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Background Educational aspects in the training of advanced life support (ALS) represent a key role in critical care management of patients with out-of-hospital cardiac arrest (OHCA) and received special attention in guidelines of various international societies. While a positive association of feedback on ALS performance in training conditions is well established, data on the impact of a real-life post-resuscitation feedback on both ALS quality and outcome remain scarce and inconclusive. We aimed to elucidate the impact of a standardized post-resuscitation feedback on quality of ALS and improvements in patient outcome, in a real-life out-of-hospital setting. Methods We prospectively enrolled and analyzed 2209 patients presenting with OHCA receiving resuscitation attempts by the municipal emergency medical service (EMS) of Vienna over a two-year period. A standardized post-resuscitation feedback protocol was delivered to the respective EMS-team to elucidate its impact on the quality of ALS. Results We observed that both chest compression rates and ratios were in accordance to recommendations of recent guidelines. While interruptions of chest compressions longer than 30 s declined during the observation period (−6.5%) rates of the recommended chest compressions during defibrillator-charging periods increased (+8.9%). Since the percentage of ROSC and 30-day survival remained balanced, the frequencies of both survival until hospital discharge (+6.3%) and favorable neurological outcome (+16%) in survivors significantly increased during the observation period. Conclusion Improvements in the quality of advanced life support as well the patient outcome were observed after the implementation of a standardized post-resuscitation feedback protocol.

Background In CPR, sufficient compression depth is essential. The American Heart Association ("at least 5cm", AHA-R) and the European Resuscitation Council ("at least 5cm, but not to exceed 6cm", ERC-R) recommendations differ, and both are hardly achieved. This study aims to investigate the effects of differing target depth instructions on compression depth performances of professional and lay-rescuers. Methods 110 professional-rescuers and 110 lay-rescuers were randomized (1:1, 4 groups) to estimate the AHA-R or ERC-R on a paper sheet (given horizontal axis) using a pencil and to perform chest compressions according to AHA-R or ERC-R on a manikin. Distance estimation and compression depth were the outcome variables. Results Professional-rescuers estimated the distance according to AHA-R in 19/55 (34.5%) and to ERC-R in 20/55 (36.4%) cases ( p =0.84). Professional-rescuers achieved correct compression depth according to AHA-R in 39/55 (70.9%) and to ERC-R in 36/55 (65.4%) cases ( p =0.97). Lay-rescuers estimated the distance correctly according to AHA-R in 18/55 (32.7%) and to ERC-R in 20/55 (36.4%) cases ( p =0.59). Lay-rescuers yielded correct compression depth according to AHA-R in 39/55 (70.9%) and to ERC-R in 26/55 (47.3%) cases ( p =0.02). Conclusion Professional and lay-rescuers have severe difficulties in correctly estimating distance on a sheet of paper. Professional-rescuers are able to yield AHA-R and ERC-R targets likewise. In lay-rescuers AHA-R was associated with significantly higher success rates. The inability to estimate distance could explain the failure to appropriately perform chest compressions. For teaching lay-rescuers, the AHA-R with no upper limit of compression depth might be preferable.

a b s t r a c t Background: Deficits in cognitive function are a well-known dysfunction in survivors of cardiac arrest. However, data concerning memory function in this neurological vulnerable patient collective remain scarce and inconclusive. Therefore, we aimed to assess multiple aspects of retrospective and prospective memory performance in patients after cardiac arrest. Methods: We prospectively enrolled 33 survivors of cardiac arrest, with cerebral performance categories (CPC) 1 and 2 and a control-group (n = 33) matched in sex, age and educational-level. To assess retrospec- tive and prospective memory performance we administrated 4 weeks after cardiac arrest the "Rey Adult Learning Test" (RAVLT), the "Digit-Span-Backwards Test", the "Logic-Memory Test" and the "Red-Pencil Test". Results: Results indicate an impairment in immediate and delayed free recall, but not in recognition. However, the overall impairment in immediate recall was qualified by analyzing RAVLT performance, showing that patients were only impaired in trials 4 and 5 of the learning sequence. Moreover, working and prospective memory as well as prose recall were worse in cardiac arrest survivors. Cranial computed tomography was available in 61% of all patients (n = 20) but there was no specific neurological damage detectable that could be linked to this cognitive impairment. Conclusion: Episodic long-term memory functioning appears to be particularly impaired after cardiac arrest. In contrast, short-term memory storage, even tested via free-call, seems not to be affected. Based on cranial computed tomography we suggest that global brain ischemia rather than focal brain lesions appear to underlie these effects.

a b s t r a c t Aim: Improvement in predicting survival after out-of-hospital cardiac arrest is of major medical, scientific and socioeconomic interest. The current study aimed at developing an accurate outcome-prediction tool for patients following out-of-hospital cardiac arrests. Methods: This retrospective cohort study was based on a cardiac arrest registry. From out-of-hospital cardiac arrest patients (n = 1932), a set of variables established before restoration of spontaneous circula- tion was explored using multivariable logistic regression. To obtain reliable estimates of the classification performance the patients were allocated to training (oldest 80%) and validation (most recent 20%) sets. The main performance parameter was the area under the ROC curve (AUC), classifying patients into survivors/non-survivors after 30 days. Based on rankings of importance, a subset of variables was selected that would have the same predictive power as the entire set. This reduced-variable set was used to derive a comprehensive score to predict mortality. Results: The average AUC was 0.827 (CI 0.793-0.861) for a logistic regression model using all 21 vari- ables. This was significantly better than the AUC for any single considered variable. The total amount of adrenaline, number of minutes to sustained restoration of spontaneous circulation, patient age and first rhythm had the same predictive power as all 21 variables. Based on this finding, our score was built and had excellent predictive accuracy (the AUC was 0.810), discriminating patients into 10%, 30%, 50%, 70%, and 90% survival probabilities. Conclusion: The current results are promising to increase prognostication accuracy, and we are confident that our score will be helpful in the daily clinical routine.

Cardiac arrest centers have been associated with improved outcome for patients after cardiac arrest. Aim of this study was to investigate the effect on outcome depending on admission to high-, medium- or low volume centers.Analysis from a prospective, multicenter registry for out of hospital cardiac arrest patients treated by the emergency medical service of Vienna, Austria. The frequency of cardiac arrest patients admitted per center/year (low50; medium 50-100; high100) was correlated to favorable outcome (30-day survival with cerebral performance category of 1 or 2).Out of 2238 patients (years 2013-2015) with emergency medical service resuscitation, 861 (32% female, age 64 (51;73) years) were admitted to 7 different centers. Favorable outcome was achieved in 267 patients (31%). Survivors were younger (58 vs. 66 years; p0.001), showed shockable initial heart rhythm more frequently (72 vs. 35%; p0.001), had shorter CPR durations (22 vs. 29min; p0.001) and were more likely to be treated in a high frequency center (OR 1.6; CI: 1.2-2.1; p=0.001). In multivariate analysis, age below 65 years (OR 15; CI: 3.3-271.4; p=0.001), shockable initial heart rhythm (OR 10.1; CI: 2.4-42.6; p=0.002), immediate bystander or emergency medical service CPR (OR 11.2; CI: 1.4-93.3; p=0.025) and admission to a center with a frequency of100 OHCA patients/year (OR 5.2; CI: 1.2-21.7; p=0.025) was associated with favorable outcome.High frequency of post-cardiac arrest treatment in a specialized center seems to be an independent predictor for favorable outcome in an unselected population of patients after out of hospital cardiac arrest.

Aim of the study: Application of mild hypothermia (32–33 ◦C) has been shown to improve neurological outcome in patients with cardiac arrest. However, hypothermia affects hemostasis, and even mild hypothermia is associated with bleeding and increased transfusion requirements in surgery patients. On the other hand, crystalloid hemodilution has been shown to induce a hypercoagulable state. The study aim was to elucidate in which way the induction of mild therapeutic hypothermia by a bolus infusion of cold crystalloids affects the coagulation system of patients with cardiac arrest. Methods: This was a prospective pilot study in 18 patients with cardiac arrest and return of spontaneous circulation (ROSC). Mild hypothermia was initiated by a bolus infusion of cold 0.9% saline fluid (4 ◦C; 30 ml/kg/30 min) and maintained for 24 h. At 0 h (before hypothermia), 1, 6 and 24 h we assessed coagulation parameters (PT, APPT), platelet count and performed thrombelastography (ROTEM) after in vitro addition of heparinase. Results: A total amount of 2528 (±528) ml of 0.9% saline fluid was given. Hematocrit (p < 0.01) and platelet count (−27%; p < 0.05) declined, whereas APTT increased (2.7-fold; p < 0.01) during the observation period. All ROTEM parameters besides clotting time (CT) after 1 h (−20%; p < 0.05) did not significantly change. Conclusion: Mild hypothermia only slightly prolonged clotting time as measured by rotation thrombelastography. Therefore, therapeutic hypothermia initiated by cold crystalloid fluids has only minor overall effects on coagulation in patients with cardiac arrest.

Summary Aims The Hypothermia after Cardiac Arrest (HACA) trial assessed whether mild therapeutic hypothermia improved the rate of good neurological recovery in patients after ventricular fibrillation cardiac arrest of presumed cardiac origin. We evaluated the impact of hypothermia on myocardial injury. Methods Re-analysis of a HACA trial subset for our department (cooling, n =55; controls, n =56). Plasma levels of CK, CKMB and ST-scores were used as a measure of infarct size. Results Area under the curve (AUC) for CK was 28,786U/l×24h (IQR 5646–44,998) in the cooling group and 20,373U/l×24h (IQR 8211–30,801) for controls ( p =0.40), for CKMB AUC was 1691U/l×24h (IQR 724–3330) and 1187U/l×24h (IQR 490–2469), respectively ( p =0.18). The ST score was −40% (IQR [−55]−[+16]) in the cooling group ( n =23) and −22% (IQR [−84]−[+33]) for controls ( n =24) ( p =0.76). When the cooling group was stratified into early (≤8h) and longer (>8h) time to target temperature, the early group displayed a significantly lower CK 7340U/l×24h (IQR 3921–33,753) vs. 38,986U/l×24h (IQR 23,945–57,514, p =0.007) and a lower CKMB. Conclusion Cooling after successful resuscitation for ventricular fibrillation cardiac arrest did not influence infarct size. Cautious interpretation of the subgroup analysis may indicate a favourable trend for early cooling.

Summary Aim of the study Mild therapeutic hypothermia is a promising new therapy for patients resuscitated from cardiac arrest. Early and fast induction of hypothermia seems to be crucial for best results. The aim of the study was to investigate the feasibility and safety of a new surface cooling method using cold metal plates. Subjects and methods Twelve adult human-sized swine (79±9kg) were cooled from 38 to 33°C brain temperature. The skin surface was covered with −20°C metal plates (M), as compared to ice packs, alcohol rubs, and fans used in a control group (C). Each method was tested during spontaneous circulation and, after re-warming, during cardiac arrest. Temperatures were recorded continuously. Data are given as mean±standard deviation or as median (interquartile range), if not normally distributed. Comparisons between the treatment groups were performed with the independent samples t -test, or the Mann–Whitney rank-sum test. Results During spontaneous circulation, cooling rates were 9.3±1.4°C/h (M), and 6.1±1.4°C/h (C) ( p =0.003); no skin lesions were observed. During cardiac arrest, cooling rates were 4.1°C/h (1.8–4.8) (M), and 3.7°C/h (3.1–5.3) (C) ( p =0.9); no skin lesions were observed. Conclusion Cooling with cold metal plates was an effective method for rapid induction of mild therapeutic hypothermia in adult human-sized swine during spontaneous circulation, without any signs of skin damage. This new surface-cooling device, independent of energy supply during use, should be further investigated.

Summary Aim of the study There is sufficient evidence that therapeutic hypothermia after non-traumatic cardiac arrest improves neurological outcome and reduces mortality. Many different invasive and non-invasive cooling devices are currently available. Our purpose was to show the efficacy, safety and feasibility using a non-invasive cooling device to control patient temperature within a range of 33–37 °C. Materials and methods A convenience sample of patients who have been resuscitated successfully from cardiac arrest and were intended for mild hypothermia therapy according to the guidelines and inclusion criteria were studied in a prospective observational case series at an emergency department of a tertiary care university hospital. The Medivance Arctic Sun System provides a new, non-invasive approach to reach a target temperature of 33 °C quickly, to maintain the target temperature for 24 h, and then to actively re-warm at 0.4 °C/h to normothermia. Cooling was applied using the Arctic Sun in 27 patients. Data are presented as median and the interquartile range (25, 75%). Results Median age was 58 (49.5, 70) years. Time from cooling start to target temperature was 137 (96, 168) min, cooling rate was 1.2 °C/h (0.8, 1.5), stability of target temperature during hypothermia maintenance phase was satisfactory at 33.0 °C (32.9, 33.1), and duration of re-warming was 428 (394, 452) min. Conclusion Using the Arctic Sun System in post-resuscitation care medicine for cooling cardiac arrest survivors is feasible and has proven to be highly effective in lowering patients’ temperature rapidly without inducing skin irritations.

Summary Background No accurate, independent biomarker has been identified that could reliably predict neurological outcome early after cardiac arrest. We speculated that brain natriuretic peptide (BNP) measured at hospital admission may predict patient outcome. Methods BNP-levels were measured in 155 comatose cardiac arrest survivors (108 male, 58 years [IQR 49–68]) (median time to ROSC 11 min; IQR 20–30) during a 6-year study period. Cardiovascular co-morbidities and resuscitation history were assessed according to the Utstein-style and patients were followed for 6-month neurological outcome measured by cerebral performance category (CPC) and survival. Results Seventy patients (45%) suffered from unfavourable neurological outcome and 79 deaths (51%) occurred during the first 6 months. BNP was significantly associated with an adverse neurological outcome and mortality, independent of the prearrest health condition and cardiac arrest characteristics (median 60 pg/ml; IQR 10–230). Adjusted odds ratios for poor neurological outcome at 6 months were 1.14 (95% CI 0.51–2.53), 1.76 (95% CI 0.80–3.88) and 2.25 (95% CI 1.05–4.81), for increasing quartiles of BNP as compared to the lowest quartile. Adjusted odds ratios for mortality until 6 months were 1.09 (95% CI 0.35–3.40), 2.81 (0.80–9.90) and 4.7 (1.27–17.35) compared to the lowest quartile, respectively. Conclusion Brain natriuretic peptide levels on admission predict neurological outcome at 6 months and survival after cardiac arrest.

Summary Aims To investigate the potential for finding an alternative for the ‘pulse check’ during CPR, we studied the use of thoracic impedance measured via the defibrillator pads for circulation assessment during CPR. Materials and methods Transthoracic impedance, ECG and arterial pressures were recorded on 69 patients with a resulting data set of 434 segments. The circulatory-related impedance waveform was first isolated manually and features characterising its shape were suggested. Results The features were correlated with corresponding blood pressure measurements, where a low, but significant, correlation coefficient (0.3) was found. By dividing the data set in groups of sufficient and insufficient circulation and using a neural network, we found that trends in features of the impedance waveform showed a discriminative potential for the two groups. Our classifier achieved a sensitivity of 90% for recognising insufficient circulation with a specificity of 82%. Conclusions We have shown that the circulation-related information found in the impedance signal may be used for circulatory assessment, especially the recognition of restoration of spontaneous circulation after cardiac arrest.

Summary Aim In cardiopulmonary resuscitation, different ratios of compression to ventilation with regard to optimal oxygen transport are considered. We hypothesised that the end tidal fraction of oxygen might increase from levels found in the conventional compression–ventilation ratio of 15:2 if more consecutive ventilations are given because the rescuer would hyperventilate. The second hypothesis was that the air blown into an infant with mouth to mouth ventilation consists of rescuer's dead space air only, meaning that the fraction of oxygen should increase. Methods In a basic life support simulation, we measured the expired air of rescuers using a VmaxST ® (Sensormedics, USA) respiratory gas analyser connected to an adult and to an infant resuscitation manikin. Fourteen participants performed five different compression–ventilation ratios (30:2, 30:5, 50:5, 100:10 and 5:1). These were compared to a ratio of 15:2 (control group). Results We found a significant increase in end tidal oxygen in 30:2 (16.3%), 30:5 (16.8%), 50:5 (16.8%), 100:10 (17.0%) compared to 15:2 (15.9%), p ≤0.004 for all groups versus control; p for trend: 0.014. In the infant CPR observation (ratio 5:1), the difference with the adult control group (15:2) also reached statistical significance (17.9% versus 15.9%, p =0.0005). Conclusion Increasing consecutive compressions and ventilations above 15:2 leads to a statistically significant increase in expired fraction of oxygen. In infant ventilation, the air exhaled into a victim contains some dead space air with a higher end tidal oxygen fraction than in adults.

Summary Aim of the study Bradycardia may represent a serious emergency. The need for temporary and permanent pacing is unknown. Methods We analysed a registry for the incidence, symptoms, presenting rhythm, underlying mechanism, management and outcome of patients presenting with compromising bradycardia to the emergency department of a university hospital retrospectively during a 10-year period. Results We identified 277 patients, 173 male (62%), median age 68 (IQR 58–78), median ventricular rate 33 min−1 (IQR 30–40). The leading symptoms were syncope [94 (33%)], dizziness [61 (22%)], collapse [46 (17%)], angina [46 (17%)] and dyspnoea/heart failure [30 (11%)]. The initial ECG showed high grade AV block [134 (48%)], sinus bradycardia/AV block [46 (17%)], sinu-atrial arrest [42 (15%)], bradycardic atrial fibrillation [39 (14%)] and pacemaker-failure [16 (6%)]. The underlying mechanisms were primary disturbance of cardiac automaticity and/or conduction [135 (49%)], adverse drug effect [58 (21%)], acute myocardial infarction [40 (14%)], pacemaker failure [16 (6%)], intoxication [16 (6%)] and electrolyte disorder [12 patients (4%)]. In 107 (39%) patients bed rest resolved the symptoms. Intravenous drugs to increase ventricular rate were given to 170 (61%) patients, 54 (20%) required additional temporary transvenous/transcutaneous pacing. Two severely intoxicated patients could be stabilised only by cardiopulmonary bypass. A permanent pacemaker was implanted in 137 patients (50%). Mortality was 5% at 30 days. Conclusion In our cohort, about 20% of the patients presenting with compromising bradycardia required temporary emergency pacing for initial stabilisation, in 50% permanent pacing had to be established.

Summary Objective Outcome after cardiac arrest is known to be influenced by immediate access to resuscitation. We aimed to analyse the location of arrest in relation to the prognostic value for outcome. Design Retrospective review from prospective databases (ambulance routine documentation database and emergency department database on patients treated for cardiac arrest). Setting: Vienna (1.7 million inhabitants) ambulance service and tertiary care facility (university clinics). Patients: Two independent cohorts: (1) a population-based cohort of patients who were treated for cardiac arrest by the municipal ambulance service outside the hospital. The endpoint in this group was survival to hospital admission with spontaneous circulation. (2) A cohort of patients who were admitted to the emergency department after successful out of hospital resuscitation. The endpoint in this group was survival to 6 months with good neurological status (best Cerebral Performance Category 1 or 2 within 6 months). Measurements We analysed whether the location of non-traumatic adult out-of-hospital cardiac arrest (public versus private place) was a predictor for good outcome. Results Patients who had cardiac arrest in a public location were more likely to arrive in hospital alive (39% versus 31%, crude OR 1.4, 95% CI 1.001–1.975, p = 0.049) and were more likely to have a good neurological outcome after 6 months (35% versus 25%, crude OR 1.65, adjusted OR 1.59, 95% CI 1.07–2.36, p = 0.023), compared to patients who had cardiac arrest in a non-public location. Conclusion Cardiac arrest in a public location is independently associated with a better outcome.

Summary Purpose The feasibility and acceptance of providing sudden cardiac arrest survivors with life supporting first aid training and automated external defibrillators (AEDs) at their homes is unknown. Preliminary experiences are reported here. Methods Trained medical students provided life supporting first aid courses including AED training to cardiac arrest survivors. Patients were asked to invite relatives and friends to such training sessions at their home. Laerdal Little Anne™ and Heartstart™ AED Trainer were used. An AED was placed at the patients’ disposal. A refresher course took place 1 year later. Questionnaires were used to evaluate the project. Results Since 1999, 88 families have been trained and provided with an AED. Immediately after the training 90% (66% “agree”, 24% “maybe yes”) believed they would perform first aid correctly, 1 year later 98% did so (68% “agree”, 29% “maybe yes”) (p = 0.03). Families considered feeling much safer having an AED at home. The handling of an AED was regarded to be easy and AEDs would even be used on strangers. Only on one occasion an AED was used in a real emergency situation. Conclusion Providing patients and relatives with life support first aid and AED training at their homes is feasible and has raised no major objections by the family members. All have considered handling of an AED much simpler than providing basic life support and therefore none think that it would be a major problem to use it in case of an emergency. This still has to be proven.

Objectives: The aim was to assess the knowledge of life-supporting first-aid in both cardiac arrest survivors and relatives, and their willingness to have a semi-automatic external defibrillator in their homes and use it in an emergency. Material and methods: Cardiac arrest survivors, their families, friends, neighbours and co-workers were interviewed by medical students using prepared questionnaires. Their knowledge and self-assessment of life-supporting first-aid, their willingness to have a semi-automatic defibrillator in their homes and their willingness to use it in an emergency before and after a course in cardiopulmonary resuscitation (CPR) with a semi-automatic external defibrillator was evaluated. Courses were taught by medical students who had received special training in basic and advanced life support. Results: Both patients and relatives, after a course of 2–3 h, were no longer afraid of making mistakes by providing life-supporting first-aid. The automated external defibrillator (AED) was generally accepted and considered easy to handle. Conclusion: We consider equipping high-risk patients and their families with AEDs as a viable method of increasing their survival in case of a recurring cardiac arrest. This, of course, should be corroborated by further studies.

Background: Mild therapeutic hypothermia (MTH) improves neurological outcome in patients after cardiac arrest. From animal and human studies it appears that hypothermia impairs renal function. The aim of this study was to examine the effects of MTH on renal function in humans. Methods: Patients were participants recruited in one of the centres of the hypothermia after cardiac arrest-multicenter trial. We measured serum creatinine and creatinine clearance (CCr) within 24 h of MTH, at 4 hourly intervals. Patients were followed for acute renal failure and need for renal supportive therapy for 28 days. Results: We included 60 patients (32 hypothermic, 28 normothermic). Median serum creatinine on admission was [{119 μmol/l (IQR 108–133)} {1.35 mg/dl (IQR 1.22–1.50)}] in hypothermic and [{114 μmol/l (IQR 99–131)} {1.29 mg/dl (IQR 1.12–1.48)}] in normothermic patients, and decreased to [{69 μmol/l (IQR 62–84)} {0.78 mg/dl (IQR 0.70–0.95)}] in the hypothermic group and to [{88 μmol/l (IQR 71–123)} {1.00 mg/dl (IQR 0.80–1.39)}] in the normothermic group within 24 h. CCr was decreased on admission. Within 24 h CCr improved to normal values in normothermic patients [1.53 ml/s (IQR 1.15–2.35) {92 ml/min (IQR 69–141)}] and remained low in hypothermic patients [0.88 ml/s (IQR 0.63–1.38) {53 ml/min (IQR 38–83)}] (P=0.0006). No difference was found between the groups in the development of acute renal failure or the need for renal supportive therapy. Conclusion: Twenty four hours of MTH was associated with a delayed improvement in renal function. This was not reflected in the serum creatinine values, which were low in the hypothermic group. This transient impaired renal function appeared to be completely reversible within 4 weeks.

Several predictors of survival have been described in selected subgroups of patients suffering from acute myocardial infarction. However, data on unselected patients with acute myocardial infarction and cardiogenic shock, including patients with out-of hospital cardiac arrest, are missing. We aimed to assess predictors of survival for an unselected cohort of patients representative of clinical practice who experienced acute myocardial infarction and required continuous catecholamine support for circulatory failure.The study was performed at a 2000 bed university hospital. All consecutive patients admitted to our emergency department with acute myocardial infarction were prospectively enrolled in a clinical trial from 1993 to 2000.A retrospective cohort study was performed on patients with myocardial infarction requiring catecholamine support within the first 24 h. Primary endpoint was in-hospital mortality.The analysis was carried out on 262 patients, 189 men (72%), median age 65 years (IQR 53-73). Out-of-hospital cardiac arrest was reported in 47% (122/262). In-hospital mortality was 53% (138/262). Survivors as compared to non-survivors exhibited significant differences with respect to age (60 vs. 68 years, P0.0001), systolic and diastolic blood pressure on admission (110 vs. 102 mmHg, P=0.01 and 64 vs. 58 mmHg, P=0.006, respectively), initial blood serum lactate (6.8 vs. 8.3, P=0.01), peak CKMB level (93 vs. 138 U/l, P=0.005), use of adrenaline (epinephrine) (38 vs. 68%, P0.0001) and any attempt of revascularisation (76 vs. 63%, P=0.03). In a multivariate model younger age [OR 1.06 (CI 1.03-1.10), P0.001], no use of adrenaline [OR 2.63 (CI 1.35-5.26) P=0.005] and lower peak CKMB [OR 1.01 (CI 1.01-1.01), P0.0001] were independently associated with in-hospital survival.In unselected patients including CPR survivors with acute myocardial infarction requiring continuous catecholamine support, younger age, the absence of continuous adrenaline administration and a lower peak CKMB were independently associated with increased in-hospital survival.

Since adrenaline (epinephrine) also has negative effects during and after cardiopulmonary resuscitation (CPR) a non-adrenergic vasoconstrictor like endothelin might be an alternative to increase vital organ blood flow. We studied the effect of different doses of endothelin-1 compared with adrenaline on the ability to resuscitate, cerebral and myocardial blood flow (MBF) in a closed chest cardiac arrest pig model. After 5 min of ventricular fibrillation, CPR with a ventilator and a mechanical compression device was started. At 10 min, 31 pigs were randomized to receive a single dose of endothelin-1 50, 100 or 200 microg or repeated doses of adrenaline 0.04 mg kg(-1) or saline every 3 min. After 25 min, the pigs were defibrillated to achieve restoration of spontaneous circulation. Blood flow was measured with the fluorescent microsphere method. In animals receiving endothelin-1 50, 100 and 200 microg the cerebral blood flow (CBF) increased from median 28 (25th; 75th quartile: 16; 40), 32 (15; 48) and 17 (4; 65) to 36 (31; 54), 47 (39; 57) and 63 (35; 83) ml min(-1) per 100 g, respectively, 6 min after drug administration (P0.05 endothelin-1 50 microg vs. Control, P0.01 endothelin-1 100 and 200 microg vs. Control). At the same time CBF decreased in the control and adrenaline group from 36 (21; 41) and 39 (15; 50) to 12 (2; 25) and 24 (15; 26) ml min(-1) per 100 g, respectively, (P0.05 adrenaline vs. endothelin-1 200 microg). There was no difference in MBF between the treatment groups despite a higher coronary perfusion pressure (CoPP) in the endothelin-1 groups. Restoration of spontaneous circulation could be only achieved in the endothelin-1 50 microg (3 of 7; 43%) and 100 microg (5 of 7; 71%) group. This study suggests that endothelin-1 enhances CBF during CPR better than adrenaline and increases resuscitation success.

Objectives: The recurrence rate of lethal cardiac events after the survival of a primary cardiac arrest in patients not having received an implantable cardioverter defibrillator (ICD) is investigated. Background: According to current guidelines, only a small percentage of patients after successful cardiopulmonary resuscitation due to an underlying cardiac problem are eligible for the implantation of an ICD. Methods: For retrospective analysis, we used a data registry of patients admitted to an emergency department after cardiac arrest. Patients who had a primary cardiac cause for their cardiac arrest and who did not die within the first month after successful restoration of spontaneous circulation were selected. Results: From 1246 patients, 360 met the inclusion criteria. A second lethal cardiac event occurred in 94 (26%). Of those 94 patients, 57 (61%) had good neurological function before their second cardiac arrest. Of the survivors with good neurological function, 47 (82%) did not have an ICD or a cardiac transplant. Another cardiac arrest due to a primary cardiac event occurred in 34 (72%) of these patients. Conclusions: Cardiac arrest survivors without an apparent indication for an ICD have a high risk of suffering from a re-arrest of cardiac origin.

Objective: the aim of the study is to investigate the effect of thrombolytic therapy on neurological outcome in patients after cardiac arrest due to acute myocardial infarction. Laboratory investigations have demonstrated that thrombolytic therapy after cardiopulmonary resuscitation improves neurological function. Methods: from July 1991 to June 1996, patients with witnessed ventricular fibrillation cardiac arrest due to acute MI and successful restoration of spontaneous circulation admitted to the emergency department were analyzed retrospectively. A logistic regression model was used to assess the association between thrombolytic therapy and neurological outcome [best cerebral performance category (CPC) within 6 months after cardiac arrest]. Results: all 157 patients [median age 57 years (IQR 50–69)] were analyzed. Thrombolytic therapy was applied in 42 patients (27%). With thrombolytic therapy good functional neurological recovery (CPC 1 or 2) was achieved more frequently (69 vs. 50%, P =0.03). After controlling for age, prehospital dosage of epinephrine, and the duration of cardiac arrest we found a non significant trend towards good neurological recovery when thrombolytic therapy was given (OR 1.9, 95% CI 0.8–4.6). Conclusion: thrombolytic therapy after cardiac arrest due to acute myocardial infarction is associated with improved neurological outcome.

The aim of the study was to evaluate the demographics, haemodynamics, ECG characteristics, underlying disease, tachycardia termination and outcome of patients with sustained ventricular tachycardia (VT). We registered 75 patients presenting with VT (51 male, median age 63) from December 1993 to August 1998 in our emergency department (ED). Seventeen of these patients were haemodynamically unstable (23%), and 58 patients were stable (77%); there was no difference in the tachycardia cycle length (median 320 ms) and QRS width (median 140ms) between the two groups; however, five of the seven patients with polymorphic VT pattern were in the unstable group. Ischaemic heart disease was the underlying disorder in 57 patients (76%). Acute myocardial infarction (AMI) was present in 12 of the 58 stable (21%) compared to 11 of the 17 unstable (65%) patients. In three patients (4%) VT terminated spontaneously, in 34 patients (45%) VT was terminated by first-line intravenous drug therapy, and in 38 patients (51%) including all 17 unstable and 22 stable who failed to respond to the intravenous antiarrhythmic therapy challenge out of 55 patients, VT was terminated by electrical therapy. Within 2 days, 48 patients (64%) were transferred to an open ward, 13 (17%) still needed intensive care, nine (12%) were discharged to home and five (7%) died. Death occurred due to cardiac failure from AMI with extensive anterior wall infarction in three patients, and due to constrictive pericarditis and reocclusion of stented LAD each in one patient. At presentation in the emergency department, the majority of the patients with VT were haemodynamically stable, thus allowing first-line antiarrhythmic drug administration. However, in the course of the disease, half needed electrical therapy for definitive termination of the tachycardia. Therefore, direct current cardioversion must be available in the emergency department. Haemodynamic instability and death occurs significantly more often if VT occurs during the course of AMI.

Objective: To show whether in an in-hospital cardiac arrest, early defibrillation can also be performed by hospital staff trained only in basic life support. Background: The International Liaison Committee on Resuscitation (ILCOR) endorses the concept that in many settings non-medical individuals should be allowed and encouraged to use defibrillators. Methods: Five different groups of hospital staff were evaluated whether they were able to correctly operate an automatic external defibrillator in a simulated sudden cardiac arrest situation without any prior instruction. The participants were assigned either to the ‘basic life support-trained' group (BLS, n =40) or to the ‘advanced life support-trained' group (ALS, n =40). Results: All persons of the ‘only BLS-trained' group delivered the three sequential (‘stacked') shocks with the automatic external defibrillator when persistent ventricular fibrillation was simulated. The ‘ALS-trained' persons successfully delivered the three shocks with the automatic external defibrillator in 98% of the cases. When this group used a conventional defibrillator, only 88% were able to deliver the three shocks, however they were able to do it significantly more quickly. Conclusion: Using an automatic defibrillator without any prior instruction, even persons trained only in BLS were able to deliver three sequential shocks in a simulated persistent ventricular fibrillation cardiac arrest.

After successful resuscitation from cardiac arrest, prolonged contractile failure has been demonstrated in animal experiments. No systematic evaluation of myocardial contractility following successful resuscitation after human cardiac arrest exists. The aim of this study was to assess left ventricular contractility following human cardiac arrest with successful resuscitation. In 20 adult patients after cardiac arrest and in four control patients, the relation between meridional wall stress (MWS) and rate-corrected mean velocity of circumferential fibre shortening (Vcf(c)), a load independent and rate corrected index of left ventricular contractility was measured within 4 h after return of spontaneous circulation and after 24 h by means of transoesophageal echocardiography. As the normal values of Vcf(c) depend on MWS, a normal deviate (z) was calculated. A normal z-score is defined as 0+/-2,-2 indicates reduced contractility,+ 2 increased contractility. Data are presented as median and the interquartile range (IQR). For the comparison of related samples the Wilcoxon sign test was used. In most patients after cardiac arrest contractility was severely impaired within 4 h after successful resuscitation [z - 7.0 (IQR - 8.9 - (-2.5))]. Contractility did not significantly improve within the observational period [z after 24 h - 3.7 (IQR - 7.9 - (-1.8))] (P = 0.3). The four control patients had normal left ventricular contractility on arrival (z 0.0, range - 0.9-0.8) and after 24 h (z 0.7, range - 1.5-2.7). In conclusion non-invasive wall stress analysis can be applied to quantitate systolic left ventricular function, which was severely compromised in most patients within the first 24 h after successful resuscitation. Whether depression of left ventricular function is caused by cardiac arrest itself or by the underlying disease remains speculative.

The purpose of this study was to describe the life of survivors after successful resuscitation and to see if there was an association with the type of emergency cardiac care. The ‘Utstein-style’ data of patients surviving non-traumatic cardiac arrest 24 (14–32) months were prospectively collected. The everyday activities and psychological concerns of patients with a cerebral performance category (CPC) of 1 and 2 using a questionnaire were analyzed. The χ 2 -square test was used for statistical analysis. The questionnaires of 92 patients (median age 59, IQR 51–68; females 36) were evaluated. Patients enjoy life (84%; n =73), have depression (36%; n =31), consider their survival a ‘second chance’ (84%; n =73) and fear that they may suffer cardiac arrest again (56%; n =45). The average quality of life is 7 on a scale from 0 (worst) to 10 (perfect). The majority of cardiac arrest survivors have a satisfactory life. No significant correlation between the type of emergency cardiac care and post cardiac arrest life was found. The fact that there was no association with the type of emergency cardiac care may be due to the narrow selection of patients (CPC 1 and 2), the small number of patients or factors contributing to post cardiac arrest life other than emergency treatment.

Objectives: This study sought to determine the influence of resuscitative procedures, such as chest compressions and external defibrillation, on the release of creatine kinase (CK)-MB and cardiac troponin T (cTnT). Methods: In 87 patients with out-of-hospital cardiac arrest and successful cardiopulmonary resuscitation (CPR), the initial ECG rhythm, the duration of cardiac arrest and CPR, and the number of defibrillations were assessed on arrival in the hospital. The serum CK-MB and cTnT were measured 12 h after the event. We also assessed whether the patient developed cardiogenic shock within 12 h, and if the patient had acute myocardial infarction (AMI), which was confirmed or eliminated by of typical ECG findings, thallium-201 myocardial scintigraphy, or autopsy within the hospital stay. A backward stepwise linear regression model was applied to assess the association between the markers of myocardial injury (CK-MB and cTnT) and the above clinical variables. Results: CK-MB concentrations were independently associated with the presence of AMI [B 68.5 (SE 28.5, P =0.018)], the duration of CPR (as a measure of trauma to the chest by means of chest compressions) [B 2.07 (SE 1.01, P =0.045)] and cardiogenic shock [B 52.3 (SE 23.4, P =0.03)]. The remaining clinical variables listed were excluded by the model. Cardiac troponin T concentrations were only associated with the presence of AMI [B 4.86 (SE 1.34, P =0.0005)]. There was a non-significant association between increasing serum cTnT concentrations and the presence of cardiogenic shock [B 2.51 (SE 1.46, P =0.09)]. The remaining clinical variables were excluded by the model. Conclusion: The release of CK-MB appears to be influenced by the duration of resuscitation and the presence of cardiogenic shock. This has to be considered when interpreting serum CK-MB concentrations after CPR. The release of cTnT seems to be only associated with acute myocardial infarction, but not with the duration of chest compressions, or with the number of defibrillations administered.

We report a case of acute inhalation injury of nitric acid in a 56-year old white male. The patient presented conscious and dyspnoic at the emergency department after cleaning a copper chandelier with nitric acid. He had to be intubated 2 h after admission and mechanically ventilated because of fulminant respiratory insufficiency. As all sources of mechanical ventilation failed, extracorporeal membrane oxygenation had to be established 7 h after admission. With the additional use of surfactant and low dose inhalation therapy with nitric oxide (NO), the patient could be stabilised for 3 days and lung function improved temporarily. Despite all efforts the patient died at the fourth day from refactory respiratory failure. Pathologic examination revealed massive pulmonary edema without signs of inflammation. Thus, nitric acid inhalation induced pulmonary edema appears to be a most severe situation in which even most modern therapeutic interventions fail. As, in respect of recent literature and our case no promising therapy for nitric acid inhalation pulmonary edema is available, our efforts have to be directed towards prevention of nitric acid exposure.

The aim of the study was to compare the effect of a 30 and 50% duty cycle on coronary perfusion pressure (CPP) and end tidal carbon dioxide (ETCO2) and to determine whether a duty cycle of 30% can be achieved manually. After 3 min of ventricular fibrillation cardiac arrest, pigs were resuscitated in two groups with changing duty cycles every 3 min: group A starting with 50 and then 30%; and group B starting with 30 and then 50%. After administration of epinephrine, duty cycles in group A were 50 and then 30%, in group B initially 30% and then 50% Before administration of epinephrine, no significant differences in CPP between the 30 and 50% duty cycles were found; after epinephrine CPP increased with both duty cycles. ETCO2 did not vary before epinephrine; after epinephrine, there were statistically significant differences but there is doubt regarding the clinical relevance of these differences. Survival was 4/6 in group A and 3/5 in group B (NS). It is possible to perform a manual duty cycle of 30%. However, our data do not support the use of a 30% duty cycle during cardiopulmonary resuscitation (CPR).

Anomalies of coronary artery origin can be of little clinical significance and only an incidental autopsy finding. However recent case reports have shown that a wide range of potential pathologic alterations of congenital coronary anomalies are associated with clinical symptoms and exercise related sudden death. We describe the case of a 16-year-old girl who sustained a cardiac arrest and died after cardiopulmonary resuscitation (CPR) of intractable cardiogenic shock. The sporty and previously healthy girl suddenly fainted after swimming in a tributary of the Danube. Autopsy revealed an anomalous origin of the left coronary artery from the anterior sinus of Valsalva and its course between aorta and pulmonary artery. The cause of this anomalous origin and possible mechanism for sudden death is discussed. We conclude that this congenital anomaly should be considered in cases of major cardiac events in young people.

An emergency department providing critical care will have an effect on outcome and intensive-care-units' resources by avoiding unnecessary or futile intensive-care admissions and thereby save hospital expenses. The study focussed on this result.The study employed a retrospective analysis of prospectively collected data of out-of-hospital cardiac arrest patients with return of spontaneous circulation, comatose on arrival. Outcomes and length of stay of patients who either stayed at the 'emergency department only' or were 'transferred in addition to an intensive care unit' were compared. Linear regression with log length of stay as outcome and 'emergency department only' as predictor with covariates was used for modelling.From 1991 to 2008, out of 1236 patients (age 57 ± 15 years, female 31%), the 'emergency department only' group (n=349 (28%)) survived to discharge in 81(23%) cases, with a median length-of-stay in critical care of 1.7 (interquartile range 0.8; 3.1) days. The patients 'transferred in addition to an intensive care unit' (n=887 (72%)), with a survival rate of 55% (n=486, p0.001) stayed 10 (5; 18) days (p0.001). The length-of-stay in hospital was significantly shorter if patients were treated in the 'emergency department only' independent of other cardiac-arrest-related factors (regression coefficient -1.42, confidence interval -1.60 to -1.24).An emergency department with critical care prevents admissions to intensive care units in 28% of patients with out-of-hospital cardiac arrest. It saves intensive-care-unit resources and shortens length of stay for comatose out-of-hospital cardiac-arrest survivors, regardless of their outcome.

Summary Aim of the study The admission blood glucose level after cardiac arrest is predictive of outcome. However the blood glucose levels in the post-resuscitation period, that are optimal remains a matter of debate. We wanted to assess an association between blood glucose levels at 12 h after restoration of spontaneous circulation and neurological recovery over 6 months. Materials and methods A total of 234 patients from a multi-centre trial examining the effect of mild hypothermia on neurological outcome were included. According to the serum glucose level at 12 h after restoration of spontaneous circulation, quartiles (Q) were generated: Median (range) glucose concentrations were for QI 100 (67–115 mg/dl), QII 130 (116–143 mg/dl), QIII 162 (144–193 mg/dl) and QIV 265 (194–464 mg/dl). Results In univariate analysis there was a strong non-linear association between blood glucose and good neurological outcome (odds ratio compared to QIV): QI 8.05 (3.03–21.4), QII 13.41 (4.9–36.67), QIII 1.88 (0.67–5.26). After adjustment for sex, age, “no-flow” and “low-flow” time, adrenaline (epinephrine) dose, history of coronary artery disease and myocardial infarction, and therapeutic hypothermia, this association still remained strong: QI 4.55 (1.28–16.12), QII 13.02 (3.29–49.9), QIII 1.37 (0.38–5.64). Conclusion There is a strong non-linear association of survival with good neurological outcome and blood glucose levels 12 h after cardiac arrest even after adjusting for potential confounders. Not only strict normoglycaemia, but also blood glucose levels from 116 to 143 mg/dl were correlated with survival and good neurological outcome, which might have an important therapeutic implication.

Summary Aim To evaluate the frequency, presentation, treatment and outcome of cardiopulmonary resuscitation-associated major liver injury in patients after non-traumatic in- or out-of-hospital cardiac arrest. Materials and methods Retrospective analysis of a cardiac arrest registry in a tertiary care hospital emergency department. We reviewed patients charts, laboratory data, diagnostic imaging studies and autoptic findings. Results Within 14.5 years, major liver injury (rupture/laceration, haemorrhage/haematoma) was found in 15 of 2558 cardiac arrest victims (0.6%). Eleven were male (73%), median age was 58 (IQR 53-67). In seven, resuscitation was started out-of-hospital. In 9 of the 15 patients, liver injury was correctly diagnosed intra vitam. In 5, haematocrit level was low on admission, in 8 haematocrit dropped significantly during observation; haemostasis was compromised in 13 patients, 4 of them receiving thrombolytic therapy. Bedside abdominal sonography showed free intra-peritoneal fluid in 8 of 9 cases examined. In 11 patients, we found liver rupture/laceration, in 4 liver haemorrhage/haematoma. The site of injury was the left liver lobe in 11, six underwent emergent surgery. Two of 15 patients survived to 6 months in good neurological condition, 1 after emergency surgery. No patient died from bleeding due to liver injury. Conclusion Our single centre observation confirms that resuscitation-associated major liver injury is infrequent and shows that most patients had compromised haemostasis. Low or dropping haematocrit should trigger suspicion. Bedside sonography reveals intra-peritoneal fluid or liver injury. A conservative therapeutic approach or emergency surgery may be warranted. Major liver injury alone scarcely appears to influence overall outcome.

Summary Aim of the study Cold infusions have proved to be effective for induction of therapeutic hypothermia after cardiac arrest but so far have not been used for hypothermia maintenance. This study investigates if hypothermia can be induced and maintained by repetitive infusions of cold fluids and muscle relaxants. Material and methods Patients were eligible, if they had a cardiac arrest of presumed cardiac origin and no clinical signs of pulmonary oedema or severely reduced left ventricular function. Rocuronium (0.5mg/kg bolus, 0.5mg/kg/h for maintenance) and crystalloids (30ml/kg/30min for induction, 10ml/kg every 6h for 24h maintenance) were administered via large bore peripheral venous cannulae. If patients failed to reach 33±1°C bladder temperature within 60min, endovascular cooling was applied. Results Twenty patients with a mean age of 57 (±15) years and mean body mass index of 27 (±4)kg/m 2 were included (14 males). Mean temperature at initiation of cooling (median 27 (IQR 16; 87)min after admission) was 35.4 (±0.9)°C. In 13 patients (65%) the target temperature was reached within 60min, 7 patients (35%) failed to reach the target temperature. Maintaining the target temperature was possible in three (15%) patients and no adverse events were observed. Conclusion Cold infusions are effective for induction of hypothermia after cardiac arrest, but for maintenance additional cooling techniques are necessary in most cases.

In general automated external defibrillators (AED) are handled easily, but some untrained lay rescuers may have major problems with the use of such products. This may result in delayed shock delivery and delay in basic life support (BLS) after use of the AED. To study the effect of voice prompts and design solutions we tested the time from the first shock to the initiation of BLS for six defibrillators available in Austria.Volunteers, who had no AED training, were evaluated to see when they delivered the first shock and how often BLS was started after the voice prompts were given by the defibrillators.Time to first shock delivered ranged from 78 (95% CI: 68-89) to 128 (95% CI: 110-146)s. The defibrillator-type had a significant influence on the time to first shock delivered (P0.0001). The proportion of volunteers who started BLS after defibrillation ranged from 93 to 33% and differed significantly between the AEDs used (P0.03).We demonstrated that there are significant differences between AEDs, concerning important operational outcomes like time to first shock and the start of BLS. Further research and development is urgently required to optimise user-friendliness and operational outcomes.

Objective: Thrombolytic therapy in patients with massive pulmonary embolism (MPE) and prolonged cardiopulmonary resuscitation (CPR) is subject to debate. This study was performed to determine whether (1) thrombolytic treatment increases the risk of bleeding complications, (2) if the risk of bleeding is influenced by the duration of CPR and if (3) thrombolytic therapy improves outcome. Design: Retrospective cohort study. Setting: Emergency department of a tertiary care university hospital. Patients and methods: Sixty-six patients with cardiac arrest (CA) due to MPE admitted between July 1993 and December 2001. Thirty-six patients received thrombolysis (TL) and were compared with 30 patients without thrombolytic therapy. Bleeding complications were assessed by clinical evidence or autopsy. Results: Major bleeding complications appear to occur more frequently in patients treated with thrombolytics (9/36 (25%) vs. 3/30 (10%)) even though the difference was statistically not significant ( P =0.15). It appears that CPR duration >10 min has no adverse impact on major bleeding complications. No difference in the rate of major bleeding complications between thrombolyzed patients who had a CPR duration of ≤10 or >10 min could be observed (2/8 (25%) vs. 7/28 (25%), P =0.99). In thrombolyzed patients a return of spontaneous circulation could be achieved more frequently (24/36 (67%) vs.13/30 (43%) in controls, P =0.06) and survival after 24 h was higher (19/36 (53%) vs. 7/30 (23%), P =0.01). Survival to discharge was also higher in the TL group (7/36 (19%) vs. 2/30 (7%)), but not statistically significant ( P =0.15). Conclusion: Although severe bleeding complications tend to occur more frequently in patients undergoing TL, the benefit of this treatment might outweigh the risk of bleeding.

Objective: To evaluate the frequency, presentation and outcome of non-traumatic aortic dissection/rupture as a cause of cardiac arrest. Design: Retrospective analysis of a cardiac arrest registry in a tertiary care hospital emergency department. Results: Over 11.5 years, aortic dissection/rupture was identified as the immediate cause of cardiac arrest in 46 (2,3%) out of 1990 patients with sudden cardiac arrest, primarily affecting the abdominal aorta in 25 and the thoracic aorta in 21 cases. The characteristics of the 46 patients were as follows: male gender (74%), median age 71 years (IQR 59–76), high co-morbidity (89%), previously known aortic aneurysm (33%), pulseless electric activity (70%) as initial cardiac rhythm. When performed, bedside abdominal sonography or echocardiography was almost always diagnostic. Patients with abdominal aortic dissection/rupture had abdominal (52%) and/or flank pain (32%). Patients with thoracic aortic dissection/rupture complained of chest pain (48%) or dyspnoea (19%). Return of spontaneous circulation occurred in 12 (26%) of 46 patients, emergency surgery was performed in eight of these patients, 2 (4%) survived to discharge in good neurological condition. Conclusions: Cardiac arrest caused by aortic dissection/rupture is rare, and mortality remains very high, even when circulation can be restored initially. Common features such as previously known aortic aneurysm, old age, male gender and pulseless electrical activity as initial cardiac rhythm should increase suspicion of the condition.

Background: Mass media deliver pertinacious rumours that lunar phases influence the progress and long-term results in several medical procedures. Peer reviewed studies support this, e.g. in myocardial infarction, others do not. Methods: We looked retrospectively at the dates of cardiac arrests (CA; n =368) of cardiac origin and of acute myocardial infarctions (AMI) with consecutive thrombolytic therapy or acute PTCA ( n =872) and at the lunar phases at the corresponding dates. Medical data had been collected prospectively on the patient's admission. The lunar phases were defined as full moon±1 day, new moon±1 day and the days in between as waning and waxing moon. The incidence of these cardiac events at each phase was calculated as days with a case divided by the total number of days of the specific moon phase in the observation period (1992–1998). Wilcoxon Rank Test was used for statistical analysis. Results: AMI and CA occurred on equal percentages of days within each lunar phase: AMI on 35% of all days with new moon, on 38% of full moon days, on 39% waning, and on 41% of the waxing moon days; CA on 19, 17, 16 and 16% of all days of the respective lunar phase. This difference was not significant. Conclusion: Lunar phases do not appear to correlate with acute coronary events leading to myocardial infarction or sudden cardiac death.

Study objective: To assess the safety and the accuracy of a 4 h stepwise diagnostic approach relying on clinical judgement in unselected patients with acute chest pain. Design: Prospective cohort study. Setting: Emergency department (ED) of a tertiary care university hospital. Patients: 1288 unselected patients presenting with acute chest pain. Interventions: After history and physical examination, clinical judgement (step I), governed the need for further patient evaluation: baseline 12 lead electrocardiogramm (ECG) and laboratory examinations (step II), serial 12 lead ECG and laboratory examinations after 4 h (step III), and 4 h troponin T measurement (step IV) to exclude or to confirm a coronary origin of chest pain. Patients were followed clinically for 6 months for future occurrence of cardiac events (myocardial infarction, percutaneous transluminal coronary angioplasty (PTCA), CABG, cardiac death), any death and for accuracy of the ED diagnosis in non-coronary chest pain patients. Measurements and results: Chest pain was diagnosed to be coronary in origin in 381 and non-coronary in 907 patients, respectively. Cardiac events occurred during follow up in 240 (19%) of 1288 patients, in 233 of 381 (61%) with presumed coronary and seven of 907 (1%) with presumed non-coronary chest pain. Sensitivity, specificity, positive predictive value and negative predictive value for correct detection of coronary chest pain were 97, 86, 61 and 99%, respectively. In non-coronary chest pain patients the agreement between the ED diagnosis and the final diagnosis was good (k � /0.71, 95% confidence interval (CI) 0.67 � /0.75). Conclusions: The 4 h stepwise approach guided by clinical judgement was safe for ruling out impending cardiac events in unselected patients with acute chest pain. However, more extensiv ee valuation is necessary for accurate rule-in of coronary chest pain. # 2002 Elsevier Science Ireland Ltd. All rights reserved.

Intra-aortic balloon pump (IABP) counterpulsation in cardiogenic shock (CS) is suggested as bridging therapy to definite emergency revascularization, heart transplantation and acute valvular repair. Data concerning the use of IABP counterpulsation in an emergency department (ED) are rare.We reviewed retrospectively the charts of patients who had been treated by IABP counterpulsation in the ED of a tertiary care university hospital during a 7-year period. We analyzed indications for IABP treatment, complications of IABP use and studied various predictors for 30-day survival.Overall 88 (68 male) patients, median age 60 years (IQR 53-69 years) were treated with IABP counterpulsation. CS was caused by acute coronary syndrome (ACS), acute cardiomyopathy decompensation of (CMP) and aortic stenosis (AS) in 77 (87%), ten (12%) and one (1%) patients, respectively. Complications attributed to the insertion or maintenance of IABP were observed in nine (10%) patients. Thirty four patients (38%; 24 male) survived. Compared to non-survivors, these patients were younger (56 vs. 63 years; P0.023) and had significant lower serum lactate levels before IABP insertion (3 vs. 5.5 mmol/l; P0.002). Logistic regression analysis identified age (P0.04) and serum lactate serum level before IABP (P0.01) as independent predictors for survival. In the 77 patients with ACS PTCA tended to be associated with a higher rate of survival (P0.09).Initiation of IABP counterpulsation in patients with CS in an ED appears safe. Low levels of serum lactate and younger age were independent predictors of survival. In patients with ACS PTCA may contribute to improved outcome.

Purpose and background: We investigated the plasma levels of endothelin 1/2 in patients with acute symptoms relating to a known or newly diagnosed aortic aneurysm in order to investigate the possible role of peptides in the development of the disease. Methods: Endothelin 1/2 plasma levels were determined in patients admitted to the emergency unit with suspected acute aortic disease. The history, type of aneurysm, outcome and laboratory findings were determined and compared to endothelin 1/2 levels collected on admission. Results: In patients with ruptured aneurysm ( n =27) or acute aortic dissection ( n =18) the endothelin 1/2 median levels were higher 1.1 (25th and 75th quartile 0.7, 1.7) fmol/ml than in patients ( n =20) with pre-existing aneurysm 0.7 (0.4, 1.1) fmol/ml ( P =0.013). Patients who died had significantly higher endothelin levels 1.3 (0.8, 1.9) fmol/ml than the survivors 0.8 (0.5, 1.4) fmol/ml ( P =0.04). In a logistic regression analysis, only a higher blood pressure on admission was an independent predictor of survival. Conclusion: Endothelin 1/2 levels are elevated in patients with acute dissection or ruptured aneurysm, but they are not an independent predictor of survival.

Objective: Physical exhaustion is a frequent condition in emergency medical teams after in-house emergency runs, which might affect the quality of advanced care. Newly available light-weight scooters may reduce exertion as measured by the cardiovascular response in these circumstances and, therefore, may reduce physical exhaustion on arrival. Methods: We undertook a randomised cross-over trial in a simulated in-house emergency alarm run to examine the influence of scooting compared with conventional running on pulse rate (primary outcome), manual skilfulness and response time. Results: We tested 24 emergency department professionals in eight emergency medical teams. After scooting the pulse rate was significantly lower compared with conventional running [157 (IQR 145–169) vs. 170 (IQR 154–175) min −1 , P =0.004]. After the simulated emergency alarm run no difference was found in manual skilfulness and response time between scooting and running. Conclusion: Using scooters for simulated in-house emergency alarm runs markedly reduces the cardiovascular response of emergency medical teams.

Objective: The components of the ‘chain of survival’ remain the strongest pathway to save more people from out-of-hospital cardiac arrest. The ‘Utstein Style’ terminology has been applied to this study to evaluate survival in patients cared for by Emergency Medical Technicians — Defibrillation (EMT-D) and physicians in a rural alpine area. Methods: Over a 6-year period in a descriptive observational study with prospective data collection special efforts were made to identify weaknesses in the ‘links’ of our emergency cardiac care system considering the special geographical and legal aspects. Data from all emergency calls dispatched by the ambulance centre for patients with cardiac arrest were collected and are presented as a median and interquartile range. Results: We recorded 368 cardiac arrests and in 338 patients resuscitation was attempted. Ventricular fibrillation (VF) was observed in 118 patients (35%), of whom 13 (4%) were defibrillated by EMT-Ds and 105 (31%) by physicians. Response times were 1 (0,2) min to call, 8 (6–11) min to arrival of first tier and 16 (10–26) min to defibrillation. Restoration of spontaneous circulation was achieved in 54 (46%) VF-patients. In EMT-D vs. physician treated VF-patients 1 year survival was 1 (8%) versus 20 (19%). Conclusion: With the exception of publications on avalanche victims and mountaineers, there are no reports of patients with out-of-hospital cardiac arrest in alpine areas. Response intervals and survival rate are not as poor as might be expected and are similar to metropolitan areas.

Objectives: to evaluate self-assessment of first aid knowledge, readiness to make use of it in case of a medical emergency and judgement of a 1-day CPR course by cardiac arrest survivors, their family members and friends as compared to the general public. Background: the recurrence rate of a cardiac arrest after successful resuscitation is high and most of out-of-hospital cardiac arrests occur at the patient's home. Methods: medical students trained in basic and advanced life support provided 101 members of the target group and 94 of a sex and age matched control group with a 1-day course in CPR. Results: after the course, half of the participants in both groups considered their knowledge of first aid to be very good or good. The readiness to perform first aid in a medical emergency increased significantly. Of the target group 96% of the participants as compared with the control group where 91% felt confident to recognise a cardiac arrest; 79 versus 68% considered themselves capable to perform CPR if needed. The course was judged as very good in 71 versus 69% and as good in 25 versus 27% with no differences between groups. Conclusion: one-day CPR courses are well accepted by cardiac arrest survivors, their family members and friends and help to reduce fears of reacting in medical emergencies. They seem to be more motivated to gain and use first aid knowledge than others.

Safety and effectiveness are the goals in treating patients with arrhythmias. In an open prospective study, we observed the efficacy and safety of up to 2 mg intravenous ibutilide, a new class III antiarrhythmic agent in haemodynamically stable patients presenting in the emergency department (ED) with symptoms of recent-onset (

A 79-year 65 kg male called the ambulance service 4 h after ingestion of 100 tablets of digoxin 0.1 mg complaining of nausea and vomiting. The ECG showed an idioventricular escape rhythm with a heart rate of 30/min. After 0.5 mg atropine, heart rate increased to 80/min. Soon after admission to the emergency department, the patient developed electromechanical dissociation. Due to persistent cardiac arrest, percutaneous cardiopulmonary bypass was started, and the ECG rhythm changed to ventricular fibrillation. Several attempts to terminate ventricular fibrillation by electrical defibrillation failed. Fifty-eight minutes after cardiac arrest, antidigoxin-Fab was administered and 1 h 25 min after cardiac arrest, ventricular fibrillation was terminated by the tenth electrical defibrillation attempt. Initially, the patient's overall status improved over the next 2 days, but then he developed a severe adult respiratory distress syndrome and died of unresponsive septic shock 12 days after ingestion of digoxin. This case demonstrates that percutaneous cardiopulmonary bypass may provide support in patients with cardiac arrest due to massive digoxin overdose. This temporary support can maintain adequate tissue perfusion during the time required for drug neutralization in order to achieve successful defibrillation. Percutaneous cardiopulmonary bypass should be considered in patients with severe, but temporary cardiac dysfunction due to a life-threatening drug overdose.