BioMed Research International: Emergency Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Risk Factors for Emergency Department Short Time Readmission in Stratified Population Tue, 17 Nov 2015 08:24:47 +0000 Background. Emergency department (ED) readmissions are considered an indicator of healthcare quality that is particularly relevant in older adults. The primary objective of this study was to identify key factors for predicting patients returning to the ED within 30 days of being discharged. Methods. We analysed patients who attended our ED in June 2014, stratified into four groups based on the Kaiser pyramid. We collected data on more than 100 variables per case including demographic and clinical characteristics and drug treatments. We identified the variables with the highest discriminating power to predict ED readmission and constructed classifiers using machine learning methods to provide predictions. Results. Classifier performance distinguishing between patients who were and were not readmitted (within 30 days), in terms of average accuracy (AC). The variables with the greatest discriminating power were age, comorbidity, reasons for consultation, social factors, and drug treatments. Conclusions. It is possible to predict readmissions in stratified groups with high accuracy and to identify the most important factors influencing the event. Therefore, it will be possible to develop interventions to improve the quality of care provided to ED patients. Ariadna Besga, Borja Ayerdi, Guillermo Alcalde, Alberto Manzano, Pedro Lopetegui, Manuel Graña, and Ana González-Pinto Copyright © 2015 Ariadna Besga et al. All rights reserved. Advances in Airway Management and Ventilation Strategies in Emergency Medicine Wed, 24 Jun 2015 07:39:59 +0000 Tomasz Gaszynski, Kamil Toker, Massimiliano Carassiti, Athanasios Chalkias, and Jestin N. Carlson Copyright © 2015 Tomasz Gaszynski et al. All rights reserved. Impact of Video Laryngoscopy on Advanced Airway Management by Critical Care Transport Paramedics and Nurses Using the CMAC Pocket Monitor Wed, 17 Jun 2015 07:38:24 +0000 Accurate endotracheal intubation for patients in extremis or at risk of physiologic decompensation is the gold standard for emergency medicine. Field intubation is a complex process and time to intubation, number of attempts, and hypoxia have all been shown to correlate with increases in morbidity and mortality. Expanding laryngoscope technology which incorporates active video, in addition to direct laryngoscopy, offers providers improved and varied tools to employ in management of the advanced airway. Over a nine-year period a helicopter emergency medical services team, comprised of a flight paramedic and flight nurse, intended to intubate 790 patients. Comparative data analysis was performed and demonstrated that the introduction of the CMAC video laryngoscope improved nearly every measure of success in airway management. Overall intubation success increased from 94.9% to 99.0%, first pass success rates increased from 75.4% to 94.9%, combined first and second pass success rates increased from 89.2% to 97.4%, and mean number of intubation attempts decreased from 1.33 to 1.08. Bradley Boehringer, Michael Choate, Shelley Hurwitz, Peter V. R. Tilney, and Thomas Judge Copyright © 2015 Bradley Boehringer et al. All rights reserved. Airway Management of the Patient with Maxillofacial Trauma: Review of the Literature and Suggested Clinical Approach Tue, 16 Jun 2015 12:46:55 +0000 According to the Advanced Trauma Life Support recommendations for managing patients with life-threatening injuries, securing the airway is the first task of a primary caregiver. Airway management of patients with maxillofacial trauma is complex and crucial because it can dictate a patient’s survival. Securing the airway of patients with maxillofacial trauma is often extremely difficult because the trauma involves the patient’s airway and their breathing is compromised. In these patients, mask ventilation and endotracheal intubation are anticipated to be difficult. Additionally, some of these patients may not yet have been cleared of a cervical spine injury, and all are regarded as having a full stomach and having an increased risk of regurgitation and pulmonary aspiration. The requirements of the intended maxillofacial operation may often preclude the use of an oral intubation tube, and alternative methods for securing the airway should be considered before the start of the surgery. In order to improve the clinical outcome of patients with maxillofacial trauma, cooperation between maxillofacial surgeons, anesthesiologists, and trauma specialists is needed. In this review, we discuss the complexity and difficulties of securing the airway of patients with maxillofacial trauma and present our approach for airway management of such patients. Michal Barak, Hany Bahouth, Yoav Leiser, and Imad Abu El-Naaj Copyright © 2015 Michal Barak et al. All rights reserved. The AirView Study: Comparison of Intubation Conditions and Ease between the Airtraq-AirView and the King Vision Tue, 16 Jun 2015 12:46:25 +0000 We conducted a study assessing the quality and speed of intubation between the Airtraq with its new iPhone AirView app and the King Vision in a manikin. The primary endpoint was reduction of time needed for intubation. Secondary endpoints included times necessary for intubation. 30 anaesthetists randomly performed 3 intubations with each device on a difficult airway manikin. Participants had a professional experience of 12 years: 60.0% possessed the Airtraq in their hospital, 46.7% the King Vision, and 20.0% both. Median time difference [IQR] to identify glottis (1.1 [−1.3; 3.9] ), for tube insertion (2.1 [−2.6; 9.4] ) and lung ventilation (2.8 [−2.4; 11.5] ), was shorter with the Airtraq-AirView. Median time for glottis visualization was significantly shorter with the Airtraq-AirView (5.3 [4.0; 8.4] versus 6.4 [4.6; 9.1]). Cormack Lehane before intubation was better with the King Vision (); no difference was noted during intubation, for subjective device insertion or quality of epiglottis visualisation. Assessment of tracheal tube insertion was better with the Airtraq-AirView. The Airtraq-AirView allows faster identification of the landmarks and intubation in a difficult airway manikin, while clinical relevance remains to be studied. Anaesthetists assessed the intubation better with the Airtraq-AirView. Patrick Schoettker and Jocelyn Corniche Copyright © 2015 Patrick Schoettker and Jocelyn Corniche. All rights reserved. A Randomized Comparison Simulating Face to Face Endotracheal Intubation of Pentax Airway Scope, C-MAC Video Laryngoscope, Glidescope Video Laryngoscope, and Macintosh Laryngoscope Tue, 16 Jun 2015 12:38:55 +0000 Objectives. Early airway management is very important for severely ill patients. This study aimed to investigate the efficacy of face to face intubation in four different types of laryngoscopes (Macintosh laryngoscope, Pentax airway scope (AWS), Glidescope video laryngoscope (GVL), and C-MAC video laryngoscope (C-MAC)). Method. Ninety-five nurses and emergency medical technicians were trained to use the AWS, C-MAC, GVL and Macintosh laryngoscope with standard airway trainer manikin and face to face intubation. We compared VCET (vocal cord exposure time), tube pass time, 1st ventilation time, VCET to tube pass time, tube pass time to 1st ventilation time, and POGO (percentage of glottis opening) score. In addition, we compared success rate according to the number of attempts and complications. Result. VCET was similar among all laryngoscopes and POGO score was higher in AWS. AWS and Macintosh blade were faster than GVL and C-MAC in total intubation time. Face to face intubation success rate was lower in GVL than other laryngoscopes. Conclusion. AWS and Macintosh were favorable laryngoscopes in face to face intubation. GVL had disadvantage performing face to face intubation. Hyun Young Choi, Young Min Oh, Gu Hyun Kang, Hyunggoo Kang, Yong Soo Jang, Wonhee Kim, Euichung Kim, Young Soon Cho, Hyukjoong Choi, Hyunjong Kim, and Gyoung Yong Kim Copyright © 2015 Hyun Young Choi et al. All rights reserved. Percutaneous Transtracheal Jet Ventilation with Various Upper Airway Obstruction Tue, 16 Jun 2015 12:13:19 +0000 A “cannot-ventilate, cannot-intubate” situation is critical. In difficult airway management, transtracheal jet ventilation (TTJV) has been recommended as an invasive procedure, but specialized equipment is required. However, the influence of upper airway resistance (UAR) during TTJV has not been clarified. The aim of this study was to compare TTJV using a manual jet ventilator (MJV) and the oxygen flush device of the anesthetic machine (AM). We made a model lung offering variable UAR by adjustment of tracheal tube size that can ventilate through a 14-G cannula. We measured side flow due to the Venturi effect during TTJV, inspired tidal volume (TVi), and expiratory time under various inspiratory times. No Venturi effect was detected during TTJV with either device. With the MJV, TVi tended to increase in proportion to UAR. With AM, significant variations in TVi was not detected with changes in any UAR. In conclusion, UAR influenced forward flow of TTJV in the model lung. The influence of choked flow from the Venturi effect was minimal under all UAR settings with the MJV, but the AM could not deliver sufficient flow. Tomoki Doi, Tetsuya Miyashita, Ryousuke Furuya, Hitoshi Sato, Shunsuke Takaki, and Takahisa Goto Copyright © 2015 Tomoki Doi et al. All rights reserved. Comparison of Pentax-AWS Airwayscope and Glidescope for Infant Tracheal Intubation by Anesthesiologists during Cardiopulmonary Arrest Simulation: A Randomized Crossover Trial Tue, 16 Jun 2015 09:38:34 +0000 Background. Recent guidelines for infant cardiopulmonary resuscitation emphasize that all rescuers should minimize interruption of chest compressions, even for endotracheal intubation. We compared the utility of the Pentax-AWS Airwayscope (AWS) with the Glidescope (GS) during chest compressions on an infant manikin. Methods. Twenty-four anesthesiologists with more than two years of experience performed tracheal intubation on an infant manikin using the AWS and GS, with or without chest compressions. Results. In GS trials, none of the participants failed without compressions, while three failed with compressions. In AWS trials, all participants succeeded regardless of chest compressions. Intubation time was significantly longer with chest compressions with the GS (), but not with the AWS. Difficulty of operation on a visual analog scale (VAS) for laryngoscopy did not increase significantly with chest compressions with either the GS or the AWS, while the VAS for tube passage through the glottis increased with compressions with the GS, but not with the AWS. Conclusion. We conclude that in infant simulations managed by anesthesiologists, the AWS performed better than the GS for endotracheal intubation with chest compressions. Shunsuke Fujiwara, Nobuyasu Komasawa, Sayuri Matsunami, Daisuke Okada, and Toshiaki Minami Copyright © 2015 Shunsuke Fujiwara et al. All rights reserved. Assessment of Movement Patterns during Intubation between Novice and Experienced Providers Using Mobile Sensors: A Preliminary, Proof of Concept Study Tue, 16 Jun 2015 09:31:17 +0000 Background. There are likely marked differences in endotracheal intubation (ETI) techniques between novice and experienced providers. We performed a proof of concept study to determine if portable motion technology could identify the motion components of ETI between novice and experienced providers. Methods. We recruited a sample of novice and experienced providers to perform ETIs on a cadaver. Their movements during ETI were recorded with inertial measurement units (IMUs) on the left wrist. The signals were assessed visually between novice and experienced providers to identify areas of differences at key steps during ETI. We then calculated spectral smoothness (SS), a quantitative measure inversely related to movement variability, for all ETI attempts. Results. We enrolled five novice and five experienced providers. When visually inspecting the data, we noted maximum variability when inserting the blade of the laryngoscope into the mouth and while visualizing the glottic opening. Novice providers also had greater overall variability in their movement patterns (SS novice 6.4 versus SS experienced 26.6). Conclusion. Portable IMUs can be used to detect differences in movement patterns between novice and experienced providers in cadavers. Future ETI educational efforts may utilize portable IMUs to help accelerate the learning curve of novice providers. Jestin N. Carlson, Samarjit Das, Stephanie Spring, Adam Frisch, Fernando De la Torre, and Jessica Hodgins Copyright © 2015 Jestin N. Carlson et al. All rights reserved. Comparisons of the Pentax-AWS, Glidescope, and Macintosh Laryngoscopes for Intubation Performance during Mechanical Chest Compressions in Left Lateral Tilt: A Randomized Simulation Study of Maternal Cardiopulmonary Resuscitation Tue, 16 Jun 2015 08:36:14 +0000 Purpose. Rapid advanced airway management is important in maternal cardiopulmonary resuscitation (CPR). This study aimed to compare intubation performances among Pentax-AWS (AWS), Glidescope (GVL), and Macintosh laryngoscope (MCL) during mechanical chest compression in 15° and 30° left lateral tilt. Methods. In 19 emergency physicians, a prospective randomized crossover study was conducted to examine the three laryngoscopes. Primary outcomes were the intubation time and the success rate for intubation. Results. The median intubation time using AWS was shorter than that of GVL and MCL in both tilt degrees. The time to visualize the glottic view in GVL and AWS was significantly lower than that of MCL (all ), whereas there was no significant difference between the two video laryngoscopes (in 15° tilt, ; in 30° tilt, ). The progression of tracheal tube using AWS was faster than that of MCL and GVL in both degrees (all ). Intubations using AWS and GVL showed higher success rate than that of Macintosh laryngoscopes. Conclusions. The AWS could be an appropriate laryngoscope for airway management of pregnant women in tilt CPR considering intubation time and success rate. Sanghyun Lee, Wonhee Kim, Hyunggoo Kang, Jaehoon Oh, Tae Ho Lim, Yoonjae Lee, Changsun Kim, and Jun Hwi Cho Copyright © 2015 Sanghyun Lee et al. All rights reserved. Comparison of Malated Ringer’s with Two Other Balanced Crystalloid Solutions in Resuscitation of Both Severe and Moderate Hemorrhagic Shock in Rats Wed, 27 May 2015 10:24:03 +0000 In preclinical treatment of polytraumatized patients crystalloids are preferentially used. To avoid metabolic acidosis, metabolizable anions like lactate or acetate are used to replace chloride in these solutions. We here studied the effects of malated Ringer’s in resuscitation of both shock severities in comparison to lactated and acetated Ringer’s. Male Wistar rats underwent severe (mean arterial blood pressure (MAP) of 25–30 mmHg) or moderate (MAP 40–45 mmHg) hemorrhagic shock. Adjacent to the shock period animals were resuscitated with acetated (AR), lactated (LR), or malated Ringer’s (MR) and observed for 150 min. MR improved survival compared with LR and AR in severe hemorrhagic shock whereas it was equally effective to LR and superior to AR in moderate hemorrhagic shock. In all other parameters tested, MR was also effective similar to the other solutions under these conditions. We conclude that MR is preferable to AR and LR in resuscitation of hemorrhagic shock independent of shock depth. The positive effects of MR may stem from the absence of any adverse impact on energy metabolism under both conditions. Judith Keitel, Bjoern Hussmann, Sven Lendemans, Herbert de Groot, and Ricarda Rohrig Copyright © 2015 Judith Keitel et al. All rights reserved. Differential Effects of Endotracheal Suctioning on Gas Exchanges in Patients with Acute Respiratory Failure under Pressure-Controlled and Volume-Controlled Ventilation Tue, 14 Apr 2015 11:13:07 +0000 This study was conducted to evaluate the effects of open endotracheal suctioning on gas exchange and respiratory mechanics in ARF patients under the modes of PCV or VCV. Ninety-six ARF patients were treated with open endotracheal suctioning and their variations in respiratory mechanics and gas exchange after the suctions were compared. Under PCV mode, compared with the initial level of tidal volume (VT), ARF patients showed 30.0% and 27.8% decrease at 1 min and 10 min, respectively. Furthermore, the initial respiratory system compliance (Crs) decreased by 29.6% and 28.5% at 1 min and 10 min, respectively. Under VCV mode, compared with the initial level, 38.6% and 37.5% increase in peak airway pressure (PAP) were found at 1 min and 10 min, respectively. Under PCV mode, the initial PaO2 increased by 6.4% and 10.2 % at 3 min and 10 min, respectively, while 18.9% and 30.6% increase of the initial PaO2 were observed under VCV mode. Summarily, endotracheal suctioning may impair gas exchange and decrease lung compliance in ARF patients receiving mechanical ventilation under both PCV and VCV modes, but endotracheal suctioning effects on gas exchange were more severe and longer-lasting under PCV mode than VCV. Xiao-Wei Liu, Yan Jin, Tao Ma, Bo Qu, and Zhi Liu Copyright © 2015 Xiao-Wei Liu et al. All rights reserved. Prehospital Volume Therapy as an Independent Risk Factor after Trauma Thu, 09 Apr 2015 14:12:00 +0000 Background. Prehospital volume therapy remains widely used after trauma, while evidence regarding its disadvantages is growing. The primary objective of this study was to investigate the volume administered in a prehospital setting as an independent risk factor for mortality. Material and Methods. Patients who met the following criteria were analyzed retrospectively: Injury Severity Score = 16, primary admission (between 2002 and 2010), and age = 16 years. The following data had to be available: volume administered (including packed red cells), blood pressure, Glasgow Coma Scale, therapeutic measures, and laboratory results. Following a univariate analysis, independent risk factors for mortality after trauma were investigated using a multivariate regression analysis. Results. A collective of 7,641 patients met the inclusion criteria, showing that increasing volumes administered in a prehospital setting were an independent risk factor for mortality (odds ratio: 1.34). This tendency was even more pronounced in patients without severe traumatic brain injury (TBI) (odds ratio: 2.71), while the opposite tendency was observed in patients with TBI. Conclusions. Prehospital volume therapy in patients without severe TBI represents an independent risk factor for mortality. In such cases, respiratory and circulatory conditions should be stabilized during permissive hypotension, and patient transfer should not be delayed. Bjoern Hussmann, Matthias Heuer, Rolf Lefering, Alexander Touma, Carsten Schoeneberg, Judith Keitel, and Sven Lendemans Copyright © 2015 Bjoern Hussmann et al. All rights reserved. Sulfated Polysaccharides Isolated from Cloned Grateloupia filicina and Their Anticoagulant Activity Tue, 07 Apr 2015 10:40:30 +0000 Sulfated polysaccharides (GSP) were isolated from the cloned Grateloupia filicina which was cultured in Jiaozhou Bay, Qingdao, China. The yield of GSP was 15.75%. The total sugar and sulfate were 40.90 and 19.89%, respectively. And the average molecular weight was 11.7 KDa. The results of neutral sugar analysis showed that GSP was mainly sulfated polysaccharides of galactose. The experiments for activated partial thromboplastin time (APTT), prothrombin time (PT), and thrombin time (TT) anticoagulant assays in vitro indicated that GSP was a good potential anticoagulant. Therefore, this study supplied new thought for the cloned Grateloupia filicina exploitation of high-value products. Xiaolin Chen, Shengfeng Yang, Jinxia Wang, Lin Song, Ronge Xing, Song Liu, Huahua Yu, and Pengcheng Li Copyright © 2015 Xiaolin Chen et al. All rights reserved. Time for a Break: Admissions to an Urban Emergency Department after Working Out—A Retrospective Study from Switzerland Wed, 04 Feb 2015 14:23:58 +0000 Background. The present retrospective study was intended to investigate whether working out and other low-speed sports can provoke cardiovascular, neurological, or traumatic damage. Material and Methods. Patient data from 2007 to 2013 was collected and saved at the university department of emergency medicine in an electronic patient record database. Results. Of the 138 patients included in this study, 83.3% () were male and 16.7% female (). Most admissions were due to musculoskeletal accidents (; 55.8%), followed by neurological incidents (; 16.7%), cardiovascular incidents (; 13.8%), soft tissue injuries (; 2.2%), and others (; 11.6%). The mean age of the allover injured people was 36.7 years. The majority of the patients (; 81.9%) were treated as outpatients; 24 (17.4%) were inpatients. Discussion. In Switzerland, this is the first study that describes emergency department admissions after workout and examines trauma and neurological and cardiovascular incidents. As specific injuries, such as brain haemorrhages, STEMIs, and epileptic seizures, were relatively frequent, it was hypothesised that workout with its physiological changes may be an actual trigger for these injuries, at least for a specific population. Conclusion. Strenuous physical activity may trigger the risk of cardiovascular, neurological, or trauma events. Valentina A. Imstepf, Christian T. Braun, Meret E. Ricklin, and Aristomenis K. Exadaktylos Copyright © 2015 Valentina A. Imstepf et al. All rights reserved. Thaliporphine Derivative Improves Acute Lung Injury after Traumatic Brain Injury Sun, 01 Feb 2015 14:24:44 +0000 Acute lung injury (ALI) occurs frequently in patients with severe traumatic brain injury (TBI) and is associated with a poor clinical outcome. Aquaporins (AQPs), particularly AQP1 and AQP4, maintain water balances between the epithelial and microvascular domains of the lung. Since pulmonary edema (PE) usually occurs in the TBI-induced ALI patients, we investigated the effects of a thaliporphine derivative, TM-1, on the expression of AQPs and histological outcomes in the lung following TBI in rats. TM-1 administered (10 mg/kg, intraperitoneal injection) at 3 or 4 h after TBI significantly reduced the elevated mRNA expression and protein levels of AQP1 and AQP4 and diminished the wet/dry weight ratio, which reflects PE, in the lung at 8 and 24 h after TBI. Postinjury TM-1 administration also improved histopathological changes at 8 and 24 h after TBI. PE was accompanied with tissue pathological changes because a positive correlation between the lung injury score and the wet/dry weight ratio in the same animal was observed. Postinjury administration of TM-1 improved ALI and reduced PE at 8 and 24 h following TBI. The pulmonary-protective effect of TM-1 may be attributed to, at least in part, downregulation of AQP1 and AQP4 expression after TBI. Gunng-Shinng Chen, Kuo-Feng Huang, Chien-Chu Huang, and Jia-Yi Wang Copyright © 2015 Gunng-Shinng Chen et al. All rights reserved. The Effect of Various Types of Motorcycle Helmets on Cervical Spine Injury in Head Injury Patients: A Multicenter Study in Taiwan Sun, 01 Feb 2015 11:33:58 +0000 Introduction. The relationship between cervical spine injury (CSI) and helmet in head injury (HI) patients following motorcycle crashes is crucial. Controversy still exists; therefore we evaluated the effect of various types of helmets on CSI in HI patients following motorcycle crashes and researched the mechanism of this effect. Patients and Methods. A total of 5225 patients of motorcycle crashes between 2000 and 2009 were extracted from the Head Injury Registry in Taiwan. These patients were divided into case and control groups according to the presence of concomitant CSI. Helmet use and types were separately compared between the two groups and the odds ratio of CSI was obtained by using multiple logistic regression analysis. Results. We observed that 173 (3.3%) of the HI patients were associated with CSI. The HI patients using a helmet (odds ratio (OR) = 0.31, 95% confidence interval (CI) = 0.19−0.49), full-coverage helmet (0.19, 0.10−0.36), and partial-coverage helmet (0.35, 0.21−0.56) exhibited a significantly decreased rate of CSI compared with those without a helmet. Conclusion. Wearing full-coverage and partial-coverage helmets significantly reduced the risk of CSI among HI patients following motorcycle crashes. This effect may be due to the smooth surface and hard padding materials of helmet. Carlos Lam, Mau-Roung Lin, Shu-Fen Chu, Shin-Han Tsai, Chyi-Huey Bai, and Wen-Ta Chiu Copyright © 2015 Carlos Lam et al. All rights reserved. Predictors of Mortality and Prehospital Monitoring Limitations in Blunt Trauma Patients Sun, 01 Feb 2015 11:03:42 +0000 This study aimed at determining predictors of in-hospital mortality and prehospital monitoring limitations in severely injured intubated blunt trauma patients. We retrospectively reviewed patients’ charts. Prehospital vital signs, Injury Severity Score (ISS), initial Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), arterial blood gases, and lactate were compared in two study groups: survivors () and nonsurvivors (). There were no significant differences in prehospital vital signs between compared groups. Nonsurvivors were older (), with lower initial GCS () and higher ISS (), along with higher lactate () and larger base deficit (BD; ), whereas RTS () was lower in nonsurvivors. For predicting mortality, area under the curve (AUC) was calculated: for lactate 0.82 (), for ISS 0.82 (), and for BD 0.69 (). Lactate level of 3.4 mmol/L or more was 82% sensitive and 75% specific for predicting in-hospital death. In a multivariate logistic regression model, ISS (), GCS (), and age () were found to be independent predictors of in-hospital mortality. The AUC for regression model was 0.93 (). Increased levels of lactate and BD on admission indicate more severe occult hypoperfusion in nonsurvivors whereas vital signs did not differ between the groups. Matej Strnad, Vesna Borovnik Lesjak, Vitka Vujanović, Tine Pelcl, and Miljenko Križmarić Copyright © 2015 Matej Strnad et al. All rights reserved. Clearance Rate and BP-ANN Model in Paraquat Poisoned Patients Treated with Hemoperfusion Wed, 28 Jan 2015 14:37:53 +0000 In order to investigate the effect of hemoperfusion (HP) on the clearance rate of paraquat (PQ) and develop a clearance model, 41 PQ-poisoned patients who acquired acute PQ intoxication received HP treatment. PQ concentrations were determined by high performance liquid chromatography (HPLC). According to initial PQ concentration, study subjects were divided into two groups: Low-PQ group (0.05–1.0 μg/mL) and High-PQ group (1.0–10 μg/mL). After initial HP treatment, PQ concentrations decreased in both groups. However, in the High-PQ group, PQ levels remained in excess of 0.05 μg/mL and increased when the second HP treatment was initiated. Based on the PQ concentrations before and after HP treatment, the mean clearance rate of PQ calculated was 73 ± 15%. We also established a backpropagation artificial neural network (BP-ANN) model, which set PQ concentrations before HP treatment as input data and after HP treatment as output data. When it is used to predict PQ concentration after HP treatment, high prediction accuracy () can be obtained in this model. In conclusion, HP is an effective way to clear PQ from the blood, and the PQ concentration after HP treatment can be predicted by BP-ANN model. Lufeng Hu, Guangliang Hong, Jianshe Ma, Xianqin Wang, Guanyang Lin, Xiuhua Zhang, and Zhongqiu Lu Copyright © 2015 Lufeng Hu et al. All rights reserved. Cardiac Arrest and Cardiopulmonary Resuscitation: Starting from Basic Science and Bioengineering Research to Improve Resuscitation Outcome Wed, 31 Dec 2014 12:48:12 +0000 Giuseppe Ristagno, Tommaso Pellis, and Yongqin Li Copyright © 2014 Giuseppe Ristagno et al. All rights reserved. A New Method for Feedback on the Quality of Chest Compressions during Cardiopulmonary Resuscitation Thu, 28 Aug 2014 15:37:54 +0000 Quality of cardiopulmonary resuscitation (CPR) improves through the use of CPR feedback devices. Most feedback devices integrate the acceleration twice to estimate compression depth. However, they use additional sensors or processing techniques to compensate for large displacement drifts caused by integration. This study introduces an accelerometer-based method that avoids integration by using spectral techniques on short duration acceleration intervals. We used a manikin placed on a hard surface, a sternal triaxial accelerometer, and a photoelectric distance sensor (gold standard). Twenty volunteers provided 60 s of continuous compressions to test various rates (80–140 min−1), depths (3–5 cm), and accelerometer misalignment conditions. A total of 320 records with 35312 compressions were analysed. The global root-mean-square errors in rate and depth were below 1.5 min−1 and 2 mm for analysis intervals between 2 and 5 s. For 3 s analysis intervals the 95% levels of agreement between the method and the gold standard were within −1.64–1.67 min−1 and −1.69–1.72 mm, respectively. Accurate feedback on chest compression rate and depth is feasible applying spectral techniques to the acceleration. The method avoids additional techniques to compensate for the integration displacement drift, improving accuracy, and simplifying current accelerometer-based devices. Digna M. González-Otero, Jesus Ruiz, Sofía Ruiz de Gauna, Unai Irusta, Unai Ayala, and Erik Alonso Copyright © 2014 Digna M. González-Otero et al. All rights reserved. Clinical Research of Mortality in Emergency Air Medical Transport Mon, 04 Aug 2014 10:52:42 +0000 Introduction. EAMT in Taiwan has experienced increasing demand in the past few years. The objective is to analyze the trend of EAMT in the past six years and mortality rate within three days of patients undergoing interfacility transport in Taiwan. Material and Method. We conducted a retrospective review of patients who were airlifted from remote islands to main island between 2006 and 2011. Main outcome measures are EAMT number (EAMT-N), EAMT per thousand population (EAMT frequency, EAMT-F), number of mortality (Mor-N), and mortality rate within three days after EAMT (Mor-R). Results and Discussion. Overall mortality rate is 7.54% in 1684 airlifted patients. Acute myocardial infarction (AMI, 26.3%) and traumatic brain injury (TBI, 25.8%) comprise the majority in diagnosis (52.1%). However, Mor-R in these two categories is significantly low in AMI (3.5%) and TBI (5.1%). Conclusion. The present study demonstrates that physician density is not related to EAMT-N but to physician number. As general population ages (10%), the average age of patient who underwent EAMT doubled (21%). This study also leaves room for discussion regarding futile medical care. The results can be used as a reference for increasing utilization of EAMT in current National Health Care Scheme. Wan-Lin Chen, Hon-Ping Ma, Chih-Hsiung Wu, Hung-Yi Chiou, Yun Yen, Wen-Ta Chiu, and Shin-Han Tsai Copyright © 2014 Wan-Lin Chen et al. All rights reserved. The Prognostic and Risk-Stratified Value of Heart-Type Fatty-Acid-Binding Protein in Community Acquired Pneumonia in Emergency Department Wed, 16 Jul 2014 12:09:25 +0000 Objective. To evaluate the prognostic and risk stratified ability of heart-type fatty-acid-binding protein (H-FABP) in patients with community acquired pneumonia (CAP) in emergency department (ED) and to compare it with Pneumonia Severity Index (PSI) and CURB-65. Methods. Consecutive adult CAP patients admitted to the ED of Beijing Chao-Yang Hospital were enrolled. Circulating H-FABP and troponin I were measured. PSI and CURB-65 were calculated in all patients. The differences in 28-day mortality and requirement for mechanical ventilation (MV) or a vasopressor within 6 h after ED arrival were compared in patients with positive H-FABP (≥7 ng/mL) and negative ones (<7 ng/mL). Receiver operating characteristic (ROC) curve and logistic regression were used to assess the predictive value of H-FABP. Results. From August to November 2012, 229 CAP patients were enrolled. The 28-day mortality, PSI, CURB-65, and incidence of using MV or a vasopressor were much higher in H-FABP-positive patients than in negative ones (). H-FABP was an independent predictor of the 28-day mortality. The area under the ROC curve (AUC) of H-FABP was 0.751. Combination of H-FABP and CURB-65 (AUC = 0.824) or H-FABP and PSI (AUC = 0.820) improved their prognostic performance. Conclusions. H-FABP was valuable for prognosis and risk stratification in CAP patients in ED. Yun-Xia Chen and Chun-Sheng Li Copyright © 2014 Yun-Xia Chen and Chun-Sheng Li. All rights reserved. Missed Opportunities: Evolution of Patients Leaving without Being Seen or against Medical Advice during a Six-Year Period in a Swiss Tertiary Hospital Emergency Department Thu, 12 Jun 2014 12:25:12 +0000 Aim. The study aimed at describing the evolution over a 6-year period of patients leaving the emergency department (ED) before being seen (“left without being seen” or LWBS) or against medical advice (“left against medical advice” or LAMA) and at describing their characteristics. Methods. A retrospective database analysis of all adult patients who are admitted to the ED, between 2005 and 2010, and who left before being evaluated or against medical advice, in a tertiary university hospital. Results. During the study period, among the 307,716 patients who were registered in the ED, 1,157 LWBS (0.4%) and 1,853 LAMA (0.9%) patients were identified. These proportions remained stable over the period. The patients had an average age of years for LWBS and years for LAMA. The median time spent in the ED before leaving was 102.4 minutes for the LWBS patients and 226 minutes for LAMA patients. The most frequent reason for LAMA was related to the excessive length of stay. Conclusion. The rates of LWBS and LAMA patients were low and remained stable. The patients shared similar characteristics and reasons for leaving were largely related to the length of stay or waiting time. Pierre-Nicolas Carron, Bertrand Yersin, Lionel Trueb, Philippe Gonin, and Olivier Hugli Copyright © 2014 Pierre-Nicolas Carron et al. All rights reserved. Endotracheal Intubation Using the Macintosh Laryngoscope or KingVision Video Laryngoscope during Uninterrupted Chest Compression Wed, 04 Jun 2014 11:52:12 +0000 Objective. Advanced airway management, endotracheal intubation (ETI), during CPR is more difficult than, for example, during anesthesia. However, new devices such as video laryngoscopes should help in such circumstances. The aim of this study was to assess the performance of the KingVision video laryngoscopes in a manikin cardiopulmonary resuscitation (CPR) scenario. Methods. Thirty students enrolled in the third year of paramedic school took part in the study. The simulated CPR scenario was ETI using the standard laryngoscope with a Macintosh blade (MCL) and ETI using the KingVision video laryngoscope performed during uninterrupted chest compressions. The primary endpoints were the time needed for ETI and the success ratio. Results. The mean time required for intubation was similar for both laryngoscopes: 16.6 (SD 5.11, median 15.64, range 7.9–27.9) seconds versus 17.91 (SD 5.6, median 16.28, range 10.6–28.6) seconds for the MCL and KingVision, respectively (). On the first attempt at ETI, the success rate during CPR was comparable between the evaluated laryngoscopes: . Conclusion. The KingVision video laryngoscope proves to be less superior when used for endotracheal intubation during CPR compared to the standard laryngoscope with a Mackintosh blade. This proves true in terms of shortening the time needed for ETI and increasing the success ratio. Ewelina Gaszynska and Tomasz Gaszynski Copyright © 2014 Ewelina Gaszynska and Tomasz Gaszynski. All rights reserved. From Mouth-to-Mouth to Bag-Valve-Mask Ventilation: Evolution and Characteristics of Actual Devices—A Review of the Literature Tue, 27 May 2014 00:00:00 +0000 Manual ventilation is a vital procedure, which remains difficult to achieve for patients who require ventilatory support. It has to be performed by experienced healthcare providers that are regularly trained for the use of bag-valve-mask (BVM) in emergency situations. We will give in this paper, a historical view on manual ventilation’s evolution throughout the last decades and describe the technical characteristics, advantages, and hazards of the main devices currently found in the market. Artificial ventilation has developed progressively and research is still going on to improve the actual devices used. Throughout the past years, a brand-new generation of ventilators was developed, but little was done for manual ventilation. Many adverse outcomes due to faulty valve or misassembly were reported in the literature, as well as some difficulties to ensure efficient insufflation according to usual respiratory parameters. These serious incidents underline the importance of BVM system routine check and especially the unidirectional valve reassembly after sterilization, by only experienced and trained personnel. Single use built-in devices may prevent disassembly problems and are safer than the reusable ones. Through new devices and technical improvements, the safety of BVM might be increased. Abdo Khoury, Sylvère Hugonnot, Johan Cossus, Alban De Luca, Thibaut Desmettre, Fatimata Seydou Sall, and Gilles Capellier Copyright © 2014 Abdo Khoury et al. All rights reserved. Effect of Engaging Trainees by Assessing Peer Performance: A Randomised Controlled Trial Using Simulated Patient Scenarios Tue, 20 May 2014 06:12:36 +0000 Introduction. The aim of this study was to explore the learning effect of engaging trainees by assessing peer performance during simulation-based training. Methods. Eighty-four final year medical students participated in the study. The intervention involved trainees assessing peer performance during training. Outcome measures were in-training performance and performance, both of which were measured two weeks after the course. Trainees’ performances were videotaped and assessed by two expert raters using a checklist that included a global rating. Trainees’ satisfaction with the training was also evaluated. Results. The intervention group obtained a significantly higher overall in-training performance score than the control group: mean checklist score 20.87 (SD 2.51) versus 19.14 (SD 2.65) and mean global rating 3.25 SD (0.99) versus 2.95 (SD 1.09) . Postcourse performance did not show any significant difference between the two groups. Trainees who assessed peer performance were more satisfied with the training than those who did not: mean 6.36 (SD 1.00) versus 5.74 (SD 1.33) . Conclusion. Engaging trainees in the assessment of peer performance had an immediate effect on in-training performance, but not on the learning outcome measured two weeks later. Trainees had a positive attitude towards the training format. Charlotte Loumann Krogh, Charlotte Ringsted, Charles B. Kromann, Maria Birkvad Rasmussen, Tobias Todsen, Rasmus Lundhus Jørgensen, Rikke Borre Jacobsen, Jørgen B. Dahl, and Lars Konge Copyright © 2014 Charlotte Loumann Krogh et al. All rights reserved. A Reliable Method for Rhythm Analysis during Cardiopulmonary Resuscitation Wed, 07 May 2014 14:23:38 +0000 Interruptions in cardiopulmonary resuscitation (CPR) compromise defibrillation success. However, CPR must be interrupted to analyze the rhythm because although current methods for rhythm analysis during CPR have high sensitivity for shockable rhythms, the specificity for nonshockable rhythms is still too low. This paper introduces a new approach to rhythm analysis during CPR that combines two strategies: a state-of-the-art CPR artifact suppression filter and a shock advice algorithm (SAA) designed to optimally classify the filtered signal. Emphasis is on designing an algorithm with high specificity. The SAA includes a detector for low electrical activity rhythms to increase the specificity, and a shock/no-shock decision algorithm based on a support vector machine classifier using slope and frequency features. For this study, 1185 shockable and 6482 nonshockable 9-s segments corrupted by CPR artifacts were obtained from 247 patients suffering out-of-hospital cardiac arrest. The segments were split into a training and a test set. For the test set, the sensitivity and specificity for rhythm analysis during CPR were 91.0% and 96.6%, respectively. This new approach shows an important increase in specificity without compromising the sensitivity when compared to previous studies. U. Ayala, U. Irusta, J. Ruiz, T. Eftestøl, J. Kramer-Johansen, F. Alonso-Atienza, E. Alonso, and D. González-Otero Copyright © 2014 U. Ayala et al. All rights reserved. Downtime after Critical Incidents in Emergency Medical Technicians/Paramedics Sun, 04 May 2014 00:00:00 +0000 Effective workplace-based interventions after critical incidents (CIs) are needed for emergency medical technicians (EMT)/paramedics. The evidence for a period out of service post-CI (downtime) is sparse; however it may prevent posttraumatic stress disorder (PTSD) and burnout symptoms. We examined the hypothesis that downtime post-CI is associated with fewer symptoms of four long-term emotional sequelae in EMT/paramedics: depression, PTSD, burnout, and stress-related emotional symptoms (accepted cut-offs defined high scores). Two hundred and one paramedics completed questionnaires concerning an index CI including downtime experience, acute distress, and current emotional symptoms. Nearly 75% received downtime; 59% found it helpful; 84% spent it with peers. Downtime was associated only with lower depression symptoms, not with other outcomes. The optimal period for downtime was between 30 minutes and end of shift, with 1 day being less effective. Planned testing of mediation of the association between downtime and depression by either calming acute post-CI distress or feeling helped by others was not performed because post-CI distress was not associated with downtime and perceived helpfulness was not associated with depression. These results suggest that outcomes of CIs follow different pathways and may require different interventions. A brief downtime is a relatively simple and effective strategy in preventing later depression symptoms. Janice Halpern, Robert G. Maunder, Brian Schwartz, and Maria Gurevich Copyright © 2014 Janice Halpern et al. All rights reserved. Knowledge of Signs and Symptoms of Heart Attack and Stroke among Singapore Residents Thu, 10 Apr 2014 14:09:10 +0000 Aim. To determine the level of knowledge of signs and symptoms of heart attack and stroke in Singapore resident population, in comparison to the global community. Methods. A population based, random sample of 7,840 household addresses was selected from a validated national sampling frame. Each participant was asked eight questions on signs and symptoms of heart attack and 10 questions on stroke. Results. The response rate was 65.2% with 4,192 respondents. The level of knowledge for preselected, common signs and symptoms of heart attack and stroke was 57.8% and 57.1%, respectively. The respondents scored a mean of 5.0 (SD 2.4) out of 8 for heart attack, while they scored a mean of 6.8 (SD 2.9) out of 10 for stroke. Respondents who were ≥50 years, with lower educational level, and unemployed/retired had the least knowledge about both conditions. The level of knowledge of signs and symptoms of heart attack and stroke in Singapore is comparable to USA and Canada. Conclusion. We found a comparable knowledge of stroke and heart attack signs and symptoms in the community to countries within the same economic, educational, and healthcare strata. However older persons, those with lower educational level and those who are unemployed/retired, require more public health education efforts. Joy Li Juan Quah, Susan Yap, Si Oon Cheah, Yih Yng Ng, E. Shaun Goh, Nausheen Doctor, Benjamin Sieu-Hon Leong, Ling Tiah, Michael Yih Chong Chia, and Marcus Eng Hock Ong Copyright © 2014 Joy Li Juan Quah et al. All rights reserved. Epidemiology of Hospitalized Traumatic Pelvic Fractures and Their Combined Injuries in Taiwan: 2000–2011 National Health Insurance Data Surveillance Tue, 01 Apr 2014 08:21:16 +0000 Background. From the viewpoint of prehospital emergency medicine, a greater proportion of pelvic fractures not of a life-threatening status but combined with other injuries need more comprehensive recognition. Methods. A 12-year nationwide health database of inpatients was reviewed. All cases diagnosed as pelvic fractures were enrolled. The associated injuries classified into 20 categories were further analyzed. Results. During 2000–2011, the hospitalized incidence of pelvic fractures in Taiwan ranged from 17.17 to 19.42 per 100,000, and an increasing trend with age was observed. The mean case-fatality rate was 1.6% for females and 2.1% for males; male patients with pelvic fractures had a significantly higher risk of death than female patients after adjusting for other covariates. 74.2% of these cases were combined with other injuries. The most common associated injuries in an identified body region were other orthopedic fractures of the lower limbs (21.50%), spine/trunk (20.97%), or upper limbs (18.18%), followed by significant head injuries (17.59%), intra-abdominal injuries (11.00%), and thoracic injuries (7.20%). Conclusion. The incidence of hospitalized pelvic fractures in Taiwan was low and the case-fatality rate was lower than those of other countries. Concurrently, coexistence of major combined injuries with pelvic fractures was easily treated at medical centers. Nan-Ping Yang, Chien-Lung Chan, Dachen Chu, Yu-Zhen Lin, Kai-Biao Lin, Ching-Shao Yu, I-Liang Yu, Nien-Tzu Chang, and Yi-Hui Lee Copyright © 2014 Nan-Ping Yang et al. All rights reserved. Removal of Cardiopulmonary Resuscitation Artifacts with an Enhanced Adaptive Filtering Method: An Experimental Trial Thu, 27 Mar 2014 12:35:29 +0000 Current automated external defibrillators mandate interruptions of chest compression to avoid the effect of artifacts produced by CPR for reliable rhythm analyses. But even seconds of interruption of chest compression during CPR adversely affects the rate of restoration of spontaneous circulation and survival. Numerous digital signal processing techniques have been developed to remove the artifacts or interpret the corrupted ECG with promising result, but the performance is still inadequate, especially for nonshockable rhythms. In the present study, we suppressed the CPR artifacts with an enhanced adaptive filtering method. The performance of the method was evaluated by comparing the sensitivity and specificity for shockable rhythm detection before and after filtering the CPR corrupted ECG signals. The dataset comprised 283 segments of shockable and 280 segments of nonshockable ECG signals during CPR recorded from 22 adult pigs that experienced prolonged cardiac arrest. For the unfiltered signals, the sensitivity and specificity were 99.3% and 46.8%, respectively. After filtering, a sensitivity of 93.3% and a specificity of 96.0% were achieved. This animal trial demonstrated that the enhanced adaptive filtering method could significantly improve the detection of nonshockable rhythms without compromising the ability to detect a shockable rhythm during uninterrupted CPR. Yushun Gong, Tao Yu, Bihua Chen, Mi He, and Yongqin Li Copyright © 2014 Yushun Gong et al. All rights reserved. Reoxygenation of Asphyxiated Newborn Piglets: Administration of 100% Oxygen Causes Significantly Higher Apoptosis in Cortical Neurons, as Compared to 21% Tue, 25 Mar 2014 13:30:09 +0000 Objective. Evaluation of neuronal changes in an animal experimental model of normocapnic hypoxia- reoxygenation. Materials and Methods. Fifty male piglets were the study subjects; normocapnic hypoxia was induced in 40 piglets and ten were sham-operated (controls). When bradycardia and/or severe hypotension occurred, reoxygenation was initiated. Animals were allocated in 4 groups according to the oxygen concentration, they were resuscitated with 18%, 21%, 40%, and 100% O2. Persisting asystole despite 10 minutes of cardiopulmonary resuscitation and return of spontaneous circulation were the endpoints of the experiment. Surviving animals were euthanized and brain cortex samples were collected, hematoxylin and eosin-stained, and examined for apoptotic bodies observing 10 consecutive high power fields. Results. Histological examination of the control group did not show any pathological change. On the contrary, apoptosis of neurons was found in 87.5% of treated animals. When specimens were examined according to the oxygen concentration used for resuscitation, we found marked intergroup variability; a higher percentage of apoptotic neurons was observed in piglets of group 4 (100% oxygen) compared to the others (). Conclusions. This preliminary data shows that normocapnic hypoxia and reoxygenation in Landrace/Large White piglets resulted in significant histological changes in the brain cortex. The degree of pathological changes in cortical neurons was significantly associated with the oxygen concentration used for reoxygenation, with a higher percentage of apoptotic neurons being observed in piglets reoxygenated with 100% compared to 18% O2 and to 21% O2. G. Faa, V. Fanos, D. Fanni, C. Gerosa, A. Faa, M. Fraschini, M. E. Pais, E. Di Felice, A. Papalois, M. Varsami, T. Xanthos, and N. Iacovidou Copyright © 2014 G. Faa et al. All rights reserved. Assessment of a Human Cadaver Model for Training Emergency Medicine Residents in the Ultrasound Diagnosis of Pneumothorax Tue, 25 Mar 2014 08:20:17 +0000 Objectives. To assess a human cadaver model for training emergency medicine residents in the ultrasound diagnosis of pneumothorax. Methods. Single-blinded observational study using a human cadaveric model at an academic medical center. Three lightly embalmed cadavers were used to create three “normal lungs” and three lungs modeling a “pneumothorax.” The residents were blinded to the side and number of pneumothoraces, as well as to each other’s findings. Each resident performed an ultrasound examination on all six lung models during ventilation of cadavers. They were evaluated on their ability to identify the presence or absence of the sliding-lung sign and seashore sign. Results. A total of 84 ultrasound examinations (42-“normal lung,” 42-“pneumothorax”) were performed. A sliding-lung sign was accurately identified in 39 scans, and the seashore sign was accurately identified in 34 scans. The sensitivity and specificity for the sliding-lung sign were 93% (95% CI, 85–100%) and 90% (95% CI, 81–99%), respectively. The sensitivity and specificity for the seashore sign were 80% (95% CI, 68–92%) and 83% (95% CI, 72–94%), respectively. Conclusions. Lightly embalmed human cadavers may provide an excellent model for mimicking the sonographic appearance of pneumothorax. Srikar Adhikari, Wesley Zeger, Michael Wadman, Richard Walker, and Carol Lomneth Copyright © 2014 Srikar Adhikari et al. All rights reserved. Hypoxia-Induced Endothelial Damage and Microthrombosis in Myocardial Vessels of Newborn Landrace/Large White Piglets Tue, 04 Mar 2014 07:31:51 +0000 Objective. Evaluating the presence of endothelial changes in myocardial vessels in an experimental model of hypoxia and resuscitation in newborn piglets. Methods. Fifty male Landrace/Large White neonatal piglets were studied: ten of them were allocated in group A (control group, SHAM-operated). In group B (forty animals, experimental group) normocapnic hypoxia was induced by decreasing inspired concentration of O2 to 6%–8%. When the animals developed bradycardia or severe hypotension, reoxygenation was initiated. The animals of group B were allocated in 4 subgroups of 10, according to the concentration of O2 they were resuscitated with (groups 1, 2, 3, and 4 received 18%, 21%, 40%, and 100% O2, resp.). Results. Control group animals did not show any significant endothelial lesions. Contrarily, endothelial lesions were detected in all experimental group cases. When these lesions were analyzed in the different heart zones, no significant difference in their incidence was observed; analyzing the frequency in the animals of the 4 subgroups, only microthrombosis showed a higher frequency in animals in groups 4 and 3. Conclusions. Endothelial damage represents a diffuse pathological feature in the myocardial vessels of piglets subjected to normocapnic hypoxia and resuscitation suggesting a possible role of hyperoxygenation in aggravating endothelial damage. Armando Faa, Theodoros Xanthos, Vassilios Fanos, Daniela Fanni, Clara Gerosa, Pietro Pampaloni, Maria Elena Pais, Gavino Faa, and Nicoletta Iacovidou Copyright © 2014 Armando Faa et al. All rights reserved. Oxygenation, Ventilation, and Airway Management in Out-of-Hospital Cardiac Arrest: A Review Mon, 03 Mar 2014 07:02:13 +0000 Recently published evidence has challenged some protocols related to oxygenation, ventilation, and airway management for out-of-hospital cardiac arrest. Interrupting chest compressions to attempt airway intervention in the early stages of OHCA in adults may worsen patient outcomes. The change of BLS algorithms from ABC to CAB was recommended by the AHA in 2010. Passive insufflation of oxygen into a patent airway may provide oxygenation in the early stages of cardiac arrest. Various alternatives to tracheal intubation or bag-mask ventilation have been trialled for prehospital airway management. Simple methods of airway management are associated with similar outcomes as tracheal intubation in patients with OHCA. The insertion of a laryngeal mask airway is probably associated with worse neurologically intact survival rates in comparison with other methods of airway management. Hyperoxemia following OHCA may have a deleterious effect on the neurological recovery of patients. Extracorporeal oxygenation techniques have been utilized by specialized centers, though their use in OHCA remains controversial. Chest hyperinflation and positive airway pressure may have a negative impact on hemodynamics during resuscitation and should be avoided. Dyscarbia in the postresuscitation period is relatively common, mainly in association with therapeutic hypothermia, and may worsen neurological outcome. Tomas Henlin, Pavel Michalek, Tomas Tyll, John D. Hinds, and Milos Dobias Copyright © 2014 Tomas Henlin et al. All rights reserved. The Progress of Emergency Medicine in Taiwan, China, and Hong Kong: Perspective from Publications in Emergency Medicine Journals, 1992–2011 Sun, 23 Feb 2014 06:25:55 +0000 Study Objective. The progress of emergency medicine (EM) in Taiwan, China, and Hong Kong was evaluated from the perspective of publications in EM journals. Methods. This was a retrospective study. All articles published from 1992 to 2011 in all journals in the EM category in the 2010 Journal Citation Reports (JCR) were included. A computerized literature search was conducted using the SciVerse Scopus database. The slope (β) of the linear regression was used to evaluate the trends in the numbers of articles as well as the ratios to the total number of EM journal articles. Results. The trends in the numbers of articles from Taiwan, China, and Hong Kong were 6.170, 1.908, and 2.835 and the trends in the ratios of their publication numbers to the total number of EM journal articles were 15.0 × 10−4, 4.60 × 10−4, and 6.80 × 10−4, respectively. All -values were <0.01. The mean, median, and 75th percentiles of the number of citations in all EM journals were greater than those of these three areas. Conclusions. The publications from Taiwan, China, and Hong Kong have increased at a higher rate than those of the overall EM field in the past 20 years and indicated the rapid progress in these three areas. Ching-Hsing Lee, Chung-Hsien Chaou, and Chih-Chuan Lin Copyright © 2014 Ching-Hsing Lee et al. All rights reserved. Impaired Cerebral Mitochondrial Oxidative Phosphorylation Function in a Rat Model of Ventricular Fibrillation and Cardiopulmonary Resuscitation Tue, 18 Feb 2014 10:27:46 +0000 Postcardiac arrest brain injury significantly contributes to mortality and morbidity in patients suffering from cardiac arrest (CA). Evidence that shows that mitochondrial dysfunction appears to be a key factor in tissue damage after ischemia/reperfusion is accumulating. However, limited data are available regarding the cerebral mitochondrial dysfunction during CA and cardiopulmonary resuscitation (CPR) and its relationship to the alterations of high-energy phosphate. Here, we sought to identify alterations of mitochondrial morphology and oxidative phosphorylation function as well as high-energy phosphates during CA and CPR in a rat model of ventricular fibrillation (VF). We found that impairment of mitochondrial respiration and partial depletion of adenosine triphosphate (ATP) and phosphocreatine (PCr) developed in the cerebral cortex and hippocampus following a prolonged cardiac arrest. Optimal CPR might ameliorate the deranged phosphorus metabolism and preserve mitochondrial function. No obvious ultrastructural abnormalities of mitochondria have been found during CA. We conclude that CA causes cerebral mitochondrial dysfunction along with decay of high-energy phosphates, which would be mitigated with CPR. This study may broaden our understanding of the pathogenic processes underlying global cerebral ischemic injury and provide a potential therapeutic strategy that aimed at preserving cerebral mitochondrial function during CA. Jun Jiang, Xiangshao Fang, Yue Fu, Wen Xu, Longyuan Jiang, and Zitong Huang Copyright © 2014 Jun Jiang et al. All rights reserved. Metabolomics Network Characterization of Resuscitation after Normocapnic Hypoxia in a Newborn Piglet Model Supports the Hypothesis That Room Air Is Better Tue, 18 Feb 2014 08:08:59 +0000 Perinatal asphyxia is attributed to hypoxia and/or ischemia around the time of birth and may lead to multiorgan dysfunction. Aim of this research article is to investigate whether different metabolomic profiles occurred according to oxygen concentration administered at resuscitation. In order to perform the experiment, forty newborn piglets were subjected to normocapnic hypoxia and reoxygenation and were randomly allocated in 4 groups resuscitated with different oxygen concentrations, 18%, 21%, 40%, and 100%, respectively. Urine metabolic profiles at baseline and at hypoxia were analysed by 1H-NMR spectroscopy and metabolites were also identified by multivariate statistical analysis. Metabolic pathways associations were also built up by ingenuity pathway analysis (IPA). Bioinformatics analysis of metabolites characterized the effect of metabolism in the 4 groups; it showed that the 21% of oxygen is the most “physiological” and appropriate concentration to be used for resuscitation. Our data indicate that resuscitation with 21% of oxygen seems to be optimal in terms of survival, rapidity of resuscitation, and metabolic profile in the present animal model. These findings need to be confirmed with metabolomics in human and, if so, the knowledge of the perinatal asphyxia condition may significantly improve. V. Fanos, A. Noto, T. Xanthos, M. Lussu, F. Murgia, L. Barberini, G. Finco, E. d'Aloja, A. Papalois, N. Iacovidou, and L. Atzori Copyright © 2014 V. Fanos et al. All rights reserved. Routine Follow-Up Cranial Computed Tomography for Deeply Sedated, Intubated, and Ventilated Multiple Trauma Patients with Suspected Severe Head Injury Mon, 20 Jan 2014 09:40:39 +0000 Background. Missed or delayed detection of progressive neuronal damage after traumatic brain injury (TBI) may have negative impact on the outcome. We investigated whether routine follow-up CT is beneficial in sedated and mechanically ventilated trauma patients. Methods. The study design is a retrospective chart review. A routine follow-up cCT was performed 6 hours after the admission scan. We defined 2 groups of patients, group I: patients with equal or recurrent pathologies and group II: patients with new findings or progression of known pathologies. Results. A progression of intracranial injury was found in 63 patients (42%) and 18 patients (12%) had new findings in cCT 2 (group II). In group II a change in therapy was found in 44 out of 81 patients (54%). 55 patients with progression or new findings on the second cCT had no clinical signs of neurological deterioration. Of those 24 patients (44%) had therapeutic consequences due to the results of the follow-up cCT. Conclusion. We found new diagnosis or progression of intracranial pathology in 54% of the patients. In 54% of patients with new findings and progression of pathology, therapy was changed due to the results of follow-up cCT. In trauma patients who are sedated and ventilated for different reasons a routine follow-up CT is beneficial. Thomas Erik Wurmb, Stefan Schlereth, Markus Kredel, Ralf M. Muellenbach, Christian Wunder, Jörg Brederlau, Norbert Roewer, Werner Kenn, and Ekkehard Kunze Copyright © 2014 Thomas Erik Wurmb et al. All rights reserved. Towards the Automated Analysis and Database Development of Defibrillator Data from Cardiac Arrest Sun, 12 Jan 2014 12:24:08 +0000 Background. During resuscitation of cardiac arrest victims a variety of information in electronic format is recorded as part of the documentation of the patient care contact and in order to be provided for case review for quality improvement. Such review requires considerable effort and resources. There is also the problem of interobserver effects. Objective. We show that it is possible to efficiently analyze resuscitation episodes automatically using a minimal set of the available information. Methods and Results. A minimal set of variables is defined which describe therapeutic events (compression sequences and defibrillations) and corresponding patient response events (annotated rhythm transitions). From this a state sequence representation of the resuscitation episode is constructed and an algorithm is developed for reasoning with this representation and extract review variables automatically. As a case study, the method is applied to the data abstraction process used in the King County EMS. The automatically generated variables are compared to the original ones with accuracies for 18 variables and for the remaining four variables. Conclusions. It is possible to use the information present in the CPR process data recorded by the AED along with rhythm and chest compression annotations to automate the episode review. Trygve Eftestøl and Lawrence D. Sherman Copyright © 2014 Trygve Eftestøl and Lawrence D. Sherman. All rights reserved. Rhythm Analysis during Cardiopulmonary Resuscitation: Past, Present, and Future Thu, 09 Jan 2014 12:29:50 +0000 Survival from out-of-hospital cardiac arrest depends largely on two factors: early cardiopulmonary resuscitation (CPR) and early defibrillation. CPR must be interrupted for a reliable automated rhythm analysis because chest compressions induce artifacts in the ECG. Unfortunately, interrupting CPR adversely affects survival. In the last twenty years, research has been focused on designing methods for analysis of ECG during chest compressions. Most approaches are based either on adaptive filters to remove the CPR artifact or on robust algorithms which directly diagnose the corrupted ECG. In general, all the methods report low specificity values when tested on short ECG segments, but how to evaluate the real impact on CPR delivery of continuous rhythm analysis during CPR is still unknown. Recently, researchers have proposed a new methodology to measure this impact. Moreover, new strategies for fast rhythm analysis during ventilation pauses or high-specificity algorithms have been reported. Our objective is to present a thorough review of the field as the starting point for these late developments and to underline the open questions and future lines of research to be explored in the following years. Sofia Ruiz de Gauna, Unai Irusta, Jesus Ruiz, Unai Ayala, Elisabete Aramendi, and Trygve Eftestøl Copyright © 2014 Sofia Ruiz de Gauna et al. All rights reserved. Outcome of Prolonged Ventricular Fibrillation and CPR in a Rat Model of Chronic Ischemic Left Ventricular Dysfunction Tue, 17 Dec 2013 14:02:11 +0000 Patients with chronic left ventricular (LV) dysfunction are assumed to have a lower chance of successful CPR and lower likelihood of ultimate survival. However, these assumptions have rarely been documented. Therefore, we investigated the outcome of prolonged ventricular fibrillation (VF) and CPR in a rat model of chronic LV dysfunction. Sprague-Dawley rats were randomized to (1) chronic LV dysfunction: animals underwent left coronary artery ligation; and (2) sham control. Echocardiography was used to measure cardiac performance before surgery and 4 weeks after surgery. Four weeks after surgical intervention, 8 min of VF was induced and defibrillation was delivered after 8 min of CPR. LV dilation and low ejection fraction were observed 4 weeks after coronary ligation. With optimal chest compressions, coronary perfusion pressure values during CPR were well maintained and indistinguishable between groups. There were no differences in resuscitability and numbers of shock required for successful resuscitation between groups. Despite the significantly decreased cardiac index in LV dysfunction animals before induction of VF, no differences in cardiac index were observed between groups following resuscitation, which was associated with the insignificant difference in postresuscitation survival. In conclusion, the outcomes of CPR were not compromised by the preexisting chronic LV dysfunction. Xiangshao Fang, Lei Huang, Shijie Sun, Max Harry Weil, and Wanchun Tang Copyright © 2013 Xiangshao Fang et al. All rights reserved. Improved Early Postresuscitation EEG Activity for Animals Treated with Hypothermia Predicted 96 hr Neurological Outcome and Survival in a Rat Model of Cardiac Arrest Wed, 04 Dec 2013 17:49:50 +0000 Purpose. To investigate the effect of hypothermia on 96 hr neurological outcome and survival by quantitatively characterizing early postresuscitation EEG in a rat model of cardiac arrest. Materials and Methods. In twenty male Sprague-Dawley rats, cardiac arrest was induced through high frequency transesophageal cardiac pacing. Cardiopulmonary resuscitation was initiated after 5 mins untreated arrest. Immediately after resuscitation, animals were randomized to either 2 hrs of hypothermia () or normothermia (). EEG, ECG, aortic pressure, and core temperature were continuously recorded for 6 hrs. Neurological outcome was evaluated daily during the 96 hrs postresuscitation period. Results. No differences in the baseline measurements and resuscitation outcome were observed between groups. However, 96 hr neurological deficit score (204 ± 255 versus 500 ± 0, ) and survival (6/10 versus 0/10, ) were significantly better in the hypothermic group. Quantitative analysis of early postresuscitation EEG revealed that burst frequency and spectrum entropy were greatly improved in the hypothermic group and correlated with 96 hr neurological outcome and survival. Conclusion. The improved burst frequency during burst suppression period and preserved spectrum entropy after restoration of continuous background EEG activity for animals treated with hypothermia predicted favorable neurological outcome and survival in this rat model of cardiac arrest. Bihua Chen, Feng-Qing Song, Lei-Lei Sun, Ling-Yan Lei, Wei-Ni Gan, Meng-Hua Chen, and Yongqin Li Copyright © 2013 Bihua Chen et al. All rights reserved. Even Four Minutes of Poor Quality of CPR Compromises Outcome in a Porcine Model of Prolonged Cardiac Arrest Mon, 02 Dec 2013 13:45:37 +0000 Objective. Untrained bystanders usually delivered suboptimal chest compression to victims who suffered from cardiac arrest in out-of-hospital settings. We therefore investigated the hemodynamics and resuscitation outcome of initial suboptimal quality of chest compressions compared to the optimal ones in a porcine model of cardiac arrest. Methods. Fourteen Yorkshire pigs weighted 30 ± 2 kg were randomized into good and poor cardiopulmonary resuscitation (CPR) groups. Ventricular fibrillation was electrically induced and untreated for 6 mins. In good CPR group, animals received high quality manual chest compressions according to the Guidelines (25% of animal’s anterior-posterior thoracic diameter) during first two minutes of CPR compared with poor (70% of the optimal depth) compressions. After that, a 120-J biphasic shock was delivered. If the animal did not acquire return of spontaneous circulation, another 2 mins of CPR and shock followed. Four minutes later, both groups received optimal CPR until total 10 mins of CPR has been finished. Results. All seven animals in good CPR group were resuscitated compared with only two in poor CPR group (). The delayed optimal compressions which followed 4 mins of suboptimal compressions failed to increase the lower coronary perfusion pressure of five non-survival animals in poor CPR group. Conclusions. In a porcine model of prolonged cardiac arrest, even four minutes of initial poor quality of CPR compromises the hemodynamics and survival outcome. Heng Li, Lei Zhang, Zhengfei Yang, Zitong Huang, Bihua Chen, Yongqin Li, and Tao Yu Copyright © 2013 Heng Li et al. All rights reserved. The Usefulness of 3-Dimensional Virtual Simulation Using Haptics in Training Orotracheal Intubation Thu, 19 Sep 2013 08:20:36 +0000 Objectives. Airway control is the most critical treatment. The most common and basic method of endotracheal intubation is orotracheal intubation. To perform accurate and rapid tracheal intubation, appropriate education and training are required. We developed the virtual simulation program utilizing the 3-dimensional display and haptic device to exercise orotracheal intubation, and the educational effect of this program was compared with that of the mannequin method. Method. The control group used airway mannequin and virtual intubation group was trained with new program. We videotaped both groups during objective structured clinical examination (OSCE) with airway mannequin. The video was reviewed and scored, and the rate of success and time were calculated. Result. The success rate was 78.6% in virtual intubation group and 93.3% in control group (). There was no difference in overall score of OSCE (21.14 ± 4.28 in virtual intubation group and 23.33 ± 4.45 in control group, ), the time spent in successful intubation (), and the number of trials (). Conclusion. The virtual simulation with haptics had a similar effect compared with mannequin, but it could be more cost effective and convenient than mannequin training in time and space. Dong Hoon Lee, Jae Gyu Kim, Chan Woong Kim, Chang Ha Lee, and Jae Hee Lim Copyright © 2013 Dong Hoon Lee et al. All rights reserved. The Predictive Value of Adrenomedullin for Development of Severe Sepsis and Septic Shock in Emergency Department Sun, 04 Aug 2013 14:10:05 +0000 Objective. The aim of the study was to assess adrenomedullin (AM) as a predictor for development of severe sepsis and septic shock in emergency department (ED). Method. From December 2011 to October 2012, 372 consecutive septic patients admitted to ED were enrolled. AM was examined in every patient. All patients were followed up for 3 days. The outcome variable was development of severe sepsis or septic shock. The predictive ability of AM was evaluated by binary logistic regression analysis and receiver operating characteristic (ROC) curve. Result. On admission, the differences of AM among patients with different comorbidities, infections, and culture results were not significant. AM level was higher in patients who progressed than in who did not (41.63 ± 6.55 versus 31.31 ± 7.71 ng/L, ). AM was the only independent predictor of outcome. The area under ROC curve of AM was 0.847. With a cutoff value of 41.24 ng/L, the sensitivity was 67.6%, the specificity was 90.0%, the positive predictive value was 61.5%, the negative predictive value was 92.2%, the positive likelihood ratio was 6.78, and the negative likelihood ratio was 0.36. Conclusion. Adrenomedullin is valuable for predicting development of severe sepsis and septic shock in ED. Yun-Xia Chen and Chun-Sheng Li Copyright © 2013 Yun-Xia Chen and Chun-Sheng Li. All rights reserved. What Is the Incidence of Intracranial Bleeding in Patients with Mild Traumatic Brain Injury? A Retrospective Study in 3088 Canadian CT Head Rule Patients Mon, 15 Jul 2013 14:14:06 +0000 Objective. Only limited data exists in terms of the incidence of intracranial bleeding (ICB) in patients with mild traumatic brain injury (MTBI). Methods. We retrospectively identified 3088 patients (mean age 41 range (7–99) years) presenting with isolated MTBI and GCS 14-15 at our Emergency Department who had undergone cranial CT (CCT) between 2002 and 2011. Indication for CCT was according to the “Canadian CT head rules.” Patients with ICB were either submitted for neurosurgical treatment or kept under surveillance for at least 24 hours. Pearson’s correlation coefficient was used to correlate the incidence of ICB with age, gender, or intake of coumarins, platelet aggregation inhibitors, or heparins. Results. 149 patients (4.8%) had ICB on CCT. No patient with ICB died or deteriorated neurologically. The incidence of ICB increased with age and intake of anticoagulants without clinically relevant correlation (; ; ; ). Conclusion. Our data show an incidence of 4.8% for ICB after MTBI. However, neurological deterioration after MTBI seems to be rare, and the need for neurosurgical intervention is only required in selected cases. The general need for CCT in patients after MTBI is therefore questionable, and clinical surveillance may be sufficient when CCT is not available. C. E. Albers, M. von Allmen, D. S. Evangelopoulos, A. K. Zisakis, H. Zimmermann, and A. K. Exadaktylos Copyright © 2013 C. E. Albers et al. All rights reserved.