BioMed Research International: Emergency Medicine The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Factors Affecting Unscheduled Return Visits to the Emergency Department among Minor Head Injury Patients Tue, 05 Sep 2017 06:14:13 +0000 Study Objectives. Differences between returning and non-returning minor head injury (MHI) emergency department (ED) patients, between the characteristics of the first visit and revisit, and between admitted and nonadmitted returning patients were investigated. Methods. This was a retrospective study. All discharged ED patients with ICD-9 codes 850.0 to 850.9, 920, and 959.01 in 2013 were enrolled. Patients’ demographic data, vital signs, Glasgow Coma Scale, ED diagnosis, length of stay, triage levels, ED examinations performed, and comorbidities were recorded for analysis. Results. A total of 2,815 patients were enrolled. Of 57 (2%) patients who revisited the ED, 47 (82%) were discharged from the ED and ten (18%) were admitted to the hospital. Patients who returned to the ED were older, and they exhibited more comorbidities. Those who presented with vomiting, triage level of 1 or 2, and GCS score of <15 and who received more blood tests during their first visit were more likely to be admitted when they returned to the ED. Conclusions. Discharging MHI patients who are older or exhibit comorbidities only when symptoms and concerns are relieved completely, providing clear discharge instructions, and arranging timely clinical follow-ups may help reduce such patients’ return rate. Kuo-Cheng Wang, Chung-Hsien Chaou, Peng-Huei Liu, Cheng-Yu Chien, and Ching-Hsing Lee Copyright © 2017 Kuo-Cheng Wang et al. All rights reserved. Using a Cloud Computing System to Reduce Door-to-Balloon Time in Acute ST-Elevation Myocardial Infarction Patients Transferred for Percutaneous Coronary Intervention Wed, 16 Aug 2017 09:59:10 +0000 Background. This study evaluated the impact on clinical outcomes using a cloud computing system to reduce percutaneous coronary intervention hospital door-to-balloon (DTB) time for ST segment elevation myocardial infarction (STEMI). Methods. A total of 369 patients before and after implementation of the transfer protocol were enrolled. Of these patients, 262 were transferred through protocol while the other 107 patients were transferred through the traditional referral process. Results. There were no significant differences in DTB time, pain to door of STEMI receiving center arrival time, and pain to balloon time between the two groups. Pain to electrocardiography time in patients with Killip I/II and catheterization laboratory to balloon time in patients with Killip III/IV were significantly reduced in transferred through protocol group compared to in traditional referral process group (both ). There were also no remarkable differences in the complication rate and 30-day mortality between two groups. The multivariate analysis revealed that the independent predictors of 30-day mortality were elderly patients, advanced Killip score, and higher level of troponin-I. Conclusions. This study showed that patients transferred through our present protocol could reduce pain to electrocardiography and catheterization laboratory to balloon time in Killip I/II and III/IV patients separately. However, this study showed that using a cloud computing system in our present protocol did not reduce DTB time. Chi-Kung Ho, Fu-Cheng Chen, Yung-Lung Chen, Hui-Ting Wang, Chien-Ho Lee, Wen-Jung Chung, Cheng-Jui Lin, Shu-Kai Hsueh, Shin-Chiang Hung, Kuan-Han Wu, Chu-Feng Liu, Chia-Te Kung, and Cheng-I Cheng Copyright © 2017 Chi-Kung Ho et al. All rights reserved. Baseline Characteristics of the Paediatric Observation Priority Score in Emergency Departments outside Its Centre of Derivation Mon, 24 Jul 2017 00:00:00 +0000 Objectives and Background. Scoring systems in Emergency Departments (EDs) are rarely validated. This study aimed to examine the Paediatric Observation Priority Score (POPS), a method of quantifying patient acuity, in EDs in the United Kingdom, and determine baseline performance characteristics. Methods. POPS was implemented in 4 EDs for children (ages of 0 to 16) with participants grouped into 3 categories: discharged from ED, discharged but with return within 7 days, and admitted for less or more than 24 hours. Results. 3323 participants with POPS scores ranging from 0 to 11 (mean = 2.33) were included. The proportion of each POPS score varied between sites with approximately 10–20% being POPS 0 and 12–25% POPS greater than 4. Odds ratio of readmission with POPS 5–9 against 0–4 was 2.05 (CI 1.20 to 3.52). POPS 0–4 showed no significant difference (p = 0.93) in relation to admission/discharge rates between sites with a significant difference found (p < 0.01) for POPS > 5. Conclusion. It is feasible to implement POPS into EDs with similar performance characteristics to the original site of development. There is now evidence to support a wider health service evaluation to refine and improve the performance of POPS. Damian Roland, Fawaz Arshad, Tim Coats, and Ffion Davies Copyright © 2017 Damian Roland et al. All rights reserved. Learning and Treatment of Anaphylaxis by Laypeople: A Simulation Study Using Pupilar Technology Wed, 05 Jul 2017 00:00:00 +0000 An anaphylactic shock is a time-critical emergency situation. The decision-making during emergencies is an important responsibility but difficult to study. Eye-tracking technology allows us to identify visual patterns involved in the decision-making. The aim of this pilot study was to evaluate two training models for the recognition and treatment of anaphylaxis by laypeople, based on expert assessment and eye-tracking technology. A cross-sectional quasi-experimental simulation study was made to evaluate the identification and treatment of anaphylaxis. 50 subjects were randomly assigned to four groups: three groups watching different training videos with content supervised by sanitary personnel and one control group who received face-to-face training during paediatric practice. To evaluate the learning, a simulation scenario represented by an anaphylaxis’ victim was designed. A device capturing eye movement as well as expert valuation was used to evaluate the performance. The subjects that underwent paediatric face-to-face training achieved better and faster recognition of the anaphylaxis. They also used the adrenaline injector with better precision and less mistakes, and they needed a smaller number of visual fixations to recognise the anaphylaxis and to make the decision to inject epinephrine. Analysing the different video formats, mixed results were obtained. Therefore, they should be tested to evaluate their usability before implementation. Felipe Fernandez-Mendez, Nieves Maria Saez-Gallego, Roberto Barcala-Furelos, Cristian Abelairas-Gomez, Alexis Padron-Cabo, Alexandra Perez-Ferreiros, Carlos Garcia-Magan, Jose Moure-Gonzalez, Onofre Contreras-Jordan, and Antonio Rodriguez-Nuñez Copyright © 2017 Felipe Fernandez-Mendez et al. All rights reserved. Cardiovascular Emergencies Sun, 02 Jul 2017 08:04:04 +0000 Yu-Jun Chang, Shih-Lin Chang, Eric Chong, Kazuyoshi Suenari, and Antonios Michalopoulos Copyright © 2017 Yu-Jun Chang et al. All rights reserved. Intracranial Hematoma Detection by Near Infrared Spectroscopy in a Helicopter Emergency Medical Service: Practical Experience Thu, 22 Jun 2017 07:18:54 +0000 In (helicopter) emergency medical services, (H)EMS, the prehospital detection of intracranial hematomas should improve patient care and the triage to specialized neurosurgical hospitals. Recently, noninvasive detection of intracranial hematomas became possible by applying transcranial near infrared spectroscopy (NIRS). Herein, second-generation devices are currently available, for example, the Infrascanner 2000 (Infrascan), that appear suited also for prehospital (H)EMS applications. Since (H)EMS operations are time-critical, we studied the Infrascanner 2000 as a “first-time-right” monitor in healthy volunteers (, hospital employees, no neurologic history). Further, we studied the implementation of the Infrascanner 2000 in a European HEMS organization (Lifeliner 1, Amsterdam, The Netherlands). The principal results of our study were as follows: The screening for intracranial hematomas in healthy volunteers with first-time-right intention resulted in a marked rate of virtual hematomas (false positive results, i.e., 12/17), rendering more time consuming repeat measurements advisable. The results of the implementation of the Infrascanner in HEMS suggest that NIRS-based intracranial hematoma detection is feasible in the HEMS setting. However, some drawbacks exist and their possible solutions are discussed. Future studies will have to demonstrate how NIRS-based intracranial hematoma detection will improve prehospital decision making in (H)EMS and ultimately patient outcome. Patrick Schober, Sebastiaan M. Bossers, and Lothar A. Schwarte Copyright © 2017 Patrick Schober et al. All rights reserved. Predictors of Extracorporeal Membrane Oxygenation Support for Children with Acute Myocarditis Thu, 11 May 2017 06:36:24 +0000 The clinical presentation of acute myocarditis in children may range from asymptomatic to sudden cardiac arrest. This study analyzed the clinical spectrum of acute myocarditis in children to identify factors that could aid primary care physicians to predict the need for extracorporeal membrane oxygenation (ECMO) earlier and consult the pediatric cardiologist promptly. Between October 2011 and September 2016, we retrospectively analyzed 60 patients aged 18 years or younger who were admitted to our pediatric emergency department with a definite diagnosis of acute myocarditis. Data on demographics, presentation, laboratory tests, electrocardiogram and echocardiography findings, treatment modalities, complications, and long-term outcomes were obtained. During the study period, 60 patients (32 male, 28 female; mean age, years) were diagnosed with acute myocarditis. Fever, cough, and chest pain were the most common symptoms (68.3%, 56.7%, and 53.3%, resp.). Arrhythmia and left ventricular ejection fraction (LVEF) < 60%, vomiting, weakness, and seizure were more common in the ECMO group than in the non-ECMO group, with statistical significance (). Female sex, vomiting, weakness, seizure, arrhythmia, and echocardiography showing LVEF < 60% may predict the need for ECMO. Initial serum troponin-I cutoff values greater than 14.21 ng/mL may also indicate the need for ECMO support for children with acute myocarditis. Han-Ping Wu, Mao-Jen Lin, Wen-Chieh Yang, Kang-Hsi Wu, and Chun-Yu Chen Copyright © 2017 Han-Ping Wu et al. All rights reserved. Endotracheal Intubation Using a Direct Laryngoscope and the Protective Performances of Respirators: A Randomized Trial Thu, 27 Apr 2017 00:00:00 +0000 Purpose. Emergency physicians are at risk for infection during invasive procedures, and the respirators can reduce this risk. This study aimed to determine whether endotracheal intubation using direct laryngoscopes affected protection performances of respirators. Methods. A randomized crossover study of 24 emergency physicians was performed. We performed quantitative fit tests using respirators (cup type, fold type without a valve, and fold type with a valve) before and during intubation. The primary outcome was respirators’ fit factors (FF), and secondary outcomes were acceptable protection (percentage of scores above 100 FF [FF%]). Results. 24 pieces of data were analyzed. Compared to fold-type respirator without a valve, FF and FF% values were lower when participants wore a cup-type respirator (200 FF [200-200] versus 200 FF [102.75–200], 100% [78.61–100] versus 74.16% [36.1–98.9]; all ) or fold-type respirator with a valve (200 FF [200-200] versus 142.5 FF [63.50–200], 100% [76.10–100] versus 62.50% [8.13–100]; all ). There were no significant differences in intubation time and success rate according to respirator types. Conclusions. Motion during endotracheal intubation using direct laryngoscopes influenced the protective performance of some respirators. Therefore, emergency physicians should identify and wear respirators that provide the best personalized fit for intended tasks. Taeho Lim, Sanghyun Lee, Jaehoon Oh, Hyunggoo Kang, Chiwon Ahn, Yeongtak Song, Juncheol Lee, and Hyungoo Shin Copyright © 2017 Taeho Lim et al. All rights reserved. The Association between Door-to-Balloon Time of Less Than 60 Minutes and Prognosis of Patients Developing ST Segment Elevation Myocardial Infarction and Undergoing Primary Percutaneous Coronary Intervention Tue, 04 Apr 2017 07:13:52 +0000 Background. The study aimed to verify the effect of primary percutaneous coronary intervention (PPCI) with <60 min door-to-balloon time on ST segment elevation myocardial infarction (STEMI) patients’ prognoses. Methods. Outcomes of patients receiving PPCI with door-to-balloon time of <60 min were compared with those of patients receiving PPCI with door-to-balloon time 60–90 min. Result. Totally, 241 STEMI patients (191 with Killip classes I or II) and 104 (71 with Killip classes I or II) received PPCI with door-to-balloon time <60 and 60–90 min, respectively. Killip classes I and II patients with door-to-balloon time <60 min had better thrombolysis in myocardial infarction (TIMI) flow (9.2% fewer patients with TIMI flow <3, ) and 8.0% lower 30-day mortality rate () than those with 60–90 min. After controlling the confounding factors with logistic regression, patients with door-to-balloon time <60 min had lower incidences of TIMI flow <3 (aOR = 0.4, 95% CI = 0.20–0.76), 30-day recurrent myocardial infarction (aOR = 0.3, 95% CI = 0.10–0.91), and 30-day mortality (aOR = 0.3, 95% CI = 0.09–0.77) than those with 60–90 min. Conclusion. Door-to-balloon time <60 min is associated with better blood flow in the infarct-related artery and lower 30-day recurrent myocardial infarction and 30-day mortality rates. Fu-Cheng Chen, Yan-Ren Lin, Chia-Te Kung, Cheng-I Cheng, and Chao-Jui Li Copyright © 2017 Fu-Cheng Chen et al. All rights reserved. Can Limited Education of Lung Ultrasound Be Conducted to Medical Students Properly? A Pilot Study Tue, 28 Mar 2017 00:00:00 +0000 Objectives. Lung ultrasonography (LUS) is a useful examination to identify lung problems. Unfortunately, there are currently no LUS educational programs for medical students. We designed a brief LUS training course for medical students during the ED rotation. The purpose of training was improving cognitive and psychomotor learning domains, knowledge of ultrasound, knowledge of LUS, image acquisition, and image interpretation. Methods. Forty students in their fourth year of medical school were enrolled in this study. Student achievement was evaluated through examinations of cognitive and psychomotor skills. A survey was administered following the training. Results. The average test result was 42.1 ± 13.7 before training and 82.6 ± 10.7 after training. With respect to the assessment of LUS performance, the acceptable rates for right and left anterior chest wall scanning and right and left posterolateral scanning were 95%, 97.5%, 92.5%, and 100%, respectively. The students felt a high level of confidence in their ability to administer LUS to patients after training and they agreed that inclusion of LUS training in the medical school curriculum is necessary. Conclusion. This study showed that, among the medical students without ultrasound experience, limited LUS education to improve their knowledge, image acquisition, and interpretation ability was successful. Jang Sun Lim, Sanghun Lee, Han Ho Do, and Kyu Ho Oh Copyright © 2017 Jang Sun Lim et al. All rights reserved. Hemodynamic Analysis of Pediatric Septic Shock and Cardiogenic Shock Using Transpulmonary Thermodilution Thu, 16 Mar 2017 00:00:00 +0000 Septic shock and cardiogenic shock are the two most common types of shock in children admitted to pediatric intensive care units (PICUs). The aim of the study was to investigate which hemodynamic variables were associated with mortality in children with shock. We retrospectively analyzed 50 children with shock (37 septic shock cases and 13 cardiogenic shock cases) in the PICU and monitored their hemodynamics using transpulmonary thermodilution from 2003 to 2016. Clinical factors were analyzed between the patients with septic and cardiogenic shock. In addition, hemodynamic parameters associated with mortality were analyzed. The 28-day mortality was significantly higher in the septic group than in the cardiogenic group (). Initially, the parameters of cardiac output and cardiac contractility were higher in the septic group () while the parameters of preload and afterload were all higher in the cardiogenic group (). Cardiac index was significantly lower in the nonsurvivors of cardiogenic shock at the time of initial admission and after the first 24 hours (both ), while systemic vascular resistance index (SVRI) was significantly lower in the nonsurvivors of septic shock (). Therefore, during the first 24 hours after intensive care, SVRI and cardiac index are the most important hemodynamic parameters associated with mortality. En-Pei Lee, Shao-Hsuan Hsia, Jainn-Jim Lin, Oi-Wa Chan, Jung Lee, Chia-Ying Lin, and Han-Ping Wu Copyright © 2017 En-Pei Lee et al. All rights reserved. Public Knowledge and Attitudes towards Bystander Cardiopulmonary Resuscitation in China Tue, 07 Mar 2017 09:58:38 +0000 The rate of bystander CPR is much lower in China than in developed countries. This survey was implemented to assess the current status of layperson CPR training, to analyze the willingness of bystanders to perform CPR, and to identify barriers to improving bystander CPR rates. The questionnaire included individual information, current status of bystander CPR training, and individual’s willingness and attitude towards performing CPR. There were 25.6% laypersons who took CPR training. The majority (98.6%) of laypersons would perform CPR on their family members, but fewer laypersons (76.3%) were willing to perform CPR on strangers. Most respondents (53.2%) were worried about legal issues. If laws were implemented to protect bystanders who give aid, the number of laypersons who were not willing to perform CPR on strangers dropped from 23.7% to 2.4%. An increasing number of people in China know CPR compared with the situation in the past. CPR training in China is much less common than in many developed countries. The barriers are that laypersons are not well-trained and they fear being prosecuted for unsuccessful CPR. More accredited CPR training courses are needed in China. The laws should be passed to protect bystanders who provide assistance. Meng Chen, Yue Wang, Xuan Li, Lina Hou, Yufeng Wang, Jie Liu, and Fei Han Copyright © 2017 Meng Chen et al. All rights reserved. Clinical and Prognostic Significance of Positive Hepatojugular Reflux on Discharge in Acute Heart Failure: Insights from the ESCAPE Trial Tue, 21 Feb 2017 06:23:48 +0000 Background. There has been a decline in emphasis of the value of physical examination in heart failure (HF) with increased reliance on cardiac imaging. We aim to study the clinical and prognostic significance of positive hepatojugular reflux (HJR) on discharge in patients hospitalized with HF. Methods. Using the ESCAPE trial data, patients were compared according to the presence or absence of a positive HJR on discharge. The primary study endpoints were all-cause mortality and a composite endpoint of death, rehospitalization, and cardiac transplant during the first 6 months after discharge. Results. Among 392 patients (age: 56 years, 74% men), the HJR correlated well with clinical and objective hemodynamic markers of volume overload including right atrial pressure (RAP, ), pulmonary capillary wedge pressure (PCWP, ), and inferior vena cava size during inspiration () and expiration (). The RAP had the highest AUC for predicting a positive HJR on admission (AUC: 0.655, ) and discharge (AUC: 0.672, ). Cox’s proportional hazards analysis revealed that a positive HJR on discharge is an independent predictor of 6-month mortality (estimated hazard ratio: 1.689; 95% CI: 1.032–2.764; ) after adjusting for age, baseline creatinine, baseline hematocrit, baseline NYHA class, chronic obstructive pulmonary disease, and the presence of tricuspid regurgitation. Conclusion. The HJR should be routinely checked in patients admitted with acute HF throughout hospitalization and especially on discharge as it serves as an important prognostic marker for postdischarge outcomes. Hesham R. Omar and Maya Guglin Copyright © 2017 Hesham R. Omar and Maya Guglin. All rights reserved. Demographics and Clinical Features of Postresuscitation Comorbidities in Long-Term Survivors of Out-of-Hospital Cardiac Arrest: A National Follow-Up Study Mon, 13 Feb 2017 00:00:00 +0000 The outcome of patients suffering from out-of-hospital cardiac arrest (OHCA) is very poor, and postresuscitation comorbidities increase long-term mortality. This study aims to analyze new-onset postresuscitation comorbidities in patients who survived from OHCA for over one year. The Taiwan National Health Insurance (NHI) Database was used in this study. Study and comparison groups were created to analyze the risk of suffering from new-onset postresuscitation comorbidities from 2011 to 2012 (until December 31, 2013). The study group included 1,346 long-term OHCA survivors; the comparison group consisted of 4,038 matched non-OHCA patients. Demographics, patient characteristics, and risk of suffering comorbidities (using Cox proportional hazards models) were analyzed. We found that urinary tract infections (, 16.72%), pneumonia (, 15.30%), septicemia (, 13.67%), heart failure (, 8.25%) gastrointestinal hemorrhage (, 8.02%), epilepsy or recurrent seizures (, 7.28%), and chronic kidney disease (, 4.61%) were the most common comorbidities. Furthermore, OHCA survivors were at much higher risk (than comparison patients) of experiencing epilepsy or recurrent seizures (HR = 20.83; 95% CI: 12.24–35.43), septicemia (HR = 8.98; 95% CI: 6.84–11.79), pneumonia (HR = 5.82; 95% CI: 4.66–7.26), and heart failure (HR = 4.88; 95% CI: 3.65–6.53). Most importantly, most comorbidities occurred within the first half year after OHCA. Chih-Pei Su, Jr-Hau Wu, Mei-Chueh Yang, Ching-Hui Liao, Hsiu-Ying Hsu, Chin-Fu Chang, Shou-Jen Lan, Chiao-Lee Chu, and Yan-Ren Lin Copyright © 2017 Chih-Pei Su et al. All rights reserved. Saving the On-Scene Time for Out-of-Hospital Cardiac Arrest Patients: The Registered Nurses’ Role and Performance in Emergency Medical Service Teams Thu, 09 Feb 2017 00:00:00 +0000 For out-of-hospital cardiac arrest (OHCA) patients, every second is vital for their life. Shortening the prehospital time is a challenge to emergency medical service (EMS) experts. This study focuses on the on-scene time evaluation of the registered nurses (RNs) participating in already existing EMS teams, in order to explore their role and performance in different EMS cases. In total, 1247 cases were separated into trauma and nontrauma cases. The nontrauma cases were subcategorized into OHCA (NT-O), critical (NT-C), and noncritical (NT-NC) cases, whereas the trauma cases were subcategorized into collar-and-spinal board fixation (T-CS), fracture fixation (T-F), and general trauma (T-G) cases. The average on-scene time of RN-attended cases showed a decrease of 21.05% in NT-O, 3.28% in NT-C, 0% in NT-NC, 18.44% in T-CS, 13.56% in T-F, and 3.46% in T-G compared to non-RN-attended. In NT-O and T-CS cases, the RNs’ attendance can notably save the on-scene time with a statistical significance ( and .017, resp.). Furthermore, the return of spontaneous circulation within two hours () rate in the NT-O cases was increased by 12.86%. Based on the findings, the role of RNs in the EMTs could save the golden time in the prehospital medical care in Taiwan. Ming-Wei Lin, Che-Yu Wu, Chih-Long Pan, Zhong Tian, Jyh-Horng Wen, and Jet-Chau Wen Copyright © 2017 Ming-Wei Lin et al. All rights reserved. Can the Preoperative Serum Lactate Level Predict the Extent of Bowel Ischemia in Patients Presenting to the Emergency Department with Acute Mesenteric Ischemia? Sun, 05 Feb 2017 00:00:00 +0000 Purpose. Early recognition of acute mesenteric ischemia (AMI) can be challenging. Extensive bowel necrosis secondary to AMI is associated with high rates of mortality. The aim of this study was to investigate the association between preoperative serum lactate level and the extent of bowel ischemia in patients with AMI. Methods. Data of patients with abdominal pain and elevated serum lactate undergoing emergency laparotomy for suspected AMI within 24 hours of presentation was retrospectively abstracted. The length of the ischemic bowel segment was compared with the preoperative serum lactate level. Results. 36 female and 39 male patients, with median age 73.1 ± 12.3 years, were included for analysis. The median preoperative lactate was 2.96 ± 2.59 mmol/l in patients with ≤50 cm, 6.86 ± 4.08 mmol/l in patients with 51–100 cm, 4.73 ± 2.76 mmol/l in patients with >100 cm ischemic bowel, and 14.07 ± 4.91 mmol/l in the group with multivisceral ischemia. Conclusion. Although elevated serum lactate might permit an early suspicion and thus influence the clinical decision-making with regard to prioritization of surgery in patients with suspected AMI, a linear relationship between serum lactate and the extent of bowel ischemia could not be established in this study. Peter C. Ambe, Kai Kang, Marios Papadakis, and Hubert Zirngibl Copyright © 2017 Peter C. Ambe et al. All rights reserved. Prognostic Analysis for Cardiogenic Shock in Patients with Acute Myocardial Infarction Receiving Percutaneous Coronary Intervention Mon, 30 Jan 2017 00:00:00 +0000 Cardiogenic shock (CS) is uncommon in patients suffering from acute myocardial infarction (AMI). Long-term outcome and adverse predictors for outcomes in AMI patients with CS receiving percutaneous coronary interventions (PCI) are unclear. A total of 482 AMI patients who received PCI were collected, including 53 CS and 429 non-CS. Predictors for AMI patients with CS including recurrent MI, cardiovascular (CV) mortality, all-cause mortality, and repeated-PCI were analyzed. The CS group had a lower central systolic pressure and central diastolic pressure (both ). AMI patients with hypertension history were less prone to develop CS (). Calcium channel blockers and statins were less frequently used by the CS group than the non-CS group (both ) after discharge. Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score, CV mortality, and all-cause mortality were higher in the CS group than the non-CS group (all ). For patients with CS, stroke history was a predictor of recurrent MI (). CS, age, SYNTAX score, and diabetes were predictors of CV mortality (all ). CS, age, SYNTAX score, and stroke history were predictors for all-cause mortality (all ). CS, age, and current smoking were predictors for repeated-PCI (all ). Mao-Jen Lin, Chun-Yu Chen, Hau-De Lin, and Han-Ping Wu Copyright © 2017 Mao-Jen Lin et al. All rights reserved. Shock, Cardiac Arrest, and Resuscitation Tue, 03 Jan 2017 00:00:00 +0000 Yan-Ren Lin, Kee-Chong Ng, Aristomenis K. Exadaktylos, John M. Ryan, and Han-Ping Wu Copyright © 2017 Yan-Ren Lin et al. All rights reserved. Remote Postconditioning Alone and Combined with Hypothermia Improved Postresuscitation Cardiac and Neurological Outcomes in Swine Tue, 20 Dec 2016 14:34:39 +0000 Objective. Previously, we demonstrated that remote ischemic postconditioning (RIpostC) improved postresuscitation myocardial and cerebral functions in rat. Here, we investigated the effects of RIpostC alone and combined with therapeutic hypothermia (TH) on cardiac and neurological outcomes after CPR in swine. Methods. Twenty-one pigs were subjected to 10 mins of VF and then 5 mins of CPR. The animals were randomized to receive RIpostC alone, or its combination with TH, or sham control. RIpostC was induced by 4 cycles of limb ischemia followed by reperfusion. TH was implemented by surface cooling to reach a temperature of 32–34°C. Results. During 72 hrs after resuscitation, lower level of cardiac troponin I and greater stroke volume and global ejection fraction were observed in animals that received RIpostC when compared to the control. RIpostC also decreased serum levels of neuron-specific enolase and S100B and increased neurologic alertness score after resuscitation. The combination of RIpostC and TH resulted in greater improvement in cardiac and neurological outcomes than RIpostC alone. Conclusion. RIpostC was conducive to improving postresuscitation myocardial and cerebral functions and reducing their organ injuries. Its combination with TH further enhanced its protective effects. Jiefeng Xu, Zeng Huang, Sen Ye, Moli Wang, Ya Fang, and Zilong Li Copyright © 2016 Jiefeng Xu et al. All rights reserved. Early Administration of Glutamine Protects Cardiomyocytes from Post-Cardiac Arrest Acidosis Mon, 12 Dec 2016 11:17:42 +0000 Postcardiac arrest acidosis can decrease survival. Effective medications without adverse side effects are still not well characterized. We aimed to analyze whether early administration of glutamine could improve survival and protect cardiomyocytes from postcardiac arrest acidosis using animal and cell models. Forty Wistar rats with postcardiac arrest acidosis (blood pH < 7.2) were included. They were divided into study (500 mg/kg L-alanyl-L-glutamine, ) and control (normal saline, ) groups. Each of the rats received resuscitation. The outcomes were compared between the two groups. In addition, cardiomyocytes derived from human induced pluripotent stem cells were exposed to HBSS with different pH levels (7.3 or 6.5) or to culture medium (control). Apoptosis-related markers and beating function were analyzed. We found that the duration of survival was significantly longer in the study group (). In addition, in pH 6.5 or pH 7.3 HBSS buffer, the expression levels of cell stress (p53) and apoptosis (caspase-3, Bcl-xL) markers were significantly lower in cardiomyocytes treated with 50 mM L-glutamine than those without L-glutamine (RT-PCR). L-glutamine also increased the beating function of cardiomyocytes, especially at the lower pH level (6.5). More importantly, glutamine decreased cardiomyocyte apoptosis and increased these cells’ beating function at a low pH level. Yan-Ren Lin, Chao-Jui Li, Shih-Han Syu, Cheng-Hao Wen, Waradee Buddhakosai, Han-Ping Wu, Cheng Hsu Chen, Huai-En Lu, and Wen-Liang Chen Copyright © 2016 Yan-Ren Lin et al. All rights reserved. A Feasibility Study for Measuring Accurate Chest Compression Depth and Rate on Soft Surfaces Using Two Accelerometers and Spectral Analysis Thu, 24 Nov 2016 09:41:54 +0000 Background. Cardiopulmonary resuscitation (CPR) feedback devices are being increasingly used. However, current accelerometer-based devices overestimate chest displacement when CPR is performed on soft surfaces, which may lead to insufficient compression depth. Aim. To assess the performance of a new algorithm for measuring compression depth and rate based on two accelerometers in a simulated resuscitation scenario. Materials and Methods. Compressions were provided to a manikin on two mattresses, foam and sprung, with and without a backboard. One accelerometer was placed on the chest and the second at the manikin’s back. Chest displacement and mattress displacement were calculated from the spectral analysis of the corresponding acceleration every 2 seconds and subtracted to compute the actual sternal-spinal displacement. Compression rate was obtained from the chest acceleration. Results. Median unsigned error in depth was 2.1 mm (4.4%). Error was 2.4 mm in the foam and 1.7 mm in the sprung mattress (). Error was 3.1/2.0 mm and 1.8/1.6 mm with/without backboard for foam and sprung, respectively (). Median error in rate was 0.9 cpm (1.0%), with no significant differences between test conditions. Conclusion. The system provided accurate feedback on chest compression depth and rate on soft surfaces. Our solution compensated mattress displacement, avoiding overestimation of compression depth when CPR is performed on soft surfaces. Sofía Ruiz de Gauna, Digna M. González-Otero, Jesus Ruiz, J. J. Gutiérrez, and James K. Russell Copyright © 2016 Sofía Ruiz de Gauna et al. All rights reserved. Teaching Life-Saving Manoeuvres in Primary School Sun, 13 Nov 2016 13:17:56 +0000 Introduction. In the event of sudden cardiac arrest (SCA) early intervention provided by a layperson can be life-saving. Teaching first aid in primary school may increase the lifelong ability and motivation of young people to take action in an emergency. Objective. The aim of this article is to report a training experience on BLSD (Basic Life Support and Defibrillation) designed for a group of pupils in an Italian primary school, with assessment of its effectiveness at a distance. Methods. The assessment was carried out using a multiple choice questionnaire on a sample of 130 pupils aged 11-12, 62 trained in BLSD and 68 as a control group. The trained group also performed an emergency simulation to assess their learning of practical skills. Results. Using the test, significant differences emerged in the questionnaire scores between the case-control group. The results of the skill test were positive, even for the most difficult manoeuvres such as opening airways, assessing breathing, or using an AED (Automated External Defibrillator). Conclusion. Although there are still some open questions regarding the ability to retain these skills in the medium/long term, the study shows that life-saving manoeuvres can be effectively taught to primary school pupils. Sara Calicchia, Giovanna Cangiano, Silvia Capanna, Mariangela De Rosa, and Bruno Papaleo Copyright © 2016 Sara Calicchia et al. All rights reserved. Ventricular Fibrillation-Induced Cardiac Arrest Results in Regional Cardiac Injury Preferentially in Left Anterior Descending Coronary Artery Territory in Piglet Model Wed, 02 Nov 2016 07:05:44 +0000 Objective. Decreased cardiac function after resuscitation from cardiac arrest (CA) results from global ischemia of the myocardium. In the evolution of postarrest myocardial dysfunction, preferential involvement of any coronary arterial territory is not known. We hypothesized that there is no preferential involvement of any coronary artery during electrical induced ventricular fibrillation (VF) in piglet model. Design. Prospective, randomized controlled study. Methods. 12 piglets were randomized to baseline and electrical induced VF. After 5 min, the animals were resuscitated according to AHA PALS guidelines. After return of spontaneous circulation (ROSC), animals were observed for an additional 4 hours prior to cardiac MRI. Data (mean ± SD) was analyzed using unpaired t-test; value ≤ 0.05 was considered statistically significant. Results. Segmental wall motion (mm; baseline versus postarrest group) in segment 7 (left anterior descending (LAD)) was versus , . In segment 13, it was versus , . In segment 14, it was versus , . Conclusion. Postarrest myocardial dysfunction resulted in segmental wall motion defects in the LAD territory. There were no perfusion defects in the involved segments. Giridhar Kaliki Venkata, John R. Forder, Dan Clark, Andre Shih, Sharda Udassi, Srinivasarao Badugu, Melissa A. Lamb, Stacy L. Porvasnik, Renata S. Shih, Dalia Colon-Lopez, Arno L. Zaritsky, Ikram U. Haque, and Jai P. Udassi Copyright © 2016 Giridhar Kaliki Venkata et al. All rights reserved. Effect of Erythropoietin on Postresuscitation Renal Function in a Swine Model of Ventricular Fibrillation Tue, 25 Oct 2016 05:51:09 +0000 Purpose. To investigate the effect of EPO administration on postresuscitation renal function. Methods. Twenty-four female Landrace/Large-White piglets aged 10–15 weeks with average weight of  kg were randomly assigned to 2 different groups of 12 subjects each. After the end of an 8-minute ventricular fibrillation, the control group (Group C) received saline as placebo, whereas the EPO group (Group E) received EPO 5000 U/kg. The animals were resuscitated according to the 2010 European Resuscitation Council Guidelines for Resuscitation. Results. Five animals (41.67%) from Group C and 11 animals (91.67%) from Group E achieved ROSC (). Eight animals (66.67%, 5 surviving and 3 nonsurviving) from Group C suffered severe kidney damage or AKI compared to animals from Group E, in which none of the swine had evidence of severe kidney damage or AKI (). There was a statistically significant difference in all tested biochemical markers between the two groups, as well as a positive correlation of creatinine with NGAL, L-FABP, and IL-18 (summed mean values’ , 0.01, and 0.004, resp.). Conclusions. Administration of EPO protected swine from postresuscitation acute kidney injury. Charalampos Pantazopoulos, Nicoletta Iacovidou, Evangelia Kouskouni, Paraskevi Pliatsika, Apostolos Papalois, Georgios Kaparos, Dimitrios Barouxis, Panagiotis Vasileiou, Pavlos Lelovas, Olympia Kotsilianou, Ioannis Pantazopoulos, Georgios Gkiokas, Clara Garosa, Gavino Faa, and Theodoros Xanthos Copyright © 2016 Charalampos Pantazopoulos et al. All rights reserved. Could Mean Platelet Volume Be a Reliable Indicator for Acute Mesenteric Ischemia Diagnosis? A Case-Control Study Tue, 11 Oct 2016 08:09:19 +0000 Objective. Acute mesenteric ischemia (AMI) is a disease, usually seen in elderly people and accompanied by comorbid diseases. Mean platelet volume (MPV), the significant indicator of platelet activation and function, is associated with AMI. In this study, we considered that we can use MPV as a reliable indicator in the diagnosis of AMI. Methods. This study was conducted among AMI patients with two control groups. Age, gender, MPV, platelet count, concomitant diseases, abdominal computed tomography, and patient outcomes were recorded for evaluation. Control group I contained 41 healthy patients whose ages-genders were matched. Control group II contained 41 patients with no AMI, whose ages-genders-concomitant diseases were matched. Results. Of the total 41 AMI patients, 22 were female and 19 were male. The average age of them was (44–91) years. MPV was significantly increased in the AMI () and control group II () in comparison with healthy control groups. In the comparison of the AMI patients with their matched controls for concomitant diseases, no statistical difference was found in the MPV values. Conclusion. MPV may be used as an indicator of AMI only if the patient has no concomitant diseases. The existence of a concomitant disease brings into question the reliability of high MPV values as a suitable indicator. Vermi Degerli, Isil Ergin, Fulya Yilmaz Duran, Mehmet Akif Ustuner, and Ozgur Duran Copyright © 2016 Vermi Degerli et al. All rights reserved. The Prognosis of Cardiac Origin and Noncardiac Origin in-Hospital Cardiac Arrest Occurring during Night Shifts Tue, 27 Sep 2016 11:22:36 +0000 Background. The survival rates of in-hospital cardiac arrests (IHCAs) are reportedly low at night, but the difference between the survival rates of cardiac origin and noncardiac origin IHCAs occurring at night remains unclear. Methods. Outcomes of IHCAs during different shifts (night, day, and evening) were compared and stratified according to the etiology (cardiac and noncardiac origin). Result. The rate of return of spontaneous circulation (ROSC) was 24.7% lower for cardiac origin IHCA and 19.4% lower for noncardiac origin IHCA in the night shift than in the other shifts. The survival rate was 8.4% lower for cardiac origin IHCA occurring during the night shift, but there was no difference for noncardiac origin IHCA. After adjusting the potential confounders, chances of ROSC (aOR: 0.3, CI: 0.15–0.63) and survival to discharge (aOR: 0.1; CI: 0.01–0.90) related to cardiac origin IHCA were lower during night shifts. Regarding noncardiac origin IHCA, chances of ROSC (aOR: 0.5, CI: 0.30–0.78) were lower in the night shift, but chances of survival to discharge (aOR: 1.3, CI: 0.43–3.69) were similar in these two groups. Conclusion. IHCA occurring at night increases mortality, and this is more apparent for cardiac origin IHCAs than for noncardiac origin IHCA. Yuan-Jhen Syue, Jyun-Bin Huang, Fu-Jen Cheng, Chia-Te Kung, and Chao-Jui Li Copyright © 2016 Yuan-Jhen Syue et al. All rights reserved. Comparing McGRATH® MAC, C-MAC®, and Macintosh Laryngoscopes Operated by Medical Students: A Randomized, Crossover, Manikin Study Thu, 15 Sep 2016 12:23:10 +0000 We hypothesized that the McGRATH MAC would decrease the time of intubation compared to C-MAC for novices. Thirty-nine medical students who had used the Macintosh blade to intubate a manikin fewer than 3 times were recruited. The participants performed sequential intubations on the manikin in two simulated settings that included a normal airway and a difficult airway (tongue edema). The intubation time, success rate of intubation, Cormack-Lehane grade at laryngoscopy, and difficulty using the device were recorded. Each participant was asked to identify the device that was most useful. The intubation time decreased significantly and by a similar amount to the McGRATH MAC and C-MAC compared to the Macintosh blade ( and , resp.). In the difficult airway, the intubation times were similar among the three devices. The McGRATH MAC and C-MAC significantly increased the success rate of intubation, improved the Cormack-Lehane grade, and decreased the difficulty score compared to the Macintosh blade in both airway settings. The majority of participants selected the McGRATH MAC as the most useful device. The McGRATH MAC and C-MAC may offer similar benefits for intubation compared to the Macintosh blade in normal and difficult airway situations. Myungju Shin, Sun Joon Bai, Ki-Young Lee, Ein Oh, and Hyun Joo Kim Copyright © 2016 Myungju Shin et al. All rights reserved. Evaluation of Smartphone Applications for Cardiopulmonary Resuscitation Training in South Korea Wed, 07 Sep 2016 16:47:59 +0000 Objective. There are many smartphone-based applications (apps) for cardiopulmonary resuscitation (CPR) training. We investigated the conformity and the learnability/usability of these apps for CPR training and real-life supports. Methods. We conducted a mixed-method, sequential explanatory study to assess CPR training apps downloaded on two apps stores in South Korea. Apps were collected with inclusion criteria as follows, Korean-language instruction, training features, and emergency supports for real-life incidents, and analyzed with two tests; 15 medical experts evaluated the apps’ contents according to current Basic Life Support guidelines in conformity test, and 15 nonmedical individuals examined the apps using System Usability Scale (SUS) in the learnability/usability test. Results. Out of 79 selected apps, five apps were included and analyzed. For conformity (ICC, 0.95, ), means of all apps were greater than 12 of 20 points, indicating that they were well designed according to current guidelines. Three of the five apps yielded acceptable level (greater than 68 of 100 points) for learnability/usability. Conclusion. All the included apps followed current BLS guidelines and a majority offered acceptable learnability/usability for layperson. Current and developmental smartphone-based CPR training apps should include accurate CPR information and be easy to use for laypersons that are potential rescuers in real-life incidents. For Clinical Trials. This is a clinical trial, registered at the Clinical Research Information Service (CRIS,, number KCT0001840. Chiwon Ahn, Yongtak Cho, Jaehoon Oh, Yeongtak Song, Tae Ho Lim, Hyunggoo Kang, and Juncheol Lee Copyright © 2016 Chiwon Ahn et al. All rights reserved. DARE Train-the-Trainer Pedagogy Development Using 2-Round Delphi Methodology Wed, 31 Aug 2016 06:17:35 +0000 The Dispatcher-Assisted first REsponder programme aims to equip the public with skills to perform hands-only cardiopulmonary resuscitation (CPR) and to use an automated external defibrillator (AED). By familiarising them with instructions given by a medical dispatcher during an out-of-hospital cardiac arrest call, they will be prepared and empowered to react in an emergency. We aim to formalise curriculum and standardise the way information is conveyed to the participants. A panel of 20 experts were chosen. Using Delphi methodology, selected issues were classified into open-ended and close-ended questions. Consensus for an item was established at a 70% agreement rate within the panel. Questions that had 60%–69% agreement were edited and sent to the panel for another round of voting. After 2 rounds of voting, 70 consensus statements were agreed upon. These covered the following: focus of CPR; qualities and qualifications of trainers; recognition of agonal breathing; head-tilt-chin lift; landmark for chest compression; performance of CPR when injuries are present; trainers’ involvement in training lay people; modesty of female patients during CPR; AED usage; content of trainer’s manual; addressing of questions and answers; updates-dissemination to trainers and attendance of refresher courses. Recommendations for pedagogy for trainers of dispatcher-assisted CPR programmes were developed. Wei Wei Dayna Yong, Phek Hui Jade Kua, Swee Sung Soon, Pin Pin Maeve Pek, and Marcus Eng Hock Ong Copyright © 2016 Wei Wei Dayna Yong et al. All rights reserved. Insertion Success of the Laryngeal Tube in Emergency Airway Management Wed, 24 Aug 2016 17:59:23 +0000 Background. Emergency airway management (AM) is a priority when resuscitating critically ill or severely injured patients. The goal of this study was to determine the success rates of LT insertion during AM. Methods. Studies that included LT first-pass insertion (FPI) and overall-pass insertion (OPI) success by emergency medical services and in-hospital providers performing AM for emergency situations as well as for scheduled surgery published until July 2014 were searched systematically in Medline. Results. Data of 36 studies ( = 1,897) reported a LT FPI success by physicians of 82.5% with an OPI success of 93.6% (). A cumulative analysis of all 53 studies ( = 3,600) led to FPI and OPI success of 80.1% and 92.6% (), respectively. The results of 26 studies ( = 2,159) comparing the LT with the laryngeal mask airway (LMA) demonstrated a FPI success of 77.0 versus 78.7% () and an OPI success of 92.2 versus 97.7% (). Conclusion. LT insertion failed in the first attempt in one out of five patients, with an overall failure rate in one out of 14 patients. When compared with the LT, the LMA had a cumulative 5.5% better OPI success rate. Michael Bernhard, André Gries, Alexandra Ramshorn-Zimmer, Volker Wenzel, and Bjoern Hossfeld Copyright © 2016 Michael Bernhard et al. All rights reserved. Hypotensive Resuscitation among Trauma Patients Tue, 09 Aug 2016 13:01:56 +0000 Hemorrhagic shock is a principal cause of death among trauma patients within the first 24 hours after injury. Optimal fluid resuscitation strategies have been examined for nearly a century, more recently with several randomized controlled trials. Hypotensive resuscitation, also called permissive hypotension, is a resuscitation strategy that uses limited fluids and blood products during the early stages of treatment for hemorrhagic shock. A lower-than-normal blood pressure is maintained until operative control of the bleeding can occur. The randomized controlled trials examining restricted fluid resuscitation have demonstrated that aggressive fluid resuscitation in the prehospital and hospital setting leads to more complications than hypotensive resuscitation, with disparate findings on the survival benefit. Since the populations studied in each randomized controlled trial are slightly different, as is the timing of intervention and targeted vitals, there is still a need for a large, multicenter trial that can examine the benefit of hypotensive resuscitation in both blunt and penetrating trauma patients. Matthew M. Carrick, Jan Leonard, Denetta S. Slone, Charles W. Mains, and David Bar-Or Copyright © 2016 Matthew M. Carrick et al. All rights reserved. The Effect of the Duration of Basic Life Support Training on the Learners’ Cardiopulmonary and Automated External Defibrillator Skills Wed, 27 Jul 2016 08:34:31 +0000 Background. Basic life support (BLS) training with hands-on practice can improve performance during simulated cardiac arrest, although the optimal duration for BLS training is unknown. This study aimed to assess the effectiveness of various BLS training durations for acquiring cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) skills. Methods. We randomised 485 South Korean nonmedical college students into four levels of BLS training: level 1 (40 min), level 2 (80 min), level 3 (120 min), and level 4 (180 min). Before and after each level, the participants completed questionnaires regarding their willingness to perform CPR and use AEDs, and their psychomotor skills for CPR and AED use were assessed using a manikin with Skill-Reporter™ software. Results. There were no significant differences between levels 1 and 2, although levels 3 and 4 exhibited significant differences in the proportion of overall adequate chest compressions () and average chest compression depth (). All levels exhibited a greater posttest willingness to perform CPR and use AEDs (all, ). Conclusions. Brief BLS training provided a moderate level of skill for performing CPR and using AEDs. However, high-quality skills for CPR required longer and hands-on training, particularly hands-on training with AEDs. Jin Hyuck Lee, Youngsuk Cho, Ku Hyun Kang, Gyu Chong Cho, Keun Jeong Song, and Chang Hee Lee Copyright © 2016 Jin Hyuck Lee et al. All rights reserved. Cardiopulmonary Resuscitation Pattern Evaluation Based on Ensemble Empirical Mode Decomposition Filter via Nonlinear Approaches Tue, 26 Jul 2016 15:45:40 +0000 Good quality cardiopulmonary resuscitation (CPR) is the mainstay of treatment for managing patients with out-of-hospital cardiac arrest (OHCA). Assessment of the quality of the CPR delivered is now possible through the electrocardiography (ECG) signal that can be collected by an automated external defibrillator (AED). This study evaluates a nonlinear approximation of the CPR given to the asystole patients. The raw ECG signal is filtered using ensemble empirical mode decomposition (EEMD), and the CPR-related intrinsic mode functions (IMF) are chosen to be evaluated. In addition, sample entropy (SE), complexity index (CI), and detrended fluctuation algorithm (DFA) are collated and statistical analysis is performed using ANOVA. The primary outcome measure assessed is the patient survival rate after two hours. CPR pattern of 951 asystole patients was analyzed for quality of CPR delivered. There was no significant difference observed in the CPR-related IMFs peak-to-peak interval analysis for patients who are younger or older than 60 years of age, similarly to the amplitude difference evaluation for SE and DFA. However, there is a difference noted for the CI (). The results show that patients group younger than 60 years have higher survival rate with high complexity of the CPR-IMFs amplitude differences. Muammar Sadrawi, Wei-Zen Sun, Matthew Huei-Ming Ma, Chun-Yi Dai, Maysam F. Abbod, and Jiann-Shing Shieh Copyright © 2016 Muammar Sadrawi et al. All rights reserved. Elderly and Nonelderly Use of a Dedicated Ambulance Corps’ Emergency Medical Services in Taiwan Mon, 11 Jul 2016 11:29:05 +0000 Backgrounds and Aim. Taiwan’s population is gradually aging; however, there are no comparative data on emergency medical services (EMS) use between the elderly and nonelderly. Methods. We analyzed the emergency calls dealt with between January 1 and April 4, 2014, by EMS in one city in Taiwan. All calls were divided into two groups: elderly (≥65 years) and nonelderly (<65 years). Nontransport and transport calls were compared between the groups for demographic characteristics, transport time, reasons for calling EMS, vital signs, and emergency management. Results. There were 1,001 EMS calls: 226 nontransport and 775 transport calls. The elderly accounted for significantly () fewer (28 (9.2%)) nontransport calls than did the nonelderly (136 (21.4%)). In the transport calls, 276 (35.6%) were the elderly. The elderly had a higher proportion of histories for cardiovascular disease, cerebrovascular disease, hypertension, diabetes, end-stage renal disease, cancer, Parkinson’s disease, and Alzheimer’s disease. In addition, the elderly had significantly longer total transport time, more nontrauma reasons, and poorer consciousness levels and lower oxygen saturation and needed more respiratory management and more frequent resuscitation during transport than did the nonelderly. Conclusion. The elderly have more specific needs than do the nonelderly. Adapting EMS training, operations, and government policies to aging societies is mandatory and should begin now. Chien-Chia Huang, Wei-Lung Chen, Chien-Chin Hsu, Hung-Jung Lin, Shih-Bin Su, How-Ran Guo, Chien-Cheng Huang, and Pi-Ching Chen Copyright © 2016 Chien-Chia Huang et al. All rights reserved. Evaluation of Potential Clinical Surrogate Markers of a Trauma Induced Alteration of Clotting Factor Activities Tue, 28 Jun 2016 07:00:07 +0000 Objective. The aim of this study was to identify routinely available clinical surrogate markers for potential clotting factor alterations following multiple trauma. Methods. In 68 patients admitted directly from the scene of the accident, all soluble clotting factors were analyzed and clinical data was collected prospectively. Ten healthy subjects served as control group. Results. Patients showed reduced activities of clotting factors II, V, VII, and X and calcium levels (all to 0.01). Levels of hemoglobin and base deficit correlated moderately to highly with the activities of a number of clotting factors. Nonsurvivors and patients who needed preclinical intubation or hemostatic therapy showed significantly reduced factor activities at admission. In contrast, factor VIII activity was markedly elevated after injury in general (), but reduced in nonsurvivors (). Conclusions. Multiple trauma causes an early reduction of the activities of nearly all soluble clotting factors in general. Initial hemoglobin and, with certain qualifications, base deficit levels demonstrated a potential value in detecting those underlying clotting factor deficiencies. Nevertheless, their role as triggers of a hemostatic therapy as well as the observed response of factor VIII to multiple trauma and also its potential prognostic value needs further evaluation. Manuel Burggraf, Arzu Payas, Carsten Schoeneberg, Alexander Wegner, Max Daniel Kauther, and Sven Lendemans Copyright © 2016 Manuel Burggraf et al. All rights reserved. Acute Aortic Dissection Biomarkers Identified Using Isobaric Tags for Relative and Absolute Quantitation Wed, 15 Jun 2016 09:15:56 +0000 The purpose of this study was to evaluate the utility of potential serum biomarkers for acute aortic dissection (AAD) that were identified by isobaric Tags for Relative and Absolute Quantitation (iTRAQ) approaches. Serum samples from 20 AAD patients and 20 healthy volunteers were analyzed using iTRAQ technology. Protein validation was performed using samples from 120 patients with chest pain. A total of 355 proteins were identified with the iTRAQ approach; 164 proteins reached the strict quantitative standard, and 125 proteins were increased or decreased more than 1.2-fold (64 and 61 proteins were up- and downregulated, resp.). Lumican, C-reactive protein (CRP), thrombospondin-1 (TSP-1), and D-dimer were selected as candidate biomarkers for the validation tests. Receiver operating characteristic (ROC) curves show that Lumican and D-dimer have diagnostic value (area under the curves [AUCs] 0.895 and 0.891, ). For Lumican, the diagnostic sensitivity and specificity were 73.33% and 98.33%, while the corresponding values for D-dimer were 93.33% and 68.33%. For Lumican and D-dimer AAD combined diagnosis, the sensitivity and specificity were 88.33% and 95%, respectively. In conclusion, Lumican has good specificity and D-dimer has good sensitivity for the diagnosis of AAD, while the combined detection of D-dimer and Lumican has better diagnostic value. Ziya Xiao, Yuan Xue, Chenling Yao, Guorong Gu, Yaping Zhang, Jin Zhang, Fan Fan, Xiao Luan, Zhi Deng, Zhengang Tao, Zhen-ju Song, Chaoyang Tong, and Haojun Wang Copyright © 2016 Ziya Xiao et al. All rights reserved. Assessment of Diagnostic and Prognostic Role of Copeptin in the Clinical Setting of Sepsis Mon, 06 Jun 2016 08:50:58 +0000 The diagnostic and prognostic usefulness of copeptin were evaluated in septic patients, as compared to procalcitonin assessment. In this single centre and observational study 105 patients were enrolled: 24 with sepsis, 25 with severe sepsis, 15 with septic shock, and 41 controls, divided in two subgroups (15 patients with gastrointestinal bleeding and 26 with suspected SIRS secondary to trauma, acute coronary syndrome, and pulmonary embolism). Biomarkers were determined at the first medical evaluation and thereafter 24, 48, and 72 hours after admission. Definitive diagnosis and in-hospital survival rates at 30 days were obtained through analysis of medical records. At entry, copeptin proved to be able to distinguish cases from controls and also sepsis group from septic shock group, while procalcitonin could distinguish also severe sepsis from septic shock group. Areas under the ROC curve for copeptin and procalcitonin were 0.845 and 0.861, respectively. Noteworthy, patients with copeptin concentrations higher than the threshold value (23.2 pmol/L), calculated from the ROC curve, at admission presented higher 30-day mortality. No significant differences were found in copeptin temporal profile among different subgroups. Copeptin showed promising diagnostic and prognostic role in the management of sepsis, together with its possible role in monitoring the response to treatment. Stefania Battista, Umberto Audisio, Claudia Galluzzo, Matteo Maggiorotto, Monica Masoero, Daniela Forno, Elisa Pizzolato, Marco Ulla, Manuela Lucchiari, Annarita Vitale, Corrado Moiraghi, Enrico Lupia, Fabio Settanni, and Giulio Mengozzi Copyright © 2016 Stefania Battista et al. All rights reserved. Evaluation of Bag-Valve-Mask Ventilation in Manikin Studies: What Are the Current Limitations? Mon, 16 May 2016 13:26:04 +0000 Introduction. Manikin-based studies for evaluation of ventilation performance show high heterogeneity in the analysis and experimental methods used as we pointed out in previous studies. In this work, we aim to evaluate these potential limitations and propose a new analysis methodology to reliably assess ventilation performance. Methods. One hundred forty healthcare providers were selected to ventilate a manikin with two adult self-inflating bags in random order. Ventilation parameters were analysed using different published analysis methods compared to ours. Results. Using different methods impacts the evaluation of ventilation efficiency which ranges from 0% to 45.71%. Our new method proved relevant and showed that all professionals tend to cause hyperventilation and revealed a significant relationship between professional category, grip strength of the hand keeping the mask, and ventilation performance ( and , resp.). Conclusion. Using adequate analysis methods is crucial to avoid many biases. Extrapolations to humans still have to be taken with caution as many factors impact the evaluation of ventilation performance. Healthcare professionals tend to cause hyperventilation with current devices. We believe this problem could be prevented by implementing monitoring tools in order to give direct feedback to healthcare professionals regarding ventilation efficiency and ventilatory parameter values. A. Khoury, F. S. Sall, A. De Luca, A. Pugin, S. Pili-Floury, L. Pazart, and G. Capellier Copyright © 2016 A. Khoury et al. All rights reserved. Serum Procalcitonin and Procalcitonin Clearance as a Prognostic Biomarker in Patients with Severe Sepsis and Septic Shock Sun, 20 Mar 2016 14:16:16 +0000 We evaluated the tendency of the plasma concentration and procalcitonin (PCT) clearance (PCTc) to act as biomarkers of prognosis in patients with severe sepsis and septic shock. From 2011 to 2013, we prospectively analyzed patients with sepsis admitted to the intensive care unit (ICU). The serum PCT was evaluated at the time of sepsis diagnosis and again after 48 h (day 3) and 96 h (day 5). PCTc after 48 h (PCTc-day 3) and 96 h (PCTc-day 5) was also calculated to evaluate the prognostic value for survival in patients with sepsis. A total of 48 patients were included. Overall mortality was 16.7% (8 patients). PCTc was higher in survivors than in nonsurvivors, with significant differences on day 3 and day 5 (; , resp.); however, serum PCT levels on day 1, day 3, and day 5 were not significant prognostic factors for survival. The prognosis of patients with severe sepsis and septic shock may be associated with PCTc. Dynamic changes of PCT reflected as PCTc at 48 h (day 3) and 96 h (day 5) after admission to the ICU may serve as a predictor of survival in critically ill patients with severe sepsis. Min-Yi Huang, Chun-Yu Chen, Ju-Huei Chien, Kun-Hsi Wu, Yu-Jun Chang, Kang-Hsi Wu, and Han-Ping Wu Copyright © 2016 Min-Yi Huang et al. All rights reserved. Role of Extracranial Carotid Duplex and Computed Tomography Perfusion Scanning in Evaluating Perfusion Status of Pericarotid Stenting Tue, 08 Mar 2016 11:47:08 +0000 Carotid stenting is an effective treatment of choice in terms of treating ischemic stroke patients with concomitant carotid stenosis. Though computed tomography perfusion scan has been recognized as a standard tool to monitor/follow up this group of patients, not everyone could endure due to underlying medical illness. In contrast, carotid duplex is a noninvasive assessment tool and could track patient clinical condition in real time. In this study we found that “resistance index” of the carotid ultrasound could detect flow changes before and after the stenting procedure, thus having great capacity to replace the role of computed tomography perfusion exam. Chih-Ming Lin, Yu-Jun Chang, Chi-Kuang Liu, Cheng-Sheng Yu, and Henry Horng-Shing Lu Copyright © 2016 Chih-Ming Lin et al. All rights reserved. Airway Management with Cervical Spine Immobilisation: A Comparison between the Macintosh Laryngoscope, Truview Evo2, and Totaltrack VLM Used by Novices—A Manikin Study Mon, 29 Feb 2016 08:37:41 +0000 Airway management in patients with suspected cervical spine injury plays an important role in the pathway of care of trauma patients. The aim of this study was to evaluate three different airway devices during intubation of a patient with reduced cervical spine mobility. Forty students of the third year of emergency medicine studies participated in the study (, ). The time required to obtain a view of the entry to the larynx and successful ventilation time were recorded. Cormack-Lehane laryngoscopic view and damage to the incisors were also assessed. All three airway devices were used by each student (a novice) and they were randomly chosen. The mean time required to obtain the entry-to-the-larynx view was the shortest for the Macintosh laryngoscope 13.4 s (±2.14). Truview Evo2 had the shortest successful ventilation time 35.7 s (±9.27). The best view of the entry to the larynx was obtained by the Totaltrack VLM device. The Truview Evo2 and Totaltrack VLM may be an alternative to the classic Macintosh laryngoscope for intubation of trauma patients with suspected injury to the cervical spine. The use of new devices enables achieving better laryngoscopic view as well as minimising incisor damage during intubation. Dawid Aleksandrowicz and Tomasz Gaszyński Copyright © 2016 Dawid Aleksandrowicz and Tomasz Gaszyński. All rights reserved. G-CSF Administration after the Intraosseous Infusion of Hypertonic Hydroxyethyl Starches Accelerating Wound Healing Combined with Hemorrhagic Shock Wed, 17 Feb 2016 09:26:52 +0000 Objective. To evaluate the therapeutic effects of G-CSF administration after intraosseous (IO) resuscitation in hemorrhagic shock (HS) combined with cutaneous injury rats. Methods. The rats were randomly divided into four groups: (1) HS with resuscitation (blank), (2) HS with resuscitation + G-CSF (G-CSF, 200 μg/kg body weight, subcutaneous injection), (3) HS with resuscitation + normal saline solution injection (normal saline), and (4) HS + G-CSF injection without resuscitation (Unres/G-CSF). To estimate the treatment effects, the vital signs of alteration were first evaluated, and then wound closure rates and homing of MSCs and EPCs to the wound skins and vasculogenesis were measured. Besides, inflammation and vasculogenesis related mRNA expressions were also examined. Results. IO infusion hypertonic hydroxyethyl starch (HHES) exhibited beneficial volume expansion roles and G-CSF administration accelerated wound healing 3 days ahead of other groups under hemorrhagic shock. Circulating and the homing of MSCs and EPCs at wound skins were significantly elevated at 6 h after G-CSF treatment. Inflammation was declined since 3 d while angiogenesis was more obvious in G-CSF treated group on day 9. Conclusions. These results suggested that the synergistical application of HHES and G-CSF has life-saving effects and is beneficial for improving wound healing in HS combined with cutaneous injury rats. Hong Huang, Jiejie Liu, Haojie Hao, Chuan Tong, Dongdong Ti, Huiling Liu, Haijing Song, Chaoguang Jiang, Xiaobing Fu, and Weidong Han Copyright © 2016 Hong Huang et al. All rights reserved. The Effect of Perioperative Ischemia and Reperfusion on Multiorgan Dysfunction following Abdominal Aortic Aneurysm Repair Mon, 21 Dec 2015 09:36:43 +0000 Abdominal aortic aneurysms (AAAs) are relatively common and are potentially life-threatening medical problems. The aim of this review is to provide an overview of the effect of I/R injury on multiorgan failure following AAA repair. The PubMed, CINAHL, EMBASE, Medline, Cochrane Review, and Scopus databases were comprehensively searched for articles concerning the pathophysiology of I/R and its systemic effects. Cross-referencing was performed using the bibliographies from the articles obtained. Articles retrieved were restricted to those published in English. One of the most prominent characteristics of AAA open repair is the double physiological phenomenon of ischemia-reperfusion (I/R) that happens either at the time of clamping or following the aortic clamp removal. Ischemia-reperfusion injury causes significant pathophysiological disturbances to distant organs, increasing the possibility for postoperative multiorgan failure. Although tissue injury is mediated by diverse mechanisms, microvascular dysfunction seems to be the final outcome of I/R. Konstantina Katseni, Athanasios Chalkias, Thomas Kotsis, Nikolaos Dafnios, Vassilis Arapoglou, Georgios Kaparos, Emmanuel Logothetis, Nicoletta Iacovidou, Eleni Karvouni, and Konstantinos Katsenis Copyright © 2015 Konstantina Katseni et al. 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) P=0.003 and mean global rating 3.25 SD (0.99) versus 2.95 (SD 1.09) P=0.014. 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) P=0.025. 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.