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

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

Characteristic of school injuries in Asia: a cross-national, multi-center observational study.

BACKGROUND: To prevent school injuries, thorough epidemiological data is an essential foundation. We aimed to investigate the characteristics of school injuries in Asia and explore risk factors for major trauma. METHODS: This retrospective study was conducted in the participating centers of the Pan-Asian Trauma Outcome Study from October 2015 to December 2020. Subjects who reported "school" as the site of injury were included. Major trauma was defined as an Injury Severity Score (ISS) value of ≥16. RESULTS: In total, 1305 injury cases (1.0% of 127,715 events) occurred at schools. Among these, 68.2% were children. Unintentional injuries were the leading cause and intentional injuries comprised 7.5% of the cohort. Major trauma accounted for 7.1% of those with documented ISS values. Multivariable regression revealed associations between major trauma and factors, including age, intention of injury (self-harm), type of injury (traffic injuries, falls), and body part injured (head, thorax, and abdomen). Twenty-two (1.7%) died, with six deaths related to self-harm. Females represented 28.4% of injuries but accounted for 40.9% of all deaths. CONCLUSIONS: In Asia, injuries at schools affect a significant number of children. Although the incidence of injuries was higher in males, self-inflicted injuries and mortality cases were relatively higher in females. IMPACT: Epidemiological data and risk factors for major trauma resulting from school injuries in Asia are lacking. This study identified significant risk factors for major trauma occurring at schools, including age, intention of injury (self-harm), injury type (traffic injuries, falls), and body part injured (head, thoracic, and abdominal injuries). Although the incidence of injuries was higher in males, the incidence of self-harm injuries and mortality rates were higher in females. The results of this would make a significant contribution to the development of prevention strategies and relative policies concerning school injuries.

Association between Conversion to Shockable Rhythms and Survival with Favorable Neurological Outcomes for Out-of-Hospital Cardiac Arrests.

BACKGROUND: The initial cardiac rhythm in out-of-hospital cardiac arrest (OHCA) portends different prognoses and affects treatment decisions. Initial shockable rhythms are associated with good survival and neurological outcomes but there is conflicting evidence for those who initially present with non-shockable rhythms. The aim of this study is to evaluate if OHCA with conversion from non-shockable (i.e., asystole and pulseless electrical activity) rhythms to shockable rhythms compared to OHCA remaining in non-shockable rhythms is associated with better survival and neurological outcomes. METHOD: OHCA cases from the Pan-Asian Resuscitation Outcomes Study registry in 13 countries between January 2009 and February 2018 were retrospectively analyzed. Cases with missing initial rhythms, age <18 years, presumed non-medical cause of arrest, and not conveyed by emergency medical services were excluded. Multivariable logistic regression analysis was performed to evaluate the relationship between initial and subsequent shockable rhythm, survival to discharge, and survival with favorable neurological outcomes (cerebral performance category 1 or 2). RESULTS: Of the 116,387 cases included. 11,153 (9.6%) had initial shockable rhythms and 9,765 (8.4%) subsequently converted to shockable rhythms. Japan had the lowest proportion of OHCA patients with initial shockable rhythms (7.3%). For OHCA with initial shockable rhythm, the adjusted odds ratios (aOR) for survival and good neurological outcomes were 8.11 (95% confidence interval [CI] 7.62-8.63) and 15.4 (95%CI 14.1-16.8) respectively. For OHCA that converted from initial non-shockable to shockable rhythms, the aORs for survival and good neurological outcomes were 1.23 (95%CI 1.10-1.37) and 1.61 (95%CI 1.35-1.91) respectively. The aORs for survival and good neurological outcomes were 1.48 (95%CI 1.22-1.79) and 1.92 (95%CI 1.3 - 2.84) respectively for initial asystole, while the aOR for survival in initial pulseless electrical activity patients was 0.83 (95%CI 0.71-0.98). Prehospital adrenaline administration had the highest aOR (2.05, 95%CI 1.93-2.18) for conversion to shockable rhythm. CONCLUSION: In this ambidirectional cohort study, conversion from non-shockable to shockable rhythm was associated with improved survival and neurologic outcomes compared to rhythms that continued to be non-shockable. Continued advanced resuscitation may be beneficial for OHCA with subsequent conversion to shockable rhythms.

Modified physiologic criteria for the field triage scheme: Efficacy of major trauma recognition in different age groups in Asia.

BACKGROUND: Major trauma is a leading cause of unexpected death globally, with increasing age-adjusted death rates for unintentional injuries. Field triage schemes (FTSs) assist emergency medical technicians in identifying appropriate medical care facilities for patients. While full FTSs may improve sensitivity, step-by-step field triage is time-consuming. A simplified FTS (sFTS) that uses only physiological and anatomical criteria may offer a more rapid decision-making process. However, evidence for this approach is limited, and its performance in identifying all age groups requiring trauma center resources in Asia remains unclear. METHODS: We conducted a multinational retrospective cohort study involving adult trauma patients admitted to emergency departments in the included countries from 2016 to 2020. Prehospital and hospital data were reviewed from the Pan-Asia Trauma Outcomes Study database. Patients aged ≥18 years transported by emergency medical services were included. Patients lacking data regarding age, sex, physiological criteria, or injury severity scores were excluded. We examined the performance of sFTS in all age groups and fine-tuned physiological criteria to improve sFTS performance in identifying high-risk trauma patients in different age groups. RESULTS: The sensitivity and specificity of the physiological and anatomical criteria for identifying major trauma (injury severity score ≥ 16) were 80.6% and 58.8%, respectively. The modified sFTS showed increased sensitivity and decreased specificity, with more pronounced changes in the young age group. Adding the shock index further increased sensitivity in both age groups. CONCLUSIONS: sFTS using only physiological and anatomical criteria is suboptimal for Asian adult patients with trauma of all age groups. Adjusting the physiological criteria and adding a shock index as a triage tool can improve the sensitivity of severely injured patients, particularly in young age groups. A swift field triage process can maintain acceptable sensitivity and specificity in severely injured patients.

Prehospital neurologic assessment using mobile phones: Comparison between neurologists and emergency physicians.

BACKGROUND: Ambulance-based telestroke may be a promising solution to improving stroke care. We assessed the technical feasibility and reliability of prehospital evaluations using commercial mobile phones with fifth-generation wireless communication technology. METHODS: Six standardized patients portrayed scripted stroke scenarios during ambulance transport in an urban city and were remotely evaluated by independent raters using tablets (three neurologists and three emergency physicians) in a hospital, assisted by paramedics (trained in National Institute of Health Stroke Scale [NIHSS] assessment) in the ambulance; commercial cellular networks were utilized for videoconferencing transmission. The primary outcomes were mean difference (MD) and correlation of NIHSS scores between the face-to-face and remote assessments. We also examined the Bland-Altman plot for itemized NIHSS components, and Kaplan-Meier curves were used to compare the differences in the duration of the two evaluations between neurologists and emergency physicians. RESULTS: We conducted 32 ambulance runs and successfully completed all NIHSS examinations. No significant difference was found between the face-to-face and remote evaluations (MD, 0.782; 95% confidence interval [CI], -0.520-0.395). The correlation of NIHSS scores between the two methods was 0.994 (95% CI, 0.945-1.026), and three items exhibited the highest frequency of runs, with score differences between the two methods. There were no significant differences between neurologists and emergency physicians in the mean evaluation duration and NIHSS scores for the two methods. CONCLUSION: Prehospital evaluation using commercial mobile phones with fifth-generation wireless communication technology is feasible and reliable during ambulance transport in urban areas. Emergency physicians and neurologists performed similarly in stroke evaluations.

Epidemiology and Prehospital Care of Pediatric Unintentional Injuries Among Countries with Different Economic Status in Asia: A Cross-National, Multi-Center Observational Study.

OBJECTIVE: Injury is a major cause of morbidity and mortality in children. However, the epidemiology and prehospital care for pediatric unintentional injuries in Asia are still unclear. METHODS: A total of 9,737 pediatric patients aged <18 years with unintentional injuries cared for at participating centers of the Pan-Asian Trauma Outcome Study (PATOS) from October 2015 to December 2020 were reviewed retrospectively. Patients were divided into two groups: those <8 and those ≥8 years of age. Variables such as patient demographics, injury epidemiology, Injury Severity Score (ISS), and prehospital care were collected. Injury severity and administered prehospital care stratified by gross national income were also analyzed. RESULTS: Pediatric unintentional injuries accounted for 9.4% of EMS-transported trauma cases in the participating Asian centers, and the mortality rate was 0.88%. The leading cause of injury was traffic injuries in older children aged ≥8 years (56.5%), while falls at home were common among young children aged <8 years (43.9%). Compared with younger children, older children with similar ISS tended to receive more prehospital interventions. Uneven disease severity was found in that older children in lower-middle and upper-middle-income countries had higher ISS compared with those in high-income countries. The performance of prehospital interventions also differed among countries with different gross national incomes. Immobilizations were the most performed prehospital intervention followed by oxygen administration, airway management, and pain control; only one patient received prehospital thoracentesis. Procedures were performed more frequently in high-income countries than in upper-middle-income and lower-middle-income countries. CONCLUSIONS: The major cause of injury was road traffic injuries in older children, while falls at home were common among young children. Prehospital care in pediatric unintentional injuries in Asian countries was not standardized and might be insufficient, and the economic status of countries may affect the implementation of prehospital care.

Development and Validation of a Risk Score for Predicting Ischemic Stroke After Transient Ischemic Attack.

BACKGROUND: A risk stratification scale is essential to identify high-risk patients who had transient ischemic attack (TIA) to prevent subsequent permanent disability caused by ischemic stroke. OBJECTIVE: This study aimed to develop and validate a scoring system to predict acute ischemic stroke within 90 days after TIA in an emergency department (ED). METHODS: We retrospectively analyzed the data of patients with TIA in a stroke registry between January 2011 and September 2018. Characteristics, medication history, electrocardiogram (ECG), and imaging findings were collected. Univariable and multivariable stepwise logistic regression analyses were performed to create an integer point system. The area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow (HL) test were used to examine discrimination and calibration. Youden's Index was also used to determine the best cutoff value. RESULTS: A total of 557 patients were included, and the occurrence rate of acute ischemic stroke within 90 days after TIA was 5.03%. After multivariable analysis, a new integer point system was created-MESH (Medication Electrocardiogram Stenosis Hypodense) score-which contained medication history (antiplatelet medication taken before admission, 1 point), right bundle branch block on electrocardiogram (1 point), intracranial stenosis ≥ 50% (1 point), and size of the hypodense area on computed tomography (diameter ≥ 4 cm, 2 points). The MESH score showed adequate discrimination (AUC = 0.78) and calibration (HL test = 0.78). The best cutoff value was 2 points, with a sensitivity of 60.71% and specificity of 81.66%. CONCLUSIONS: The MESH score indicated improved accuracy for TIA risk stratification in the ED setting.

Comparing the effects of blended learning and traditional instruction on basic life support for laypersons: A randomized controlled trial.

BACKGROUND/PURPOSE: Blended learning offers the advantages of both instructor-led and self-instruction methods in basic life support (BLS). Our study aims to compare the effects of blended learning with those of traditional instructor-led methods on the performance of laypersons taking BLS courses. METHODS: A total of 108 participants were randomly assigned to three groups: traditional instruction (group A, n = 36), blended learning with two rounds of practice (group B, n = 36), and blended learning with three rounds of practice (group C, n = 36). Group A received a 90-min lecture and a 30-min hands-on practice session using a manikin and a metronome. Participants in groups B and C received 18-min standardized online video lessons and performed hands-on practice twice and thrice, respectively. The primary outcome was chest compression at a correct speed (100-120 compressions per min) after the training course. Secondary outcomes included knowledge test scores, attitudes and confidence, and individual skill performance after training. RESULTS: Patient characteristics were similar between the groups. Blended learning with practicing thrice resulted in the highest compressions at a correct speed (group A vs. B vs. C, 68.09 vs 80.03 vs 89.42, p = 0.015) and the shortest average hands-off time (group A vs. B vs. C, 1.12 vs 0.86 vs 0.17 s, p = 0.015). Both blended groups performed better in confirming environmental safety (p < 0.001). No differences in scores of the knowledge test, attitude, or confidence were noted among the three groups. CONCLUSION: Blended learning with three rounds of hands-on practice may be considered an alternative teaching method.

Effect of crew ratio of advanced life support-trained personnel on patients with out-of-hospital cardiac arrest: A systematic review and meta-analysis.

BACKGROUND/PURPOSE: This review aimed to investigate the effect of crew ratios of on-scene advanced life support (ALS)-trained personnel on patients with out-of-hospital cardiac arrest (OHCA). METHODS: We systematically searched PubMed, Ovid EMBASE, and the Cochrane Central Register of Controlled Trials databases from the inception date until September 30, 2022, for eligible studies. Two reviewers independently screened the studies for relevance, extracted data, and quality. We compared the effect of the ratio of on-scene ALS-trained personnel >50 % to those with a ratio ≤50 % among prehospital personnel on the clinical outcomes of OHCA patients. The primary outcome was survival-to-discharge and secondary outcomes were any return of spontaneous circulation (ROSC), sustained ROSC (≥2 h), and favourable neurological outcome at discharge (cerebral performance category scores: 1 or 2). Pooled odds ratios (ORs) were calculated, and the certainty of evidence was assessed. RESULTS: From 10,864 references, we identified four non-randomised studies, including 16,475 patients. Two studies were performed in Japan and two in Taiwan. There were significant differences in survival-to-discharge (OR: 1.24, 95 % confidence interval [CI]: 1.07-1.44, I2: 7 %), any ROSC (OR:1.22, 95 % CI: 1.04-1.43, I2: 74 %) and sustained ROSC (OR: 1.39, 95 % CI: 1.16-1.65, I2: 40 %), but insignificant differences in favourable neurological outcome at discharge. The overall certainty of evidence was rated as very low for all outcomes. CONCLUSION: Prehospital ALS care with a ratio of on-scene ALS-trained personnel >50 % could improve OHCA patient outcomes than crew ratios ≤50 %. Further studies are required to reach a robust conclusion.

Machine Learning-Based Text Analysis to Predict Severely Injured Patients in Emergency Medical Dispatch: Model Development and Validation.

BACKGROUND: Early recognition of severely injured patients in prehospital settings is of paramount importance for timely treatment and transportation of patients to further treatment facilities. The dispatching accuracy has seldom been addressed in previous studies. OBJECTIVE: In this study, we aimed to build a machine learning-based model through text mining of emergency calls for the automated identification of severely injured patients after a road accident. METHODS: Audio recordings of road accidents in Taipei City, Taiwan, in 2018 were obtained and randomly sampled. Data on call transfers or non-Mandarin speeches were excluded. To predict cases of severe trauma identified on-site by emergency medical technicians, all included cases were evaluated by both humans (6 dispatchers) and a machine learning model, that is, a prehospital-activated major trauma (PAMT) model. The PAMT model was developed using term frequency-inverse document frequency, rule-based classification, and a Bernoulli naïve Bayes classifier. Repeated random subsampling cross-validation was applied to evaluate the robustness of the model. The prediction performance of dispatchers and the PAMT model, in severe cases, was compared. Performance was indicated by sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. RESULTS: Although the mean sensitivity and negative predictive value obtained by the PAMT model were higher than those of dispatchers, they obtained higher mean specificity, positive predictive value, and accuracy. The mean accuracy of the PAMT model, from certainty level 0 (lowest certainty) to level 6 (highest certainty), was higher except for levels 5 and 6. The overall performances of the dispatchers and the PAMT model were similar; however, the PAMT model had higher accuracy in cases where the dispatchers were less certain of their judgments. CONCLUSIONS: A machine learning-based model, called the PAMT model, was developed to predict severe road accident trauma. The results of our study suggest that the accuracy of the PAMT model is not superior to that of the participating dispatchers; however, it may assist dispatchers when they lack confidence while making a judgment.

Characteristics, prognostic factors, and chronological trends of out-of-hospital cardiac arrests with shockable rhythms in Taiwan - A 7-year observational study.

BACKGROUND: The study aimed to explore the characteristics, predictors, and chronological trends of outcomes for adult out-of-hospital cardiac arrests (OHCAs) with shockable rhythms. METHODS: A 7-year, community-wide observational study using an Utstein-style registry was conducted. Patients who were not transported, those who experienced trauma and those who lacked electronic electrocardiography data were excluded; those with initial shockable rhythms of ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) were included. Outcomes were survival of discharge (SOD) and favorable neurological status (CPC 1-2). The outcome predictors, chronological trends, and their relationship with system interventions were analyzed. RESULTS: Of the 1544 shockable OHCAs (incidence 12.6%) included, 97.6% had VF and 2.4% had pVT. VF showed better outcomes than pVT. Predictors for both outcomes (SOD; CPC 1-2) were chronological change (adjusted odds ratio [aOR]: 1.133; 1.176), younger age (aOR: 0.973; 0.967), shorter response time (aOR: 0.998; 0.999), shorter scene time (aOR: 0.999; 0.999), witnessed collapse (aOR: 1.668; 1.670), and bystander cardiopulmonary resuscitation (BCPR) (aOR: 1.448; 1.576). Predictors for only SOD were public location (aOR: 1.450) and successful prehospital defibrillation (aOR: 3.374). The use of the supraglottic airway was associated with adverse outcomes. Chronologically with system interventions, BCPR rate, the proportion of shockable OHCA, and improved neurological outcomes increased over time. CONCLUSION: The incidence of shockable OHCA remained low in Asian community. VF showed better outcomes than pVT. Over time, the incidence of shockable rhythm, BCPR rate and patient outcomes did improve with health system interventions. The number of prehospital defibrillations did not predict outcomes.

Expanding resources of endovascular thrombectomy: An optimization model.

BACKGROUND/PURPOSE: Recently optimized models for selecting the locations of hospitals capable of providing endovascular thrombectomy (EVT) did not consider the accuracy of the prehospital stroke scale assessment and possibility of secondary transport. Our study aimed to propose a new model for selecting existing hospitals with intravenous thrombolysis capability to become EVT-capable hospitals. METHODS: A sequential order was provided to upgrade hospitals providing intravenous thrombolysis, using a mixed integer programming model based on current medical resource allocation. In addition, we drafted a centralized plan to redistribute existing EVT resources by redetermining locations of EVT-capable hospitals. Using historical data of 7679 on-scene patients with suspected stroke, the model was implemented to determine the hospital that maximizes the number of patients receiving EVT treatment within call-to-definitive-treatment time. RESULTS: All suspected stroke patients were sent to EVT-capable hospitals directly under the current medical resource allocation model. After upgrading one additional hospital to become an EVT-capable hospital, the percentage of patients receiving definitive treatment within the standard call-to-definitive-treatment time was elevated from 68.82% to 72.97%. In the model, assuming that there is no hospital providing EVT, all patients suspected of stroke will be sent to EVT-capable hospitals directly after upgrading three or more hospitals to be able to provide treatment. CONCLUSION: All patients eligible for acute stroke treatment are sent to EVT-capable hospitals in the simulation under the current medical resource allocation model. This model can be utilized to provide insights for capacity redistribution in other regions.

Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

Strategies on locations of public access defibrillator: A systematic review.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a critical condition with poor outcomes. Although the survival rate increases in those who undergo defibrillation, the utility of on-time defibrillation among bystanders remained low. An evaluation of the deployment strategy for public access defibrillators (PADs) is necessary to increase their use and accessibility. This study was to conduct a systematic review for deployment strategies of PADs. METHODS: Two authors independently searched for articles published before October 2019 from PubMed, Embase, Web of Science, and Cochrane Library. An independent librarian provided the search strategy and assisted the literature research. We included articles that were focused on the main topic, but excluded those which were missing results or that used an unclear definition. The qualitative outcomes were the utility and OHCA coverage of PADs. We performed a qualitative analysis across the studies, but a quantitative analysis was not available due to the studies' heterogeneity in design and variety of outcomes. RESULTS: We eventually included 15 studies. Three strategies were presented: guidelines-based, grid-based, and landmark-based. The guidelines-based deployment was common fit for OHCA events. The grid-based method increased the use of bystander defibrillation 3-fold, and 30-day survival doubled. The top 3 landmarks in the landmark-based strategy were offices (18.6%), schools (13.3%), and sports facilities (12.9%). Utility of PADs might increase if we optimize PAD location by mathematical modeling and evaluation feedback. CONCLUSION: Three deployment strategies were presented. Although the optimal method could not be fully identified, a more efficient PAD deployment could benefit the population in terms of OHCA coverage and survival among patients with OHCA.

Combined intravenous immunoglobulin and baricitinib treatment for severe COVID-19 with rhabdomyolysis: A case report.

Since December 2019, the outbreak of coronavirus disease 2019 (COVID-19) has spread rapidly around the world. The severity of COVID-19 ranges from asymptomatic carriers to severe acute respiratory distress syndrome (ARDS). Accumulating evidence has shown that COVID-19 may be associated with multiple organ complications including cardiac injury, viral myositis and neurological deficits. Numerous laboratory biomarkers including lymphocytes, platelets, lactate dehydrogenase and creatine kinase (CK) have been associated with the prognostic outcomes of patients with COVID-19. However, dynamic correlations between levels of biomarkers and clinical course have not been studied. Herein, we report a 74-year-old female patient with severe COVID-19 which progressed to ARDS requiring intubation and mechanical ventilation. The laboratory findings showed lymphopenia, hypogammaglobulinemia, and elevated inflammatory biomarkers and CK. She received intensive therapy with hydroxychloroquine, lopinavir/ritonavir, and azithromycin with limited effects. Immunomodulatory treatments with high dose intravenous immunoglobulin and baricitinib were prescribed with satisfactory biochemical, radiographic and clinical recovery. We found an interesting correlation between serum CK elevation and inflammatory biomarkers, which reflected clinical improvement. This case demonstrates that inflammatory biomarkers, cytokines, and CK level correlated with disease severity and treatment response, and combined use of intravenous immunoglobulin and baricitinib is a potential treatment in patients with severe COVID-19.

Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: Update of the Utstein Resuscitation Registry Template for In-Hospital Cardiac Arrest: A Consensus Report From a Task Force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia).

Utstein-style reporting templates provide a structured framework with which to compare systems of care for cardiac arrest. The 2004 Utstein reporting template encompassed both out-of-hospital and in-hospital cardiac arrest. A 2015 update of the Utstein template focused on out-of-hospital cardiac arrest, which makes this update of the in-hospital template timely. Representatives of the International Liaison Committee on Resuscitation developed an updated in-hospital Utstein reporting template iteratively by meeting face-to-face, by teleconference, and by online surveys between 2013 and 2018. Data elements were grouped by hospital factors, patient variables, pre-event factors, cardiac arrest and postresuscitation processes, and outcomes. Elements were classified as core or supplemental by use of a modified Delphi process. Variables were described as core if they were considered essential. Core variables should enable reasonable comparisons between systems and are considered essential for quality improvement programs. Together with core variables, supplementary variables are considered useful for research.

Association between prehospital time and outcome of trauma patients in 4 Asian countries: A cross-national, multicenter cohort study.

BACKGROUND: Whether rapid transportation can benefit patients with trauma remains controversial. We determined the association between prehospital time and outcome to explore the concept of the "golden hour" for injured patients. METHODS AND FINDINGS: We conducted a retrospective cohort study of trauma patients transported from the scene to hospitals by emergency medical service (EMS) from January 1, 2016, to November 30, 2018, using data from the Pan-Asia Trauma Outcomes Study (PATOS) database. Prehospital time intervals were categorized into response time (RT), scene to hospital time (SH), and total prehospital time (TPT). The outcomes were 30-day mortality and functional status at hospital discharge. Multivariable logistic regression was used to investigate the association of prehospital time and outcomes to adjust for factors including age, sex, mechanism and type of injury, Injury Severity Score (ISS), Revised Trauma Score (RTS), and prehospital interventions. Overall, 24,365 patients from 4 countries (645 patients from Japan, 16,476 patients from Korea, 5,358 patients from Malaysia, and 1,886 patients from Taiwan) were included in the analysis. Among included patients, the median age was 45 years (lower quartile [Q1]-upper quartile [Q3]: 25-62), and 15,498 (63.6%) patients were male. Median (Q1-Q3) RT, SH, and TPT were 20 (Q1-Q3: 12-39), 21 (Q1-Q3: 16-29), and 47 (Q1-Q3: 32-60) minutes, respectively. In all, 280 patients (1.1%) died within 30 days after injury. Prehospital time intervals were not associated with 30-day mortality. The adjusted odds ratios (aORs) per 10 minutes of RT, SH, and TPT were 0.99 (95% CI 0.92-1.06, p = 0.740), 1.08 (95% CI 1.00-1.17, p = 0.065), and 1.03 (95% CI 0.98-1.09, p = 0.236), respectively. However, long prehospital time was detrimental to functional survival. The aORs of RT, SH, and TPT per 10-minute delay were 1.06 (95% CI 1.04-1.08, p < 0.001), 1.05 (95% CI 1.01-1.08, p = 0.007), and 1.06 (95% CI 1.04-1.08, p < 0.001), respectively. The key limitation of our study is the missing data inherent to the retrospective design. Another major limitation is the aggregate nature of the data from different countries and unaccounted confounders such as in-hospital management. CONCLUSIONS: Longer prehospital time was not associated with an increased risk of 30-day mortality, but it may be associated with increased risk of poor functional outcomes in injured patients. This finding supports the concept of the "golden hour" for trauma patients during prehospital care in the countries studied.

Application of high-fidelity simulation in critical care residency training as an effective learning, assessment, and prediction tool for clinical performance.

BACKGROUND/PURPOSE: This study was conducted to assess: 1) the impact of the HFS curriculum on residents' knowledge and skills, and 2) the correlation between learning outcomes and the clinical performance. METHODS: An HFS-based curriculum was implemented for junior residents prior to their ICU rotations. Residents completed written tests before (pre-test) and after (post-test) the curriculum and were assessed on their performance during the simulation sessions. Clinical performance was evaluated using global rating for knowledge, clinical skills, and leadership and decision-making skills. RESULTS: Complete data on pre-, post-test, simulation performance assessment, and clinical performance evaluation were available for 69 residents. Residents scored higher on their written post-test (64.6) compared with the pre-test (57.0) (p < 0.01). The simulation performance of residents improved between their first (3.43) and second (3.60) sessions (p < 0.05). Post-test scores correlated poorly with simulation performance (r = 0.03-0.28). Multivariable linear regression analysis revealed that clinical performance correlated better and significantly with simulation performance than the post-test for knowledge and clinical skills. CONCLUSION: HFS is an effective training strategy, and can also be a complementary assessment tool to the written examinations and has better correlation with clinical performance.

The Effect of Successful Intubation on Patient Outcomes After Out-of-Hospital Cardiac Arrest in Taipei.

STUDY OBJECTIVE: The effect of out-of-hospital intubation in patients with out-of-hospital cardiac arrest remains controversial. The Taipei City paramedics are the earliest authorized to perform out-of-hospital intubation among Asian areas. This study evaluates the association between successful intubation and out-of-hospital cardiac arrest survival in Taipei. METHODS: We analyzed 6 years of Utstein-based registry data from nontrauma adult patients with out-of-hospital cardiac arrest who underwent out-of-hospital airway management including intubation, laryngeal mask airway, or bag-valve-mask ventilation. The primary analysis was intubation success on patient outcomes. The primary outcome was survival to discharge and the secondary outcomes included sustained return of spontaneous circulation and favorable neurologic survival. Sensitivity analysis was performed with intubation attempts rather than intubation success. Subgroup analysis of advanced life support-serviced districts was also performed. RESULTS: A total of 10,853 cases from 2008 to 2013 were analyzed. Among out-of-hospital cardiac arrest patients receiving airway management, successful intubation, laryngeal mask airway, and bag-valve-mask ventilation was reported in 1,541, 3,099, and 6,213 cases, respectively. Compared with bag-valve-mask device use, successful out-of-hospital intubation was associated with improved chances of sustained return of spontaneous circulation (adjusted odds ratio [aOR] 1.91; 95% confidence interval [CI] 1.66 to 2.19), survival to discharge (aOR 1.98; 95% CI 1.57 to 2.49), and favorable neurologic outcome (aOR 1.44; 95% CI 1.03 to 2.03). The results were comparable in sensitivity and subgroup analyses. CONCLUSION: In nontrauma adult out-of-hospital cardiac arrest in Taipei, successful out-of-hospital intubation was associated with improved odds of sustained return of spontaneous circulation, survival to discharge, and favorable neurologic outcome.

A novel depth estimation algorithm of chest compression for feedback of high-quality cardiopulmonary resuscitation based on a smartwatch.

INTRODUCTION: High-quality cardiopulmonary resuscitation (CPR) is a key factor affecting cardiac arrest survival. Accurate monitoring and real-time feedback are emphasized to improve CPR quality. The purpose of this study was to develop and validate a novel depth estimation algorithm based on a smartwatch equipped with a built-in accelerometer for feedback instructions during CPR. METHODS: For data collection and model building, researchers wore an Android Wear smartwatch and performed chest compression-only CPR on a Resusci Anne QCPR training manikin. We developed an algorithm based on the assumptions that (1) maximal acceleration measured by the smartwatch accelerometer and the chest compression depth (CCD) are positively correlated and (2) the magnitude of acceleration at a specific time point and interval is correlated with its neighboring points. We defined a statistic value M as a function of time and the magnitude of maximal acceleration. We labeled and processed collected data and determined the relationship between M value, compression rate and CCD. We built a model accordingly, and developed a smartwatch app capable of detecting CCD. For validation, researchers wore a smartwatch with the preinstalled app and performed chest compression-only CPR on the manikin at target sessions. We compared the CCD results given by the smartwatch and the reference using the Wilcoxon Signed Rank Test (WSRT), and used Bland-Altman (BA) analysis to assess the agreement between the two methods. RESULTS: We analyzed a total of 3978 compressions that covered the target rate of 80-140/min and CCD of 4-7 cm. WSRT showed that there was no significant difference between the two methods (P = 0.084). By BA analysis the mean of differences was 0.003 and the bias between the two methods was not significant (95% CI: -0.079 to 0.085). CONCLUSION: Our study indicates that the algorithm developed for estimating CCD based on a smartwatch with a built-in accelerometer is promising. Further studies will be conducted to evaluate its application for CPR training and clinical practice.