Publication of the Utstein style template has made it possible to evaluate and compare national, regional, and hospital based Emergency Medical Services. This research was a national investigation to ...present outcome data for out-of-hospital cardiac arrest (OHCA) patients in Japan. 3029 OHCA patients who were transported to 10 Emergency and Critical Care Medical Center from November 1997 to April 1999 were recorded according to the Utstein style and the outcome evaluated by logistic regression analysis. Among 3029 OHCA patients, 109 were found dead. The remaining 2920 patients who underwent cardiopulmonary resuscitation (CPR) by emergency medical technicians (EMT) were included in this study. Among these patients, 1294 were considered of primary cardiac origin patients by the EMT and 722 of these patients suffered a witnessed cardiac arrest. Bystander CPR were performed in 28.4% of these witnessed patients and the discharge rate was 3.5% overall and 11.4% in witnessed VF/VT. Outcome analysis showed that a discharge rate in witnessed primary cardiac arrest was 30% in prehospital resuscitation which was 7.5 times higher than in-hospital emergency room resuscitation groups (4.0%). The longer the interval between an emergency telephone call and defibrillation, the lower the 1 month survival rate, which reached almost 0% at 30 min. Follow up evaluation after discharge revealed that the survival rate rapidly decreased from 24 h to 3 months, then became a plateau in primary cardiac patients was rapidly decreased from 24 h to 1 month, then became a near plateau in non-cardiac origin group. To improve the resuscitation rate in the prehospital phase, a prehospital medical control system should be developed with expansion of on scene techniques by Japanese paramedics such as tracheal intubation, administration of emergency drugs and early defibrillation with standing orders. Education and motivation of first responders will be needed and every effort should be concentrated on improving bystander CPR rate.
O registo segundo o modelo de Utstein tornou possı́vel avaliar e comparar Serviços de Emergência Médica hospitalares, regionais e nacionais. Este estudo foi uma investigação nacional dos resultados dos doentes vı́timas de paragem cardı́aca pré-hospitalar (OHCA) no Japão. Foram registados 3029 doentes vı́timas de OHCA que foram transportados para 10 Centros Médicos de Emergência e Cuidados Intensivos entre Novembro de 1997 e Abril de 1999, de acordo com o modelo Utstein, sendo o resultado final avaliado por análise de regressão logı́stica. Dos 3029 doentes 109 foram encontrados mortos. Os restantes 2920 doentes que foram submetidos a reanimação cardiopulmonar (CPR) por técnicos de emergência médica (EMT) e incluı́dos neste estudo. 1294 doentes, foram considerados pelos EMT como tedno PCR de origem cardı́aca primária e 722 destes sofreram paragem cardı́aca presenciada. Em 28,4% das paragens presenciadas foi realizada CPR pelas testemunhas e a taxa de alta foi de 3.5% em geral e de 11.4% na VF/VT presenciada. A análise dos resultados revelou que a taxa de alta na paragem cardı́aca presenciada foi de 30% na reanimação pré-hospitalar, o que corresponde a 7.5 vezes mais do que a taxa na reanimação intra-hospitalar (4.0%). Quanto maior o intervalo entre uma chamada telefónica de emergência e a desfibrilhação, menor a taxa de sobrevivência ao fim de um mês, que atingiu quase 0% aos 30 min. A avaliação após alta revelou que a sobrevivência média diminuiu rapidamente das 24 horas até aos 3 meses e depois tornou-se estacionária nos doentes cardı́acos primários; nos doentes com origem no grupo não cardı́aco, diminuiu rapidamente das 24 horas até um mês e depois tornou-se quase estacionária. Para melhorar a taxa de reanimação na fase pré-hospitalar deveria ser desenvolvido um sistema de controlo médico pré-hospitalar com extensão das técnicas dos paramédicos Japoneses nos cenários práticos, tais como entubação traqueal, administração de drogas de emergência e desfibrilhação precoce. É necessário educar e motivar as primeiras ajudas e todos os esforços deveriam ser concentrados na melhoria da taxa de CPR pelas testemunhas.
La publicación del templado del estilo Utstein ha hecho posible evaluar y comparar datos nacionales, regionales y servicios de emergencias médicas con base en hospitales. Este estudio fue una investigación nacional para presentar datos de resultados de pacientes de paro cardı́aco extrahospitalario (OHCA) en Japón. 3029 pacientes de paro cardı́aco extrahospitalario que fueron transportados a 10 centros de emergencia y centros médicos de cuidados crı́ticos, entre Noviembre 1997 y Abril 1999, fueron registrados de acuerdo al estilo Utstein y el resultado evaluado con análisis de regresión logı́stica . De 3029 pacientes de paro extrahospitalario, 109 fueron encontrados muertos. Se incluyeron los restantes 2920 pacientes que fueron sometidos a reanimación cardiopulmonar (RCP) por los técnicos en emergencias médicas (EMT). De estos pacientes, 1924 fueron considerados de origen cardiaco primario por los EMT y 722 de ellos sufrieron un paro cardı́aco presenciado. Se realizó RCP por testigos en el 28.4% de estos paros presenciados. La tasa de alta fue de 3.5% para todo el grupo, y de 11.4% para los paros presenciados por VF/VT. El análisis de resultados mostró que la tasa de alta en pacientes vı́ctimas de paro presenciado de origen cardı́aco fue 30% en resucitación prehospitalaria lo que fue 7.5 veces más alta que en grupo de resucitación intrahospitalaria (4%). Cuanto más largo fuera el intervalo entre la llamada telefónica de emergencia y la desfibrilación, menor fue la sobrevida a un mes, la que alcanzó casi un 0% a los 30 min. El seguimiento después del alta hospitalaria reveló que la tasa de sobrevida disminuyó rápidamente de 24 horas a 3 meses, luego aparecı́a un plateau en los pacientes de etiologı́a cardı́aca, y rápidamente disminuye de 24 hrs a 1 mes, y luego aparece casi un plateau del grupo de origen no cardı́aco. Para mejorar el pronóstico del paro cardı́aco prehospitalario, debe desarrollarse un sistema de control médico prehospitalario con expansión de técnicas en la escena por medio de órdenes establecidas y realizadas por paramédicos japoneses, tales como intubación traqueal, administración de drogas de emergencias y desfibrilación temprana,. Será necesaria la educación y motivación de los primeros respondedores, y el esfuerzo debe concentrarse en mejorar la tasa de RCP por testigos.
Objective: To evaluate the influence of age at the time of gastrostomy placement as a prognostic factor and examine the survival rate in long-term hospitalized patients with gastrostomy. Methods: The ...subjects were 408 inpatients with gastrostomy admitted to our hospital between December 2005 and March 2012. All inpatients, including the present subjects, received oral care in the form of attendant care by nurses or caregivers. First, the subjects were divided into two groups according to sex. Second, the subjects were divided into four groups according to the age at the time of gastrostomy placement: the sixties group (60-69 years), seventies group (70-79 years), eighties group (80-89 years), and nineties group (90-99 years). Each survival curve was drawn using the Kaplan-Meier method, and the log-rank tests were used for statistical analysis. The Cox proportional hazard models were used to calculate hazard ratios. Results: The overall survival rates at one year and five years after gastrostomy placement were 75.4% and 23.2%, respectively. The median survival period was 32.2 months. A significantly better prognosis was observed in women than in men; the age-adjusted hazard ratio was 1.748 (95% CI, 1.364-2.242) for men. The eighties and nineties groups exhibited significantly poorer prognoses than that of the sixties group (p<0.008); the sex-adjusted hazard ratios were 2.173 (95% CI, 1.341-3.521) and 3.071 (95% CI, 1.627-5.797), respectively. Conclusions: These results suggest that oral care, even after gastrostomy placement, can improve the prognosis in patients with gastrostomy. Physicians should therefore be cautious when recommending gastrostomy placement for patients aged>80 years.
First, to examine factors that may be related to brain swelling, which was identified by the absence or compression of the lateral and third ventricles and perimesencephalic cisterns on brain ...computed tomography (CT) scans in the early postresuscitation period in patients who suffered an out-of-hospital cardiac arrest. Second, to characterize the neurologic outcome in those patients in whom cardiac arrest was followed by brain swelling.
Prospective and retrospective analyses.
General ICU, tertiary care hospital.
Fifty-three patients (35 male, 18 female) who had an out-of-hospital cardiac arrest and who also had a brain CT examination on the third day after resuscitation. The 53 patients were divided into two groups: group A (25 patients) experienced brain swelling on postresuscitation day 3; group B (28 patients) did not experience noticeable brain swelling.
None.
There was a significant difference between the two groups in the etiology of the cardiac arrest. Twenty-three of 25 patients in group A had cardiac arrest due to respiratory distress, whereas this finding was true in only five patients in group B. In laboratory data, arterial pH was significantly lower in group A than in group B (6.93 vs. 7.09), as was base deficit (-21.0 mmol/L in group A vs. -13.7 mmol/L in group B). Neurologic outcome was evaluated 1 wk after resuscitation. There were significantly more patients in group A who were not awake and who were diagnosed as brain dead.
The cause of brain swelling may be related to the development of the metabolic acidosis (possibly lactic acidosis) due to hypoxia before the resuscitation period. Brain swelling may be one of the indicators that predicts a poor neurologic outcome in the patients who suffer an out-of-hospital cardiac arrest.
Distigmine bromide is an anticholinesterase used to treat urinary retention. We describe a case of life-threatening cholinergic crisis induced by a usual oral dose of distigmine bromide for ...postoperative urinary retention. An 82-year-old man with mild chronic renal failure was transferred to our emergency room due to cholinergic crisis accompanied by cyanosis, hypotension, and consciousness disturbance. The patient was 10mg/day of distigmine bromide orally administered for 2 days. The patient's serum cholinesterase decreased to 3IU/l. Mechanical ventilation, fluid resuscitation, and inotropic support were started. A few days after admission, despite continuous low serum cholinesterase, his toxic symptoms almost disappeared. Extubation was done, and the patient had an event-free recovery. The possibility of cholinergic crisis should be considered when patients with renal failure are given distigmine bromide. During cholinergic crisis, toxic symptoms do not parallel serum cholinesterase. Cholinergic crisis should thus be treated while carefully observing clinical symptoms.
Several symptoms following acute suppression of thyroid function during antihyperthyroid therapy remain yet to be uniformly recognized. We present a case manifesting electrolyte disorder, psychosis, ...and cardiac arrest during antihyperthyroid therapy. A 46-year-old woman diagnosed with hyperthyroidism and treated with propylthiouracil and β-blocker for a month was admitted to another hospital reporting dyspnea. A few hours after admission, she suddenly underwent cardiac arrest. After immediate cardiopulmonary resuscitation, severe hypocalcemia and cardiomegaly were diagnosed. She was transferred to our emergency room due to her obscure clinical course and severe hypocalcemia. She also experienced hallucinations. Electrocardiography, echocardiography, and chest radiography showed no abnormalities. Calcium administration gradually lowered her serum calcium to within normal range on day 5 after admission. Her mental disturbance disappeared and thyroid function returned to normal. Her severe electrolyte disorder also improved after treatment. She was discharged from the hospital in good condition. Hypocalcemia following acute suppression of thyroid function has been recently recognized as “hungry bone syndrome.” Different psychiatric symptoms and cardiocirculatory disturbances are observed during antihyperthyroid treatment. As our case showes, the importance of intensive care for patients with hyperthyroidism cannot be overemphasized.
In 1991, we introduced percutaneous cardio-pulmonary support (PCPS) at our hospital as a way to conduct aggressive cardiopulmonary cerebral resuscitation for patients with out-of-hospital ...cardiopulmonary arrest, but the system under which the decision to apply PCPS is made at the hospital and preparations then made could exceed the time limitations imposed for cerebral resuscitation. Thus, we have collaborated with the physician-manned ambulance system, which has been in operation since 1995, and in April 2000 introduced a pre-hospital PCPS order treatment strategy for patients with out-of-hospital cardiogenic cardiopulmonary arrest, who do not respond to drug administration or electrical cardioversion. Under this system, PCPS is aggressively and rapidly instituted by having the physician-manned ambulance initiate the PCPS order and initiate hospital preparations for PCPS. In 13 patients treated under the pre-hospital PCPS order system, the mean time elapsed from arrival at the hospital until initiation of PCPS was 18.8min, and the minimum was 8min. In 45 patients for whom the decision to initiate PCPS was made at the hospital (in-hospital order), the mean time from arrival until initiation of PCPS was 43.7min. The outcome under the pre-hospital order system was full recovery in 5 patients, complete disability in 2 patients, and death in 7 patients, so the proportion achieving full recovery was 38.5% better than 13.3% in 45 patients treated under the in-hospital order system. In cardiopulmonary cerebral resuscitation, rapid return of stable cerebral circulation is critical for determining survival and functional prognosis. We believe that our system in which the physician-manned ambulance monitors the response to drug administration and electrical cardioversion and initiates the order to prepare for PCPS at the hospital is the most sensible treatment strategy to achieve a rapid return of stable cerebral circulation in cardiopulmonary cerebral resuscitation.
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