Aims: The HOPE score, based on covariates available at hospital admission, predicts the probability of inhospital survival after extracorporeal life support (ECLS) rewarming of a given hypothermic cardiac arrest patient with accidental hypothermia. Our goal was to externally validate the HOPE score. Methods: We included consecutive hypothermic arrested patients who underwent rewarming with ECLS. The sample comprised 122 patients. The six independent predictors of survival included in the HOPE score were collected for each patient: age, sex, mechanism of hypothermia, core temperature at admission, serum potassium level at admission and duration of CPR. The primary outcome parameter was survival to hospital discharge. Results: Overall, 51 of the 122 included patients survived, resulting in an empirical (global) probability of survival of 42% (95% CI=[33-51%]). This was close to the average HOPE survival probability of 38% calculated for patients from the validation cohort, while the Hosmer-Lemeshow test comparing empirical and HOPE (i.e. estimated) probabilities of survival was not significant (p=0.08), suggesting good calibration. The corresponding area under the receiver operating characteristic curve was 0.825 (95% CI=[0.753-0.897]), confirming the excellent discrimination of the model. The negative predictive value of a HOPE score cutoff of <0.10 was excellent (97%). Conclusions: This study provides the first external validation of the HOPE score reaching good calibration and excellent discrimination. Clinically, the prediction of the HOPE score remains accurate in the validation sample. The HOPE score may replace serum potassium in the future as the triage tool when considering ECLS rewarming of a hypothermic cardiac arrest victim.
Prolonged cardiac arrest (CA) may lead to neurologic deficit in survivors. Good outcome is especially rare when CA was unwitnessed. However, accidental hypothermia is a very specific cause of CA. Our goal was to describe the outcomes of patients who suffered from unwitnessed hypothermic cardiac arrest (UHCA) supported with Extracorporeal Life Support (ECLS). We included consecutive patients’ cohorts identified by systematic literature review concerning patients suffering from UHCA and rewarmed with ECLS. Patients were divided into four subgroups regarding the mechanism of cooling, namely: air exposure; immersion; submersion; and avalanche. A statistical analysis was performed in order to identify the clinical parameters associated with good outcome (survival and absence of neurologic impairment). A total of 221 patients were included into the study. The overall survival rate was 27%. Most of the survivors (83%), had no neurologic deficit. Asystole was the presenting CA rhythm in 48% survivors, of which 79% survived with good neurologic outcome. Variables associated with survival included the following: female gender (P < .001); low core temperature (P = .005); non‐asphyxia‐related mechanism of cooling (P < .001); pulseless electrical activity as an initial rhythm (P < .001); high blood pH (P < .001); low lactate levels (P = .003); low serum potassium concentration (P < .001); and short resuscitation duration (P = .004). Severely hypothermic patients with unwitnessed CA may survive with good neurologic outcome, including those presenting as asystole. The initial blood pH, potassium, and lactate concentration may help predict outcome in hypothermic CA.
BackgroundTension gastrothorax is a kind of obstructive shock with prolapse and distention of the stomach into the thoracic cavity. Progressive gastric distension leads to mediastinal shift, reduced venous return, decreased cardiac output, and ultimately cardiac arrest. Therefore, it is crucial to decompress the stomach distension for the initial resuscitation of tension gastrothorax.Case presentationA 75-year-old female was transported to our resuscitation bay due to motor vehicle crash. At the time of arrival to our hospital, the patient developed cardiac arrest. While undergoing cardiopulmonary resuscitation, an unstable pelvic ring was recognized, so we performed a resuscitative thoracotomy to control hemorrhage and to perform direct cardiac massage. Once we performed the thoracotomy, the stomach and omentum prolapsed out of the thoracotomy site and through the diaphragm rupture site and spontaneous circulation was recovered. Neither the descending aorta nor the heart was collapsed. Although we had continued the treatment for severe pelvic fracture (including blood transufusions), the patient died. Given that (1) the stomach prolapsed out of the body at the time of the thoracotomy; (2) at the same timing, spontaneous circulation returned; and (3) the descending aorta and heart did not collapse, we hypothesized that the main cause of the initial cardiac arrest was tension gastrothorax.ConclusionsRecognition of tension gastrothorax pathophysiology, which is a form of obstructive shock, makes it possible to manage this injury correctly.
Organophosphorus (OP) pesticide poisoning is a leading cause of morbidity and mortality in the developing world, affecting an estimated three million people annually. Much of the morbidity is directly related to muscle weakness, which develops 1-4 days after poisoning. This muscle weakness, termed the intermediate syndrome (IMS), leads to respiratory, bulbar, and proximal limb weakness and frequently necessitates the use of mechanical ventilation. While not entirely understood, the IMS is most likely due to persistently elevated acetylcholine (ACh), which activates nicotinic ACh receptors at the neuromuscular junction (NMJ). Thus, the NMJ is potentially a target-rich area for the development of new therapies for acute OP poisoning. In this manuscript, we discuss what is known about the IMS and studies investigating the use of nicotinic ACh receptor antagonists to prevent or mitigate NMJ dysfunction after acute OP poisoning.
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