Hyuk Jun Yang

Multidetector CT findings of skeletal chest injuries secondary to cardiopulmonary resuscitation

INTRODUCTION Rib and sternal fractures are frequent complications of cardiopulmonary resuscitation (CPR) in adults. This is the first study to evaluate the MDCT findings of chest injuries secondary to CPR, by comparing with the findings of radiography. METHODS For 40 patients who underwent MDCT after CPR for a non-traumatic cause of cardiac arrest, we evaluated the MDCT findings of the CPR associated traumatic chest injuries and compared the diagnostic performance of chest radiography and MDCT for the evaluation of chest injuries. RESULTS MDCT revealed that 26 patients (65%) had rib fractures and 12 patients (30%) had sternal fractures. However, radiography detected only 10 patients who had rib fractures. In 25 of the 26 cases, multiple ribs were fractured (ranging up to 13 rib fractures), and the rib fractures were bilateral in 18 of these cases. The majority of rib fractures were located in the anterior part of the thoracic cage. Six of the patients had fracture-related complications (pneumothorax=1, subclavian vein injury=1, chest wall hematoma=4). The sternal fractures predominantly occurred in the middle and lower third of the sternal body (five each for the middle and lower third of the sternal body). CONCLUSION Rib and sternal fractures are frequent complications in patients who underwent CPR. MDCT is useful for the evaluation of chest injuries secondary to CPR as compared with that of radiography and also for the evaluation of the fracture-related complications.

Hormonal responses upon return of spontaneous circulation after cardiac arrest: a retrospective cohort study

IntroductionCardiac arrest is often fatal and can be extremely stressful to patients, even if spontaneous rhythm is returned. The purpose of this study was to analyze the hormonal response after return of spontaneous circulation (ROSC).MethodsThis is a retrospective review of the chart and laboratory findings in a single medical facility. The patients admitted to the intensive care unit after successful resuscitation after out-of-hospital cardiac arrest were retrospectively identified and evaluated. Patients with hormonal diseases, patients who received cortisol treatment, those experiencing trauma, and pregnant women were excluded. Serum cortisol, adrenocorticotropic hormone (ACTH), and anti-diuretic hormone (ADH (vasopressin)) were analyzed and a corticotropin-stimulation test was performed. Mortality at one week and one month after admission, and neurologic outcome (cerebral performance category (CPC)) one month after admission were evaluated.ResultsA total of 117 patients, including 84 males (71.8%), were evaluated in this study. One week and one month after admission, 87 (74.4%) and 65 patients (55.6%) survived, respectively. Relative adrenal insufficiency, and higher plasma ACTH and ADH levels were associated with shock-related mortality (P = 0.046, 0.005, and 0.037, respectively), and ACTH and ADH levels were also associated with late mortality (P = 0.002 and 0.004, respectively). Patients with relative adrenal insufficiency, ACTH ≧5 pg/mL, and ADH ≧30 pg/mL, had a two-fold increased risk of a poor outcome (shock-related mortality): (odds ratio (OR), 2.601 and 95% confidence interval (CI), 1.015 to 6.664; OR, 2.759 and 95% CI, 1.060 to 7.185; OR, 2.576 and 95% CI, 1.051 to 6.313, respectively). Thirty-five patients (29.9%) had a good CPC (1 to 2), and 82 patients (70.1%) had a bad CPC (3 to 5). Age ≧50 years and an ADH ≧30 pg/mL were associated with a bad CPC (OR, 4.564 and 95% CI, 1.794 to 11.612; OR, 6.568 and 95% CI, 1.918 to 22.483, respectively).ConclusionsThe patients with relative adrenal insufficiency and higher blood levels of ACTH and ADH upon ROSC after cardiac arrest had a poor outcome. The effectiveness of administration of cortisol and ADH to patients upon ROSC after cardiac arrest is uncertain and additional studies are needed.

Effectiveness of each target body temperature during therapeutic hypothermia after cardiac arrest

PURPOSE According to the 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation, unconscious adult patients with a return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest should be cooled to 32°C to 34°C for 12 to 24 hours. However, it is unclear which target temperature is more adequate. In this study, we prospectively evaluated the outcome and adverse effects following 3 target temperatures (32°C, 33°C, and 34°C) during therapeutic hypothermia with ROSC after out-of-hospital cardiac arrest. METHODS This is a prospective study of patients with ROSC (>24 hours) after out-of-hospital cardiac arrest who were admitted to the intensive care unit in a tertiary hospital and underwent therapeutic hypothermia during a 22-month period between March 2007 and December 2008. RESULTS Sixty-two patients were included. The number of male patients was 44. The mean (SD) ages of the patients was 54.61 (2.002) years. There were 13, 22, and 28 patients who were enrolled in the target temperatures (32°C, 33°C, and 34°C, respectively). There were no significant differences after each target temperature with respect to mortality and neurologic outcomes. Regarding adverse effects, hypotension during the maintenance of therapeutic hypothermia significantly increased when the target temperature was 32°C (P = .023). Based on multivariate analysis, hypotension during the maintenance of therapeutic hypothermia was increased more than 6 times at 32°C compared with 33°C (odds ratio, 6.800; 95% confidence interval, 1.428-32.373). CONCLUSION When performing therapeutic hypothermia in patients with ROSC after an out-of-hospital cardiac arrest, the target temperature would be set to 33°C or 34°C, rather than 32°C. Further multicenter randomized controlled studies may be needed in the future.

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

Blood ammonia is a predictive biomarker of neurologic outcome in cardiac arrest patients treated with therapeutic hypothermia

PURPOSE The aim of this study was to investigate the value of commonly examined laboratory measurements, including ammonia and lactate, in predicting neurologic outcome of out-of-hospital cardiac arrest (OHCA) patients treated with therapeutic hypothermia (TH). METHODS This was a retrospective cohort study of patients with a return of spontaneous circulation after OHCA who were treated with TH between February 2007 and July 2010. We measured typical blood measurements on arrival at the emergency department. The subjects were classified into 2 groups: the good neurologic outcome group (Cerebral Performance Category [CPC] 1-2 at 1 month) and the poor neurologic outcome group (Cerebral Performance Category 3-5). We compared blood biomarker levels and basal characteristics between the 2 groups. Logistic regression analyses were performed to determine independent biomarkers that predict poor neurologic outcome. RESULTS A total of 117 patients were included. Between the 2 groups, significantly different levels of blood measurements included hemoglobin level, pH, Pao(2), Paco(2), base excess, albumin, glucose, potassium, chloride, bilirubin, phosphorous, and ammonia. In multivariate analyses, blood ammonia level (>96 mg/dL; odds ratio [OR], 7.240; 95% confidence interval [CI], 1.718-30.512), noncardiac causes (OR, 46.215; 95% CI, 9.670-220.873), and time interval from collapse to return of spontaneous circulation (>33 min; OR, 5.943; 95% CI, 1.543-22.886) were significantly related to poor neurologic outcome. CONCLUSION Among the blood measurements on emergency department arrival, blood ammonia (>96 mg/dL) was the only independent predictive biomarker of poor neurologic outcome. Thus, higher blood ammonia level was associated with poor neurologic outcome in OHCA patients treated with TH.

Part 9: First Aid 2015 International Consensus on First Aid Science With Treatment Recommendations

### Definition of First Aid The International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force first met in June 2013. Comprising nominated members from around the globe appointed by each ILCOR member organization, the task force members first agreed to the goals of first aid and produced a definition of first aid as it might apply to the international setting. Task force members considered an agreed-upon definition essential for the subsequent development of research questions, evidence evaluation, and treatment recommendations. First aid is defined as the helping behaviors and initial care provided for an acute illness or injury. First aid can be initiated by anyone in any situation. A first aid provider is defined as someone trained in first aid who should The goals of first aid are to preserve life, alleviate suffering, prevent further illness or injury, and promote recovery. This definition of first aid addresses the need to recognize injury and illness, the requirement to develop a specific skill base, and the need for first aid providers to simultaneously provide immediate care and activate emergency medical services (EMS) or other medical care as required. First aid assessments and interventions should be medically sound and based on evidence-based medicine or, in the absence of such evidence, on expert medical consensus. The scope of first aid is not purely scientific, as both training and regulatory requirements will influence it. Because the scope of first aid varies among countries, states, and provinces, the treatment recommendations contained herein may need to be refined according to circumstances, need, and regulatory constraints. One difference between this 2015 definition and that used for the 2010 process is that the …

Sternal fracture in the emergency department: Diagnostic value of multidetector CT with sagittal and coronal reconstruction images

BACKGROUND Multidetector CT (MDCT) is being increasingly used for patients with traumatic injuries in the emergency room. This is the first study to evaluate the diagnostic performance of MDCT for sternal fracture. PATIENTS AND METHODS For 87 patients who had motor vehicle accidents, we evaluated the diagnostic performance of MDCT for the sternal fractures. For 31 patients who underwent both MDCT and lateral radiography for the sternum, we compared the diagnostic performance of two examinations for the evaluation of sternal fracture. RESULTS Thirty-two patients had sternal fractures and all the sternal fractures (sensitivity=100%) were detected on MDCT, especially on the sagittal reconstruction images. However, the axial and coronal images detected 65% and 59% of all sternal fractures, respectively. For 31 patients who underwent both MDCT and lateral radiography for the sternum, MDCT showed superior diagnostic performance compared to that of radiography (accuracy=97% and 77%, respectively, P=.02). For the one case that showed false positivity for sternal fracture on MDCT due to respiratory artifact, the lateral radiography enabled making the correct diagnosis. CONCLUSION Sternal fracture is frequently seen in patients who have blunt trauma injury secondary to motor vehicle accidents. MDCT, particularly sagittal images detect all of the sternal fractures, is superior to lateral radiography for diagnosis of sternal fracture. In the limited case that CT has severe motion artifact, additional radiography could help the diagnosis of sternal fracture.

Part 9: First aid

### Definition of First Aid The International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force first met in June 2013. Comprising nominated members from around the globe appointed by each ILCOR member organization, the task force members first agreed to the goals of first aid and produced a definition of first aid as it might apply to the international setting. Task force members considered an agreed-upon definition essential for the subsequent development of research questions, evidence evaluation, and treatment recommendations. First aid is defined as the helping behaviors and initial care provided for an acute illness or injury. First aid can be initiated by anyone in any situation. A first aid provider is defined as someone trained in first aid who should The goals of first aid are to preserve life, alleviate suffering, prevent further illness or injury, and promote recovery. This definition of first aid addresses the need to recognize injury and illness, the requirement to develop a specific skill base, and the need for first aid providers to simultaneously provide immediate care and activate emergency medical services (EMS) or other medical care as required. First aid assessments and interventions should be medically sound and based on evidence-based medicine or, in the absence of such evidence, on expert medical consensus. The scope of first aid is not purely scientific, as both training and regulatory requirements will influence it. Because the scope of first aid varies among countries, states, and provinces, the treatment recommendations contained herein may need to be refined according to circumstances, need, and regulatory constraints. One difference between this 2015 definition and that used for the 2010 process is that the …

Multidetector CT and radiographic findings of lung injuries secondary to cardiopulmonary resuscitation

OBJECTIVES Lung injury is one of the complications of cardiopulmonary resuscitation (CPR). This is the first study to describe the MDCT and radiographic findings of lung injuries secondary to CPR. METHODS A total of 44 patients who underwent CPR for a non-traumatic cause of cardiac arrest were retrospectively included in this study. We evaluated the presence of lung injuries in the initial chest radiograph and MDCT performed immediately after CPR and described the MDCT and radiographic findings of the CPR-associated lung injuries. Finally, we evaluated the temporal pattern of lung injury on the follow-up radiographies. RESULTS Chest CT demonstrated lung injury in 54 lungs of 35 patients, while initial chest radiography detected lung abnormality in 37 lungs of 28 patients. The most common patterns of lung injuries on chest CT were bilateral (n=19), ground-glass opacity (n=30) and consolidation (n=26), distributed along the bronchovascular bundles (n=13). Most of the abnormalities were located in the posterior part of both upper lobes and both lower lobes (n=29). Among seven patients who did not have abnormalities in the initial chest radiograph, lung abnormalities were detected on the follow-up radiographies (mean follow-up duration=1.6 days, range=1-3 days) in five patients, and 28 patients who had lung abnormalities on initial radiograph were improved (n=19) or aggravated (n=8) on the follow-up radiographies. CONCLUSIONS Lung injuries are frequent complications in patients who underwent CPR. Compared with radiography, MDCT has benefits for the detection and characterisation of CPR-associated lung injuries. The most common findings of lung injuries after CPR were bilateral ground glass opacity and consolidation, usually in the dependent area of both lungs.

Evaluation of the 2010 American Heart Association Guidelines for infant CPR finger/thumb positions for chest compression: A study using computed tomography

INTRODUCTION We sought to verify, using computed tomography (CT) examinations of infants, which the left ventricle (LV) is compressed and abdominal compression avoided by using the chest compression landmarks recommended by the 2010 American Heart Association (AHA) Guidelines for infant cardiopulmonary resuscitation (CPR). METHODS Using CT examinations of 63 infants performed between March 2002 and July 2011, we retrospectively measured the distance between the INL and the xiphoid process, and the distance of the lower third (LT) of the sternum. The distances between LV maximal diameter (LVMD) and xiphoid processes were also measured to determine whether LVs would be compressed by chest compressions. These distances were compared with the finger placements by 20 adults, when placed on infant mannequins for simulated two-finger or two-thumb infant CPR. RESULTS The mean distances of the INL and the LT of the sternum were 32 ± 8 mm and 12 ± 2 mm from the xiphoid, respectively. The LVMD was placed 15 ± 6 mm from the xiphoid process. When we overlaid the width of adult finger placement (a mean of 28 mm for two-finger technique, and 23 mm for two-thumb technique), the LV was compressed in 57 patients (90.5%) and 59 patients (93.7%), respectively. The upper abdomen was compressed in 22 patients (34.9%) by the two-finger technique and in 16 patients (25.3%) by the two-thumb technique with the range of 0.3-10.8mm. CONCLUSION When applying the 2010 AHA Guidelines for infant CPR, recommended finger placement allows for adequate compression of the LV in more than 90% of patients. In 23-35% of infants, the upper abdomen is compressed from 0.3mm to 10.7 mm.