible acute coronary symptoms before admission to a chest pain unit.

OBJECTIVE: This study aimed to develop a triage tool to more effectively triage possible ACS patients presenting to the emergency department (ED) before admission to a protocol-driven chest pain unit (CPU). METHODS: Seven hundred ninety-three clinical cases, randomly selected from 7962 possible ACS cases, were used to develop and test an ACS triage model using cluster analysis and stepwise logistic regression. RESULTS: The ACS triage model, logit (suspected ACS patient)=-5.283+1.894×chest pain+1.612×age+1.222×male+0.958×proximal radiation pain+0.962×shock+0.519×acute heart failure, with a threshold value set at 2.5, was developed to triage patients. Compared to four existing methods, the chest-pain strategy, the Zarich's strategy, the flowchart, and the heart broken index (HBI), the ACS triage model had better performance. CONCLUSION: This study developed an ACS triage model for triaging possible ACS patients. The model could be used as a rapid tool in EDs to reduce the workloads of ED nurses and physicians in relation to admissions to the CPU.

Similar rebleeding rate in 3-day and 7-day intravenous ceftriaxone prophylaxis for patients with acute variceal bleeding.

BACKGROUND/PURPOSE: Although prophylactic antibiotics have been recommended for cirrhotic patients with upper gastrointestinal bleeding, the duration of its use remains an inconclusive issue. We designed this study to investigate the duration of antibiotic prophylaxis for cirrhotic patients with acute esophageal variceal bleeding. METHODS: We enrolled those patients suffering from acute esophageal variceal bleeding and receiving band ligation. They were randomly allocated to two groups to receive prophylactic antibiotics; Group I: receiving intravenous ceftriaxone 500 mg every 12 hours for 3 days, and Group II: same regimen for 7 days. We used rebleeding rate within 14 days as the primary end point and also evaluated the survival rate within 28 days and the amount of transfusion during admission. RESULTS: There were 38 patients in Group I and 33 patients in Group II that completed the study course for analysis. Overall, there was no significant difference in the baseline characteristics between these two groups. There were three patients both in Group I and Group II who developed rebleeding within 14 days (8% vs. 9%, p > 0.99). There was also no difference between Group I and Group II in transfusion amount (2.71 ± 2.84 units vs. 3.18 ± 4.07, p = 0.839) and survival rate in 28 days (100 vs. 97%, p = 0.465). CONCLUSION: Our small scale study demonstrated that there was no difference in the rebleeding rate between 3-day and 7-day ceftriaxone prophylaxis for cirrhotic patients with acute esophageal variceal bleeding. There was also no difference in 28 day survival rate between these two groups.