A case of refractory ventricular fibrillation after caffeine poisoning successfully treated by supportive care.

Caffeine (1,3,7-trimethylxantine), a structural analog of adenosine, is widely used as a central nervous system stimulant in beverages and drugs. Caffeine overdose induces hypokalemia, fatal ventricular fibrillation, and cardiac arrest, resulting in death. We describe a case of caffeine overdose that presented with refractory ventricular fibrillation that was treated with supportive care because invasive care for severely ill patients was limited due to the COVID-19 pandemic. A 20-year-old woman with no underlying medical history ingested 90,200-mg caffeine tablets (total dose 18 g) in a suicide attempt. She was transported to the emergency department 45 min after ingestion with dizziness, palpitations, nausea, and vomiting. She developed cardiac arrest 80 min after ingesting the caffeine, with refractory ventricular tachycardia that recurred for about 2.5 h. Advanced life support including defibrillation was started immediately and we gave intravenous Intralipid emulsion, potassium chloride, amiodarone, and esmolol, without hemodialysis or extracorporeal membrane oxygenation (ECMO). The ventricular fibrillation was stopped 4 h after ingestion. As supportive care, mechanical ventilation, sedatives, and neuromuscular blockade were continued until 12 h after ingestion. Although she suffered from prolonged, refractory ventricular tachycardia, she recovered without complications. This case report describes the clinical course of severe caffeine intoxication without an active elimination method, such as hemodialysis or ECMO and explores the treatment of caffeine intoxication with a literature review.

Association between Paramedic Workforce and Survival Rate in Prehospital Advanced Life Support in Out-of-Hospital Cardiac Arrest Patients.

The low survival rate of out-of-hospital cardiac arrest (OHCA) patients is a global public health challenge. We analyzed the relationship between the number of prehospital EMS personnel and survival admission, survival discharge, and good neurologic outcomes in OHCA patients. This was a retrospective observational study. Adult nontraumatic OHCA patients from January 1, 2015, to December 31, 2018, were included from 12 cities in the Gyeonggi province, a metropolitan area located in the suburbs of the capital of the Republic of Korea. By comparing the insufficient EMS team (four or five EMS personnel) and the sufficient EMS team (six EMS personnel), we showed the survival rate of each group. Using propensity score matching, we reduced the bias of the confounding variables. A total of 3,632 OHCA patients were included. After propensity score matching, survival to admission was higher in the sufficient EMS team than in the insufficient EMS team (odds ratio (OR): 1.38, 95% confidence interval (CI): 1.04-1.84, P=0.03). Survival-to-discharge was similar (OR: 1.70, CI: 1.20-2.40, P=0.03), but there was no significant outcome in good neurologic outcomes (OR: 0.88, CI: 0.57-1.36, P=0.58). Our findings suggest that a sufficient EMS team (six EMS personnel) could improve the survival admission and discharge of OHCA patients compared to an insufficient EMS team (four or five EMS personnel). However, there was no significant difference in neurologic outcomes according to the number of EMS personnel.

Ingestion exposure to nitrosamines in chlorinated drinking water.

OBJECTIVES: N-Nitrosodimethylamine (NDMA) is classified as a probable human carcinogen by the United States Environmental Protection Agency (US EPA) and is formed during the chlorination of municipal drinking water. In this study, selected nitrosamines were measured in chlorinated drinking water collected from Chuncheon, Kangwon-do, Republic of Korea, and a risk assessment for NDMA was conducted. METHODS: Twelve water samples were collected from 2 treatment plants and 10 household taps. Samples were analyzed for 6 nitrosamines via solid-phase extraction cleanup followed by conversion to dansyl derivatives and high-performance liquid chromatography-fluorescence detection (HPLC-FLD). Considering the dietary patterns of Korean people and the concentration change of NDMA by boiling, a carcinogenic risk assessment from ingestion exposure was conducted following the US EPA guidelines. RESULTS: NDMA concentrations ranged between 26.1 and 112.0 ng/L. NDMA in water was found to be thermally stable, and thus its concentration at the end of boiling was greater than before thermal treatment owing to the decrease in water volume. The estimated excess lifetime carcinogenic risk exceeded the regulatory baseline risk of 10(-5). CONCLUSIONS: This result suggests that more extensive studies need to be conducted on nitrosamine concentration distributions over the country and the source of relatively high nitrosamine concentrations.