Grey-to-White Matter Ratio Values in Early Head Computed Tomography (CT) as a Predictor of Neurologic Outcomes in Survivors of Out-of-Hospital Cardiac Arrest Based on Severity of Hypoxic-Ischemic Brain Injury.

BACKGROUND: Hypoxic-ischemic brain injury (HIBI) is a common complication of out-of-hospital cardiac arrest (OHCA). OBJECTIVES: We investigated whether grey-to-white matter ratio (GWR) values, measured using early head computed tomography (HCT), were associated with neurologic outcomes based on the severity of HIBI in survivors of OHCA. METHODS: This retrospective multicenter study included adult comatose OHCA survivors who underwent an HCT scan within 2 h after the return of spontaneous circulation. HIBI severity was assessed using the revised post-Cardiac Arrest Syndrome for Therapeutic hypothermia (rCAST) scale (low, moderate, and severe). Poor neurologic outcomes were defined as Cerebral Performance Categories 3 to 5 at 6 months after OHCA. RESULTS: Among 354 patients, 27% were women and 224 (63.3%) had poor neurologic outcomes. The distribution of severity was 19.5% low, 47.5% moderate, and 33.1% severe. The area under the receiver operating curves of the GWR values for predicting rCAST severity (low, moderate, and severe) were 0.52, 0.62, and 0.79, respectively. The severe group had significantly higher predictive performance than the moderate group (p = 0.02). Multivariate logistic regression analysis revealed a significant association between GWR values and poor neurologic outcomes in the moderate group (adjusted odds ratio = 0.012, 95% CI 0.0-0.54, p = 0.02). CONCLUSIONS: In this cohort study, GWR values measured using early HCT demonstrated variations in predicting neurologic outcomes based on HIBI severity. Furthermore, GWR in the moderate group was associated with poor neurologic outcomes.

Comparison of cosmetic appearances after facial lacerations repaired by junior residents and experts.

PURPOSE: The technical factors which improve cosmetic outcomes and which need to be emphasized in education of junior residents have yet to be described. We compared cases in which suturing was performed by either junior emergency medicine residents or experts, in order to determine the focus of future education and training. METHODS: Wound registry data was reviewed and retrospectively analyzed from September 2015 to February 2016. Only patients who visited the emergency room with facial lacerations were enrolled, and their wound registry data sheets were reviewed. Practitioners were divided into junior resident and expert groups. We assessed the progress using the Stony Brook Scar Evaluation Scale (SBSES) 5-10 days following suturing. RESULTS: Sixty-six patients were enrolled; 43 (65.2%) were men. The median (interquartile range) cosmetic scores (SBSES scale) for suturing performed by junior residents or experts were 3 (2-4) and 5 (4-5), respectively (p = 0.001). The percentage of maximum scores for each SBSES category was significantly lower in the junior resident group than in the expert group for width (68% vs. 86%), hatch marks (68% vs. 93%), and overall appearance (41% vs. 80%) (all p < 0.001). CONCLUSIONS: There were significant differences in scar widths and hatch marks, which were attributable to the skill level of the practitioner who performed the suturing of facial lacerations. Junior residents should be educated about maintenance of proper tension, atraumatic technique, and performing appropriate trimming or debridement.

Comparison of overlapping (OP) and adjacent thumb positions (AP) for cardiac compressions using the encircling method in infants.

OBJECTIVES: The aim of this manikin study was to compare the efficiency between overlapping (OP) and adjacent thumb positions (AP) for cardiac compressions using the encircling method in infants. METHODS: The study conducted from December 2010 to August 2011 involved 48 volunteers who were students in the emergency medical technician course. The authors let volunteers practice OP and AP as a crossover design. The authors monitored the simulated mean arterial pressure (MAP) generated during a 5-min chest compression. The fatigue level of the volunteers after the chest compression was evaluated with the Likert scale. RESULTS: There were no significant differences in MAP between the dominant hand and the non-dominant hand as the lower thumb of OP. Significant differences were observed in simulated systolic blood pressure, MAP and simulated pulse pressure between OP and AP at 1, 2, 3, 4 and 5 min. There were no significant differences among the changes in heart rate, respiratory rate and end-tidal CO(2) during a 5-min chest compression by OP and AP. The Likert scale scores (1 no fatigue to 5 = extreme fatigue) during the 5-min chest compressions were higher in AP than in OP at 2, 3 and 5 min. CONCLUSION: Higher intrathoracic pressures were achieved by OP in this study. However, further studies are needed to validate these effects of overlapping thumbs technique in infant cardiopulmonary resuscitation, not manikin.

Does Combining Biomarkers and Brain Images Provide Improved Prognostic Predictive Performance for Out-Of-Hospital Cardiac Arrest Survivors before Target Temperature Management?

We examined whether combining biomarkers measurements and brain images early after the return of spontaneous circulation improves prognostic performance compared with the use of either biomarkers or brain images for patients with cardiac arrest following target temperature management (TTM). This retrospective observational study involved comatose out-of-hospital cardiac arrest survivors. We analyzed neuron-specific enolase levels in serum (NSE) or cerebrospinal fluid (CSF), grey-to-white matter ratio by brain computed tomography, presence of high signal intensity (HSI) in diffusion-weighted imaging (DWI), and voxel-based apparent diffusion coefficient (ADC). Of the 58 patients, 33 (56.9%) had poor neurologic outcomes. CSF NSE levels showed better prognostic performance (area under the curve (AUC) 0.873, 95% confidence interval (CI) 0.749-0.950) than serum NSE levels (AUC 0.792, 95% CI 0.644-0.888). HSI in DWI showed the best prognostic performance (AUC 0.833, 95% CI 0.711-0.919). Combining CSF NSE levels and HSI in DWI had better prognostic performance (AUC 0.925, 95% CI 0.813-0.981) than each individual method, followed by the combination of serum NSE levels and HSI on DWI and that of CSF NSE levels and the percentage of voxels of ADC (AUC 0.901, 95% CI 0.792-0.965; AUC 0.849, 95% CI 0.717-0.935, respectively). Combining CSF/serum NSE levels and HSI in DWI before TTM improved the prognostic performance compared to either each individual method or other combinations.

Ultra-early neurologic outcome prediction of out-of-hospital cardiac arrest survivors using combined diffusion-weighted imaging findings and quantitative analysis of apparent diffusion coefficient.

AIM: This study examined whether the presence of cortical necrosis (CN) on ultra-early diffusion-weighted imaging (DWI) and the severity of cytotoxic oedema (CytE) with cerebral oedema (CbrE), measured using quantitative analysis of apparent diffusion coefficient (ADC), could predict neurological outcomes before targeted temperature management in out-of-hospital cardiac arrest survivors (OHCAs). METHODS: In this retrospective study, the first DWI with ADC scans was performed within 6 h; the second was obtained between 72 and 96 h after return of spontaneous circulation. The primary outcome was neurological outcomes at 6 months after OHCA. The % voxels of ADC value (PV) was calculated; CbrE and CytE values were > or < than 650-6 mm2/s, respectively. The best performance PV was obtained from CytE (thld-CytE) and CbrE values (thld-CbrE). Prognostic performances of CN, thld-CytE, thld-CbrE, and converted scores were calculated in combination. The changes in DWI findings and the difference between the PV (ΔPV) from the first and second DWI were analysed. RESULTS: Thirty-six patients were included. CN (area under receiver operating characteristic curve [AUC] = 0.800), thld-CytE (PV420; AUC = 0.730), and thld-CbrE (PV1090; AUC = 0.775) showed meaningful performance, and the combined score showed best performance for poor outcome prediction (AUC = 0.956). DWI findings of CN patients was worse at the second DWI. ΔPV significantly increased in the poor outcome group, CN patients, and the group including both, thld-CytE and thld-CbrE. CONCLUSIONS: In OHCAs, ultra-early DWI with ADC could successfully predict poor neurological outcomes by combining scores of CN, thld-CytE, and thld-CbrE.

Usefulness of Intracranial Pressure and Mean Arterial Pressure for Predicting Neurological Prognosis in Cardiac Arrest Survivors Who Undergo Target Temperature Management.

We aimed to compare the relationship of mean arterial pressure (MAP) and intracranial pressure (ICP) to predict the neurological prognosis in cardiac arrest (CA) survivors. We retrospectively examined out-of-hospital CA patients treated with targeted temperature management. ICP was measured using cerebrospinal fluid (CSF) pressure, whereas MAP was measured as blood pressure monitored through the radial or femoral artery during CSF pressure measurement. Primary outcome was 6-month neurological outcome. Of 92 enrolled patients, the favorable outcome group comprised 31 (34%) patients. The median and interquartile range of MAP were significantly higher and ICP was significantly lower in patients with favorable neurological outcomes than in those with unfavorable neurological outcomes (94.3 mmHg [80.0-105.3] vs. 82.0 mmHg [65.3-96.3], p = 0.021 and 9.4 mmHg [10.8-8.7] vs. 18.8 mmHg [20.0-15.7], p < 0.001, respectively). ICP showed the higher area under the receiver operating characteristic curve (area under curve [AUC] = 0.953, 95% confidence interval [CI] = 0.888-0.986) for neurological outcome prediction. MAP showed the lower AUC (0.648, 95% CI = 0.541-0.744). Higher accurate prognosis was predicted by ICP than MAP, and the prognostic performance was good. Prospective multicenter studies are required to confirm these results.

Usefulness of a quantitative analysis of the cerebrospinal fluid volume proportion in brain computed tomography for predicting neurological prognosis in cardiac arrest survivors who undergo target temperature management.

PURPOSE: Brain swelling post-cardiac arrest may affect cerebrospinal fluid volume. We aimed to investigate the prognostic performance of the proportion of cerebrospinal fluid volume (pCSFV) using brain computed tomography (CT) in cardiac arrest survivors. MATERIALS AND METHODS: This retrospective multicentre study included adult comatose cardiac arrest survivors who underwent brain CT scan prior to target temperature management (TTM) from 2015 to 2016. Grey-to-white matter ratio (GWR) and pCSFV values were calculated. pCSFV analysis was performed using automated quantitative analysis programming. The primary outcome was a 6-month neurological outcome. RESULTS: Of 251 patients (median age, 57 years), 173 (68.9%) were male, 87 (34.7%) had a shockable rhythm, and 160 (63.7%) had unfavourable neurological outcomes. GWR but not pCSFV was significantly higher in terms of favourable neurological outcomes (p = .015). pCSFV prognostic performances were similar to GWR, and were poor overall, (0.521; 95% confidence interval [CI], 0.446-0.694 vs. 0.515; 95% CI, 0.441-0.589). After adjusting for covariates, pCSFV but not GWR was independently associated with neurological outcome 6 months following cardiac arrest (p = .049). CONCLUSION: pCSFV was independently associated with neurological outcome 6 months following cardiac arrest, however prognostic performance was not good.

Is it possible to reduce intra-hospital transport time for computed tomography evaluation in critically ill cases using the Easy Tube Arrange Device?

OBJECTIVE: Patients are often transported within the hospital, especially in cases of critical illness for which computed tomography (CT) is performed. Since increased transport time increases the risks of complications, reducing transport time is important for patient safety. This study aimed to evaluate the ability of our newly invented device, the Easy Tube Arrange Device (ETAD), to reduce transport time for CT evaluation in cases of critical illness. METHODS: This prospective randomized control study included 60 volunteers. Each participant arranged five or six intravenous fluid lines, monitoring lines (noninvasive blood pressure, electrocardiography, central venous pressure, arterial catheter), and therapeutic equipment (O2 supply device, Foley catheter) on a Resusci Anne mannequin. We measured transport time for the CT evaluation by using conventional and ETAD method. RESULTS: The median transport time for CT evaluation was 488.50 seconds (95% confidence interval [CI], 462.75 to 514.75) and, 503.50 seconds (95% CI, 489.50 to 526.75) with 5 and 6 fluid lines using the conventional method and 364.50 seconds (95% CI, 335.00 to 388.75), and 363.50 seconds (95% CI, 331.75 to 377.75) with ETAD (all P<0.001). The time differences were 131.50 (95% CI, 89.25 to 174.50) and 148.00 (95% CI, 116.00 to 177.75) (all P<0.001). CONCLUSION: The transport time for CT evaluation was reduced using the ETAD, which would be expected to reduce the complications that may occur during transport in cases of critical illness.

Reduction of intra-hospital transport time using the easy tube arrange device.

OBJECTIVE: Critically ill patients sometimes require transport to another location. Longer intra-hospital transport time increases the risk of hemodynamic instability and associated complications. Therefore, reducing intra-hospital transport time is critical. Our objective was to evaluate whether or not a new device the easy tube arrange device (ETAD) has the potential to reduce intra-hospital transport time of critically ill patients. METHODS: We enrolled volunteers for this prospective randomized controlled study. Each participant arranged four, five, and six fluid tubings, monitoring lines, and therapeutic equipment on a cardiopulmonary resuscitation training mannequin (Resusci Anne). The time required to arrange the fluid tubings for intra-hospital transport using two different methods was evaluated. RESULTS: The median time to arrange four, five, and six fluid tubings was 86.00 (76.50 to 98.50), 96.00 (86.00 to 113.00), and 115.50 (93.00 to 130.75) seconds, respectively, using the conventional method and 60.50 (52.50 to 72.75), 69.00 (57.75 to 80.80), and 72.50 (64.75 to 90.50) seconds using the ETAD (all P<0.001). The total duration (for preparing the basic setting and organizing before and after the transport) was 280.00 (268.75 to 293.00), 315.50 (304.75 to 330.75), and 338.00 (319.50 to 360.25) seconds for four, five, and six fluid tubings, respectively, using the conventional method and 274.50 (261.75 to 289.25), 288.00 (271.75 to 298.25), and 301.00 (284.50 to 310.75) seconds, respectively, using the new method (P=0.024, P<0.001, and P<0.001, respectively). CONCLUSION: The ETAD was convenient to use, reduced the time to arrange medical tubings, and is expected to assist medical staff during intra-hospital transport.

A study on the disaster medical response during the Mauna Ocean Resort gymnasium collapse.

OBJECTIVE: To investigate and document the disaster medical response during the Gyeongju Mauna Ocean Resort gymnasium collapse on February 17, 2014. METHODS: Official records of each institution were verified to select the study population. All the medical records and emergency medical service run sheets were reviewed by an emergency physician. Personal or telephonic interviews were conducted, without a separate questionnaire, if the institutions or agencies crucial to disaster response did not have official records or if information from different institutions was inconsistent. RESULTS: One hundred fifty-five accident victims treated at 12 hospitals, mostly for minor wounds, were included in this study. The collapse killed 10 people. Although the news of collapse was disseminated in 4 minutes, dispatch of 4 disaster medical assistance teams took at least 69 minutes to take the decision of dispatch. Four point five percent were treated at the accident site, 56.7% were transferred to 2 hospitals that were nearest to the collapse site, and 42.6% were transferred to hospitals that were poorly prepared to handle disaster victims. CONCLUSION: In the Gyeongju Mauna Ocean Resort gymnasium collapse, the initial triage and distribution of patients was inefficient and medical assistance arrived late. These problems had also been noted in prior mass casualty incidents.

Analysis on sports and recreation activity-related eye injuries presenting to the Emergency Department.

AIM: To investigate the incidence and general characteristics of sports-related eye injuries in patients visiting the Emergency Department. METHODS: A cross-sectional, multi-center, observational study. Patients with an injured eye who visited the Emergency Department at one of nine hospitals in Korea were enrolled. All data were prospectively collected between March and September 2010 using a questionnaire. Eye injuries that occurred during risky sports were examined by gender and age. Additionally, the rate of open globe injuries that occurred with and without protective eyewear was examined for each activity. Continuous variables were compared using Student's t-test and categorical variables were compared using Chi-square test. RESULTS: A total of 446 patients had sports-related eye injuries. Teenagers (10-19 years old) and young adults (20-29 years old) had the most eye injuries. Eye injuries accounted for 0.2% of Emergency Department patients. Baseball was the most common cause of sports-related eye injuries, followed by soccer and hiking. Protective gear was worn by 9.4% of all patients. Patients that were 30-39 years of age had the highest rate of protective gear use, followed by patients that were 40-49 years of age. The proportion of sports-related eye injuries that were open-globe injuries was highest for soccer and hiking. CONCLUSION: Although injuries were most common in patients below the age of 10 years, these patients had the lowest rate of protective eyewear use. Injuries in adults over 40 years of age most commonly occurred during hiking, but the rate of protective eyewear use was low. Young athletes should be educated on and provided with protective eyewear and policies protective gear use should be established. For older adults, eye protection should be encouraged, especially during hiking.

A comparison of the area of chest compression by the superimposed-thumb and the alongside-thumb techniques for infant cardiopulmonary resuscitation.

OBJECTIVES: We investigated whether the superimposed-thumb technique could reduce the chest compression area in infant cardiopulmonary resuscitation (CPR). METHODS: Charts and multidirectional computed tomography images of infants presented to four hospitals from January 2007 to September 2010 were reviewed retrospectively. We measured at the point of maximal anterior-posterior heart diameter the width of the sternum meter (S(ap)), vertical heart length from S(ap), length and width of the superimposed-thumb technique and length and width of the alongside-thumb technique. We studied the structures located underneath thumbs superimposed and thumbs alongside at S(ap) and S(nipple) (the sternum of the inter-nipple line). RESULTS: In the 84 infants enrolled, the width of the sternum at S(ap), and the vertical heart length from S(ap) were 0.85 ± 0.31 and 1.71 ± 0.47 cm, respectively. The length and width of the superimposed-thumb technique were 1.65 ± 0.13 and 2.73 ± 0.22 cm, respectively. The length and width of the alongside-thumb technique were 3.00 ± 0.48 and 3.77 ± 0.24 cm, respectively. The liver was situated underneath thumbs superimposed at S(ap) in 59.5% infants. The livers and lungs of 73.8% and 64.3% infants, respectively, were underneath thumbs alongside at S(nipple). CONCLUSION: In this study, we confirmed that the superimposed-thumb technique may reduce chest compression area in infant CPR. The lungs or livers were located more often underneath thumbs alongside at S(nipple) than underneath thumbs superimposed at S(ap). However, further studies are needed to validate the efficiency and safety of this technique.

Magnetic resonance imaging as a diagnostic adjunct to Wernicke encephalopathy in the ED.

This report describes usefulness of magnetic resonance imaging (MRI) for the evaluation of the patient suspected of Wernicke encephalopathy (WE). Magnetic resonance imaging shows characteristic findings of symmetric hyperintense lesions predominantly located in the bilateral medial thalami, the periaqueductal regions, and the mamillary bodies. The diagnosis of Wernicke encephalopathy has been based generally on history and clinical symptoms. We now believe that MRI could be used as a diagnostic adjunct in the patient suspected of WE.

Diffusion-weighted MRI as a screening tool of stroke in the ED.

This report describes a novel imaging technology for the evaluation of stroke patients. Diffusion-weighted magnetic resonance imaging can visualize hyperacute ischemic stroke which cannot be seen on computed tomography; moreover, it only takes few minutes to scan. We believe that diffusion-weighted magnetic resonance imaging, rather than routine computed tomography, should be considered when the emergency physician evaluates a patient with acute ischemic stroke.