Background: This study evaluated the association between the results of immediate brain computed tomography (CT) scans and outcome in patients who were treated with therapeutic hypothermia after cardiac arrest. The evaluation was based on the changes in the ratio of gray matter to white matter. Methods: A total of 167 patients who were successfully resuscitated after cardiac arrest from March 2009 to December 2011 were included in this study. We selected 51 patients who received a brain CT scan within 1 hour after the return of spontaneous circulation (ROSC) and who had been treated with therapeutic hypothermia. Circular regions of measurement (10 mm²) were placed over regions of interest (ROIs), and the average attenuations in gray matter (GM) and white matter (WM) were recorded in the basal ganglia, at the level of the centrum semiovale and in the high convexity area. Three GM-to-WM ratios (GWRs) were calculated: one for the basal ganglia, one for the cerebrum and the average of the two. The neurological outcomes were assessed using the Cerebral Performance Category (CPC) scale at the time of hospital discharge, and a good neurological outcome was defined as a CPC score of 1 or 2. Results: The average GWR was the strongest predictor of poor neurological outcome as determined using receiver operating characteristic curves (basal ganglia area under the curve (AUC) = 0.716; cerebrum AUC = 0.685; average AUC = 0.747). An average GWR < 1.14 predicted a poor neurological outcome with a sensitivity of 13.3% (95% confidence interval (CI) 3.8-30.7), a specificity of 100% (95% CI 83.9-100), a positive predictive value of 100% (95% CI 2.5-100), and a negative predictive value of 44.7% (CI 28.9-58.9). Conclusions: Our study demonstrated that low GWRs in the immediate brain CT scans of patients treated with therapeutic hypothermia after ROSC were associated with poor neurological outcomes. Immediate brain CT scans could help predict outcome after cardiac arrest.

Background—Modern treatments have improved the survival rate following cardiac arrest, but prognostication remains a challenge. We examined the prognostic value of continuous electroencephalography according to time by performing amplitude-integrated electroencephalography on cardiac arrest patients receiving therapeutic hypothermia.

Introduction: The aim of this study was to examine whether the patterns of diffusion-weighted imaging (DWI) abnormalities and quantitative regional apparent diffusion coefficient (ADC) values can predict the clinical outcome of comatose patients following cardiac arrest. Methods: Thirty-nine patients resuscitated from out-of-hospital cardiac arrest were prospectively investigated. Within five days of resuscitation, axial DWIs were obtained and ADC maps were generated using two 1.5-T magnetic resonance scanners. The neurological outcomes of the patients were assessed using the Glasgow Outcome Scale (GOS) score at three months after the cardiac arrest. The brain injuries were categorised into four patterns: normal, isolated cortical injury, isolated deep grey nuclei injury, and mixed injuries (cortex and deep grey nuclei). Twenty-three subjects with normal DWIs served as controls. The ADC and percent ADC values (the ADC percentage as compared to the control data from the corresponding region) were obtained in various regions of the brains. We analysed the differences between the favourable (GOS score 4 to 5) and unfavourable (GOS score 1 to 3) groups with regard to clinical data, the DWI abnormalities, and the ADC and percent ADC values. Results: The restricted diffusion abnormalities in the cerebral cortex, caudate nucleus, putamen and thalamus were significantly different between the favourable (n = 13) and unfavourable (n = 26) outcome groups. The cortical pattern of injury was seen in one patient (3%), the deep grey nuclei pattern in three patients (8%), the cortex and deep grey nuclei pattern in 21 patients (54%), and normal DWI findings in 14 patients (36%). The cortex and deep grey nuclei pattern was significantly associated with the unfavourable outcome (20 patients with unfavourable vs. 1 patient with favourable outcomes, P < 0.001). In the 22 patients with quantitative ADC analyses, severely reduced ADCs were noted in the unfavourable outcome group. The optimal cutoffs for the mean ADC and the percent ADC values determined by receiver operating characteristic (ROC) curve analysis in the cortex, caudate nucleus, putamen, and thalamus predicted the unfavourable outcome with sensitivities of 67 to 93% and a specificity of 100%. Conclusions: The patterns of brain injury in early diffusion-weighted imaging (DWI) (less than or equal to five days after resuscitation) and the quantitative measurement of regional ADC may be useful for predicting the clinical outcome of comatose patients after cardiac arrest.

Background: We evaluated the validity of the Canadian Triage and Acuity Scale (CTAS) in elderly emergency department (ED) patients. In particular, we examined the sensitivity and specificity of the CTAS for identifying elderly patients who received an immediate life-saving intervention in the ED. Methods: We reviewed the medical records of consecutive patients who were 65 years of age or older and presented to a single academic ED within a three-month period. The CTAS triage scores were compared to actual patient course, including disposition, discharge outcome and resource utilization. We calculated the sensitivity and specificity of the CTAS triage for identifying patients who received an immediate intervention. Results: Of the 1903 consecutive patients who were ≥ 65 years of age, 113 (5.9%) had a CTAS level of 1, 174 (9.1%) had a CTAS level of 2, 1154 (60.6%) had a CTAS level of 3, 347 (18.2%) had a CTAS level of 4, and 115 (6.0%) had a CTAS level of 5. As a patient's triage score increased, the severity (such as mortality and intensive care unit admission) and resource utilization increased significantly. Ninety-four of the patients received a life-saving intervention within an hour following their arrival to the ED. The CTAS scores for these patients were 1, 2 and 3 for 46, 46 and 2 patients, respectively. The sensitivity and specificity of a CTAS score of ≤ 2 for identifying patients for receiving an immediate intervention were 97.9% and 89.2%, respectively. Conclusions: The CTAS is a triage tool with high validity for elderly patients, and it is an especially useful tool for categorizing severity and for recognizing elderly patients who require immediate life-saving intervention.

Background: This study was designed to compare the effectiveness of using auscultation, pH measurements of gastric aspirates, and ultrasonography as physical examination methods to verify nasogastric tube(NGT) placement in emergency room patients with low consciousness who require NGT insertion. Methods: The study included 47 patients who were all over 18 years of age. In all patients, tube placement was verified by chest X-rays. Auscultation, pH analysis of gastric aspirates, and ultrasonography were conducted on each patient in random order. The mean patient age was 57.62 ± 17.24 years, and 28 males (59.6%) and 19 females (40.4%) were included. The NGT was inserted by an emergency room resident. For pH testing, gastric aspirates were dropped onto litmus paper, and the resulting color of the paper was compared with a reference table. Ultrasonography was performed by an emergency medicine specialist, and the chest X-ray examination was interpreted by a different emergency medicine specialist who did not conduct the ultrasonography test. The results of the auscultation, gastric aspirate pH, and ultrasonography examinations were compared with the results of the chest x-ray examination. Results: The sensitivity and specificity were 100% and 33.3%, respectively, for auscultation and 86.4% and 66.7%, respectively, for ultrasonography. Kappa values were the highest for auscultation at 0.484 compared to chest x-rays, followed by 0.299 for ultrasonography and 0.444 for pH analysis of the gastric aspirate. The ultrasonography has a positive predictive value of 97.4% and a negative predictive value of 25%. Conclusions: Ultrasonography is useful for confirming the results of auscultation after NGT insertion among patients with low consciousness at an emergency center. When ultrasound findings suggest that the NGT placement is not gastric, additional chest X-ray should be performed.

Purpose: To assess the performance of the post-cardiac arrest (CA) prognostication strategy algorithm recommended by the European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) in 2020. Methods: This was a retrospective analysis of the Korean Hypothermia Network Prospective Registry 1.0. Unconscious patients without confounders at day 4 (72–96 h) after return of spontaneous circulation (ROSC) were included. The association between the prognostic factors included in the prognostication strategy algorithm, except status myoclonus and the neurological outcome, was investigated, and finally, the prognostic performance of the prognostication strategy algorithm was evaluated. Poor outcome was defined as cerebral performance categories 3–5 at 6 months after ROSC. Results: A total of 660 patients were included in the final analysis. Of those, 108 (16.4%) patients had a good neurological outcome at 6 months after CA. The 2020 ERC/ESICM prognostication strategy algorithm identified patients with poor neurological outcome with 60.2% sensitivity (95% CI 55.9–64.4) and 100% specificity (95% CI 93.9–100) among patients who were unconscious or had a GCS_M score ≤ 3 and with 58.2% sensitivity (95% CI 53.9–62.3) and 100% specificity (95% CI 96.6–100) among unconscious patients. When two prognostic factors were combined, any combination of prognostic factors had a false positive rate (FPR) of 0 (95% CI 0–5.6 for combination of no PR/CR and poor CT, 0–30.8 for combination of No SSEP N20 and NSE 60). Conclusion: The 2020 ERC/ESICM prognostication strategy algorithm predicted poor outcome without an FPR and with sensitivities of 58.2–60.2%. Any combinations of two predictors recommended by ERC/ESICM showed 0% of FPR.