Kyeong Ryong Lee

Chest injury following cardiopulmonary resuscitation: A prospective computed tomography evaluation

INTRODUCTION Traumatic chest injuries may occur following cardiopulmonary resuscitation (CPR). The aim of this study was to address the frequency of injuries, especially rib and sternal fractures, and also to identify factors that contribute to post-CPR trauma. METHODS This study was a prospective cross-sectional study conducted in the emergency departments (ED) of eight academic tertiary care centers. To evaluate injuries secondary to CPR, we performed chest computed tomography (CT) in patients who were successfully resuscitated from cardiac arrest. Contributing factors that might be related to injuries were also investigated. RESULTS We enrolled 71 patients between 1 January 2011 and 30 June 2011. Rib and sternal fractures were diagnosed in 22 and 3 patients, respectively. Females were more susceptible to rib fracture (p=0.036). When non-physicians participated as chest compressors in the ED, more ribs were fractured (p=0.048). The duration of CPR and number of compressors were not contributing factors to trauma secondary to CPR. There was a wide variation in the frequency of rib fractures from hospital to hospital (0-83.3%). In high-risk hospitals (in which more than 50% of patients had rib fractures), the average age of the patients was higher, and non-physicians took part in ED CPR more often than they did at low-risk hospitals. CONCLUSION The incidence of rib fracture following CPR was different in various hospitals. The presence of non-physician chest compressors in the ED was one of the contributing factors to rib fracture. Further studies on the influence of resuscitators and relation between quality of chest compression and CPR-induced injuries are warranted to reduce complications following CPR.

A different rescuer changing strategy between 30:2 cardiopulmonary resuscitation and hands-only cardiopulmonary resuscitation that considers rescuer factors: A randomised cross-over simulation study with a time-dependent analysis

AIM To compare the time-dependent changes in the quality of chest compressions in 30:2 cardiopulmonary resuscitation (CPR) and hands-only cardiopulmonary resuscitation (HO-CPR) and to evaluate how individual rescuer factors affect the quality of chest compressions over time for both CPR techniques. METHODS Total 1028 adult hospital and university workers participated in CPR training programs including sessions of 30:2 CPR and HO-CPR. Tests of both CPR methods were performed in a random order using a manikin with Skill-Reporter™. Data were collected from 863 subjects. The time-dependent changes in chest compressions quality and the effects of individual rescuer factors (age, gender, body mass index (BMI), prior CPR training and experience) were analysed using the general linear model for a repeated-measures procedure. RESULTS In HO-CPR, the mean proportion of correct compressions depth (MPCD) decreased significantly throughout the time sectors following 20-40s (74.4-50.4% in 100-120 s) compared to 30:2 CPR (83.4-76.3% in 100-120 s) (p<0.0001). A significant decline of MPCD (MPCD<70%) was initially observed at 40-60s in HO-CPR, however, this pattern was not observed in 30:2 CPR. Individual rescuer factors minimally affected the time-dependent change in MPCD during 30:2 CPR. For HO-CPR, all rescuer factors except for male or obese/overweight (BMI≥25) were associated with a significant declines of MPCD, and these decline were usually observed from 40 to 60s. CONCLUSION Switching rescuers at an interval of 2-min is reasonable for 30:2 CPR. However, for HO-CPR switching rescuers every 1-min may be preferable except when rescuers are male or obese/overweight (BMI≥25).

[Nurses' cardiopulmonary resuscitation performance during the first 5 minutes in in-situ simulated cardiac arrest].

PURPOSE The purpose of this study was to analyze the cardiopulmonary resuscitation skills and teamwork of nurses in simulated cardiac arrests in the hospital. METHODS A descriptive study was conducted with 35 teams of 3 to 4 registered nurses each in a university hospital located in Seoul. A mannequin simulator was used to enact simulated cardiac arrest. Assessment included critical actions, time elapsed to initiation of critical actions, quality of cardiac compression, and teamwork which comprised leadership behavior and communication among team members. RESULTS Among the 35 teams, 54% recognized apnea, 43% determined pulselessness. Eighty percent of the teams compressed at an average elapsed time of 108±75 seconds with 35%, 36%, and 67% mean rates of correct compression depth, rate, and placement, respectively. Thirty-seven percent of the teams defibrillated at 224±67 seconds. Leadership behavior and communication among team members were absent in 63% and 69% of the teams, respectively. CONCLUSION The skills of the nurses in this study cannot be considered adequate in terms of appropriate and timely actions required for resuscitation. Future resuscitation education should focus on improving the quality of cardiopulmonary resuscitation including team performance targeting the first responders of cardiac arrest.

Video laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators ☆

AIM This study compared endotracheal intubation (ETI) performance during cardiopulmonary resuscitation (CPR) between direct laryngoscopy (DL) and video laryngoscopy (VL) (GlideScope(®)) by experienced intubators (>50 successful ETIs). METHODS This was a prospective randomized controlled study conducted in an emergency department between 2011 and 2013. Intubators who used DL or VL were randomly allocated to ETI during CPR. Data were collected from recorded video clips and rhythm sheets. The success, speed, complications, and chest compressions interruption were compared between the two devices. RESULTS Total 140 ETIs by experienced intubators using DL (n=69) and VL (n=71) were analysed. There were no significant differences between DL and VL in the ETI success rate (92.8% vs. 95.8%; p=0.490), first-attempt success rate (87.0% vs. 94.4%; p=0.204), and median time to complete ETI (51 [36-67] vs. 42 [34-62]s; p=0.143). In both groups, oesophageal intubation and dental injuries seldom occurred. However, longer chest compressions interruption occurred using DL (4.0 [1.0-11.0]s) compared with VL (0.0 [0.0-1.0]s) and frequent serious no-flow (interruption>10s) occurred with DL (18/69 [26.1%]) compared with VL (0/71) (p<0.001). For highly experienced intubators (>80 successful ETIs), frequent serious no-flow occurred in DL (14/55 [25.5%] vs. 0/57 in VL). CONCLUSIONS The ETI success, speed and complications during CPR did not differ significantly between the two devices for experienced intubators. However, the VL was superior in terms of completion of ETI without chest compression interruptions. TRIAL REGISTRATION Clinical Research Information Service (CRIS) in South Korea KCT0000849.

Effects of combination therapy of docetaxel with selenium on the human breast cancer cell lines MDA-MB-231 and MCF-7

Purpose The anticancer property and cytoprotective role of selenium in chemotherapy have been reported. However, the combination effects of selenium on chemotherapy for advanced breast cancer have not yet been clearly defined. The purpose of this study was to investigate the combined effects of selenium on chemotherapy using docetaxel on breast cancer cell lines. Methods Under adherent culture conditions, two breast cancer cell lines, MDA-MB-231 and MCF-7, were treated with docetaxel at 500pM and selenium at 100nM, 1µM, or 10µM. Changes in cell growth, cell cycle duration, and degree of apoptosis after 72 hours in each treated group were evaluated. Results In the MDA-MB-231 cells, the combination therapy group (docetaxel at 500pM plus selenium at 10µM) showed a significantly decreased percentage of cell growth (15% vs. 28%; P = 0.004), a significantly increased percentage of late apoptosis (63% vs. 26%; P = 0.001), and an increased cell cycle arrest in the G2/M phase (P = 0.001) compared with the solitary docetaxel therapy group. Isobologram analysis demonstrated the synergistic effect of the combination therapy in the MDA-MB-231 cells. However, in the MCF-7 cells, no significant differences in the percentage of cell growth apoptosis, the percentage of apoptosis, and the pattern of cell cycle arrest were noted between the combination therapy groups and the solitary docetaxel therapy group. Conclusion Our in vitro study indicated that the combination of selenium with docetaxel inhibits cell proliferation through apoptosis and cell arrest in the G2/M phase in MDA-MB-231 breast cancer cells.

Neurologic outcome of comatose survivors after hanging: a retrospective multicenter study

PURPOSE The aim of this study is to identify the neurologic outcome of hanging patients and prognostic factors. MATERIALS AND METHODS We retrospectively investigated comatose hanging patients who arrived at the emergency departments (EDs) of twelve academic tertiary care centers during a period of seven years (2006-2012). Patients were analyzed separately according to whether out-of-hospital cardiac arrest (OHCA) occurred or not. The neurologic outcome was evaluated using the Cerebral Performance Category (CPC) at the time of hospital discharge. RESULTS A total of 1118 patients were admitted to the ED after hanging attempts. There were 159 comatose patients who did not experience OHCA. Twelve (7.5%) of 159 patients were discharged from the hospital with a poor neurologic outcome (CPC 3-5). These 12 patients received only conservative management without therapeutic hypothermia. On multivariate logistic regression analysis, mental state upon ED arrival and arterial pH were predicting factors for poor prognosis. One hundred twenty-one patients suffered OHCA and experienced restored spontaneous circulation after cardiopulmonary resuscitation. Among them, only five (4.1%) patients recovered consciousness to the level of CPC 1-2. The initial arterial pH and HCO3(-) were prognostic factors in hanging patients with OHCA. CONCLUSIONS Even though cardiac arrest did not occur after hanging injuries, 7.5% of patients could not recover consciousness. Therapeutic hypothermia should be considered for such patients. If OHCA occurred after the hanging injury, the proportion of patients with good neurologic outcome was very low at 4.1%.

Efficacy of the Disposcope endoscope, a new video laryngoscope, for endotracheal intubation in patients with cervical spine immobilisation by semirigid neck collar: comparison with the Macintosh laryngoscope using a simulation study on a manikin

Objective To evaluate whether endotracheal intubation in patients with cervical spine immobilisation by a semirigid neck collar is easier using the Disposcope endoscope (DE), a new video laryngoscope, than with the Macintosh laryngoscope (ML). Methods Sixty-eight medical interns who participated in a training programme for endotracheal intubation using the DE and ML were recruited to the randomised crossover trial 1 week after completing the training programme. In the trial, they used both the DE and the ML to perform intubation on a manikin wearing a semirigid neck collar. The time required to view the vocal cords and to complete intubation, successful endotracheal intubation, modified Cormack–Lehane classification (CL grade) and dental injury were recorded and analysed. Results The mean (SD) time to view the vocal cords was significantly shorter with the DE than with the ML (10.0 (7.0) vs 20.8 (18.9) s; p<0.0001). There were higher rates of CL grades 1 and 2a (69.1% and 22.1%) using the DE than with the ML (10.3% and 14.7%). All 68 participants had a higher rate of successful endotracheal intubation using the DE than using the ML (68 (100%) vs 47 (69.1%); p<0.0001). It took less time to complete endotracheal intubation with the DE than with the ML (p<0.0001). Conclusions In patients with cervical spine immobilisation by a semirigid neck collar, the DE may be a more effective device for endotracheal intubation than the ML.

Lidocaine Induces Endoplasmic Reticulum Stress-Associated Apoptosis in Vitro and in Vivo

We demonstrated that upregulation of both gene expression of endoplasmic reticulum (ER) stress chaperones (BiP, calnexin, calreticulin, and PDI) and ER stress sensors (ATF6, IRE1 and PERK) was induced by lidocaine, a local anesthetic, in PC12 cells. In addition to gene regulation, lidocaine also induced typical ER stress phenomena such as ART6 proteolytic cleavage, eIF2 alpha phosphorylation, and XBP1 mRNA splicing. In in vivo experiments, while lidocaine downregulated gene expression of antiapoptotic factors (Bcl-2 and Bcl-xl), pro-apoptotic factor (Bak and Bax) gene expression was upregulated. Furthermore, lidocaine induced apoptosis, as measured histochemically, and upregulated PARP1, a DNA damage repair enzyme. These results are the first to show that lidocaine induces apoptosis through ER stress in vitro and in vivo.

Efficacy of various types of laryngoscope (direct, Pentax Airway Scope and GlideScope) for endotracheal intubation in various cervical immobilisation scenarios: a randomised cross-over simulation study

Objective To compare the efficacy of direct laryngoscopy (DL), Pentax Airway Scope (PAWS) and GlideScope video laryngoscope (GVL) systems for endotracheal intubation (ETI) in various cervical immobilisation scenarios: manual in-line stabilisation (MILS), Philadelphia neck collar (PNC) (moderate limit of mouth opening) and Stifneck collar (SNC) (severe limit of mouth opening). Design Randomised cross-over simulation study. Setting and Participants 35 physicians who had >30 successful ETI experiences at a tertiary hospital in Seoul, Korea. Primary and secondary outcome measures Participants performed ETI using PAWS, GVL and DL randomly in simulated MILS, PNC and SNC scenarios in our simulation centre. The end points were successful ETI and the time to complete ETI. In addition, modified Cormack-Lehane (CL) classification and pressure to teeth were recorded. Results In MILS, there were no significant differences in the rate of success of ETI between the three devices: 33/35(94.3%) for DL vs 32/35(91.4%) for GVL vs 35/35(100.0%) for PAWS; p=0.230). PAWS achieved successful ETI more quickly (19.8 s) than DL (29.6 s) and GVL (35.4 s). For the PNC scenario, a higher rate of successful ETI was achieved with GVL 33/35 (94.3%) than PAWS 29/35 (82.9%) or DL 25/35 (71.4%) (p=0.040). For the SNC scenario, a higher rate of successful ETI was achieved with GVL 28/35(80.0%) than with DL 14/35(40.0%) and PAWS 7/35(20.0%) (p<0.001). For the PNC and SNC scenarios, GVL provided a relatively good view of the glottis, but a frequent pressure to teeth occurred. Conclusions All three devices are suitable for ETI in MILS. DL is not suitable in both neck collar scenarios. PAWS showed faster intubations in MILS, but was not suitable in the SNC scenario. GVL is most suitable in all cervical immobilisation scenarios, but may cause pressure to teeth more frequently.

Value of plasma neutrophil gelatinase-associated lipocalin in predicting the mortality of patients with sepsis at the emergency department.

BACKGROUND Sepsis is a major cause of morbidity and mortality in the emergency department. This study aimed to evaluate the assessment of severity of sepsis by and prognostic value of plasma neutrophil gelatinase-associated lipocalin (NGAL) compared with other widely used biological markers of inflammation in patients with sepsis. METHODS NGAL, procalcitonin, and C-reactive protein values were measured in 470 patients with suspected sepsis, and the Mortality in Emergency Department Sepsis (MEDS) score was obtained for all enrolled subjects, who were followed for up to 28days. RESULTS The median plasma NGAL value was increased with sepsis severity according to the MEDS score. The plasma NGAL value was higher in nonsurvivors than in survivors. The area under the receiver operating characteristic curve of NGAL (0.797) was greater than that of procalcitonin (0.599) and MEDS score (0.774) in predicting 28-day hospital mortality. Multivariable logistic regression found that the plasma NGAL value was an independent predictor for hospital mortality in patients with sepsis. The plasma NGAL values were positively correlated with C-reactive protein and procalcitonin levels, and MEDS scores. CONCLUSIONS Plasma NGAL is a valuable biological marker in the assessment of severity and prediction of prognosis of patients with sepsis in the emergency department.