Tae Han Kim

The Scene Time Interval and Basic Life Support Termination of Resuscitation Rule in Adult Out-of-Hospital Cardiac Arrest

We validated the basic life support termination of resuscitation (BLS TOR) rule retrospectively using Out-of-Hospital Cardiac Arrest (OHCA) data of metropolitan emergency medical service (EMS) in Korea. We also tested it by investigating the scene time interval for supplementing the BLS TOR rule. OHCA database of Seoul (January 2011 to December 2012) was used, which is composed of ambulance data and hospital medical record review. EMS-treated OHCA and 19 yr or older victims were enrolled, after excluding cases occurred in the ambulance and with incomplete information. The primary and secondary outcomes were hospital mortality and poor neurologic outcome. After calculating the sensitivity (SS), specificity (SP), and the positive and negative predictive values (PPV and NPV), tested the rule according to the scene time interval group for sensitivity analysis. Of total 4,835 analyzed patients, 3,361 (69.5%) cases met all 3 criteria of the BLS TOR rule. Of these, 3,224 (95.9%) were dead at discharge (SS,73.5%; SP,69.6%; PPV,95.9%; NPV, 21.3%) and 3,342 (99.4%) showed poor neurologic outcome at discharge (SS, 75.2%; SP, 89.9%; PPV, 99.4%; NPV, 11.5%). The cut-off scene time intervals for 100% SS and PPV were more than 20 min for survival to discharge and more than 14 min for good neurological recovery. The BLS TOR rule showed relatively lower SS and PPV in OHCA data in Seoul, Korea. Graphical Abstract

Quality between mechanical compression on reducible stretcher versus manual compression on standard stretcher in small elevator.

OBJECTIVES Manual cardiopulmonary resuscitation (CPR) during vertical transport in small elevators using standard stretcher for out-of-hospital cardiac arrest can raise concerns with diminishing quality. Mechanical CPR on a reducible stretcher (RS-CPR) that can be shortened in the length was tested to compare the CPR quality with manual CPR on a standard stretcher (SS-CPR). METHODS A randomized crossover manikin simulation was designed. Three teams of emergency medical technicians were recruited to perform serial CPR simulations using two different protocols (RS-CPR and SS-CPR) according to a randomization; the first 6 minutes of manual CPR at the scene was identical for both scenarios and two different protocols during vertical transport in a small elevator followed on a basis of cross-over assignment. The LUCAS-2 Chest Compression System (Zolife AB, Lund, Sweden) was used for RS-CPR. CPR quality was measured using a resuscitation manikin (Resusci Anne QCPR, Laerdal Medical, Stavanger, Norway) in terms of no flow fraction, compression depth, and rate (median and IQR). RESULTS A total of 42 simulations were analyzed. CPR quality did not differ significantly at the scene. No flow fraction (%) was significantly lower when the stretcher was moving in RS-CPR then SS-CPR (36.0 (33.8-38.7) vs 44.0 (36.8-54.4), P< .01). RS-CPR showed significantly better quality than SS-CPR; 93.2 (50.6-95.6) vs 14.8 (0-20.8) for adequate depth (P< 0.01), and 97.5 (96.6-98.2) vs 68.9(43.4-78.5) for adequate rate (P< .01). CONCLUSION Mechanical CPR on a reducible stretcher during vertical transport showed significant improvement in CPR quality in terms of no-flow fraction, compression depth, and rate compared with manual CPR on a standard stretcher.

Influence of personal protective equipment on the performance of life-saving interventions by emergency medical service personnel

Prompt live-saving interventions, such as cardiopulmonary resuscitation (CPR), intravenous cannulation (IVC), and endotracheal intubation (ETI), are important for severely injured victims of chemical, biological, radiological, and nuclear (CBRN) disasters. Interventions sometime have to be performed by emergency medical service (EMS) personnel with personal protective equipment (PPE) worn in warm zones. We designed a randomized crossover simulation aimed to compare the performance of life-saving interventions in repetitive simulation of single-rescuer resuscitation wearing level-C PPE in the warm zone of a CBRN disaster. The success rate and completion time of IVC and ETI according to the presence of PPE were compared. The quality of 4-minute single-rescuer CPR was measured and compared as well. We found that the performance level of life-saving interventions performed in a simulated setting of disaster decreased when performed by EMS personnel wearing level-C PPE. Further efforts of optimizing current PPE for EMS personnel based on this study are needed.

Chest Compression Fraction between Mechanical Compressions on a Reducible Stretcher and Manual Compressions on a Standard Stretcher during Transport in Out-of-Hospital Cardiac Arrests: The Ambulance Stretcher Innovation of Asian Cardiopulmonary Resuscitation (ASIA-CPR) Pilot Trial

ABSTRACT Background: Cardiopulmonary resuscitation (CPR) with the use of mechanical devices is recommended during ambulance transport. However, the CPR quality en route and while in transfer to the emergency department (ED) for out-of-hospital cardiac arrests (OHCAs) remains uncertain. We developed a mechanical CPR device outfitted on a reducible stretcher (M-CPR) and compared with standard manual CPR on a standard stretcher (S-CPR) to evaluate CPR quality. Methods: Adult OHCAs transported by five ambulances in a metropolitan area with a population of 3.5 million (many of whom lived in high-rise buildings) from September to October (before-phase) and November to December (after-phase) in 2015 were collected. The reducible stretcher was developed for use in a small elevator during the transfer from scene to ambulance, and the AutoPulse® (ZOLL Medical, Chelmsford, MA, USA) was used for M-CPR. Chest compression fraction (CCF) was measured by transthoracic impedance data using an X-series® cardiac monitor (ZOLL Medical) during time from attachment to patient to arrival to the ED. A comparison of CCF using a Wilcoxon signed-rank test evaluated the difference between the before- and after-phases. Results: Of the eligible 49 OHCAs, 31 (21 in the before-phase and 10 in the after-phase) were analyzed, excluding patients for whom CCF was not measured, for whom M-CPR was not used, who had a return of spontaneous circulation in the field before transport, or who collapsed during transport. There were no differences in demographic data. Median total CCF (median, q1–q3) was significantly higher in the after-phase M-CPR group (85.2, 83.4–86.3) than in the before-phase S-CPR group (80.1, 68.0–85.2) (p = 0.03). Conclusion: Mechanical CPR on the reducible stretcher during the transport of OHCAs to the ED showed a much higher chest compression fraction than standard manual CPR.

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

OBJECTIVE The 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). METHODS From 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 (reference = ECC). 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. RESULTS The 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%, p < .001). The survival rate was 46.4% for all (ECC 45.4%, EDC 48.5%, IVC 50.5%, ICC 34.2%, p < .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). CONCLUSION The 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.

Implementation of a bundle of Utstein cardiopulmonary resuscitation programs to improve survival outcomes after out-of-hospital cardiac arrest in a metropolis: A before and after study

INTRODUCTION The study aimed to determine the effect of community implementation of a bundles of cardiopulmonary resuscitation (CPR) programs on outcomes in out-of-hospital cardiac arrest (OHCA). METHODS A before- and after-intervention study was performed in a metropolis. Emergency medical services (EMS)-treated adults and cardiac OHCAs were included. Three new CPR programs was implemented in January 2015: 1) a high-quality dispatcher-assisted CPR program (DACPR), 2) a multi-tier response (MTR) program using fire engines or basic life support vehicles, and 3) a feedback CPR (FCPR) program with professional recording and feedback of CPR process. The outcomes (cerebral performance category 1 or 2, good CPC) and survival to discharge) were compared between study period (2015-2016) and control period (2013-2014). RESULTS Overall, 6201 and 6469 patients were included in the control period and the study period, respectively. During the post-intervention period, the proportion of OHCA patients who underwent three types of cardiopulmonary resuscitation programs increased significantly compared to those in the pre-intervention period. DACPR increased from 38.3% to 44.3%, MTR increased from 0.0% to 37.5%, and FCPR increased from 25.3% to 61.5%. (All p values <0.001). Good neurological recovery and survival to discharge were significantly increased from 5.4% to 6.8%, and from 9.6% to 10.9%. The adjusted odds ratio (95% confidence intervals) of the study period was 1.45 (1.12-1.87) for good CPC, and 1.31 (1.09-1.58) for survival to discharge. CONCLUSIONS The citywide implementation of a bundle of UTIS CPR programs was associated with significantly better OHCA outcomes.

Neurological Favorable Outcomes Associated with EMS Compliance and On-Scene Resuscitation Time Protocol

Abstract Purpose: Korean national emergency care protocol for EMS providers recommends a minimum of 5 minutes of on-scene resuscitation before transport to hospital in cases of Out-of-Hospital Cardiac Arrest (OHCA). We compared survival outcome of OHCA patients according to scene time interval (STI)-protocol compliance of EMS. Methods: EMS treated adult OHCAs with presumed cardiac etiology during a two-year period were analyzed. Non-compliance was defined as hospital transport with STI less than 6 minutes without return of spontaneous circulation (ROSC) on scene. Propensity score for compliance with protocol was calculated and based on the calculated propensity score, 1:1 matching was performed between compliance and non-compliance group. Univariate analysis as well as multivariable logistic model was used to evaluate the effect of compliance to survival outcome. Results: Among a total of 28,100 OHCAs, EMS transported 7,026 (25.0%) cardiac arrests without ROSC on the scene with an STI less than 6 minutes. A total of 6,854 cases in each group were matched using propensity score matching. Overall survival to discharge rate did not differ in both groups (4.6% for compliance group vs. 4.5 for non-compliance group, p = 0.78). Adjusted odds ratio of compliance for survival to discharge were 1.12 (95% CI 0.92–1.36). More patients with favorable neurological outcome was shown in compliance group (2.5% vs. 1.7%, p < 0.01) and adjusted odds ratio was 1.91 (95% CI 1.42–2.59). Conclusions: Although survival to discharge rate did not differ for patient with EMS non-compliance with STI protocol, lesser patients survived with favorable neurological outcomes when EMS did not stay for sufficient time on scene in OHCA before transport.

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.

Characteristics and outcomes of patients with cold-related local injuries and accidental hypothermia from emergency department–based surveillance network in northern region of South Korea:

Background: Cold weather has been known to cause various cold-related local injuries as well as accidental hypothermia. Objectives: The aim of this study is to investigate the basal characteristics, outcomes, and risk factors of patients with cold-related comorbidities using prospective emergency department–based surveillance system in high-risk area. Methods: We designed a prospective emergency department–based surveillance system throughout northern part of Gyeonggi province located in the northernmost of South Korea. A total of 20 emergency departments participated in the surveillance system. Patients who visited emergency department with cold-related comorbidities from 1 December 2012 to 28 February 2013 were prospectively enrolled in final analysis. We analyzed risk factors associated with outcome and correlation between climate factor (wind-chill index) and incidence. Results: During the study period, 54 patients with cold-related comorbidities were used for final analysis, including 35 hypothermia, 15 frostbite, and 4 trench foot. Among 35 patients with accidental hypothermia, 11 patients were admitted to intensive care unit and defined to have major adverse outcome. Hypothermic patient with major adverse outcome had lesser possession of coat as outwear when exposed to the cold (9.1% vs 58.3%, p < 0.01). Lower wind-chill index was likely to develop higher incidence of cold-related comorbidities (incidence rate ratio per 1°C decrease in wind-chill index: 1.086 (95% confidence interval: 1.038–1.135)). Conclusion: Patients with cold-related comorbidities were successfully monitored with emergency department–based surveillance system. Absence of coat was associated with major adverse outcomes in patient with accidental hypothermia. Lower wind-chill index was associated with higher incidence of cold-related comorbidities.

Gender disparities in percutaneous coronary intervention in out-of-hospital cardiac arrest: A nationwide cross-sectional observational study

Background: Quality of post‐arrest care is considered a significant factor for overall survival and neurological outcomes in out‐of‐hospital cardiac arrest (OHCA). However, previous studies suggested gender differences in invasive treatments including percutaneous coronary intervention (PCI). In this study, we evaluated gender disparities in the delivery of PCI among OHCA patients. Methods: All adults OHCA patients with presumed cardiac etiology and sustained ROSC between 2013 and 2016 were included in the study. Main exposure was gender and primary outcome was PCI treatment. Multivariable logistic regression was used to analyze the association between gender and PCI treatment, adjusting for patient, community, prehospital, and hospital factors. The time interval from return of spontaneous circulation (ROSC) to PCI and survival outcomes were also analyzed as secondary and tertiary outcomes. Results: A total of 20,675 patients were included for final analysis. Multivariable analysis showed that female patients were significantly less likely to receive PCI compared to males with adjusted odds ratio (OR) of 0.40 (95% CI 0.30–0.53). However, among those who received PCI, there were no significant associations between gender and time from ROSC to PCI (≤90 vs. >90 min). Overall survival outcomes were not significantly associated with gender after adjusting for PCI and other confounding factors (OR = 0.87, 95% CI 0.71–1.08 for survival to discharge and OR = 0.87, 95% CI 0.70–1.08 for good neurological recovery). Conclusions: Among sustained ROSC patients following OHCA, female patients were significantly less likely to undergo PCI than males. Further studies are warranted to reduce gender disparities in caring for post‐arrest patients.