A novel CPR-assist device vs. established chest compression techniques in infant CPR: A manikin study.

INTRODUCTION: Guidelines for infant CPR recommend the two-thumb encircling hands technique (TTT) and the two-finger technique (TFT) for chest compression. Some devices have been designed to assist with infant CPR, but are often not readily available. Syringe plungers may serve as an alternative infant CPR assist device given their availability in most hospitals. In this study, we aimed to determine whether CPR using a syringe plunger could improve CPR quality measurements on the Resusci-Baby manikin compared with traditional methods of infant CPR. METHODS: Compression area with a diameter of 1 to 2 cm is recommended in previous infant CPR device researches. In this is a randomized crossover manikin study, we examined the efficacy of the Syringe Plunger Technique (SPT) which uses the plunger of the 20 ml syringe with a 2 cm diameter flat piston, commonly available in hospital, for infant External Chest Compressions (ECC). Participants performed TTT, TFT and SPT ECC on Resusci® Baby QCPR® according to 2020 BLS guidelines. RESULTS: Sixty healthcare providers participated in this project. The median (IQR) ECC depths in the TTT, TFT and SPT in the first minute were 41 mm (40-42), 40 mm (38-41) and 40 mm (39-41), respectively, with p < 0.001. The median (IQR) ECC recoil in the TTT, TFT and SPT groups in the first minute was 15% (1-93), 64% (18-96) and 53% (8-95), respectively, with p = 0.003. The result in the second minute had similar findings. The SPT had the best QCPR score and less fatigue. CONCLUSION: The performance of chest compression depth and re-rebound ratio was statistically different among the three groups. TTT has good ECC depth and depth accuracy but poor recoil. TFT is the complete opposite. SPT can achieve a depth close to TTT and has a good recoil performance as TFT. Regarding comprehensive performance, SPT obtains the highest QCPR score, and SPT is also less fatigued. SPT may be an effective alternative technique for infant CPR.

Biomechanical analysis of force distribution in one-handed and two-handed adult chest compression: a randomised crossover observational study.

INTRODUCTION: The standard method of chest compression for adults is a two-handed procedure. One-handed external chest compression (ECC) is used in some situations such as during transport of patients who had an out-of-hospital cardiac arrest, but the quality of one-handed ECC is still not well known. The distribution of force is related to the quality of chest compression and may affect the risk of injury. This study aimed to determine the differences in the quality and potential safety concern between one-handed ECC and two- handed ECC. METHODS: In this randomised crossover study, participants recruited from National Cheng Kung University Hospital and the ambulance team from the fire bureau were asked to perform one-handed and two-handed ECC on the Resusci Anne manikin according to standard 2015 ECC guidelines. The MatScan Pressure Measurement system was used to investigate the compression pressure and force distribution. RESULTS: Two-handed ECC had better results than one-handed ECC in terms of the median (IQR) depth (51.00 (41.50-54.75) mm vs 42.00 (27.00-49.00) mm, p=0.018), the proportion of depth accuracy (82.05% (13.95%-99.86%) vs 11.17% (0.00%-42.13%), p=0.028) and the proportion of incomplete recoil (0.23% (0.01%-0.44%) vs 2.42% (0.60%-4.21%), p=0.002). The maximum force (45.72 (36.10-80.84) kgf vs 35.64 (24.13-74.34) kgf, p<0.001) and ulnar-radial force difference (7.13 (-16.58 to 21.07) kgf vs 23.93 (11.19-38.74) kgf, p<0.001) showed statistically significant differences. The perceived fatigue of two-handed ECC versus one-handed ECC was 5.00 (3.00-6.00) vs 6.00 (5.00-8.00), p<0.001. CONCLUSION: The quality of one-handed ECC, based on depth and recoil, is worse than that of standard two-handed ECC. The pressure and force distribution of one-handed ECC result in greater ulnar pronation of the hand than that of two-handed ECC. One-handed ECC more easily causes operator fatigue. Acknowledging these findings and adjusting training for one-handed ECC would potentially improve the quality of cardiopulmonary resuscitation during transport.

Biomechanical analysis of force distribution in one-handed and two-handed child chest compression- a randomized crossover observational study.

BACKGROUND: Even force distribution would generate efficient external chest compression (ECC). Little research has been done to compare force distribution between one-hand (OH) and two-handed (TH) during child ECC. Therefore, this study was to investigate force distribution, rescuer perceived fatigue and discomfort/pain when applying OH and TH ECC in children. METHODS: Crossover manikin study. Thirty-five emergency department registered nurses performed lone rescuer ECC using TH and OH techniques, each for 2 min at a rate of at least 100 compressions/min. A Resusci Junior Basic manikin equipped with a MatScan pressure measurement system was used to collect data. The perceived exertion scale (modified Borg scale) and numerical rating scale (NRS) was applied to evaluate the fatigue and physical pain of delivering chest compressions. RESULTS: The maximum compression force (kg) delivered was 56.58 ± 13.67 for TH and 45.12 ± 7.90 for OH ECC (p <  0.001). The maximum-minimum force difference force delivered by TH and OH ECC was 52.24 ± 13.43 and 41.36 ± 7.57, respectively (p <  0.001). The mean caudal force delivered by TH and OH ECC was 29.45 ± 16.70 and 34.03 ± 12.01, respectively (p = 0.198). The mean cranial force delivered by TH and OH ECC was 27.13 ± 11.30 and 11.09 ± 9.72, respectively (p <  0.001). The caudal-cranial pressure difference delivered by TH and OH ECC was 19.14 ± 15.96 and 26.94 ± 14.48, respectively (p = 0.016). The perceived exertion and NRS for OH ECC was higher than that of the TH method (p < 0.001, p = 0.004, respectively). CONCLUSIONS: The TH method produced greater compression force, had more efficient compression, and delivered a more even force distribution, and produced less fatigue and physical pain in the rescuer than the OH method. TRIAL REGISTRATION: The Cheng Kung University Institutional Review Board A-ER-103-387. http://nckuhirb.med.ncku.edu.tw/sitemap.php.

How does the side of approach impact the force delivered during external chest compression?

BACKGROUND: We investigated the biomechanics of four external chest compression (ECC) approaches involving different sides of approach and hand placement during cardiopulmonary resuscitation (CPR). METHODS: A total of 60 participants (30 women and 30 men) with CPR certification performed standard continuous 2-min ECC on a Resusci Anne manikin with real-time feedback in four scenarios: rescuer at the manikin's right side with right hand chest contact (RsRc), rescuer at the manikin's right side with left hand chest contact (RsLc), rescuer at the manikin's left side with left hand chest contact (LsLc), and rescuer at the manikin's left side with right hand chest contact (LsRc). Pressure distribution maps of the palm, peak compression pressure, and compression forces were analysed. RESULTS: The participants' mean age, height, and weight was 24.8 ± 4.8 years, 165.8 ± 8.7 cm, and 62.7 ± 13.5 kg, respectively. Of the participants, 58 and 2 were right- and left-handed, respectively. Significant between-scenario differences were observed in ulnar-side palm pressure. Ulnar-radial pressure differences were higher in the LsLc and RsRc groups than in the LsRc and RsLc groups (0.69 ± 0.62 and 0.73 ± 050 kg/cm2 vs. 0.49 ± 0.49 and 0.50 ± 0.59 kg/cm2; respectively; p < 0.05). Ulnar-radial force differences were higher in the LsLc and RsRs groups than in the sLsLc and RsRs groups. CONCLUSIONS: The higher differences in pressure and force under the LsLc and RsRc approaches may lead to higher risks of potential injury. When performing standard-quality ECC, the LsRc and RsLc approaches, in which compression pressure and force are better distributed, may be more suitable than RsRc or LsLc.

Dry Wearable Textile Electrodes for Portable Electrical Impedance Tomography.

Electrical impedance tomography (EIT), a noninvasive and radiation-free medical imaging technique, has been used for continuous real-time regional lung aeration. However, adhesive electrodes could cause discomfort and increase the risk of skin injury during prolonged measurement. Additionally, the conductive gel between the electrodes and skin could evaporate in long-term usage and deteriorate the signal quality. To address these issues, in this work, textile electrodes integrated with a clothing belt are proposed to achieve EIT lung imaging along with a custom portable EIT system. The simulation and experimental results have verified the validity of the proposed portable EIT system. Furthermore, the imaging results of using the proposed textile electrodes were compared with commercial electrocardiogram electrodes to evaluate their performance.

Validation of MEDS score in predicting short-term mortality of adults with community-onset bacteremia.

BACKGROUND: The Mortality in Emergency Department Sepsis (MEDS) score can be used to stratify ED patients with suspected infections according to mortality risk. However, it has yet to be externally validated for patients having bloodstream infections. METHODS: We retrospectively computed clinical information for the MEDS score, Pitt bacteremia score (PBS), Charlson comorbidity index (CCI), and McCabe-Jackson comorbid classification (MJCC) for adults with community-onset bacteremia. The MEDS score was validated by the comparisons with the following scoring systems: the PBS, CCI, MJCC, PBS plus MJCC, and PBS plus CCI. We evaluated goodness-of-fit statistics and c-statistics as measures of model calibration and discrimination, respectively. RESULTS: Of 2328 adults, a good calibration for 28-day crude mortality was obtained only in the MEDS score and PBS plus MJCC; a higher c-statistic (0.870, P < 0.001) were achieved by the MEDS score, compared to the PBS, CCI MJCC, PBS plus MJCC, and PBS plus CCI. A high c-statistic was observed in two combinative scoring system: the PBS plus CCI (0.855, P < 0.001) and PBS plus MJCC (0.843, P < 0.001). According to the Kaplan-Meier curves, 28-day crude mortality significantly differed between patients with scores equal to or higher than selected cutoff values and those with scores lower than selected cutoff values: 10 in the MEDS score and 5 in the PBS plus MJCC, respectively. CONCLUSION: The MEDS score is an excellent predictor of short-term outcomes in patients with community-onset bacteremia because it provides estimates with higher calibration and discrimination than those of the other scoring systems.

Association of injury pattern and entrapment location inside damaged buildings in the 2016 Taiwan earthquake.

BACKGROUND/PURPOSE: To explore the association of patient injury patterns and entrapped locations inside damaged buildings in the 2016 Taiwan earthquake. METHODS: A retrospective analysis was conducted using the Tainan incident registry system. Residents inside nine conjunctive, 16-story (49.3 m in height) reinforced concrete buildings were categorized as non-injured, injured, and dead. Residents were classified into different groups according to their entrapped locations in height and the severity of building damage. The field triage acuity and trauma severity among groups were compared. Statistical significance was set at the level of 0.05. RESULTS: There were 309 enrollees with 76 (24.6%) non-injured, 118 (38.2%) injured, and 115 (37.2%) dead. Residents either in the high floors (odds ratio [OR] = 2.9, 95% CI: 1.5-5.8, p = 0.003) or in the collapsed buildings (OR = 18.2, 95% CI: 7.6-43.6, p < 0.001) were more likely to be dead. Injured patients who were located in the high floors were more likely to have severe field triage acuities (adjusted OR = 14.7, 95% CI: 1.8-118.0, p = 0.012); intracranial hemorrhage (12.5%), intrathoracic injury (18.8%), or intra-abdominal damage (12.5%) (All p < 0.05); the need for emergency surgical intervention (31.3%, p = 0.035); and major trauma (18.8%, p = 0.001). Residents in the collapsed buildings were more likely to have a crush injury (80.0%, p < 0.001) or crush syndrome (80.0%, p < 0.001). CONCLUSION: People entrapped at different heights of floors or in differently damaged buildings could have a distinct pattern of injury. Our findings may facilitate strategic approaches of patients entrapped in damaged buildings and may contribute to future training for field searches and rescues after earthquakes.

Ambulance traffic accidents in Taiwan.

BACKGROUND/PURPOSE: Ambulance traffic accidents (ATAs) are the leading cause of occupation-related fatalities among emergency medical service (EMS) personnel. We aim to use the Taiwan national surveillance system to analyze the characteristics of ATAs and to assist EMS directors in developing policies governing ambulance operations. METHODS: A retrospective, cross-sectional and largely descriptive study was conducted using Taiwan national traffic accidents surveillance data from January 1, 2011 to October 31, 2016. RESULTS: Among the 1,627,217 traffic accidents during the study period, 715 ATAs caused 8 deaths within 24 h and 1844 injured patients. On average, there was one ATA for every 8598 ambulance runs. Compared to overall traffic accidents, ATAs were 1.7 times more likely to result in death and 1.9 times more likely to have injured patients. Among the 715 ATAs, 8 (1.1%) ATAs were fatal and 707 (98.9%) were nonfatal. All 8 fatalities were associated with motorcycles. The urban areas were significantly higher than the rural areas in the annual number of ATAs (14.2 ± 7.3 [7.0-26.7] versus 3.1 ± 1.9 [0.5-8.4], p = 0.013), the number of ATA-associated fatalities per year (0.2 ± 0.2 [0.0-0.7] versus 0.1 ± 0.1 [0.0-0.2], p = 0.022), and the annual number of injured patients (who needed urgent hospital visits) in ATAs (19.4 ± 7.3 [10.5-30.9] versus 5.2 ± 3.8 [0.9-15.3], p < 0.001). CONCLUSION: The ATA-associated fatality rate in Taiwan was high, and all fatalities were associated with motorcycles. ATAs in a highly motorcycle-populated area may require further investigation. An ambulance traffic accident reporting system should be built to provide EMS policy guidance for ATA reduction and outcome improvements.

Community-onset febrile illness in HIV-infected adults: variable pathogens in terms of CD4 counts and transmission routes.

OBJECTIVES: The objective of the study is to investigate the causes of febrile illness among HIV-infected adults visiting the emergency department (ED) of a designated hospital for HIV care in Taiwan, an area of a low HIV prevalence. METHODS: From January 2004 to December 2012, all febrile HIV-infected adults visiting the ED were retrospectively investigated. Recent CD4 lymphocyte counts near ED visits and HIV transmission route were designated as major predictors for the analyses. All variables and clinical information were derived from chart records. RESULTS: Of the 196 eligible HIV-infected adults, major causes of febrile illness were lower respiratory tract infections (68, 34.7%), skin and soft tissue infections (31, 15.8%), intra-abdominal infections (22, 11.2%), and urinary tract infections (11, 5.6%). There were 150 pathogens identified. Staphylococcus aureus (51, 34.0%) and Pneumocystis jirovecii (26, 17.3%) were the major pathogens. In a multivariate analysis, injection drug use (odds ratio, 15.18; P < .001) and skin and soft tissue infections (odds ratio, 18.45; P = .001) were independently associated with S aureus infections, and the proportion of S aureus increased steadily with CD4 lymphocyte count (γ = 0.99; P = .01). Of pneumonic patients with recognized pathogens, P. jirovecii pneumonia was frequently associated with patients having a CD4 lymphocyte count of less than 100 cells/mm(3) (25/25, 100% vs 16/30, 53.3%; P < .001). CONCLUSIONS: The causes of febrile illness in HIV-infected adults visiting the ED varied according to CD4 count and transmission route. Two independent risk factors, intravenous drug use and skin and soft tissue infections, were associated with S aureus infections. For HIV-infected adults with lower respiratory tract infections, a CD4 lymphocyte count of less than 100 cells/mm(3) was a risk factor for P. jirovecii pneumonia.

Clinical features and impact of empirical therapy in cirrhotic adults with community-onset bacteremia.

OBJECTIVES: The objectives were to investigate the clinical characteristics of community-onset bacteremia in cirrhotic adults visiting the emergency department (ED), as well as the clinical impact of empirical antibiotics on their outcome. METHODS: Cirrhotic adults with community-onset bacteremia who visited the ED from January 2005 to December 2009 were included retrospectively. Clinical data and outcome were collected from the medical chart. The in vitro susceptibility was measured by the broth microdilution method. RESULTS: Of the 246 bacteremic episodes in cirrhotic patients, the major sources of bacteremia included intraabdominal infections (111, 45.1%), primary bacteremia (43, 17.5%), urinary tract infection (39, 15.9%), and soft tissue infection (22, 8.9%). Of the 258 bacteremic pathogens identified, Escherichia coli (83 isolates, 33.7%) and Klebsiella pneumoniae (61, 23.6%) were the most common microorganisms. In the multivariate analysis, delayed appropriate antibiotic therapy (>72 hours; odds ratio [OR], 4.29; P=.003), serum creatinine greater than 1.5 mg/dL at the ED (OR, 3.12; P=.005), severe sepsis (OR, 3.61; P=.01), Pittsburgh bacteremia score of at least 4 (OR, 2.66; P=.04), bacteremia due to pneumonia (OR, 5.44; P=.02), and a comorbidity of diabetes mellitus (OR, 3.54; P=.004) were independently associated with the 28-day mortality. CONCLUSIONS: Focusing on cirrhotic adults with community-onset bacteremia, we emphasized that the cirrhosis severity is one of the critical factors when choosing empirical antimicrobial therapy and that the strategy of empirical therapy is warranted for cirrhotic adults with severe decompensation (Child's C group). For critically ill patients, especially in those with Child's C group, only piperacillin/tazobactam, ertapenem, or imipenem treatment was warranted because of susceptibility rate of greater than 90%.

Different clinical presentation of community-onset bacteremia among neutropenic adults in the ED.

OBJECTIVES: To analyze the differences in clinical presentation and characteristics of community-onset bacteremia between neutropenic and nonneutropenic adults visiting the emergency department. METHODS: A case-control study with a ratio of 1:2 was conducted retrospectively over a 6-year period. Demographic characteristics, microorganisms, severity of illness, and clinical outcomes determined from medical records were analyzed. RESULTS: In total, 116 neutropenic adults (case patients) and 232 nonneutropenic adults (control patients) were examined. Significant differences in the source of bacteremia, susceptibility, and species of bacteremia-causing organisms between the case patients and control patients were observed by univariate analyses. Significantly more patients presenting with an initial syndrome of severe sepsis or septic shock at the emergency department, having high Pittsburgh bacteremia scores (≥4 points) or having severe comorbidities (McCabe classification), and high 28-day mortality rates were discovered in the case group, compared with the control group. Of note, Pseudomonas aeruginosa (32/137 [23.4%] vs 8/272 [2.9%], P < .001) was more often isolated from the case patients. In a further analysis using a multivariate regression to demonstrate the independent predictors of P aeruginosa infection, patients with neutropenia remained as an independent risk factors (odds ratio, 7.48; P < .001). CONCLUSIONS: This study demonstrated obvious differences of community-onset bacteremia in severity, the distribution of microorganisms, and susceptibility between neutropenic and nonneutropenic patients. Antipseudomonas therapy was empirically suggested for neutropenic patients with community-onset bacteremia and reducing the need for a glycopeptide.

Different clinical presentation of community-onset bacteremia among human immunodeficiency virus-infected and human immunodeficiency virus-uninfected adults in the ED.

OBJECTIVES: The objective of this study is to analyze the differences in clinical presentation and outcome of community-onset bacteremia between human immunodeficiency virus (HIV)-infected adults and HIV-uninfected adults visiting the emergency department (ED). METHODS: A multicenter, case-control study with a ratio of 1:4 was conducted retrospectively over an 8-year period. Demographic characteristics, severity of illness, and clinical outcomes determined from chart records were analyzed. RESULTS: In total, 74 HIV-infected adults (case patients) and 288 HIV-uninfected adults (control patients) were examined. Significant differences in clinical presentation, severity, and the source of bacteremia as well as bacteremia-causing microorganisms between the case patients and control patients were observed by univariate analyses. Using multivariate analyses, the following variables were positively associated with case patients: male sex (odds ratio [OR], 3.42; P = .01), bacteremia due to endocarditis (OR, 7.68; P = .007), bacteremia due to Salmonella enteritidis (OR, 4.29; P = .03), and comorbidity with chronic hepatitis (OR, 5.65; P < .001). Moreover, several independent risk factors of 28-day mortality were discovered, including inappropriate empirical antibiotic therapy after the ED visit (OR, 9.01; P < .001), an initial syndrome with septic shock (OR, 5.37; P < .001); a Pittsburgh bacteremia score greater than or equal to 4 points at the ED (OR, 4.28; P = .002), severe underlying disease based on McCabe classification (rapid and ultimately fatal; OR, 3.31; P = .002), and bacteremia due to pneumonia (OR, 2.66; P = .03). Of note, HIV infection was not a significant factor affecting 28-day mortality. CONCLUSIONS: This study demonstrated that the clinical characteristics, the severity, and the character of bacteremia in HIV-infected and uninfected patients varied among community-onset bacteremic patients visiting the ED, despite the limited impact of HIV infection on short-term outcomes.

Electromyography activity of selected trunk muscles during cardiopulmonary resuscitation.

BACKGROUND: Understanding trunk muscle activity during chest compression may improve cardiopulmonary resuscitation (CPR) training strategies of CPR or prevent low back pain. This study investigates the trunk muscle activity pattern of chest compression in health care providers to determine the pattern alternation during chest compression. METHODS: Thirty-one experienced health care providers performed CPR for 5 minutes at a frequency of 100 compressions per minute. An electromyography (EMG) system was used to record muscle activity in the first minute, the third minute, and the fifth minute. Electrodes were placed bilaterally over the pectoralis major, latissimus dorsi, rectus abdominis, erector spinae, and gluteus maximus. We calculated the root mean square (RMS) value and maximal amplitude of the EMG activity, median frequency, and delivered force. RESULTS: The maximal amplitude of EMG of the pectoralis major, erector spinae, and rectus abdominis showed large muscle activity above 45% of maximal voluntary contraction under chest compression. There were no significant differences in the RMS value of one chest compression cycle (RMS100%) and median frequency for all muscles at the first, third, and fifth minutes. Only gluteus maximus showed significant imbalance. The EMG ratios (erector spinae/rectus abdominis; erector spinae/gluteus maximus) increased significantly over time. The delivered force, compression depth, and number of correct depth decreased significantly over time. CONCLUSION: We suggest that the muscle power training for the pectoralis major, erector spinae, and rectus abdominis could be helpful for health care providers. Keeping muscle activity balance of bilateral gluteus maximus and maintaining the same level of EMG ratios might be the keys to prevent low back pain while performing CPR.

Push-fast recommendation on performing CPR causes excessive chest compression rates, a manikin model.

BACKGROUND: Increasing chest compression rate during cardiopulmonary resuscitation can affect the workload and, ultimately, the quality of chest compression. This study examines the effects of compression at the rate of as-fast-as-you-can on cardiopulmonary resuscitation (CPR) performance. METHODS: A crossover, randomized-to-order design was used. Each participant performed chest compressions without ventilation on a manikin with 2 compression rates: 100 per minute (100-cpm) and "push as-fast-as you-can" (PF). The participants performed chest compressions at a rate of either 100-cpm or PF and subsequently switched to the other after a 50-minute rest. RESULTS: Forty-two CPR-qualified nonprofessionals voluntarily participated in the study. During the PF session, the rescuers performed CPR with higher compression rates (156.8 vs 101.6 cpm), more compressions (787.2 vs 510.8 per 5 minutes), and more duty cycles (51.0% vs 41.7%), but a lower percentage of effective compressions (47.7% vs 57.9%) and a lower compression depth (35.6 vs 38.0 mm) than they did during the 100-cpm session. The CPR quality deteriorated in numbers and percentile of effective compression since the third minute in the PF session and the fourth minute in the 100-cpm session. The percentile of compressions with adequate depth in the 100-cpm sessions was higher than that in the PF sessions during the second, third, and fourth minutes of CPR. CONCLUSION: Push-fast technique showed a significant decrease in the percentile of effective chest compression compared with the 100-cpm technique during the 5-minute hand-only CPR. The PF technique exhibited a trend toward increased fatigue in the rescuers, which can result in early decay of CPR quality.

Electrolyte abnormalities and laboratory findings in patients with out-of-hospital cardiac arrest who have kidney disease.

PURPOSES: Although electrolyte abnormalities have been generally considered the major cause of out-of-hospital cardiac arrest (OHCA) in patients with kidney disease (KD), this association has never been prospectively validated. METHODS: A prospective, observational study was conducted in a tertiary university hospital between January 2008 and December 2009. The study sample consisted of consecutively admitted patients with nontraumatic OHCA. Based on the estimated glomerular filtration rate (eGFR, unit: milliliters per minute per 1.73 m(2)), the enrollees were divided into 3 groups: group A (normal kidney function or mild KD; eGFR, 60.0), group B (moderate KD; eGFR between 15.0 and 59.9), and group C (severe KD; eGFR<15.0 or on dialysis). The laboratory findings of the groups were compared. Two-tailed P values less than .005 were considered significant. RESULTS: Two hundred thirty-four enrollees (137 were male) were divided into 3 groups: group A (n = 51; 21.8%), group B (n = 128; 54.7%), and group C (n = 55; 23.5%). Compared with the other 2 groups, group C presented significantly higher serum potassium and magnesium and lower pH and hemoglobin level (all P < .005). After stratifications of the significant variables, a post hoc analysis revealed that group C presented significantly higher incidences of hypermagnesemia (Mg >2.5 mmol/L) and severe hyperkalemia (K >6.5 mmol/L) (both P < .005) than the other 2 groups. The odds ratios of the incidence of severe hyperkalemia in group C was 3.37 (95% confidence intervals, 1.46-7.77) compared with group A (50.9% vs 23.5%, P < .005). CONCLUSIONS: Severe hyperkalemia is common in patients with OHCA who have severe KD and should be considered during resuscitation for these patients.

Prognostic values of blood ammonia and partial pressure of ammonia on hospital arrival in out-of-hospital cardiac arrests.

PURPOSES: Outcome prediction for out-of-hospital cardiac arrest (OHCA) is of medical, ethical, and socioeconomic importance. We hypothesized that blood ammonia may reflect tissue hypoxia in OHCA patients and conducted this study to evaluate the prognostic value of ammonia for the return of spontaneous circulation (ROSC). METHODS: This prospective, observational study was conducted in a tertiary university hospital between January 2008 and December 2008. The subjects consisted of OHCA patients who were sent to the emergency department (ED). The primary outcome was ROSC. The prognostic values were calculated for ammonia levels and the partial pressure of ammonia (pNH(3)), and the results were depicted as a receiver operating characteristics curve with an area under the curve. RESULTS: Among 119 patients enrolled in this study, 28 patients (23.5%) achieved ROSC. Ammonia levels and pNH(3) in the non-ROSC group were significantly higher than those in the ROSC group (167.0 µmol/L vs 80.0 µmol/L, P < .05; 2.61 × 10(-5) vs 1.67 × 10(-5) mm Hg, P < .05, respectively). The predictive capacity of area under the curve for ammonia and pNH(3) for non-ROSC was 0.85 (95% confidence interval, 0.75-0.95) and 0.73 (95% confidence interval, 0.61-0.84), respectively. The multivariate analysis confirmed that ammonia and pNH(3) are independent predictors of non-ROSC. The prognostic value of ammonia was better than that of pNH(3). The cutoff level for ammonia of 84 µmol/L was 94.5% sensitive and 75.0% specific for predicting non-ROSC with a diagnostic accuracy of 89.9%. CONCLUSIONS: Hyperammonemia on ED arrival is independently predictive of non-ROSC for OHCA patients. The findings may offer useful information for clinical management.

Development of an educational program for staffs of emergency medical service to improve their awareness of stroke within 3 hours of symptom onset: a pilot study.

PURPOSE: Timely identification and transport are crucial for the pre-hospital management of stroke by emergency medical service (EMS) providers. In this preliminary study, our aim was to develop an educational program which can improve 1) stroke knowledge and 2) triage accuracy of identifying acute stroke within 3 hours of symptom onset by dedicated EMS providers in Tainan city. METHODS: A total of 33 providers received a written test before, immediately after, and 3 months after completing the educational program, which was about stroke knowledge, diagnosis, and management. The test (total score, 39) contained three sections: two on stroke knowledge (consisting of true-false and choice questions) and one on clinical scenarios (situational descriptions and videos). RESULTS: The mean total score improved significantly immediately after the program. An increase in mean score was also noted for all three sections. The increase in total score lasted 3 months. The linear regression model showed greater improvement on scores correlated with lower pretest total score only, not correlated with age, gender, work year and the learning or working experience. CONCLUSION: The educational program increased knowledge about stroke and improved the accuracy of triage by dedicated EMS providers. Further investigation is needed to determine the effectiveness of similar educational programs for non-dedicated EMS responders.