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On-scene resuscitation time is associated with out-of-hospital cardiac arrest (OHCA) outcomes. We developed and validated reinforcement learning models for individualized on-scene resuscitation times, leveraging nationwide Korean data. Adult OHCA patients with a medical cause of arrest were included (N = 73,905). The optimal policy was derived from conservative Q-learning to maximize survival. The on-scene return of spontaneous circulation hazard rates estimated from the Random Survival Forest were used as intermediate rewards to handle sparse rewards, while patients' historical survival was reflected in the terminal rewards. The optimal policy increased the survival to hospital discharge rate from 9.6% to 12.5% (95% CI: 12.2–12.8) and the good neurological recovery rate from 5.4% to 7.5% (95% CI: 7.3–7.7). The recommended maximum on-scene resuscitation times for patients demonstrated a bimodal distribution, varying with patient, emergency medical services, and OHCA characteristics. Our survival analysis-based approach generates explainable rewards, reducing subjectivity in reinforcement learning. [ABSTRACT FROM AUTHOR]

Background: Shock is a life‐threatening condition that is associated with high mortality and morbidity. Therefore, the timely identification and management of this condition are important. We aimed to develop a prediction model for vasopressor use based on concise serial arterial blood pressure data. Methods: We collected continuous arterial blood pressure from patients admitted to the emergency department (ED) resuscitation room. Patients with an initial systolic blood pressure lower than 90 mmHg were included in the study. We developed prediction models using convolutional neural networks (CNNs) and long short‐term memory (LSTM) networks. Discrimination performance was assessed using the area under the receiver operating characteristic curve (AUROC) and the area under the precision–recall curve (AUPRC). Results: A total of 120 patients were enrolled in the study. The CNN and LSTM models yielded AUROCs ranging from 0.731 to 0.834 for predicting the need for vasopressor infusion within different time frames (30 min, 1 h, and 6 h). LSTM outperformed the CNN in terms of predicting vasopressor infusion within 30 min and 1 h (p value < 0.05). The AUPRC values ranged from 0.200 to 0.252, and sensitivity–specificity analyses indicated that the models have potential for clinical applications. Conclusion: This study used serial arterial blood pressure data to construct a promising prediction model for the need for vasopressors in hypotensive ED patients. The simplicity and accuracy of the model provide valuable insights for developing a clinical decision support tool for resuscitation in emergency settings. [ABSTRACT FROM AUTHOR]

Objective: Driving under the influence (DUI) of alcohol is a major risk factor for fatal road traffic injuries (RTIs) worldwide. This study aimed to investigate the relationship between the implementation of new acts on DUI of alcohol and the clinical outcomes of patients with severe RTIs in Korea. Methods: This is a community-based cross-sectional study using a nationwide severe trauma registry in Korea. In 2018, 2 acts with the Yoon Chang-Ho Act (Yoon's Act) were passed to strengthen the punishment for drunk driving fatal RTIs (first Yoon's act) and lower the blood alcohol concentration limit to restrict driver's licenses (second Yoon's act). The first Yoon's act was implemented on December 18, 2018, and the second Yoon's act was implemented on June 25, 2019. The study periods were categorized as pre-Act-1, pre-Act-2, Act-1, and Act-2 according to the application of Yoon's Act, and the study outcome was in-hospital mortality. Multivariable logistic regression analysis was conducted to estimate the relationship of the new acts and in-hospital mortality. Results: Among a total of 20,376 patients with severe RTIs and 7,928 patients (drivers) with RTIs (hereafter drivers), the in-hospital mortality rates were 20.8% and 17.0%, and alcohol-related RTIs accounted for 9.7% and 8.1%, respectively. Severe RTIs tended to increase with each period (25.5 cases/day, 24.5 cases/day, 26.8 cases/day, and 30.4 cases/day, P for trend <.01). In-hospital mortality significantly decreased during the Act-2 period compared to the pre-Act-2 period for all patients with severe RTIs (adjusted odds ratio = 0.54, 95% confidence interval 0.43–0.67) and drivers with RTIs (adjusted odds ratio = 0.50, 95% confidence interval 0.34–0.73). Conclusions: Implementation of the new acts on DUI of alcohol was associated with lower odds for in-hospital mortality for patients with severe RTIs. Further studies are needed to evaluate the long-term impact of the new acts on reducing alcohol-related RTIs. [ABSTRACT FROM AUTHOR]

There is insufficient evidence supporting the theory that mechanical ventilation can replace the manual ventilation method during CPR. Is using automatic mechanical ventilation (MV) feasible and comparable to the manual ventilation method during CPR? This pilot randomized controlled trial compared MV and manual bag ventilation (BV) during CPR after out-of-hospital cardiac arrest (OHCA). Patients with medical OHCA arriving at the ED were randomly assigned to two groups: an MV group using a mechanical ventilator and a BV group using a bag valve mask. Primary outcome was any return of spontaneous circulation (ROSC). Secondary outcomes were changes of arterial blood gas analysis results during CPR. Tidal volume, minute volume, and peak airway pressure were also analyzed. A total of 60 patients were enrolled, and 30 patients were randomly assigned to each group. There were no statistically significant differences in basic characteristics of OHCA patients between the two groups. The rate of any return of spontaneous circulation was 56.7% in the MV group and 43.3% in the BV group, indicating no significant (P =.439) difference between the two groups. There were also no statistically significant differences in changes of PH, P co 2 , P o 2 , bicarbonate, or lactate levels during CPR between the two groups (P values =.798, 0.249,.515,.876, and.878, respectively). Significantly lower tidal volume (P <.001) and minute volume (P =.009) were observed in the MV group. In this pilot trial, the use of MV instead of BV during CPR was feasible and could serve as a viable alternative. A multicenter randomized controlled trial is needed to create sufficient evidence for ventilation guidelines during CPR. ClinicalTrials.gov ; No.: NCT05550454; URL: www.clinicaltrials.gov. [Display omitted] [ABSTRACT FROM AUTHOR]

Extracorporeal life support (ECLS) for out-of-hospital cardiac arrest (OHCA) is increasing. There is little evidence identifying the association between hospital ECLS case volumes and outcomes in different populations receiving ECLS or conventional cardiopulmonary resuscitation (CPR). The goal of this investigation was to identify the association between ECLS case volumes and clinical outcomes of OHCA patients. This cross-sectional observational study used the National OHCA Registry for adult OHCA cases in Seoul, Korea between January 2015 and December 2019. If the ECLS volume during the study period was >20, the institution was defined as a high-volume ECLS center. Others were defined as low-volume ECLS centers. Outcomes were good neurologic recovery (cerebral performance category 1 or 2) and survival to discharge. We performed multivariate logistic regression and interaction analyses to assess the association between case volume and clinical outcome. Of the 17,248 OHCA cases, 3,731 were transported to high-volume centers. Among the patients who underwent ECLS, those at high-volume centers had a higher neurologic recovery rate than those at low-volume centers (17.0% vs. 12.0%), and the adjusted OR for good neurologic recovery was 2.22 (95% confidence interval (CI): 1.15–4.28) in high-volume centers compared to low-volume centers. For patients who received conventional CPR, high-volume centers also showed higher survival-to-discharge rates (adjusted OR of 1.16, 95%CI: 1.01–1.34). High-volume ECLS centers showed better neurological recovery in patients who underwent ECLS. High-volume centers also had better survival-to-discharge rates than low-volume centers for patients not receiving ECLS. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to develop and validate machine learning models for data entry error detection in a national out-of-hospital cardiac arrest (OHCA) prehospital patient care report database. Methods: Adult OHCAs of presumed cardiac etiology were included. Data entry errors were defined as discrepancies between the coded data and the free-text note documenting the intervention or event; for example, information that was recorded as "absent" in the coded data but "present" in the free-text note. Machine learning models using the extreme gradient boosting, logistic regression, extreme gradient boosting outlier detection, and K-nearest neighbor outlier detection algorithms for error detection within nine core variables were developed and then validated for each variable. Results: Among 12,100 OHCAs, the proportion of cases with at least one error type was 16.2%. The area under the receiver operating characteristic curve (AUC) of the best-performing model (model with the highest AUC for each outcome variable) was 0.71–0.95. Machine learning models detected errors most efficiently for outcome place and initial rhythm errors; 82.6% of place errors and 93.8% of initial rhythm errors could be detected while checking 11 and 35% of data, respectively, compared to the strategy of checking all data. Conclusion: Machine learning models can detect data entry errors in care reports of emergency medical services (EMS) clinicians with acceptable performance and likely can improve the efficiency of the process of data quality control. EMS organizations that provide more prehospital interventions for OHCA patients could have higher error rates and may benefit from the adoption of error-detection models. [ABSTRACT FROM AUTHOR]

Asia is experiencing a demographic shift toward an aging population at an unrivaled rate. This can influence the characteristics and outcomes of trauma. We aim to examine different characteristics of older adult trauma patients compared to younger adult trauma patients and describe factors that affect the outcomes in Asian countries. This is a retrospective, international, multicenter study of trauma across participating centers in the Pan Asian Trauma Outcome Study (PATOS) registry, which included trauma cases aged ≥18 years, brought to the emergency department (ED) by emergency medical services (EMS) from October 2015 to November 2018. Data of older adults (≥65 years) and younger adults (<65 years) were analyzed and compared. The primary outcome measure was in-hospital mortality, and secondary outcomes were disability at discharge and hospital and intensive care unit (ICU) length of stays. Of 39,804 trauma patients, 10,770 (27.1%) were older adults. Trauma occurred more among older adult women (54.7% vs 33.2%, p < 0.001). Falls were more frequent in older adults (66.3% vs 24.9%, p < 0.001) who also had higher mean Injury Severity Score (ISS) compared to the younger adult trauma patient (5.4 ± 6.78 vs 4.76 ± 8.60, p < 0.001). Older adult trauma patients had a greater incidence of poor Glasgow Outcome Scale (GOS) (13.4% vs 4.1%, p < 0.001), higher hospital mortality (1.5% vs 0.9%, p < 0.001) and longer median hospital length of stay (12.8 vs 9.8, p < 0.001). Multiple logistic regression revealed age (adjusted odds ratio [AOR] 1.06, 95%CI 1.02–1.04, p < 0.001), male sex (AOR 1.60, 95%CI 1.04–2.46, p = 0.032), head and face injuries (AOR 3.25, 95%CI 2.06–5.11, p < 0.001), abdominal and pelvic injuries (AOR 2.78, 95%CI 1.48–5.23, p = 0.002), cardiovascular (AOR 2.71, 95%CI 1.40–5.22, p = 0.003), pulmonary (AOR 3.13, 95%CI 1.30–7.53, p = 0.011) and cancer (AOR 2.03, 95%CI 1.02–4.06, p = 0.045) comorbidities, severe ISS (AOR 2.06, 95%CI 1.23–3.45, p = 0.006), and Glasgow Coma Scale (GCS) ≤8 (AOR 12.50, 95%CI 6.95–22.48, p < 0.001) were significant predictors of hospital mortality. Older trauma patients in the Asian region have a higher mortality rate than their younger counterparts, with many significant predictors. These findings illustrate the different characteristics of older trauma patients and their potential to influence the outcome. Preventive measures for elderly trauma should be targeted based on these factors. [ABSTRACT FROM AUTHOR]

Background: Insomnia and depression have been known to be risk factors of several diseases, including coronary heart disease. We hypothesized that insomnia affects the out-of-hospital cardiac arrest (OHCA) incidence, and these effects may vary depending on whether it is accompanied by depression. This study aimed to determine the association between insomnia and OHCA incidence and whether the effect of insomnia is influenced by depression. Methods: This prospective multicenter case-control study was performed using Phase II Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiology Surveillance (CAPTURES-II) project database for OHCA cases and community-based controls in Korea. The main exposure was history of insomnia. We conducted conditional logistic regression analysis to estimate the effect of insomnia on the risk of OHCA incidence and performed interaction analysis between insomnia and depression. Finally, subgroup analysis was conducted in the patients with insomnia. Results: Insomnia was not associated with increased OHCA risk (0.95 [0.64–1.40]). In the interaction analysis, insomnia interacted with depression on OHCA incidence in the young population. Insomnia was associated with significantly higher odds of OHCA incidence (3.65 [1.29–10.33]) in patients with depression than in those without depression (0.84 [0.59–1.17]). In the subgroup analysis, depression increased OHCA incidence only in patients who were not taking insomnia medication (3.66 [1.15–11.66]). Conclusion: Insomnia with depression is a risk factor for OHCA in the young population. This trend was maintained only in the population not consuming insomnia medication. Early and active medical intervention for patients with insomnia may contribute to lowering the risk of OHCA. [ABSTRACT FROM AUTHOR]

This study aimed to investigate the effects of adding advanced cardiac life support (ACLS) training to an existing basic life support program and the operation of a designated team response for patients with out-of-hospital cardiac arrest (OHCA) on prehospital return of spontaneous circulation (ROSC) and ACLS management. A natural experimental study was conducted for emergency medical service (EMS)-treated adult patients with OHCA in 2020. In 2019, a quarter of the EMS clinicians were trained in a 3-day ACLS courses, and they were designated to be dispatched first in suspected OHCA. Some were dispatched only to major emergencies, such as OHCA and myocardial infarction (dedicated team), while others were dispatched to all emergencies with priority to major ones (non-dedicated team). The exposure was the ambulance response type: dedicated, non-dedicated, and basic teams (others). The primary outcome was prehospital ROSC. The secondary outcomes were prehospital ACLS (advanced airway management and intravenous access). A multivariable logistic regression analysis was conducted to investigate the effect of ambulance response type on study outcomes. Among 23,512 eligible patients with OHCA, 54.8% (12,874) were treated by the basic team, 36.5% (8,580) by the non-dedicated ACLS team, and 8.8% (2,058) were treated by the dedicated ACLS team. Prehospital ROSC was greater for the designated team than for the basic team (dedicated ACLS team 13.8%, non-dedicated ACLS team 11.3%, and basic team 6.7%) (p < 0.01). In the final logistic regression analysis, compared with the basic team, the designated ACLS team was associated with a higher probability of prehospital ROSC (AOR (95% CIs), 1.88 (1.68–2.09) compared to the non-dedicated ACLS team, and 2.46 (2.09-2.90) compared to the dedicated ACLS team), prehospital advanced airway management (1.72 (1.57-1.87) and 1.73 (1.48-2.03), respectively), and intravenous access (2.29 (2.16-2.43) and 2.76 (2.50-3.04), respectively). Additional ACLS training and operation of a designated OHCA team response were associated with higher rates of prehospital ROSC and prehospital ACLS provision. However, further research is needed to find the optimal operation for EMS to improve survival outcomes. [ABSTRACT FROM AUTHOR]

Early diagnosis and intervention by visiting the emergency department (ED) are important for traumatic brain injury (TBI). We evaluate the factors associated with delayed ED visits in patients with intracranial TBI. A retrospective multicenter observational study using the ED-based injury in-depth surveillance database (EDIIS) was designed. Patients with intracranial TBI with an alert mentality at ED presentation from 2014 to 2019 were enrolled. Patients were categorized into four groups according to ED visit time after injury (<1 h, 1–3 h, 3–12 h, and >12 h). ED visits after 12 h were defined as delayed ED visits. The factors associated with delayed ED visits were identified using multivariable logistic regression analysis. Among 15,620 patients with TBI enrolled in the final analysis, 2,190 (14.0%) visited the ED 12 h after injury. Multivariable analysis identified the following factors as independent predictors for delayed ED visit such as unintentionally struck by or against an object or unintentional fall as a trauma mechanism, injury during ordinary activities, indoor injury, injury during nighttime, winter season, combined subdural hemorrhage and epidural hemorrhage. In patients with intracranial TBI with an alert mentality, multiple factors related to patient demographics and injury characteristics were associated with the time interval from injury to ED visit. [ABSTRACT FROM AUTHOR]

Background: There is inconclusive evidence regarding the effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA) patients. We aimed to evaluate the association between ECPR and neurologic recovery in OHCA patients using time-dependent propensity score matching analysis. Methods: Using a nationwide OHCA registry, adult medical OHCA patients who underwent CPR at the emergency department between 2013 and 2020 were included. The primary outcome was a good neurological recovery at discharge. Time-dependent propensity score matching was used to match patients who received ECPR to those at risk for ECPR within the same time interval. Risk ratios (RRs) and 95% confidence intervals (CIs) were estimated, and stratified analysis by the timing of ECPR was also performed. Results: Among 118,391 eligible patients, 484 received ECPR. After 1:4 time-dependent propensity score matching, 458 patients in the ECPR group and 1832 patients in the no ECPR group were included in the matched cohort. In the matched cohort, ECPR was not associated with good neurological recovery (10.3% in ECPR and 6.9% in no ECPR; RR [95% CI] 1.28 [0.85–1.93]). In the stratified analyses according to the timing of matching, ECPR with a pump-on within 45 min after emergency department arrival was associated with favourable neurological outcomes (RR [95% CI] 2.51 [1.33–4.75] in 1–30 min, 1.81 [1.11–2.93] in 31–45 min, 1.07 (0.56–2.04) in 46–60 min, and 0.45 (0.11–1.91) in over 60 min). Conclusions: ECPR itself was not associated with good neurological recovery, but early ECPR was positively associated with good neurological recovery. Research on how to perform ECPR at an early stage and clinical trials to evaluate the effect of ECPR is warranted. [ABSTRACT FROM AUTHOR]

Sex disparities have been reported in the prehospital and in-hospital care among patients with out-of-hospital cardiac arrest (OHCA). The aim of this study was to investigate the association between sex and prehospital advanced cardiac life support (ACLS) interventions provided by emergency medical services (EMS). This was a cross-sectional observational study using a nationwide OHCA registry in South Korea. The study included adult OHCAs with presumed cardiac etiology from January 2016 to December 2019. The main exposure was the sex of the victim, and the primary outcomes were prehospital ACLS interventions, including advanced airway management (AAM), intravenous access (IV), and epinephrine (EPI) administration. Multivariable logistic regression analysis accounted for age group, health insurance, comorbidities, place of arrest, urbanization level, witness status, bystander CPR and initial rhythm was performed to calculate adjusted odds ratios (AORs) with 95% confidence intervals (95% CIs). Among 71,154 eligible patients, females with OHCA received less prehospital ACLS interventions than males: risk difference, (95% CIs) −2.76 (-3.41;-2.11) for AAM, −6.03 (-6.79;-5.27) for IV, and −3.81 (-4.37;-3.25) for EPI. In multivariable logistic regression analysis, female sex was significantly associated with a lower probability of prehospital ACLS provision: AOR, (95% CIs) 0.87 (0.84-0.91) for AAM, 0.85 (0.82-0.88) for IV, and 0.81 (0.77-0.84) for EPI. Compared to male patients, female patients were less likely to receive prehospital ACLS. This offers opportunities for EMS systems to reduce disparities and to improve compliance with OHCA resuscitation guidelines and outcomes through quality improvement and educational interventions. [ABSTRACT FROM AUTHOR]

Continuous and non-invasive measurement of intracranial pressure (ICP) in traumatic brain injury (TBI) is important to recognize increased ICP (IICP), which can reduce treatment delays. The purpose of this study was to develop an electroencephalogram (EEG)-based prediction model for IICP in a porcine TBI model. Thirty swine were anaesthetized and underwent IICP by inflating a Foley catheter in the intracranial space. Single-channel EEG data were collected every 6 min in 10 mmHg increments in the ICP from baseline to 50 mmHg. We developed EEG-based models to predict the IICP (equal or over 25 mmHg) using four algorithms: logistic regression (LR), naive Bayes (NB), support vector machine (SVM), and random forest (RF). We assessed the performance of each model based on the accuracy, sensitivity, specificity, and AUC values. The accuracy of each prediction model for IICP was 0.773 for SVM, 0.749 for NB, 0.746 for RF, and 0.706 for LR. The AUC of each model was 0.860 for SVM, 0.824 for NB, 0.802 for RF, and 0.748 for LR. We developed a machine learning prediction model for IICP using single-channel EEG signals in a swine TBI experimental model. The SVM model showed good predictive power with the highest AUC value. [ABSTRACT FROM AUTHOR]

Objectives: Area‐level socioeconomic status (SES) is associated with the incidence of out‐of‐hospital cardiac arrest (OHCA); however, the effects of individual‐level SES on OHCA occurrence are unknown. This study investigated whether individual‐level SES is associated with the occurrence of OHCA. Methods: This case–control study used data from the nationwide OHCA registry and the National Health Information Database (NHID) in Korea. All adult patients with OHCA of a medical etiology from 2013 to 2018 were included. Four controls were matched to each OHCA patient based on age and sex. The exposure was individual‐level SES measured by insurance type and premium, which is based on income in Korea. National Health Insurance (NHI) beneficiaries were divided into four groups (Q1–Q4), and medical aid beneficiaries were separately classified as the lowest SES group. The adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for the outcomes were calculated. Stratified analyses were conducted according to age and sex. Results: A total of 105,443 cases were matched with 421,772 controls. OHCA occurred more frequently in the lower SES groups. Compared with the highest SES group (Q1), the aORs for OHCA occurrence increased as the SES decreased (aORs [95% CI] were 1.21 [1.19–1.24] for Q2, 1.33 [1.31–1.36] for Q3, 1.32 [1.30–1.35] for Q4, and 2.08 [2.02–2.13] for medical aid). Disparity by individual‐level SES appeared to be greater in males than in females and greater in the young and middle‐aged adults than in older adults. Conclusions: Low individual‐level SES was associated with a higher probability of OHCA occurrence. Efforts are needed to reduce SES disparities in the occurrence of OHCA. [ABSTRACT FROM AUTHOR]

Background: Recently, speech and video information recognition technology (SVRT) has developed rapidly. Introducing SVRT into the emergency medical practice process may lead to improvements in health care. The purpose of this study was to evaluate the level of acceptance of SVRT among patients, caregivers and emergency medical staff. Methods: Structured questionnaires were developed for the patient or caregiver group and the emergency medical staff group. The survey was performed in one tertiary academic hospital emergency department. Questions were optimized for each specific group, and responses were provided mostly using Likert 5-scales. Additional multivariable logistic regression analyses for the whole cohort and subgroups were conducted to calculate odds ratios (OR) and confidence intervals (CI) to examine the association between individual characteristics and SVRT acceptance. Results: Of 264 participants, respondents demonstrated a positive attitude and acceptance toward SVRT and artificial intelligence (AI) in future; 179 (67.8%) for video recordings, and 190 (72.0%) for speech recordings. A multivariable logistic regression model revealed that several factors were associated with acceptance of SVRT in emergency medical practice: belief in health care improvement by signal analysis technology (OR, 95% CIs: 2.48 (1.15–5.42)) and AI (OR, 95% CIs: 1.70 (0.91–3.17)), reliability of AI application in emergency medicine (OR, 95% CIs: 2.36 (1.28–4.35)) and the security of personal information (OR, 95% CIs: 1.98 (1.10–3.63)). Conclusion: A high level of acceptance toward SVRT has been shown in patients or caregivers, and it also appears to be associated with positive attitudes toward new technology, AI and security of personal information. [ABSTRACT FROM AUTHOR]

Background: Termination-of-resuscitation rules (TORRs) in out-of-hospital cardiac arrest (OHCA) patients have been applied in western countries; in Asia, two TORRs were developed and have not been externally validated widely. We aimed to externally validate the TORRs using the registry of Pan-Asian Resuscitation Outcomes Study (PAROS). Methods: PAROS enrolled 66,780 OHCA patients in seven Asian countries from 1 January 2009 to 31 December 2012. The American Heart Association-Basic Life Support and AHA-ALS (AHA-BLS), AHA-Advanced Life Support (AHA-ALS), Goto, and Shibahashi TORRs were selected. The diagnostic test characteristics and area under the receiver operating characteristic curve (AUC) were calculated. We further determined the most suitable TORR in Asia and analysed the variable differences between subgroups. Results: We included 55,064 patients in the final analysis. The sensitivity, specificity, negative predictive value, positive predictive value, and AUC, respectively, for AHA-BLS, AHA-ALS, Goto, Shibashi TORRs were 79.0%, 80.0%, 19.6%, 98.5%, and 0.80; 48.6%, 88.3%, 9.8%, 98.5%, and 0.60; 53.8%, 91.4%, 11.2%, 99.0%, and 0.73; and 35.0%, 94.2%, 8.4%, 99.0%, and 0.65. In countries using the Goto TORR with PPV<99%, OHCA patients were younger, had more males, a higher rate of shockable rhythm, witnessed collapse, pre-hospital defibrillation, and survival to discharge, compared with countries using the Goto TORR with PPV ≥99%. Conclusions: There was no single TORR fit for all Asian countries. The Goto TORR can be considered the most suitable; however, a high predictive performance with PPV ≥99% was not achieved in three countries using it (Korea, Malaysia, and Taiwan). [ABSTRACT FROM AUTHOR]

Objective: Major trauma is a major concern in public health and a leading cause of mortality worldwide. This study aimed to evaluate the association between the prehospital scene time interval (STI) and survival in emergency medical service (EMS)-assessed major trauma patients admitted to the intensive care unit (ICU). Methods: A retrospective observational study using the Pan-Asian Trauma Outcomes Study (PATOS) database was conducted. Adult trauma patients with injury severity scores (ISSs) greater than 15 who were admitted to the ICU were selected. EMS STIs were categorized into three groups: short (0–8 minutes), intermediate (9–16 minutes), and long (over 16 minutes). The primary outcome was survival to hospital discharge, and the secondary outcome was good neurological outcome at hospital discharge. Multivariable logistic regression analysis was conducted to calculate odds ratios and confidence intervals, adjusting for age, sex, mechanism of injury, prehospital alertness, prehospital shock index, response time interval, and EMS intervention (airway, oxygen supplementation, and intravenous fluid administration). Sensitivity analysis for patients who underwent surgery or nontraumatic brain injury cases and interaction analysis by EMS intervention were performed. Results: Data from a total of 1,874 eligible patients were analyzed. Intermediate and long STIs showed significant associations with outcomes, with adjusted ORs (95% CI) of 1.21 (1.07–1.38) in the intermediate STI group and 1.74 (1.55–1.96) in the long STI group for survival and 1.37 (1.32–1.40) in the intermediate STI group and 1.31 (1.22–1.41) in the long STI group for neurological outcome. In the sensitivity analysis, the highest ORs were found in the intermediate STI group, with adjusted ORs (95% CI) of 1.40 (1.37–1.42) for survival and 1.32 (1.26–1.38) for neurological outcome. In the interaction analysis, EMS intervention showed a positive interaction effect with an intermediate STI on survival. Conclusion: In EMS-assessed adult major trauma patients admitted to the ICU, we found significant associations between STIs longer than 8 minutes and outcomes. EMS intervention has a positive interaction effect with an intermediate STI on survival. More research is needed to understand the implications of practice for major trauma in the field. [ABSTRACT FROM AUTHOR]

Prehospital fluid resuscitation with crystalloids in patients following trauma remain controversial. This study aimed to investigate the association between prehospital fluid resuscitation and outcomes of trauma patients in Asia. We conducted a retrospective cohort study of trauma patients between 2016 and 2018 using data from the Pan-Asia Trauma Outcomes Study (PATOS) database. Prehospital fluid resuscitation was defined as any administration of intravenous crystalloid fluid on the ambulance before arrival to hospitals. The outcomes were in-hospital mortality and poor functional outcomes, defined as Modified Rankin Scale ≥ 4. Propensity score matching (PSM) was used to equalize potential prognostic factors in both groups. This study included 31,735 patients from six countries in Asia, and 4318 (13.6%) patients had ever received prehospital fluid resuscitation. The patients receiving prehospital fluid resuscitation had a higher risk of in-hospital mortality, with an adjusted odds ratio (aOR) of 2.02, 95% confidence interval (CI) 1.32–3.10, p = 0.001 in PSM analysis. Prehospital fluid resuscitation was also associated with poor functional outcomes, with an OR 1.73, 95% CI: 1.48–2.03, p < 0.001 in PSM analysis. Prehospital fluid resuscitation in patients with major trauma (injury severity score ≥ 16) presented a higher risk of poor functional outcomes (aOR = 2.65, 95% CI: 1.89–3.73 in PSM analysis, pinteraction = 0.006) via subgroup analysis. Prehospital fluid resuscitation of trauma patients is associated with higher in-hospital mortality and poor functional outcomes in the subgroup in countries studied. [ABSTRACT FROM AUTHOR]

Aims: A short awareness time interval (ATI, time from witnessing the arrest to calling for help) and bystander cardiopulmonary resuscitation (CPR) are important factors affecting neurological recovery after out-of-hospital cardiac arrest (OHCA). This study investigated the association of the location of OHCA with the length of ATI and bystander CPR.Methods: This population-based observational study used the nationwide Korea OHCA database and included all adults with layperson-witnessed OHCA with presumed cardiac aetiology between 2013 and 2017. The exposure was the location of OHCA (public places, private housing and nursing facilities). The primary outcome was short ATI, defined as <4 min from witnessing to calling for emergency medical service (EMS). The secondary outcome was the frequency of provision of bystander CPR. Multivariable logistic regression analysis was performed to evaluate the association of location of OHCA with study outcomes.Results: Of 30 373 eligible OHCAs, 66.6% occurred in private housing, 24.0% occurred in public places and 9.4% occurred in nursing facilities. In 67.3% of the cases, EMS was activated within 4 min of collapse, most frequently in public places (public places 77.0%, private housing 64.2% and nursing facilities 64.8%; p<0.01). The overall rate of bystander CPR was 65.5% with highest in nursing facilities (77.0%), followed by public places (70.1%) and private housing 62.3%; p<0.01). Compared with public places, the adjusted ORs (AORs) (95% CIs) for a short ATI were 0.58 (0.54 to 0.62) in private housing and 0.62 (0.56 to 0.69) in nursing facilities. The AORs (95% CIs) for bystander CPR were 0.75 (0.71 to 0.80) in private housing and 1.57 (1.41 to 1.75) in nursing facilities.Conclusion: OHCAs in private housing and nursing facilities were less likely to have immediate EMS activation after collapse than in public places. A public education is needed to increase the awareness of necessity of prompt EMS activation. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the risks of diabetes mellitus (DM) on out-of-hospital cardiac arrest (OHCA) and to investigate whether the risks of DM on OHCA varied according to the diagnostic and therapeutic characteristics of diabetes. We conducted a multicenter prospective case–control study in 17 University hospitals in Korea from September 2017 to December 2020. Cases were EMS-treated OHCA patients aged 20 to 79 with a presumed cardiac etiology. Community-based controls were recruited at a 1:2 ratio after matching for age, sex, and urbanization level of residence. A structured questionnaire and laboratory findings were collected from cases and controls. Multivariable conditional logistic regression analyses were conducted to estimate the risk of DM on OHCA by characteristics. A total of 772 OHCA cases and 1544 community-based controls were analyzed. A total of 242 (31.3%) OHCAs and 292 (18.9%) controls were previously diagnosed with DM. The proportions of type I DM (10.7% vs. 2.1%) and insulin therapy (15.3% vs. 6.5%) were higher in OHCAs with DM than in controls with DM. The duration of DM was longer in OHCAs than in controls (median 12 vs. 7 years). DM was associated with an increased risk of OHCA (aOR (95% CI), 2.13 (1.64–2.75)). Compared to the no diabetes group, the risks of OHCA increased in the diabetes patients with type I DM (5.26 (1.72–16.08)) and type II DM group (1.63 (1.18–2.27)), a long duration of DM prevalence (1.04 (1.02–1.06) per 1-year prevalence duration), and a high HbA1c level (1.38 (1.19–1.60) per 1% increase). By treatment modality, the aOR (95% CI) was lowest in the oral hypoglycemic agent (1.47 (1.08–2.01)) and highest in the insulin (6.63 (3.04–14.44)) groups. DM was associated with an increased risk of OHCA, and the risk magnitudes varied according to the diagnostic and therapeutic characteristics. [ABSTRACT FROM AUTHOR]

Background: Differences in the classification results among triage nurses in the emergency room can be improved by training or applying an algorithm. This study aimed to confirm whether the agreement among triage nurses could be improved through learner-led problem-based learning. Methods: This study had a single-group time series design to investigate the effect of problem-based learning led by triage nurses on the agreement of Korean Triage and Acuity Scale classification results for patients who visited the emergency department. We extracted 300 patients each in May and August 2018 before learning began and 300 patients each in May and August 2019 after learning. Results: After problem-based learning was applied, the self-efficacy of triage nurses for emergency patient classification increased statistically significantly compared to before learning (7.88 ± 0.96, p <.001), and the weighted kappa coefficient was also found to be almost perfectly agreement (0.835, p <.001). Conclusions: In this study, problem-based learning improved the inter-rater agreement of Korean Triage and Acuity Scale classification results and self-efficacy of triage nurses. Therefore, problem-based learning can contribute to patient safety in the emergency department by enhancing the expertise of triage nurses and increasing the accuracy of triage classification. [ABSTRACT FROM AUTHOR]

Delivery of automatic electrical defibrillator (AED) by unmanned aerial vehicle (UAV) was suggested for out-of-hospital cardiac arrest (OHCA). The goal of this study is to assess the effect of topographic and weather conditions on call to AED attach time by UAV-AED. We included OHCA patients from 2013 to 2016 in Seoul, South Korea. We developed a UAV-AED flight simulator using topographic information of Seoul for Euclidean and topographic flight pathway including vertical flight to overcome high-rise structures. We used 4 kinds of UAV flight scenarios according to weather conditions or visibility. Primary outcome was emergency medical service (EMS) call to AED attach time. Secondary outcome was pre-arrival rate of UAV-AED before current EMS based AED delivery. Call to AED attach time in topographic pathway was 7.0 min in flight and control advanced UAV and 8.0 min in basic UAV model. Pre-arrival rate in Euclidean pathway was 38.0% and 16.3% for flight and control advanced UAV and basic UAV. Pre-arrival rate in the topographic pathway was 27.0% and 11.7%, respectively. UAV-AED topographic flight took longer call to AED attach time than Euclidean pathway. Pre-arrival rate of flight and control advanced UAV was decreased in topographic flight pathway compared to Euclidean pathway. [ABSTRACT FROM AUTHOR]

Hemorrhage, a main cause of mortality in patients with trauma, affects vital signs such as blood pressure and heart rate. Shock index (SI), calculated as heart rate divided by systolic blood pressure, is widely used to estimate the shock status of patients with hemorrhage. The difference in SI between the emergency department and prehospital field can indirectly reflect urgency after trauma. We aimed to determine the association between delta SI (DSI) and in-hospital mortality in patients with torso or extremity trauma. Patients with DSI >0.1 are expected to be associated with high mortality. This retrospective, observational study used data from the Pan-Asian Trauma Outcomes Study. Patients aged 18–85 years with abdomen, chest, upper extremity, lower extremity, or external injury location were included. Patients from China, Indonesia, Japan, Philippines, Thailand, and Vietnam; those who were transferred from another facility; those who were transferred without the use of emergency medical service; those with prehospital cardiac arrest; those with unknown exposure and outcomes were excluded. The exposure and primary outcome were DSI and in-hospital mortality, respectively. The secondary and tertiary outcome was intensive care unit (ICU) admission and massive transfusion, respectively. Multivariate logistic regression analysis was performed to test the association between DSI and outcome. In total, 21,534 patients were enrolled according to the inclusion and exclusion criteria. There were 3,033 patients with DSI >0.1. The in-hospital mortality rate in the DSI >0.1 and ≤0.1 groups was 2.0% and 0.8%, respectively. In multivariate logistic regression analysis, the DSI ≤0.1 group was considered the reference group. The unadjusted and adjusted odds ratios of in-hospital mortality in the DSI >0.1 group were 2.54 (95% confidence interval [CI] 1.88–3.42) and 2.82 (95% CI 2.08–3.84), respectively. The urgency of traumatic hemorrhage can be determined using DSI, which can help hospital staff to provide proper trauma management, such as early trauma surgery or embolization. [ABSTRACT FROM AUTHOR]

Background: Due to an aging population and the increasing proportion of patients with various comorbidities, the number of patients with acute ischemic heart disease (AIHD) who present to the emergency department (ED) with atypical chest pain is increasing. The aim of this study was to develop and validate a prediction model for AIHD in patients with atypical chest pain. Methods and results: A chest pain workup registry, ED administrative database, and clinical data warehouse database were analyzed and integrated by using nonidentifiable key factors to create a comprehensive clinical dataset in a single academic ED from 2014 to 2018. Demographic findings, vital signs, and routine laboratory test results were assessed for their ability to predict AIHD. An extreme gradient boosting (XGB) model was developed and evaluated, and its performance was compared to that of a single-variable model and logistic regression model. The area under the receiver operating characteristic curve (AUROC) was calculated to assess discrimination. A calibration plot and partial dependence plots were also used in the analyses. Overall, 4,978 patients were analyzed. Of the 3,833 patients in the training cohort, 453 (11.8%) had AIHD; of the 1,145 patients in the validation cohort, 166 (14.5%) had AIHD. XGB, troponin (single-variable), and logistic regression models showed similar discrimination power (AUROC [95% confidence interval]: XGB model, 0.75 [0.71–0.79]; troponin model, 0.73 [0.69–0.77]; logistic regression model, 0.73 [0.70–0.79]). Most patients were classified as non-AIHD; calibration was good in patients with a low predicted probability of AIHD in all prediction models. Unlike in the logistic regression model, a nonlinear relationship-like threshold and U-shaped relationship between variables and the probability of AIHD were revealed in the XGB model. Conclusion: We developed and validated an AIHD prediction model for patients with atypical chest pain by using an XGB model. [ABSTRACT FROM AUTHOR]

Background: Calcium level is associated with sudden cardiac death based on several cohort studies. However, there is limited evidence on the association between ionized calcium, active form of calcium, and resuscitation outcome. This study aimed to evaluate the potential role of ionized calcium in predicting resuscitation outcome in patients with out-of-hospital cardiac arrest. Methods: We analyzed the Korean Cardiac Arrest Research Consortium data (KoCARC) registry, a web-based multicenter registry that included 65 participating hospitals throughout the Republic of Korea. The patients with out-of-hospital cardiac arrest over 19 years old and acquired laboratory data including calcium, ionized calcium, potassium, phosphorus, creatinine, albumin at emergency department (ED) arrival were included. The primary outcome was successful rate of return of spontaneous circulation (ROSC) and the secondary outcomes were survival hospital discharge and favorable neurological outcome (cerebral performance category 1 or 2) at hospital discharge. Results: Eight-hundred and eighty-three patients were enrolled in the final analysis and 448 cases (54%) had ROSC. In multivariable logistic regression analysis, ionized calcium level was associated with ROSC (odds ratio, 1.77; 95% CI1.28–2.45; p = 0.001) even though calcium level was not associated with ROSC (odds ratio, 0.87; 95% CI 0.70–1.08; p = 0.199). However, ionized calcium level was not associated with survival discharge (odds ratio, 0.99; 95% CI 0.72–1.36; p = 0.948) or favorable neurologic outcome (odds ratio, 0.45; 95% CI 0.03–6.55, p = 0.560). Conclusion: A high ionized calcium level measured during cardiopulmonary resuscitation was associated with an increased likelihood of ROSC. [ABSTRACT FROM AUTHOR]

Background: Whether rapid transportation can benefit patients with trauma remains controversial. We determined the association between prehospital time and outcome to explore the concept of the "golden hour" for injured patients.Methods and Findings: We conducted a retrospective cohort study of trauma patients transported from the scene to hospitals by emergency medical service (EMS) from January 1, 2016, to November 30, 2018, using data from the Pan-Asia Trauma Outcomes Study (PATOS) database. Prehospital time intervals were categorized into response time (RT), scene to hospital time (SH), and total prehospital time (TPT). The outcomes were 30-day mortality and functional status at hospital discharge. Multivariable logistic regression was used to investigate the association of prehospital time and outcomes to adjust for factors including age, sex, mechanism and type of injury, Injury Severity Score (ISS), Revised Trauma Score (RTS), and prehospital interventions. Overall, 24,365 patients from 4 countries (645 patients from Japan, 16,476 patients from Korea, 5,358 patients from Malaysia, and 1,886 patients from Taiwan) were included in the analysis. Among included patients, the median age was 45 years (lower quartile [Q1]-upper quartile [Q3]: 25-62), and 15,498 (63.6%) patients were male. Median (Q1-Q3) RT, SH, and TPT were 20 (Q1-Q3: 12-39), 21 (Q1-Q3: 16-29), and 47 (Q1-Q3: 32-60) minutes, respectively. In all, 280 patients (1.1%) died within 30 days after injury. Prehospital time intervals were not associated with 30-day mortality. The adjusted odds ratios (aORs) per 10 minutes of RT, SH, and TPT were 0.99 (95% CI 0.92-1.06, p = 0.740), 1.08 (95% CI 1.00-1.17, p = 0.065), and 1.03 (95% CI 0.98-1.09, p = 0.236), respectively. However, long prehospital time was detrimental to functional survival. The aORs of RT, SH, and TPT per 10-minute delay were 1.06 (95% CI 1.04-1.08, p < 0.001), 1.05 (95% CI 1.01-1.08, p = 0.007), and 1.06 (95% CI 1.04-1.08, p < 0.001), respectively. The key limitation of our study is the missing data inherent to the retrospective design. Another major limitation is the aggregate nature of the data from different countries and unaccounted confounders such as in-hospital management.Conclusions: Longer prehospital time was not associated with an increased risk of 30-day mortality, but it may be associated with increased risk of poor functional outcomes in injured patients. This finding supports the concept of the "golden hour" for trauma patients during prehospital care in the countries studied. [ABSTRACT FROM AUTHOR]

Background: Background: Serum albumin has been known as a strong predictive value of mortality in various disease conditions, severe burns, major surgeries, stroke, myocardial infarction, etc. But little is known for the effect of serum albumin level on out-of-hospital cardiac arrest patients. Objectives: This study aimed to investigate the effect of serum albumin level on the outcome of out of hospital cardiac arrest. Methods: This study was a prospective hospital-based patient cohort study, conducted during January to December 2014 at 27 emergency departments in Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance project. The albumin was measured immediately after arrival to the emergency department during cardiopulmonary resuscitation, and albumin was categorized into two groups, group < 3.5 g/dL group and ⩾ 3.5 g/dL group. The primary outcome was a good neurological recovery at discharge (cerebral performance category scale 1 or 2). Multivariable logistic regression was used for adjusting for confounders. Results: During the study period, 1616 out-of-hospital cardiac arrest patients with presumed cardiac etiology were enrolled, and the total of 1013 patients were analyzed in this study. A total 452 (44.6%) patients had serum albumin level less than 3.5 g/dL. The serum albumin ⩾ 3.5 g/dL group showed better neurological outcomes than the serum albumin < 3.5 g/dL group: 18.5% versus 4.0%, and ⩾ 3.5 g/dL group had higher survival discharge rates than the < 3.5 g/dL group: 23.9% versus 9.1% (p < 0.01). After adjusting for potential covariates, patients with serum albumin ⩾ 3.5 g/dL had a higher odds of good neurological recovery (adjusted odds ratio: 2.94 (95% confidence interval: [1.57, 5.49])), and higher survival to discharge (adjusted odds ratio: 1.74 (95% confidence interval: [1.10, 2.76])). Conclusion: Low serum albumin levels are associated with a worse neurologic outcome in patients with out-of-hospital cardiac arrest. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to investigate the association between coronary angiography (CAG) with and without percutaneous coronary intervention (PCI) after out-of-hospital cardiac arrest (OHCA) and neurological recovery and to determine the influence of primary electrocardiogram or patient age on the effects of CAG. Methods: Adult patients with OHCA with cardiac etiology who were admitted to PCI-capable hospitals from 2016 to 2017 were enrolled in this study from the nationwide OHCA registry of Korea. Coronary intervention was categorized into three groups: No CAG, CAG without PCI, and CAG with PCI. The endpoint was good neurological recovery. Multivariable logistic regression and interaction analyses (intervention × electrocardiogram and intervention × age) were conducted by calculating adjusted odds ratios (aORs) and 95% confidence intervals (CI). Results: Of a total of 6,802 eligible OHCA patients, 1,218 (17.9%) underwent CAG without PCI and 1,136 (16.7%) underwent CAG with PCI. The CAG without PCI and CAG with PCI groups were more likely to have good neurological recovery than the No CAG group (57.4% vs. 61.6% vs. 16.3%; 3.39 [2.83–4.06] for CAG without PCI and 3.32 [2.74–4.01] for CAG with PCI). Interaction analysis showed that although the effect size differed according to patient characteristics, both CAG groups were associated with an increased likelihood of good neurological recovery, regardless of primary electrocardiogram and age group. In younger patients, CAG with PCI had greater outcome benefits than CAG without PCI (8.54 [4.31–16.95] vs. 4.10 [2.69–6.24]), whereas CAG without PCI had a larger effect size than CAG with PCI in elderly patients (4.46 [2.59–7.68] vs. 2.92 [1.80–4.73]) (p value for interaction 0.02). Conclusions: Post-resuscitation CAG with and without PCI are associated with better neurological recovery in patients with OHCA, regardless of primary electrocardiogram and patient age. [ABSTRACT FROM AUTHOR]

Background: The evidence supporting delivery of quality cardiopulmonary resuscitation is growing and significant attention has been focused on improving bystander cardiopulmonary resuscitation education for laypeople. The aim of this randomized trial was to assess the effectiveness of instructor's real-time objective feedback during cardiopulmonary resuscitation training compared to conventional feedback in terms of trainee's cardiopulmonary resuscitation quality. Methods: We performed a cluster-randomized trial of community cardiopulmonary resuscitation training classes at Nowon District Health Community Center in Seoul. Cardiopulmonary resuscitation training classes were randomized into either intervention (instructor's objective real-time feedback based on the QCPR Classroom device) or control (conventional, instructor's judgment-based feedback) group. The primary outcome was total cardiopulmonary resuscitation score, which is an overall measure of chest compression quality. Secondary outcomes were individual cardiopulmonary resuscitation performance parameters, including compression rate, depth, and release. Generalized linear mixed models were used to analyze the outcome data, accounting for both random and fixed effects. Results: A total of 149 training sessions (2613 trainees) were randomized into 70 intervention (1262 trainees) and 79 control (1351 trainees) groups. Trainees in the QCPR feedback group significantly increased overall cardiopulmonary resuscitation score performance compared with those in the conventional feedback group (model-based mean Δ increment from baseline to session 5: 11.2 (95% confidence interval 9.2–13.2) and 8.0 (6.0–9.9), respectively; p = 0.02). Individual parameters of compression depth and release also showed higher improvement among trainees in QCPR group with positive trends (p < 0.08 for both). Conclusion: This randomized trial suggests beneficial effect of instructor's real-time objective feedback on the quality of layperson's cardiopulmonary resuscitation performance. [ABSTRACT FROM AUTHOR]

Aims: This study aims to test the association between the place-provider-matrix (PPM) of bystander cardiopulmonary resuscitation (CPR) and outcomes of out-of-hospital cardiac arrest (OHCA). Methods: Adult patients with OHCA with a cardiac etiology from 2012 to 2017 in Korea were analyzed, excluding patients who had unknown information on place, type of bystander, or outcome. The PPM was categorized into six groups by two types of places (public versus home) and three types of providers (trained responder (TR), family bystander, and layperson bystander). Outcomes were survival to discharge and good cerebral performance category (CPC) of 1 or 2. Multivariable logistic regression analysis was performed to test the association between PPM group and outcomes with adjustment for potential confounders to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs) (reference = Public-TR). Results: A total of 73,057 patients were analyzed and were categorized into Public-TR (0.6%), Home-TR (0.3%), Public-Family (1.8%), Home-Family (79.8%), Public-Layperson (9.9%), and Home-Layperson (7.6%) groups. Compared with the Public-TR group, the AORs (95% CIs) for survival to discharge were 0.61 (0.35–1.05) in the Home-TR group, 0.85 (0.62–1.17) in the Public-Family group, 0.38 (0.29–0.50) in the Home-Family group, 1.12 (0.85–1.49) in the Public-Layperson group, and 0.42 (0.31–0.57) in the Home-Layperson group. The AORs (95% CIs) for good CPC were 0.58 (0.27–1.25) in the Home-TR group, 0.88 (0.61–1.27) in the Public-Family group, 0.38 (0.28–0.52) in the Home-Family group, 1.20 (0.87–1.65) in the Public-Layperson group, and 0.42 (0.30–0.59) in the Home-Layperson group. Conclusion: The OHCA outcomes of the Home-Family and Home-Layperson groups were worse than those of the Public-TR group. This finding suggests that OHCA occurring in private places with family or layperson bystanders requires a new strategy, such as dispatching trained responders to the scene to improve CPR outcomes. [ABSTRACT FROM AUTHOR]

Objective: A multi-tiered response (MTR) system has been controversial in terms of cost-effectiveness and outcome improvement. It remains uncertain whether a cardiopulmonary resuscitation (CPR)-targeted tiered response system is associated with better outcomes after out-of-hospital cardiac arrest (OHCA). This study aimed to investigate the effect of an MTR on OHCA outcomes. Methods: A natural experimental study was conducted for resuscitation-attempted adult OHCAs. The MTR system was implemented in Korea by the National Fire Agency in 2015 across the country where the single-tiered ambulance response system existed. The MTR program had the following 3 components: 1) detection of OHCA by dispatcher, 2) dispatch of ambulance or fire engine in addition to routine dispatch of ambulance, and 3) performance of team CPR. The study period of 2015–2016 was divided by 6 months (phases I [reference], II, III, and IV). The endpoints were prehospital defibrillation, prehospital return of spontaneous circulation (PROSC), survival to discharge and good neurological recovery. A multivariable logistic regression analysis was performed to evaluate the effect of the intervention, and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were calculated, adjusting for potential confounders. Results: A total of 32,663 eligible OHCA cases were evaluated during the study period. As the intervention program spread, the MTR with ambulance increased (from 7.0% in phase I to 53.7% in phase IV, p for trend < 0.01). During the study period, prehospital defibrillation increased from 23.6% in phase I to 26.9% in phase IV and the study outcome was improved from 7.4 to 12.6% for PROSC, from 6.7 to 9.1% for survival to discharge, and from 4.5 to 5.8% for good neurological outcome (p for trend < 0.01 for all). Compared with phase I, the AORs (95% CI) of phase IV were 1.16 (1.08–1.25) for prehospital defibrillation, 1.82 (1.63–2.04) for PROSC, 1.37 (1.21–1.56) for survival to discharge, and 1.23 (1.06–1.43) for good neurological outcome. Conclusion: The nationwide implementation of a multi-tiered response system for OHCA was associated with increased prehospital defibrillation and improved outcomes of OHCA patients. [ABSTRACT FROM AUTHOR]

Objective: To minimize risk and prevent harmful incidents during interhospital transport, the critical care transport unit service called Seoul Mobile Intensive Care Unit (SMICU) was organized and initiated its service within the city of Seoul. We sought to evaluate the effectiveness of critical care transport units on outcomes of critically ill patients undergoing interhospital transport in Seoul. Methods: A retrospective observational case–control study was designed to evaluate the effectiveness of critical care transport units on outcomes of critically ill patients undergoing interhospital transport. ED patients transported from other hospitals in Seoul during 2016 were identified in the National Emergency Department Information System (NEDIS) and according to use of the SMICU. One-to-one propensity matching was performed to balance covariates between groups. The association of SMICU transport on survival outcome was calculated in a multivariable logistic regression model. Results: Among 42,188 ED patients transported from other hospitals in 2016, 482 (1.1%) of patients were transported by SMICU. Patients transported by SMICU had a higher proportion of severe emergency disease and use of a mechanical ventilator. The adjusted odds ratio for 24-hour mortality after interhospital transport was 0.45 (95% CI: 0.26–0.81) in total cohort and was 0.34 (95% CI: 0.16–0.71) in a one-to-one propensity-matched cohort. Conclusions: Transport by specialized critical care transport unit for patients undergoing interhospital transport was associated with lower 24-hour mortality, demonstrating the benefits of the SMICU. [ABSTRACT FROM AUTHOR]

Objectives: The association between the time from arrest to extracorporeal cardiopulmonary resuscitation (ECPR) and survival from out‐of‐hospital cardiac arrest (OHCA) is unclear. The aim of this study was to determine whether time to ECPR is associated with survival in OHCA. Methods: We analysed the Korean national OHCA registry from 2013 to 2016. We included adult witnessed OHCA patients with presumed cardiac aetiology who underwent ECPR. Patients were excluded if their arrest times or outcomes were unknown. The primary outcome was survival to discharge. Multivariable logistic regression analysis controlling for potential confounders was conducted and adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated to determine the association between time to ECPR and survival. Results: There were 40 352 witnessed OHCAs with presumed cardiac aetiology. One hundred and forty patients had ECPR applied on arriving at their ED, 13 of these patients survived to discharge and seven were neurologically intact. Median time from arrest to ECPR was 74 min (IQR 61–90). Time from arrest to ECPR was significantly and inversely associated with survival to discharge for every 10 min increase in time (AOR 0.73, 95% CI 0.53–1.00) in 10 min intervals. AOR for time from arrest to ECPR ≤60 min was independently associated with improved survival (AOR 6.48, 95% CI 1.54–27.20). Conclusion: Early initiation of ECPR is associated with improved survival after OHCA. Because we analysed a nationwide OHCA registry, which lacks uniform selection criteria for ECPR, further prospective study is warranted. [ABSTRACT FROM AUTHOR]

High‐quality bystander cardiopulmonary resuscitation (CPR) and early defibrillation in the community are important for survival in out‐of hospital‐cardiac‐arrest, but maintaining the quality of CPR in bystanders is difficult. We aimed to determine the effect of an automated external defibrillator (AED) with real‐time feedback on the quality of bystander CPR in a community setting. A before‐and‐after simulation study was designed. Trainees of basic life support education were recruited for the simulation experiment. Each team consisted of two bystanders with different roles (initial witness and CPR supporter). 82 teams performed simulation scenarios with the real‐time feedback function of AED disabled initially, and then repeated it with feedback function enabled. Quality measures of chest compression depth and no‐flow fraction were compared between each of the two simulation scenarios. CPR quality data from 82 teams were analysed. The mean percentage of chest compressions with adequate depth was significantly higher in simulations with real‐time feedback (78.1% vs. 89.3%, p < 0.01). Similarly, no‐flow fractions were lower in simulation scenarios with real‐time feedback (32.0% vs. 30.3% p = 0.05). In a subgroup with the lowest percentage of adequate depth performance in the initial simulation without real‐time feedback, a mean increase of 47.7% (95% CI 31.3–64.0) in the fraction of chest compressions with adequate depth was seen with real‐time feedback. Use of an AED with real‐time feedback improves the quality of bystander CPR in a simulated community setting. The positive effect of real‐time feedback is greatest among people with a low level of CPR skill. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the association of prehospital advanced airway management (AAM) on outcomes of emergency medical service (EMS)-witnessed out-of-hospital cardiac arrest (OHCA) according to the location of arrest.Methods: We evaluated a Korean national OHCA database from 2012 to 2016. Adults with EMS-witnessed, non-traumatic OHCA were included. Patients were categorised into four groups according to whether prehospital AAM was conducted (yes/no) and location of arrest ('at scene' or 'in the ambulance'). The primary outcome was discharge with good neurological recovery (cerebral performance category 1 or 2). Multivariable logistic regression analysis was conducted to evaluate the association between AAM and outcome according to the location of arrest.Results: Among 6620 cases, 1425 (21.5%) cases of arrest occurred 'at the scene', and 5195 (78.5%) cases of arrest occurred 'in an ambulance'. Prehospital AAM was performed in 272 (19.1%) OHCAs occurring 'at the scene' and 645 (12.4%) OHCAs occurring 'in an ambulance'. Patients with OHCA in the ambulance who had prehospital AAM showed the lowest good neurological recovery rate (6.0%) compared with OHCAs in the ambulance with no AAM (8.9%), OHCA at scene with AAM (10.7%) and OHCA at scene with no AAM (7.7%). For OHCAs occurring in the ambulance, the use of AAM had an adjusted OR of 0.67 (95% CI 0.45 to 0.98) for good neurological recovery.Conclusion: Our data show no benefit of AAM in patients with EMS-witnessed OHCA. For patients with OHCA occurring in the ambulance, AAM was associated with worse clinical outcome. [ABSTRACT FROM AUTHOR]

Background: It is unclear whether effect size of the hypoxia is different on in-hospital mortality and disability according to hypotension status in the field. Methods: Adult severe trauma (ST) patients during 2012-13 who were treated by emergency medical services (EMS) and had abnormal revised trauma scores in the field or who had positive trauma triage criteria were analyzed. Exposure was hypoxia (<94%) measured by EMS. End points were hospital mortality and disability defined as a Glasgow Outcome Scale that decreased by 2 points or more. Multivariable logistic regression with interaction model between hypoxia and hypotension was used for outcomes to calculate the adjusted odds ratios (AOR) with 95% confidence intervals (95% CIs) after adjusting for potential confounders. Results: A total of 17,406 EMS-ST patients were analyzed. Of those, 2,598 (14.9%) died, and 3,292 (21.5%) were considered disabled at discharge. The total hypoxia group showed higher mortality and disability indices (35.7 and 51.2%) than the non-hypoxia group (10.7 and 15.9%) (each p-value < 0.0001). The AOR of hypoxia was 2.15 (1.92-2.40) for mortality and was 1.97 (1.75-2.21) for disability. In the interaction model, AORs for mortality by hypoxia in the hypotensive and non-hypotensive groups were 2.66 (2.32-3.04) and 1.74 (1.61-1.87), respectively (P < 0.0001 for interaction). The AORs for disability in the hypotensive and non-hypotensive groups were 2.17 (1.87-2.53) and 1.55 (1.42-1.69), respectively (P < 0.0001 for interaction). Conclusions: The effect of hypoxia was much greater in the hypotensive group than in the non-hypotensive group both in terms of mortality and disability. [ABSTRACT FROM AUTHOR]

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

Background: Understanding the epidemiological characteristics of anaphylaxis-associated out-of-hospital cardiac arrest (OHCA) is the first step toward developing preventative strategies and optimizing care systems. We aimed to describe and compare epidemiological features and clinical outcomes among patients with anaphylaxis-associated OHCAs according to causative agent groups. Methods: We identified emergency medical service (EMS)-treated anaphylaxis-associated OHCA patients from a nationwide OHCA registry between 2008 and 2015. We compared epidemiological characteristics and outcomes according to causal agents (a natural agents group and an iatrogenic agents group) and evaluated temporal variability in incidence. Multivariate logistic regression analysis was performed to compare survival to discharge between causative agent groups. Results: During the study period (8 years), the total number of anaphylaxis-associated OHCAs was 233. A total of 224 eligible cases were included in the analysis. There were 192 patients (85.6%) in the natural agents group and 32 patients (14.3%) in the iatrogenic agents group. There was significant diurnal and seasonal variability in the frequency of anaphylaxis-associated OHCAs (p values<0.01 for both), with the highest incidences occurring during the day (7:01 am to 3 pm; 64.6%) and in summer (June to August, 48.7%). Compared with the natural agents group, the adjusted odds ratio (AOR) for survival to discharge in the iatrogenic agents group was statistically insignificant (AOR 3.61, 95% CI 0.86 to 15.06). Conclusion: The incidence of anaphylaxis-associated OHCA is considerably low, and significant temporal variability, with a peak during the day and in summer, is evident. Anaphylaxis-associated OHCA is more common by natural agents than by iatrogenic agents, but no difference in the survival-to-discharge rate is evident. [ABSTRACT FROM AUTHOR]

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

Introduction: The deployment of first responders in a public place is one of the interventions that is used for increasing bystander cardiopulmonary resuscitation (CPR) of out-of-hospital cardiac arrests (OHCA). We studied the association between the presence of a first responder and the survival of OHCA that occurred during a period of exercise in a public place. Methods: All of the adult OHCAs of a presumed cardiac etiology that occurred during a period of exercise in a public place and that were witnessed by a bystander between 2013 and 2015 were analyzed. The main exposure of interest was the characteristics of the bystander (first responder vs. layperson). The endpoints were the provision of bystander CPR and good neurological recovery. Multivariable logistic regression analysis, adjusting for patient-environment and prehospital factors, was performed. Results: A total of 870 patients had a cardiac arrest during a period of exercise in a public place, and 58 (6.7%) patients were witnessed by the first responder. The OHCAs witnessed by first responders were more likely to result in bystander CPR than those witnessed by laypersons (89.7% vs. 75.4%, p = 0.01, adjusted OR (95% CI): 3.51 (1.44–8.55)). In terms of good neurological recovery, the OHCAs witnessed by first responders had a higher likelihood than the patients witnessed by laypersons (37.9% vs, 24.0%, p = 0.02, adjusted OR (95% CI): 2.92 (1.33–6.40)). Conclusion: The OHCAs occurred during a period of exercise in a public place and whom first responders witnessed were more likely to receive bystander CPR and to have a neurologically intact survival. [ABSTRACT FROM AUTHOR]

Background: Trauma is a major health burden and a time-dependent critical emergency condition among developing and developed countries. In Asia, trauma has become a rapidly expanding epidemic and has spread out to many underdeveloped and developing countries through rapid urbanization and industrialization. Most casualties of severe trauma, which results in significant mortality and disability are assessed and transported by prehospital providers including physicians, professional providers, and volunteer providers. Trauma registries have been developed in mostly developed countries and measure care quality, process, and outcomes. In general, existing registries tend to focus on inhospital care rather than prehospital care. Methods: The Pan-Asia Trauma Outcomes Study (PATOS) was proposed in 2013 and initiated in November, 2015 in order to establish a collaborative standardized study to measure the capabilities, processes and outcomes of trauma care throughout Asia. The PATOS is an international, multicenter, and observational research network to collect trauma cases transported by emergency medical services (EMS) providers. Data are collected from the participating hospital emergency departments in various countries in Asia which receive trauma patients from EMS. Data variables collected include 1) injury epidemiologic factors, 2) EMS factors, 3) emergency department care factors, 4) hospital care factors, and 5) trauma system factors. The authors expect to achieve a sample size of 67,230 cases over the next 2 years of data collection to analyze the association between potential risks and outcomes of trauma. Conclusion: The PATOS network is expected to provide comparison of the trauma EMS systems and to benchmark best practice with participating communities. [ABSTRACT FROM AUTHOR]

Objective The present study aimed to determine whether the time of out-of-hospital cardiac arrest ( OHCA) is associated with survival rate and neurological outcome after OHCA, as well as to compare the effect size of time of OHCA across six Asian regions. Methods We collected data from the Pan-Asian Resuscitation Outcomes Study registry, six Asian regions (Tokyo, Osaka, Aichi, Seoul, Taipei and Singapore) from 2009 to 2012. Adult OHCA cases were divided depending on the arrest time: I (00.01-06.00 hours), II (06.01-12.00 hours), III (12.01-18.00 hours) and IV (18.01-24.00 hours). Using a multivariable logistic regression analysis, we compared the outcomes of survival and good neurological recovery. Results Of 65 413 cases treated by the emergency medical service, 36 706 (56.1%) cases were analysed. There was the lowest OHCA incidence in time block I. Compared with time block I, the adjusted odds ratios and 95% confidence intervals for the standardised survival rate were 1.6 (1.3-1.9) in time block II, 1.4 (1.2-1.7) in time block III and 1.2 (1.0-1.4) in time block IV. Regarding the good neurological recovery rate, compared with time block I, the adjusted odds ratios and 95% confidence intervals were 1.9 (1.5-2.4) in time block II, 1.7 (1.3-2.1) in time block III and 1.4 (1.1-1.7) in time block IV. However, in the subgroup analysis, there were regional differences between Japan and the other regions. Conclusions We found diurnal similarities in OHCA occurrence, as well as differences in survival rate and good neurological recovery rate among Asian regions. [ABSTRACT FROM AUTHOR]

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

Objective:Prehospital time potentially impacts clinical outcomes in severely injured trauma patients. The importance of individual components, including scene and response time, however, is controversial. Our objective was to determine the impact of prehospital times on survival in severely injured patients.Methods:We reviewed injured trauma patients enrolled in a Korean EMS trauma registry during 2012. Severe trauma patients were defined as having either a “V” or lower in the AVPU system, a systolic blood pressure ≤90mmHg, or respiratory rate <10 or >29. Patients with Injury Severity Scores(ISS) < 9 were excluded. Patients were categorized by scene time into 4 groups as follows: <3 minutes, 3–6 minutes, 6–9 minutes, and ≥9 minutes and by prehospital time as follows: <16 minutes, 16–24 minutes, 24–32 minutes, and ≥32 minutes. The primary outcome was in-hospital mortality. Multiple linear regression analysis was used to adjust for possible confounders.Results:A total of 2,257 eligible patients were analyzed. Scene time was <3 minutes in 220 (9.7%), 3–6 in 865 (38.3%), 6–9 in 587 (26.0%), and ≥9 in 585 (25.9%). In-hospital mortality was 396 (17.5%). Compared to a scene time 6 to 9 minutes, mortality was higher as the scene time decreased: odds ratio (OR) = 1.3(3 to <6), OR = 1.9(0 to <3). Mortality was slightly decreased as prehospital time increased, OR = 1.0(16 to <24), OR = 0.9(24 to <32), OR = 0.7(≥32).Conclusion:Longer prehospital times did not increase mortality in severely injured trauma patients in Korea. Furthermore, longer scene times were associated with lower mortality. [ABSTRACT FROM PUBLISHER]