Cardiac arrest in the toilet: clinical characteristics and resuscitation profiles

Prevalence of intracranial hemorrhage amongst patients presenting with out-of-hospital cardiac arrest: A systematic review and meta-analysis

INTRODUCTION

An unknown proportion of out-of-hospital cardiac arrest (OHCA) is caused by intracranial hemorrhage (ICH). There is uncertainty over the role of early head computed tomography (CT) in non-traumatic OHCA due to uncertain diagnostic yield and ways to identify high-risk patients. This study aimed to identify the prevalence of ICH in non-traumatic OHCA and possible predictors.

METHODS

PubMed, EMBASE, and the Cochrane library were searched from inception to January 2022. Data extraction and quality assessment were independently reviewed by two authors. Meta-analyses estimated the prevalence of ICH amongst OHCA patients and pre-specified subgroups and geographical settings. Subgroup analysis were used to explore potential clinical predictors.

RESULTS

23 studies involving 54,349 patients were included. The pooled ICH prevalence was 4.28% (95%CI: 3.31-5.24). Asia had a significantly larger risk ratio (RR= 3.93, P value < 0.0001) than Europe. The ICH subgroup was significantly more likely to be female (OR: 2.16; 95%CI: 1.10-4.26), and less likely to experience shockable rhythms compared with non-shockable rhythms (OR: 0.22; 95% CI: 0.04-1.22), achieve ROSC prior to arrival (OR: 0.27; 95%CI: 0.10-0.77), and survive to discharge compared to those without ICH (OR: 0.26; 95%CI: 0.11-0.59).

CONCLUSIONS

One in twenty OHCA have ICH at the time of presentation. An early head CT scan should be strongly considered after return of spontaneous circulation (ROSC), especially in patients who are female, with non-shockable rhythm and did not attain ROSC prior to arrival. These finding should influence clinical protocols to favor routine scans especially in Asia where prevalence is higher.

Design and evaluation of a novel approach to invisible electrocardiography (ECG) in sanitary facilities using polymeric electrodes

Multiple wearable devices for cardiovascular self-monitoring have been proposed over the years, with growing evidence showing their effectiveness in the detection of pathologies that would otherwise be unnoticed through standard routine exams. In particular, Electrocardiography (ECG) has been an important tool for such purpose. However, wearables have known limitations, chief among which are the need for a voluntary action so that the ECG trace can be taken, battery lifetime, and abandonment. To effectively address these, novel solutions are needed, which has recently paved the way for “invisible” (aka “off-the-person”) sensing approaches. In this article we describe the design and experimental evaluation of a system for invisible ECG monitoring at home. For this purpose, a new sensor design was proposed, novel materials have been explored, and a proof-of-concept data collection system was created in the form of a toilet seat, enabling ECG measurements as an extension of the regular use of sanitary facilities, without requiring body-worn devices. In order to evaluate the proposed approach, measurements were performed using our system and a gold standard equipment, involving 10 healthy subjects. For the acquisition of the ECG signals on the toilet seat, polymeric electrodes with different textures were produced and tested. According to the results obtained, some of the textures did not allow the acquisition of signals in all users. However, a pyramidal texture showed the best results in relation to heart rate and ECG waveform morphology. For a texture that has shown 0% signal loss, the mean heart rate difference between the reference and experimental device was − 1.778 ± 4.654 Beats per minute (BPM); in terms of ECG waveform, the best cases present a Pearson correlation coefficient above 0.99.

Public health impact of daily life triggers of sudden cardiac death: A systematic review and comparative risk assessment

BACKGROUND

Sudden cardiac death (SCD) may be triggered by daily circumstances and activities such as stressful psycho-emotional events, physical exertion or substance misuse. We calculated population attributable fractions (PAFs) to estimate the public health relevance of daily life triggers of SCD and to compare their population impacts.

METHODS

We searched PubMed, Scopus and the Web of Science citation databases to retrieve studies of triggers of SCD and cardiac arrest that would enable a computation of PAFs. When more studies investigated the same trigger, a meta-analytical pooled risk random-effect estimate was used.

RESULTS

Of the retrieved studies, eight provided data enabling computation of PAFs. The prevalence of exposure within population for SCD triggers in the control periods ranged from 1.06% for influenza infection to 8.73% for recent use of cannabis. Triggers ordered from the highest to the lowest risk increase were: physical exertion, recent cocaine use, episodic alcohol consumption, recent amphetamine use, episodic coffee consumption, psycho-emotional stress within the previous month, influenza infection, and recent cannabis use. The relative risk increase ranged from 1.10 to 4.98. By accounting for both the magnitude of the risk increase and the prevalence in the population, the present estimates of PAF assign 14.5% (95% confidence interval [CI] 4.9-28.5) of all SCDs to episodic alcohol consumption, 9.4% (95% CI 1.2-29.3) to physical exertion, 6.9% (95% CI 0.3-25.0) to cocaine, 6% (95% CI 1.2-14.6) to episodic coffee consumption, 3% (95% CI 0.4-6.8) to psycho-emotional stress in the previous month, 1.7% (95% CI -0.9 to 12.9) to amphetamines, 0.9% (95% CI -4.9 to 12.5) to cannabis, and 0.3% (95% CI 0.2-0.4) to influenza infections.

CONCLUSIONS

In addition to episodic alcohol consumption, a trigger with the greatest public health importance for SCD, episodic physical exertion, cocaine use and coffee consumption also show a considerable population impact.

The SADDEN DEATH Study: Results from a Pilot Study in Non-ICU COVID-19 Spanish Patients

Introduction: The worldwide pandemic, coronavirus disease 2019 (COVID-19) is a novel infection with serious clinical manifestations, including death. Our aim is to describe the first non-ICU Spanish deceased series with COVID-19, comparing specifically between unexpected and expected deaths. Methods: In this single-centre study, all deceased inpatients with laboratory-confirmed COVID-19 who had died from March 4 to April 16, 2020 were consecutively included. Demographic, clinical, treatment, and laboratory data, were analyzed and compared between groups. Factors associated with unexpected death were identified by multivariable logistic regression methods. Results: In total, 324 deceased patients were included. Median age was 82 years (IQR 76-87); 55.9% males. The most common cardiovascular risk factors were hypertension (78.4%), hyperlipidemia (57.7%), and diabetes (34.3%). Other common comorbidities were chronic kidney disease (40.1%), chronic pulmonary disease (30.3%), active cancer (13%), and immunosuppression (13%). The Confusion, BUN, Respiratory Rate, Systolic BP and age ≥65 (CURB-65) score at admission was >2 in 40.7% of patients. During hospitalization, 77.8% of patients received antivirals, 43.3% systemic corticosteroids, and 22.2% full anticoagulation. The rate of bacterial co-infection was 5.5%, and 105 (32.4%) patients had an increased level of troponin I. The median time from initiation of therapy to death was 5 days (IQR 3.0-8.0). In 45 patients (13.9%), the death was exclusively attributed to COVID-19, and in 254 patients (78.4%), both COVID-19 and the clinical status before admission contributed to death. Progressive respiratory failure was the most frequent cause of death (92.0%). Twenty-five patients (7.7%) had an unexpected death. Factors independently associated with unexpected death were male sex, chronic kidney disease, insulin-treated diabetes, and functional independence. Conclusions: This case series provides in-depth characterization of hospitalized non-ICU COVID-19 patients who died in Madrid. Male sex, insulin-treated diabetes, chronic kidney disease, and independency for activities of daily living are predictors of unexpected death.

Out-of-hospital cardiac arrests in the toilet in Japan: a population-based descriptive study

Aim

This study aimed to reveal the characteristics and outcomes of patients with out‐of‐hospital cardiac arrests (OHCAs) occurring in the toilet. These traits provide useful clues for the prevention of OHCAs and the improvement of prehospital care for these patients.

Methods

Out‐of‐hospital cardiac arrest data were obtained from the population‐based, Utstein‐style registry in Osaka City, Japan, between 2009 and 2015. This study identified patients with OHCAs that occurred inside the toilet. The primary end‐point was 1‐month survival with favorable neurological outcome after OHCA.

Results

During the 7‐year study period, a total of 18,458 OHCAs were identified. Of these cases, 849 (4.6%) occurred inside the toilet. Among them, the analysis included 733 patients. The distribution depicting monthly OHCA occurrences showed that OHCAs tended to occur in cold months (28.1% [206/733] from October to December and 30.0% [220/733] from January to March). Most OHCAs occurring inside the toilet were of cardiac origin (91.5% [671/733]), and 36.2% (265/733) were witnessed by bystanders. The proportion of patients with ventricular fibrillation was 5.2% (38/733) and those receiving shocks by public‐access automated external defibrillators was 0.4% (3/733). The proportion of patients with 1‐month survival with favorable neurological outcome was 1.9% (14/733).

Conclusions

Out‐of‐hospital cardiac arrests occurring inside the toilet accounted for 4.6% of all OHCAs and were frequently observed during cold months, and their outcome was poor. Establishment of preventive measures against OHCAs occurring in the toilet as well as earlier recognition of OHCAs are needed.

Acute coronary syndromes occurring while driving: frequency and patient characteristics

Background

Acute coronary syndrome (ACS) may occur during any human activity, including driving. The objectives of this study were to report the frequency of ACS occurring while driving, clarify patient characteristics, and analyze the behavioral patterns of drivers who sustained ACS.

Methods

A single-center, retrospective observational study was conducted using prospectively acquired data. Among 1605 ACS patients admitted between January 2011 and December 2016, 65 (60 men/5 women) patients who sustained ACS while driving were identified. Clinical variables were compared between these 65 patients and 1540 patients who sustained ACS while performing other activities. Furthermore, multivariable regression analysis was performed to identify variables associated with ACS.

Results

The frequency of ACS occurring while driving was 4.0% (65/1605). Compared with patients who sustained ACS while performing other activities, those who sustained ACS while driving were significantly younger (66.2 ± 13.0 vs. 57.5 ± 12.2 years, p < 0.001) and more likely to smoke (34.2 vs. 60.0%, p < 0.001). Multivariable regression analysis showed that age (OR 0.961; 95% CI 0.940–0.982) and current smoking (OR 1.978; 95% CI 1.145–3.417) were associated with ACS. While 55 drivers (85%) who remained conscious after ACS could seek medical attention without causing accidents, the other 10 (15%) who sustained cardiac arrest caused accidents.

Conclusions

The association between current smoking and ACS occurring while driving suggests that smoking cessation is advised for smokers who drive from the standpoint of driving safety. We expect that prospective studies be conducted to verify our findings and identify individuals at risk for ACS while driving.

Electronic supplementary material

The online version of this article (10.1186/s12199-017-0689-5) contains supplementary material, which is available to authorized users.

Clinical characteristics of stroke occurring in the toilet: Are older adults more vulnerable?

AIM

While autonomic imbalance during defecation/micturition can cause hemodynamic instability, stroke occurring in the toilet has rarely been investigated. The objective of the present study was to clarify the frequency and clinical characteristics of toilet-related stroke.

METHODS

Clinical data prospectively acquired between January 2011 and December 2015 on 1939 patients with acute stroke (1224 cerebral infarctions [CI], 505 intracerebral hemorrhages [ICH] and 210 subarachnoid hemorrhages [SAH]) were reviewed to identify patients with a toilet-related stroke. For each stroke type, the ratios of stroke occurring during defecation/micturition to those occurring during other activities were calculated. Subsequently, how patients with toilet-related stroke were brought to medical attention was investigated. Whether older patients (aged >65 years) had an elevated ratio of toilet-related stroke was investigated in each stroke type.

RESULTS

A total of 108 patients (41 CI, 37 ICH and 30 subarachnoid hemorrhages) sustained a stroke in the toilet. The ratio of toilet-related stroke was highest in subarachnoid hemorrhages (14.3%), followed by ICH (7.3%). Circadian differences existed among the three stroke types: toilet-related CI were more likely to occur in the night-time than ICH. Patients with toilet-related CI were significantly more likely to sustain cardioembolic stroke. In all three stroke types, <40% of patients could call for help by themselves. Older patients showed a significantly higher proportion of toilet-related stroke in CI, but not in hemorrhagic strokes.

CONCLUSIONS

The toilet is a closed space where stroke occurs disproportionately frequently. Effort to reduce the incidence of toilet-related strokes is warranted, as early patient detection is not always feasible. Geriatr Gerontol Int 2018; 18: 250-255.

Clinical Characteristics of Stroke Occurring while Bathing

BACKGROUND

Stroke can occur during any human activity. Although cardiac arrests or drowning accidents while bathing have been studied extensively, there are few studies focusing on stroke occurring while bathing. The objectives of this study were to evaluate the clinical characteristics of stroke occurring while bathing and the association between stroke and drowning accidents.

METHODS

Clinical data prospectively acquired between January 2011 and December 2015 on 1939 patients with stroke (1224 cerebral infarctions [CIs], 505 intracerebral hemorrhages [ICHs], and 210 subarachnoid hemorrhages [SAHs]) were reviewed to identify patients who sustained a stroke while bathing. The ratio of bathing-related strokes to strokes occurring during other activities was evaluated. Moreover, the demographics of these 2 groups were compared in each stroke type.

RESULTS

Among the 1939 patients, 78 (CI, 32; ICH, 28; and SAH, 18) sustained a stroke while bathing. The ratio of bathing to other activities in the SAH group was the highest (8.6%), followed by the ICH group (5.5%), whereas that in the CI group was the lowest (2.6%). Regardless of stroke type, only a minority of patients were found to have collapsed inside the bathtub.

CONCLUSIONS

The higher ratio of bathing in hemorrhagic strokes may indicate that there is a small risk of hemorrhagic stroke while bathing in vulnerable subjects. This retrospective study did not establish a causal relationship between bathing and stroke nor identify risk factors, which means that future prospective studies are warranted. The finding that the great majority of bathing-related stroke patients were found to have collapsed outside the bathtub suggests that the involvement of stroke in drowning accidents in the bathtub may be small.