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Extracorporeal cardiopulmonary resuscitation (ECPR) facilitates resuscitation with immediate and precise temperature control. This study aimed to determine the optimal reperfusion temperature to minimize neurological damage after ventricular fibrillation cardiac arrest (VFCA). Twenty-four rats were randomized (n = 8 per group) to normothermia (NT = 37°C), mild hypothermia (MH = 33°C) or moderate hypothermia (MOD = 27°C). The rats were subjected to 10 minutes of VFCA, before 15 minutes of ECPR at their respective target temperature. After ECPR weaning, rats in the MOD group were rapidly rewarmed to 33°C, and temperature maintained at 33°C (MH/MOD) or 37°C (NT) for 12 hours before slow rewarming to normothermia (MH/MOD). The primary outcome was 30-day survival with overall performance category (OPC) 1 or 2 (1 = normal, 2 = slight disability, 3 = severe disability, 4 = comatose, 5 = dead). Secondary outcomes included awakening rate (OPC ≤ 3) and neurological deficit score (NDS, from 0 = normal to 100 = brain dead). The survival rate did not differ between reperfusion temperatures (NT = 25%, MH = 63%, MOD = 38%, p = 0.301). MH had the lowest NDS (NT = 4[IQR 3-4], MH = 2[1-2], MOD = 5[3-5], p = 0.044) and highest awakening rate (NT = 25%, MH = 88%, MOD = 75%, p = 0.024). In conclusion, ECPR with 33°C reperfusion did not statistically significantly improve survival after VFCA when compared with 37°C or 27°C reperfusion but was neuroprotective as measured by awakening rate and neurological function., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All authors have disclosed that they do not have any conflicts of interest regarding the study. WB received speaker’s honoraria from Zoll and BD. AS received speaker’s honoraria from Getinge group.

Aims: Transoesophageal echocardiography (TOE) has increasingly been described as a possible complementary and point-of-care approach for patients with cardiac arrest (CA). It provides information about potentially reversible causes and prognosis and allows monitoring of resuscitation efforts without affecting ongoing chest compressions. The aim of this study was to assess the feasibility of TOE performed by emergency physicians (EPs) during CA in an emergency department (ED)., Methods and Results: This prospective study was performed at the Department of Emergency Medicine at the Medical University of Vienna from February 2020 to February 2021. All patients of ≥18 years old presenting with ongoing resuscitation efforts were screened. After exclusion of potential contraindications, a TOE examination was performed and documented by EPs according to a standardized four-view imaging protocol. The primary endpoint represents feasibility defined as successful probe insertion and acquisition of interpretable images. Of 99 patients with ongoing non-traumatic CA treated in the ED, a total of 62 patients were considered to be examined by TOE. The examination was feasible in 57 patients (92%) [females, 14 (25%), mean age 53 ± 13, and witnessed collapse 48 (84%)]. Within these, the examiners observed 51 major findings in 32 different patients (66%). In 21 patients (37%), these findings led to a direct change of therapy. In 18 patients (32%), the examiner found ventricular contractions without detectable pulse. No TOE-related complications were found., Conclusion: Our findings suggest that EPs may be able to acquire and interpret TOE images in the majority of patients during CA using a standardized four-view imaging protocol., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Face-to-face medical education was restricted during the COVID-19 pandemic, leading to alternative teaching methods. Moodle ® (Modular Object-Oriented Dynamic Learning Environment) - an online course format - has not yet been sufficiently evaluated for its feasibility and effectiveness in teaching cardiopulmonary resuscitation., Methods: Medical students in the eighth semester took part in a Moodle ® course teaching basic life support, the ABCDE-approach, airway management, and advanced life support. The content was presented using digital background information and interactive videos. A multiple-choice test was conducted at the beginning and at the end of the course. Subjective ratings were included as well., Results: Out of 594 students, who were enrolled in the online course, 531 could be included in this study. The median percentage of correctly answered multiple-choice test questions increased after completing the course [78.9%, interquartile range ( IQR ) 69.3-86.8 vs. 97.4%, IQR 92.1-100, p < 0.001]. There was no gender difference in the median percentage of correctly answered questions before (female: 79.8%, IQR 70.2-86.8, male: 78.1%, IQR 68.4-86.8, p = 0.412) or after (female: 97.4%, IQR 92.1-100, male: 96.5%, IQR 92.6-100, p = 0.233) the course. On a 5-point Likert scale, 78.7% of students self-reported ≥4 when asked for a subjective increase in knowledge. Noteworthy, on a 10-point Likert scale, male students self-reported their higher confidence in performing CPR [female 6 (5-7), male 7 (6-8), p < 0.001]., Conclusion: The Moodle ® course led to a significant increase in theoretical knowledge. It proved to be a feasible substitute for face-to-face courses - both objectively and subjectively., Competing Interests: Author SS is ILCOR EIT Task Force Member. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Ettl, Schriefl, Grafeneder, Thallner, Mueller, Fischer, Schlegel, Sigmund, Holzer and Schnaubelt.)

Introduction: In former studies, the arterio-alveolar carbon dioxide gradient (ΔCO 2 ) predicted in-hospital mortality after initially survived cardiac arrest. As early outcome predictors are urgently needed, we evaluated ΔCO 2 as predictor for good neurological outcome in our cohort., Methods: We retrospectively analyzed all patients ≥18 years of age after non-traumatic in- and out of hospital cardiac arrest in the year 2018 from our resuscitation database. Patients without advanced airway management, incomplete datasets or without return of spontaneous circulation were excluded. The first arterial pCO 2 after admission and the etCO 2 in mmHg at the time of blood sampling were recorded from patient's charts. We then calculated ΔCO 2 (pCO 2 - etCO 2 ). For baseline analyses, ΔCO 2 was dichotomized into a low and high group with separation at the median. Good neurological outcome on day 30, expressed as Cerebral Performance Category 1-2, defined our primary endpoint. Survival to 30 days was used as secondary endpoint., Results: Out of 302 screened patients, 128 remained eligible for analyses. ΔCO 2 was lower in 30-day survivors with good neurological outcome (12.2 mmHg vs. 18.8 mmHg, p = 0.009) and in 30-day survivors (12.5 mmHg vs. 20.0 mmHg, p = 0.001). In patients with high ΔCO 2 , a cardiac etiology of arrest was found less often. They had a higher body mass index, longer duration of resuscitation, higher amounts of epinephrine, lower pO 2 levels but both higher pCO2 and blood lactate levels, resulting in lower blood pH and HCO 3 - levels at admission. In a crude binary logistic regression analysis, ΔCO 2 was associated with 30-day neurological outcome (OR = 1.041 per mmHg of ΔCO 2 , 95% CI 1.008-1.074, p = 0.014). This association persisted after the adjustment for age, sex, witnessed arrest and shockable first rhythm. However, after addition of the duration of resuscitation or the cumulative epinephrine dosage to the model, ΔCO 2 lost its association., Conclusion: ΔCO 2 at admission after a successfully resuscitated cardiac arrest is associated with 30 days survival with good neurological outcome. However, a higher ΔCO 2 may rather be a surrogate for unfavorable resuscitation circumstances than an independent outcome predictor., Competing Interests: Declaration of Competing Interest On behalf of all authors of the manuscript “The difference between arterial pCO(2) and etCO(2) after cardiac arrest – outcome predictor or marker of unfavorable resuscitation circumstances?”, I declare that there are no conflicts of interest., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The clinical value of a prognostic score depends on its out-of-sample validity because inaccurate outcome prediction can be not only useless but potentially fatal. We aimed to evaluate the out-of-sample validity of a recently developed and highly accurate Korean prognostic score for predicting neurologic outcome after cardiac arrest in an independent, plausibly related sample of European cardiac arrest survivors., Methods: Analysis of data from a European cardiac arrest center, certified in compliance with the specifications of the German Council for Resuscitation. The study sample included adults with nontraumatic out-of-hospital cardiac arrest admitted between 2013 and 2018. Exposure was the PROgnostication using LOGistic regression model for Unselected adult cardiac arrest patients in the Early stages (PROLOGUE) score, including 12 clinical variables readily available at hospital admission. The outcome was poor 30-day neurologic function, as assessed using the cerebral performance category scale. The risk of a poor outcome was calculated using the PROLOGUE score regression equation. Predicted risk deciles were compared to observed outcome estimates in a complete-case analysis, a best-case analysis, and a multiple-data-imputation analysis using the Markov chain Monte Carlo method., Results: A total of 1051 patients (median 61 years, IQR 50-71; 29% female) were analyzed. A total of 808 patients (77%) were included in the complete-case analysis. The PROLOGUE score overestimated the risk of poor neurologic outcomes in the range of 40% to 100% predicted risk, involving 63% of patients. The model fit did not improve after missing data imputation., Conclusions: In a plausibly related sample of European cardiac arrest survivors, risk prediction by the PROLOGUE score was largely too pessimistic and failed to replicate the high accuracy found in the original study. Using the PROLOGUE score as an example, this study highlights the compelling need for independent validation of a proposed prognostic score to prevent potentially fatal mispredictions.

Objective: Targeted temperature management (TTM) is part of standard post-resuscitation care. TTM may downregulate cytochrome enzyme activity and thus impact drug metabolism. This study compared the pharmacokinetics (PK) of pantoprazole, a probe drug of CYP2C19-dependent metabolism, at different stages of TTM following cardiac arrest., Methods: This prospective controlled study was performed at the Medical University of Vienna and enrolled 16 patients following cardiac arrest. The patients completed up to three study periods (each lasting 24 h) in which plasma concentrations of pantoprazole were quantified: (P1) hypothermia (33 °C) after admission, (P2) normothermia after rewarming (36 °C, intensive care), and (P3) normothermia during recovery (normal ward, control group). PK was analysed using non-compartmental analysis and nonlinear mixed-effects modelling., Results: 16 patients completed periods P1 and P2; ten completed P3. The median half-life of pantoprazole was 2.4 h (quartiles: 1.8-4.8 h) in P1, 2.8 h (2.1-6.8 h, p = 0.046 vs. P1, p = 0.005 vs. P3) in P2 and 1.2 h (0.9 - 2.3 h, p = 0.007 vs. P1) in P3. A two-compartment model described the PK data best. Typical values for clearance were estimated separately for each study period, indicating 40% and 29% reductions during P1 and P2, respectively, compared to P3. The central volume of distribution was estimated separately for P2, indicating a 64% increase compared to P1 and P3., Conclusion: CYP2C19-dependent drug metabolism is downregulated during TTM following cardiac arrest. These results may influence drug choice and dosing of similarly metabolized drugs and may be helpful for designing studies in similar clinical situations., (Copyright © 2021 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Background: High-quality Basic Life Support (BLS), the first step in the Utstein formula for survival, needs effective education for all kinds of population groups. The feasibility of BLS courses for refugees is not well investigated yet., Methods: We conducted BLS courses including automated external defibrillator (AED) training for refugees in Austria from 2016 to 2019. Pre-course and after course attitudes and knowledge towards cardiopulmonary resuscitation (CPR) were assessed via questionnaires in the individuals' native languages, validated by native speaker interpreters., Results: We included 147 participants (66% male; 22 [17-34] years; 28% <18 years) from 19 countries (74% from the Middle East). While the availability of BLS courses in the participants' home countries was low (37%), we noted increased awareness towards CPR and AED use after our courses. Willingness to perform CPR increased from 25% to 99%. A positive impact on the participants' perception of integration into their new environment was noted after CPR training. Higher level of education, male gender, age <18 years and past traumatizing experiences positively affected willingness or performance of CPR., Conclusion: BLS education for refugees is feasible and increases their willingness to perform CPR in emergency situations, with the potential to improve survival after cardiac arrest. Individuals with either past traumatizing experiences, higher education or those <18 years might be eligible for advanced life support education. Interestingly, these BLS courses bear the potential to foster resilience and integration. Therefore, CPR education for refuge should be generally offered and further evaluated., (© 2021 The Authors. European Journal of Clinical Investigation published by John Wiley & Sons Ltd on behalf of Stichting European Society for Clinical Investigation Journal Foundation.)

Abstract: Gastrointestinal ischemia with reperfusion tissue injury contributes to post-cardiac arrest syndrome. We hypothesized that diarrhea is a symptom of intestinal ischemia/reperfusion injury and investigated whether the occurrence of early diarrhea (≤12 hours) after successful cardiopulmonary resuscitation is associated with an unfavorable neurological outcome.We analyzed data from the Vienna Clinical Cardiac Arrest Registry. Inclusion criteria comprised ≥18 years of age, a witnessed, non-traumatic out-of-hospital cardiac arrest, return of spontaneous circulation (ROSC), initial shockable rhythm, and ST-segment elevation in electrocardiogram after ROSC with consecutive coronary angiography. Patients with diarrhea caused by other factors (e.g., infections, antibiotic treatment, or chronic diseases) were excluded. The primary endpoint was neurological function between patients with or without "early diarrhea" (≤12 hours after ROSC) according to cerebral performance categories.We included 156 patients between 2005 and 2012. The rate of unfavorable neurologic outcome was higher in patients with early diarrhea (67% vs 37%). In univariate analysis, the crude odds ratio for unfavorable neurologic outcome was 3.42 (95% confidence interval, 1.11-10.56, P = .03) for early diarrhea. After multivariate adjustment for traditional prognostication markers the odds ratio of early diarrhea was 5.90 (95% confidence interval, 1.28-27.06, P = .02).In conclusion, early diarrhea within 12 hours after successful cardiopulmonary resuscitation was associated with an unfavorable neurological outcome., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: In cardiac arrest survivors, metabolic parameters [pH value, lactate concentration, and base deficit (BD)] are routinely added to peri-arrest factors (including age, sex, bystander cardiopulmonary resuscitation, shockable first rhythm, resuscitation duration, adrenaline dose) to enhance early outcome prediction. However, the additional value of this strategy remains unclear. Methods: We used our resuscitation database to screen all patients ≥18 years who had suffered in- or out-of-hospital cardiac arrest (IHCA, OHCA) between January 1st, 2005 and May 1st, 2019. Patients with incomplete data, without return of spontaneous circulation or treatment with sodium bicarbonate were excluded. To analyse the added value of metabolic parameters to prognosticate neurological function, we built three models using logistic regression. These models included: (1) Peri-arrest factors only, (2) peri-arrest factors plus metabolic parameters and (3) metabolic parameters only. Receiver operating characteristics curves regarding 30-day good neurological function (Cerebral Performance Category 1-2) were analysed. Results: A total of 2,317 patients (OHCA: n = 1842) were included. In patients with OHCA, model 1 and 2 had comparable predictive value. Model 3 was inferior compared to model 1. In IHCA patients, model 2 performed best, whereas both metabolic (model 3) and peri-arrest factors (model 1) demonstrated similar power. PH, lactate and BD had interchangeable areas under the curve in both IHCA and OHCA. Conclusion: Although metabolic parameters may play a role in IHCA, no additional value in the prediction of good neurological outcome could be found in patients with OHCA. This highlights the importance of accurate anamnesis especially in patients with OHCA., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Mueller, Grafeneder, Schoergenhofer, Schwameis, Schriefl, Poppe, Clodi, Koch, Sterz, Holzer and Ettl.)

Background: Coronary artery disease (CAD) is the most common cause of sudden cardiac arrest (SCA). Although coronary angiography (CAG) should be performed also in the absence of ST-elevation (STE) after sustained return of spontaneous circulation (ROSC), this recommendation is not well implemented in daily routine., Methods: A retrospective database analysis was conducted in a tertiary care center between January 2005 and December 2014. We included all SCA patients aged ≥ 18 years with presumed cardiac cause and sustained ROSC in the absence of STE at hospital admission. The rate and timing of CAG were defined as the primary endpoints. As secondary endpoints, the reasons pro and contra CAG were analyzed. Furthermore, we observed if the signs and symptoms used for decision making occurred more often in patients with treatable CAD., Results: We included 645 (53.6%) of the 1203 screened patients, CAG was performed in 343 (53.2%) patients with a diagnosis of occlusive CAD in 214 (62.4%) patients. Of these, 151 (71.0%) patients had occlusive CAD treated with coronary intervention, thrombus aspiration, or coronary artery bypass grafting. In an adjusted binomial logistic regression analysis, age ≥ 70 years, female sex, non-shockable rhythms, and cardiomyopathy were associated with withholding of CAG. In patients diagnosed and treated with occlusive CAD, initially shockable rhythms, previously diagnosed CAD, hypertension, and smoking were found more often., Conclusion: Although selection bias is unavoidable due to the retrospective design of this study, a high proportion of the examined patients had occlusive CAD. The criteria used for patient selection may be suboptimal., (© 2021. The Author(s).)

Background: The post-cardiac arrest (CA) phase is characterized by high fluid requirements, endothelial activation and increased vascular permeability. Erythrocytes are large cells and may not leave circulation despite massive capillary leak. We hypothesized that dynamic changes in hemoglobin concentrations may reflect the degree of vascular permeability and may be associated with neurologic function after CA. Methods: We included patients ≥18 years, who suffered a non-traumatic CA between 2013 and 2018 from the prospective Vienna Clinical Cardiac Arrest Registry. Patients without return of spontaneous circulation (ROSC), with extracorporeal life support, with any form of bleeding, undergoing surgery, receiving transfusions, without targeted temperature management or with incomplete datasets for multivariable analysis were excluded. The primary outcome was neurologic function at day 30 assessed by the Cerebral Performance Category scale. Differences of hemoglobin concentrations at admission and 12 h after ROSC were calculated and associations with neurologic function were investigated by uni- and multivariable logistic regression. Results: Two hundred and seventy-five patients were eligible for analysis of which 143 (52%) had poor neurologic function. For every g/dl increase in hemoglobin from admission to 12 h the odds of poor neurologic function increased by 26% (crude OR 1.26, 1.07-1.49, p = 0.006). The effect remained unchanged after adjustment for fluid balance and traditional prognostication markers (adjusted OR 1.27, 1.05-1.54, p = 0.014). Conclusion: Increasing hemoglobin levels in spite of a positive fluid balance may serve as a surrogate parameter of vascular permeability and are associated with poor neurologic function in the early post-cardiac arrest period., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Schriefl, Schoergenhofer, Ettl, Poppe, Clodi, Mueller, Grafeneder, Jilma, Magnet, Buchtele, Boegl, Holzer, Sterz and Schwameis.)

Whether admission C-reactive protein (aCRP) concentrations are associated with neurological outcome after out-of-hospital cardiac arrest (OHCA) is controversial. Based on established kinetics of CRP, we hypothesized that aCRP may reflect the pre-arrest state of health and investigated associations with neurological outcome. Prospectively collected data from the Vienna Clinical Cardiac Arrest Registry of the Department of Emergency Medicine were analysed. Adults (≥ 18 years) who suffered a non-traumatic OHCA between January 2013 and December 2018, without return of spontaneous circulation or extracorporeal cardiopulmonary resuscitation therapy were eligible. The primary endpoint was a composite of unfavourable neurologic function or death (defined as Cerebral Performance Category 3-5) at 30 days. Associations of CRP levels drawn within 30 min of hospital admission were assessed using binary logistic regression. ACRP concentrations were overall low in our population (n = 832), but higher in the unfavourable outcome group [median: 0.44 (quartiles 0.15-1.44) mg/dL vs. 0.26 (0.11-0.62) mg/dL, p < 0.001]. The crude odds ratio for higher aCRP concentrations was 1.19 (95% CI 1.10-1.28, p < 0.001, per mg/dL) to have unfavourable neurological outcome. After multivariate adjustment for traditional prognostication markers the odds ratio of higher aCRP concentrations was 1.13 (95% CI 1.04-1.22, p = 0.002). Sensitivity of aCRP was low, but specificity for unfavourable neurological outcome was 90% for the cut-off at 1.5 mg/dL and 97.5% for 5 mg/dL CRP. In conclusion, high aCRP levels are associated with unfavourable neurological outcome at day 30 after OHCA.

Coagulation abnormalities after successful resuscitation from cardiac arrest may be associated with unfavorable neurologic outcome. We investigated a potential association of activated partial thromboplastin time (aPTT) with neurologic outcome in adult cardiac arrest survivors. Therefore, we included all adults ≥18 years of age who suffered a nontraumatic cardiac arrest and had achieved return of spontaneous circulation between January 2013 and December 2018. Patients receiving anticoagulants or thrombolytic therapy and those subjected to extracorporeal membrane oxygenation support were excluded. Routine blood sampling was performed on admission as soon as a vascular access was available. The primary outcome was 30-day neurologic function, assessed by the Cerebral Performance Category scale (3-5 = unfavorable neurologic function). Multivariable regression was used to assess associations between normal (≤41 seconds) and prolonged (>41 seconds) aPTT on admission (exposure) and the primary outcome. Results are given as odds ratio (OR) with 95% confidence intervals (95% CIs). Out of 1,591 cardiac arrest patients treated between 2013 and 2018, 360 patients (32% female; median age: 60 years [interquartile range: 48-70]) were eligible for analysis. A total of 263 patients (73%) had unfavorable neurologic function at day 30. aPTT prolongation >41 seconds was associated with a 190% increase in crude OR of unfavorable neurologic function (crude OR: 2.89; 95% CI: 1.78-4.68, p  < 0.001) and with more than double the odds after adjustment for traditional risk factors (adjusted OR: 2.01; 95% CI: 1.13-3.60, p  = 0.018). In conclusion, aPTT prolongation on admission is associated with unfavorable neurologic outcome after successful resuscitation from cardiac arrest., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Most western emergency medical services provide advanced life support in out-of-hospital cardiac arrest aiming for a return of spontaneous circulation at the scene. Little attention is given to prehospital time management in the case of out-of-hospital cardiac arrest with regard to early coronary angiography or to the start of extracorporeal cardiopulmonary resuscitation treatment within 60 minutes after out-of-hospital cardiac arrest onset. We investigated the emergency medical services on-scene time, defined as emergency medical services arrival at the scene until departure to the hospital, and its association with 30-day survival with favourable neurological outcome after out-of-hospital cardiac arrest., Methods: All patients of over 18 years of age with non-traumatic, non-emergency medical services witnessed out-of-hospital cardiac arrest between July 2013 and August 2015 from the Vienna Cardiac Arrest Registry were included in this retrospective observational study., Results: Out of 2149 out-of-hospital cardiac arrest patients, a total of 1687 (79%) patients were eligible for analyses. These patients were stratified into groups according to the on-scene time (<35 minutes, 35-45 minutes, 45-60 minutes, >60 minutes). Within short on-scene time groups, out-of-hospital cardiac arrest occurred more often in public and bystander cardiopulmonary resuscitation was more common (both P <0.001). Patients who did not achieve return of spontaneous circulation at the scene showed higher rates of 30-day survival with favourable neurological outcome with an on-scene time of less than 35 minutes (adjusted odds ratio 5.00, 95% confidence interval 1.39-17.96)., Conclusion: An emergency medical services on-scene time of less than 35 minutes was associated with higher rates of survival and favourable outcomes. It seems to be reasonable to develop time optimised advance life support protocols to minimise the on-scene time in view of further treatments such as early coronary angiography as part of post-resuscitation care or extracorporeal cardiopulmonary resuscitation in refractory out-of-hospital cardiac arrest.

Background: The COVID-19 pandemic has resulted in the suspension of the entire teaching program at the Medical University of Vienna till the end of the summer semester. As the department that is responsible for emergency medicine teaching, we adapted the program to continue the courses and maintain the learning progress. Our objective is to evaluate the number of courses conducted and report the methods used. Methods: Teaching was measured as credit hours per week (CHW) in accordance with the university's prospectus. One CHW represents 15 academic hours (45 min) in one semester. Webinars were conducted using the CISCO Webex Events®, Webex Training, and ZOOM®. The Moodle® was utilized for resuscitation courses. Results: Courses and clerkships equivalent to 80.2 out of 101.4 CHW (79.1%) could be held during the ongoing crisis in the summer semester. Courses in the winter semester were all completed. In the human medicine curriculum, 73.7 out of 94.9 CHW (77.7%) could be conducted. In the case of emergency lectures for the dentistry curriculum, all courses were conducted through webinars (6.5 CHW, 100%). After calculating the exact number of students in each class, it has been determined that courses and clerkships equivalent to 78.7% could be conducted. Conclusion: Despite the challenge of preparing for the treatment of numerous patients during the ongoing pandemic, we could shoulder a majority of our teaching responsibilities. Although sufficient skill training could not be imparted under these circumstances, we could provide sufficient theoretical knowledge to allow students to continue studies., (Copyright © 2020 Mueller, Schriefl, Holzer, Roeggla, Laggner and Ettl.)

Purpose: The cornu ammonis 1 (CA1) region of the hippocampus is specifically vulnerable to global ischemia. We hypothesized that histopathological outcome in a ventricular fibrillation cardiac arrest (VFCA) rat model depends on the time point of the examination., Methods: Male Sprague-Dawley rats were put into VFCA for 8 min, received chest compressions for 2 min, and were defibrillated to achieve return of spontaneous circulation. Animals surviving for 80 min, 14 days and 140 days were compared with controls. Viable neurons were counted in a 500 μm sector of the CA1 region and layer thickness measured. Microglia cells and astrocytes were counted in a 250×300 μm aspect., Results: Control and 80 min surviving animals had similar numbers of pyramidal neurons in the CA1 region. In 14 days and 140 days survivors neuron numbers and layer thickness were severely diminished compared with controls (P < 0.001). Two-thirds of the 140 days survivors showed significantly more viable neurons than the last third. Microglia was increased in 14 days survivors compared with controls and 140 days survivors, while astrocytes increased in 14 days and 140 days survivors compared with controls (P < 0.001). 140 days survivors had significantly higher astrocyte counts compared with 14 days survivors., Conclusions: The amount and type of brain lesions present after global ischemia depend on the survival time. A consistent reduction in pyramidal cells in the CA1 region was present in all animals 14 days after VFCA, but in two-thirds of animals a repopulation of pyramidal cells seems to have taken place after 140 days.

Endotoxemia after cardiopulmonary resuscitation (CPR) is associated with unfavorable outcome. Proprotein convertase subtilisin/kexin type-9 (PCSK-9) regulates low-density lipoprotein receptors, which mediate the hepatic uptake of endotoxins. We hypothesized that PCSK-9 concentrations are associated with neurological outcome in patients after CPR. Successfully resuscitated out-of-hospital cardiac arrest patients were included prospectively ( n = 79). PCSK-9 levels were measured on admission, 12 h and 24 h thereafter, and after rewarming. The primary outcome was favorable neurologic function at day 30, defined by cerebral performance categories (CPC 1-2 = favorable vs. CPC 3-5 = unfavorable). Receiver operating characteristic curve analysis was used to identify the PCSK-9 level cut-off for optimal discrimination between favorable and unfavorable 30-day neurologic function. Logistic regression models were calculated to estimate the effect of PCSK-9 levels on the primary outcome, given as odds ratio (OR) and 95% confidence interval (95%CI). PCSK-9 levels on admission were significantly lower in patients with favorable 30-day neurologic function (median 158 ng/mL, (quartiles: 124-225) vs. 207 ng/mL (174-259); p = 0.019). The optimally discriminating PCSK-9 level cut-off was 165ng/mL. In patients with PCSK-9 levels ≥ 165 ng/mL, the odds of unfavorable neurological outcome were 4.7-fold higher compared to those with PCSK-9 levels < 165 ng/mL. In conclusion, low PCSK-9 levels were associated with favorable neurologic function., Competing Interests: The authors declare no conflict of interest.

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 increase between each consecutive year was also significant. Paramedics more frequently inserted the LT than physicians (RR 1.80 (95%CI 1.48-2.16); p < 0.001). Female patients received a LT less frequently (RR 0.84 (95%CI 0.72-0.97), p = 0.013). There was no difference regarding airway device due to underlying causes requiring airway management and no relationship to the NACA-score. Conclusion: In a European EMS system of physician and paramedic response, the proportion of airway managed by LT over ETT rose considerably over five years. Although the ET is still the gold standard, the LT is gaining in importance for EMS physicians and paramedics.

Background: There is an increasing use of extracorporeal life support in refractory cardiac arrest. Recent studies highlighted the importance of an early and accurate patient selection for this invasive procedure., Objectives: The aim of this study was to retrospectively validate a six-criteria-screening-checklist (witnessed collapse, bystander-cardiopulmonary resuscitation/first medical contact <5 min, shockable, age <70 years, end tidal carbon dioxide >14 mmHg and pupils not anisocoric/distorted/mydriatic) as an early screening tool in patients treated with extracorporeal cardiopulmonary resuscitation (eCPR) at the emergency department., Design: Retrospective observational study., Setting/patients: All patients at least 18 years of age with nontraumatic cardiac arrest and without return of spontaneous circulation before eCPR treatment at our department between January 2013 and December 2018 were included in this retrospective observational study., Intervention: No specific intervention was set in this observational study., Main Outcome Measures: Primary outcome was the rate of patients who fulfilled all criteria, secondary outcome was 30-day and 6-month survival in accordance with the criteria., Results: Overall, data from a total of 92 patients were eligible for analyses. Out of these, 27 patients (29%) met all criteria. Patients, who fulfilled all criteria, showed significantly higher odds for 30-day survival [OR 6.0 (95% CI 1.78 to 20.19)] P = 0.004. Patients, who did not fulfil all criteria, showed significantly higher rates of early mortality after eCPR initiation [OR 4.57 (95% CI 1.69 to 12.37)] P = 0.003., Conclusion: Patients fulfilling all inclusion criteria showed higher rates of survival after eCPR. Our results affirm that there is a possibility and even an obvious necessity for early patient selection based on standardised criteria before eCPR treatment. Large randomised trials are urgently needed to answer this question accurately.

Background: Early prognostication in post-cardiac arrest (CA) patients remains challenging and biomarkers have evolved as helpful tools in risk assessment. The stress-response cytokine growth differentiation factor-15 (GDF-15) is dramatically up-regulated during various kinds of tissue injury and predicts outcome in many pathological conditions. We aimed to assess the predictive value of circulating GDF-15 in post-CA patients., Methods: This prospective observational study included 128 consecutive patients (median age 60.3 years, 75.8% male) with return of spontaneous circulation after in- or out-of-hospital CA who were treated at a tertiary university hospital. GDF-15 serum levels were determined at admission., Results: A total of 52 patients (40.6%) died during the 6-month follow-up. Median GDF-15 levels were significantly lower in survivors (1601 ng/L (interquartile range: 1114-2983 ng/L) than in non-survivors (3172 ng/L (1927-8340 ng/L); p < 0.001). GDF-15 levels were also significantly lower in patients with favourable neurological 6-month outcome (cerebral performance category (CPC) 1-2) than in those with poor neurological outcome (CPC 3-5; p < 0.001). GDF-15 significantly predicted 6-month mortality in univariate Cox regression analysis (hazard ratio (HR) per 1-standard deviation increase 1.76 [95% confidence interval (CI) 1.35-2.31; p < 0.001] and remained significant after multivariable adjustment (HR 1.57 [95% CI 1.19-2.07; p = 0.001]). Subgroup analysis revealed that the association between GDF-15 and 6-month outcome was present both in patients with in- and out-of-hospital CA., Conclusions: GDF-15 predicts poor survival and neurological outcome in post-CA patients. GDF-15 may reflect the extent of hypoxic injury to the brain and other organs and might help to improve early risk stratification after CA., (Copyright © 2019. Published by Elsevier B.V.)

Background: Early outcome prediction in out-of-hospital cardiac arrest is still a challenge. End-tidal carbon dioxide (ETCO2) has been shown to be a reliable parameter to reflect the quality of cardiopulmonary resuscitation and the chance of return of spontaneous circulation (ROSC)., Objectives: This study assessed the validity of early capnography as a predictive factor for ROSC and survival in out-of-hospital cardiac arrest victims with an underlying nonshockable rhythm., Design: Retrospective observational study., Setting/patients: During a 2-year observational period, data from 2223 out-of-hospital cardiac arrest victims within the city of Vienna were analysed. The focus was on the following patients: age more than 18 years, an underlying nonshockable rhythm, and advanced airway management within the first 15 min of advanced life support with subsequent capnography., Intervention: No specific intervention was set in this observational study., Main Outcome Measures: The first measured ETCO2, assessed immediately after placement of an advanced airway, was used for further analysis. The primary outcome was defined as sustained ROSC, and the secondary outcome was 30-day survival., Results: A total of 526 patients met the inclusion criteria. These were stratified into three groups according to initial ETCO2 values (<20, 20 to 45, >45 mmHg). Baseline data and resuscitation factors were similar among all groups. The odds of sustained ROSC and survival were significantly higher for patients presenting with higher values of initial ETCO2 (>45 mmHg): 3.59 [95% CI, 2.19 to 5.85] P = 0.001 and 5.02 [95% CI, 2.25 to 11.23] P = 0.001, respectively. On the contrary ETCO2 levels less than 20 mmHg were associated with significantly poorer outcomes., Conclusion: Patients with a nonshockable out-of-hospital cardiac arrest who presented with higher values of initial ETCO2 had an increased chance of sustained ROSC and survival. This finding could help decision making as regards continuation of resuscitation efforts.

Background: Cardio-pulmonary-resuscitation (CPR) training starting at the age of 12 years is recommended internationally. Training younger children is not recommended because young children lack the physical ability to perform adequate CPR and discouragement to perform CPR later is apprehended. The aim of this study was to answer the following questions: Are younger children discouraged after CPR training? Is discouragement caused by their lack in physical ability to perform adequate chest compressions on a standard manikin and would the use of manikins with a reduced resistance affect their motivation or performance?, Methods: We investigated the motivation and CPR performance of children aged 8-13 years after CPR training on manikins of different chest stiffness in a prospective, randomized, single-blind, controlled trial. 322 children underwent randomization and received 30 minutes CPR training in small groups at school. We used two optically identical resuscitation manikins with different compression resistances of 45kg and 30kg. Motivation was assessed with a self-administered questionnaire. Performance was measured with the Resusci®Anne SkillReporter™., Findings: Motivation after the training was generally high and there was no difference between the two groups in any of the questionnaire items on motivation: Children had fun (98 vs. 99%; P = 0.32), were interested in the training (99 vs. 98%; P = 0.65), and were glad to train resuscitation again in the future (89 vs. 91%; P = 0.89). CPR performance was generally poor (median compression score (8, IQR 1-45 and 29, IQR 11-54; P<0.001) and the mean compression depth was lower in the 45kg-resistance than in the 30kg-resistance group (33±10mm vs. 41±9; P<0.001)., Conclusions: Compression resistances of manikins, though influencing CPR performance, did not discourage 8 to 13 year old children after CPR training. The findings refute the view that young children are discouraged when receiving CPR training even though they are physically not able to perform adequate CPR., Competing Interests: The authors have declared that no competing interest exists.

Background: Outcome is generally poor in out of hospital cardiac arrests (OHCA) with initial non-shockable rhythms. Termination of resuscitation rules facilitate early prognostication at the scene to cease resuscitation attempts in futile situations and to proceed advanced life support in promising conditions. As pulseless electrical activity (PEA) is present as first rhythm in every 4th OHCA we were interested if the initial electrical frequency in PEA predicts survival., Methods: All patients >18 years of age with non-traumatic OHCA and PEA as first rhythm between August 2013 and August 2015 from the Vienna Cardiac Arrest Registry were included in this retrospective observational study. Defibrillator and epidemiological data from the emergency medical system as survival data were processed considering the initial electrical activity in PEA and 30 days survival., Results: Out of 2149 OHCA patients, a total of 504 PEA patients were eligible for analyses. These patients were stratified into 4 groups according the initial electrical frequency in PEA: 10-24/min, 25-39/min, 40-59/min, >60/min. Compared to a frequency >60/min all other subgroups were associated with higher mortality especially those with an initial electrical frequency 10-24 (adjusted OR 0.56 (0.39-0.79) p = .001 for each category chance). QRS duration in PEA did not influence outcome. Patients in the >60/min group showed a 30-days-survival rate of 22% and a good neurological outcome in 15% of all patients - comparable to shockable cardiac arrest rhythms., Conclusion: Regardless of other resuscitation factors, higher initial electrical frequency in PEA is associated with increased odds of survival and good neurological outcome., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Extracorporeal life support (ECLS) for cardiopulmonary resuscitation (CPR) may increase end organ perfusion and thus survival when conventional CPR fails. The aim was to investigate, if after ventricular fibrillation cardiac arrest in rodents ECLS improves outcome compared with conventional CPR., Methods: In 24 adult male Sprague-Dawley rats (460-510 g) resuscitation was started after 10 min of no-flow with ECLS (consisting of an open reservoir, roller pump, and membrane oxygenator, connected to cannulas in the jugular vein and femoral artery, n = 8) or CPR (mechanical chest compressions plus ventilations, n = 8) and compared with a sham group (n = 8). After return of spontaneous circulation (ROSC), all rats were maintained at 33°C for 12 h. Survival to 14 days, neurologic deficit scores and overall performance categories were assessed., Results: ECLS leads to sustained ROSC in 8 of 8 (100%) and neurological intact survival to 14 days in 7 of 8 rats (88%), compared with 5 of 8 (63%) and 1 of 8 CPR rats. The median survival time was 14 days (IQR: 14-14) in the ECLS and 1 day (IQR: 0 to 5) for the CPR group (P = 0.004)., Conclusion: In a rat model of prolonged ventricular fibrillation cardiac arrest, ECLS with mild hypothermia produces 100% resuscitability and 88% long-term survival, significantly better than conventional CPR.

Objectives: The quality of telephone-assisted cardiopulmonary resuscitation (CPR) needs improvement. This study investigates whether a dispatchers' perception is an adequate measure of the actual quality of CPR provided by laypersons., Material and Methods: Individual participant data from 3 randomized simulation trials, with identical methodology but different interventions, were combined for this analysis. Professional dispatchers gave telephone assistance to laypersons, who each provided 10 minutes of CPR on a manikin. Dispatchers were requested to classify the quality of providers' CPR as adequate or inadequate. Based on actual readings from manikins we classified providers' performance as adequate at 5-6 cm for depth and 100-120 compressions per minute (cpm) for rate. We calculated metrics of dispatcher accuracy., Results: Six dispatchers rated the performance of 94 laypersons (38 women [42%]) with a mean (SD) age of 37 (14) years. In 905 analyzed minutes of telephone-assisted CPR, the mean compression depth and rate was 41 (13) mm and 98 (24) cpm, respectively. Analysis of dispatchers' diagnostic test accuracy for adequate compression depth yielded a sensitivity of 65% (95 CI 36%-95%) and specificity of 42% (95% CI, 32%-53%). Analysis of their assessment of adequate compression rate yielded a sensitivity of 75% (95% CI, 64%-86%) and specificity of 42% (95% CI, 32%-52%). Although dispatchers always underestimated the actual values of CPR parameters, the female dispatchers evaluations were less inaccurate than the evaluations of make dispatchers; the dispatchers overall (males and females together) underestimated the adequacy of female laypersons' CPR performance to a greater degree than female dispatchers did., Conclusion: The ability of dispatchers to estimate the quality of telephone-assisted CPR is limited. Dispatchers estimates of CPR adequacy needs to be studied further in order to find ways that telephone-assisted CPR might be improved.

Aim: 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., Methods: 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., Results: 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., Conclusions: 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.

Objectives: We investigated the effect on compression rate and depth of a conventional metronome and a voice metronome in simulated telephone-assisted, protocol-driven bystander Cardiopulmonary resucitation (CPR) compared to standard instruction., Material and Methods: Thirty-six lay volunteers performed 10 minutes of compression-only CPR in a prospective, investigator-blinded, 3-arm study on a manikin. Participants were randomized either to standard instruction ("push down firmly, 5 cm"), a regular metronome pacing 110 beats per minute (bpm), or a voice metronome continuously prompting "deep-deepdeep- deeper" at 110 bpm. The primary outcome was deviation from the ideal chest compression target range (50 mm compression depth x 100 compressions per minute x 10 minutes = 50 m). Secondary outcomes were CPR quality measures (compression and leaning depth, rate, no-flow times) and participants' related physiological response (heart rate, blood pressure and nine hole peg test and borg scales score). We used a linear regression model to calculate effects., Results: The mean (SD) deviation from the ideal target range (50 m) was -11 (9) m in the standard group, -20 (11) m in the conventional metronome group (adjusted difference [95%, CI], 9.0 [1.2-17.5 m], P=.03), and -18 (9) m in the voice metronome group (adjusted difference, 7.2 [-0.9-15.3] m, P=.08). Secondary outcomes (CPR quality measures and physiological response of participants to CPR performance) showed no significant differences., Conclusion: Compared to standard instruction, the conventional metronome showed a significant negative effect on the chest compression target range. The voice metronome showed a non-significant negative effect and therefore cannot be recommended for regular use in telephone-assisted CPR.