Yong Su Lim

Hormonal responses upon return of spontaneous circulation after cardiac arrest: a retrospective cohort study

IntroductionCardiac arrest is often fatal and can be extremely stressful to patients, even if spontaneous rhythm is returned. The purpose of this study was to analyze the hormonal response after return of spontaneous circulation (ROSC).MethodsThis is a retrospective review of the chart and laboratory findings in a single medical facility. The patients admitted to the intensive care unit after successful resuscitation after out-of-hospital cardiac arrest were retrospectively identified and evaluated. Patients with hormonal diseases, patients who received cortisol treatment, those experiencing trauma, and pregnant women were excluded. Serum cortisol, adrenocorticotropic hormone (ACTH), and anti-diuretic hormone (ADH (vasopressin)) were analyzed and a corticotropin-stimulation test was performed. Mortality at one week and one month after admission, and neurologic outcome (cerebral performance category (CPC)) one month after admission were evaluated.ResultsA total of 117 patients, including 84 males (71.8%), were evaluated in this study. One week and one month after admission, 87 (74.4%) and 65 patients (55.6%) survived, respectively. Relative adrenal insufficiency, and higher plasma ACTH and ADH levels were associated with shock-related mortality (P = 0.046, 0.005, and 0.037, respectively), and ACTH and ADH levels were also associated with late mortality (P = 0.002 and 0.004, respectively). Patients with relative adrenal insufficiency, ACTH ≧5 pg/mL, and ADH ≧30 pg/mL, had a two-fold increased risk of a poor outcome (shock-related mortality): (odds ratio (OR), 2.601 and 95% confidence interval (CI), 1.015 to 6.664; OR, 2.759 and 95% CI, 1.060 to 7.185; OR, 2.576 and 95% CI, 1.051 to 6.313, respectively). Thirty-five patients (29.9%) had a good CPC (1 to 2), and 82 patients (70.1%) had a bad CPC (3 to 5). Age ≧50 years and an ADH ≧30 pg/mL were associated with a bad CPC (OR, 4.564 and 95% CI, 1.794 to 11.612; OR, 6.568 and 95% CI, 1.918 to 22.483, respectively).ConclusionsThe patients with relative adrenal insufficiency and higher blood levels of ACTH and ADH upon ROSC after cardiac arrest had a poor outcome. The effectiveness of administration of cortisol and ADH to patients upon ROSC after cardiac arrest is uncertain and additional studies are needed.

Effectiveness of each target body temperature during therapeutic hypothermia after cardiac arrest

PURPOSE According to the 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation, unconscious adult patients with a return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest should be cooled to 32°C to 34°C for 12 to 24 hours. However, it is unclear which target temperature is more adequate. In this study, we prospectively evaluated the outcome and adverse effects following 3 target temperatures (32°C, 33°C, and 34°C) during therapeutic hypothermia with ROSC after out-of-hospital cardiac arrest. METHODS This is a prospective study of patients with ROSC (>24 hours) after out-of-hospital cardiac arrest who were admitted to the intensive care unit in a tertiary hospital and underwent therapeutic hypothermia during a 22-month period between March 2007 and December 2008. RESULTS Sixty-two patients were included. The number of male patients was 44. The mean (SD) ages of the patients was 54.61 (2.002) years. There were 13, 22, and 28 patients who were enrolled in the target temperatures (32°C, 33°C, and 34°C, respectively). There were no significant differences after each target temperature with respect to mortality and neurologic outcomes. Regarding adverse effects, hypotension during the maintenance of therapeutic hypothermia significantly increased when the target temperature was 32°C (P = .023). Based on multivariate analysis, hypotension during the maintenance of therapeutic hypothermia was increased more than 6 times at 32°C compared with 33°C (odds ratio, 6.800; 95% confidence interval, 1.428-32.373). CONCLUSION When performing therapeutic hypothermia in patients with ROSC after an out-of-hospital cardiac arrest, the target temperature would be set to 33°C or 34°C, rather than 32°C. Further multicenter randomized controlled studies may be needed in the future.

Blood ammonia is a predictive biomarker of neurologic outcome in cardiac arrest patients treated with therapeutic hypothermia

PURPOSE The aim of this study was to investigate the value of commonly examined laboratory measurements, including ammonia and lactate, in predicting neurologic outcome of out-of-hospital cardiac arrest (OHCA) patients treated with therapeutic hypothermia (TH). METHODS This was a retrospective cohort study of patients with a return of spontaneous circulation after OHCA who were treated with TH between February 2007 and July 2010. We measured typical blood measurements on arrival at the emergency department. The subjects were classified into 2 groups: the good neurologic outcome group (Cerebral Performance Category [CPC] 1-2 at 1 month) and the poor neurologic outcome group (Cerebral Performance Category 3-5). We compared blood biomarker levels and basal characteristics between the 2 groups. Logistic regression analyses were performed to determine independent biomarkers that predict poor neurologic outcome. RESULTS A total of 117 patients were included. Between the 2 groups, significantly different levels of blood measurements included hemoglobin level, pH, Pao(2), Paco(2), base excess, albumin, glucose, potassium, chloride, bilirubin, phosphorous, and ammonia. In multivariate analyses, blood ammonia level (>96 mg/dL; odds ratio [OR], 7.240; 95% confidence interval [CI], 1.718-30.512), noncardiac causes (OR, 46.215; 95% CI, 9.670-220.873), and time interval from collapse to return of spontaneous circulation (>33 min; OR, 5.943; 95% CI, 1.543-22.886) were significantly related to poor neurologic outcome. CONCLUSION Among the blood measurements on emergency department arrival, blood ammonia (>96 mg/dL) was the only independent predictive biomarker of poor neurologic outcome. Thus, higher blood ammonia level was associated with poor neurologic outcome in OHCA patients treated with TH.

Costal osteochondroma presenting as haemothorax and diaphragmatic laceration

We report the unusual case of an 11-year-old girl who suffered a large haemothorax and lacerated left hemidiaphragm because of a costal osteochondroma arising from the left sixth rib near the costochondral junction. Surgical excision of the osteochondroma was performed and the lacerated diaphragm was repaired.

Spontaneous rupture of intercostal artery after severe cough

Pleural or abdominal hematomas induced by spontaneous rupture of intercostal artery are very rare but can often cause fatal problems leading to hypovolemic shock. Spontaneous rupture of intercostal artery mostly occurs in association with neurofibromatosis type 1, coarctation of aorta, or trauma. In the absence of these conditions, there are very few cases. We report a 39-year-old man who complained of left flank pain after severe cough for a few days. His final diagnosis was hematoma of the left lateral abdominal wall induced by rupture of the left 11th intercostal artery. He was treated immediately by transarterial embolization. Without any serious problems during hospitalization, he was discharged. This case indicates that, in generally healthy individuals, even mild physical force such as cough can lead to rupture of the intercostal artery. Although it is very rare, injury to the intercostal artery should be considered when patients complain of unexplained chest pain, abdominal pain, or flank pain after strong cough or sneezing.

Severe human poisoning with a flufenoxuron-containing insecticide: report of a case with transient myocardial dysfunction and review of the literature

Abstract Context. Flufenoxuron (Cascade™) is a new benzoylurea insecticide. We describe a case of human poisoning with previously unreported cardiac complications and review other case reports in the literature. Case details. A 54-year-old stuporous man who had ingested a flufenoxuron-containing insecticide presented to the emergency department with severely unstable vital signs and lactic acidosis which continued to worsen over time. He was treated with gastric lavage and infusion of sodium bicarbonate, crystalloid, and dopamine. The patient was initially unresponsive, but recovered from shock after norepinephrine treatment. While electrocardiography showed no abnormal findings, cardiac enzymes remained elevated for several days. Initial echocardiography showed global left ventricular hypokinesia and a left ventricular ejection fraction of 40%, but echocardiography after 45 h showed normal results. On the sixth day, he was discharged after rejecting medical advice for further evaluation. Discussion. Severe lactic acidosis, shock, elevation of cardiac enzymes, and global left ventricular hypokinesia can occur in human poisoning with flufenoxuron-containing insecticide, and norepinephrine is preferable for the management of shock.

Incidence and clinical features of intracranial hemorrhage causing out-of-hospital cardiac arrest: a multicenter retrospective study

OBJECTIVE The general incidence of intracranial hemorrhage (ICH) as a cause of out-of-hospital cardiac arrest (OHCA) remains unclear, although the incidence of subarachnoid hemorrhage has been determined to be 4% to 18%. The main objectives of our study were to describe the incidence of ICH in OHCA and the different laboratory findings between ICH and non-ICH groups. METHODS A retrospective cohort study using the prospective OHCA registry was conducted at three university hospitals in Korea. All cases of OHCA that occurred over a period of 6 years, from January 2009 to December 2014, were examined. Pre-hospital and in-hospital variables and laboratory data taken during CPR were examined in order to compare the ICH and non-ICH groups. RESULTS A total of 2716 patients with OHCA were registered in the database. Among the 804 patients included in the final analysis, ICH was the cause of cardiac arrest in 92 patients (11.4%). Of those with ICH, 79 (86%) patients also had subarachnoid hemorrhage. No patient had a good neurological outcome in the ICH group. There were statistically significant differences in gender, age, pre-hospital return of spontaneous circulation, survival to hospital discharge, good neurologic outcomes, serum sodium, potassium, glucose, Pco2, and Po2 during CPR between the ICH and non-ICH groups. In multivariate analysis, gender, age, potassium, glucose and Po2 levels differed significantly between the two groups. CONCLUSIONS OHCA patients with confirmed ICH were identified in about 11% of cases after return of spontaneous circulation. Gender, age, higher glucose, and lower potassium and Po2 levels during CPR were associated with ICH.

Comparison of epidemiology, emergency care, and outcomes of acute ischemic stroke between young adults and elderly in Korean population: a multicenter observational study.

Stroke in young adults has been known to show a lower incidence and a better prognosis. Only a few studies have examined the epidemiology and outcomes of ischemic stroke in young adults and compared them with the elderly in Korean population. All consecutive patients with ischemic stroke visiting 29 participating emergency departments were enrolled from November 2007 to October 2009. Patients with less than 15 yr of age and unknown information on age and confirmed diagnosis were excluded. We categorized the patients into young adults (15 to 45 yr) and elderly (46 yr and older) groups. Of 39,156 enrolled all stroke patients, 25,818 with ischemic stroke were included and analyzed (young adult; n=1,431, 5.5%). Young adult patients showed lower prevalence of most chronic diseases but significantly higher prevalence in exercise, current smoking, and alcohol consumption. Hospital mortality was significantly lower in young adults than elderly (1.1% vs. 3.1%, P<0.001). Higher number of patients in elderly group (68.1%) showed worsening change of modified Rankin Scale than young adults (65.2%). Young adults ischemic stroke showed favorable hospital outcomes than the elderly in Korean population. Graphical Abstract

Age is related to neurological outcome in patients with out-of-hospital cardiac arrest (OHCA) receiving therapeutic hypothermia (TH)

Introduction In this study, we retrospectively reviewed the patients’ outcomes after cardiac arrest based on age in one center, to determine whether geriatric patients had worse outcomes. Methods This was a single‐center, retrospective cohort study. The patients admitted to the intensive care unit on successful resuscitation after OHCA were retrospectively identified and evaluated. Results This was a retrospective cohort study of patients over 18 years of‐age with return of spontaneous circulation (ROSC) (> 24 h) after cardiac arrest who were admitted to the emergency intensive care unit (EICU) and received post‐cardiac arrest care between March 2007 and December 2013. Finally, a total of 295 patients were enrolled during the study period; of these, 79 patients (36.6%) had a good cerebral performance category (CPC). In stepwise multivariate analysis, young age (per 10 years) (odds ratio [OR] 1.42, 95% CI 1.00–1.99, p = 0.044), high hemoglobin level (per 1 g/dL) (OR 1.31, 95% CI 1.07–1.60, p = 0.008), non‐diabetic patients (OR 15.21, 95% CI 1.85–125.3, p = 0.01), cardiogenic cardiac arrest (OR 8.68, 95% CI 3.72–20.30, p < 0.001), pre‐hospital cardiopulmonary resuscitation (CPR) by bystander (OR 3.61, 95% CI 1.23–10.57, p = 0.019), short time from collapsed to ACLS (per 1 min) (OR 1.12, 95% CI 1.06–1.18, p < 0.001) had good CPC at 6‐month post‐admission. Conclusion Elderly patients with OHCA had a poor neurological outcome; but several other factors were also related with the outcome. In decision‐making for resuscitation, physicians should consider the patients’ physiologic factors as well as age.

Performance on the APACHE II, SAPS II, SOFA and the OHCA score of post-cardiac arrest patients treated with therapeutic hypothermia

Objective This study assessed the ability of the Acute Physiologic and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II, Sequential Organ Failure Assessment (SOFA) score, and out-of-hospital cardiac arrest (OHCA) score to predict the outcome of OHCA patients who underwent therapeutic hypothermia (TH). Methods This study included OHCA patients treated with TH between January 2010 and December 2013. The APACHE II score, SAPS II, and SOFA score were calculated at the time of admission and 24 h and 48 h after intensive care unit admission. The OHCA score was calculated at the time of admission. The area under the curve (AUC) of the receiver operating characteristic curve and logistic regression analysis were used to evaluate outcome predictability. Results Data from a total of 173 patients were included in the analysis. The APACHE II score at 0 h and 48 h, SAPS II at 48 h, and OHCA score had moderate discrimination for mortality (AUC: 0.715, 0.750, 0.720, 0.740). For neurologic outcomes, the APACHE II score at 0 h and 48 h, SAPS II at 0 h and 48 h, and OHCA score showed moderate discrimination (AUC: 0.752, 0.738, 0.771, 0.771, 0.764). The APACHE II score, SAPS II and SOFA score at various time points, in addition to the OHCA score, were independent predictors of mortality and a poor neurologic outcome. Conclusions The APACHE II score, SAPS II, SOFA score, and OHCA score have different capabilities in discriminating and estimating hospital mortality and neurologic outcomes. The OHCA score, APACHE II score and SAPS II at time zero and 48 h offer moderate predictive accuracy. Other scores at 0 h and 48 h, except for the SOFA score, are independently associated with 30-day mortality and poor cerebral performance.