Epidemiology and outcomes of anaphylaxis-associated out-of-hospital cardiac arrest

A potentially lifesaving error: unintentional high-dose adrenaline administration in anaphylaxis-induced cardiac arrest; a case report

BACKGROUND

Cardiopulmonary resuscitation is a crucial skill for emergency medical services. As high-risk-low-frequency events pose an immense mental load to providers, concepts of crew resource management, non-technical skills and the science of human errors are intended to prepare healthcare providers for high-pressure situations. However, medical errors occur, and organizations and institutions face the challenge of providing a blame-free error culture to achieve continuous improvement by avoiding similar errors in the future. In this case, we report a critical medical error during an anaphylaxis-associated cardiac arrest, its handling and the unexpected yet favourable outcome for the patient.

CASE PRESENTATION

During an out-of-hospital cardiac arrest due to chemotherapy-induced anaphylaxis, a patient received a 10-fold dose of epinephrine due to shortcomings in communication and standardization via a central venous port catheter. The patient converted from a non-shockable rhythm into a pulseless ventricular tachycardia and subsequently into ventricular fibrillation. The patient was cardioverted and defibrillated and had a return of spontaneous circulation with profound hypotension only 6 min after the administration of 10 mg epinephrine. The patient survived without any residues or neurological impairment.

CONCLUSIONS

This case demonstrates the potential deleterious effects of shortcomings in communication and deviation from standard protocols, especially in emergencies. Here, precise instructions, closed-loop communication and unambiguous labelling of syringes would probably have avoided the epinephrine overdose central to this case. Interestingly, this serious error may have saved the patient's life, as it led to the development of a shockable rhythm. Furthermore, as the patient was still in profound hypotension after administering 10 mg of epinephrine, this high dose might have counteracted the severe vasoplegic state in anaphylaxis-associated cardiac arrest. Lastly, as the patient was receiving care for advanced malignancy, the likelihood of termination of resuscitation in the initial non-shockable cardiac arrest was significant and possibly averted by the medication error.

Impact of Awareness Time Interval on the Effect of Bystander Cardiopulmonary Resuscitation on Out-of-Hospital Cardiac Arrest: A Nationwide Study

PURPOSE

The awareness time interval (ATI), the time from the witnessed event to emergency medical service (EMS) activation, is an important factor influencing out-of-hospital cardiac arrest (OHCA) outcomes. Since bystander cardiopulmonary resuscitation (BCPR) is provided after cardiac arrest is recognized, the effect of BCPR may vary depending on ATI delay. We aimed to investigate whether ATI modifies the effect of BCPR on OHCA outcomes.

MATERIALS AND METHODS

A population-based observational study was conducted with EMS-treated witnessed adult (≥18 years) OHCAs between 2013 and 2018. The exposure variable was provision of BCPR. The primary outcome was a good neurological outcome defined as cerebral performance category scale 1or 2 (good CPC). Multivariable logistic regression analysis was conducted using the ATI group (-1, 1-5, 5- min) as the interaction term.

RESULTS

Of 34366 eligible OHCAs, 65.5% received BCPR. EMS was activated within 1 min in 45.9%, within 1-5 min in 29.2%, and after 5 min in 24.9% cases. In the adjusted interaction model, compared with no BCPR, a longer ATI resulted in smaller adjusted odds ratios for good CPC in the BCPR group [5.33 (4.17-6.82) for ATI ≤1 min, 5.14 (4.00-6.60) for 1-5 min, and 2.14 (1.63-2.81) for ATI >5 min].

CONCLUSION

The effect of BCPR on improving the chances for a good neurological outcome decreased as time from collapse to EMS activation increased. The importance of early recognition of OHCA and EMS activation should be emphasized in BCPR training.

Individual socioeconomic status and risk of out-of-hospital cardiac arrest: A nationwide case-control analysis

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.

Cardiac arrest caused by anaphylaxis refractory to prompt management: A case series and review of the literature

BACKGROUND

Anaphylaxis is a potentially life-threatening condition that occurs in the emergency department (ED). Although anaphylaxis is rapidly recognized and treated in the hospital compared with that in the community, in some cases, it does not respond to proper management.

OBJECTIVE

The aim of this study is to describe our experience of cases of refractory anaphylaxis leading to cardiac arrest in hospital, to review their characteristics compared with those seen in the community, and to discuss the best management practices for anaphylaxis-induced cardiac arrest with a literature review.

METHODS

We reviewed the medical records of patients referred to the ED with possible in-hospital anaphylaxis between January 2017 and May 2021. According to the anaphylaxis protocol, epinephrine, corticosteroid, and antihistamine were administered immediately on-site at our institution before the study period. Refractory anaphylaxis was defined as the development of anaphylaxis-induced cardiac arrest even after following the anaphylaxis protocol.

RESULTS

A total of 246 cases were evaluated for possible anaphylaxis, with 236 cases meeting the criteria for a diagnosis of anaphylaxis. Among them, 178 patients showed the signs and symptoms of shock, and cardiac arrest occurred in 6 patients (2.5%). Of the six patients, three had a return of spontaneous circulation before admission to the ED, while two died due to refractory cardiac arrest despite resuscitation in the ED. Following post-cardiac arrest care, including temperature management, one patient who received extracorporeal cardiopulmonary resuscitation survived neurologically intact.

CONCLUSION

We present our case series to highlight the risk of developing refractory anaphylaxis with subsequent in-hospital cardiac arrest. Patients may progress to cardiac arrest within minutes despite prompt recognition and management. If patients present with potentially fatal symptoms, a more aggressive approach, including intravenous adrenaline infusion, should be taken.

Characteristics of anaphylaxis patients who visited emergency departments in Korea: Results from a national emergency department information system

Background

Anaphylaxis is an allergic disease with fatal respiratory or cardiovascular symptoms that require immediate emergency treatment. We aimed to understand the characteristics and frequency of emergency department (ED) visits of patients with anaphylaxis in Korea.

Methods

Between 2007 and 2013, using data from 147 ED from the National Emergency Department Information System in Korea, we retrospectively evaluated patients with a primary diagnosis of anaphylaxis.

Results

During the study, a total 23,313 patients visited the ED due to anaphylaxis. The number of patients with anaphylaxis who visited the ED increased from 3.0 per 100,000 population in 2007 to 11.6 per 100,000 population in 2013 (P<0.001). Overall, the frequency of anaphylaxis emergency department visits increased by 1.24 times each year (95% CI 1.23–1.25). The risk of visiting ED due to anaphylaxis by population-based age-specific group was highest in the 60–69 years old (OR 2.30, 95% CI 1.96–2.70). Deaths from anaphylaxis increased by 1.35 times per year (95% CI 1.13–1.62). The causes of anaphylaxis were unknown (80.8%; 95% CI 80.35–81.38), drugs (8.9%; 95% CI 8.47–9.24), food (4.1%; 95% CI 3.87–4.39), bees (3.2%; 95% CI 3.02–3.48) and arthropods (2.3%; 95% CI 2.11–2.48). In 2009, drugs were the most common cause of anaphylaxis in November (35.5%), followed by food in May (15.5%) (P<0.001). Between July and September, stings from insects were the most common causes (P<0.001). By age, food was the most common cause in children aged <6 years (7.6%, <12 months; 9.0%, 1–6 years) and drugs in those aged ≥7 years. The 7-year overall mortality rate was 0.104 case per 1,000,000 population; men accounted for 77.8% of the deaths. By region, the number of cases was the highest in metropolitan areas, Gyeonggi and Seoul; however, the number of anaphylaxis cases per 100,000 population was the highest in Jeju and Gangwon.

Conclusion

Based on ICD-10 codes, the number of ED visits due to anaphylaxis is increasing in Korea, and the incidence of anaphylaxis varies by region, season, and age.

Mortality rate and prognostic factors for dogs with severe anaphylaxis: 67 cases (2016-2018)

OBJECTIVE

To determine mortality rates for dogs with severe anaphylaxis and identify potential prognostic factors.

ANIMALS

67 dogs with suspected anaphylaxis graded as severe.

PROCEDURES

Dogs were classified on the basis of outcome as survivors and nonsurvivors. Medical records were reviewed, and data were extracted including signalment, examination findings, time to hospital admission from onset of clinical signs, CBC results, serum biochemical analysis results, coagulation testing results, and findings on abdominal ultrasonography. Initial treatment within the first 6 hours after hospital admission was recorded for analysis, specifically including the use of epinephrine, diphenhydramine, corticosteroids, antimicrobials, fresh-frozen plasma, and supplemental dextrose.

RESULTS

The overall mortality rate was 14.9% (10/67) for dogs with anaphylaxis graded as severe. Serum phosphorus concentration and prothrombin time (PT) were significantly higher in nonsurvivors, compared with survivors. Nonsurvivors had lower presenting body temperatures than survivors. Serum phosphorus concentration ≥ 12.0 mmol/L, hypoglycemia within 6 hours after hospital admission, high PT value, concurrently high PT and partial thromboplastin time (PTT) values > 50% above the reference range limit, and the need for supplemental dextrose were associated with death. The incidences of coagulopathy and peritoneal effusion were unexpectedly high (85.2% and 65.5% of dogs, respectively) but were not indicative of survival.

CONCLUSIONS AND CLINICAL RELEVANCE

Despite the poor presenting clinical condition seen in dogs with severe anaphylaxis, the rate of survival with treatment was fairly high. Coagulopathy and the presence of peritoneal effusion were common findings in dogs with severe anaphylaxis. Serum phosphorus concentration ≥ 12.0 mmol/L, high PT value, concurrent increases of PT and PTT values > 50% above reference range limits, hypoglycemia within 6 hours after hospital admission, and the need for supplemental dextrose were associated with death.

Outcomes after out-of-hospital cardiac arrests by anaphylaxis: A nationwide population-based observational study

AIM

The objective of this study was to focus on outcomes of anaphylaxis-associated out-of hospital cardiac arrest (OHCA) in non-cardiac cases.

METHODS

All residents with OHCA due to non-cardiac cause in Japan from 2013 to 2015 were included for analysis. Propensity score matching and logistic regression analyses were used to assess outcome-related factors in anaphylaxis cases and non-anaphylaxis cases. The comparison group was comprised of non-anaphylaxis cases, which consisted of other cases of non-cardiac etiology.

RESULTS

A total of 375,874 OHCA cases were included, of which 148,598 were due to non-cardiac cause. In these non-cardiac OHCA cases, 147 were due to anaphylaxis, with an annual incidence of 0.04 per 100,000. In the patients' characteristics, witnessed ratio, shockable rhythm, defibrillation by emergency medical services (EMS), and treatment with adrenaline by EMS were significantly greater in the anaphylaxis cases compared with the non-anaphylaxis cases. In anaphylaxis cases, the crude 1-month survival rate (32.7% versus 5.3%) and crude favorable neurological outcomes rate (24.5% versus 2.2%) were higher compared with non-anaphylaxis cases (P < 0.001). The differences in outcomes between the two types of cases were also marked after we adjusted these variables by propensity score matching. By logistic regression analyses, administration of a drug by EMS was negatively associated with good neurological outcomes (odds ratio, 0.27; 95% confidence interval, 0.09-0.87), but bystander cardiopulmonary resuscitation was positively associated with good neurological outcomes (odds ratio, 2.33; 95% confidence interval, 0.99-5.52).

CONCLUSION

Neurological outcome was markedly more favorable in cases with anaphylaxis than non-anaphylaxis cases. Further studies are needed to explain this result.

Effect of Implementation of Cardiopulmonary Resuscitation-Targeted Multi-Tier Response System on Outcomes After Out-of-Hospital Cardiac Arrest: A Before-and-After Population-Based Study

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.