Se Min Choi

Early brain computed tomography findings are associated with outcome in patients treated with therapeutic hypothermia after out-of-hospital cardiac arrest

BackgroundThis study evaluated the association between the results of immediate brain computed tomography (CT) scans and outcome in patients who were treated with therapeutic hypothermia after cardiac arrest. The evaluation was based on the changes in the ratio of gray matter to white matter.MethodsA total of 167 patients who were successfully resuscitated after cardiac arrest from March 2009 to December 2011 were included in this study. We selected 51 patients who received a brain CT scan within 1 hour after the return of spontaneous circulation (ROSC) and who had been treated with therapeutic hypothermia. Circular regions of measurement (10 mm2) were placed over regions of interest (ROIs), and the average attenuations in gray matter (GM) and white matter (WM) were recorded in the basal ganglia, at the level of the centrum semiovale and in the high convexity area. Three GM-to-WM ratios (GWRs) were calculated: one for the basal ganglia, one for the cerebrum and the average of the two. The neurological outcomes were assessed using the Cerebral Performance Category (CPC) scale at the time of hospital discharge, and a good neurological outcome was defined as a CPC score of 1 or 2.ResultsThe average GWR was the strongest predictor of poor neurological outcome as determined using receiver operating characteristic curves (basal ganglia area under the curve (AUC) = 0.716; cerebrum AUC = 0.685; average AUC = 0.747). An average GWR < 1.14 predicted a poor neurological outcome with a sensitivity of 13.3% (95% confidence interval (CI) 3.8-30.7), a specificity of 100% (95% CI 83.9-100), a positive predictive value of 100% (95% CI 2.5-100), and a negative predictive value of 44.7% (CI 28.9-58.9).ConclusionsOur study demonstrated that low GWRs in the immediate brain CT scans of patients treated with therapeutic hypothermia after ROSC were associated with poor neurological outcomes. Immediate brain CT scans could help predict outcome after cardiac arrest.

The effectiveness of ultrasonography in verifying the placement of a nasogastric tube in patients with low consciousness at an emergency center

BackgroundThis study was designed to compare the effectiveness of using auscultation, pH measurements of gastric aspirates, and ultrasonography as physical examination methods to verify nasogastric tube(NGT) placement in emergency room patients with low consciousness who require NGT insertion.MethodsThe study included 47 patients who were all over 18 years of age. In all patients, tube placement was verified by chest X-rays. Auscultation, pH analysis of gastric aspirates, and ultrasonography were conducted on each patient in random order. The mean patient age was 57.62 ± 17.24 years, and 28 males (59.6%) and 19 females (40.4%) were included. The NGT was inserted by an emergency room resident. For pH testing, gastric aspirates were dropped onto litmus paper, and the resulting color of the paper was compared with a reference table. Ultrasonography was performed by an emergency medicine specialist, and the chest X-ray examination was interpreted by a different emergency medicine specialist who did not conduct the ultrasonography test. The results of the auscultation, gastric aspirate pH, and ultrasonography examinations were compared with the results of the chest x-ray examination.ResultsThe sensitivity and specificity were 100% and 33.3%, respectively, for auscultation and 86.4% and 66.7%, respectively, for ultrasonography. Kappa values were the highest for auscultation at 0.484 compared to chest x-rays, followed by 0.299 for ultrasonography and 0.444 for pH analysis of the gastric aspirate. The ultrasonography has a positive predictive value of 97.4% and a negative predictive value of 25%.ConclusionsUltrasonography is useful for confirming the results of auscultation after NGT insertion among patients with low consciousness at an emergency center. When ultrasound findings suggest that the NGT placement is not gastric, additional chest X-ray should be performed.

Combination treatment with 17β-estradiol and therapeutic hypothermia for transient global cerebral ischemia in rats

OBJECTIVE Therapeutic hypothermia is now regarded as the only effective treatment of global ischemic injury after cardiac arrest. Numerous studies of the neuroprotective effects of 17β-estradiol have yielded conflicting results depending on administration route and dose. Herein, we investigated the neuroprotective effect of postischemic 17β-estradiol administration combined with therapeutic hypothermia. METHODS Twenty-one rats were randomly divided into 4 groups: control (group I), therapeutic hypothermia (group II), 17β-estradiol treatment (group III), and therapeutic hypothermia combined with 17β-estradiol treatment (group IV). One rat was assigned to a sham operation group. With the exception of the sham-operated rat, all animals underwent transient global cerebral ischemia for 20 minutes by the 4-vessel occlusion method. Hypothermia was maintained at 33°C for 2 hours in groups II and IV, and 17β-estradiol (10 μg/kg) was intraperitoneally administered to rats in groups III and IV. Neurologic deficit scores and hippocampal cornu ammonis 1 neuronal injury were assessed 72 hours postischemia. RESULTS The neurologic deficit score was not significantly different among the groups. The percentage of normal neurons in the hippocampal cornu ammonis 1 was 7.32% ± 0.88% in group I, 53.65% ± 2.52% in group II, 51.6% ± 3.44% in group III, and 79.79% ± 1.6% in group IV. The neuroprotective effect in the combined treatment group was markedly greater than in the single treatment groups, which suggests that hypothermia and 17β-estradiol work synergistically to exert neuroprotection. CONCLUSION Postischemic administration of low-dose 17β-estradiol appears to be neuroprotective after transient global ischemia, and its effect is potentiated by therapeutic hypothermia.

Focused and Corrective Feedback Versus Structured and Supported Debriefing in a Simulation-based Cardiac Arrest Team Training: A Pilot Randomized Controlled Study

Objective The aim of the study was to compare the educational impact of two postsimulation debriefing methods—focused and corrective feedback (FCF) versus Structured and Supported Debriefing (SSD)—on team dynamics in simulation-based cardiac arrest team training. Methods This was a pilot randomized controlled study conducted at a simulation center. Fourth-year medical students were randomly assigned to the FCF or SSD group, with each team composed of six students and a confederate. Each team participated in two simulations and the assigned debriefing (FCF or SSD) sessions and then underwent a test simulation. Two trained raters blindly assessed all of the recorded simulations using checklists. The primary outcome was the improvement in team dynamics scores between baseline and test simulation. The secondary outcomes were improvements before and after training in team clinical performance scores, self-assessed comprehension of and confidence in cardiac arrest management and team dynamics, as well as evaluations of the postsimulation debriefing intervention. Results In total, 95 students participated [FCF (8 teams, n = 47) and SSD (8 teams, n = 48)]. The SSD team dynamics score during the test simulation was higher than at baseline [baseline: 74.5 (65.9–80.9), test: 85.0 (71.9–87.6), P = 0.035]. However, there were no differences in the improvement in the team dynamics or team clinical performance scores between the two groups (P = 0.328, respectively). Conclusions There was no significant difference in improvement in team dynamics scores during the test simulation compared with baseline between the SSD and FCF groups in a simulation-based cardiac arrest team training in fourth-year Korean medical students.

Therapeutic hypothermia complicated by spontaneous brain stem hemorrhage

Hypothermia increases clotting time, which is known as hypothermic coagulopathy. However, prothrombin time and activated partial thromboplastin time prolongation associated with therapeutic hypothermia is usually mild and thus, hypothermic coagulopathy is not considered to cause clinically significant bleeding. On the other hand, PT and aPTT do not seem to reflect the severity of hypothermic coagulopathy. Serious bleeding complications of therapeutic hypothermia has not been reported previously. Herein, we introduce a case of spontaneous brain stem hemorrhage as a complication of therapeutic hypothermia-induced coagulopathy.

Suicidal hanging patient with complete tracheal rupture

In attempted suicide, laryngotracheal rupture caused by hanging leads to rapid death at the scene or before arrival at hospital. The case presented here describes a patient with complete tracheal rupture from an attempted suicidal hanging who was successfully resuscitated. Pre-hospital providers transferred the patient to hospital without being aware of the possibility of airway damage. Cardiac arrest occurred shortly after arrival at hospital. During the cardiopulmonary resuscitation, endotracheal intubation was performed, and fortunately, the tracheal tube was located just below the ruptured trachea and thus enabled ventilation. For patients suspected of having airway damage at the pre-hospital stage, awareness of the patient’s condition and adequate airway management are important. The management of laryngotracheal rupture which suggests that for patients not adequately ventilated, immediate treatment with flexible fiberoptic intubation or tracheostomy is needed to secure the airway. Equipment and personnel at the receiving hospital need to be prepared for immediate treatment.