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OBJECTIVE Several cooling methods have been investigated for inducing mild hypothermia (33-36 degrees C) after cardiac arrest, brain trauma, or stroke. To achieve its best effect, therapeutic hypothermia has to be applied very early after the ischemic insult; otherwise, the beneficial effect would be diminished or even abrogated. The aim of this study was to investigate the effectiveness and safety of extracorporeal venovenous cooling as compared with endovascular cooling. DESIGN Swine were cooled in a randomized crossover design from 38 degrees C to 33 degrees C brain temperature, either with extracorporeal venovenous cooling or with endovascular cooling. SETTING Laboratory investigation. SUBJECTS Six swine of human size (85 to 101 kg). INTERVENTIONS Swine were randomly cooled with the first device, and after achieving the target brain temperature, re-warmed via the same technique and with heating lamps to baseline temperature. Then the other catheter was inserted and cooling was performed with the second device. MEASUREMENTS Brain, pulmonary artery and tympanic temperature, blood pressure, and heart rate were recorded continuously. Laboratory samples, including free hemoglobin, were taken at predefined temperature points during cooling. Comparisons between and within (baseline vs. 33 degrees C) the treatment groups were performed with the paired Student's t-test. MAIN RESULTS The time needed to reduce brain temperature from 38.0 degrees C to 33.0 degrees C was 41 +/- 17 mins with venovenous cooling and 126 +/- 37 mins with endovascular cooling (p = .001). Heart rate and mean arterial pressure decreased moderately during cooling and were significantly lower at 33 degrees C than at baseline in both groups, without differences between groups. None of the swine developed significant hemolysis, arrhythmias, or bleeding. CONCLUSIONS Extracorporeal venovenous cooling was an effective and safe method to rapidly induce therapeutic mild hypothermia in human-sized swine. It seems to be promising for further application and investigation in patients.

Acute Stanford type A aortic dissection is associated with substantial perioperative morbidity and mortality. A sepsis-like state may lead to antithrombin (AT) III consumption and deficiency. The impact of preoperative AT III activity on outcome in patients undergoing emergency surgery is yet unknown.We measured preoperative AT III activity in 99 consecutive patients undergoing emergency aortic surgery for Stanford type A aortic dissection during a 4-year period in a retrospective study. Cardiovascular co-morbidities, risk factors and surgical data were recorded and patients were followed for 30-day mortality, and occurrence of multiple organ failure (MOF).During the first 30 days, 15 patients (15%) died, and 8 patients (8%) had MOF. Median AT III levels (IQR) in 30-day non-survivors versus survivors were 64% (52-72) versus 90% (75-97) (p0.001), and in patients with versus without MOF were 66% (52.3-77.3) versus 88% (72-96) (p=0.018), respectively. Adjusted odds ratios for 30-day mortality and MOF for AT III activity (per % increments) were 0.92 (p=0.007), and 0.96 (p=0.012), respectively, indicating a significant inverse relationship between AT III activity and outcome.There is a strong inverse association between preoperative AT III activity and adverse outcome in patients undergoing surgical repair of acute Stanford type A aortic dissection. Larger studies are necessary to determine a cut-off value for AT III and to assess whether patients with low AT III levels benefit targeted therapeutic interventions.

Reports of acute mountain sickness (AMS) at moderate altitude show a wide variability, possibly because of different investigation methods. The aim of our study was to investigate the impact of investigation methods on AMS incidence. Hackett's established AMS score (a structured interview and physical examination), the new Lake Louise AMS score (a self-reported questionnaire) and oxygen saturation were determined in 99 alpinists after ascent to 2.94 km altitude. AMS incidence was 8% in Hackett's AMS score and 25% in the Lake Louise AMS score. Oxygen saturation correlated inversely with Hackett's AMS score with no significant correlation with the Lake Louise AMS score. At moderate altitude, the new Lake Louise AMS score overestimates AMS incidence considerably. Hackett's AMS score remains the gold standard for evaluating AMS incidence.

In this study, we evaluated whether median fibrillation frequency (MF) and mean fibrillation amplitude (AMP) reflect coronary perfusion pressure (CoPP) and predict successful defibrillation. MF, AMP, and CoPP were measured during prolonged ventricular fibrillation (VF) cardiac arrest and resuscitation in pigs. After 5 min of VF, cardiopulmonary resuscitation was started. At 10 min, the pigs received randomly a single dose of endothelin-1 50 mug (n = 7), 100 mug (n = 7), or 200 mug (n = 5), or repeated doses of epinephrine 0.04 mg/kg (n = 6), or saline (n = 6) every 3 min. At 25 min, the pigs were defibrillated to achieve restoration of spontaneous circulation (ROSC). In a nonparametric spectral analysis of the individual MF versus CoPP and AMP versus CoPP curves, we found no link between the different curves in different animals or therapies. No difference was found in MF in pigs with ROSC (n = 8) compared with animals not achieving ROSC (n = 23) immediately before defibrillation (P = 0.85). Our data suggest that, in prolonged VF cardiac arrest, MF and AMP might not be useful tools to reflect myocardial perfusion.

We investigated the relationship between lactate clearance and outcome in patients surviving the first 48 hours after cardiac arrest. We conducted the study in the emergency department of an urban tertiary care hospital. We analyzed the data for all 48-hour survivors after successful resuscitation from cardiac arrest during a 10-year period. Serial lactate measurements, demographic data, and key cardiac arrest data were correlated to survival and best neurologic outcome within 6 months after cardiac arrest. Parameters showing significant results in univariate analysis were tested for significance in a logistic regression model. Of 1502 screened patients, 394 were analyzed. Survivors (n = 194, 49%) had lower lactate levels on admission (median, 7.8 [interquartile range, 5.4-10.8] vs 9 [6.6-11.9] mmol/L), after 24 hours (1.4 [1-2.5] vs 1.7 [1.1-3] mmol/L), and after 48 hours (1.2 [0.9-1.6] vs 1.5 [1.1-2.3] mmol/L). Patients with favorable neurologic outcome (n = 186, 47%) showed lower levels on admission (7.6 [5.4-10.3] vs 9.2 [6.7-12.1] mmol/L) and after 48 hours (1.2 [0.9-1.6] vs 1.5 [1-2.2] mmol/L). In multivariate analysis, lactate levels at 48 hours were an independent predictor for mortality (odds ratio [OR]: 1.49 increase per mmol/L, 95% confidence interval [CI]: 1.17-1.89) and unfavorable neurologic outcome (OR: 1.28 increase per mmol/L, 95% CI: 1.08-1.51). Lactate levels higher than 2 mmol/L after 48 hours predicted mortality with a specificity of 86% and poor neurologic outcome with a specificity of 87%. Sensitivity for both end points was 31%. Lactate at 48 hours after cardiac arrest is an independent predictor of mortality and unfavorable neurologic outcome. Persisting hyperlactatemia over 48 hours predicts a poor prognosis.

Background— Platelet activation is a hallmark of acute coronary syndromes. Numerous lines of evidence suggest a mechanistic link between von Willebrand factor or platelet hyperfunction and myocardial damage in patients with acute coronary syndromes. Thus, we assessed whether platelet function under high shear rates (collagen adenosine diphosphate closure times [CADP-CTs]) measured with the platelet function analyzer (PFA-100) may be enhanced in patients with myocardial infarction (MI) and whether it may predict the extent of myocardial damage as measured by creatine kinase (CK-MB) or troponin T (TnT) levels. Methods and Results— Patients with acute chest pain or symptoms suggestive of acute coronary syndromes (n=216) were prospectively examined at an emergency department. CADP-CT was significantly shorter in patients with MI, particularly in those with an ST-segment-elevation MI (STEMI) compared with the other patient groups (unstable angina, stable coronary artery disease, or controls). Furthermore, CADP-CT and collagen epinephrine–CT at presentation were independent predictors of myocardial damage as measured by CK-MB or TnT. Patients with MI whose CADP-CT values fell in the first quartile had 3-fold higher CK-MB and TnT levels than those in the fourth quartile. Conclusions— Patients with STEMI have significantly enhanced platelet function when measured under high shear rates. CADP-CT is an independent predictor of the severity of MI, as measured by markers of cardiac necrosis. Measurement of platelet function with the PFA-100 may help in the risk stratification of patients presenting with MI.

Background The role of Chlamydia pneumoniae in the pathogenesis of aortic aneurysm is controversial. We investigated the presence of C. pneumoniae in tissue samples excised from patients and controls. Methods Aortic wall specimens were obtained from 17 patients with acute Stanford type A aortic dissection, 25 patients with thoracic aortic aneurysms (TAA) and 23 patients with abdominal aortic aneurysms (AAA). Eighty-three tissue samples of 73 control patients free of aortic disease were obtained either at surgery or autopsy. The presence of Chlamydia subspecies DNA (sequences specific for all known Chlamydiaceae ) and DNA of C. pneumoniae , C. trachomatis and C. psittaci were assessed by a validated highly sensitive and specific real time polymerase chain reaction (PCR) analysis. Atherosclerotic risk factors were assessed in all patients. Results We failed to detect C. pneumoniae and C. psittaci -DNA in any of the 148 vessel specimens. C. trachomatis -DNA was detected in 1/65 patients and in none of 83 controls ( P =0.43). Chlamydia subspecies DNA was found in samples of eight cases and in one control ( P =0.01), however, no significant differences were found between the subgroups aortic dissection ( P =0.09), TAA ( P =0.99) and AAA ( P =0.15) and respective controls. Conclusions C. pneumoniae does not play a clinically relevant role in acute and chronic aortic disease. The impact of other organisms of the family Chlamydiaceae needs further evaluation.

Myocardial ischemia is a rare but severe and possibly life threatening manifestation of hyperthyroidism, but does not usually result in persistent ischemia. We report on a 71-year-old woman who had undergone total thyroidectomy with subsequent irradiation because of follicular carcinoma 3 years ago. Since then, she had been maintained on oral levothyroxine replacement therapy at a dose of 0.15 mg alternating with 0.2 mg daily. When latent hypothyroidism became evident despite replacement therapy, the dose of levothyroxine was increased to 0.3 mg a day. Three weeks later, the patient suffered from an acute posterior myocardial infarction, although she had no previous history of coronary artery disease. Subsequent coronary arteriograms revealed no evidence of disease of the major vessels. Myocardial scintigraphy 3 weeks after infarction still revealed a persistent perfusion defect. Since it is known that thyroid hormones increase oxygen demand, the rapid elevation of oxygen utilization caused by thyrotoxicosis factitia is likely to be responsible for this patient's myocardial infarction. The case illustrates that a sudden increase in levothyroxine replacement dose should be avoided.

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

Because pulmonary embolism (PE) and its treatment carry substantial risk of morbidity and mortality, accurate diagnosis is essential. We report two cases with allergic reactions, in which PE was suggested by routine ECG and D-dimer elevation and strengthened by spiral CT. Therapy with low-molecular-weight heparin was initiated and long-term anticoagulation was considered. As their histories did not reveal any predisposing factor to PE, the cases were re-evaluated. Elevation of D-dimer was now attributed to allergic reaction, ECG abnormalities were considered as constitutional, and findings from spiral CT attributed to breathing artifacts and partial-volume effects. The diagnosis of PE was therefore rejected and anticoagulant treatment discontinued without sequelae. These cases show the importance of determining clinical probability before ordering further diagnostic tests and critical interpretation of test results suggestive of PE, based on prior probability of the disease.

Background: Recently updated guidelines by the American College of Cardiology/American Heart Association and the European Society of Cardiology recommend at least 12 hours bed rest in patients with uncomplicated myocardial infarction. Methods: We performed a systematic literature review and meta-analysis of randomized and quasi-randomized controlled trials comparing short versus prolonged bed rest in patients with uncomplicated acute myocardial infarction. Results: We found 15 trials with 1332 patients assigned to a short period of bed rest (range 2 to 12 days) and 1326 patients assigned to prolonged bed rest (range 5 to 28 days). Generally, the studies were outdated and seemed to be of poor methodologic reporting quality. There was no evidence that shorter bed rest was more harmful than longer bed rest in terms of death, reinfarction, post-infarction angina, or thromboembolic events. Conclusion: We concluded that bed rest ranging from 2 to 12 days seems to be as safe as longer periods of bed rest.

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

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

Chlamydia species are suspected of being involved in the pathogenesis and progression of aortic aneurysms. We investigated serum levels of Chlamydia antibodies in patients with thoracic aortic aneurysms (TAA) and abdominal aortic aneurysms (AAA) compared to levels in healthy individuals.We included 35 consecutive patients with TAA, 42 patients with AAA and 42 age- and sex-matched healthy controls in a case control study. Serum antibodies (IgM and IgG) against Chlamydia lipopolysaccharide (LPS), Chlamydia pneumoniae and Chlamydia trachomatis were measured by recombinant ELISA and quantified by measurement of optical density.Patients with TAA exhibited median immunoglobulin levels against Chlamydia LPS (IgM 0.090, IgG 0.266), C. pneumoniae (IgM 0.023, IgG 0.264) and C. trachomatis (IgG 0.247) comparable to those of healthy subjects [Chlamydia LPS IgM 0.209 (p = 0.1), IgG 0.301 (p = 0.2); C. pneumoniae IgM 0.051 (p = 0.07), IgG 0.516 (p = 0.1); C. trachomatis IgG 0.153 (p = 0.2)]. Patients with AAA had higher serum levels of IgG against Chlamydia LPS (0.560) compared to healthy individuals [0.301 (p = 0.04)], but no significant elevation of antibodies against C. pneumoniae [IgM 0.029 (p = 0.1), IgG 0.545 (p = 0.9)] and C. trachomatis [IgG 0.219 (p = 0.3)].Thoracic aortic aneurysms were not associated with signs of Chlamydia infection or immunopathogenicity. In contrast, patients with abdominal aortic aneurysms exhibited elevated levels of immunoglobulin against Chlamydia LPS, reflecting an unspecific Chlamydia immunopathogenicity. However, elevated levels of antibodies against distinct Chlamydia species were also not found in AAA patients.

Comparison of oscillometric blood pressure measurement with two different devices (M3000A using a new algorithm and M1008A using an established algorithm, both Hewlett Packard) and evaluation of current recommendations concerning the relation between cuff size and upper arm circumference in critically ill patients.Prospective data collection.Emergency department in a 2000-bed inner-city hospital.A total of 30 patients categorized into three groups according to their upper arm circumference (I, 18-25 cm; II, 25.1-33 cm; III, 33.1-47.5 cm) were enrolled in the study protocol. INTERVENTIONS In each patient, two noninvasive blood pressure devices with three different cuff sizes were used to perform oscillometric blood pressure measurement. Invasive mean arterial blood pressure measurement was done by cannulation of the radial artery.Overall, 1,011 pairs of simultaneous oscillometric and invasive blood pressure measurements were collected in 30 patients (group I, n = 10; group II, n = 10; group III, n = 10). The overall discrepancy between both methods with the M3000A was -2.4 +/- 11.8 mm Hg (p.0001) and, with the M1008A, -5.3 +/- 11.6 mm Hg (p.0001) if the recommended cuff size according to the upper arm circumference was used (352 measurements). If smaller cuff sizes than recommended were used (308 measurements performed in group II and III), the overall discrepancy between both methods with the M3000A was 1.3 +/- 13.4 mm Hg (p.024) and, with the M1008A, -2.3 +/- 11.5 mm Hg (p.0001).The new algorithm reduced the overall bias of the oscillometric method but still showed a significant discrepancy between both methods of blood pressure measurement, primarily due to the mismatch between upper arm circumference and cuff size. The improvement of the algorithm alone could not result in a sufficient improvement of oscillometric blood pressure measurement. A reevaluation of the recommendations concerning the relation between upper arm circumference and cuff size are urgently required if oscillometric blood pressure measurement should become a reasonable alternative to intra-arterial blood pressure measurement in critically ill patients.

To assess whether the sum of ST segment elevation and depression (ST segment deviation score [SUMSTdev]) is a better predictor for 24 h, nonfatal complications in patients with acute myocardial infarction (MI) than the sum of ST segment elevation (SUMSTelev) alone in the admission electrocardiogram.Patients with acute MI receiving thrombolytic therapy were observed and ST scores were evaluated. Nonfatal, 24 h complications were defined as acute congestive heart failure or severe rhythm disturbances within 24 h after the start of thrombolysis. The outcome measures were the relationship between both the SUMSTdev and the SUMSTelev and the occurence of 24 h complications, and the identification of a cut-off value with the highest sensitivity and specificity for the prediction of complications.Three hundred eighty-two patients (288 male patients, mean age 58 years) with acute MI (179 patients with anterior MI) were included in the study. The SUMSTdev was significantly higher in patients with 24 h complications than in patients without complications (anterior MI 23.9 mm versus 11.5 mm, respectively, P0.001; inferior MI 21.6 mm versus 12.0 mm, respectively, P0.001). Using the receiver operating characteristic analysis, the SUMSTdev significantly improved the ability to estimate the occurence of 24 h complications for anterior and inferior MI compared with the SUMSTelev (anterior MI 0.87+/-0.03 versus 0.84+/-0.03, P=0.04; inferior MI 0.79+/-0.03 versus 0.74+/-0.04, P=0.03). The optimal cut-off for the SUMSTdev was found at 16 mm for anterior MI and 13 mm for inferior MI. Multivariate regression analysis showed that the SUMSTdev was an independent predictor of the occurrence of early complications in patients with anterior MI (odds ratio 28.4, 95% CI 11.0 to 73.6, P0.0001) and inferior MI (odds ratio 9.7, 95% CI 4.7 to 20.2, P0.001).The SUMSTdev is superior to the SUMSTelev in predicting 24 h, nonfatal complications after acute MI. The use of the SUMSTdev is therefore recommended for the stratification of patients with acute MI into low and high risk patients.

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

Pulmonary congestion is associated with poor outcome in patients with acute coronary syndromes. In consecutive patients presenting with acute unexplained chest pain to a primary care facility, the prognostic impact of pulmonary congestion is indeterminate. Therefore, we assessed the predictive value of clinical signs of pulmonary congestion in patients presenting with acute chest pain to an emergency department with regard to the origin of the symptoms.1288 consecutive patients with acute chest pain were prospectively assessed for clinical signs of pulmonary congestion. The diagnosis was confirmed by chest radiography. The association of pulmonary congestion and short- and intermediate-term mortality in patients with coronary (n = 381) and non-coronary (n = 907) causes of chest pain was determined using multivariate Cox regression analysis.108 (8%) patients had clinical signs of pulmonary congestion. Within the mean follow-up period of 23 months (SD 4) 67 patients died, mainly within the first 6 months. Of 108 patients with pulmonary congestion, 82 (76%) had coronary and 26 (24%) had non-coronary chest pain. Pulmonary congestion was independently associated with mortality in patients with coronary chest pain (hazard ratio 6.4, 95% confidence interval 2.5 to 16.1, p0.0001), both in patients with acute coronary syndromes or angina pectoris. However, in patients with non-coronary chest pain we observed no independent association of pulmonary congestion with outcome.Clinical signs of pulmonary congestion indicate an increased risk for poor outcome in patients with chest pain due to myocardial ischemia. Mortality of these patients is high, particularly in the first months after presentation. Therefore, hospital admission is warranted, including patients with angina pectoris, who otherwise may be candidates for early discharge.

Pulmonary embolism (PE) is a potentially fatal disorder with highly varying mortality rates. To provide information that is more precise for prospective intervention studies, we analysed the data of our patients with PE, defining clinically relevant subgroups with respect to their individual mortality rates.We studied 283 consecutive patients with confirmed PE diagnosis, with respect to demographic data, risk factors for thromboembolic disease and clinical signs. In addition, diagnostic and therapeutic interventions such as blood gas analysis (BGA), lactate and D-dimer determination, electrocardiography (ECG), echocardiography, spiral computer tomography (Spiral CT), ventilation/perfusion lung scintigraphy (V/Q-Scan), thrombolytic therapy, mechanical ventilation, and cardiopulmonary resuscitation (CPR), were accounted for. Study endpoint was mortality rates on day three.Overall, mortality rate was 15% (42 of 283). Mortality rates differed considerably; 95% of patients with cardiac arrest on arrival (21 of 22), 85% of patients with cardiac arrest--not in hospital (28 of 33), 80% of patients receiving mechanical ventilation (40 of 50), 77% of patients needing cardiopulmonary resuscitation within the first 24 hours (37 of 48), 37% of patients with syncope (18 of 49), 30% of patients receiving thrombolytic treatment (25 of 87), 26% of patients on whom lactate measurement was performed (36 of 139), 18% of patients on whom blood gas analysis was done (35 of 197), 17% of patients on whom echocardiography was performed (34 of 195), 8% of patients with twelve complete lead ECG recordings (21 of 262) and D-Dimer determination (12 of 148), 2% of patients tested on Spiral CT (5 of 226) and 1% where a V/Q-Scan was performed (1 of 74).Patients with PE who received mechanical ventilation, cardiopulmonary resuscitation, and thrombolytic treatment had very high mortality rates of 80, 77 and 30% respectively. However, patients stable enough for diagnostic procedures as Spiral CTs and V/Q-Scans had mortality rates of 1 to 2%. These facts are to be considered when planning pulmonary embolism intervention trials in which reduction of mortality is a defined endpoint.

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.We evaluated plasma coagulation markers, including a newly developed sF bedside test, prothrombin fragment (F(1+2)), sF, and D-dimer, in a cross-sectional trial with 184 patients suggestive of ACS.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 (P0.001 for noncardiac chest pain vs ACS), yielding an overall specificity of 92% and a sensitivity of 35%. The sensitivity of the established coagulation markers was significantly less to detect ACS (11% for F(1+2), 20% for thrombus precursor protein, and 18% for D-dimer; P0.02 vs sF bedside test). The sF bedside test presented the earliest objective indicator of impending myocardial damage in the majority (10 of 13) of ACS patients with a normal or nondiagnostic electrocardiogram (ECG).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.

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

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

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

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

Epistaxis and hypertension are frequent in the general population, but an association is still controversial. Aim of this retrospective cohort study was to test if active epistaxis at emergency department (ED) presentation is associated with hypertension. Patients with active epistaxis at ED presentation (n = 271; 73%) were compared with controls without active bleeding (n = 101; 27%). By multivariate logistic regression modeling we found that active epistaxis was independently associated with history of hypertension (odds ratio 2.8 [95% CI 1.4 to 5.6; P =.004] adjusted for age, gender, rhinitis, diffuse bleeding, and malignant diseases). Patients with active epistaxis had higher blood pressure at presentation compared with controls (systolic blood pressure 165 v 153 mmHg, P

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

Background About two thirds of adults suffer from backpain at some time during their life. In the emergency room many patients with acute back pain are treated with intravenous non-steroidal analgesics. Whether this treatment is superior to oral administration of non-steroidal analgesics is unknown. Intravenous administration, however, requires considerable amounts of resources and accounts for high workload in busy clinics. In the further course centrally acting muscle relaxants are prescribed but the effectiveness remains unclear. The objective of this study is on the one hand to compare the effectiveness of intravenous with oral non-steroidal analgesics for acute treatment and on the other hand to compare the effectiveness of a centrally active muscle relaxant with placebo given for three days after presentation to the ED (emergency department). Methods/Design This study is intended as a randomised controlled factorial trial mainly for two reasons: (1) the sequence of treatments resembles the actual proceedings in every-day clinical practice, which is important for the generalisability of the results and (2) this design allows to take interactions between the two sequential treatment strategies into account. There is a patient preference arm included because patients preference is an important issue providing valuable information: (1) it allows to assess the interaction between desired treatment and outcome, (2) results can be extrapolated to a wider group while (3) conserving the advantages of a fully randomised controlled trial. Conclusion We hope to shed more light on the effectiveness of treatment modalities available for acute low back pain.

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.

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

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

Background: Intravascular ultrasound (IVUS) predictors of native culprit lesion morphology for occurrence of major adverse cardiac events (MACE) have not been reported. Moreover, the published data on IVUS predictors of restenosis include patients with stable and unstable angina, although the development and progression of atherosclerosis related to unstable coronary syndrome is different from that of stable angina. Hypothesis: This study investigated whether IVUS-de-rived qualitative and quantitative parameters of native (prean-gioplastic) plaque morphologic features can predict major adverse cardiac events in patients with unstable angina. Methods: Clinical (age, gender, coronary risk factors), qualitative and quantitative angiographic (lesion localization, morphology, pre- and postangioplastic minimal lumen diameter, reference diameter, and percent diameter stenosis), and IVUS variables (soft/fibrocalcific plaque, calcification, presence of thrombus or plaque disruption, different types of arterial remodeling, pre- or postangioplastic minimal lumen, external elastic membrane and plaque cross-sectional area, and plaque burden of the target lesion and reference segments) were analyzed by regression analyses using the Cox model, assuming proportional hazards. Results: Of 60 consecutively enrolled patients, 21 suffered from MACE, while 39 remained event-free during the follow-up period. Multivariate regression analyses revealed that the presence of adaptive remodeling [p = 0.0177, risk ratio (RR) = 3.108, with 95% confidence interval (CI) = 1.371—8.289] and the preangioplastic lumen cross-sectional area (p = 0.0130, RR = 0.869, with 95% CI = 0.667—0.913) are independent predictors of MACE during follow-up, as is postangioplastic angiographic minimal lumen diameter (p = 0.0330, RR = 0.715 with 95% CI = 0.678—0.812). Conclusions: Adaptive remodeling and preangioplastic lumen cross-sectional area determined by IVUS and postangioplastic minimal lumen diameter calculated by quantitative angiography are significant independent predictors of time-dependent MACE in patients with unstable angina.

The efficacy, pharmacokinetics, safety, and tolerability of E 047/1, an amiodarone derivative, were evaluated in patients with acute supraventricular or ventricular arrhythmia. In an open, nonrandomized prospective multicenter trial, 20 patients were treated with three different i.v. dosage regimens of E 047/1. Arrhythmia termination indicated efficacy. Pharmacokinetics were determined by measurements of drug plasma levels. Safety was judged by changes of blood pressure, heart rate, ECG parameters, and appearance of adverse events. For local tolerability, effects at the site of infusion were assessed. In patients with atrial fibrillation and/or atrial flutter, drug plasma levels and prolongation of QT interval were correlated with efficacy. In 10 (50%) patients, therapeutic intervention with E 047/1 was successful. Drug plasma levels rapidly decreased within 1 h after administration. Blood pressure values and ECG parameters stayed constant during the observation period. Proarrhythmic effects were not observed. As adverse events, vertigo, vomiting, and nausea in three (15%) and hypotension in one (5%) patient, respectively, occurred in the high-dose bolus regimen only. At the site of infusion, no adverse effects were found. No dependency between drug plasma levels and arrhythmia termination was found. E 047/1 has proven to be efficient and safe in the treatment of arrhythmia. E 047/1 is characterized by rapid plasma elimination, absence of proarrhythmic or cardiodepressive effects, mild adverse events, and excellent local tolerability. For further investigation, we recommend a combined bolus- and weight-adapted infusion regimen.

Objective. In patients presenting with acute myocardial infarction the pathophysiologic and prognostic value of serum C-reactive protein is not well defined. This study assessed the association between serum C-reactive protein levels on admission and mortality in patients admitted because of acute myocardial infarction. Design. Retrospective cohort study. Setting. Tertiary care centre. Patients. A total of 729 patients with acute myocardial infarction admitted within a period of 3 years. Main outcome measures. C-reactive protein levels on admission, cardiovascular risk factors and survival within the observational period. Results. Within the 3-year observational period, 118 patients died of a cardiovascular cause. With increasing serum C-reactive protein levels ( 10 mg dL -1 ) mortality also increased (14%, 19%, 20%, 39% and 28%, respectively). When controlling for the confounding effect of age, thrombolytic treatment, the time interval between onset of pain and admission, smoking, diabetes mellitus, hypercholesterolemia, hypertension, and elevated creatine kinase on admission in a multivariate Cox regression model, there was only a weak and nonsignificant association between increased serum C-reactive protein and the risk of death. Conclusions. Patients with elevated concentrations of serum C-reactive protein admitted to the hospital because of acute myocardial infarction are at an increased risk of dying. This association is however. largely explained by other baseline variables, in particular by an estimate of the duration of myocardial ischaemia. If C-reactive protein measured by means of an ultra-sensitive assay is more suitable for risk stratification of unselected patients with acute myocardial infarction, needs further study.

Objective.—To evaluate the performance of a visual troponin T rapid test in the hands of nontraditionally trained personnel of 2 critical care units in comparison to 3 laboratories. Methods.—Method comparisons of the troponin T rapid test versus cardiac troponin T enzyme-linked immunosorbent assay were performed with 804 samples from 510 patients with suspected acute coronary syndromes. Cross-reactivity with skeletal troponin T was studied up to 5000 μg/L. Results.—Laboratories and critical care units obtained comparable results in the analytical cutoff of the test (0.11 and 0.10 μg/L) and in the diagnostic sensitivities in the detection of acute myocardial infarction (96% and 93% after 8 hours) and of high-risk patients with unstable angina pectoris (100% and 100%). Different percentages of false-positive results (0.2% and 3%) were found, which may reflect different objectives and strategies in these hospital units. The cross-reactivity with skeletal troponin T was less than 0.01%. Conclusions.—The troponin T rapid test gives reliable results not only when used by laboratory personnel experienced in the execution of analytical methods, but also in the hands of nurses and physicians working in clinical units outside the laboratory.

We analyzed the medical records of patients with an established diagnosis of acute renal infarction to identify predictive parameters of this rare disease. Seventeen patients (8 male) who were admitted to our emergency department between May 1994 and January 1998 were diagnosed by contrast-enhanced computed tomography (CT) as having acute renal infarction (0.007% of all patients). We screened the records of the 17 patients for a history with increased risk for thromboembolism, clinical symptoms, and urine and blood laboratory results known to be associated with acute renal infarction. A history with increased risk for thromboembolism with 1 or more risk factors was found in 14 of 17 patients (82%); risk factors were atrial fibrillation (n = 11), previous embolism (n = 6), mitral stenosis (n = 6), hypertension (n = 9), and ischemic cardiac disease (n = 7). All patients reported persisting pain predominantly from the flank (n = 11), abdomen (n = 4), and lower back (n = 2). On admission, elevated serum lactate dehydrogenase was found in 16 (94%) patients, and hematuria was found in 12 (71%) of 17 patients. After 24 hours all patients showed an elevated serum lactate dehydrogenase, and 14 (82%) had a positive test for hematuria. Our findings suggest that in all patients presenting with the triad--high risk of a thromboembolic event, persisting flank/abdominal/lower back pain, elevated serum levels of lactate dehydrogenase and/or hematuria within 24 hours after pain onset--contrast-enhanced CT should be performed as soon as possible to rule out or to prove acute renal infarction.

Background and Purpose —The prediction of neurological outcome in comatose cardiac arrest survivors has enormous ethical and socioeconomic implications. The purpose of the present study was to investigate the prognostic relevance of the time course of serum neuron-specific enolase (NSE) as a biochemical marker of hypoxic brain damage. Methods —Serial analysis of serum NSE levels was performed in 56 patients resuscitated from witnessed, nontraumatic, normothermic, in- or out-of-hospital cardiac arrest. The neurological outcome was evaluated with the use of the cerebral performance category (CPC) within 6 months after restoration of spontaneous circulation (ROSC). The Mann-Whitney U test was used to compare patients with good (CPC 1 to 2) and bad (CPC 3 to 4) neurological outcome. The diagnostic performance at different time points after ROSC was described in terms of areas under receiver operating characteristic curves according to standard methods. Results —Patients with a bad neurological outcome (CPC 3 to 4) had significantly higher NSE levels than those with a good neurological outcome at 12 ( P =0.004), 24 ( P =0.04), 48 ( P P P Conclusions —Serum NSE levels are valuable adjunctive parameters for assessing neurological outcome after cardiac arrest.

Epinephrine is the drug of choice in advanced cardiac life support, but it can have deleterious side effects after restoration of spontaneous circulation.To investigate the association between the cumulative epinephrine dose used in advanced cardiac life support and neurologic outcome after cardiac arrest.Retrospective cohort study.University hospital.Adults admitted to the emergency department with witnessed, nontraumatic, normothermic ventricular fibrillation cardiac arrest and unsuccessful initial defibrillation.Functional neurologic outcome was regularly assessed by cerebral performance category (CPC) within 6 months after cardiac arrest. A CPC of 1 or 2 was defined as favorable recovery.Among 178 enrolled patients, the median cumulative epinephrine dose administered was 4 mg (range, 0 to 50 mg). In 151 patients (84%), spontaneous circulation was restored; 63 of these 151 patients (42%) had favorable neurologic recovery. Patients with an unfavorable CPC received a significantly higher cumulative dose of epinephrine than did patients with a favorable CPC (4 mg compared with 1 mg; P0.001). This finding persisted after stratification by duration of resuscitation. After possible cofounders were controlled for, the cumulative epinephrine dose remained an independent predictor of unfavorable neurologic outcome.The results indicate that an increasing cumulative dose of epinephrine administered during resuscitation is independently associated with unfavorable neurologic outcome after ventricular fibrillation cardiac arrest.

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

SummaryWe examined the effect of intravenous enalaprilat on the course of PAI-1 plasma levels in 23 patients with acute myocardial infarction undergoing thrombolytic therapy. All patients received 100 mg aspirin, 1000 IU/h heparin, thrombolysis with 100 mg rt-PA within 90 min, and betablockers. Eleven out of 23 patients received 5 mg enalaprilat intravenously prior to thrombolysis. Blood samples for determination of PAI-1 plasma levels were collected on admission, 2, 4, 6, 12, and 24 h after thrombolysis. PAI-1 plasma levels in patients receiving enalaprilat were similar to those of the control patients before thrombolysis (5 ng/ml, 95% confidence interval: 2-10 vs. 7 ng/ml, 95% confidence interval: 2-10; p = 0.5). The PAI-1AUC was 9 ng/ml/h (95% confidence interval: 5-10) in the enalaprilat group and 19 ng/ml/h (95% confidence interval: 13-26) in the control group (p = 0.0006). The maximum difference was observed 6 h after thrombolysis (enalaprilat: 13 ng/ml, 95% confidence interval: 5-25, control: 42 ng/ml, 95% confidence interval: 18-55; p = 0.003).Our study clearly demonstrates that application of intravenous enalaprilat prior to thrombolysis attenuates the thrombolysis-related increase of PAI-1. This finding may suggest a possible therapeutic approach to influence the fibrinolytic system in patients with acute myocardial infarction after thrombolysis.

The aim of the study was to evaluate the referral of outpatients with non-traumatic conditions for radiographic examinations and to assess the impact of the radiological report on the patient's management in an emergency department. In a prospectively designed study, 1223 X-ray examinations of 1116 non-trauma outpatients (640 males, 476 females; mean age: 44 +/- 18 years) requested over a 10-month period were evaluated. Patients were classified into four groups according to the presenting complaints (respiratory, abdominal, neurological or non specific symptoms). Analysis of data included the influence of age and presenting symptoms on the likelihood of abnormal radiological findings and the impact of the radiological result on the further management of the patient. In 455 (40.8%) patients an abnormal radiological result was observed. The likelihood of an abnormal radiological findings increased with age (age40 years: 33%; age40 years; 47%; p0.05). Whereas the rate of abnormal radiological findings was high in patients with specific symptoms (respiratory: 69%; abdominal: 37%; neurological: 38%), in patients with non-specific symptoms only 25% of all radiological examinations revealed an abnormality. The radiological result had an impact on the further management in 948 (85%) patients. As 45% of all radiographic examinations revealing a normal radiological result had a clinical impact, normal radiological reports are just as helpful as abnormal radiological findings in the management of non-trauma outpatients in an emergency department. Thus, we assume that the radiological result has a major impact on the management of non-trauma outpatients in the emergency department.

To assess the relationship between the sum of ST-segment elevations (ST score) in the admission ECG and the occurrence of early complications in patients with acute myocardial infarction (MI).We conducted an observational study of patients who presented with acute anterior or inferior MI to the ED of a 2,000-bed inner-city hospital. Age, sex, time from onset of pain and the start of thrombolysis, and ST score were evaluated by the emergency physician. "Early complications" were defined as acute congestive heart failure or severe rhythm disturbances in the 24 hours after the start of thrombolysis. The outcome measures were the relationship between ST score and the occurrence of early complications; the influence of age, sex, or time between onset of pain and thrombolysis; and identification of a cutoff value with the highest sensitivity and specificity for prediction of complications.We included 243 patients (194 men, 49 women; mean age, 56.6 years) with acute MI (anterior, 119; inferior, 124) who underwent thrombolysis in our analysis. ST score was significantly greater in patients with early complications, compared with patients without complications (anterior, 10.3 versus 19.4 mm [P.001]; inferior, 6.9 versus 10.4 mm [P.001]). Receiver-operator curve analysis revealed an ST score of 13 mm in patients with anterior MI and 9 mm in patients with inferior MI as the cutoff value with the greatest sensitivity and specificity for predicting early complications of MI. (For anterior MI, sensitivity was .79, specificity .73; for inferior MI, sensitivity was .64 and specificity .68.). On multivariate regression analysis, ST score was an independent predictor of the occurrence of at least one complication. (For anterior MI, the odds ratio [OR] was 9.7 and the 95% confidence interval [CI] 3.9 to 25.1; for inferior MI the OR was 5.0 and the 95% CI 2.0 to 12.8). Age, sex, and interval from onset of pain to treatment had no significant effect on the occurrence of early complications.The absolute ST score is useful in estimating the probability of early complications in patients with acute MI receiving thrombolytic therapy. A cutoff value of 13 mm for anterior MI and 9 mm for inferior MI stratifies patients into high- and low-risk subgroups for the development of acute congestive heart failure and severe rhythm disturbances during the first 24 hours of hospitalization.

Objective: To assess the safety and efficacy of urapidil compared to sodium nitroprusside in the treatment of hypertensive emergencies. Design: randomized, prospective clinical study. Setting: Emergency department in a 2000-bed inner city hospital. Patients: Eighty-one patients with hypertensive emergencies defined as elevation of systolic blood pressure above 200 mmHg and/or diastolic blood pressure above 110 mmHg plus evidence of end-organ damage were included in the study protocol. The efficacy of therapy was defined as 1) blood pressure reduction below 180/95 mmHg within 90 min and 2) no re-elevation of blood pressure during a 4-h follow-up period in primary responders. The safety of both drugs was defined as the number of minor and major side effects during treatment. Interventions: Patients received either sodium nitroprusside (n = 35; continuous intravenous administration with a starting dose of 0.5 μg/kg per min; increase in increments of 0.5 μg/kg per min every 15 min until response to treatment or a maximum of 3 μg/kg per min) or urapidil (n = 46; intravenous bolus; starting dose: 12.5 mg; repetitive administration of 12.5 mg every 15 min until response or a maximum dose of 75 mg). Measurements and results: Blood pressure was measured every 2.5 min by using a non-invasive oscillometric blood pressure measurement unit. Response to treatment within 90 min was observed in 75 (93 %) patients (urapidil: n = 41 [89 %]; nitroprusside: n = 34 [97 %]; p = 0.18). During the follow-up period 8/34 (24 %) patients in the nitroprusside group and 1/41 (2 %) patients in the urapidil group exhibited blood pressure re-elevation. Major side effects were observed in seven patients receiving nitroprusside and two patients in the urapidil group (p = 0.04). Conclusion: Urapidil is equally effective, compared to sodium nitroprusside, in the treatment of hypertensive emergencies. Due to a smaller number of adverse events, urapidil is a reasonable alternative to nitroprusside in the treatment of hypertensive emergencies.

Experimental data suggest that postischemic blood glucose concentration plays an important role in modulating both ischemic cerebral infarction and selective neuronal necrosis. This study investigated the association between functional neurological recovery and blood glucose concentrations in human cardiac arrest survivors. A group of 145 nondiabetic patients were evaluated after witnessed ventricular fibrillation cardiac arrest. Data regarding cardiac arrest were collected according to an internationally accepted protocol immediately after arrival. Blood glucose was measured on admission and 6, 12, and 24 h thereafter. To control for duration of cardiac arrest and cardiogenic shock, both known to influence outcome as well as blood glucose, levels, Spearman rank partial correlation was used. In this multivariate analysis, a high admission blood glucose level tended to be associated with poor neurological outcome ( rs = −0.16, n = 142, p = 0.06). The association between high median blood glucose levels over 24 h and poor neurological outcome was strong and statistically significant ( rs = −0.2, n = 145, p = 0.015). High blood glucose concentrations occurring over the first 24 h after cardiac arrest have deleterious effects on functional neurological recovery. Whether cardiac arrest survivors might benefit from reduction of blood glucose levels needs further investigation.

The purpose of the study was to evalute the impact of the renin-angiotensin-aldosterone (RAA) system on blood pressure (BP) response in patients with hypertensive emergencies and urgencies treated with intravenous enalaprilat. Thirty-five patients with a systolic BP (SBP)210 mm Hg and/or diastolic BP (DBP)110 mm Hg received 5 mg enalaprilat intravenously. The extent of systolic and DBP reduction was correlated with pretreatment concentrations of angiotensin II (ANGII) (SBP: r = -0.47; P = 0.006; DBP: r = -0.55; P = 0.001) and plasma renin activity (PRA) (SBP: r = -0.49; P = 0.003; DBP: r = 0.48; P = 0.007). Non-responders to enalaprilat exhibited significant lower pretreatment levels of PRA, angiotensin-converting enzyme (ACE) and ANG II compared to responders (PRA: 5.5 +/- 3.7 vs 1.1 +/- 2.2 ng/ml/h, P0.001; ACE: 12.8 +/- 3.5 vs 8.2 +/- 4.8 U/l, P = 0.003; ANG 11:8.7 +/- 6.2 vs 5.0 +/- 3.8 pg/ml, P = 0.04). In patients with severe hypotension following application of enalaprilat ANG II concentrations were significantly higher compared to patients with mean arterial BP reduction25% (12.3 +/- 6.7 vs 5.6 +/- 4.0 pg/ml,P = 0.013). These data indicate that PRA and ANG II are the major determinants for BP response to enalaprilat. This relation between BP response and RAA system activity have important clinical implications for the treatment of patients with severe hypertension. Primary therapeutic failure indicates that the RAA system contributes very little to the hypertensive status of the patient. Thus, repetitive application on an ACE inhibitor in primary responders is clinically unhelpful and may result in an unnecessary delay of an effective BP reduction. In contrast, high ANG II concentrations are associated with a considerable risk for severe hypotension after enolanalaprilat application. Therefore, the status of the RAA system determines the efficacy as well as the safety of ACE inhibitor treatment in patients with severe hypertension.

Objectives.This study sought to evaluate the diagnostic value of the biochemical markers creatine kinase (CK), creatine kinase-MB fraction (CK-MB) and cardiac troponin T (cTNT) to diagnose acute myocardial infarction (AMI) after cardiopulmonary resuscitation (CPR).Background.Elevations of CK and CK-MB after CPR are a frequent finding and might be associated with ischemic myocardial injury, as well as physical trauma to the chest.Methods.Patients who had cardiac arrest and primary successful resuscitation were included in the study. The diagnosis of AMI was confirmed or ruled out by means of typical electrocardiographic findings, thallium-201 myocardial scintigraphy or autopsy, if death occurred during the hospital period, in 39 primary survivors of sudden cardiac death. In 24 patients (62%) the diagnosis of AMI was established. Serum cTNT, CK and CK-MB were measured, and the CK-MB/CK ratio was calculated on admission and after 12 h.Results.On admission all markers of myocardial injury proved to be weak methods for the diagnosis of AMI. After 12 h cTNT as well as CK-MB exhibited a similar diagnostic performance; CK and the CK-MB/CK ratio proved to be worthless. Sensitivity and specificity for a cTNT cutoff value of 0.6 ng/ml, 12 h after cardiac arrest, were 96% and 80%, respectively. For a CK-MB cutoff value of 26 U/liter, sensitivity was 96% and specificity was 73%.Conclusions.Cardiac TNT and CK-MB are valuable tools in detecting AMI as the cause of sudden cardiac death. However, there is a considerable lack of sensitivity and specificity. Cardiac injury is probably caused not only by AMI, but also by myocardial damage related to CPR efforts.