Real-Time Tracheal Ultrasound vs. Capnography for Intubation Confirmation during CPR Wearing a Powered Air-Purifying Respirator in COVID-19 Era.

This study aimed to compare the accuracy of real-time trans-tracheal ultrasound (TTUS) with capnography to confirm intubation in cardiopulmonary resuscitation (CPR) while wearing a powered air-purifying respirator (PAPR). This setting reflects increased caution due to contagious diseases. This single-center, prospective, comparative study enrolled patients requiring CPR while wearing a PAPR who visited the emergency department of a tertiary medical center from December 2020 to August 2022. A physician performed the TTUS in real time and recorded the tube placement assessment. Another healthcare provider attached waveform capnography to the tube and recorded end-tidal carbon dioxide (EtCO2) after five ventilations. The accuracy and agreement of both methods compared with direct laryngoscopic visualization of tube placement, and the time taken by both methods was evaluated. Thirty-three patients with cardiac arrest were analyzed. TTUS confirmed tube placement with 100% accuracy, sensitivity, and specificity, whereas capnography demonstrated 97% accuracy, 96.8% sensitivity, and 100% specificity. The Kappa values for TTUS and capnography compared to direct visualization were 1.0 and 0.7843, respectively. EtCO2 was measured in 45 (37-59) seconds (median (interquartile range)), whereas TTUS required only 12 (8-23) seconds, indicating that TTUS was significantly faster (p < 0.001). No significant correlation was found between the physician's TTUS proficiency and image acquisition time. This study demonstrated that TTUS is more accurate and faster than EtCO2 measurement for confirming endotracheal tube placement during CPR, particularly in the context of PAPR usage in pandemic conditions.

Prognostic Performance of Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation III, and Simplified Acute Physiology Score II Scores in Patients with Suspected Infection According to Intensive Care Unit Type.

We investigated the prognostic performance of scoring systems by the intensive care unit (ICU) type. This was a retrospective observational study using data from the Marketplace for Medical Information in the Intensive Care IV database. The primary outcome was in-hospital mortality. We obtained Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation (APACHE) III, and Simplified Acute Physiology Score (SAPS) II scores in each ICU type. Prognostic performance was evaluated with the area under the receiver operating characteristic curve (AUROC) and was compared among ICU types. A total of 29,618 patients were analyzed, and the in-hospital mortality was 12.4%. The overall prognostic performance of APACHE III was significantly higher than those of SOFA and SAPS II (0.807, [95% confidence interval, 0.799-0.814], 0.785 [0.773-0.797], and 0.795 [0.787-0.811], respectively). The prognostic performance of SOFA, APACHE III, and SAPS II scores was significantly different between ICU types. The AUROC ranges of SOFA, APACHE III, and SAPS II were 0.723-0.826, 0.728-0.860, and 0.759-0.819, respectively. The neurosurgical and surgical ICUs had lower prognostic performance than other ICU types. The prognostic performance of scoring systems in patients with suspected infection is significantly different according to ICU type. APACHE III systems have the highest prediction performance. ICU type may be a significant factor in the prognostication.

A Pilot Study Evaluating LV Diastolic Function with M-Mode Measurement of Mitral Valve Movement in the Parasternal Long Axis View.

This pilot study aimed to develop a new, reliable, and easy-to-use method for the evaluation of diastolic function through the M-mode measurement of mitral valve (MV) movement in the parasternal long axis (PSLA), similar to E-point septal separation (EPSS) used for systolic function estimation. Thirty healthy volunteers from a tertiary emergency department (ED) underwent M-mode measurements of the MV anterior leaflet in the PSLA view. EPSS, A-point septal separation (APSS), A-point opening length (APOL), and E-point opening length (EPOL) were measured in the PSLA view, along with the E and A velocities and e' velocity in the apical four-chamber view. Correlation analyses were performed to assess the relationship between M-mode and Doppler measurements, and the measurement time was evaluated. No significant correlations were found between M-mode and Doppler measurements in the study. However, M-mode measurements exhibited high reproducibility and faster acquisition, and the EPOL value consistently exceeded the APOL value, resembling the E and A pattern. These findings suggest that visually assessing the M-mode pattern on the MV anterior leaflet in the PSLA view may be a practical approach to estimating diastolic function in the ED. Further investigations with a larger and more diverse patient population are needed to validate these findings.

Point-of-care ultrasound compression of the carotid artery for pulse determination in cardiopulmonary resuscitation.

AIM: To identify whether a novel pulse check technique, carotid artery compression using an ultrasound probe, can reduce pulse check times compared to manual palpation (MP). METHODS: This prospective study was conducted in an emergency department between February and December 2021. A physician applied point-of-care ultrasound-carotid artery compression (POCUS-CAC) and assessed the carotid artery compressibility and pulsatility by probe compression during rhythm check time. Another clinician performed MP of the femoral artery. The primary outcome was the difference in the average time for pulse assessment between POCUS-CAC and MP. The secondary outcomes included the time difference in each pulse check between methods, the proportion of times greater than 5 s and 10 s, and the prediction of return of spontaneous circulation (ROSC) during ongoing chest compression. RESULTS: 25 cardiac arrest patients and 155 pulse checks were analyzed. The median (interquartile range) average time to carotid pulse identification per patient using POCUS-CAC was 1.62 (1.14-2.14) s compared to 3.50 (2.99-4.99) s with MP. In all 155 pulse checks, the POCUS-CAC time to determine ROSC was significantly shortened to 0.44 times the MP time (P < 0.001). The POCUS-CAC approach never exceeded 10 s, and the number of patients who required more than 5 s was significantly lower (5 vs. 37, P < 0.001). Under continuous chest compression, six pulse checks predicted the ROSC. CONCLUSIONS: We found that emergency physicians could quickly determine pulses by applying simple POCUS compression of the carotid artery in cardiac arrest patients.

Online Learning versus Hands-On Learning of Basic Ocular Ultrasound Skills: A Randomized Controlled Non-Inferiority Trial.

Background and objectives: Ocular ultrasound is a core application of point-of-care ultrasound (POCUS) to assist physicians in promptly identifying various ocular diseases at the bedside; however, hands-on POCUS training is challenging during a pandemic. Materials and Methods: A randomized controlled non-inferiority trial was conducted in an academic emergency department from October 2020 to April 2021. Thirty-two participants were randomly assigned to one of two groups. Group H (hands-on learning group) participated individually in a hands-on session with a standardized patient for 30 min, whereas Group O (online learning group) learned training materials and video clips for 20 min. They scanned four eyeballs of two standardized patients sequentially following the ocular POCUS scan protocol. Repeated POCUS scans were performed 2 weeks later to assess skill maintenance. Both groups completed the pre- and post-surveys and knowledge tests. Two emergency medicine faculty members blindly evaluated the data and assigned a score of 0−25. The primary endpoint was the initial total score of scan quality evaluated using non-inferiority analysis (generalized estimating equation). The secondary endpoints were total scores for scan quality after 2 weeks, scan time, and knowledge test scores. Results: The least squares means of the total scores were 21.7 (0.35) for Group O and 21.3 (0.25) for Group H, and the lower bound of the 95% confidence interval (CI) was greater than the non-inferiority margin of minus 2 (95% CI: −0.48−1.17). The second scan scores were not significantly different from those of the first scan. The groups did not differ in scanning time or knowledge test results; however, Group H showed higher subjective satisfaction with the training method (p < 0.001). Conclusion: This study showed that basic online ocular ultrasound education was not inferior to hands-on education, suggesting that it could be a useful educational approach in the pandemic era.

Use of Gallbladder Width Measurement by Computed Tomography in the Diagnosis of Acute Cholecystitis.

This study aimed to evaluate the diagnostic value of gallbladder width measurement with computed tomography (CT) in patients with acute cholecystitis. This retrospective case−control study was conducted between March 2016 and March 2020 at a tertiary emergency department. Of 310 patients, 254 patients with acute cholecystitis confirmed by surgery were compared with 254 patients diagnosed with other diseases (controls). In the acute cholecystitis group, the number of older patients with underlying illnesses was much higher (64% of men). Upon CT, the median (interquartile range [IQR]) gallbladder width was significantly longer in patients with acute cholecystitis (2.26 [1.82−2.78] cm vs. 3.73 [3.32−4.16] cm, p < 0.001). The optimal cut-off value of gallbladder width for differentiating acute cholecystitis was 3.12 cm, showing a sensitivity of 88% and specificity of 86%. In a multivariable analysis using a logistic regression model for diagnosing acute cholecystitis with CT findings (gallbladder width, length, stone, wall thickening, and pericholecystic fluid), a gallbladder width of ≥3.12 cm was significantly meaningful, even when adjusting for other variables (odds ratio 37.9; p < 0.001). Therefore, an increase in gallbladder width (≥3.12 cm) measured with CT can be a simple and sensitive diagnostic sign of acute cholecystitis, supporting the underlying pathophysiology of bile outflow obstruction.

Impact of Insurance Benefits and Education on Point-of-Care Ultrasound Use in a Single Emergency Department: An Interrupted Time Series Analysis.

Background and Objectives: Point-of-care ultrasound (POCUS) is a useful tool that helps clinicians properly treat patients in emergency department (ED). This study aimed to evaluate the impact of specific interventions on the use of POCUS in the ED. Materials and Methods: This retrospective study used an interrupted time series analysis to assess how interventions changed the use of POCUS in the emergency department of a tertiary medical institute in South Korea from October 2016 to February 2021. We chose two main interventions-expansion of benefit coverage of the National Health Insurance (NHI) for emergency ultrasound (EUS) and annual ultrasound educational workshops. The primary variable was the EUS rate, defined as the number of EUS scans per 1000 eligible patients per month. We compared the level and slope of EUS rates before and after interventions. Results: A total of 5188 scanned records were included. Before interventions, the EUS rate had increased gradually. After interventions, except for the first workshop, the EUS rate immediately increased significantly (p < 0.05). The difference in the EUS rate according to the expansion of the NHI was estimated to be the largest (p < 0.001). However, the change in slope significantly decreased after the third workshop during the coronavirus disease 2019 pandemic (p = 0.004). The EUS rate increased significantly in the presence of physicians participating in intensive POCUS training (p < 0.001). Conclusion: This study found that expansion of insurance coverage for EUS and ultrasound education led to a significant and immediate increase in the use of POCUS, suggesting that POCUS use can be increased by improving education and insurance benefits.

Echocardiographic Assessment of Patients with Pulmonary Tumor Thrombotic Microangiopathy First Diagnosed in the Emergency Department.

Pulmonary tumor thrombotic microangiopathy (PTTM) is a fatal disease that obstructs pulmonary vessels, leading to pulmonary hypertension (PH) and right-sided heart failure causing rapid progressive dyspnea in patients with cancer. This retrospective chart review involved nine patients with PTTM who were first clinically diagnosed in a tertiary emergency department (ED) between January 2015 and June 2021. They underwent laboratory tests, chest radiography, chest computed tomography (CT), and echocardiography. All patients presented with severe and rapidly progressive dyspnea within a few days, a high oxygen demand. The right ventricle (RV): left ventricle ratio was >1 on chest CT, and no life-threatening pulmonary thromboembolism (PTE) was observed. Echocardiographic findings indicated that all patients had moderate-to-severe RV dilatation with a D-shaped LV. The median tricuspid regurgitation maximum velocity was 3.8 m/s, and the median RV systolic pressure was 63 mmHg, indicating severe PH. The median value of tricuspid annular plane systolic excursion was 15 mm, showing a decrease in RV systolic function, and McConnell's sign was observed in five patients. Two patients immediately underwent chemotherapy and are currently alive. PTTM should be suspected and evaluated using echocardiography in patients with cancer presenting to the ED with acute dyspnea and RV failure without PTE.

Impact of Personal Protective Equipment on Out-of-Hospital Cardiac Arrest Resuscitation in Coronavirus Pandemic.

Background and Objectives: This retrospective study evaluated the clinical impact of enhanced personal protective equipment (PPE) on the clinical outcomes in patients with out-of-hospital cardiac arrest. Moreover, by focusing on the use of a powered air-purifying respirator (PAPR), we investigated the medical personnel's perceptions of wearing PAPR during cardiopulmonary resuscitation. Materials and Methods: According to the arrival time at the emergency department, the patients were categorized into a conventional PPE group (1 August 2019 to 20 January 2020) and an enhanced PPE group (21 January 2020, to 31 August 2020). The primary outcomes of this analysis were the return of spontaneous circulation (ROSC) rate. Additionally, subjective perception of the medical staff regarding the effect of wearing enhanced PPE during cardiopulmonary resuscitation (CPR) was evaluated by conducting a survey. Results: This study included 130 out-of-hospital cardiac arrest (OHCA) patients, with 73 and 57 patients in the conventional and enhanced PPE groups, respectively. The median time intervals to first intubation and to report the first arterial blood gas analysis results were longer in the enhanced PPE group than in the conventional PPE group (3 min vs. 2 min; p = 0.020 and 8 min vs. 3 min; p < 0.001, respectively). However, there were no significant differences in the ROSC rate (odds ratio (OR) = 0.79, 95% confidence interval (CI): 0.38-1.67; p = 0.542) and 1 month survival (OR 0.38, 95% CI: 0.07-2.10; p = 0.266) between the two groups. In total, 67 emergent department (ED) professionals responded to the questionnaire. Although a significant number of respondents experienced inconveniences with PAPR use, they agreed that PAPR was necessary during the CPR procedure for protection and reduction of infection transmission. Conclusion: The use of enhanced PPE, including PAPR, affected the performance of CPR to some extent but did not alter patient outcomes. PAPR use during the resuscitation of OHCA patients might positively impact the psychological stability of the medical staff.

The effect of norepinephrine on common carotid artery blood flow in septic shock patients.

This study was designed to evaluate the hemodynamic effect of norepinephrine (NE) on the peak systolic velocity (PSV), diameter, and blood flow of the common carotid artery (CCA) using the point-of-care ultrasound (POCUS) in patients with septic shock. The study involved patients above 18 years old with septic shock. Arterial monitoring, carotid ultrasonography, and transthoracic echocardiography were performed before NE administration (T0). When the mean arterial pressure exceeded 65 mmHg after NE administration (T1), the measurement was repeated. Twenty-four patients (median age 67 [interquartile range: 54-77] years; 42% female) with septic shock were examined in this study. Before (T0) and after (T1) NE administration, the PSV (mean, standard deviation [SD]) changed from 85.3 (21.1) cm/s to 83.5 (23.5) cm/s (p = 0.417); this change was not significant. However, the diameter and blood flow of the CCA increased significantly from 0.6 (0.09) cm and 0.75 (0.27) L/min to 0.66 (0.09) cm and 0.85 (0.27) L/min, respectively (p < 0.001). The diameter of the left ventricular outflow tract (LVOT) remained unchanged, but the velocity time integral of the LVOT increased significantly from 21.7 (4.39) cm to 23.6 (5.14) cm. There was no significant correlation between changes in blood flow of the CCA and changes in cardiac output (coefficient -0.365, p = 0.079). In conclusion, NE increased the diameter and blood flow of the CCA significantly, without changing the PSV in patients with septic shock.

Respiratory Protection Effect of Ear-loop-type KF94 Masks according to the Wearing Method in COVID-19 Pandemic: a Randomized, Open-label Study.

BACKGROUND: Ear-loop-type Korean Filter 94 masks (KF94 masks, equivalent to the N95 and FFP2) are broadly used in health care settings in Korea for the coronavirus disease 2019 pandemic. METHODS: A prospective randomized open-label study was designed to identify differences in the fitting performance between mask wearing methods in three different types of KF94 mask with ear loops between January to March 2021. General-fitting involved wearing an ear-loop-type KF94 mask, and tight-fitting involved wearing a mask aided by a clip connecting the ear loops. Each of the 30 participants wore three types of masks according to a randomly assigned order in both methods and performed a total of six quantitative fit tests (QNFTs) according to the occupational safety and health administration protocol. RESULTS: All fit factors (FFs) measured by the QNFT were significantly higher for tight-fitting method with the clip in all KF94 masks (P < 0.001). However, the total FFs were very low, with a median (interquartile range) of 6 (3-23) and 29 (9-116) for general-fitting and tight-fitting, respectively. When wearing tightly, the horizontal 3-fold type mask with adjustable ear-loop length had the highest FF, with a median of 125, and the QNFT pass rate (FF ≥ 100) increased significantly from 4 (13%) to 18 (60%). CONCLUSION: Even with sufficient filter efficiency, ear-loop-type-KF94 masks do not provide adequate protection. However, in relatively low-risk environments, wearing a face-seal adjustable KF94 mask and tight wearing with a clip can improve respiratory protection for healthcare workers. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04794556.

The Use of Point-of-care Ultrasound in Emergency Medical Centers in Korea: a National Cross-sectional Survey.

BACKGROUND: Point-of-care ultrasound (POCUS) is an essential tool in emergency medicine (EM). We aimed to investigate the current status and perception of POCUS use in emergency medical centers in Korea. METHODS: A cross-sectional, nationwide survey was conducted using a mobile survey of physicians at emergency medical centers in Korea. The first message was sent on November 27, 2020, and the second message was sent on December 3, 2020 to the non-responders. The questionnaire comprised 6 categories and 24 questionnaires on demographics, current practice, education, perception, and barriers to the use of POCUS. RESULTS: A total of 467 physicians participated in the survey (a response rate of 32% among 1,458 target physicians), of which 43% were residents and 57% were EM specialists. Most of the respondents (96%) answered that they use POCUS, of which 89% reported using it at least once a week. The most frequently used types of POCUS were focused assessment with sonography for trauma (68%) and echocardiography (66%). Musculoskeletal, male genital, and pediatric scans were rarely performed tests but ranked as of the scans physicians most wanted to learn. About 73% of the respondents received ultrasound education, and 41% received ultrasound education at their own institutions. Nevertheless, education-related barriers are still the biggest deterrent to POCUS use (60%). In addition, multivariate multinomial logistic regression analysis revealed that the greater the number of ultrasound devices and the total number of physicians in the emergency center, the more likely they were to use POCUS every day. CONCLUSION: This study found that most physicians currently working in emergency medical centers in Korea more frequently perform various types of ultrasound scans compared to those 10 years prior. To further promote the use of POCUS, it is important to have an appropriate number of ultrasound devices and physicians in the emergency center along with systematic POCUS education.

Cardiac Magnetic Resonance Imaging for Nonischemic Cardiac Disease in Out-of-Hospital Cardiac Arrest Survivors Treated with Targeted Temperature Management: A Multicenter Retrospective Analysis.

(1) Background: Cardiac magnetic resonance (CMR) imaging is an emerging tool for investigating nonischemic cardiomyopathies and cardiac systemic disease. However, data on the cardiac arrest population are limited. This study aimed to evaluate the usefulness of CMR imaging in out-of-hospital cardiac arrest (OHCA) survivors treated with targeted temperature management (TTM). (2) Methods: We conducted the retrospective observational study using a multicenter registry of adult non-traumatic comatose OHCA survivors who underwent TTM between January 2010 and December 2019. Of the 949 patients, 389 with OHCA of non-cardiac cause, 145 with significant lesions in the coronary artery, 151 who died during TTM, 81 without further evaluation due to anticipated poor neurological outcome, and 51 whose etiology is underlying disease were excluded. In 36 of the 132 remaining patients, the etiologies included variant angina, long QT syndrome, and complete atrioventricular block in ancillary studies. Fifty-six patients were diagnosed idiopathic ventricular fibrillation without CMR. (3) Results: CMR imaging was performed in the remaining 40 patients with cardiac arrest of unknown cause. The median time from cardiac arrest to CMR imaging was 10.1 days. The CMR finding was normal in 23 patients, non-diagnostic in 12, and abnormal in 5, which suggested non-ischemic cardiomyopathy but did not support the final diagnosis. (4) Conclusions: CMR imaging may not be useful for identifying unknown causes of cardiac arrest in OHCA survivors treated with targeted temperature management without definitive diagnosis even after coronary angiography, echocardiography, and electrophysiology studies. However, further large-scale studies will be needed to confirm these findings.

Are loose-fitting powered air-purifying respirators safe during chest compression? A simulation study.

BACKGROUND: The application of appropriate personal protective equipment for respiratory protection to health care workers is a cornerstone for providing safe healthcare in emergency departments. We investigated the protective effect and usefulness of loose-fitting powered air-purifying respirators (PAPRs) during chest compression. METHODS: This was a single-center simulation study performed from May 2019 to July 2019 in a tertiary hospital. We measured the concentrations of ambient aerosol and particles inside the loose-fitting PAPR during chest compression, and this ratio was set as the simulated workplace protecting factor (SWPF). According to the National Institute for Occupational Safety and Health regulations, the assigned protection factor (APF) of loose-fitting PAPRs is 25. Thus, the loose-fitting PAPRs were assumed to have a protective effect when the SWPF were ≥ 250 (APF × 10). We measured the SWPF of PAPR in real time during chest compression and also investigated the problems encountered during its use. RESULTS: Ninety-one participants (median age 29 [interquartile range (IQR): 26-32] years; 74% female) completed the simulation. None of the participants failed with SWPF below 250 during three sessions of chest compression. The median (IQR) values of SWPF at three cycles were 17,063 (10,145-26,373), 15,683 (9477-32,394), and 16,960 (7695-27,279). There was no disconnection of equipment or mechanical failures during chest compression. In addition, most participants (83%) replied that they rarely or never experienced difficulty in verbal communication and felt that the loose-fitting PAPR was comfortable. CONCLUSIONS: The loose-fitting PAPRs provided sufficient respiratory protection without disturbances during chest compression.

N95 filtering facepiece respirators do not reliably afford respiratory protection during chest compression: A simulation study.

BACKGROUND: N95 filtering facepiece respirators (N95 respirators) may not provide adequate protection against respiratory infections during chest compression due to inappropriate fitting. METHODS: This was a single-center simulation study performed from December 1, 2016, to December 31, 2016. Each participant underwent quantitative fit test (QNFT) of N95 respirators according to the Occupational Safety and Health Administration protocol. Adequacy of respirator fit was represented by the fit factor (FF), which is calculated as the number of ambient particles divided by the number inside the respirator. We divided all participants into the group that passed the overall fit test but failed at least one individual exercise (partially passed group [PPG]) and the group that passed all exercises (all passed group [APG]). Then, the participants performed three sessions of continuous chest compressions, each with a duration of 2 min, while undergoing real-time fit testing. The primary outcome was any failure (FF < 100) of the fit test during the three bouts of chest compression. RESULTS: Forty-four participants passed the QNFT. Overall, 73% (n = 32) of the participants failed at least one of the three sessions of chest compression; the number of participants who failed was significantly higher in the PPG than in the APG (94% vs. 61%; p = 0.02). Approximately 18% (n = 8) of the participants experienced mask fit failures, such as strap slipping. CONCLUSIONS: Even if the participants passed the QNFT, the N95 respirator did not provide adequate protection against respiratory infections during chest compression.

Coronary angiography is related to improved clinical outcome of out-of-hospital cardiac arrest with initial non-shockable rhythm.

OBJECTIVE: Coronary angiography (CAG) for survivors of out-of-hospital cardiac arrest (OHCA) enables early identification of coronary artery disease and revascularization, which might improve clinical outcome. However, little is known for the role of CAG in patients with initial non-shockable cardiac rhythm. METHODS: We investigated clinical outcomes of successfully resuscitated 670 adult OHCA patients who were transferred to 27 hospitals in Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance (CAPTURES), a Korean nationwide multicenter registry. The primary outcome was 30-day survival with good neurological outcome. Propensity score matching and inverse probability of treatment weighting analyses were performed to account for indication bias. RESULTS: A total of 401 (60%) patients showed initial non-shockable rhythm. CAG was performed only in 13% of patients with non-shockable rhythm (53 out of 401 patients), whereas more than half of patients with shockable rhythm (149 out of 269 patients, 55%). Clinical outcome of patients who underwent CAG was superior to patients without CAG in both non-shockable (hazard ratio (HR) = 3.6, 95% confidence interval (CI) = 2.5-5.2) and shockable rhythm (HR = 3.7, 95% CI = 2.5-5.4, p < 0.001, all). Further analysis after propensity score matching or inverse probability of treatment weighting showed consistent findings (HR ranged from 2.0 to 3.2, p < 0.001, all). CONCLUSIONS: Performing CAG was related to better survival with good neurological outcome of OHCA patients with initial non-shockable rhythms as well as shockable rhythms.