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

Abstract

AimThis 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.MethodsOut‐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.ResultsDuring 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).ConclusionsOut‐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.

Unusual Cause of Cardiac Arrest

“…Fisher-Hubbard et al estimated the outpatient incidence of defecation-induced cardiac arrests as 2.3% to 7.4% in patients with cardiovascular disease. Kiyohara et al identified that 4.6% of out-of-hospital cardiac arrest occurred inside the restroom, and the number of patients with the initial shockable rhythm was 5.2%. Based on these studies, it is suggestive that one of the unrecognized causes of sudden cardiac death in patients with heart failure is defecation-induced bradyarrhythmia.…”

Adult influenza epidemic is associated with out-of-hospital cardiac arrest

“…We have reported the associations between OHCA-CA and dental caries, [8] seafood consumption, [9] and consumption of carbonated beverages [10] using the All-Japan Utstein Registry. Cold month in the toilet, [11] severe emotional stress, [12,13] climate, [14][15][16] and temperature [17][18][19] have also been reported to be causes of OHCA-CA in Japan.…”

Does the position of the body impact the return of spontaneous circulation and hospital survival in sudden cardiac arrest patients?

“…Reports regarding body position at EMS arrival to the arrested patient in the literature are scarce, and this was not the primary consideration of the available publications [11,12,16]. The victim's body position at EMS arrival was not included in the Utstein style reporting of cardiac arrest; therefore, the data were not systematically collected.…”

“…However, some information is available from papers regarding the occurrence of cardiac arrest in toilets or circumstances of OHCA recorded on video [16]. Kiyohara et al [12] reported that 4.6% of OHCA in Japan occurred in a toilet. The outcome of these events was poor, mainly because of delayed recognition.…”

“…However, it cannot be ruled out that sitting may be associated with activities involved in the cause of cardiac arrest, such as passing urine or stool [12]. Delay in assuming a horizontal position is likely to extend the duration of loss of consciousness (LOC) and potentially lead to permanent cardiac arrest [13].…”