The contributions of emergency physicians to out-of-hospital cardiopulmonary arrest: an analysis of the national Utstein Registry data.

BACKGROUND: Emergency physicians are likely to play an important role in the "chain of survival." The relationship between the number of emergency physicians and out-of-hospital cardiopulmonary arrest (OHCA) prognosis is not well understood. OBJECTIVE: We assessed the impact of the number of emergency physicians on the outcomes of OHCA. METHODS: In a nationwide, population-based, observational study, we enrolled 120,721 adults aged ≥ 18 years with OHCA, from January 1, 2010 to December 31, 2010. We used the countrywide Utstein Registry database coupled with health statistics data surveyed by the Ministry of Health, Labour and Welfare. The primary endpoint was favorable neurological outcomes 1 month after OHCA. RESULTS: During the study period, OHCA occurred in 25,580 people (21.2%) in an area with the number of emergency physicians/100,000 population < 1.5, in 62,299 people (51.6%) in an area with ≥ 1.5 and < 3.0 emergency physicians/100,000 population, in 30,948 people (25.6%) in an area with ≥ 3.0 and < 4.5 emergency physicians/100,000 population, and in 1894 people (1.6%) in an area with ≥ 4.5 emergency physicians/100,000 population. Patient prognosis became more favorable as the number of emergency physicians increased (1-month survival: 5.08% vs. 5.81% vs. 5.90% vs. 8.82%, p < 0.0001; and favorable neurological outcomes: 2.64% vs. 2.84% vs. 3.23% vs. 3.54%, p < 0.0001; for emergency physicians/100,000 population of < 1.5, ≥ 1.5 and < 3.0, ≥ 3.0 and < 4.5, and ≥ 4.5, respectively). The adjusted odds ratio for favorable neurological outcomes per increase of one emergency physician/100,000 population was 1.06 (95% confidence interval 1.01-1.11, p = 0.0163). CONCLUSION: An increased number of emergency physicians/100,000 population is likely to be associated with improved outcomes.

Effective pre-hospital care for out-of-hospital cardiac arrest caused by respiratory disease.

BACKGROUND: The relationship between pre-hospital care and the prognosis of out-of-hospital cardiac arrest (OHCA) caused by respiratory disease is unclear. This study aimed to assess the impact of pre-hospital care on the prognosis of OHCA caused by respiratory disease. METHODS: In a nationwide, population-based, observational study, we enrolled 121,081 adults aged ≥18 years who experienced OHCA from January 1, 2010, to December 31, 2010. The primary endpoint was favourable neurological outcomes. RESULTS: Of the 120,256 eligible adult OHCA patients, 7,071 (5.9%) experienced OHCA caused by respiratory disease. Of these 7,071 patients, 3,911 (55.3%) received no cardiopulmonary resuscitation (CPR), 2,403 (34.0%) received chest-compression-only CPR, and 757 (10.7%) received conventional CPR by a bystander. There was no significant difference between the three types of bystander CPR with regard to the neurological outcome (no CPR: OR 0.68, 95%CI 0.39-1.24, p=0.1951; chest-compression-only CPR: OR 0.68, 95%CI 0.37-1.29, p=0.2295; and conventional CPR: as a reference). Pre-hospital administration of epinephrine (OR 0.37, 95%CI 0.13-0.85, p=0.0170) and the implementation of advanced airway management (OR 0.32, 95%CI 0.19-0.52, p<0.0001) were associated with poor neurological outcomes. CONCLUSIONS: Even in OHCA caused by respiratory disease, not only pre-hospital epinephrine administration but also pre-hospital advanced airway management and rescue breathing in bystander CPR may not be critical.

Application of cerebral oxygen saturation to prediction of the futility of resuscitation for out-of-hospital cardiopulmonary arrest patients: a single-center, prospective, observational study: can cerebral regional oxygen saturation predict the futility of CPR?

BACKGROUND: Cerebral regional oxygen saturation (rSO2) can be measured immediately and noninvasively just after arrival at the hospital and may be useful for evaluating the futility of resuscitation for a patient with out-of-hospital cardiopulmonary arrest (OHCA). We examined the best practices involving cerebral rSO2 as an indicator of the futility of resuscitation. METHODS: This study was a single-center, prospective, observational analysis of a cohort of consecutive adult OHCA patients who were transported to the University of Tokyo Hospital from October 1, 2012, to September 30, 2013, and whose cerebral rSO2 values were measured. RESULTS: During the study period, 69 adult OHCA patients were enrolled. Of the 54 patients with initial lower cerebral rSO2 values of 26% or less, 47 patients failed to achieve return of spontaneous circulation (ROSC) in the receiver operating characteristic curve analysis (optimal cutoff, 26%; sensitivity, 88.7%; specificity, 56.3%; positive predictive value, 87.0%; negative predictive value, 60.0%; area under the curve [AUC], 0.714; P = .0033). The AUC for the initial lower cerebral rSO2 value was greater than that for blood pH (AUC, 0.620; P = .1687) or lactate values (AUC, 0.627; P = .1081) measured upon arrival at the hospital as well as that for initial higher (AUC, 0.650; P = .1788) or average (AUC, 0.677; P = .0235) cerebral rSO2 values. The adjusted odds ratio of the initial lower cerebral rSO2 values of 26% or less for ROSC was 0.11 (95% confidence interval, 0.01-0.63; P = .0129). CONCLUSIONS: Initial lower cerebral rSO2 just after arrival at the hospital, as a static indicator, is associated with non-ROSC. However, an initially lower cerebral rSO2 alone does not yield a diagnosis performance sufficient for evaluating the futility of resuscitation.

Applicability of the prehospital termination of resuscitation rule in an area dense with hospitals in Tokyo: a single-center, retrospective, observational study: is the pre hospital TOR rule applicable in Tokyo?

BACKGROUND: It is unclear whether the prehospital termination of resuscitation (TOR) rule is applicable in specific situations such as in areas extremely dense with hospitals. OBJECTIVES: The objective of the study is to assess whether the prehospital TOR rule is applicable in the emergency medical services system in Japan, specifically, in an area dense with hospitals in Tokyo. METHODS: This study was a retrospective, observational analysis of a cohort of adult out-of-hospital cardiopulmonary arrest (OHCA) patients who were transported to the University of Tokyo Hospital from April 1, 2009, to March 31, 2011. RESULTS: During the study period, 189 adult OHCA patients were enrolled. Of the 189 patients, 108 patients met the prehospital TOR rule. The outcomes were significantly worse in the prehospital TOR rule-positive group than in the prehospital TOR-negative group, with 0.9% vs 11.1% of patients, respectively, surviving until discharge (relative risk [RR], 1.11; 95% confidence interval [CI], 1.03-1.21; P = .0020) and 0.0% vs 7.4% of patients, respectively, discharged with a favorable neurologic outcome (RR, 1.08; 95% CI, 1.02-1.15; P = .0040). The prehospital TOR rule had a positive predictive value (PPV) of 99.1% (95% CI, 96.3-99.8) and a specificity of 90.0% (95% CI, 60.5-98.2) for death and a PPV of 100.0% (95% CI, 97.9-100.0) and a specificity of 100.0% (95% CI, 61.7-100.0) for an unfavorable neurologic outcome. CONCLUSIONS: This study suggested that the prehospital TOR rule predicted unfavorable outcomes even in an area dense with hospitals in Tokyo and might be helpful for identifying the OHCA patients for whom resuscitation efforts would be fruitless.

EDTA-dependent pseudothrombocytopenia complicated by eosinophilic pneumonia.

EDTA-dependent pseudothrombocytopenia (EDTA-PTCP) is a phenomenon that occurs in vitro when EDTA reacts with harvested blood. EDTA-dependent pseudothrombocytopenia usually does not indicate thrombocytopenia in vivo. Here, we report the first case of EDTA-PTCP complicated by eosinophilic pneumonia. A 70-year-old man with rectal cancer was admitted to the hospital for a liver abscess and rectal cancer. At the time of admission, his platelet count was 20,000/µL, but a peripheral blood smear showed platelet aggregation and the platelet count for a kanamycin-added EDTA blood sample was 180,000/µL. The patient's respiratory status worsened after treatment for the liver abscess and rectal cancer. The patient's bronchoalveolar lavage contained 45% eosinophils, and a diagnosis of acute eosinophilic pneumonia was made. In recent studies, the occurrence of eosinophilic disease has been shown in idiopathic thrombocytopenic purpura. EDTA-dependent pseudothrombocytopenia is an in vitro phenomenon, although platelet activation that results in eosinophil invasion may occur in severe cases.

How long should resuscitative efforts be continued in adult out-of-hospital cardiac arrest?

The neurological prognosis of out-of-hospital cardiac arrest (OHCA) is extremely poor, particularly in patients who require prolonged cardiopulmonary resuscitation (CPR). However, the upper limit of CPR duration is unclear. We present a case of a 51-year-old man with nonhypothermic OHCA. He was discharged without neurological sequelae despite long duration CPR lasting 143 minutes, which is the longest duration among adult nonhypothermic OHCA cases reported. There are some patients for whom CPR duration might not be associated with prognosis. To determine when to terminate resuscitative efforts or whether more lifesaving medical resources should be provided, a prognostic indicator other than CPR duration is needed.

The effects of dynamic axial loading on the rat growth plate.

Longitudinal bone growth can be suppressed by compressive loading. In this study, we applied three different magnitudes (17, 8.5, and 4N) of compressive force to growing rat ulnas 10 minutes/day for 8 days and investigated the effects on the distal growth plate biology. Further, to investigate growth rate recovery after cessation of loading, we examined rats 7 days after the loading period. Longitudinal growth of the ulna was suppressed in a dose-dependent manner by applied compressive force. In the 17N group, the longitudinal mineralization rate (LMR) at the distal growth plate was suppressed completely by loading and did not recover. However, in the 8.5N and 4N groups, LMR suppression recovered in 1 week. In the 17N group, growth plate height and hypertrophic zone height were significantly greater than control; the number of hypertrophic chondrocytes was increased; and some traumatic changes such as cracks in the growth plate were found. In addition, 17N loading suppressed cartilage mineralization and capillary invasion beneath the growth plate, although the number of chondrocytes synthesizing vascular endothelial growth factor (VEGF) was increased. Our study shows longitudinal growth suppression caused by axial loading of the ulna, which is proportional to the magnitude of load. Only the largest load (17N) caused morphological changes in the distal growth plate cartilage. There was no association found between mineralization and type X collagen localization or capillary invasion and VEGF expression.

Impact of seasonal temperature environment on the neurologic prognosis of out-of-hospital cardiac arrest: a nationwide, population-based cohort study.

OBJECTIVE: The relationship between environmental factors, such as winter or cold environments, and the onset of out-of-hospital cardiac arrest (OHCA) is well known. However, the association between environmental factors and the neurologic outcome of OHCA is poorly understood. This study aimed to assess the impact of the ambient temperature on the neurologic outcome of adult OHCA. METHODS: In a nationwide, population-based, observational study, we enrolled 121,081 adults 18 years or older who experienced an OHCA from January 1, 2010, to December 31, 2010. We used the All-Japan Utstein Registry database coupled with climate statistics data from the Japan Meteorological Agency. The primary end point was favorable neurologic outcome 1 month after OHCA. RESULTS: Of the eligible 120,721 adult patients with OHCA, 7747 cases of OHCA (6.4%) occurred during the cold season, 80,739 (66.9%) occurred during the midseason, and 32,235 (26.7%) occurred during the warm season. The adults who experienced an OHCA during the cold season exhibited a significantly lower rate of a favorable neurologic outcome than did those who experienced an OHCA during the warm season (2.4% vs 3.3%; odds ratio, 0.73; 95% confidence interval, 0.62-0.85; P < .0001). The adjusted odds ratio for favorable neurologic outcome per 1°C increase in the monthly ambient temperature was 1.006 (95% confidence interval, 1.002-1.010; P = .0080). CONCLUSIONS: The seasonal ambient temperature is likely to affect favorable neurologic outcome. A lower seasonal ambient temperature may exacerbate the neurologic outcome of OHCA.

Predictors of favorable and poor prognosis in unwitnessed out-of-hospital cardiac arrest with a non-shockable initial rhythm.

BACKGROUND: Unwitnessed OHCA patients with non-shockable initial rhythms account for nearly half of all OHCA patients, and their prognosis is extremely poor. To date, no studies have focused on these patients. This study aimed to investigating the predictors of favorable and poor prognosis in these patients. METHODS: We conducted a nationwide, population-based, observational study of data from the All Japan Utstein Registry, which included 121,081 adult OHCA patients subjected to resuscitation attempts from January 1, 2010 to December 31, 2010. The primary endpoint was favorable neurological outcome one month after OHCA. RESULTS: Of the eligible 120,721 patients, 68,024 (56.3%) were unwitnessed OHCA patients with non-shockable initial rhythms. A younger age (18-64 years: as a reference; 65-84 years: OR 0.68, 95% CI 0.54-0.87, p=0.0019; ≥85 years: OR 0.46, 95% CI 0.33-0.63, p<0.0001), conversion to shockable rhythm (OR 2.14, 95% CI 1.43-3.13, p=0.0003), and pre-hospital ROSC (OR 94.85, 95% CI 75.71-119.35, p<0.0001) were independently associated with a favorable neurological outcome. Favorable neurological outcome rate was 28.8% in unwitnessed OHCA patients with non-shockable initial rhythms with all three favorable predictors, and 0.18% in patients without any of the three predictors (OR 230.34, 95% CI 127.37-402.96, P<0.0001). CONCLUSIONS: It may be worthwhile to provide maximum lifesaving medical resources for patients with all of the favorable predictors (<65 years, conversion to shockable rhythm, and pre-hospital ROSC); however, continued resuscitation efforts for patients without these predictors should likely be restrained.

Sudden cardiac arrest caused by tuberculous pericarditis with hemorrhagic pericardial effusion.

As tuberculosis still exists in Japan, tuberculous pericarditis is a major health issue. Tuberculous pericarditis is difficult to diagnose and leads to poor outcomes when left untreated. We herein report the case of a patient who was admitted to the hospital after undergoing resuscitation for cardiopulmonary arrest. Mycobacterium tuberculosis was detected in his hemorrhagic pericardial fluid and tuberculous pericarditis was diagnosed. The administration of antituberculous medication resulted in marked improvements. A diagnosis of tuberculous pericarditis, in addition to other causes such as malignant tumors, should therefore be considered in the differential diagnosis for cases presenting with hemorrhagic pericardial effusion, even in those involving sudden cardiac arrest.