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The effects of the angiotensin II receptor blocker candesartan and the angiotensin‐converting enzyme inhibitor lisinopril on the fibrinolytic system were investigated in a double‐blinded, prospective, randomized study. Seventy‐seven hypertensive patients taking candesartan (n=41) and lisinopril (n=36) with a systolic blood pressure >130 mm Hg and/or a diastolic blood pressure >80 mm Hg obtained by 24‐hour ambulatory blood pressure measurement were included in the study. Blood pressure, plasminogen activator inhibitor 1 (PAI‐1), tissue plasminogen activator (tPA), and the molar ratio of PAI‐1/tPA were determined before treatment and 6 weeks later. Blood pressure decreased in both groups (candesartan, 155/85 mm Hg to 140/84 mm Hg; P

Demographische Daten belegen, dass die Zahl der uber 80-Jahrigen in den kommenden Jahren weiter ansteigen wird. Aufgrund dieser Tatsache haben wir Grunde fur Rettungseinlieferungen an die Notfallaufnahme und das weitere Management dieser Patienten analysiert und mit den Jungeren verglichen. Es wurde eine retrospektive Analyse von Daten eines prospektiven Registers durchgefuhrt in der konsekutiv alle, von Rettungsorganisationen an die Notfallaufnahme des AKH Wien eingelieferten Patienten, erfasst werden. In dieser Datenbank werden die Diagnosen (im ICD-10-Code), Alter und Geschlecht jener Patienten registriert sowie der unmittelbare Ausgang der Erkrankung, das weitere Management und die unmittelbar applizierten intensivtherapeutischen Interventionen erfasst. Die Patienten wurden nach Alter in eine Gruppe

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.

Background: At very early stages of acute myocardial infarction (AMI), highly sensitive biomarkers are still lacking. Aim: To evaluate the utility of human heart-type fatty acid-binding protein (h-FABP) for early diagnosis of AMI. Design: Prospective diagnostic study. Methods: Consecutive patients presenting to the emergency department with chest pain or dyspnoea within 24 h of symptom onset were included. At presentation, the h-FABP test result was compared to the standard diagnostic work-up, including repeated ECG and troponin T measurements. Sensitivity analysis was performed for inconclusive tests. Results: We enrolled 280 patients presenting to hospital with a median symptom onset of 3 h (IQR 2–6 h): 109 (39%) had AMI. At presentation, h-FABP had a sensitivity of 69% (95%CI 59–77) and specificity of 74% (95%CI 66–80); 45 tests were false-positive and 34 were false-negative. Omitting inconclusive tests increased sensitivity and specificity only slightly. AMI was identified significantly earlier by h-FABP than by troponin T (24 vs. 8 patients, p = 0.005). Discussion: Although h-FABP can help to detect myocardial damage at an early stage in patients with chest pain or dyspnoea, it appears unsuitable as a stand-alone test for ruling out AMI.

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.

Introduction: Ibutilide is a rapid-acting antiarrhythmic drug with worldwide use for conversion of recent-onset atrial fibrillation. Vernakalant is a novel drug, which is likewise used intravenously, with proven effectiveness and safety compared to placebo and amiodarone in randomized clinical trials. Hypothesis: We hypothesized that the time to sinus rhythm and the conversion rate within 90 minutes is different between vernakalant and ibutilide in patients with recent-onset atrial fibrillation. Methods: A randomized, controlled, open-label trial registered at clinicaltrials.gov (NCT01447862) was performed in one hundred patients with recent-onset atrial fibrillation treated at the emergency department of a tertiary care hospital. Patients received up to two short-infusions of vernakalant (n= 49; 3mg/kg, 2mg/kg) or ibutilide (n= 51; 1mg, 1mg) according to the manufacturer’s instructions. Clinical and laboratory variables, adverse events, conversion rates and time to conversion were recorded. Results: Time to conversion of AF to sinus rhythm was significantly shorter in the vernakalant group compared to the ibutilide group (median time: 10min vs. 26min, p=0.02), and likewise the conversion success within 90 minutes was significantly higher (69% vs. 43%, p=0.01) in the vernakalant group. In both groups no serious adverse events occurred. Conclusion: Vernakalant was significantly faster and more effective in converting recent-onset atrial fibrillation to sinus rhythm at the emergency department.

More than 20 years ago we reported an analysis of a case series of elderly critically ill patients with acute kidney injury (AKI)—then termed acute renal failure. At that time, AKI was regarded as a “simple” complication, but has since undergone a fundamental change and actually has become one of the central syndromes in the critically ill patient. We have analyzed elderly patients above 65 years of age with an AKI defined as serum creatinine above 3 mg/dl corresponding to modern KDIGO stage 3, most of them requiring renal replacement therapy (RRT). Using an extremely complete data set the diagnosis differentiated the underlying disease entity, the dominant cause of AKI, acute and chronic risk factors (comorbidities). Special aspects such as severity of disease, early AKI at admission versus late AKI, early versus later start of RRT, AKI not treated by RRT in spite of indication for RRT, various measures of short-term and long-term prognosis, renal outcome, patients dying with resolved AKI, and causes of death were evaluated. Crude mortality was 61 % which corresponds to modern studies with gross variation among the different subgroups. Age per se was not a determinant of survival either within the group of elderly patients or as compared to younger age groups. Despite an increase in mean age and disease severity during the observation period prognosis improved. A total of 17 % of patients developed a chronic kidney disease. Long-term survival as compared to the general population was low. A look back at the last two decades illustrates a remarkable evolution or rather metamorphosis of a syndrome. AKI has evolved as a central syndrome in intensive care patients, a systemic disease process associated with multiple systemic sequels and extra-renal organ injury and exerting a pronounced effect on the course of disease and short- and long-term prognosis not only of the patient but also of the kidney. Moreover, the “non-renal-naive” elderly patient with multiple comorbidities has become the most frequent ICU patient in industrialized nations.

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.

Age is an important risk factor for mortality and unfavorable outcome after successfully resuscitated cardiac arrest. Other risk factors may interact with this relationship. We conducted the current study to quantify the influence of age on mortality and unfavorable neurologic outcome of patients surviving out-of-hospital cardiac arrest, and to determine the role of other confounding variables. This study was based on a cardiac arrest registry comprising all patients with witnessed out-of-hospital cardiac arrest of cardiac origin after successful resuscitation admitted to a department of emergency medicine between September 1991 and December 2004. We assessed the association between age and mortality and the degree of neurologic impairment, adjusting for multiple risk factors. We tested for interaction between age and all other risk factors with outcome. With each year of age the adjusted odds ratio for in-hospital death increased by 1.05 (95% confidence interval [CI], 1.04-1.07), and the adjusted odds ratio for an unfavorable neurologic outcome increased by 1.04 (95% CI, 1.03-1.06). Interaction between age and sex was present, and the analysis was stratified to sex. For men we found a steep risk increase for death and unfavorable outcome after being resuscitated from cardiac arrest, with the highest risk in the oldest age quartile. For women we observed only a slight risk increase for death and almost no risk increase for unfavorable outcome. Age is a strong independent risk factor for mortality and neurologic impairment after successfully resuscitated cardiac arrest. The risk increase with advancing age is much greater in men than in women. Therefore, in women, the influence of age on prognosis after cardiac arrest may not be very important, while in men it still plays an important role. This should be considered especially when treating successfully resuscitated women and discussing the prognosis with the medical team or the patient's family.

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.

Die Notfallaufnahme der Universitatsklinik fur Notfallmedizin stellt eine Drehscheibe in der Versorgung von Vergiftungspatienten am AKH Wien dar. In der folgenden Analyse wurden die Haufigkeit exogener Vergiftungen, ihre Ursachen und das weitere Management ausgewertet um allgemeine Ruckschlusse fur die Errichtung von Notfallaufnahmen zu erhalten. Die Dateneingabe erfolgte in eine Microsoft-Access Datenbank in der neben Vergiftungsdiagnosen nach ICD-10 auch Alter, Geschlecht, ambulante/stationare Betreuung, maschinelle Beatmung, Reanimation und weitere intensivmedizinische Betreuung bzw. Tod an der Notfallaufnahme erfasst wurden. Im Jahr 2003 wurden 550 Personen mit Vergiftungen—das sind 0,7% der Gesamtpatientenanzahl von 74 117—in der Notfallaufnahme behandelt. Von diesem Kollektiv konnten 161 Patienten (29,3%) bereits nach ambulanter Versorgung wieder aus dem Spital entlassen werden. 345 Patienten (62,7%) wurden auf die Notfallstation zur weiteren Versorgung aufgenommen. Zur weiteren stationaren Behandlung wurden 171 Patienten (31,1%) auf eine Normalstation uberwiesen und 18 (3,3%) benotigten eine Transferierung auf eine Intensivstation. In 35 Fallen (6,4%) war es notwendig den Patienten zu intubieren und maschinell zu beatmen. Davon erlitten 8 Personen einen Herz-Kreislauf- Stillstand von denen 6 (75%) nach kardio-pulmonaler Reanimation verstarben. In einem Fall kam der cardio-pulmonale Bypass—leider frustran—zum Einsatz. Obwohl die Zahl der Vergiftungen gemessen an der Gesamtzahl der Patienten der Notfallaufnahme relativ gering ist, zeigt unsere Analyse doch, dass es sich um eine relevante Diagnosegruppe mit potentieller Beatmungs- und Reanimationspflichtigkeit handelt. Diese Tatsachen sind bei der Errichtung von Notfallaufnahmen zu berucksichtigen.

OBJECTIVE Induction of deep cerebral hypothermia before reperfusion might improve neurologic outcome after cardiac arrest. We hypothesized that an aortic flush with cold saline during cardiac arrest is able to induce deep cerebral hypothermia and that the cooling efficiency can be enhanced by a) increasing the arteriovenous pressure gradient during the flush with vasopressin; b) improving the cerebral microcirculation during the flush with the thrombolytic agent alteplase; and c) increasing the arteriovenous pressure gradient further with venting the right heart by draining blood during the flush. DESIGN Prospective randomized experimental study. SETTING University research laboratory. SUBJECTS Twenty-four pigs Large White breed (31-42 kg). INTERVENTIONS After 10 mins of ventricular fibrillation, pigs received an aortic flush (100 mL/kg, 4 degrees C, flow rate 35 mL/kg/min) into the descending aorta via a balloon catheter. The animals were subjected randomly to either an aortic flush with saline, saline plus vasopressin 1.2 IU/kg, saline plus alteplase 1 mg/kg, saline plus a combination of vasopressin 1.2 IU/kg and alteplase 1 mg/kg, or saline plus vasopressin 1.2 IU/kg and venting the right heart. Arterial and venous pressures and brain temperatures were recorded for an observation time of 10 mins after flush. MEASUREMENTS AND MAIN RESULTS A sufficient arteriovenous pressure gradient and deep cerebral hypothermia were only achieved with a flush containing vasopressin (brain temperature 16.1+/-1.3 degrees C in the vasopressin group vs. 35.4+/-1.5 degrees C in the saline group, p

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.

Aims The aim of the ReoPro-BRIDGING Austrian multi-centre study was to investigate the effects of abciximab (ReoPro®) on early reperfusion in ST-elevation myocardial infarction prior to or during primary percutaneous coronary angioplasty (pPCI). Methods and results Fifty-five patients with STEMI were randomized either to start abciximab (0.25 mg/kg bolus followed by 10 I¼g/min infusion) during the organization phase for pPCI (Group 1, n =28) or immediately before pPCI (Group 2, n =27). The time between first bolus of abciximab and first balloon inflation of pPCI was 83±18 vs 21±13 min in Group 1 vs 2. The pre-pPCI ST-segment resolution (55±21.4% vs 42.4±18.2%, p =0.005), TIMI flow grade 3 (29% vs 7%, p =0.042), corrected TIMI frame count (58.4±32.7 vs 78.9±28.4 frame, p =0.018) %diameter stenosis (76.3 /63.5–100/ vs 100 /73.5–100/; median /interquartile range/, p =0.023), were significantly higher in Group 1 vs Group 2. Quantitative myocardial dye intensity measurement revealed a significantly higher grade of myocardial tissue perfusion (1 /0–9.25/ vs 0 /0–3.0/ grey pixel unit, p =0.048) in Group 1 before pPCI. Rapid release of cardiac enzymes was observed in Group 1 as compared with Group 2: rate of rise of CK was 210±209 vs 97±95 U/l/h ( p =0.015). QRS score indicated a smaller infarct size in Group 1 (4.8±3.8 vs 7.6±3.5, p =0.011) on day 7. Conclusion The use of abciximab in the organization phase for pPCI results in signs of early recanalization of the infarct-related artery and a subsequent improved myocardial tissue reperfusion.

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.

Chirurgische Eingriffe zur Fettreduktion werden an Gesunden durchgefuhrt, gelten als risikoarm und werden nicht mit einem todlichen Ausgang in Zusammenhang gebracht. Infolge der grosen Wundflache und der moglichen Beeintrachtigung des kosmetischen Ergebnisses sind postoperative Blutungen eine gefurchtete Komplikation, eine Antikoagulation wird daher vielfach nur selten bis gar nicht durchgefuhrt. Wir beschreiben 3 Patientinnen, bei welchen nach chirurgischer Fettreduktion durch Dermolipektomie bzw. Abdominoplastik ein plotzlicher Kollaps mit Herz-Kreislaufstillstand aufgetreten ist. Als Ursache fur den Herz-Kreislaufstillstand, der letztlich in allen 3 Fallen zum Tod fuhrte, fand sich eine Pulmonalembolie. Die Patientinnen waren nicht oder nur inadaquat antikoaguliert. Eine fruhe Mobilisierung, Kompressionsverbande und Stutzstrumpfe konnten die Thromboembolie nicht verhindern. Bei der chirurgischen Fettreduktion ist trotz der Gefahr einer peri- und postoperativen Blutung und der fruhen Mobilisierung als Thromboembolieprophylaxe eine zusatzliche Antikoagulation zu fordern. Bei plotzlichem Auftreten von Dyspnoe, Thoraxschmerzen, Kollaps oder Herz-Kreislaufstillstand bei Patienten nach chirurgischer Fettreduktion muss an das Vorliegen einer Pulmonalembolie gedacht und entsprechende diagnostische Schritte eingeleitet werden.

Eine 62-jahrige Patientin wurde mit akutem Thoraxschmerz und vegetativer Begleitsymptomatik an der Notaufnahme eines Schwerpunktkrankenhauses aufgenommen. Vom klinischen Eindruck her stand ein akutes Koronarsyndrom an erster Stelle der Uberlegungen. Als Labor und EKG innerhalb von 8 Stunden hinsichtlich einer myokardialen Ischamie unauffallig blieben und die Patientin trotz Schmerztherapie nicht ganz beschwerdefrei war, wurde an das Vorliegen einer Pulmonalembolie gedacht und eine D-Dimer-Bestimmung angefordert, die mit 4,4 μg/ml positiv war. Zur Verifizierung einer Pulmonalembolie wurde eine Computertomographie (CT) des Thorax durchgefuhrt, die keinen Hinweis fur das Vorliegen einer Pulmonalembolie ergab. Wohl aber zeigte sie als uberraschendes Ergebnis eine Typ-A-Aortendissektion, von der Aorta ascendens bis in den Aortenbogen und die Aorta descendens reichend. Die Patientin wurde daraufhin unverzuglich entsprechend chirurgisch versorgt. Dieser Fallbericht zeigt, dass bei Patienten mit unklarem Thoraxschmerz und erhohtem D-Dimer, nach Ausschluss eines akuten Koronarsyndroms nicht nur an eine Pulmonalembolie, sondern auch an das Vorliegen einer akuten Aortendissektion gedacht werden sollte, und, dass im Rahmen einer Thorax-CT mit der Fragestellung Pulmonalembolie moglicherweise auch eine Aortendissektion erkannt werden kann.

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.

Sowohl Notfallaufnahmen als auch Intensivstationen sind mit der Betreuung von Schockpatienten befasst. Trotz unterschiedlicher Personal- und Apparateausstattung mussen im Management von Schockpatienten einheitliche Prinzipien der Schockdiagnose und -therapie verfolgt werden. Die Diagnose des Schockzustandes muss anhand objektiver Parameter (Laktat, pH-Wert, Standardbikarbonat, arterieller Blutdruck, zentraler Venendruck und Herzminutenvolumen) erfolgen. Ziel der Schockbehandlung ist die rasche Wiederherstellung einer adaquaten Gewebsperfusion durch Volumen- und Erythrozytenersatz, Verabreichung von Vasokonstriktoren, Inotropika, bzw. von Substanzen, die die Mikrozirkulation gunstig beeinflussen und durch mechanische Methoden. Zielwerte sind: mittlerer arterieller Blutdruck >80 mmHg, zentraler Venendruck >6 mmHg, Hamoglobin >8 g/dl, Herz-Index >3,5 l/min/m2. Neue Aspekte zu den Fragen der Optimierung der Hamodynamik, des optimalen Hamatokrits, der Kortisonbehandlung, der Effektivitat der intraaortalen Ballonpumpe, der Beatmungstherapie mit niedrigen Tidalvolumina und der intensiven Insulintherapie werden vorgestellt und analysiert. Neben diesen Masnahmen ist die Abklarung der Kausalitat des Schockzustandes von hochstem Interesse, weil die Behebung der Schockursache letztlich der entscheidende Schritt in der Therapie ist.

Cardiac arrest is possibly one of the most traumatizing conditions for patients, but to date, its influence on psychic morbidity remains unknown. Posttraumatic stress disorder is a unique symptom configuration after an extreme event consisting of intrusion re-experiencing, avoidance and numbness, and hyperarousal symptoms. We studied a) the prevalence of posttraumatic stress disorder (PTSD) in long term survivors of cardiac arrest; b) the role of specific stress factors related to cardiac arrest for the development of PTSD; and c) the influence of sedation and analgesia during or after cardiac arrest on the occurrence of PTSD.Prospective, cohort study.University teaching hospital.Analysis was performed in cardiac arrest survivors who were discharged with favorable neurologic outcome during an 8-yr period (1991-1999).All patients received the Davidson Trauma Score for the assessment of PTSD and a modified German version of the EuroQol questionnaire for assessment of quality of life. Cardiac arrest circumstances and administration of sedation and analgesia were assessed.Of 1,630 initially resuscitated patients, 270 patients were discharged with good neurologic outcome. A total of 226 patients were contacted, and 143 patients (63% of all eligible patients) completed the study. Mean time from cardiac arrest to follow up was 45 months (range, 24-66). Thirty-nine patients (27%; 95% confidence interval, 21% to 35%) had a Davidson Trauma Score40 and fulfilled criteria for PTSD. Patients with PTSD had a significantly lower quality of life. The only independent risk factor for the development of PTSD was younger age. There was no difference between patients with or without PTSD regarding the use of sedation and analgesia during or after cardiac arrest.The prevalence of PTSD in cardiac arrest survivors is high. Besides younger age, neither clinical factors nor the use of sedation and analgesia were associated with development of PTSD.

The evaluation of patients with acute chest pain remains challenging, as it implies the risk of fatal misdiagnosis. It is well recognized that typical angina does not specifically identify patients at high risk. We investigated the predictive value of characteristics atypical for myocardial ischemia for exclusion of acute or subacute coronary events, focusing on patients' symptoms, medical history and risk factors.We prospectively studied 1288 consecutive patients presenting with acute chest pain at a non-trauma emergency department. Patients' symptoms, history and risk factors were evaluated using seven predefined criteria and assigned as typical or atypical for ischemic coronary chest pain. Positive predictive value (PPV) and 95% confidence intervals (95% CI) were calculated to predict or exclude acute myocardial infarction (AMI) and major adverse cardiac events (MACE: cardiovascular death, percutaneous coronary interventions, bypass surgery, or myocardial infarction) within six months.AMI occurred in 168 patients (13%), and 6-months MACE (including AMI) overall in 240 patients (19%). Presence of four or more criteria typical for myocardial ischemia was associated with a PPV of 0.21 (0.17 to 0.25) for predicting AMI and 0.30 (0.25 to 0.35) for 6-months MACE. Presence of four or more criteria atypical for coronary ischemia was associated with a PPV of 0.94 (0.91 to 0.96) for excluding AMI and 0.93 (0.90 to 0.96) for excluding 6-months MACE. In 165 of 476 patients under 40 years of age (35%), four or more atypical criteria excluded AMI and 6-months MACE with PPVs of 0.98 (0.96 to 1.0).Evaluation of criteria atypical for myocardial ischemia with acute chest pain may help to identify candidates for early discharge, whereas typical characteristics have very little diagnostic value.

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.

Magnesium hat in der Notfallmedizin in verschiedener Hinsicht grose Bedeutung. Sowohl Mangelzustande wie auch Intoxikationen stellen in der klinischen Routine ein groses Problem dar. Daruber hinaus ist Magnesium, in ganz unterschiedlichen notfallmedizinischen Situationen – bei parenteraler Verabreichung – ein interessantes Medikament. Es besticht durch raschen Wirkungseintritt, grose therapeutische Breite, gute Steuerbarkeit sowie niedrige Kosten.

Kurkciyan I, Meron G, Sterz F, Mu¨llner M,Tobler K, Domanovits H, Schreiber W, Bankl HC,Laggner AN (General Hospital of Vienna, Universityof Vienna, Vienna, Austria). Major bleeding com-plications after cardiopulmonary resuscitation:impact of thrombolytic treatment. J Intern Med2003; 253: 128–135.Objective. The risk of bleeding complications causedby thrombolysis in patients with cardiac arrest andprolonged cardiopulmonary resuscitation is unclear.We evaluate the complication rate of systemicthrombolysis in patients with out-of-hospital cardiacarrest caused by acute myocardial infarction, espe-cially in relation to duration of cardiopulmonaryresuscitation.Design. The study was designed as retrospectivecohort study, the risk factor being systemic throm-bolysis and the end-point major haemorrhage,defined as life-threatening and/or need for transfu-sion. Over 10.5 years, emergency cardiac care data,therapy, major haemorrhage and outcome of 265patients with acute myocardial infarction admittedto an emergency department after successful car-diopulmonary resuscitation were registered.Results. We observed major haemorrhage in 13 of132 patients who received thrombolysis (10%, 95%confidence interval 5–15%), five of these survived todischarge, none died because of this complication.Major haemorrhage occurred in seven of 133patients in whom no thrombolytic treatment hadbeen given (5%, 95% confidence interval 1–9%),two of these survived to discharge. Taking intoaccount baseline imbalances between the groups,the risk of bleeding was slightly increased ifthrombolytics were used (odds ratio 2.5, 95% con-fidence interval 0.9–7.4) but this was not significant(P ¼ 0.09). There was no clear association betweenduration of resuscitation and bleeding complications(z for trend ¼ 1.52, P ¼ 0.12). Survival was notsignificantly better in patients receiving thromboly-sis (odds ratio 1.6, 0.9–3.0, P ¼ 0.12).Conclusions. Bleeding complications after cardio-pulmonary resuscitation are frequent, particularlyin patients with thrombolytic treatment, but do notappear to be related to the duration of resuscitation.In the light of possible benefits on outcome, throm-bolytic treatment should not be withheld in carefullyselected patients.Keywords: cardiopulmonary resuscitation, compli-cation, heart arrest, myocardial infarction,thrombolysis.

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.

Background: Diagnosis of acute coronary syndromes (ACS) is a major challenge for emergency physicians. Because soluble fibrin (sF) has been suggested as a potential early marker of impending myocardial ischemia, we were interested whether a sF bedside test could help in early identification of patients with ACS in the emergency department. Methods: We evaluated plasma coagulation markers, including a newly developed sF bedside test, prothrombin fragment (F1+2), sF, and D-dimer, in a cross-sectional trial with 184 patients suggestive of ACS. Results: Whereas 76% (13 of 17) of patients with unstable angina pectoris (UAP) had a positive sF bedside test, only 10 of 33 patients (30%) with non-ST-segment-elevation myocardial infarction and 10 of 44 patients (23%) with ST-elevation myocardial infarction tested positive. Three percent of controls (1 of 33) and 11% of patients (6 of 57) with preexisting stable angina had a positive sF bedside test (P Conclusions: A sF bedside test offers a specific tool for early identification of patients with ACS in an emergency department setting, although its sensitivity seems sufficient only for the early identification of patients with UAP. A sF bedside test could be useful, particularly in UAP patients with a nondiagnostic ECG.

The aim of the field study was to objectify physicians' vigilance, well-being, and cognitive performance in the course of 24-hr shifts with and without afternoon rest. SUBJECTS, SETTING, AND DESIGN: Eleven residents (four women, seven men; age, 33.5 +/- 4.7 yrs) were observed when doing two regular 24-hr shifts at the emergency department (randomized crossover design): one without rest, the other with a period of rest in the early afternoon (duration, 2:31 +/- 1:04 hrs) and the opportunity of having a nap (duration, 1:07 +/- 0:26 hrs, n = 6). Electroencephalography and psychometric tests were carried out at 8 am and at midnight.Measurements included subjective perception of workload, stress, and sleeping behavior; computer-analyzed electroencephalography; adjective checklist (Eigenschaftswörterliste 60 S, a self-rating scale); complex reaction time test; Pauli test (number of calculations during 3 mins); and numerical memory test.Electroencephalographic analyses showed a significant decrease in alpha power and a significant increase in beta power in the evening as compared with the morning on both days. The nocturnal increase observed in delta activity was significantly less pronounced in duties with rest than in duties without rest. Physicians felt deactivated at night. The Eigenschaftswörterliste 60 S indicated deactivation at night and a rest-induced activation in the subgroup that had taken the opportunity to sleep in the afternoon. Psychometric tests did not show any significant differences, neither between performance in the morning and evening nor between results with and without rest.As expected, electroencephalographic recordings showed nocturnal deactivation and a vigilance-promoting effect of the afternoon rest. These objective findings were in accordance with the results derived from self-rating scales. On the other hand, in short-lasting psychometric tests, performance was found unchanged after 16 hrs of routine work. In further studies, a discrimination between resting periods with and without sleep will be important.

OBJECTIVE The genetic background of hypertensive crisis is unknown. We examined the association of polymorphisms in genes involved in the renin-angiotensin-aldosterone-system with hypertensive crisis. DESIGN Population-based case-control study. SETTING Emergency department at a tertiary care university hospital. PATIENTS A total of 182 patients with essential hypertension who were admitted to an emergency department for treatment of hypertensive crisis and 182 age- and sex-matched healthy individuals. INTERVENTIONS None. MEASUREMENTS Analysis of polymorphisms in genes coding for angiotensinogen (AJT 704T-->C), angiotensin II receptor 1 (AGTR1 1166A-->C), renin (REN 2646G-->A), renin-binding protein (RENBP 61T-->C), alpha-adducin (ADD1 1378G-->T), beta-2-adrenergic receptor (ADRB2 46A-->G, 79C-->G), and angiotensin I converting enzyme (ACE I/D) was performed by polymerase chain reaction and restriction fragment length polymorphism analysis. MAIN RESULTS Among patients, the ACE I/D polymorphism showed a deviation from Hardy-Weinberg equilibrium (p =.01). In controls, all polymorphisms were in the Hardy-Weinberg equilibrium. The frequency of the DD genotype was increased in patients (n = 70, 38.5%) vs. controls (n = 51; 28.0%;p =.03; odds ratio, 1.61; 95% confidence interval, 1.03-2.50), which was due to the DD genotype in 40 male patients (44%) vs. 23 in male controls (25.3%;p =.004; odds ratio, 3.48; 95% confidence interval, 1.47-8.30). There were no differences in genotype distributions among other polymorphisms. CONCLUSION We demonstrate a possible association of the DD genotype with hypertensive crisis in men.

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.

BACKGROUND Transforming growth factor-beta (TGF-beta) is a multifunctional cytokine that has been linked to vascular remodeling processes, myocardial hypertrophy, and renal fibrosis. Recently a correlation between serum levels of TGF-beta1 and blood pressure (BP) levels in patients with end-stage renal disease was shown. In addition, it is not clear whether TGF-beta1 is a causative factor in the pathogenesis of essential hypertension and associated with hypertensive target organ damage (TOD). METHODS Using a TGF-beta1-specific sandwich ELISA, we compared plasma levels of active and total TGF-beta1 of 30 normotensive persons and 85 patients with essential hypertension with and without TOD, as measured by microalbuminuria or left ventricular hypertrophy. RESULTS Active and total TGF-beta1 levels were significantly higher in plasma of patients with essential hypertension than in normotensive controls (P < .05 and P < .01, respectively). However, neither active nor total TGF-beta1 correlated with systolic or diastolic BP (R2 < 0.14 for all parameters). Levels of active and total TGF-beta1 were significantly higher in hypertensive patients with than without TOD (P < .05). CONCLUSIONS Active and latent TGF-beta1 levels are markedly increased in plasma of hypertensive patients. We assume that TGF-beta1 contributes substantially to the development of TOD in essential hypertension, independent of BP levels.

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.

SummaryIn a placebo-controlled, double-blinded, randomized study we evaluated the effect of ramipril prior to thrombolysis on the course of PAI-1 plasma levels and on the frequency of postinfarct ischemic events in patients with acute myocardial infarction. Fifty-one out of 99 patients received 2.5 mg ramipril orally prior to thrombolysis and 12 h later. The blood samples for determination of PAI-1 plasma levels were collected on admission and 2, 4, 8, 12 and 24 h after thrombolysis. Postinfarct ischemic events were registered until coronary angiography was performed and defined as recurrent chest pain and/or evidence of ischemic signs on the ECG (ST-depression or ST-segment elevation of 1 mm in one or more inferior or anterior leads). Coronary angiography was performed within 7 days after the onset of myocardial infarction. Patients were classified into two groups: those without reperfusion of the infarct-related artery (TIMI grade 0 or 1) and those with reperfusion of the infarct-related artery (TIMI grade 2,3). On admission, PAI-1 plasma levels were similiar in both groups (ramipril: 47.1 [4.8] ng/ml; placebo: 49.1 [4.8] ng/ml). The PAI-1AUC was 77.2 [6.7] ng/ml/h in the ramipril group and 95.4 [6.2] ng/ml/h in the placebo group (p = 0.013). Significant differences between groups were observed at 4, 8 and 12 h after thrombolysis (4 h: 85.5 (11.3) vs. 116 (12.3) ng/ml, p < 0.01; 8 h: 79.1 (11.2) vs. 100.9 (9.3) ng/ml, p < 0.01; 12 hrs: 71.3 (9.5) vs. 87.4 (7.7) ng/ml, p < 0.05). The relative frequency of postinfarct ischemic events was significantly lower in the ramipril group (2.5% versus 7.1%, p = 0.001). Additionally, we observed a significant higher rate of TIMI grade 2 and 3 of the infarct-related artery in patients receiving oral ramipril compared to the placebo group (73% versus 54%; p = 0.035).Our study demonstrates a favorable effect of ramipril on the fibrinolytic system after thrombolysis associated with a lower rate of postinfarct ischemic events within the first days after myocardial infarction. Therefore, the application of ramipril prior to thrombolysis appears to be a reasonable concomitant treatment which may reduce early infarctrelated complications.

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.

Background: Based on demographic changes in the western world, the number of patients with cardiac arrest due to a cardiovascular event is continuously rising. A large variety of factors impacting on favorable neurological outcome (CPC 1-2) and the 6-month survival, are well established. The question whether the knowledge about these predictive factors result in improved outcome over the last 20 years, has not been proven within a long-term study so far. Methods: We prospectively identified 2670 patients (out-of hospital [OOH], n = 1822; in-hospital [IH], n = 848) with cardiac arrest of cardiac etiology and ventricular fibrillation as a first rhythm treated at our emergency department between January 1992 and December 2012. Chi-square test and Cochran-Mantel-Haenszel test have been used to assess differences in CPC and 6-month survival within the observation-period. Results: Within our total cohort, 2189 patients (82.0%) survived the initial event. After a follow-up period of 6 months, 1007 patients (46%) with ROSC deceased. A favorable CPC (1-2) after 6 months has been detected in 1197 patients (54.7%). Within the last 20 years there was an improvement of favorable neurological outcome (CPC 1-2) (p Independently in patients with IH cardiac arrest, 78.5% (n=666) survived the initial event, but the 6-month survival rate (n=381, 57.2%) and the favorable CPC outcome (n=443, 66.5%) were approximately higher. Independently within IH cardiac arrest patients a reduction of 6-month mortality rates (p=0.048) was found. Still there were constantly high rates of favorable neurological outcome (CPC 1-2) after 6 months, but there was no improvement within the past 20 years (p=0.665). Conclusion: We were able to demonstrate, that outcome of patients with cardiac arrest of a cardiac etiology has improved significantly within the last 20 years. This gives the impression, that critical care medicine on a high level for patients with cardiac arrest even in the emergency department could be important for outcome. If such specific cardiac arrest centers merged with emergency departments prove to be valuable for ideal patient care has to be further evaluated in detail.

UNLABELLED Important adverse effects of bystander cardiopulmonary resuscitation (CPR) are well known. We describe the number of nonmedical professional CPR-related complications in patients surviving cardiac arrest, as assessed by chest radiograph. Within 2 yr, all consecutive patients admitted to the department of emergency medicine at a university hospital who had a witnessed, nontraumatic, normothermic cardiac arrest were studied. Radiologically evaluated adverse effects were compared with Mann-Whitney U-tests between patients who received bystander basic life support (Bystander group) and patients who did not receive bystander basic life support before advanced life support was started (ALS group). For assessment of bystander CPR-associated complications, chest radiographs were used. Of 224 patients, 173 were eligible. The median age was 58 yr (interquartile range, 51-71 yr), and 126 patients (73%) were men. The incidence of adverse effects associated with assisted-ventilation maneuvers and external chest compressions did not differ significantly between groups (severe gastric insufflation, 17% vs 18% between the Bystander group [n = 59] and the ALS group [n = 96], respectively; suspicion of aspiration, 22% vs 17%, respectively; soft tissue emphysema, 2% vs 1%, respectively; and serial rib fractures, 8% vs 8%, respectively). CPR administered by nonmedical personnel did not increase the number of life support-related adverse effects in patients surviving cardiac arrest as assessed by means of chest radiograph on admission. IMPLICATIONS Complications related to cardiopulmonary bypass (CPR) are not increased when CPR is administered by nonmedical personnel, as assessed by chest radiograph. These data may be valuable in motivating lay people to perform basic life support.

Epileptische Anfalle gehoren zu den haufigsten neurologischen Notfallen im Kindes- und Jugendalter. Nach erstmaligem Auftreten eines Krampfanfalls ist eine rasche Klarung der zugrundeliegenden Ursache in Hinblick auf eine moglichst fruhe zielgerichtete Behandlung von groser Bedeutung. Als mogliche Ursachen kommen Raumforderungen, Blutungen oder Traumen, infektiose Erkrankungen des Zentralnervensystems, Stoffwechselerkrankungen, Elektrolytentgleisungen, Drogen- oder Alkoholabusus sowie Schlafentzug in Frage. In nur etwa 1% sind die Anfalle Ausdruck einer Epilepsie. Wir berichten den Fall einer bis dato immer gesund gewesenen 17-jahrigen, die wegen eines erstmals aufgetretenen, generalisierten tonisch-klonischen Anfalls an unserer Abteilung aufgenommen wurde. In der Anamnese fanden sich seit zwei Tagen bestehende starke Kopfschmerzen, die erfolgreich analgetisch behandelt wurden. Im klinisch physikalischen Status war eine Adipositas auffallig, im neurologischen Status, im Labor sowie in der craniellen Computertomographie zeigten sich keine pathologischen Befunde, sodass die Patientin primar unter der Verdachtsdiagnose einer idiopathischen Epilepsie mit Antiepileptika behandelt wurde. Unter Therapie kam es zu einer Gesichtsfeldeinschrankung und schlieslich zu weiteren generalisierten Anfallen. Eine erweiterte Diagnostik mit Lumbalpunktion, Bestimmung der Schilddrusenhormone und einem Drogenscreening blieb ebenfalls ohne pathologischen Befund. Schlieslich lieferte eine gezielte Befragung und die Harnanalyse den entscheidenden Hinweis fur die Ursache des Anfallgeschehens, welches nun doch als Symptom einer schweren Grunderkrankung zu werten war.

Objective: To establish a model based on clinical and anamnestic data easily available in the out-of-hospital setting, which facilitates the differential diagnosis between cerebral infarction and intracranial hemorrhage. Design: Retrospective study that simulates a prospective approach. Setting: Emergency Department of the University Hospital in Vienna, Austria. Patients and participants: Data of 224 patients with either intracranial hemorrhage or cerebral infarction were prospectively collected. Uni- and multivariate analysis was performed to identify neurological symptoms and anamnestic data, which were associated with either intracranial hemorrhage or cerebral infarction. Measurements and results: Unilateral weakness or sensory loss was observed more frequently in patients with infarction compared to hemorrhage (69.8% vs 11.9%, P

OBJECTIVE To assess the ratio of early (E) to late atrial (A) mitral Doppler peak flow velocity (Doppler E/A ratio) before and after adjustment for age in patients with moderate to severe hypertension, in whom left ventricular diastolic dysfunction is an early finding. Mitral flow patterns can be used to assess diastolic filling characteristics, and the Doppler E/A ratio is the parameter most commonly used, although it is known to be strongly age dependent. There are no established normal values for this ratio. DESIGN Retrospective data analysis. SETTING A 2000-bed tertiary-care teaching hospital. PATIENTS We studied 190 patients (99 women and 91 men; ages 55 +/- 13 years) with moderate to severe hypertension. INTERVENTIONS The ratio of early (E) to late atrial (A) mitral Doppler peak flow velocity was measured. As this ratio depends on age, a Z score was calculated to control for this influence. The Z score is the standardized normal deviation of the mean, with a normal value of 0 +/- 2. MAIN OUTCOME MEASURES Sensitivities and specificities for detecting an age-dependent reduction in Doppler E/A score (Z score less than -2) with a non-age-dependent Doppler E/A ratio (less than 1) were calculated. RESULTS In 106 of the patients (56%) the Doppler E/A ratio was less than 1.0. Only nine patients (4.7%) had a Z score less than -2. The sensitivity of the Doppler E/A ratio threshold of 1.0 for detecting a Z score less than -2 was 0.89 and the specificity was 0.46. A Z score less than -2 was found only in patients younger than 45 years. CONCLUSIONS The Doppler E/A ratio was reduced in a large proportion of our patients. However, after correction for age it was decreased in only 4.7% of these patients. The use of a single Doppler E/A ratio threshold value has a weak diagnostic power to detect age-independent changes in mitral flow patterns.

Objective The polymorphism 825C-->T in exon 10 of the gene GNB3 encoding the beta3 subunit of heterotrimeric guanine nucleotide binding regulatory proteins (G-proteins) results in a splicing variant (GNB3-s) in which the nucleotides 498-620 of exon 9 are deleted. The T allele has been shown to be overrepresented in patients with essential hypertension. Because GNB3-s may support the development of severe elevation of blood pressure, we hypothesized that GNB3 825C-->T may be present more frequently in patients with hypertensive crisis. Design Case control study. Setting Department of Emergency Medicine at the University Hospital of Vienna, Vienna, Austria. Patients A total of 174 patients admitted to an emergency department for treatment of hypertensive crisis diagnosed as suffering from essential hypertension. Interventions None. Measurements and main results Patients were genotyped for the 825C-->T transition in GNB3. An equal number of age- and gender-matched normotensive, healthy individuals served as the control population. The allele frequency of 825C-->T in the GNB3 gene was 0.310 in patients with hypertensive crisis and 0.342 in the control group. There was no difference in genotype distribution and allele frequency between the patients and the age- and gender-matched control group or between the observed prevalence and the occurrence rate expected from the Hardy-Weinberg principle within each group. Conclusions GNB3 825C-->T is not associated with the phenotype of hypertensive crisis in patients suffering from essential hypertension. Furthermore, our data do not support the concept that the 825C-->T transition in the GNB3 gene is associated with essential hypertension.

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 present the results of a multicenter evaluation of a new point-of-care system (Cardiac Reader) for the quantitative determination of cardiac troponin T (CARDIAC T Quantitative test) and myoglobin (CARDIAC M test) in whole blood samples. The Cardiac Reader is a CCD camera that optically reads the immunochemical test strips. The measuring range is 0.1 to 3 μg/l for CARDIAC T Quantitative and 30 to 700 μg/l for CARDIAC M. Both tests are calibrated by the manufacturer. The reaction times of the tests are 12 or 8 minutes, respectively. Method comparisons were performed with 281 heparinized blood samples from patients with suspected acute coronary syndromes. The results obtained with CARDIAC T Quantitative showed a good agreement compared with cardiac troponin T ELISA (r = 0.89; y = 0.93x + 0.02). The method comparison between CARDIAC M and Tina-quant Myoglobin also showed a good agreement between both assays (r = 0.98; y = 0.92x + 1.6). Test lot-to-lot comparisons yielded differences of 2% and 6% for CARDIACT Quantitative and of 0 to 11% for CARDIACM. The within-run imprecision with blood samples and control materials was acceptable for CARDIAC T Quantitative (CV 10 to 15%) and good for CARDIAC M (CV 5 to 10%). The between-instrument CV was below 7% for CARDIACT Quantitative and below 5% for CARDIACM. The cross-reactivity of CARDIAC T Quantitative with skeletal troponin T was approximately 0.003%. No significant analytical interference was detected for any of the assays in investigations with biotin (up to 100 μg/l), hemoglobin (up to 0.125 mmol/l), hematocrit (26 to 52%), bilirubin (up to 340 μmol/l), triglycerides (up to 5.0 mmol/l), and 18 standard drugs. With the Cardiac Reader reliable quantitative results can be easily obtained for both cardiac markers. The system is, therefore, particularly suitable for use in emergency rooms, coronary care units and small hospitals.

To compare the accuracy and reliability of thoracic electrical bioimpedance (TEB) and the arterial pulse waveform analysis with simultaneous measurement of thermodilution cardiac output (TD-CO) in critically ill patients.Prospective data collection.Emergency department and critical care unit in a 2,000-bed inner-city hospital.A total of 29 critically ill patients requiring invasive hemodynamic monitoring for clinical management were prospectively studied.Noninvasive cardiac output was simultaneously measured by a TEB device and by analysis of the arterial pulse waveform derived from the finger artery. Invasive cardiac output was determined by the thermodilution technique.A total of 175 corresponding TD-CO and noninvasive hemodynamic measurements were collected in 30-min intervals. They revealed an overall bias of 0.34 L/min/m2 (95% confidence interval, 0.24-0.44 L/min/m2; p.001) for the arterial pulse waveform analysis and of 0.61 L/min/m2 (95% confidence interval, 0.50-0.72 L/min/m2; p.001) for the TEB. In 39.4% (n = 69) of all measurements, the discrepancy between arterial pulse waveform analysis and TD-CO was0.50 L/min/m2. The discrepancies of the arterial pulse waveform analysis correlated positively with the magnitude of the cardiac index (r2 = 0.29; p.001). In 56.6% (n = 99) of all measurements, the discrepancy between TEB and TD-CO was0.50 L/min/m2. The magnitude of the discrepancies of the TEB was significantly correlated with age (r2 = 0.17; p = .02). Measurements were in phase in 93.2% of all arterial pulse waveform analysis and in 84.9% of all TEB readings (p.001).The arterial pulse waveform analysis exhibits a greater accuracy and reliability as compared with the TEB with regard to overall bias, number of inaccurate readings, and phase lags. The arterial pulse waveform analysis may be useful for the monitoring of hemodynamic changes. However, both methods fail to be a substitute for the TD-CO because of a substantial percentage of inaccurate readings.

Objectives Recent data indicate an increased vascular reactivity due to an overactivity of the sympathetic nervous system in women with pre-eclampsia. We therefore evaluated whether this increased vascular reactivity can be detected prior to the clinical manifestation of preeclampsia by the use of a physiological stimulus. Design Prospective data collection. Setting Clinic of Obstetrics and Gynecology in a 2000 bed tertiary care hospital. Participants One hundred and twenty-three pregnant women between the 16th to 20th week of gestation. Interventions A cold pressor test was performed by positioning an ice-bag on the forehead of the woman for 3 min. Blood pressure and heart rate were monitored by a continuous, noninvasive blood pressure measurement device during the stimulus and after removal of the icebag. A clinical follow-up was carried out by review of the charts after delivery to identify those women who have developed pre-eclampsia. Results Ten (8%) out of 123 pregnant women developed pre-eclampsia. During the cold pressor test systolic as well as diastolic blood pressure increased significantly and was more pronounced in women developing pre-eclampsia compared with healthy pregnant women (systolic blood pressure: 14.2 +/- 5.5 versus 8.5 +/- 7.2 mmHg, P= 0.02; diastolic blood pressure: 7.3 +/- 4.9 versus 3.9 +/- 4.7 mmHg, P=0.03). The change in heart rate was similar between both groups (8 +/- 2.6 versus 10.4 +/- 6.4 beats/min, not significant). Conclusions An increased vasoconstrictive response to a physiological stimulus is present in women with pre-eclampsia as a sign of an increased vascular reactivity prior to clinical manifestation of the disease. The cold pressor test may be a suitable diagnostic tool to identify women, who will develop pre-eclampsia. However, future studies in larger cohorts are required to establish the final value of this test.

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.

Objective: To evaluate the accuracy of oscillometric blood pressure measurement according to the relation between cuff size and upper-arm circumference in critically ill patients. Design: Prospective data collection. Setting: Emergency department in a 2,000-bed inner city hospital. Patients: Thirty-eight patients categorized into three groups according to their upper-arm circumference (group I: 18-25 cm; group II: 25.1-33 cm; and group III: 33.1-47.5 cm) were enrolled in the study protocol. Interventions: In each patient, all three cuff sizes (Hewlett-Packard Cuff 40401 B, C, and D) were used to perform an oscillometric blood pressure measurement at least within 3 mins until ten to 20 measurements for each cuff size were achieved. Invasive mean arterial blood pressure measurement was done by cannulation of the contralateral radial artery with direct transduction of the systemic arterial pressure waveform. The corresponding invasive blood pressure value was obtained at the end of each oscillometric measurement. Measurement and Main Results: Overall, 1,494 pairs of simultaneous oscillometric and invasive blood pressure measurements were collected in 38 patients (group I, n = 5; group II, n = 23; and group III, n = 10) over a total time of 72.3 hrs. Mean arterial blood pressure ranged from 35 to 165 mm Hg. The overall discrepancy between oscillometric and invasive blood pressure measurement was -6.7 ± 9.7 mm Hg (p