Gi Woon Kim

An observational study of surface versus endovascular cooling techniques in cardiac arrest patients: a propensity-matched analysis

IntroductionVarious methods and devices have been described for cooling after cardiac arrest, but the ideal cooling method remains unclear. The aim of this study was to compare the neurological outcomes, efficacies and adverse events of surface and endovascular cooling techniques in cardiac arrest patients.MethodsWe performed a multicenter, retrospective, registry-based study of adult cardiac arrest patients treated with therapeutic hypothermia presenting to 24 hospitals across South Korea from 2007 to 2012. We included patients who received therapeutic hypothermia using overall surface or endovascular cooling devices and compared the neurological outcomes, efficacies and adverse events of both cooling techniques. To adjust for differences in the baseline characteristics of each cooling method, we performed one-to-one matching by the propensity score.ResultsIn total, 803 patients were included in the analysis. Of these patients, 559 underwent surface cooling, and the remaining 244 patients underwent endovascular cooling. In the unmatched cohort, a greater number of adverse events occurred in the surface cooling group. Surface cooling was significantly associated with a poor neurological outcome (cerebral performance category 3–5) at hospital discharge (p = 0.01). After propensity score matching, surface cooling was not associated with poor neurological outcome and hospital mortality [odds ratio (OR): 1.26, 95% confidence interval (CI): 0.81-1.96, p = 0.31 and OR: 0.85, 95% CI: 0.55-1.30, p = 0.44, respectively]. Although surface cooling was associated with an increased incidence of adverse events (such as overcooling, rebound hyperthermia, rewarming related hypoglycemia and hypotension) compared with endovascular cooling, these complications were not associated with surface cooling using hydrogel pads.ConclusionsIn the overall matched cohort, no significant difference in neurological outcomes and hospital morality was observed between the surface and endovascular cooling methods.

Epidemiology and outcomes in out-of-hospital cardiac arrest: a report from the NEDIS-based cardiac arrest registry in Korea.

Sudden cardiac death (SCD) is a significant issue affecting national health policies. The National Emergency Department Information System for Cardiac Arrest (NEDIS-CA) consortium managed a prospective registry of out-of-hospital cardiac arrest (OHCA) at the emergency department (ED) level. We analyzed the NEDIS-CA data from 29 participating hospitals from January 2008 to July 2009. The primary outcomes were incidence of OHCA and final survival outcomes at discharge. Factors influencing survival outcomes were assessed as secondary outcomes. The implementation of advanced emergency management (drugs, endotracheal intubation) and post-cardiac arrest care (therapeutic hypothermia, coronary intervention) was also investigated. A total of 4,156 resuscitation-attempted OHCAs were included, of which 401 (9.6%) patients survived to discharge and 79 (1.9%) were discharged with good neurologic outcomes. During the study period, there were 1,662,470 ED visits in participant hospitals; therefore, the estimated number of resuscitation-attempted CAs was 1 per 400 ED visits (0.25%). Factors improving survival outcomes included younger age, witnessed collapse, onset in a public place, a shockable rhythm in the pre-hospital setting, and applied advanced resuscitation care. We found that active advanced multidisciplinary resuscitation efforts influenced improvement in the survival rate. Resuscitation by public witnesses improved the short-term outcomes (return of spontaneous circulation, survival admission) but did not increase the survival to discharge rate. Strategies are required to reinforce the chain of survival and high-quality cardiopulmonary resuscitation in Korea. Graphical Abstract

Cases of aminophylline and vasopressin use after failed prehospital resuscitation of cardiac arrest

Sudden cardiac death accounts for more than 500,000 deaths annually in the United States.1 Until recently, the 1992 National Conference on Cardiopulmonary Resuscitation and Emergency Cardiac Care provided the utmost advanced cardiac life support (ACLS) guidelines for the treatment of cardiac arrest.2 Recently, Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care were published, providing the most up-to-date ACLS guidelines for the treatment of cardiac arrest.3 Intravenous epinephrine is currently the recommended drug of choice for the treatment of ventricular fibrillation and pulseless ventricular tachycardia when direct-current (DC) shock therapy is ineffective.4 Because of the poor clinical outcome in patients who require epinephrine treatment for cardiac arrest, other pharmacological therapies have been examined. Several innovative pharmacologic approaches to cardiopulmonary resuscitation (CPR) have been reported in the literature. Numerous experimental studies have examined the use of various drug cocktails as a novel treatment approach. Menegazzi et al.5 compared an experimental algorithm with standard ACLS in a swine model. This experimental algorithm had a significant improvement in one-hour survival compared with those treated with standard ACLS. Furthermore, combination pharmacotherapy with delayed countershock was compared with standard ACLS in prolonged ventricular fibrillation (VF). Combination pharmacotherapy with delayed countershock produced a higher rate of restoration of spontaneous circulation (ROSC).6 There have been numerous studies regarding the potential use of aminophylline in bradyarrhythmias during cardiac arrest.7–14 Aminophylline is a nonspecific adenosine receptor blocker. Adenosine accumulates during myocardial ischemia and has been implicated as a major depressant of myocardial and electrical activity. Aminophylline may antagonize the effect of adenosine and allow restoration of electrical activity, and allow ROSC. The study assessing hormone concentration during and after CPR showed a low endogenous vasopressin plasma concentration, which was correlated with decreased ROSC.15 This has led to the potential use of vasopressin in refractory ventricular arrhythmias during cardiac arrest.15–20 Vasopressin is a potent vasoconstrictor, which increases diastolic blood pressure. It also increases coronary perfusion pressure without causing myocardial damage and shunting of pulmonary circulation. This effect is due to the β receptor response. Vasopressin has been given a class II b recommendation by the new ACLS guideline.3 We report two cases of successful CPR. In the first case, aminophylline was used to treat the bradyasystolic arrest, and in the second case, vasopressin was used to successfully treat the ventricular tachyarrhythmia. Flushing Hospital Medical Center is the first hospital built in Queens, New York, serving approximately 100 different ethnic populations with a large Asian population. Flushing Hospital Medical Center’s ambulance service operates five advanced life support (ALS) units and six basic life support (BLS) units per 24-hour period. The ALS crew has two paramedics and the BLS crew has two emergency medical technicians (EMTs) per ambulance. Our annual call volume is approximately 10,000 and the mean response time from the call to the scene is approximately 9 minutes.

Adjunctive Atropine Versus Metoclopramide: Can We Reduce Ketamine-associated Vomiting in Young Children? A Prospective, Randomized, Open, Controlled Study

OBJECTIVES Pediatric procedural sedation and analgesia (PPSA) with ketamine administration occurs commonly in the emergency department (ED). Although ketamine-associated vomiting (KAV) is a less serious complication of ketamine administration, it seems to be cumbersome and not uncommon. The authors evaluated the incidence of KAV and the prophylactic effect of adjunctive atropine and metoclopramide in children receiving ketamine sedation in the ED setting. METHODS This prospective, randomized, open, controlled study was conducted in children receiving ketamine sedation in the ED of a university-affiliated, tertiary hospital with 85,000 ED visits, including 32,000 pediatric patients from October 2010 to September 2011. The primary outcome was a measure of the incidence of KAV in the ED and after discharge according to the adjunctive drug administered. Secondary outcome measures included the time to resumption of a normal diet after ketamine sedation. RESULTS Of the 1,883 children administered ketamine for primary wound repair during the study period, a convenience sample of 338 patients aged 4 months to 5 years was enrolled. The incidences of KAV were 28.4% in the ketamine alone group, 27.9% in the ketamine with adjunctive atropine group, and 31.2% in the ketamine with adjunctive metoclopramide group (p = 0.86). The vomiting rate after discharge was 9.2% in the ketamine alone group. The nothing-by-mouth (NPO) status before sedation did not influence the incidence of KAV in any of the groups. Mean times to resumption of normal diet after ketamine administration were 7 hours 59 minutes in the ketamine alone group, 7 hours 35 minutes in the ketamine with atropine group, and 8 hours 1 minute in the ketamine with metoclopramide group (p = 0.64). CONCLUSIONS  In this study, a high rate (28.4%) of KAV was observed, consistent with prior reports using the intramuscular (IM) route. However, the authors were unable to reduce KAV using adjunctive atropine or metoclopramide. Parents or caregivers should be given more detailed discharge instructions about vomiting and diet considering the relatively long time to resuming a normal diet after ketamine sedation and the fact that KAV often occurred after ED discharge.

Does ondansetron have an effect on intramuscular ketamine-associated vomiting in children? A prospective, randomised, open, controlled study

Ketamine is one of the most commonly used sedatives for facilitating painful procedures for paediatric patients in the emergency department (ED). However, the use of ketamine is associated with a common, though not serious, adverse event usually called ketamine‐associated vomiting (KAV). The purpose of this study is to evaluate the anti‐emetic effect of adjunctive ondansetron in paediatric patients receiving ketamine sedation in the ED.

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

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

Part 8. Cardiopulmonary resuscitation education: 2015 Korean Guidelines for Cardiopulmonary Resuscitation

Cardiac arrest is a major social and public healthcare issue. According to the 2015 statistics of the Korea Centers for Disease Control and Prevention, 45.1 persons per 100,000 population had a cardiac arrest and the rate of resuscitation for cardiac arrest is 4.8%, which is low in comparison with the economic scale of the country [1]. Moreover, the mean prevalence of patients discharged with cerebral performance categories 1 or 2, which indicate good neurological prognosis for patients who had cardiac arrest, was only 2.3% [2]. This is also lower than the 9.6% of the overall survival rate to hospital discharge reported in a CARES (Cardiac Arrest Registry to Enhance Survival) research that covered the entire United States of America from 2005 to 2010 and the 8.9% reported for Osaka, Japan, from 2007 to 2009 [3,4]. In addition, resuscitation rates differ by five- to six-fold at the maximum between regions, thus requiring multilateral considerations. In order to successfully apply the newly introduced 2015 cardiopulmonary resuscitation (CPR) guidelines to the society, a well-planned integrated application strategy is required, along with an educational strategy as a core factor.

For how long can two emergency medical technicians perform high-quality cardiopulmonary resuscitation?

Objective To determine the duration and obstacles to prolonged on-scene cardiopulmonary resuscitation (CPR), and establish how long a pair of emergency medical technicians (EMTs) can provide high-quality CPR. Method Intermediate-level EMTs in Gyeonggi-do Province, Republic of Korea completed a survey regarding on-scene CPR. EMTs undergoing routine training took part in a simulation using mannequins. Parameters including compression depth, total number and rate of compressions; occurrence of incorrect hand position and incomplete chest recoil were collected over 16 2-min cycles of CPR (32 min total), with EMTs working in pairs. Result The simulation study included 43 EMTs. The median duration of on-scene CPR was 3.7 min. Fear of decrease in performance was the main obstacle to continued CPR (n = 188/254 [74.0%]). Standards for high-quality CPR were met at each of the 16 steps of the simulation. Compression rate increased significantly with time. There were no significant changes in any other parameter. Conclusion Pairs of EMTs maintained high-quality CPR for 16 cycles (32 min) with no decrease in performance. Our findings could provide evidence to recommend guidelines for duration of on-scene CPR for cardiac arrest, particularly in countries where the level and number of ambulance crews are limited.