Naoko Ohashi

Applicability of the prehospital termination of resuscitation rule in an area dense with hospitals in Tokyo: a single-center, retrospective, observational study ☆ ☆☆ ★ ★★: Is the pre hospital TOR rule applicable in Tokyo?

BACKGROUND It is unclear whether the prehospital termination of resuscitation (TOR) rule is applicable in specific situations such as in areas extremely dense with hospitals. OBJECTIVES The objective of the study is to assess whether the prehospital TOR rule is applicable in the emergency medical services system in Japan, specifically, in an area dense with hospitals in Tokyo. METHODS This study was a retrospective, observational analysis of a cohort of adult out-of-hospital cardiopulmonary arrest (OHCA) patients who were transported to the University of Tokyo Hospital from April 1, 2009, to March 31, 2011. RESULTS During the study period, 189 adult OHCA patients were enrolled. Of the 189 patients, 108 patients met the prehospital TOR rule. The outcomes were significantly worse in the prehospital TOR rule-positive group than in the prehospital TOR-negative group, with 0.9% vs 11.1% of patients, respectively, surviving until discharge (relative risk [RR], 1.11; 95% confidence interval [CI], 1.03-1.21; P = .0020) and 0.0% vs 7.4% of patients, respectively, discharged with a favorable neurologic outcome (RR, 1.08; 95% CI, 1.02-1.15; P = .0040). The prehospital TOR rule had a positive predictive value (PPV) of 99.1% (95% CI, 96.3-99.8) and a specificity of 90.0% (95% CI, 60.5-98.2) for death and a PPV of 100.0% (95% CI, 97.9-100.0) and a specificity of 100.0% (95% CI, 61.7-100.0) for an unfavorable neurologic outcome. CONCLUSIONS This study suggested that the prehospital TOR rule predicted unfavorable outcomes even in an area dense with hospitals in Tokyo and might be helpful for identifying the OHCA patients for whom resuscitation efforts would be fruitless.

Application of cerebral oxygen saturation to prediction of the futility of resuscitation for out-of-hospital cardiopulmonary arrest patients: a single-center, prospective, observational study☆ , ☆☆ ,★ Can cerebral regional oxygen saturation predict the futility of CPR?

BACKGROUND Cerebral regional oxygen saturation (rSO2) can be measured immediately and noninvasively just after arrival at the hospital and may be useful for evaluating the futility of resuscitation for a patient with out-of-hospital cardiopulmonary arrest (OHCA). We examined the best practices involving cerebral rSO₂ as an indicator of the futility of resuscitation. METHODS This study was a single-center, prospective, observational analysis of a cohort of consecutive adult OHCA patients who were transported to the University of Tokyo Hospital from October 1, 2012, to September 30, 2013, and whose cerebral rSO₂ values were measured. RESULTS During the study period, 69 adult OHCA patients were enrolled. Of the 54 patients with initial lower cerebral rSO₂ values of 26% or less, 47 patients failed to achieve return of spontaneous circulation (ROSC) in the receiver operating characteristic curve analysis (optimal cutoff, 26%; sensitivity, 88.7%; specificity, 56.3%; positive predictive value, 87.0%; negative predictive value, 60.0%; area under the curve [AUC], 0.714; P = .0033). The AUC for the initial lower cerebral rSO₂ value was greater than that for blood pH (AUC, 0.620; P = .1687) or lactate values (AUC, 0.627; P = .1081) measured upon arrival at the hospital as well as that for initial higher (AUC, 0.650; P = .1788) or average (AUC, 0.677; P = .0235) cerebral rSO₂ values. The adjusted odds ratio of the initial lower cerebral rSO₂ values of 26% or less for ROSC was 0.11 (95% confidence interval, 0.01-0.63; P = .0129). CONCLUSIONS Initial lower cerebral rSO₂ just after arrival at the hospital, as a static indicator, is associated with non-ROSC. However, an initially lower cerebral rSO₂ alone does not yield a diagnosis performance sufficient for evaluating the futility of resuscitation.

Impact of seasonal temperature environment on the neurologic prognosis of out-of-hospital cardiac arrest: A nationwide, population-based cohort study☆☆☆★

OBJECTIVE The relationship between environmental factors, such as winter or cold environments, and the onset of out-of-hospital cardiac arrest (OHCA) is well known. However, the association between environmental factors and the neurologic outcome of OHCA is poorly understood. This study aimed to assess the impact of the ambient temperature on the neurologic outcome of adult OHCA. METHODS In a nationwide, population-based, observational study, we enrolled 121,081 adults 18 years or older who experienced an OHCA from January 1, 2010, to December 31, 2010. We used the All-Japan Utstein Registry database coupled with climate statistics data from the Japan Meteorological Agency. The primary end point was favorable neurologic outcome 1 month after OHCA. RESULTS Of the eligible 120,721 adult patients with OHCA, 7747 cases of OHCA (6.4%) occurred during the cold season, 80,739 (66.9%) occurred during the midseason, and 32,235 (26.7%) occurred during the warm season. The adults who experienced an OHCA during the cold season exhibited a significantly lower rate of a favorable neurologic outcome than did those who experienced an OHCA during the warm season (2.4% vs 3.3%; odds ratio, 0.73; 95% confidence interval, 0.62-0.85; P < .0001). The adjusted odds ratio for favorable neurologic outcome per 1°C increase in the monthly ambient temperature was 1.006 (95% confidence interval, 1.002-1.010; P = .0080). CONCLUSIONS The seasonal ambient temperature is likely to affect favorable neurologic outcome. A lower seasonal ambient temperature may exacerbate the neurologic outcome of OHCA.

EDTA-dependent pseudothrombocytopenia complicated by eosinophilic pneumonia.

EDTA-dependent pseudothrombocytopenia (EDTA-PTCP) is a phenomenon that occurs in vitro when EDTA reacts with harvested blood. EDTA-dependent pseudothrombocytopenia usually does not indicate thrombocytopenia in vivo. Here, we report the first case of EDTA-PTCP complicated by eosinophilic pneumonia. A 70-year-old man with rectal cancer was admitted to the hospital for a liver abscess and rectal cancer. At the time of admission, his platelet count was 20,000/μL, but a peripheral blood smear showed platelet aggregation and the platelet count for a kanamycin-added EDTA blood sample was 180,000/μL. The patients respiratory status worsened after treatment for the liver abscess and rectal cancer. The patients bronchoalveolar lavage contained 45% eosinophils, and a diagnosis of acute eosinophilic pneumonia was made. In recent studies, the occurrence of eosinophilic disease has been shown in idiopathic thrombocytopenic purpura. EDTA-dependent pseudothrombocytopenia is an in vitro phenomenon, although platelet activation that results in eosinophil invasion may occur in severe cases.

Management of Acid Toilet Bowl Detergent-Induced Chemical Injuries

The main component of acid toilet bowl detergents used in Japan is 9.5% hydrochloric acid and cationic surfactant. Similar toilet bowl detergents are sold worldwide, and they are easily available. However, if taken in the wrong way, they prove very harmful, even a small amount. There is no specific therapy in cases of ingestion of acid toilet bowl detergent. Therefore, symptomatic treatment and general management such as controlling breathing and circulation are provided for the patient. Here, we presented a 75-year-old man attempted suicide by ingesting a large amount of acid toilet bowl detergents. In this case, we could diagnose in acute phase with careful questioning and the emergency crew activity at the scene of the accident. On the basis of the diagnosis, we provided symptomatic treatment and general management, but we were necessary for a treatment for a very long term. It was difficult to establish enteral nutrition due to chemical injury to digestive tract. That might be one of the causes of repeated infections such as bacterial translocation. The possibility of a temporary enterostomy should have been considered to establish early nutrition as part of intensive care.