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Overcrowding decreases quality of care. Triage and patient administration are possible bottlenecks. We aimed to identify factors influencing door-to-triage- and triage-to-patient administration-time in a prospective observational study at a tertiary care center with 70,000 patients per year.Measurement of aforementioned times at convenience-sampled time intervals on 16 days. Linear regression modelling with times as dependent variable, and demographic, medical and structural factors as covariables, testing for interactions with risk factor "weekend".We included 360 patients (183 female (51%)). Median door-to-triage-time was 6 (IQR 3-11) minutes, triage-to-patient administration-time was 5 (IQR 3-8) minutes. Overall door-to-triage-time was significantly shorter during weekends compared to weekdays (absolute difference 3 (IQR 1-7) minutes; 5 (IQR 3-8) vs. 8 (IQR 4-15) minutes, p 0.01). Other influencing factors were closing hours of non-emergency department healthcare facilities (3.5 min more), number of ESI 2 patients seen during the interval (3 min more for each patient per hour), and ambulance activity (2 min more for each patient per hour brought by ambulance).Day of time and week as well as frequency of patients with urgent conditions and those brought by ambulance significantly increased door-to-triage times. This should be kept in mind when organizing ED workflow.

Emergency department (ED) admissions have been rising over the last decades, especially in countries without any effective gate-keeping functions. Integration of walk-in clinics into the hospital might reduce ED-visits. Over a longer period, however, the additional service of a walk-in clinic might attract even more patients, nullifying an initial decrease in patients for the ED.This study aimed to determine short- and intermediate-term changes after the implementation of a hospital-integrated walk-in clinic. This is an observational study using routinely-collected health data. Study setting was the ED of a large tertiary care hospital in Austria, a country with universal health care and no regulations regarding level of care.ED-visits were compared between before (2015) and after (2017 and 2018) establishment of a hospital-integrated walk-in clinic.Total ED-visits decreased from 87,624 in 2015 to 67,479 in 2017, and 67,871 in 2018 (p 0.001), mainly due to a decrease in non-urgent (ESI 45) cases (45,715 (54.1%) in 2015; 33,142 (51.3%) in 2017; 30,846 (47.5%) in 2018; short term OR non-urgent vs. urgent: 0.89 (95% CI 0.88-0.91); intermediate term OR urgent vs. non-urgent: 0.76 (95% CI 0.78-0.75)). A total of 2611 (13%) (2017) and 1714 (8.5%) (2018) patients were referred back to the ED.After the introduction of the walk-in clinic, ED-visits declined significantly. This remained stable over a two-year period. Reduction in ED-visits was mainly due to low-acuity patients not requiring admission to the hospital.

The aim of this single-centre study was the comparative analysis of the GeneXpert (Cepheid Inc.) and the LIAT (Roche) system for the rapid polymerase chain reaction (PCR)-based detection of influenza A (IA) and influenza B (IB) viruses.During the 2017-2018 flu season, 651 prospectively collected samples (throat and nasal swabs) of patients with symptoms of influenza-like illness or acute respiratory infection were tested for the presence of IA and IB viruses using the GeneXpert and LIAT systems. To evaluate the usefulness for near-patient testing, a LIAT system was installed at the Department of Emergency Medicine, and sample testing was performed on site. Reference testing of all samples was performed with the Xpert Flu assay and for 313 samples in addition with the Xpert Xpress Flu/RSV (respiratory syncytial virus) assay at the central laboratory. Analysis of all samples was carried out within 24 hr after collection.Overall, 267 of the 651 samples analysed were positive for influenza viruses in at least one of the three assays investigated (IA, 88; IB, 179). The overall rates of agreement between the LIAT assay and the Xpert Flu assay was 96.0% for the detection of IA and IB viruses. The sensitivity and specificity of the LIAT assay compared to the Xpert Flu assay for the detection of IA was 98.80% (95% confidence interval (CI) 93.47-99.97%) and 99.12% (95% CI, 97.96% to 99.71%) and for the detection of IB 98.76% (95% CI 95.58-99.85%), and 96.33% (95% CI 94.26-97.81%), respectively. The LIAT assay showed a statistically significant higher detection rate of IB virus than the Xpert Flu assay (p0.01). No significant difference was found between the detection rate of the LIAT assay and the Xpert Xpress Flu/RSV assay. The mean time to the availability of a definite test result was significantly shorter with the on-site LIAT system than the GeneXpert system (mean 59 min saving time; p0.01).The LIAT system represents a robust and highly sensitive point-of-care device for the rapid PCR-based detection of influenza A and influenza B viruses.

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.

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.

Purpose To determine whether during the initial phase of head and neck cooling, jugular bulb temperature (Tjb; which may reflect brain temperature) is lower than esophageal temperature (Tes). Basic Procedures To compare Tes and Tjb, patients received head or head and neck cooling after cardiac arrest. Main Findings The first series with head cooling (n = 5; mean age 54 with a range of 41-62 years; 1 female and 4 males; mean body weight 80 kg with a range of 70-85 kg) showed a mean difference of 0.22°C (95% CI, −1.14 to 0.70; P = .55; limits of agreement, −3.17 to 2.73) between Tes and Tjb over 12 hours. For the second series, with head and neck cooling (n = 6, mean age 65 with a range of 56-76 years; 3 females and 3 males; mean body weight 75 kg with a range of 65-91 kg), Tjb was lower than Tes with a difference of 0.60°C (95% CI, 0.22 to 0.99; P = .01; limits of agreement, −3.10 to 4.30). During the first 3 hours, Tjb decreased faster than Tes (1.1°C/h [95% CI, 0.4 to 1.8; P Principal Conclusion During the initial phase of therapeutic hypothermia, Tjb seems to be lower than Tes.

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. Background: Platelet hyperfunction contributes to acute coronary syndromes (ACS). Thus, we hypothesized that platelet function under high shear stress predicts recurrent ACS during long-term follow-up of ACS patients. Patients and methods: Consecutive ACS patients (n = 208) were prospectively followed-up for an average of 28 months. Platelet function was measured with the platelet function analyzer (PFA-100®; Dade Behring, Marburg, Germany) at baseline for collagen/adenosine diphosphate closure times (CADP-CT) and for collagen/epinephrine closure times (CEPI-CT) after infusion of a uniform dose of 250 mg aspirin. Results: Of the conventional risk factors, only the prevalence of diabetes was higher in ACS patients with re-events. However, use of clopidogrel and use of beta blockers were also slightly lower in patients with re-events (P

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.

Abstract—Background: Carbon monoxide (CO) is regarded as a leading cause of morbidity and mortality. It endangers not only patients, but also health care professionals, especially emergency medical services (EMS) personnel because CO exposure is often unknown at the time EMS is called. Objective: Our objective was to report a case of unrecognized CO exposure during the treatment of a patient that finally led to the hospitalization of 11 EMS personnel. Case Report: A 71-year-old man was found unconscious in the basement of his house. EMS was called and, due to ST-segment elevations on electrocardiogram, the patient was treated for acute coronary syndrome. Unknown to EMS personnel, ongoing CO exposure was the cause of the patient’s symptoms. EMS staff finally had to be evacuated by firefighters, and a total of 12 persons, including the initial patient, had to be hospitalized. Conclusions: In the prehospital setting, hazardous environments always have to be considered as potential causes of a patient’s altered status. Together with the correct use of modern equipment, such as permanently switched-on CO detectors, this can help avoid harm to both patients and staff. 2013 Elsevier Inc.

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.

Background The association between intravascular ultrasound (IVUS) signs of plaque instability and plasma levels of biomarkers was determined in patients with unstable angina and non-ST–segment elevation myocardial infarction (UA/NSTEMI). Methods Fifty-two patients underwent coronary angiography and IVUS 8 ± 5 hours after the onset of chest pain. IVUS analysis included plaque morphology, disruption, thrombi and eccentricity, lumen, external elastic membrane, and plaque plus media areas of culprit lesion and reference segments and arterial remodeling. Plasma levels of the thrombin activation system (thrombin-antithrombin complex [TAT], tissue factor pathway inhibitor [TFPI], and prothrombin fragments 1+2 [F1+2]) and plasmin activation system (tissue and urokinase-type plasminogen activator [t-PA and u-PA], plasminogen activator inhibitor-1 [PAI-1], and D-dimer) were measured with enzyme-linked immunosorbent assay kits before angiography. Results Elevated levels of TAT (7.2 ± 6.0 μg/L), F1+2 (1.8 ± 1.0 nmol/L), TFPI (179.1 ± 131.0 ng/mL), PAI-1 (95.4 ± 54.6 ng/mL), t-PA (10.6 ± 8.8 ng/mL), and u-PA (2.6 ± 0.9 ng/mL) were found in patients with UA/NSTEMI. The serum levels of D-dimer (40.0 ± 39.5 ng/mL) remained in reference range. Expansive and constrictive remodeling were found in 18 (35%) and 12 (23%) patients, respectively. Expansive remodeling of the culprit lesion was associated with significantly higher plasma levels of PAI-1 (121.6 ± 55.0 vs 87.7 ± 61.5 and 77.4 ± 42.8 ng/ml, P = .039), and u-PA (3.0 ± 1.2 vs 2.2 ± 0.5 and 2.5 ± 0.7 ng/mL, P = .026) as compared with constrictive and neutral remodeling. Increased plasma levels of u-PA were associated with plaque rupture (3.0 ± 0.7 vs 2.5 ± 0.9 ng/mL, P = .062). Plasma levels of PAI-1 and u-PA correlated positively with plaque plus media ( P = .0297 and P = .0093) and external elastic membrane areas ( P = .010 and P = .0002). Conclusions Elevated levels of biomarkers of plasmin activation system are associated with signs of plaque instability of culprit lesion in UA/NSTEMI and might therefore serve as non-invasive determinants of the population that is at high risk for subsequent adverse events.

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.

There is increasing evidence that an inflammatory process is present in abdominal aortic aneurysms (AAAs) to varying degrees. The aim of this study was to compare acute phase reactants in patients with asymptomatic AAA, symptomatic AAA without rupture and ruptured AAA.Two hundred and twenty-five consecutive patients treated because of AAA were included in this case-control study. Polynomial logistic regression analysis was applied to compare admission C-reactive protein (CRP) and white blood count (WBC) measured in 111 asymptomatic outpatients, 52 symptomatic patients without rupture and 62 patients with rupture of the aneurysm. We adjusted for the potentially confounding effect of age, sex, haemoglobin levels and aneurysm diameter.Patients with symptomatic AAA and patients with ruptured AAA had significantly elevated CRP (p=0.002) and WBC (p0.0001) levels compared to asymptomatic patients. There was no statistically significant difference in CRP and WBC between patients with symptomatic AAA and ruptured AAA. Median CRP values of asymptomatic, symptomatic and ruptured AAA were0.5 (interquartile range (IQR)0.5-0.85), 1.1(IQR0.5-4.0) and 2.4 mg/dl (IQR 0.65-8.6), respectively, and median WBC values were 6.5 (IQR 5.5-8.0), 8.7 (IQR 6.8-11.2) and 13.2 (IQR 10.5-17.0), respectively.A significant elevation of CRP and WBC could be found in patients who presented with symptoms or rupture of an AAA. These indicators of inflammation were not observed in asymptomatic patients with AAA.

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.

Background: Carbon monoxide (CO) is known as a leading cause of unintentional poisoning death in many countries. Diagnosis is usually made by measuring carboxyhemoglobin (COHb), but due to the non-specific symptoms, the crucial step is considering CO poisoning. A possible solution might be screening emergency department (ED) patients. A cutaneous sensor that measures oxygen and CO saturation simultaneously could accomplish that. Objectives: We report a case in which CO-oximetry screening helped to identify CO poisoning in a patient with otherwise non-specific complaints presenting to a busy university hospital ED. Case Report: A 53-year-old woman presented to our ED, reporting non-specific but common symptoms including emesis and diarrhea, one-sided headache, paresthesia, and palpitations. Whereas conventional pulse oximetry showed normal results, a COHb level of 28% was measured using a CO-oximeter. This allowed a diagnosis of CO poisoning to be made at admission. The patient was treated with 100% oxygen continuous positive airway pressure ventilation, and CO washout was monitored continuously and non-invasively. In the meantime, the local fire department was alerted and found a malfunctioning water heater as the source of CO in the patient's residence. As COHb fell to normal levels and the patient reported feeling well, she was discharged the next day. Conclusion: CO-oximetry served as a powerful tool in both identifying and monitoring a CO-poisoned patient in a busy ED. Future studies should address possible sources of error using this method on a long-term basis and its level of acceptance by ED staff.

Vienna suffered an epidemic of heroin abuse in recent years, with drug-deaths due to opioids increasing from 62 in 1991 to 143 in 1993. The aim of this study was to make observations about illicit opioid-use with the ambulance service as a data source. From June 1994 to August 1995, the structured run records of the ambulance service were reviewed. Those with a presumptive diagnosis of “heroin or opiate” overdose were collected, characteristics of emergencies and patients were analyzed. The run records demonstrated a large number of non-fatal emergencies due to opioids, involving 528 men and 179 women in 1087 emergencies. These emergencies were on the average 6.8 times as prevalent as drug-fatalities. A group of 189 persons could be identified, who caused 52.2% of all emergencies and showed a threefold mortality rate during the observation period. In Vienna, the records of the municipal ambulance service provided valuable insights on opioid-abuse. We suggest local analysis of non-fatal emergencies due to opioids, as this might lead to a new source of information on illicit abuse of these drugs.

We sought to evaluate whether patients with epistaxis in the emergency department have a higher arterial blood pressure compared with patients with other medical emergencies and to study the association of elevated blood pressure during epistaxis with sustained arterial hypertension.In a prospective, cross-sectional, prevalence study we compared arterial blood pressure on admission in the ED in 213 consecutive patients treated for epistaxis with that of 213 sex- and age-matched control subjects. In 33 of those patients with elevated blood pressure during epistaxis, we evaluated the prevalence of sustained arterial hypertension. Main outcome measures were arterial blood pressure during epistaxis and evidence of sustained arterial hypertension, as determined by 24-hour ambulatory blood pressure measurement.Patients with epistaxis had significantly higher blood pressure values compared with those of control patients (systolic blood pressure 161+/-30 versus 144+/-22 mm Hg, P.001; diastolic blood pressure 84+/-19 versus 75+/-15 mm Hg, P.001). Of 33 (30%) of 108 patients with elevated blood pressure during epistaxis who were further evaluated, 26 (79%) patients were classified as having sustained arterial hypertension. Nine (27%) patients with sustained arterial hypertension were unaware of a history of hypertension. Patients with sustained arterial hypertension had significantly more episodes of epistaxis compared with patients with elevated blood pressure during epistaxis and no sustained arterial hypertension (mean 5 versus 1; P=.004).Patients with epistaxis have a higher blood pressure compared with that of control patients. Twenty-six (79%) of 33 patients with elevated blood pressure during epistaxis had sustained arterial hypertension. Nine (27%) of these patients were unaware of a history of hypertension. Continued management of patients with epistaxis and high blood pressure should include confirmation or exclusion of sustained arterial hypertension by 24-hour ambulatory blood pressure recording.

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.

Purpose: To study the impact of chronic prearrest health conditions on mortality and neurological recovery in patients after witnessed cardiac arrest and primary successful resuscitation. Patients and Methods: The study was set in the community of Vienna, Austria. Data concerning cardiopulmonary resuscitation of adult patients who survived a witnessed cardiac arrest were collected according to an internationally recommended protocol (Utstein-Style). Chronic prearrest health conditions and New York Heart Association (NYHA) functional classes were evaluated. All patients were followed up for 6 months after the event or death. Adverse outcome was defined as death or severe neurological impairment. A forward stepwise logistic regression model was applied to assess the impact of pre-arrest morbidity on unfavorable outcome, expressed as odds ratio (OR) with 95% confidence intervals (CI). Results: Of 411 patients, 269 (66%) had one or more of the following pre-arrest diseases: coronary heart disease (45%), hypertension (26%), congestive heart failure (20%), diabetes mellitus (14%), chronic pulmonary disease (6%), and cerebrovascular disease (5%). In 22% a NYHA class of III or IV was present before cardiac arrest. At 6-month follow-up, 161 (40%) of the patients were alive with favorable neurological recovery; overall mortality was 57% (n = 233). Increasing NYHA classes (OR 1.4 per NYHA class increase; CI 1.1 to 1.7) and increasing age were independent predictors of adverse outcome (OR 1.03 per 10-year increase; CI 1.01 to 1.05), as were durations of cardiac arrest (OR 1.10 per 5-minute increase; CI 1.07 to 1.12) and the presence of ventricular fibrillation or tachycardia (OR 0.3; CI 0.2 to 0.5). The remaining health conditions, as listed above, were not independently associated with outcome. Conclusions: A large proportion of patients with cardiac arrest had chronic diseases before the event. The presence of impaired functional performance in patients with structural heart disease increased unfavorable outcome within 6 months in primary cardiac arrest survivors. However, the impact of chronic prearrest conditions on outcome seems to be very small, and should not influence decisions whether to withhold or withdraw therapy.

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).

To establish baseline data on prehospital emergencies caused by opiates during a 4-month period, a retrospective analysis of run records of the Emergency Medical System in Vienna, the capital of Austria, was conducted. During the study period, there were 308 opioid emergencies involving 240 persons, an average of 2.5 overdoses per day. Severely compromised patients were treated in 67.8% of the 308 emergencies, and 79.3% of emergencies were transported to hospital; 52.5% of the involved persons were younger than 22 years of age. Sex distribution and periodicity and frequency of emergencies differed among age groups. A subgroup of individuals involved repeatedly in emergencies was identified, partly showing temporal clustering of fatal and nonfatal overdoses. Persons involved in opiate emergencies belong to heterogenous subgroups. At a local level, research should be initiated to clarify the pattern and impact of these emergencies on overall drug abuse prevention.

Many factors contribute to the risk of late death after successful rescue in a rock climbing accident. One factor may be hemodynamic and respiratory compromise by free suspension in a rope between fall and rescue. The risk probably results from using a chest harness alone or the combination of a chest harness and a sit harness. No trials on the acute cardiorespiratory response to free suspension in rock climbing have been reported so far. The effect of 3 min free suspension in a chest harness or in a sit harness on cardiopulmonary parameters was investigated in a randomized, cross-over trial in six healthy volunteers in a simulated rock climbing accident. Measurements were performed before and during the suspension at an altitude of 171 m. No statistical change in cardiopulmonary parameters was observed after free suspension in the sit harness. After free suspension in the chest harness, mean forced vital capacity decreased by 34.3% and mean forced expiratory volume decreased by 30.6%. No statistical change of arterial oxygen saturation occurred and mean end-tidal carbon dioxide increased by 11.5%. Mean heart rate decreased by 11.7%, mean systolic blood pressure decreased by 27.6%, mean diastolic blood pressure decreased by 13.1%, and mean cardiac output decreased by 36.4%. The p value for all reported changes was

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.

Energy metabolism was measured by indirect calorimetry in 86 patients with various forms of renal failure and in 24 control subjects. In patients with acute renal failure with sepsis, oxygen consumption, carbon dioxide production, and resting energy expenditure were increased (P less than 0.05). In other groups with renal failure (acute renal failure without sepsis, chronic renal failure with conservative treatment or hemodialysis, and severe untreated azotemia) these indices were not different from those of control subjects. Urea nitrogen appearance was decreased in patients with chronic renal failure undergoing conservative treatment, in those with severe untreated azotemia, and in hemodialysis patients (P less than 0.05). We conclude that renal failure has no influence on energy expenditure as long as septicemia is absent. Reduced urea nitrogen appearance rates in chronic renal failure are due to a reduced energy and protein intake. Wasting is a consequence of decreased food intake but not of hypermetabolism in chronic renal failure.

See also Levi M. Disseminated intravascular coagulation or extended intravascular coagulation in massive pulmonary embolism. This issue, pp 1475–6; Leitner JM, Jilma B, Spiel AO, Sterz F, Laggner AN, Janata KM. Massive pulmonary embolism leading to cardiac arrest is associated with consumptive coagulopathy presenting as disseminated intravascular coagulation. This issue, pp 1477–82; Thachil J. DIC score predicts mortality in massive clot coagulopathy as a result of extensive pulmonary embolism: a rebuttal. This issue, pp 1657–8.