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ZusammenfassungAkute Stoffwechselentgleisungen können für Erwachsene in Abhängigkeit von ihrem Ausmaß lebensbedrohlich sein. Dementsprechend sind eine rasche umfassende Diagnostik und Therapie sowie eine enge Überwachung der Vitalparameter und Laborbefunde erforderlich. Bei der Therapie, die sich bei der ketoazidotischen (DKA) und hyperglykämisch-hyperosmolaren (HHS) Form nicht wesentlich unterscheidet, kommt dem Ausgleich des meist beträchtlichen Flüssigkeitsdefizits mit mehreren Litern einer physiologischen kristalloiden Lösung eine vorrangige Rolle zu. Bei den Elektrolyten ist insbesondere auf eine ausgeglichene Serum-Kalium-Konzentration zu achten. Normal-Insulin oder rasch wirksame Analoga können initial als i.v.-Bolus verabreicht werden, in der Folge jedoch kontinuierlich über einen Perfusor. Die Umstellung auf eine subkutane Insulintherapie soll erst bei ausgeglichenem Säure-Basen-Haushalt und zufriedenstellender Glykämie erfolgen.

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

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

Emergency medicine and intensive care medicine have many similarities. In this review, we will first discuss the terminology of emergency medicine in a hospital in terms of a uniform designation as a department for emergency medicine or emergency department. Emergency medicine and intensive care medicine are a location-independent concept of patient care in the sense of the recognition, treatment and diagnosis of acute health disorders. Emergency medicine covers the entire range of disease severity, while intensive care medicine focuses on organ replacement and organ preservation, uses highly specialized technology for this purpose and treats only the seriously ill. The treatment of seriously ill patients in the emergency departments requires special intensive care medical knowledge both by the physicians and nursing staff. In the medical field, the curriculum for the European emergency medicine specialist takes into account all aspects necessary for the diagnosis and treatment of critically ill patients. For the nursing sector, Germany has had its own recognized specialty training program in emergency medicine for several years. However, the treatment of critically ill patients in emergency departments also requires that the emergency departments be adequately equipped. In this regard, there is an urgent need for statutory quality criteria that are concrete and structured. We know from the literature that intensive care competence in emergency departments reduces the admission rate to intensive care units and the mortality of all emergency patients. The concept of intensive care units in the emergency department is gaining popularity in the USA and should also be evaluated for implementation in the German-speaking countries.

Background We investigated the influence of population‐wide COVID‐19 lockdown measures implemented on 16, March 2020 on routine and emergency care of cancer outpatients at a tertiary care cancer centre in Vienna, Austria. Methods We compared the number/visits of cancer outpatients receiving oncological therapies at the oncologic day clinic (DC) and admissions at the emergency department (ED) of our institution in time periods before (pre‐lockdown period: 1 January – 15 March 2020) and after (post‐lockdown period: 16 March– 31 May 2020) lockdown implementation with the respective reference periods of 2018 and 2019. Additionally, we analysed Emergency Severity Index (ESI) score of unplanned cancer patient presentations to the ED in the same post‐lockdown time periods. Patient outcome was described as 3‐month mortality rate (3‐MM). Results In total, 16 703 visits at the DC and 2664 patient visits for the respective time periods were recorded at the ED. No decrease in patient visits was observed at the DC after lockdown implementation (P = .351), whereas a substantial decrease in patient visits at the ED was seen (P

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

Zusammenfassung Akute Stoffwechselentgleisungen können für Erwachsene in Abhängigkeit von ihrem Ausmaß lebensbedrohlich sein. Dementsprechend sind eine rasche umfassende Diagnostik und Therapie sowie eine enge Überwachung der Vitalparameter und Laborbefunde erforderlich. Bei der Therapie, die sich bei der ketoazidotischen (DKA) und hyperglykämisch-hyperosmolaren (HHS) Form nicht wesentlich unterscheidet, kommt dem Ausgleich des meist beträchtlichen Flüssigkeitsdefizits mit mehreren Litern einer physiologischen kristalloiden Lösung eine vorrangige Rolle zu. Bei den Elektrolyten ist insbesondere auf eine ausgeglichene Serum-Kalium-Konzentration zu achten. Normal-Insulin oder rasch wirksame Analoga können initial als i.v.-Bolus verabreicht werden, in der Folge jedoch kontinuierlich über einen Perfusor. Die Umstellung auf eine subkutane Insulintherapie soll erst bei ausgeglichenem Säure-Basen-Haushalt und zufriedenstellender Glykämie erfolgen.

Objective Early diagnosis or rule‐out of acute coronary syndrome (ACS) is a key competence of emergency medicine. Changes in the NSTE‐ACS guidelines of the European Society of Cardiology (ESC) in 2015 and 2020 both warranted a henceforth more conservative approach regarding high‐sensitivity troponin t (hsTnt) testing. We aimed to assess the impact of more conservative guidelines on the frequency of early rule‐out and prolonged observation with repeated hsTnt testing at a high‐volume tertiary care emergency department. Patients and Methods We conducted a pre‐ and post‐changeover analysis 3 months before and 3 months after transition from less (hsTnt cut‐off 30 ng/L, 3‐hour rule‐out) to more conservative (hsTnt cut‐off 14 ng/L, 1‐hour rule‐out) guidelines in 2015, comparing proportions of patients requiring repeated testing. Results We included 5442 cases of symptoms suspicious of acute cardiac origin (3451 before, 1991 after, 2370 (44%) female, age 55 (SD 19) years). The proportion of patients fulfilling early‐rule out criteria decreased from 68% (2348 patients) before to 60% (1195 patients) with the 2015 guidelines (P

Background: The COVID-19 pandemic resulted in suspension of the whole teaching program at the Medical University of Vienna until the end of summer semester. Therefore, a substantial waste of learning time threatens. As the responsible department for emergency medicine teaching, we adapted our program to continue with our courses and maintain the learning progress. Our objective was to evaluate the number of conducted courses and to report the used methods.Methods: Teaching was classified in credit hours per week (CHW). One CHW represents 15 academic hours (45 minutes) during one semester. Computations were performed on basis of the official numbers from the prospectus of the university, or - if not available - were calculated with the formula above. Webinars were performed using CISCO Webex Events®, Webex Training® and ZOOM®. We further utilized Moodle® for resuscitation courses.Results: Overall, courses and clerkships equivalent to 80.2 out of 101.4 CHW (79.1%) will be held during the ongoing crisis in summer semester. Courses in winter semester were completed regularly. In the human medicine curriculum, we could perform 73.7 out of 94.9 CHW (77.7%). In the emergency lectures for the dentistry curriculum, we could adapt all courses to webinars (6.5 CHW, 100%). After adjustment for the exact number of students in each class, courses and clerkships equivalent to 78.7% could be conducted.Conclusions: Despite the challenge to be prepared for the treatment of numerous patients during an ongoing pandemic, we could maintain the majority of our teaching responsibilities. Although sufficient skill training cannot be achieved under those circumstances, we could provide the theoretical backgrounds to allow students further continuation in their studies.

ObjectivesTo assess the predictive value of N-terminal pro-brain natriuretic peptide (NT-proBNP) and high-sensitive troponin T (hs-TnT) serum levels for mid-term mortality in patients presenting with symptomatic atrial fibrillation (AF) to an emergency department.MethodsNon-interventional cohort/follow-up study, including consecutive patients presenting to a tertiary care university emergency department due to symptomatic AF between 2012 and 2016. Multivariable Cox proportional hazard regression models were used to estimate the mortality rates and hazards per 100 patient-years (pry) for NT-proBNP and hs-TnT serum levels in quintiles.Results2574 episodes of 1754 patients (age 68 (IQR 58–75) years, female gender 1199 (44%), CHA2DS2-VASc 3 (IQR 1–4)) were recorded. Following the exclusion of incomplete datasets, 1780 episodes were available for analysis. 162 patients deceased during the mid-term follow-up (median 23 (IQR 4–38) months); the mortality rate was 4.72/100 pry. Hazard for death increased with every quintile of NT-proBNP by 1.53 (HR; 95% CI 1.27 to 1.83; pConclusionElevated NT-proBNP and hs-TnT levels are independently associated with increased mid-term mortality in patients presenting to an emergency department due to symptomatic AF.Trial registration numberNCT03272620; Results.

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

Aims: Rapid restoration of sinus rhythm is an integral part of the management of recent-onset atrial fibrillation. We aimed to assess safety and efficacy of vernakalant, a multi-channel blocking agent, in combination with external electrical cardioversion. Methods: This prospective cohort study comprised 230 patients (female 35%; median age 50 IQR 42–55) with recent-onset AF presenting to a university tertiary care center during a 6-year period. Management included intravenous vernakalant followed by electrical cardioversion in case of pharmacological failure. Results: Within 11 min (IQR 8–29), sinus rhythm could be restored by sole pharmacological management in 167 patients (73%). A left ventricular function lower than 55% (OR 3.51 (1.45–8.52)) and prior atrial fibrillation episodes being classified as persistent (OR 2.33 (1.13–4.80)) were significant predictors for non-response to vernakalant. Electrical cardioversion was successful in all patients but one within 196 min (IQR 149–300) of administration of first dosage of vernakalant. No serious adverse events could be observed. 3 patients needed further in-patient care. Conclusion: Management of recent-onset atrial fibrillation consisting of intravenous vernakalant followed by electrical cardioversion in case of failure appears safe and efficacious. Achieving a rapid conversion, this approach could potentially save resources and costs. Keywords: Vernakalant, Recent-onset atrial fibrillation, Cardioversion

Diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS) represent potentially life-threatening situations in adults. Therefore, rapid comprehensive diagnostic and therapeutic measures with close monitoring of vital and laboratory parameters are required. The treatment of DKA and HHS is essentially the same and replacement of the mostly substantial fluid deficit with several liters of a physiological crystalloid solution is the first and most important step. Serum potassium concentrations need to be carefully monitored to guide its substitution. Regular insulin or rapid acting insulin analogues can be initially administered as an i.v. bolus followed by continuous infusion. Insulin should be switched to subcutaneous injections only after correction of the acidosis and stable glucose concentrations within an acceptable range.

RATIONALE: The immunologic syndrome induced by severe acute coronavirus disease 2019 (COVID-19) is yet not fully understood. Typical patterns of clinical and laboratory features match secondary hemophagocytic lymphohistiocytosis (sHLH). However, the optimal approach to COVID-19 patients testing positive for sHLH is still unclear. PATIENT CONCERNS: Three patients with COVID-19 are reviewed. All showed hyperinflammation and cytokine storm, necessitating intensive care treatment including mechanical ventilation. DIAGNOSIS: Secondary hemophagocytic lymphohistiocytosis due to severe COVID-19; diagnosed via HScore. INTERVENTIONS: A treatment regimen of methylprednisolone, pentaglobin, and anakinra was developed and administered. OUTCOMES: One patient survived the ICU stay. Two other patients, in whom sHLH was diagnosed too late, deceased. LESSONS: A routine screening of COVID-19 patients for secondary HLH by using the HScore is feasible; especially those patients deteriorating clinically with no sufficient response to shock management might be at particular high risk. A stepwise therapeutic approach comprising corticosteroids, immunoglobulins and anakinra, accompanied by immunoadsorption, may dampen cytokine storm effects, and potentially reduce mortality.

Cardiac arrest (CA) is still associated with high mortality and morbidity. Data on the changes in management and outcomes over a long period of time are limited. Using data from a single emergency department (ED), we assessed changes over two decades.In this single-center observational study, we prospectively included 4133 patients receiving cardiopulmonary resuscitation and being admitted to the ED of a tertiary care hospital between January 1992 and December 2012.There was a significant improvement in both 6-month survival rates (+10.8%; p 0.001) and favorable neurological outcome (+4.7%; p 0.001). While the number of witnessed CA cases decreased (-4.7%; p 0.001) the proportion of patients receiving bystander basic life support increased (+8.3%; p 0.001). The proportion of patients with initially shockable ECG rhythms remained unchanged, but cardiovascular causes of CA decreased (-9.6%; p 0.001). Interestingly, the time from CA until ED admission increased (+0.1 hours; p = 0.024). The use of percutaneous coronary intervention and therapeutic hypothermia were significantly associated with survival.Outcomes of patients with CA treated at a specialized ED have improved significantly within the last 20 years. Improvements in every link in the chain of survival were noted.

Background: The endotracheal tube (ETT) is considered the gold standard in emergency airway management, although supraglottic airway devices, especially the laryngeal tube (LT), have recently gained in importance. Although regarded as an emergency device in case of failure of endotracheal intubation in most systems, we investigated the dynamics of the use of the LT in a metropolitan ambulance service without any regulations on the choice of airway device. Methods: A retrospective, observational study on all patients from the Municipal Ambulance Service, Vienna in need of advanced airway management over a 5-year period. Differences between years were compared; influencing factors for the use of the LT were analyzed using multivariable logistic regression. Results: In total 5,175 patients (mean age 62 ± 20 years, 36.6% female) underwent advanced airway management. Of these, 15.6% received the LT. LT use increased from 20 out of 1,001 (2.0%) in 2009 to 292 of 1,085 (26.9%) in 2013 (p < 0.001). The in...

While contributors to system delay in ST-elevation myocardial infarction (STEMI) are well described, predictors of patient-related delays are less clear. The aim of this study was to identify predictors that cause delayed diagnosis of STEMI in a metropolitan system of care (VIENNA STEMI network) and to investigate a possible association with long-term mortality.The study population investigated consisted of 2366 patients treated for acute STEMI in the Vienna STEMI registry from 2003-2009. Multivariable regression modelling was performed for (a) onset of pain to first medical contact (FMC) as a categorical variable (pain-to-FMC⩽60 min versus60 min: 'early presenters' versus 'late presenters'); and for (b) onset of pain-to-FMC (min) as a continuous variable.After multivariable adjustment, female sex (odds ratio (OR) 1.348; 95% confidence interval (CI) 1.013-1.792; p=0.04) and diabetes mellitus (OR 1.355; 95% CI 1.001-1.835; p=0.05) were independently associated with late presentation in STEMI patients, whereas cardiogenic shock (OR 0.582; 95% CI 0.368-0.921; p=0.021) was a predictor of early diagnosis. When onset of pain-to-FMC was treated as a continuous variable, female sex ( p=0.003), anterior infarction ( p=0.004) and diabetes mellitus ( p=0.035) were independently associated with longer delay, while hyperlipidaemia ( p=0.002) and cardiogenic shock ( p=0.017) were strong predictors of short pain-to-FMC times. Three-year-all cause mortality was 9.6% and 11.3% ( p=0.289) for early and late presenters, respectively. After adjustment for clinical factors (sex, age, diabetes, current smoking, hypertension, hyperlipidaemia, cardiogenic shock and location of myocardial infarction) only a trend for increased risk of all-cause death was observed for longer pain-to-FMC times in a cox regression model (hazard ratio (HR) 1.012; 95% CI 0.999-1.025 for every 10 min of delay; p=0.061). Interestingly, early presentation within one hour of symptom onset was not associated with three-year mortality survival (HR 1.031; 95% CI 0.676-1.573; p=0.886).In this all-comers study of STEMI patients in the VIENNA STEMI network, cardiogenic shock was the strongest predictor of short patient-related delays, whereas a history of diabetes and female sex were independent associated with late diagnosis in STEMI. After adjustment for clinical confounders, patient related delay did not significantly impact on long-term all-cause mortality.

Carbon monoxide (CO) is a leading cause of morbidity and mortality. Treatment focuses on the rapid elimination of CO and management of hypoxia. Oxygen is the cornerstone of therapy, and usually applied via a reservoir face mask. Hyperbaric oxygen therapy eliminates CO faster, but requires extensive equipment and expertise. Non-invasive continuous positive airway pressure (CPAP) ventilation using a tight mask provides a higher inspired fraction of oxygen (FiO2) compared to a reservoir face mask, and increases gas exchange. As this modality is widely available, it might represent a supplemental approach to current treatment of CO poisoning. We present two simultaneous cases of a married couple of 31- and 34-year-old patients, who concurrently suffered CO intoxication due to a faulty gas heater in their apartment. Both reported similar symptoms of headache and weakness, and carboxyhemoglobin (COHb)-levels at admission were 21% in both patients. One patient was treated by non-invasive CPAP-ventilation support with a FiO2 of 100%, whereas the other was treated by conventional oxygen inhalation. In the patient treated by CPAP, COHb-levels fell quickly to 6% within one hour, and reached 3% after 90 min, whereas it took six hours to reach the same levels in the patient with conventional treatment. This vividly illustrates the potential of CPAP therapy as an alternative to conventional oxygen inhalation in the treatment of CO poisoning.

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

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

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

Tranexamic acid and fibrinogen restore clotting in vitro and in vivo in cardiac thrombus associated hyperfibrinolysis with overt bleedings

Erratum zu: Wien Klin Wochenschr 2018 https://doi.org/10.1007/s00508-018-1423-z Die Originalversion des Beitrags enthielt leider einen Fehler in Tab. 3. In der publizierten Version war in der 1. Spalte PO4 im Plasma mit 0 und Mg mit 1,25 angegeben, wobei auch Kalzium auf einen Wert im mittleren …

6609 Background: Oncologic patients frequently seek out the ED as first contact point. Besides the rare classic oncologic emergencies other causes are supposed to be more frequent. However, little is known about reasons of patients with active malignancies to consult the ED. Methods: Retrospective data regarding emergency visits of patients with a medical history of active cancer or adjuvant therapy, who were taken by ambulance to the ED in the time period from 01.01.2017 – 31.07.2017, was collected. For OS Kaplan-Meier curves were created and univariate COX proportional hazards model analysis was used and log rank tests were performed. For statistical analysis the chi2-test was used to investigate significant relations between the three months mortality (3MM) and patient characteristics. 3MM was defined as death within 3 month of the first ED consultation. Results: From a total of 1029 patient contacts 743 met the inclusion criteria. In total 552 patients were included. The median age was 67 years (Minimum: 18y; Maximum: 95y). The vast majority of patients (480, 87%) were in a palliative setting. 243 patients (44%) were under active treatment. The biggest group of patients suffered from lung cancer (18%) followed by hematologic malignancies (14%), pancreaticobiliary tumours (11%), breast cancer (8%) and colorectal cancer (7%). In total 111 patient contacts (15%) were treatment associated, 384 patient contacts (52%) were tumor related, the remaining (248, 33%) were unrelated to either. In 533 cases (72%) inpatient treatment was necessary. The average length of stay was 9, 36 days. Furthermore the 3MM was significantly higher in elderly patients > 65y (p = 0,001), palliative patients not undergoing active treatment (p = 0,003) and patients with elevated CRP levels ( > 0,5mg/dl) (p = 0,001) at time of ED contact. In addition in our univariate analysis factors that significantly decreased the OS were age > 65, visceral metastasis and palliative patients without active treatment. Conclusions: The majority of cancer patients in this study were in a palliative setting. Moreover, cancer associated complications posed the most frequent cause for ED consultation. We could identify a higher risk for mortality for elderly patients, patients with visceral metastasis and patients undergoing best supportive care. The results may help to inform both cancer patients and primary care units about frequent complications.

Objective To investigate the feasibility of a refined aortic flush catheter and pump system to induce emergency preservation and resuscitation before extracorporeal cardiopulmonary resuscitation in a normovolemic cardiac arrest swine model simulating near real size/weight conditions of adults. Methods In this feasibility study, 8 female Large White breed pigs weighing 70 to 80 kg underwent ventricular fibrillation cardiac arrest for 15 minutes, followed by 4°C aortic flush (150 mL/kg for the brain; 50 mL/kg for the spine) via a new hardware ensued by resuscitation with extracorporeal cardiopulmonary resuscitation. Results Brain temperature was lowered from 39.9°C (interquartile range [IQR] 39.6-40.3) to 24.0°C (IQR 20.8-28.9) in 12 minutes (IQR 11-16) with a median cooling rate of 1.3°C (IQR 0.7-1.6) per minute. A median of 776 mL (IQR 673-840) per minute with a median pump pressure of 1487 mm Hg (IQR 1324-1545) were pumped to the brain. Conclusions With the new hardware, we were able to cool the brain within a few minutes in a large pig cardiac arrest model. The exact position; the design, diameter, and length of the flush catheter; and the brain perfusion pressure seem to be critical to effectively reduce brain temperature. Redistribution of peripheral blood could lead to sterile inflammation again and might be avoided.

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

In den letzten Jahren etablierten sich im deutschsprachigen Raum immer mehr interdisziplinare Notfallaufnahmen (Notfallabteilungen) mit eigenstandigen Organisationsstrukturen als Anlaufstelle fur alle Patienten mit akut aufgetretenen medizinischen Problemen. Ziel dieses Beitrags ist es, die Notwendigkeit intensivmedizinischer Kompetenz in der Notfallabteilung unter Berucksichtigung internationaler Literatur zu diskutieren. Die Notfallabteilung ist primare Anlaufstelle haufig kritisch kranker Patienten, welche sofortiger intensivmedizinischer Versorgung bedurfen. Die fruhe optimale intensivmedizinische Versorgung kritisch kranker Patienten in der Notfallabteilung kann das Outcome bei verschiedenen Krankheitsbildern verbessern. Es ist von okonomischem Nutzen, da es zu weniger Aufnahmen auf der Intensivstation sowie geringerem Behandlungsaufwand und kurzerer Liegedauer auf der Intensivstation oder im Krankenhaus kommt. Intensivmedizinische Kompetenz in der Notfallabteilung ist eine grundsatzliche Notwendigkeit. Sie kann das Outcome der Patienten verbessern und hat einen okonomischen Nutzen fur die Intensivstation und das gesamte Krankenhaus.

The induction of deep cerebral hypothermia via ice-cold saline aortic flush during prolonged ventricular fibrillation cardiac arrest, followed by hypothermic stasis and delayed resuscitation (emergency preservation and resuscitation), improved neurologic outcome after cardiac arrest in pigs, as compared to conventional resuscitation. We hypothesized that emergency preservation and resuscitation with chest compressions would further improve outcome in the same model.Prospective experimental study.University research laboratory.: Twenty-four female, large, white breed pigs (27-37 kg).Fifteen minutes of ventricular fibrillation cardiac arrest were followed by 20 mins of resuscitation with chest compressions (control, n = 8), deep cerebral hypothermia via 200 mL/kg 4 degrees C saline aortic flush and hypothermic stasis (emergency preservation and resuscitation, n = 8), and emergency preservation and resuscitation combined with chest compressions (emergency preservation and resuscitation plus chest compressions, n = 8). At 35 mins after cardiac arrest, cardiopulmonary bypass was initiated, followed by defibrillation. Mild hypothermia was continued for 20 hrs. Pigs were evaluated after 9 days using a neurologic deficit (neurologic deficit score: 100% = brain dead; 0%-10% = normal) and an overall performance category score (overall performance category score: 1 = normal; 2 = slightly handicapped; 3 = severely handicapped; 4 = comatose; 5 = dead/brain dead).Brain temperature decreased from 38.5 degrees C to 15.3 degrees C +/- 3.3 degrees C in the emergency preservation and resuscitation group, and to 11.3 degrees C +/- 1.2 degrees C in the emergency preservation and resuscitation plus chest compressions group. In the control group, restoration of spontaneous circulation was achieved in four out of eight pigs, and one survived to 9 days. In the emergency preservation and resuscitation group, restoration of spontaneous circulation was achieved in seven out of eight pigs and five survived; in the emergency preservation and resuscitation plus chest compressions group, all had restoration of spontaneous circulation and seven survived (restoration of spontaneous circulation, p = .08). Neurologic outcome for (median and interquartile range) the control group included overall performance category score of 3, neurologic deficit score of 45%; for the emergency preservation and resuscitation group, overall performance category score was 3 (2-5) and neurologic deficit score was 45% (36; 50) and in the emergency preservation and resuscitation plus chest compressions group, overall performance category score was 2 (1-3) and neurologic deficit score was 13% (5; 21) (overall performance category score, p = .04; neurologic deficit score emergency preservation and resuscitation vs. emergency preservation and resuscitation plus chest compressions, p = .003).Emergency preservation and resuscitation by deep cerebral hypothermia combined with chest compressions during prolonged cardiac arrest in pigs are feasible and improve neurologic outcome.

Eine 54-jahrige Patientin wurde vom Notarzt mit der vermeintlichen Diagnose einer diabetischen Ketoazidose (DKA) mit Koma hospitalisiert; sie erlitt unmittelbar nach dem Umlagern einen Herz-Kreislauf-Stillstand im Sinne einer pulslosen elektrischen Aktivitat (PEA). Eine kritische Bewertung der Anamnese und der ersten Blutgas- und Elektrolytwerte liesen jedoch Zweifel an der Diagnose DKA aufkommen. Nach 40 min ununterbrochener Reanimation konnten vorubergehend stabile Kreislaufverhaltnisse erzielt werden. Darunter zeigten sich im EKG ein Rechtsschenkelblock und in der transthorakalen Echokardiographie ein massiv dilatierter rechter Ventrikel. Da die Patientin danach neuerlich reanimationspflichtig wurde, wurde unter der Annahme einer massiven Pulmonalembolie (PE) eine Bolusthrombolysebehandlung mit 100 mg rtPA durchgefuhrt, womit schon nach 8 min stabile Kreislaufverhaltnisse hergestellt werden konnten. Die Patientin wurde nach 10-tagiger Intensivpflege und nach 3-wochigem Aufenthalt auf der Normalpflegestation ohne Sekundarschaden entlassen. Der vorgestellte Fallbericht zeigt auf, dass hinter dem unerwarteten Herz-Kreislauf-Stillstand bei einer Patientin mit vermeintlicher diabetischer Ketoazidose eine massive Pulmonalembolie stecken kann.

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

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

Notaufnahmen haben die Aufgabe der primaren Stabilisierung und der Initialdiagnostik, die fur eine optimale Weiterversorgung der Patienten unabdingbare Voraussetzung ist. Damit entwickeln sich die Notaufnahmen von einem Ort, der primar der Verteilung der Patienten in die verschiedenen Fachabteilungen diente, zu einer gut definierten Funktionseinheit mit einem eigenstandigen fachlichen Profil. Besonderes Augenmerk verdienen dabei intensivmedizinische Kenntnisse, die es ermoglichen, den Verlauf einer kritischen Krankheit zu antizipieren, rasch zu intervenieren und so langerfristige Intensivaufenthalte zu reduzieren. Die Intensivkompetenz fur Notfallaufnahmen ist zu fordern, weil damit die Prognose der Notfallpatienten verbessert wird, weil dies okonomisch sinnvoll ist und weil damit Intensiv- und Normalstationsbetten fur Patienten, die diese wirklich benotigen, gesichert werden.

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

Es wird der Fall einer 69-jahrigen Patientin vorgestellt, die wegen seit 5 Tagen bestehender Brustschmerzen und Atemnot hospitalisiert wurde. Bei Aufnahme zeigte die Patientin die klinischen Zeichen eines kardialen Vorwarts- und Ruckwartsversagens als Folge einer akuten Herzbeuteltamponade. Da das EKG nur unspezifische Veranderungen zeigte und der D-dimer-Wert exzessiv erhoht war, wurde an eine Aortendissektion Typ A (ADA) gedacht und eine Multi-Slice-CT-Untersuchung des Thorax veranlasst. Mit dieser Untersuchung konnte zwar die ADA ausgeschlossen werden. Uberraschender Weise fand sich jedoch eine deutlich sichtbare Perforation der freien Herzwand mit Kontrastmittelaustritt in den Herzbeutel. In konsekutiven Untersuchungen konnte ein ablaufender transmuraler Myokardinfarkt als Wegbereiter der Perforation identifiziert werden. Daher sollte bei Herzbeuteltamponade und unspezifischem EKG neben einer ADA auch eine Ruptur der freien Herzwand infolge eines ablaufenden Myokardinfarktes in die Uberlegungen zur Kausalitat einbezogen werden.

In industrial countries, the incidence of out-of-hospital sudden cardiac arrest accounts for 36 to 128 per 100000 inhabitants per year. Unfortunately, full cerebral recovery after cardiac arrest is still a rare event. A standardized treatment protocol including early decision for active therapy, treatment of the underlying cause of cardiac arrest, early revascularisation if indicated, blood pressure management to maintain adequate urine output and optimal glucose control are the basic principles of intensive care after cardiac arrest. Furthermore, mild therapeutic hypothermia therapy should be considered for unconscious patients successfully resuscitated from cardiac arrest. They should be cooled to 32-34 °C over twelve to 24 hours. The introduction of therapeutic hypothermia after cardiac arrest in everyday intensive care practice could save thousands of lives worldwide, as only six patients have to be treated to get one additional patient with favourable neurological recovery.

Durch Obstruktion der Lungenstrombahn kann im Rahmen einer fulminanten Pulmonalembolie (PE) ein Herzstillstand auftreten. Die PE ist mit 6–11% die zweithaufigste Ursache aller praklinischen Herzstillstande. Die Zeichen der oberen Einflussstauung und der Nachweis einer pulslosen elektrischen Aktivitat im ersten EKG sollten den Verdacht auf das Vorliegen einer PE lenken. Durch den Nachweis eines vergroserten rechten Ventrikels in der Echokardiographie kann dieser Verdacht erhartet werden. In dieser Situation ist unter laufenden Reanmiationsmasnahmen auf Grund der Datenlage die Bolusverabreichung von rt-PA bis zu einer Gesamtdosis von 100 mg Erfolg versprechend in Hinblick auf Wiederherstellung der Kreislauffunktion, 24-Stunden-Uberlebensrate und Spitalentlassungsrate. Das unter Thrombolyse signifikant erhohte Blutungsrisiko wird durch diese gunstigen Effekte ubertroffen. Die nach erfolgreicher Reanimation durchzufuhrende Behandlung stutzt sich auf die dafur geltenden allgemeinen Richtlinien und der Verhinderung von Rezidiven durch Dauerantikoagulation und eventuelle Implantation eines Cavaschirms.

Fur die gesetzlich vorgeschriebene Versorgung von Notfallpatienten haben die Spitaler in Osterreich notfallmedizinische Einrichtungen errichtet. Die 14 analysierten notfallmedizinischen Einrichtungen werden zwar unterschiedlich bezeichnet, sie unterstehen aber weitgehend dem Fachbereichbereich Innere Medizin. Selbst bei Eigenstandigkeit werden sie durchwegs von Internisten geleitet, wobei 64% der notfallmedizinischen Einrichtungen interdisziplinar gefuhrt werden. In 93% der notfallmedizinischen Einrichtungen werden Selbstkommer sowie Patienten, die von Rettungshubschrauber, Rettungs- bzw. Notarztwagen gebracht werden, versorgt. Die raumlichen, diagnostischen und therapeutischen Moglichkeiten der Notfalleinrichtungen sind unterschiedlich. In 3 Fallen (21,5%) liegt aber immerhin die Maximalausstattung vor. Mit Durchfuhrung zusatzlicher innerklinischer Aufgaben wie der Betreuung von Herzalarmnotrufen und Durchfuhrung von Patiententransporten ist immerhin die Halfte (7 von 14) der notfallmedizinischen Einrichtungen betraut. Trotz der Unterschiede der einzelnen Einrichtungen in Bezeichnung, Ausstattung und den therapeutischen Moglichkeiten wird deutlich, dass die klinische Notfallmedizin in Osterreich vorwiegend interdisziplinar im Verantwortungsbereich des Sonderfaches Innere Medizin betrieben wird.

To determine whether patients with hypertensive urgency have a higher risk for subsequent cardiovascular events compared with hypertensive patients without this event.Overall, 384 patients with hypertensive urgency and 295 control patients were followed up for at least 2 years. Hypertensive urgency was defined as a systolic blood pressure above 220 mmHg and/or a diastolic blood pressure above 120 mmHg without any evidence of acute end-organ damage. The control group consisted of patients admitted to the emergency department with a systolic blood pressure between 135 to 180 mmHg and a diastolic blood pressure between 85-110 mmHg. The number of cardiovascular events defined as acute coronary syndrome, acute stroke, atrial fibrillation, acute left ventricular failure and aortic aneurysm were consecutively analyzed during follow-up. The median follow-up time was 4.2 years (interquartile range 2.9-5.7 years). Twenty-six patients of the urgency group and 23 patients of the control group were lost for follow-up.Overall, 117 (17%) patients had nonfatal clinical cardiovascular events and 13 had (2%) fatal cardiovascular events. The frequency of cardiovascular events was significantly higher in patients with hypertensive urgencies (88 vs. 42; P = 0.005). The Cox regression analysis identified age (P0.001) and hypertensive urgencies (P = 0.035) as independent predictors for subsequent cardiovascular events.Hypertensive urgencies are associated with an increased risk for subsequent cardiovascular events in patients with arterial hypertension.

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

Objective Outcome after prolonged normovolemic cardiac arrest is poor, and new resuscitation strategies have to be found. We hypothesized that the induction of deep hypothermia for emergency preservation and resuscitation (EPR) during prolonged cardiac arrest, before the start of reperfusion, will mitigate the deleterious cascades leading to neuronal death and will thus improve outcome. Design Prospective experimental study. Setting University research laboratory. Subjects Thirteen pigs, Large White breed (27-37 kg). Interventions After 15 mins of ventricular fibrillation, pigs were subjected to 1) EPR (n = 6), 20 mins of hypothermic stasis induced with a cold saline aortic flush; or 2) 20 mins of conventional resuscitation (n = 7). Then cardiopulmonary bypass was initiated in both groups, followed by defibrillation. Controlled ventilation and mild hypothermia were continued for 20 hrs; survival was for 9 days. For neurologic evaluation, neurologic deficit score (100% = brain dead, 0-10% = normal), overall performance category (1 = normal, 5 = dead or brain dead), and brain histologic damage score were used. Measurements and main results In the EPR group, brain temperature decreased from 38.5 degrees C +/- 0.2 degrees C to 16.7 degrees C +/- 2.5 degrees C within 235 +/- 27 secs. Five animals achieved restoration of spontaneous circulation and survived to 9 days: two pigs with overall performance category 2 and three pigs with overall performance category 3. Their neurologic deficit score was 45% (interquartile range 35, 50) and histologic damage score was 142 (interquartile range 109, 159). In the control group, four pigs achieved restoration of spontaneous circulation: one survived to 9 days with overall performance category 3, neurologic deficit score 45%, and histologic damage score 226 (restoration of spontaneous circulation, p = .6; survival, p = .03; overall performance category, p = .02). Conclusions EPR is feasible in an experimental pig model and improves survival after prolonged cardiac arrest in pigs. Further experimental studies are needed before this concept can be brought into clinical practice.

Aims Blood d-dimer testing has been proposed as diagnostic marker with high sensitivity for exclusion of acute aortic dissection (AAD). We performed a systematic review and validated the findings in a prospective patient cohort. Methods and results We searched MEDLINE, EMBASE, CINAHL, and BIOSIS from inception until January 2007 using a combination of search terms for aortic dissection and d-dimer. Study type, type of assay used, predefined cut-off level, result of d-dimer testing, sensitivity, and specificity were abstracted. In 16 identified studies (437 patients), the reported cut-off values ranged from 0.1 to 0.9 µg/mL. d-Dimer testing provided high sensitivity (0.97 95% CI 0.94–0.98) and negative likelihood ratio (0.06 95% CI 0.02–0.13). In our cohort of 65 patients (36 male, 55%; median age 59 years, IQR 49–67) with proven AAD, d-dimer levels scattered from 0.24 to 137.88 µg/mL (median 3.47; IQR 1.55–14.49). Mean NPV for the different cut-off levels ranged from 92 % for a cut-off level of 0.9 µg/mL to 100% for a cut-off level of 0.1 µg/mL in our study population. Conclusion Current evidence supports a routine measurement of d-dimer in excluding AAD. A d-dimer

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

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

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