Association between signs of life and survival in traumatic cardiac arrest patients: A nationwide, retrospective cohort study.

Background: The clinical impact of signs of life (SOLs) in traumatic cardiac arrest (TCA) remains to be elucidated. The aim of this study was to examine the association between SOLs and survival/neurological outcomes in TCA patients. Methods: Retrospective data from the Japan Trauma Data Bank (2019-2021) was reviewed. TCA patients were assigned to one of two study groups based on the presence or absence of SOLs and compared. SOLs were defined as having at least one of following criteria: pulseless electrical activity >40 beats per minute, gasping, positive light reflex, or extremity/eye movement at hospital arrival. The primary outcome was survival at hospital discharge. The secondary outcome was favorable neurological status (Glasgow Outcome Scale score of 4 or 5) at hospital discharge. Results: A total of 1,981 patients (114 with SOLs and 1,867 without SOLs) were included. Characteristics of patients were as follows: age (median age 60.0 years old [interquartile range: 41-80] years vs. 55.4 [38-75] years), gender (male: 76/114 (66.7%) vs. 1,207/1,867 (65.0%), blunt trauma (90/111 [81.1%] vs. 1,559/1,844 [84.5%]), Injury Severity Score (29.2 [22-41] vs. 27.9 [20-34]). Patients with SOLs showed higher survival (10/114 (8.8%) vs. 25/1,867 (1.3%), OR 1.96 [CI 1.20-2.72]) and higher favorable neurological outcomes (4/110 (3.5%) vs. 6/1,865 (0.3%), OR 2.42 [CI 1.14-3.70]) compared with patients without SOLs. Conclusions: TCA patients with SOLs at hospital arrival showed higher survival and favorable neurological outcomes at hospital discharge compared with TCA patients without SOLs.

Impact of sex of bystanders who perform cardiopulmonary resuscitation on return of spontaneous circulation in out-of-hospital cardiac arrest patients: A retrospective, observational study.

Background: The impact of the sex of bystanders who initiate cardiopulmonary resuscitation (CPR) on out-of-hospital cardiac arrest (OHCA) patients has not been fully elucidated. This study aims to investigate the association between the sex of bystanders who perform CPR and the clinical outcomes of OHCA patients in real-world clinical settings. Methods: We conducted a retrospective, observational study using data from the Okayama City Fire Department in Japan. Patients were categorized based on bystanders' sex. Our primary outcomes were return of spontaneous circulation (ROSC). Our secondary outcome was 30-day survival and 30-day favorable neurological outcome, defined as Cerebral Performance Category score of 1 or 2. Multivariable logistic regression analysis was used to examine the association between these groups and outcomes. Results: The study included 3,209 patients with a comparable distribution of male (1,540 patients: 48.0%) and female bystanders (1,669 patients: 52.0%) between the groups. Overall, 221 (6.9%) ROSC at hospital arrival, 226 (7.0%) patients had 30-day survival, and 121 (3.8%) patients had 30-day favorable neurological outcomes. Bystander sex (female as reference) did not contribute to ROSC at hospital arrival (adjusted OR [aOR] 1.11, 95% CI: 0.76-1.61), 30-day survival (aOR 1.23, 95% CI: 0.83-1.82), or 30-day favorable neurological outcomes (aOR 0.66, 95% CI: 0.34-1.27). Basic life support education experience was a bystander factor positively associated with ROSC. Patient factors positively associated with ROSC were initial shockable rhythm and witness of cardiac arrest. Conclusion: There were no differences in ROSC, 30-day survival, or 30-day neurological outcomes in OHCA patients based on bystander sex.

Organ donation after extracorporeal cardiopulmonary resuscitation: a nationwide retrospective cohort study.

BACKGROUND: Limited data are available on organ donation practices and recipient outcomes, particularly when comparing donors who experienced cardiac arrest and received extracorporeal cardiopulmonary resuscitation (ECPR) followed by veno-arterial extracorporeal membrane oxygenation (ECMO) decannulation, versus those who experienced cardiac arrest without receiving ECPR. This study aims to explore organ donation practices and outcomes post-ECPR to enhance our understanding of the donation potential after cardiac arrest. METHODS: We conducted a nationwide retrospective cohort study using data from the Japan Organ Transplant Network database, covering all deceased organ donors between July 17, 2010, and August 31, 2022. We included donors who experienced at least one episode of cardiac arrest. During the study period, patients undergoing ECMO treatment were not eligible for a legal diagnosis of brain death. We compared the timeframes associated with each donor's management and the long-term graft outcomes of recipients between ECPR and non-ECPR groups. RESULTS: Among 370 brain death donors with an episode of cardiac arrest, 26 (7.0%) received ECPR and 344 (93.0%) did not; the majority were due to out-of-hospital cardiac arrests. The median duration of veno-arterial ECMO support after ECPR was 3 days. Patients in the ECPR group had significantly longer intervals from admission to organ procurement compared to those not receiving ECPR (13 vs. 9 days, P = 0.005). Lung graft survival rates were significantly lower in the ECPR group (log-rank test P = 0.009), with no significant differences in other organ graft survival rates. Of 160 circulatory death donors with an episode of cardiac arrest, 27 (16.9%) received ECPR and 133 (83.1%) did not. Time intervals from admission to organ procurement following circulatory death and graft survival showed no significant differences between ECPR and non-ECPR groups. The number of organs donated was similar between the ECPR and non-ECPR groups, regardless of brain or circulatory death. CONCLUSIONS: This nationwide study reveals that lung graft survival was lower in recipients from ECPR-treated donors, highlighting the need for targeted research and protocol adjustments in post-ECPR organ donation.

Successful Cardiac, Lung, and Kidney Transplantation from a Methanol-poisoned Donor.

Massive methanol exposure can lead to severe and detrimental effects that can result in death or brain death. As organs from patients with brain death after methanol ingestion are less likely to be recovered, these patients have been considered marginal donors. We present a case of successful multiple organ transplantation (heart, lungs, and kidneys) from a methanol-poisoned patient. Our experience illustrates that donor death from methanol intoxication does not preclude organ transplantation.

Hydrogen in Transplantation: Potential Applications and Therapeutic Implications.

Hydrogen gas, renowned for its antioxidant properties, has emerged as a novel therapeutic agent with applications across various medical domains, positioning it as a potential adjunct therapy in transplantation. Beyond its antioxidative properties, hydrogen also exerts anti-inflammatory effects by modulating pro-inflammatory cytokines and signaling pathways. Furthermore, hydrogen's capacity to activate cytoprotective pathways bolsters cellular resilience against stressors. In recent decades, significant advancements have been made in the critical medical procedure of transplantation. However, persistent challenges such as ischemia-reperfusion injury (IRI) and graft rejection continue to hinder transplant success rates. This comprehensive review explores the potential applications and therapeutic implications of hydrogen in transplantation, shedding light on its role in mitigating IRI, improving graft survival, and modulating immune responses. Through a meticulous analysis encompassing both preclinical and clinical studies, we aim to provide valuable insights into the promising utility of hydrogen as a complementary therapy in transplantation.

Changes in temporal muscle dimensions and their clinical impact in out-of-hospital cardiac arrest survivors.

Objective: This study investigates temporal muscle atrophy in out-of-hospital cardiac arrest patients post-resuscitation, seeking associations with neurological outcomes and factors associated with atrophy. Methods: Using data from six Japanese intensive care units, adult patients' post-resuscitation who underwent head computed tomography scans on admission and two to five days post-admission were assessed. Temporal muscle area, thickness, and density were quantified from a single cross-sectional image. Patients were categorized into 'atrophy' or 'no atrophy' groups based on median daily temporal muscle atrophy rates. The primary outcome was changes in temporal muscle dimensions between admission and follow-up two to five days later. Secondary outcomes included assessing the impact of temporal muscle atrophy on 30-day survival, as well as identifying any clinical factors associated with temporal muscle atrophy. Results: A total of 185 patients were analyzed. Measurements at follow-up revealed significant decreases in temporal muscle area (214 vs. 191 mm2, p < 0.001), thickness (4.9 vs. 4.7 mm, p < 0.001), and density (46 vs. 44 HU, p < 0.001) compared to those at admission. The median daily rate for temporal muscle area atrophy was 2.0% per day. There was no significant association between temporal muscle atrophy and 30-day survival (hazard ratios, 0.71; 95% CI, 0.41-1.23, p = 0.231). Multivariable logistic regression found no clinical factors significantly associated with temporal muscle atrophy. Conclusions: Temporal muscle atrophy in post-resuscitation patients occurs rapidly at 2.0% per day. However, there was no significant association with 30-day mortality or any identified clinical factors. Further investigation into its long-term functional implications is warranted.

Treatment patterns and clinician stress related to care of out-of-hospital cardiac arrest patients with a do not attempt resuscitation order.

Objective: This research investigated treatment patterns for out-of-hospital cardiac arrest patients with Do Not Attempt Resuscitation orders in Japanese emergency departments and the associated clinician stress. Methods: A cross-sectional survey was conducted at 9 hospitals in Okayama, Japan, targeting emergency department nurses and physicians. The questionnaire inquired about the last treated out-of-hospital cardiac arrest patient with a Do Not Attempt Resuscitation. We assessed emotional stress on a 0-10 scale and moral distress on a 1-5 scale among clinicians. Results: Of 208 participants, 107 (51%) had treated an out-of-hospital cardiac arrest patient with a Do Not Attempt Resuscitation order in the past 6 months. Of these, 65 (61%) clinicians used a "slow code" due to perceived futility in resuscitation (42/65 [65%]), unwillingness to terminate resuscitation upon arrival (38/65 [59%]), and absence of family at the time of patient's arrival (35/65 [54%]). Female clinicians had higher emotional stress (5 vs. 3; P = 0.007) and moral distress (3 vs. 2; P = 0.002) than males. Nurses faced more moral distress than physicians (3 vs. 2; P < 0.001). Adjusted logistic regression revealed that having performed a "slow code" (adjusted odds ratio, 5.09 [95% CI, 1.68-17.87]) and having greater ethical concerns about "slow code" (adjusted odds ratio, 0.35 [95% CI, 0.19-0.58]) were associated with high stress levels. Conclusions: The prevalent use of "slow code" for out-of-hospital cardiac arrest patients with Do Not Attempt Resuscitation orders underscores the challenges in managing these patients in clinical practice.

Transversal Survey of Emergency Medicine Policy and Quality Metrics in Japan's Regional Health Care Plans.

Introduction: It is essential to establish appropriate medical quality metrics and make improvements to safely and efficiently deliver optimum emergency medical services. The Ministry of Health, Labor and Welfare (MHLW) recommends prefectures to establish numerical quality metrics in their regional healthcare plans (RHCP). The 7th RHCP was issued by the MHLW in 2017 along with a notice of planning in covering the six-year period from 2018 to 2023. In this descriptive study, the emergency medicine policies in the 7th RHCP of each prefecture were analyzed from a quality improvement perspective. Method: The authors examined the chapters on emergency medicine in the RHCPs of 47 prefectural governments for the overall structure, cost-benefits, and connection to community-based integrated care systems. The type and number of clinical measures listed as numerical metrics and their classification methods were emphasized. Result: Regarding the overall plan structure, 40 prefectural governments began their description with an analysis of current surroundings. In total, 24 prefectural governments mentioned community-based integrated care systems but none mentioned cost-benefit analysis. Altogether, only 43 of 47 prefectural governments (91%) indicated numerical metrics. The maximum number of numerical targets for quality measures by prefecture was 19, the minimum was 0, and the median was 4 (IQR: 3-6.5); there were 220 metrics in total, with 82 structural, 96 process, and 42 outcome measures. Additionally, 13 prefectures (28%) classified quality measures according to the MHLW's guidance, 6 (13%) used their own classification manner, while the others did not classify their measures. Conclusions: There were significant differences in emergency medicine policies and quality metrics among the prefectural governments. Further research is needed to develop and establish more comprehensive and appropriate metrics based on a common methodology to improve the quality of emergency medicine.

Hydrogen inhalation attenuates lung contusion after blunt chest trauma in mice.

BACKGROUND: Lung contusion caused by blunt chest trauma evokes a severe inflammatory reaction in the pulmonary parenchyma that may be associated with acute respiratory distress syndrome. Although hydrogen gas has antioxidant and anti-inflammatory effects and is protective against multiple types of lung injury at safe concentrations, the effects of inhaled hydrogen gas on blunt lung injury have not been previously investigated. Therefore, using a mouse model, we tested the hypothesis that hydrogen inhalation after chest trauma would reduce pulmonary inflammation and acute lung injury associated with lung contusion. METHODS: Inbred male C57BL/6 mice were randomly divided into 3 groups: sham with air inhalation, lung contusion with air inhalation, and lung contusion with 1.3% hydrogen inhalation. Experimental lung contusion was induced using a highly reproducible and standardized apparatus. Immediately after induction of lung contusion, mice were placed in a chamber exposed to 1.3% hydrogen gas in the air. Histopathological analysis and real-time polymerase chain reaction in lung tissue and blood gas analysis were performed 6 hours after contusion. RESULTS: Histopathological examination of the lung tissue after contusion revealed perivascular/intra-alveolar hemorrhage, perivascular/interstitial leukocyte infiltration, and interstitial/intra-alveolar edema. These histological changes and the extent of lung contusion, as determined by computed tomography, were significantly mitigated by hydrogen inhalation. Hydrogen inhalation also significantly reduced inflammatory cytokine and chemokine mRNA levels and improved oxygenation. CONCLUSION: Hydrogen inhalation therapy significantly mitigated inflammatory responses associated with lung contusion in mice. Hydrogen inhalation therapy may be a supplemental therapeutic strategy for treating lung contusion.

Successfully treated case of severe hypothermia secondary to myxedema coma.

Background: Myxedema coma is an extremely rare but fatal endocrine emergency that requires urgent recognition and treatment. We describe a case of severe hypothermia that rapidly deteriorated to cardiac arrest that was attributed to myxedema coma. Case Presentation: A 52-year-old man without a history of hypothyroidism was transferred to our emergency department due to coma and profound hypothermia. The patient developed cardiac arrest immediately after hospital arrival but return of spontaneous circulation was achieved shortly after resuscitation. The patient was noted to have generalized, nonpitting edema, dry skin, severe respiratory acidosis, hyponatremia, and elevated creatinine kinase, which was indicative of hypothyroidism. Myxedema coma was confirmed by a thyroid profile. The patient was successfully treated with intravenous levothyroxine and glucocorticoid. Conclusion: Although myxedema coma is a rare cause of severe hypothermia, emergency physicians should be familiar with its clinical features and management.

Association of Prehospital Physician Presence During Pediatric Out-of-Hospital Cardiac Arrest With Neurologic Outcomes.

OBJECTIVES: To examine the association of prehospital physician presence with neurologic outcomes of pediatric patients with out-of-hospital cardiac arrest (OHCA). DESIGN: Retrospective cohort study. SETTING: Data from the Japanese Association for Acute Medicine-OHCA Registry. INTERVENTIONS: None. PATIENTS: Pediatric patients (age 17 yr old or younger) registered in the database between June 2014 and December 2019. MEASUREMENT AND MAIN RESULTS: We used logistic regression models with stabilized inverse probability of treatment weighting (IPTW) to estimate the associated treatment effect of a prehospital physician with 1-month neurologically intact survival. Secondary outcomes included in-hospital return of spontaneous circulation (ROSC) and 1-month survival after OHCA. A total of 1,187 patients (276 in the physician presence group and 911 in the physician absence group) were included (median age 3 yr [interquartile range 0-14 yr]; 723 [61%] male). Comparison of the physician presence group, versus the physician absence, showed 1-month favorable neurologic outcomes of 8.3% (23/276) versus 3.6% (33/911). Physician presence was associated with greater odds of 1-month neurologically intact survival after stabilized IPTW adjustment (adjusted odds ratio [aOR] 1.98, 95% CI 1.08-3.66). We also found an association in the secondary outcome between physician presence, opposed to absence, and in-hospital ROSC (aOR 1.48, 95% CI 1.08-2.04). However, we failed to identify an association with 1-month survival (aOR 1.49, 95% CI 0.97-2.88). CONCLUSIONS: Among pediatric patients with OHCA, prehospital physician presence, compared with absence, was associated almost two-fold greater odds of 1-month favorable neurologic outcomes.

Hamman's Syndrome Accompanied by Diabetic Ketoacidosis; a Case Report.

Hamman's syndrome is an uncommon clinical entity characterized by an idiopathic spontaneous pneumomediastinum as a result of a sudden increase in intra-alveolar pressure. It can be triggered by repeated vomiting or Kussmaul breathing associated with diabetic ketoacidosis (DKA). Careful attention to this particular condition is needed to avoid under-diagnosis and to provide optimal management. Herein, we report a case of an 18-year-old man complaining of chest discomfort and progressive weight loss, ultimately diagnosed with Hamman's syndrome secondary to DKA. The patient's symptoms disappeared after intravenous fluid and insulin administration, while his pneumomediastinum resolved following conservative treatment. Our report highlights the importance of recognition of the links between pneumomediastinum as a cause of chest pain in patients with DKA.

Bile pigments in emergency and critical care medicine.

Bile pigments, such as bilirubin and biliverdin, are end products of the heme degradation pathway in mammals and are widely known for their cytotoxic effects. However, recent studies have revealed that they exert cytoprotective effects through antioxidative, anti-inflammatory, and immunosuppressive properties. All these mechanisms are indispensable in the treatment of diseases in the field of emergency and critical care medicine, such as coronary ischemia, stroke, encephalomyelitis, acute lung injury/acute respiratory distress syndrome, mesenteric ischemia, and sepsis. While further research is required before the safe application of bile pigments in the clinical setting, their underlying mechanisms shed light on their utilization as therapeutic agents in the field of emergency and critical care medicine. This article aims to summarize the current understanding of bile pigments and re-evaluate their therapeutic potential in the diseases listed above.

Luminal administration of biliverdin ameliorates ischemia-reperfusion injury following intestinal transplant in rats.

BACKGROUND: Intestinal grafts are susceptible to ischemia-reperfusion injury, resulting in the loss of mucosal barrier function and graft failure. Biliverdin is known to exert a variety of cytoprotective functions against oxidative tissue injury. Because the mucosal layer is the primary site of ischemia-reperfusion injury, mucosa-targeting strategies by luminal delivery of reagents might be beneficial. We tested whether intraluminal administration of biliverdin as an adjuvant to standard preservation solutions protected against ischemia-reperfusion injury. METHODS: Orthotopic syngeneic intestinal transplants were performed on Lewis rats after 6 hours of cold preservation. Saline containing biliverdin (10 µM) or without biliverdin was introduced into the lumen of the intestinal grafts immediately before cold preservation. RESULTS: Damage to the intestinal mucosa caused by ischemia-reperfusion injury resulted in severe morphological changes, including blunting of the villi and erosion, and led to significant loss of gut barrier function 3 hours after reperfusion. These changes to the mucosa were notably ameliorated by intraluminal administration of biliverdin. Biliverdin also effectively inhibited upregulation of messenger RNAs for interleukin-6, inducible nitric oxide synthase, and C-C motif chemokine 2. Additionally, biliverdin treatment prevented the loss of expression of claudin-1, a transmembrane, tight-junction barrier protein. The 14-day survival of recipients of biliverdin-treated grafts was significantly improved as compared with the recipients of saline-treated control grafts (83.3% vs 38.9%, P = .030). CONCLUSION: This study demonstrated that luminally delivered biliverdin provides beneficial effects during the transplant of rat small intestinal grafts and could be an attractive therapeutic option in organ transplantation.

The Impact of Medical Students Teaching Basic Life Support to Laypersons.

Basic life support (BLS) courses for laypersons, including cardiopulmonary resuscitation (CPR) training, is known to improve outcomes of out-of-hospital cardiac events. We asked medical students to provide BLS training for laypersons as a part of their emergency medicine education and evaluated the effects of training on the BLS skills of laypersons. We also used a questionnaire to determine whether the medical students who provided the BLS training were themselves more confident and motivated to perform BLS compared to students who did not provide BLS training. The proportions of laypersons who reported confidence in checking for a response, performing chest compressions, and automated external defibrillator (AED) use were significantly increased after the BLS training. The proportions of medical students who reported increased confidence/motivation in terms of understanding BLS, checking for a response, chest compression, use of AED, and willingness to perform BLS were significantly greater among medical students who provided BLS instructions compared to those who did not. BLS instruction by medical students was associated with an improvement in laypersons' CPR accuracy and confidence in responding to cardiac arrest. The results indicate that medical students could gain understanding, confidence, and motivation in regard to their BLS skills by teaching BLS to laypersons.