Joo Jeong

Association of time from arrest to percutaneous coronary intervention with survival outcomes after out-of-hospital cardiac arrest ☆

BACKGROUNDnTimely post-resuscitation coronary reperfusion therapy is recommended; however, the timing of immediate coronary reperfusion for out-of-hospital cardiac arrest (OHCA) has not been established. We studied the effect of the time interval from arrest to percutaneous coronary intervention (PCI) on resuscitated OHCA patients.nnnMETHODSnAll witnessed OHCA patients with a presumed cardiac etiology received successful PCI at hospitals between 2013 and 2015, excluding cases with unknown information regarding the time from arrest to PCI and survival outcomes. The main exposure of interest was the time interval from arrest to ballooning or stent placement in coronary arteries, and cases were categorized into five groups of 0-90, 90-120, 120-150, and 150-180min and 3-6h. The endpoint was survival with good neurological recovery. Multivariable logistic regression analysis was performed, adjusting for patient-community, prehospital, and hospital factors.nnnRESULTSnA total of 765 patients (24.1% received PCI within 90min; 31.0% in 90-120min; 17.8% in 120-150min; 12.3% in 150-180min; 14.9% in 3-6h after arrest) were included. Good neurological recovery was more frequent in the early PCI groups than the delayed PCI group (63.6%, 55.3%, 47.8%, 33.0%, and 42.1%, respectively). The adjusted OR (95% CI) for good neurological recovery compared with the most early PCI group was 0.86 (0.53-1.39) in the PCI group between 90 and 120min; 0.76 (0.45-1.31) in the PCI group between 120 and 150min; 0.42 (0.22-0.79) in the PCI group between 150 and 180min; and 0.53 (0.30-0.93) in PCI group after 3h.nnnCONCLUSIONSnAmong resuscitated OHCA patients with a presumed cardiac etiology and successful PCI, patients who received a delayed coronary intervention after 150min from arrest were less likely to have neurologically intact survival compared to those who received an early intervention.

Vertical distance between umbilicus to aortic bifurcation on coronal view in Korean women

Objective To evaluate the vertical distance between umbilicus to aortic bifurcation on coronal view in Korean women and their relation with body mass index (BMI) and womans age. Methods This retrospective study included 257 women who visited emergency center at university-based hospital from January to December 2011. All women underwent abdomino-pelvic computerized tomography (CT) due to various symptoms in a supine position. By using the electronic coronal CT images, the vertical distance between umbilicus and aortic bifurcation was measured. If aortic bifurcation was located below umbilicus, the distance was expressed as minus value (i.e., caudal to umbilicus). Age of woman, body weight, height and calculated BMI (kg/m2) were also recorded. Results Aortic bifurcation was located caudal to umbilicus in 52.9% and cephalad to umbilicus in 37.4%. The vertical distance had a negative relationship with BMI (r=.0.180, P=0.004), as well as womans age (r=-0.382, P<0.001). However, a multivariate analysis revealed that the vertical distance had a significant negative relationship with womans age (P<0.001) but not with BMI (P=0.510). An equation could be drawn to estimate the vertical distance by using womans age and BMI: vertical distance (mm)=12.6-0.3×(age)-0.2×(BMI). Conclusion The vertical distance from umbilicus to aortic bifurcation on coronal view showed a significant inverse correlation with womans age, however, the distances varied widely. Most older or obese Korean women had aortic bifurcation caudal to umbilicus.

Scene time interval and good neurological recovery in out-of-hospital cardiac arrest

Objectives: It is unclear whether scene time interval (STI) is associated with better neurological recovery in the emergency medical service (EMS) system with intermediate service level. Methods: Adult out‐of‐hospital cardiac arrest (OHCA) patients with presumed cardiac etiology (2012 to 2014) were analyzed, excluding patients not‐resuscitated, occurred in ambulance/medical/nursing facility, unknown STI or extremely longer STI (> 60 min), and unknown outcomes. STI was classified into short (0.0–3.9 min), middle (4.0–7.9 min), long (8.0–11.9 min), and very‐long (12.0–59.9 min), respectively. The end point was a good cerebral performance category (CPC) 1 or 2. Multivariable logistic regression by STI group (reference = short) was performed to calculate adjusted odds ratios (AORs) with 95% confidence intervals (95% CIs) for outcomes with or without interaction term (STI * prehospital return of spontaneous circulation, (PROSC)). Results: Of 79,832 OHCA patients, 41,054 cases were analyzed; good CPC in the short (3.0%), middle (3.2%), long (3.0%), and very‐long (2.9%) STI groups were similar, respectively (p = 0.55). The AORs (95% CI) for good CPC in the final model without interaction term were 0.74 (0.58–0.95) for the middle, 0.51 (0.39–0.67) for the long, and 0.45 (0.33–0.61) for the very‐long STI group (reference = short STI). The AORs in PROSC group were 1.18 (0.97–1.44) for middle STI group, 0.72 (0.57–0.92) for long group, and 0.56 (0.42–0.77) for very‐long group. The AORs in non‐PROSC group were 1.22 (1.06–1.40) for middle STI group, 0.82 (0.70–0.96) for long group, and 0.70 (0.57–0.85) for very‐long group. Conclusion: The middle STI (4–7 min) was associated with the highest odds of neurological recovery for patients who could not be restored in the field. The STI may be a clinically useful predictor of good neurology outcome in victims of cardiac arrest.

Relationship between drowning location and outcome after drowning-associated out-of-hospital cardiac arrest: nationwide study

PURPOSEnAccidental drowning can cause out-of-hospital cardiac arrest (OHCA). We investigated the effect of drowning location on outcomes of individuals who experienced drowning-OHCA.nnnMETHODSnAll cases of emergency medical service-treated drowning-OHCA in South Korea from January 2006 to December 2013 were analyzed. Cases were excluded if there was a preceding injury, no information on event location, or suicide. Cases were divided into 4 groups: recreational water with mandatory safety regulations (group 1, public swimming pool; group 2, beach) and nonrecreational water without mandatory safety regulations (group 3, natural freshwater; group 4, seawater). The main outcome was survival to hospital discharge. Multiple logistic regression analysis was conducted using natural freshwater as the reference location.nnnRESULTSnWe analyzed 1691 drowning-OHCAs (public swimming pools, 3.4%; public beaches, 5.2%; unsupervised seawater, 33.8%; and unsupervised open freshwater, 57.6%). The rate of survival to discharge was 4.6% for all cases, 17.5% for cases in public swimming pools, 9.1% for cases in public beaches, 4.9% for cases in unsupervised seawater, and 3.3% for cases in unsupervised open freshwater (p<0.01). The adjusted odds ratios (95% confidence intervals [CIs]) for survival relative to natural freshwater were 3.97 (95% CI, 1.77-8.89) for public swimming pools, 2.81 (95% CI, 1.22-6.45) for public beaches, and 1.54 (95% CI, 0.88-2.70) for unsupervised seawater.nnnCONCLUSIONnIndividuals who experience drowning-OHCA in public locations with safety regulations had a better rate of survival. There should be improved public awareness of the significantly greater risk of drowning-OHCA in locations that have no safety regulations.

The association between acute alcohol consumption and discharge against medical advice of injured patients in the ED.

PURPOSESnA paucity of data exists on the prevalence and predictors of discharging injured patients against medical advice from emergency departments. The aim of this study is to investigate the association between acute alcohol use and being discharged against medical advice.nnnMETHODSnWe performed a prospective, observational study of injured patients enrolled into the Korean Centers for Disease and Prevention injury surveillance program in 7 tertiary, academic, and teaching hospitals from June 1, 2008, to November 31, 2011. Injured patients were assigned to 1 of 3 groups: discharged against medical advice, regular discharge, and transferred or admitted. Multivariable logistic regression models were used to analyze the association between acute alcohol use and being discharged against medical advice.nnnRESULTSnA total of 125,327 patients were enrolled, and 3473 (2.8%) were discharged against medical advice. The proportion of acute alcohol use was significantly higher among the patients who were discharged against medical advice (40.1%) than the regular discharged (16.6%) or transferred/admitted (15.5%) patients. In a regression model, acute alcohol use increased the risk of being discharged against medical advice (adjusted odds ratio, 1.86; 95% confidence interval, 1.70-2.03). In addition, we identified the interaction between acute alcohol use and intention of injury. Acute alcohol use had a significant association with the discharge against medical advice with the unintentional injury (adjusted odds ratio, 2.56; 95% confidence interval, 2.30-2.84).nnnCONCLUSIONnPatients with acute alcohol use before sustaining an injury are at increased risk of being discharged against medical advice from the emergency departments.

Preventive effects of motorcycle helmets on intracranial injury and mortality from severe road traffic injuries

Introduction Road traffic injuries caused by motorcycle crashes are one of the major public health burdens leading to high mortality, functional disability, and high medical costs. The helmet is crucial protective equipment for motorcyclists. This study aimed to measure the protective effect of motorcycle helmets on clinical outcomes and to compare the effects of high‐ and low‐speed motorcycle crashes. Methods A cross‐sectional observational study was conducted using a nationwide registry of severe trauma patients treated by emergency medical services (EMS) providers in Korea. The study population consisted of severe trauma patients injured in motorcycle crashes between January and December 2013. The primary and secondary outcomes were intracranial injury and in‐hospital mortality. We calculated adjusted odds ratios (AORs) of helmet use and motorcycle speeds for study outcomes after adjusting for potential confounders. Results Among 495 eligible patients, 105 (21.2%) patients were wearing helmets at the time of the crash, and 256 (51.7%) patients had intracranial injuries. The helmeted group was less likely to have an intracranial injury compared with the un‐helmeted group (41.0% vs. 54.6%, AOR: 0.53 (0.33–0.84)). However, there was no significant difference in in‐hospital mortality between the two groups (16.2% vs. 16.9%, AOR: 0.91 (0.49–1.69)). In the interaction analysis, there was a significant preventive effect of motorcycle helmet use on intracranial injury when the speed of the motorcycle was < 30 km/h (AOR: 0.50 (0.27–0.91)). Conclusion Wearing helmets for severe trauma patients in motorcycle crashes reduced intracranial injuries. The preventive effect on intracranial injury was significant in low‐speed motorcycle crashes.

Cooling methods of targeted temperature management and neurological recovery after out-of-hospital cardiac arrest: A nationwide multicenter multi-level analysis

OBJECTIVEnThe purpose of this study was to determine whether the cooling method used for target temperature management (TTM) was associated with neurological recovery after out-of-hospital cardiac arrest (OHCA).nnnMETHODSnFrom January 2008 to December 2016, adult OHCA patients who survived to hospitalization without any traumatic etiology and who received TTM were included. Patients who did not have information about neurological status at hospital discharge or who did not have information on target temperature management were excluded. Cooling methods were classified into four groups: (1) external device cooling (EDC) using a pad with cooling device, (2) external conventional cooling (ECC) such as ice water, fans, and simple blankets, (3) Intravascular cooling (IVC) using an intravascular cooling catheter, and (4) intracavitary cooling (ICC) using ice water for washing cavitary organ. The outcomes were good cerebral performance scale (CPC) score 1 or 2 and survival to discharge. In multivariate logistic regression analysis, the adjusted odds ratios (AORs) and the 95% confidence intervals (CIs) were calculated (referenceu202f=u202fECC). Finally, we used a GLIMMIX procedure with group-level variables (hospitals) to create a multilevel model for adjusting the clustering factor of patients being treated in the same hospital.nnnRESULTSnThe final analysis included a total of 4246 eligible patients (ECC 1386, EDC 2107, IVC 376, ICC 377). Good neurologic recovery was 20.7% for all (ECC 17.4, EDC 23.1%, IVC 26.9%, and ICC 13.3%, pu202f<u202f.001). The survival rate was 46.4% for all (ECC 45.4%, EDC 48.5%, IVC 50.5%, ICC 34.2%, pu202f<u202f.001). There were no significant differences (AOR and 95% CI) in the multi-level analysis for good neurological recovery between cooling methods compared with ECC; EDC 1.20 (0.95-1.52), IVC 1.43 (0.90-2.27), and ICC 0.71 (0.46-1.10). The ICC group had a lower survival to discharge rate compared with ECC; EDC 0.97 (0.83-1.15), IVC 0.96 (0.78-1.19), and ICC 0.63 (0.43-0.85).nnnCONCLUSIONnThe cooling methods for TTM did not show any significant difference in neurological recovery in multi-level logistic regression analysis. Only intracavitary cooling resulted in a lower survival to discharge than external surface cooling.

Association between the centralization of dispatch centers and dispatcher-assisted cardiopulmonary resuscitation programs: A natural experimental study

OBJECTIVESnWe aimed to evaluate the associations between the centralization of dispatch centers and dispatcher-assisted bystander cardiopulmonary resuscitation (DA-BCPR) for out-of-hospital cardiac arrest (OHCA) patients.nnnMETHODSnAll emergency medical services (EMS)-treated adults in Gyeonggi province (34 fire departments covering 43 counties, with a population of 12.6 million) with OHCAs of cardiac etiology were enrolled between 2013 and 2016, excluding cases witnessed by EMS providers. In Gyeonggi province, 34 agency-based dispatch centers were sequentially integrated into two province-based central dispatch centers (north and south) between November 2013 and May 2016. Exposure was the centralization of the dispatch centers. Endpoint variables were BCPR and dispatcher-provided CPR instructions. Generalized linear mixed models for multilevel regression analyses were performed.nnnRESULTSnOverall, 11,616 patients (5060 before centralization and 6556 after centralization) were included in the final analysis. The OHCAs that occurred during the after-centralization period were more likely to receive BCPR (62.6%, 50.6% BCPR-with-DA and 12.0% BCPR-without-DA) than were those that occurred before-centralization period (44.6%, 16.6% BCPR-with-DA and 28.1% BCPR-without-DA) (pu2009<u20090.01, adjusted OR: 1.59 (1.38-1.83), adjusted rate difference: 9.1% (5.0-13.2)). For dispatcher-provided CPR instructions, OHCAs diagnosed at a higher rate during the after-centralization period than during the before-centralization period (67.4% vs. 23.1%, pu2009<u20090.01, adjusted OR: 4.57 (3.26-6.42), adjusted rate difference: 30.3% (26.4-34.2)). The EMS response time was not different between the groups (p=0.26).nnnCONCLUSIONSnThe centralization of dispatch centers was associated with an improved bystander CPR rate and dispatcher-provided CPR instructions for OHCA patients.

Interactive Effect between On-Scene Hypoxia and Hypotension on Hospital Mortality and Disability in Severe Trauma

Abstract Background: It is unclear whether effect size of the hypoxia is different on in-hospital mortality and disability according to hypotension status in the field. Methods: Adult severe trauma (ST) patients during 2012–13 who were treated by emergency medical services (EMS) and had abnormal revised trauma scores in the field or who had positive trauma triage criteria were analyzed. Exposure was hypoxia (<94%) measured by EMS. End points were hospital mortality and disability defined as a Glasgow Outcome Scale that decreased by 2 points or more. Multivariable logistic regression with interaction model between hypoxia and hypotension was used for outcomes to calculate the adjusted odds ratios (AOR) with 95% confidence intervals (95% CIs) after adjusting for potential confounders. Results: A total of 17,406 EMS-ST patients were analyzed. Of those, 2,598 (14.9%) died, and 3,292 (21.5%) were considered disabled at discharge. The total hypoxia group showed higher mortality and disability indices (35.7 and 51.2%) than the non-hypoxia group (10.7 and 15.9%) (each p-value < 0.0001). The AOR of hypoxia was 2.15 (1.92–2.40) for mortality and was 1.97 (1.75–2.21) for disability. In the interaction model, AORs for mortality by hypoxia in the hypotensive and non-hypotensive groups were 2.66 (2.32–3.04) and 1.74 (1.61–1.87), respectively (P < 0.0001 for interaction). The AORs for disability in the hypotensive and non-hypotensive groups were 2.17 (1.87–2.53) and 1.55 (1.42–1.69), respectively (P < 0.0001 for interaction). Conclusions: The effect of hypoxia was much greater in the hypotensive group than in the non-hypotensive group both in terms of mortality and disability.

The Korean Triage and Acuity Scale: associations with admission, disposition, mortality and length of stay in the emergency department

ObjectivenThe Korean Triage and Acuity Scale (KTAS) was implemented in our emergency department (ED) in May 2016 and is fully integrated into the electronic medical record (EMR) system. Our objective was to determine whether the KTAS is associated with changes in admissions to the hospital, admission disposition, inpatient mortality and length of stay (LOS).nnnDesignnQuasi-experimental, uncontrolled before-and-after study.nnnSettingnThe urban tertiary teaching hospital with 1100 beds and receives approximately annual 90 000 ED visits.nnnParticipantsn122 370 patients who visited the ED during the before-and-the after period.nnnInterventionsnED staff were educated on the KTAS for 1 month, after which the KTAS evaluation period began. Admission, disposition, mortality and LOS were compared between the before period (1 June 2015 to 30 April 2016) and the after period (1 June 2016 to 30 April 2017).nnnMain outcome measuresnAdmissions to the hospital, admission disposition, inpatient mortality and LOS.nnnResultsnA total of 59 220 and 63 150 patients were included in the before-and-after periods of KTAS implementation, respectively. The pattern of admission and disposition changed significantly after implementation of the KTAS. The mean LOS was 343 min (standard deviation [SD] = 432 min) during the before period, which significantly decreased to 289 min (SD = 333 min) after implementation (P < 0.001). The total mortality rate was significantly reduced after implementation of the KTAS (213 (0.36%) vs. 179 (0.28%), P = 0.020).nnnConclusionnImplementation of the KTAS changed admission and disposition patterns and reduced the LOS and mortality in the ED.