Evaluation of Pipe Thickness by Magnetic Hammer Test with a Tunnel Magnetoresistive Sensor.

A new nondestructive inspection method, the magnetic hammer test (MHT), which uses a compact and highly sensitive tunnel magnetoresistance (TMR) sensor, is proposed. This method complements the magnetic flux leakage method and eliminates the issues of the hammer test. It can therefore detect weak magnetic fields generated by the natural vibration of a pipe with a high signal-to-noise ratio. In this study, several steel pipes with different wall thicknesses were measured using a TMR sensor to demonstrate the superiority of MHT. The results of the measurement show that wall thickness can be evaluated with the accuracy of several tens of microns from the change in the natural vibration frequency of the specimen pipe. The pipes were also inspected underwater using a waterproofed TMR sensor, which demonstrated an accuracy of less than 100 µm. The validity of these results was by simulating the shielding of magnetic fields and vibration of the pipes with the finite element method (FEM) analysis. The proposed noncontact, fast, and accurate method for thickness testing of long-distance pipes will contribute to unmanned, manpower-saving nondestructive testing (NDT) in the future.

Frailty and Neurologic Outcomes of Patients Resuscitated From Nontraumatic Out-of-Hospital Cardiac Arrest: A Prospective Observational Study.

STUDY OBJECTIVE: To elucidate the clinical utility of the Clinical Frailty Scale score for predicting poor neurologic functions in patients resuscitated from out-of-hospital cardiac arrest (OHCA). METHODS: This was a prospective, multicenter, observational study conducted between 2019 and 2021. The study included adults with nontraumatic OHCA admitted to the intensive care unit after return of spontaneous circulation (ROSC). Pre-arrest high Clinical Frailty Scale score was defined as 5 or more. Favorable neurologic outcomes defined as a Cerebral Performance Category score of 2 or less at 30 days after admission were compared between patients with and without high Clinical Frailty Scale scores. Multivariable logistic regression analyses fitted with generalized estimating equations were performed to adjust for patient characteristics, out-of-hospital information, and resuscitation content and account for within-institution clustering. RESULTS: Of 9,909 patients with OHCA during the study period, 1,216 were included, and 317 had a pre-arrest high Clinical Frailty Scale score. Favorable neurologic outcomes were fewer among patients with high Clinical Frailty Scale scores. The high Clinical Frailty Scale score group showed a lower percentage of favorable neurologic outcomes after OHCA than the low Clinical Frailty Scale score group (6.1% vs 24.4%; adjusted odds ratio, 0.45 [95% confidence interval 0.22 to 0.93]). This relationship remained in subgroups with cardiogenic OHCA, with ROSC after hospital arrival, and without a high risk of dying (Clinical Frailty Scale score of 7 or less), whereas the neurologic outcomes were comparable regardless of pre-arrest frailty in those with noncardiogenic OHCA and with ROSC before hospital arrival. CONCLUSIONS: Pre-arrest high Clinical Frailty Scale score was associated with unfavorable neurologic functions among patients resuscitated from OHCA. The Clinical Frailty Scale score would help predict clinical consequences following intensive care after ROSC.

Peripheral VA-ECMO and pericardial drainage connected to the ECMO circuit for cardiac tamponade from blowout rupture: a case report.

BACKGROUND: Left ventricular free wall rupture, particularly the blowout type, is still one of the most lethal complications of myocardial infarction and can cause catastrophic cardiac tamponade. Extracorporeal membrane oxygenation (ECMO) is often used to treat haemodynamic instability due to cardiac tamponade. However, elevated pericardial pressure can cause collapse of the right atrium, resulting in inadequate ECMO inflow and preventing the stabilisation of the circulation. Further, it can interfere with the venous return from the superior vena cava (SVC), increasing the intracranial pressure and reducing cerebral perfusion levels. CASE PRESENTATION: A 65-year-old man was hospitalised for out-of-hospital cardiac arrest. We used ECMO for cardiopulmonary resuscitation. After the establishment of ECMO, transthoracic echocardiography and left ventriculography revealed massive pericardial effusion. The treatment was supplemented with pericardial drainage since ECMO flow was frequently hampered by suction events. However, the blowout rupture led to the requirement of constant drainage from the pericardial catheter. To tend to this leak, we connected the venous cannula of ECMO and the pericardial drainage catheter. The surgery was performed with stable circulation without suction failure of ECMO. During the course of the intensive care management, the neurological prognosis of the patient was revealed to be poor, and the patient was shifted to palliative care. Unfortunately, the patient died on day 10 of hospitalisation. CONCLUSION: We present a case wherein the combination of pericardial drainage and ECMO was used to maintain circulation in a patient with massive pericardial effusion due to cardiac rupture.

Fulminant Streptococcus suis infection detected on peripheral blood smear: A case report.

Streptococcus suis, a gram-positive coccus, is recognized as an emerging zoonotic pathogen that causes serious infections in humans, such as bacterial meningitis and sepsis, with poor outcomes. The pathogen is known to be transmitted through the consumption of raw pork or occupational exposure to pigs. A previously healthy 38-year-old woman with occupational exposure to raw pork was presented to our emergency department with a clinical diagnosis of rapidly progressive septic shock. Peripheral blood smears detected chains of cocci inside granulocytes, which led to the early recognition of gram-positive cocci in short chains before the blood culture test results. Blood cultures later tested positive for S. suis serotype 2. The patient's condition deteriorated despite aggressive resuscitative measures including antibiotics, vasopressors, multiple blood transfusions, mechanical ventilation, and renal replacement therapy. Initiation of veno-arterial extracorporeal membrane oxygenation was ineffective, and the patient died 16 h after admission. The identification of bacteria in the peripheral blood smear indicated an overwhelming infection and led to the rapid recognition of bacteremia. Our report aims to raise awareness about fatal zoonotic pathogens and to promote the unique role of peripheral blood smears that could provide preliminary diagnostic information before blood culture results.

Characteristics and comparative study of thoracolumbar spine injury and dislocation fracture due to tertiary trauma.

PURPOSE: Thoracolumbar spine injury is frequently seen with high-energy trauma but dislocation fractures are relatively rare in spinal trauma, which is often neurologically severe and requires urgent treatment. Therefore, it is essential to understand other concomitant injuries when treating dislocation fractures. The purpose of this study is to determine the differences in clinical features between thoracolumbar spine injury without dislocation and thoracolumbar dislocation fracture. METHODS: We conducted an observational study using the Japan Trauma Data Bank (2004-2019). A total of 734 dislocation fractures (Type C) and 32,382 thoracolumbar spine injuries without dislocation (Non-type C) were included in the study. The patient background, injury mechanism, and major complications in both groups were compared. In addition, multivariate analysis of predictors of the diagnosis of dislocation fracture using logistic regression analysis were performed. RESULTS: Items significantly more frequent in Type C than in Non-type C were males, hypotension, bradycardia, percentage of complete paralysis, falling objects, pincer pressure, accidents during sports, and thoracic artery injury (P < 0.001); items significantly more frequent in Non-type C than in Type C were falls and traffic accidents, head injury, and pelvic trauma (P < 0.001). Logistic regression analysis showed that younger age, male, complete paralysis, bradycardia, and hypotension were associated with dislocation fracture. CONCLUSION: Five associated factors were identified in the development of thoracolumbar dislocation fractures. LEVEL OF EVIDENCE: III.

Bystander cardiopulmonary resuscitation and cardiac rhythm change over time in patients with out-of-hospital cardiac arrest.

BACKGROUND: Whether and how bystander cardiopulmonary resuscitation (CPR) modifies the cardiac rhythm after out-of-hospital cardiac arrest (OHCA) over time remains unclear. We investigated the association between bystander CPR and the likelihood of ventricular fibrillation (VF) or ventricular tachycardia (VT) as the first documented cardiac rhythm. METHODS: We identified individuals with witnessed OHCA of cardiac origin from a nationwide population-based OHCA registry in Japan between 1 January 2005 and 31 December 2019. The first documented cardiac rhythm was compared between patients who received bystander CPR and those who did not, using a 1:2 propensity score-matched analysis. RESULTS: Of 309 900 patients with witnessed OHCA of cardiac origin, 71 887 (23.2%) received bystander CPR. Propensity score matching paired 71 882 patients who received bystander CPR with 143 764 who did not. The likelihood of detecting a VF/VT rhythm was significantly higher among patients who received bystander CPR than among those who did not (OR 1.66; 95% CI 1.63 to 1.69; p<0.001). Comparing the two groups at each time point, the difference in the proportions of patients with VF/VT rhythms peaked at 15-20 min but was insignificant at 30 min postcollapse (15 min after collapse; 20.9% vs 13.9%; p<0.001). The likelihood of a pulseless electrical activity rhythm was significantly lower in patients who received bystander CPR during the first 25 min postcollapse (15 min after collapse; 26.2% vs 31.5%; p<0.001). The two groups had no significant difference in the likelihood of asystole (15 min after collapse; 51.0% vs 53.3%; p=0.078). CONCLUSION: Bystander CPR was associated with a higher VF/VT likelihood and a lower likelihood of pulseless electrical activity at first documented rhythm analysis. Our results support early CPR for OHCA and highlight the need for further research to understand whether and how CPR modifies the cardiac rhythm after arrest.

Development of Magnetocardiograph without Magnetically Shielded Room Using High-Detectivity TMR Sensors.

A magnetocardiograph that enables the clear observation of heart magnetic field mappings without magnetically shielded rooms at room temperatures has been successfully manufactured. Compared to widespread electrocardiographs, magnetocardiographs commonly have a higher spatial resolution, which is expected to lead to early diagnoses of ischemic heart disease and high diagnostic accuracy of ventricular arrhythmia, which involves the risk of sudden death. However, as the conventional superconducting quantum interference device (SQUID) magnetocardiographs require large magnetically shielded rooms and huge running costs to cool the SQUID sensors, magnetocardiography is still unfamiliar technology. Here, in order to achieve the heart field detectivity of 1.0 pT without magnetically shielded rooms and enough magnetocardiography accuracy, we aimed to improve the detectivity of tunneling magnetoresistance (TMR) sensors and to decrease the environmental and sensor noises with a mathematical algorithm. The magnetic detectivity of the TMR sensors was confirmed to be 14.1 pTrms on average in the frequency band between 0.2 and 100 Hz in uncooled states, thanks to the original multilayer structure and the innovative pattern of free layers. By constructing a sensor array using 288 TMR sensors and applying the mathematical magnetic shield technology of signal space separation (SSS), we confirmed that SSS reduces the environmental magnetic noise by -73 dB, which overtakes the general triple magnetically shielded rooms. Moreover, applying digital processing that combined the signal average of heart magnetic fields for one minute and the projection operation, we succeeded in reducing the sensor noise by about -23 dB. The heart magnetic field resolution measured on a subject in a laboratory in an office building was 0.99 pTrms and obtained magnetocardiograms and current arrow maps as clear as the SQUID magnetocardiograph does in the QRS and ST segments. Upon utilizing its superior spatial resolution, this magnetocardiograph has the potential to be an important tool for the early diagnosis of ischemic heart disease and the risk management of sudden death triggered by ventricular arrhythmia.

Extracorporeal cardiopulmonary resuscitation in adult patients with out-of-hospital cardiac arrest: a retrospective large cohort multicenter study in Japan.

BACKGROUND: The prevalence of extracorporeal cardiopulmonary resuscitation (ECPR) in patients with out-of-hospital cardiac arrest (OHCA) has been increasing rapidly worldwide. However, guidelines or clinical studies do not provide sufficient data on ECPR practice. The aim of this study was to provide real-world data on ECPR for patients with OHCA, including details of complications. METHODS: We did a retrospective database analysis of observational multicenter cohort study in Japan. Adult patients with OHCA of presumed cardiac etiology who received ECPR between 2013 and 2018 were included. The primary outcome was favorable neurological outcome at hospital discharge, defined as a cerebral performance category of 1 or 2. RESULTS: A total of 1644 patients with OHCA were included in this study. The patient age was 18-93 years (median: 60 years). Shockable rhythm in the initial cardiac rhythm at the scene was 69.4%. The median estimated low flow time was 55 min (interquartile range: 45-66 min). Favorable neurological outcome at hospital discharge was observed in 14.1% of patients, and the rate of survival to hospital discharge was 27.2%. The proportions of favorable neurological outcome at hospital discharge in terms of shockable rhythm, pulseless electrical activity, and asystole were 16.7%, 9.2%, and 3.9%, respectively. Complications were observed during ECPR in 32.7% of patients, and the most common complication was bleeding, with the rates of cannulation site bleeding and other types of hemorrhage at 16.4% and 8.5%, respectively. CONCLUSIONS: In this large cohort, data on the ECPR of 1644 patients with OHCA show that the proportion of favorable neurological outcomes at hospital discharge was 14.1%, survival rate at hospital discharge was 27.2%, and complications were observed during ECPR in 32.7%.

Association of the COVID-19 pandemic with bystander cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a population-based analysis in Tokyo, Japan.

BACKGROUND: The impact of the COVID-19 pandemic on bystander cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) is unclear. This study aimed to investigate whether rates of bystander CPR and patient outcomes changed during the initial state of emergency declared in Tokyo for the COVID-19 pandemic. METHODS: This retrospective study used data from a population-based database of OHCA maintained by the Tokyo Fire Department. By comparing data from the periods before (18 February to 6 April 2020) and during the declaration of a state of emergency (7 April 2020 to 25 May 2020), we estimated the change in bystander CPR rate, prehospital return of spontaneous circulation, and survival and neurological outcomes 1 month after OHCA, accounting for outcome trends in 2019. We performed a multivariate regression analysis to evaluate the potential mechanisms for associations between the state of emergency and these outcomes. RESULTS: The witnessed arrest rates before and after the declaration periods in 2020 were 42.5% and 45.1%, respectively, compared with 44.1% and 44.7% in the respective corresponding periods in 2019. The difference between the two periods in 2020 was not statistically significant when the trend in 2019 was considered. The bystander CPR rates before and after the declaration periods significantly increased from 34.4% to 43.9% in 2020, an 8.3% increase after adjusting for the trend in 2019. This finding was significant even after adjusting for patient and bystander characteristics and the emergency medical service response. There were no significant differences between the two periods in the other study outcomes. CONCLUSION: The COVID-19 pandemic was associated with an improvement in the bystander CPR rate in Tokyo, while patient outcomes were maintained. Pandemic-related changes in patient and bystander characteristics do not fully explain the underlying mechanism; there may be other mechanisms through which the community response to public emergency increased during the pandemic.

Evaluation of initial shockable rhythm as an indicator of short no-flow time in cardiac arrest: a national registry study.

BACKGROUND: The duration from collapse to initiation of cardiopulmonary resuscitation (no-flow time) is one of the most important determinants of outcomes after out-of-hospital cardiac arrest (OHCA). Initial shockable cardiac rhythm (ventricular fibrillation or ventricular tachycardia) is reported to be a marker of short no-flow time; however, there is conflicting evidence regarding the impact of initial shockable cardiac rhythm on treatment decisions. We investigated the association between initial shockable cardiac rhythm and the no-flow time and evaluated whether initial shockable cardiac rhythm can be a marker of short no-flow time in patients with OHCA. METHODS: Patients aged 18 years and older experiencing OHCA between 2010 and 2016 were selected from a nationwide population-based Japanese database. The association between the no-flow time duration and initial shockable cardiac rhythm was evaluated. Diagnostic accuracy was evaluated using the sensitivity, specificity and positive predictive value. RESULTS: A total of 177 634 patients were eligible for the analysis. The median age was 77 years (58.3%, men). Initial shockable cardiac rhythm was recorded in 11.8% of the patients. No-flow time duration was significantly associated with lower probability of initial shockable cardiac rhythm, with an adjusted OR of 0.97 (95% CI 0.96 to 0.97) per additional minute. The sensitivity, specificity and positive predictive value of initial shockable cardiac rhythm to identify a no-flow time of <5 min were 0.12 (95% CI 0.12 to 0.12), 0.88 (95% CI 0.88 to 0.89) and 0.35 (95% CI 0.34 to 0.35), respectively. The positive predictive values were 0.90, 0.95 and 0.99 with no-flow times of 15, 18 and 28 min, respectively. CONCLUSIONS: Although there was a significant association between initial shockable cardiac rhythm and no-flow time duration, initial shockable cardiac rhythm was not reliable when solely used as a surrogate of a short no-flow time duration after OHCA.

External validation of simplified out-of-hospital cardiac arrest and cardiac arrest hospital prognosis scores in a Japanese population: a multicentre retrospective cohort study.

BACKGROUND: The novel simplified out-of-hospital cardiac arrest (sOHCA) and simplified cardiac arrest hospital prognosis (sCAHP) scores used for prognostication of hospitalised patients have not been externally validated. Therefore, this study aimed to externally validate the sOHCA and sCAHP scores in a Japanese population. METHODS: We retrospectively analysed data from a prospectively maintained Japanese database (January 2012 to March 2013). We identified adult patients who had been resuscitated and hospitalised after intrinsic out-of-hospital cardiac arrest (OHCA) (n=2428, age ≥18 years). We validated the sOHCA and sCAHP scores with reference to the original scores in predicting 1-month unfavourable neurological outcomes (cerebral performance categories 3-5) based on the discrimination and calibration measures of area under the receiver operating characteristic curves (AUCs) and a Hosmer-Lemeshow goodness-of-fit test with a calibration plot, respectively. RESULTS: In total, 1985/2484 (82%) patients had a 1-month unfavourable neurological outcome. The original OHCA, sOHCA, original cardiac arrest hospital prognosis (CAHP) and sCAHP scores were available for 855/2428 (35%), 1359/2428 (56%), 1130/2428 (47%) and 1834/2428 (76%) patients, respectively. The AUCs of simplified scores did not differ significantly from those of the original scores, whereas the AUC of the sCAHP score was significantly higher than that of the sOHCA score (0.88 vs 0.81, p<0.001). The goodness of fit was poor in the sOHCA score (ν=8, χ2=19.1 and Hosmer-Lemeshow test: p=0.014) but not in the sCAHP score (ν=8, χ2=13.5 and Hosmer-Lemeshow test: p=0.10). CONCLUSION: The performances of the original and simplified OHCA and CAHP scores in predicting neurological outcomes in successfully resuscitated OHCA patients were acceptable. With the highest availability, similar discrimination and good calibration, the sCAHP score has promising potential for clinical implementation, although further validation studies to evaluate its clinical acceptance are necessary.

Pediatric Out-of-Hospital Traumatic Cardiopulmonary Arrest After Traffic Accidents and Termination of Resuscitation.

STUDY OBJECTIVE: We describe the characteristics and outcomes of pediatric traumatic out-of-hospital cardiac arrest after traffic accidents and validate the termination of resuscitation clinical criteria for adult traumatic out-of-hospital cardiac arrest in pediatrics. METHODS: We analyzed the records of pediatric (≤18 years) traumatic out-of-hospital cardiac arrest cases after traffic accidents in a prospectively collected nationwide database (2012 to 2016). Endpoints were 1-month favorable neurologic outcomes and 1-month survival. Validation of termination of resuscitation criteria, cardiac arrest at the scene, and unsuccessful resuscitation after cardiopulmonary resuscitation (CPR) greater than 15 minutes was performed based on specificity and positive predictive value. RESULTS: Of the 582 patients who were eligible for analyses, 8 (1.4%) and 20 (3.4%) had 1-month favorable neurologic outcome and survival, respectively. All patients with favorable neurologic outcomes had out-of-hospital return of spontaneous circulation, and the duration of CPR was significantly shorter than for those with unfavorable neurologic outcomes (4 versus 23 minutes; absolute difference -21.9 minutes; 95% confidence interval -36.3 to -7.4 minutes). The duration of out-of-hospital CPR beyond which the possibility of favorable neurologic outcomes and survival diminished to less than 1% was 15 minutes. For predicting unfavorable neurologic outcomes, the termination of resuscitation criteria provided a specificity of 1.00 (95% confidence interval 0.52 to 1.00) and a positive predictive value of 1.00 (95% confidence interval 0.99 to 1.00). CONCLUSION: The outcomes of pediatric patients with traumatic out-of-hospital cardiac arrest after traffic accidents were as poor as those of adults in previous studies. Out-of-hospital return of spontaneous circulation was a significant indicator of favorable outcomes, and the duration of out-of-hospital CPR beyond which the possibility of favorable neurologic outcomes and survival diminished to less than 1% was 15 minutes. Termination of resuscitation criteria provided an excellent positive predictive value for 1-month unfavorable neurologic outcomes after out-of-hospital cardiac arrest.

Lower Proportion of Fatal Arrhythmia in Sudden Cardiac Arrest Among Patients With Severe Mental Illness Than Nonpsychiatric Patients.

BACKGROUND: Sudden unexpected deaths occur more frequently among patients with severe mental illness (SMI), but direct evidence on the causes is still scarce. OBJECTIVE: The objective of this study is to investigate initial rhythms and characteristics of out-of-hospital cardiac arrest among patients with SMI. METHODS: We conducted a systematic chart review of adult patients who suffered from out-of-hospital cardiac arrest and transferred to Tokyo Metropolitan Bokutoh Hospital in Japan between January 2011 and December 2017. The initial rhythms, clinical characteristics, and outcomes were compared between patients with schizophrenia or mood disorders (i.e., SMI) and nonpsychiatric control patients. Values of interest were compared using Fisher's exact test or Mann-Whitney U-test, as appropriate. Multiple regression analysis was also conducted to investigate the effect of SMI on the initial rhythms. RESULTS: A total of 2631 patients were included in this study. Of these, 157 patients had SMI. Fatal arrhythmias (i.e., ventricular fibrillation and ventricular tachycardia) were less frequently noted as the initial rhythms among patients with SMI than among controls (5.7% vs. 18.8%, adjusted odds ratio = 0.27, 95% confidence interval = 0.13-0.55, P < 0.001). Patients with SMI were significantly younger (median [range], 58 years [22-85] vs. 72 years [18-108], P < 0.001) and less frequently had comorbid physical illnesses than controls (the proportion of patients without comorbidities; 58.6% vs. 37.1%, P < 0.001). Survival and neurological function at discharge were not different between the 2 groups. CONCLUSION: Fatal arrhythmia may account for a relatively small portion in excess of sudden death among patients with SMI. Furthermore, appropriate medical checkups for the patients with SMI at earlier ages would be important to prevent sudden cardiac death.

A sporadic COVID-19 pneumonia treated with extracorporeal membrane oxygenation in Tokyo, Japan: A case report.

INTRODUCTION: An ongoing outbreak of a novel coronavirus disease (coronavirus disease 2019, COVID-19) has become a global threat. While clinical reports from China to date demonstrate that the majority of cases remain relatively mild and recover with supportive care, it is also crucial to be well prepared for severe cases warranting intensive care. Initiating appropriate infection control measures may not always be achievable in primary care or in acute-care settings. CASE: A 45-year-old man was admitted to the intensive care unit due to severe pneumonia, later confirmed as COVID-19. His initial evaluation in the resuscitation room and treatments in the intensive care unit was performed under droplet and contact precaution with additional airborne protection using the N95 respirator mask. He was successfully treated in the intensive care unit with mechanical ventilation and extracorporeal membrane oxygenation for respiratory support; and antiretroviral treatment with lopinavir/ritonavir. His total intensive care unit stay was 15 days and was discharged on hospital day 24. CONCLUSIONS: Strict infection control precautions are not always an easy task, especially under urgent care in an intensive care unit. However, severe cases of COVID-19 pneumonia, or another novel infectious disease, could present at any moment and would be a continuing challenge to pursue appropriate measures. We need to be well prepared to secure healthcare workers from exposure to infectious diseases and nosocomial spread, as well as to provide necessary intensive care.

Left ventricular wall findings in non-electrocardiography-gated contrast-enhanced computed tomography after extracorporeal cardiopulmonary resuscitation.

BACKGROUND: Few studies have reported left ventricular wall findings in contrast-enhanced computed tomography (CE-CT) after extracorporeal cardiopulmonary resuscitation (ECPR). This study examined left ventricular wall CE-CT findings after ECPR and evaluated the association between these findings and the results of coronary angiography and prognosis. METHODS: We evaluated out-of-hospital cardiac arrest patients who were treated with ECPR and subsequently underwent both non-electrocardiography-gated CE-CT and coronary angiography at our center between January 2011 and April 2018. Left ventricular wall CE-CT findings were classified as follows: (1) homogeneously enhanced (HE; the left ventricular wall was homogeneously enhanced), (2) segmental defect (SD; the left ventricular wall was not segmentally enhanced according to the coronary artery territory), (3) total defect (TD; the entire left ventricular wall was not enhanced), and (4) others. Successful weaning from extracorporeal membrane oxygenation, survival to hospital discharge, and predictive ability of significant stenosis on coronary angiography were compared among patients with HE, SD, and TD patterns. RESULTS: A total of 74 patients (median age, 59 years) were eligible, 50 (68%) of whom had initial shockable rhythm. Twenty-three (31%) patients survived to hospital discharge. HE, SD, TD, and other patterns were observed in 19, 33, 11, and 11 patients, respectively. The rates of successful weaning from extracorporeal membrane oxygenation (84% vs. 39% vs. 9%, p < 0.01) and survival to hospital discharge (47% vs. 27% vs. 0%, p = 0.02) were significantly different among patients with HE, SD, and TD patterns. In post hoc analysis, patients with HE patterns had a significantly higher success rate of weaning from extracorporeal membrane oxygenation than those with SD and TD patterns. SD predicted significant stenosis with a sensitivity of 74% and specificity of 94%. CONCLUSIONS: Homogenously enhanced left ventricular wall might be a predictor of good left ventricular function recovery. In contrast, total enhancement defect in the entire left ventricular wall was associated with poor outcomes. Contrast defect matching the coronary artery territory could predict significant coronary artery stenosis with good specificity. The left ventricular wall findings in non-electrocardiography-gated CE-CT after ECPR might be useful for diagnosis and prognostic prediction.

Extracorporeal CPR for massive pulmonary embolism in a "hybrid 2136 emergency department".

AIM: Patients with massive pulmonary embolism (PE) have poor outcomes and their management remains challenging. An interventional radiology (IVR)-computed tomography (CT) system available in our emergency room (ER) allows immediate access to CT and extracorporeal membrane oxygenation (ECMO) with safe cannulation under fluoroscopy. We aimed to determine if initial treatment in this "hybrid ER" is helpful in patients with PE requiring extracorporeal cardiopulmonary resuscitation (ECPR). METHODS: The records of patients transferred to our hybrid ER between September 2014 and December 2017 who required ECPR for PE were reviewed. RESULTS: Nine consecutive patients (median age 50 [range 30-76] years) with PE requiring ECPR were identified in our hybrid ER. Five (55.6%) had at least one risk factor for PE. Six (66.7%) experienced an out-of-hospital cardiac arrest and 3 (33.3%) had a cardiac arrest in the hybrid ER. Right ventricular overload was detected on electrocardiography and bedside transthoracic echocardiography in all cases. The median pH, lactate, PaCO2, and HCO3 values on arterial blood gas analysis in the hybrid ER were 7.01 (6.68-7.26), 14 (8-22) mmol l-1, 44.7 (23.8-60.5) mmHg, and 10.4 (6.7-14.1), respectively. Four patients (44.4%) received monteplase for thrombolysis. No patient underwent surgical embolectomy. The median duration of ECMO was 69 (38-126) h. There were two ECMO-related bleeding complications. Eight patients (88.9%) survived and one died of post-resuscitation encephalopathy after weaning from ECMO. CONCLUSION: A hybrid ER may be useful for initial management of massive PE requiring ECPR and may help to improve outcomes.

Etiology of out-of-hospital cardiac arrest in psychiatric patients: Chart review.

AIM: Although sudden cardiac deaths are more common in psychiatric patients than the general population, data on their causes are very limited. The aim of this study was to investigate initial rhythms and causes of out-of-hospital cardiac arrest (OHCA) in patients with psychiatric disorders. METHODS: We conducted a systematic chart review of patients resuscitated after OHCA and hospitalized in the Tertiary Emergency Medical Center of Tokyo Metropolitan Bokutoh Hospital in Japan between January 2010 and December 2017. The initial rhythms and causes of OHCA were compared between psychiatric patients and non-psychiatric patients. Parameters of interest were compared using chi-squared test, Fisher's exact test, or the Mann-Whitney U-test, as appropriate. RESULTS: A total of 49 psychiatric and 600 non-psychiatric patients were eligible for this study. Fatal but shockable arrhythmias (i.e. ventricular fibrillation and ventricular tachycardia) were less frequently observed as initial rhythms in patients with psychiatric disorders than the others (22.4% vs 49.7%, P < 0.001). Cardiac origin was less common as the cause of OHCA (26.5% vs 58.5%, P < 0.01), while airway obstruction and pulmonary embolism were more frequent in psychiatric versus non-psychiatric patients (24.5% vs 6.5%, P < 0.01; and 12.2% vs 1.5%, P < 0.01, respectively). The results were similar when psychiatric patients were compared with sex- and age-matched controls selected from the non-psychiatric patient group. CONCLUSION: Although fatal arrhythmias may be less common, non-cardiac causes such as pulmonary embolism and airway obstruction need to be treated with high clinical suspicion in an event of sudden cardiac arrest in psychiatric patients.

Purpura fulminans with Lemierre's syndrome caused by Gemella bergeri and Eikenella corrodens: a case report.

BACKGROUND: Gemella bergeri is one of the nine species of the genus Gemella and is relatively difficult to identify. We herein describe the first case of septic shock due to a Gemella bergeri coinfection with Eikenella corrodens. CASE PRESENTATION: A 44-year-old Asian man with a medical history of IgG4-related ophthalmic disease who was prescribed corticosteroids (prednisolone) presented to our hospital with dyspnea. On arrival, he was in shock, and a purpuric eruption was noted on both legs. Contrast enhanced computed tomography showed fluid retention at the right maxillary sinus, left lung ground glass opacity, and bilateral lung irregular opacities without cavitation. Owing to suspected septic shock, fluid resuscitation and a high dose of vasopressors were started. In addition, meropenem, clindamycin, and vancomycin were administered. Repeat computed tomography confirmed left internal jugular and vertebral vein thrombosis. Following this, the patient was diagnosed with Lemierre's syndrome. Furthermore, he went into shock again on day 6 of hospitalization. Additional soft tissue infections were suspected; therefore, bilateral below the knee amputations were performed for source control. Cultures of the exudates from skin lesions and histopathological samples did not identify any pathogens, and histopathological findings showed arterial thrombosis; therefore it was concluded that the second time shock was associated with purpura fulminans. Following this, his general status improved. He was transferred to another hospital for rehabilitation. The blood culture isolates were identified as Gemella bergeri and Eikenella corrodens. Gemella bergeri was identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry and confirmed by 16S rRNA gene sequencing later. The primary focus of the infection was thought to be in the right maxillary sinus, because the resolution of the fluid retention was confirmed by repeat computed tomography. CONCLUSIONS: Gemella bergeri can be the causative pathogen of septic shock. If this pathogen cannot be identified manually or through commercial phenotypic methods, 16S rRNA gene sequencing should be considered.

Categorization of post-cardiac arrest patients according to the pattern of amplitude-integrated electroencephalography after return of spontaneous circulation.

BACKGROUND: Continuous electroencephalography (cEEG), interpreted by an experienced neurologist, has been reported to be useful in predicting neurological outcome in adult patients post cardiac arrest. Amplitude-integrated electroencephalography (aEEG) is a type of quantitative EEG and is easily interpreted by a non-neurologist. A few studies have shown the effectiveness of aEEG in prognostication among adult patients post cardiac arrest. In this study, we hypothesized that the pattern of aEEG after return of spontaneous circulation (ROSC) could successfully categorize patients post cardiac arrest according to their expected neurological outcome. METHODS: We assessed the comatose survivors of out-of-hospital cardiac arrest who received targeted temperature management with midazolam-based sedation and were monitored with aEEG at our tertiary emergency care center from January 2013 to June 2017. We categorized the patients into categories 1 (C1) to 4 (C4). C1 included patients who regained continuous normal voltage (CNV) within 12 h post ROSC, C2 included those who recovered CNV 12-36 h post ROSC, C3 included those who did not recover CNV before 36 h post ROSC, and C4 included those who had burst suppression at any time post ROSC. We evaluated the outcomes of neurological function for each category at hospital discharge. A good outcome was defined as a cerebral performance category of 1 or 2. RESULTS: A total of 61 patients were assessed (median age, 60 years), among whom 42 (70%) had an initial shockable rhythm, and 52 (85%) had cardiac etiology. Of all 61 patients, 40 (66%) survived to hospital discharge and 27 (44%) had a good neurological outcome. Of 20 patients in C1, 19 (95%) had a good outcome, while the percentage dropped to 57% among C2 patients. No patients in C3 or C4 had a good outcome. Three patients could not be classified into any category. CONCLUSIONS: The pattern of aEEG during the early post-cardiac-arrest period can successfully categorize patients according to their neurological prognoses and could be used as a potential guide to customize post-cardiac-arrest care for each patient.

Effect of ultrasonography and fluoroscopic guidance on the incidence of complications of cannulation in extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a retrospective observational study.

BACKGROUND: It remains unclear which cannulation method is best in cases of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest. We assessed the effect of ultrasound- and fluoroscopy-guided percutaneous cannulation on complication incidence, compared with that using only ultrasound guidance. METHODS: This single-center retrospective observational study was conducted between February 2011 and December 2015. In the comparison group, cannulation was performed percutaneously using only ultrasound guidance. In the exposure group, cannulation was performed percutaneously using fluoroscopy and ultrasound guidance. The primary outcome assessed was whether complications were associated with cannulation. The secondary outcome assessed was the duration from hospital arrival to extracorporeal circulation start. In addition to univariate analysis, multivariate logistic-regression analysis for cannulation complications was performed to adjust for several presumed confounders. RESULTS: Of the patients who underwent ECPR, 73 were eligible; the comparison group included 50 cases and the exposure group included 23 cases. Univariate analysis showed that the complication incidence of the exposure group was significantly lower than that of the comparison group (8.7 vs. 36.0%, p = 0.022). Duration from hospital arrival to extracorporeal circulation start was almost the same in both groups (median, 17.0 min vs. 17.0 min, p = 0.92). After multivariate logistic regression analysis, cannulation using fluoroscopy and ultrasound was independently associated with a lower complication incidence (adjusted odds ratio, 0.14; p = 0.024). CONCLUSIONS: Ultrasound- and fluoroscopy-guided cannulation may reduce the complication incidence of cannulation without delaying extracorporeal circulation start.