[Influence of extreme weather conditions on the deployment volume of emergency medical services]. / Einfluss von Wetterextrema auf Einsatzzahlen im Notarztdienst.

BACKGROUND: Due to global warming a worldwide increase in the frequency and intensity of heat waves have been forecast. In the context of the overall increasing number of emergency service calls, weather-induced effects on the number of calls are highly relevant. We evaluated the influence of extreme temperatures on emergency medical services. MATERIALS AND METHODS: The study was conducted in Bochum, Germany. The authors examined the data from 16,767 emergency calls. In addition, the daily updated temperature data were collected for each emergency doctor call. Data were collected from 01 January 2014 until 31 December 2015. The primary question was the influence of extremes of the perceived temperature (PT; on the day of the call and the three previous days) on the diagnosis group of cardiovascular diseases. A secondary question was the influence of extremes of the temperature parameters (air temperature, PT, physiological equivalent temperature [PET]) on the day of call and the three previous days. RESULTS: A total of 16,767 calls were assessed. The threshold values (upper and lower 5%) were -8.7 and 32.5 °C for PT and -0.7 and 26.7 °C for air temperature. Examination of the PT indicated a significantly increased rate of calls for cold spells on the day of the call (RR = 1.14; p = 0.033) as well as a lag effect of 3 days (RR = 1.1; p = 0.049). CONCLUSION: The present study shows that during cold spells there is an increased rate of calls for cardiovascular diseases. This effect is not only observable on the extreme day itself but also 3 days later.

Use of automated external defibrillators for in-hospital cardiac arrest : Any time, any place?

BACKGROUND: Acute treatment of in-hospital cardiac arrest (IHCA) is challenging and overall survival rates are low. However, data on the use of public-access automated external defibrillators (AEDs) for IHCA remain controversial. The aim of our study was to evaluate characteristics of patients experiencing IHCA and feasibility of public-access AED use for resuscitation in a university hospital. METHODS: IHCA events outside the intensive care unit were analysed over a period of 21 months. Patients' characteristics, AED performance, return of spontaneous circulation (ROSC) and 24 h survival were evaluated. Outcomes following adequate and inadequate AED use were compared. RESULTS: During the study period, 59 IHCAs occurred. AED was used in 28 (47.5%) of the cases. However, AED was adequately used in only 42.8% of total AED cases. AED use was not associated with an increased survival rate (12.9 vs. 10.7%, p = 0.8) compared to non-AED use. However, adequate AED use was associated with a higher survival rate (25 vs. 0%, p = 0.034) compared to inadequate AED use. Time from emergency call to application of AED >3 min was the most important factor of inadequate AED use. Adequate AED use was more often observed between 7:30 and 13:30 and in the internal medicine department. CONCLUSION: AEDs were applied in less than 50% of the IHCA events. Furthermore, AED use was inadequate in the majority of the cases. Since adequate AED use is associated with improved survival, AEDs should be available in hospital areas with patients at high risk of shockable rhythm.

[Identification of common locations of out-of-hospital cardiac arrests in a German metropolis]. / Notfallortanalyse von Herz-Kreislauf-Stillständen in einer deutschen Großstadt.

BACKGROUND: Most patients who suffer a sudden cardiac arrest initially have a shockable rhythm. Fast defibrillation and correctly performed cardiopulmonary resuscitation (CPR) are key factors for patient survival. These can be carried out by bystanders if an automated external defibrillator (AED) is available even in the absence of emergency services. AIM: The place and time of CPRs in a German city were investigated and the strategic placement of emergency medical services and AEDs necessary were evaluated. METHODS: All prehospital resuscitation attempts by Bochum's emergency services in 2011 were retrospectively analyzed. The city was divided into a grid, according to the city map to describe the location of every resuscitation. The distribution of cases was correlated to the city grid and time of day. RESULTS: There were 299 cardiac arrests (mean age 74.2 ± 12.47 years; 59% of patients were male). Most resuscitations happened in a home environment between 8 am and 8 pm. There was a higher proportion of resuscitation attempts in grid squares with a high population density. Of the resuscitations in public places 16 of 47 (34%) happened in city district centers. In 72% of all cases, only a nonshockable rhythm could be documented as primary arrhythmia on the arrival of the emergency services. Of the 299 attempted resuscitations, a return of spontaneous circulation was achieved in 41%. CONCLUSIONS: The knowledge about increased frequency of resuscitations in city centers provides insight for strategic placement of emergency devices and services in those areas. This can possibly minimize the time until first response and enables early defibrillation with AED in a first-responder program. In addition, bystanders should obtain clear instructions for resuscitation by the dispatcher of the emergency services.

[Ten years of early defibrillation: "Bochum against sudden cardiac death". Acceptance and critical analysis of using automated external defibrillators]. / Zehn Jahre Frühdefibrillation: "Bochum gegen den plötzlichen Herztod". Akzeptanz und kritische Betrachtung des Einsatzes von automatisierten externen Defibrillatoren.

BACKGROUND: There is a comprehensive early defibrillation program in Bochum (Germany); since 2003 a total of 175 automated external defibrillators (AEDs) have been installed in urban areas by the city of Bochum and private companies. These were preferably installed in places with high foot traffic, e.g., public buildings, companies, and event/shopping centers. Approximately 15,000 laypeople who work in the vicinity of the AED locations were trained in the use of defibrillators and in basic resuscitation. In addition, rescue workers on fire trucks and medically trained personnel in physicians' medical practices were equipped as "first responders" with AEDs. RESULTS: After an initiation phase, all available information after each AED use since August 2004 has been collected by the project coordinator. During the period of data collection (August 2004 to August 2013), an AED was used in a total of 17 patients who had suffered sudden cardiac death (SCD) under the project in Bochum. Eleven patients had primary ventricular fibrillation (VF). Six of these survived without neurological deficit. In another 6 patients, a nondefibrillatable rhythm disorder was diagnosed. The AEDs are reliable and showed impeccable rhythm analysis before the instructions to provide any necessary shock. DISCUSSION: Compared to the number of existing units and an estimated number of 37-100 SCD/100,000, the use of the AEDs only 17 times appears relatively small. To improve the effectiveness of the AED program in Bochum, an analysis of the emergency service responses, which were necessary because of sudden circulatory collapse, is currently being performed. This will allow areas with an increased incidence of SCD to be identified and a plan for the strategic placement of AED and emergency services can be made.

[Saving lives with dispatcher-assisted resuscitation: importance of effective telephone instruction]. / Leben retten durch leitstellengestützte Reanimation : Welche telefonische Anleitung ist sinnvoll?

BACKGROUND: Survival rates after sudden cardiac arrest could be increased if bystanders could be encouraged to perform CPR until emergency services arrive. This should be initiated by the dispatcher at the emergency control facility who receives the call. For the first time the ERC guidelines of 2010 included instructions to be given to untrained rescuers by the dispatcher. Rapid recognition of cardiac arrest and initiation of emergency measures is assured by means of specific training for the dispatchers. AIM: The aim of this investigation was to determine whether the time between an emergency call and beginning of cardiopulmonary resuscitation (CPR) could be shortened using a simple protocol and whether a relationship exists between the intensity of phone contact between dispatcher and caller and if this improves the results. MATERIALS AND METHODS: In known cases of unconsciousness, group 1 (45 persons) received short CPR instructions via the phone, where the dispatcher was on the phone for continuous advice until emergency services arrived. Group 2 (45 persons) received identical phone instructions like group 1, but the phone call was terminated by the dispatcher after the information was provided. Group 3 (29 persons) only received instructions to start CPR. RESULTS: On average, all test persons in group 1 started reanimation after 68.0 ± 33.5 s, in group 2 after 68.3 ± 25.2 s, and in group 3 after 64.9 ± 34.4 s. The compression frequency on average was 98.3/min in group 1, 84.8/min in group 2, and 85.2/min in group 3; therefore, all groups reached an average frequency of > 80/min. The correct compression depth was achieved by 47.8 % of test persons in group 1, by 44.2 % in group 2, and by 30.2 % in group 3. All volunteers felt well supported. Of the 90 people, 70 did not feel that they were missing instructions. DISCUSSION: There were no significant differences between the groups regarding the target variables. The results show that already extremely short instructions or advice by the dispatcher to start CPR is sufficient to encourage bystanders to give assistance in an emergency. Continuous support over the phone does not appear to be necessary.

[In-hospital resuscitation. Concept of first-responder resuscitation using semi-automated external defibrillators (AED)]. / Reanimation im Krankenhaus. Konzept einer "First-Responder"--Reanimation unter Einsatz semi-automatischer externer Defibrillatoren.

BACKGROUND AND OBJECTIVE: The prognosis after in-hospital resuscitation has not significantly improved in the last 40 years. This account presents the results over a three-year period of a hospital-wide emergency plan which implements the use of an automated external defibrillator (AED) by the first responder to the emergency call. BACKGROUND AND OBJECTIVE: 15 "defibrillator points" were installed, which could be reached within 30 s from all wards, out-patient departments and other areas, thus making them accessible for immediate defibrillator application. The hospital personnel is trained periodically in the alarm sequence, cardiopulmonary resuscitation and use of the defibrillator. Data on 57 patients who had sustained a cardiac arrest were prospectively recorded and analysed. RESULTS: In 46 patients (81%) the "on-the-spot" personnel (first-responder) was able to apply AED before arrival of the hospital's resuscitation team. Mean period between arrest alarm and activation of the AED was 2.2 (0.7-4.7) min. Ventricular fibrillation or ventricular tachyarrhythmia was recorded in 40 patients, making immediate shock delivery by AED possible. Restoration of the circulation was achieved in 23 (80%) of the patients and 20 (50%) were discharged home, 17 (43%) without neurological deficit. The high proportion of first-responder AED applications and evaluation of the personnel training indicate a wide acceptance of the emergency plan among the personnel. CONCLUSION: An immediate resuscitation plan consisting of an integrated programme of early defibrillation is feasible and seems to achieve an improved prognosis for patients who have sustained an in-hospital cardiac arrest.

[Acute cardiovascular reactions to cervical nerve root infiltration]. / Akute Herz-Kreislaufreaktionen bei zervikaler Spinalnervenanalgesie.

AIM: The frequency of cardiovascular adverse effects of cervical nerve root infiltration was investigated by means of a prospective study. METHOD: The hemodynamic and respiratory parameters systolic and diastolic blood pressure, heart rate, respiratory rate and oxygen saturation were monitored continuously in 56 patients undergoing cervical spine nerve root infiltration (injection of 10 ml Lidocain 0.5 %, mean depth of injection 5 cm). The monitored time frame ranged from 5 minutes before to 10 minutes after its administration, an additional holter-monitoring began 1 day prior to the injection. RESULTS: Severe complications such as syncopes were not observed in any of the 56 patients, 4 patients developed presyncopes. None of the registered parameters showed a significant change. In a group of patients with known, pre-existing cardiovascular morbidity, no significant changes occurred either. No relevant cardiac arrhythmias were observed. CONCLUSION: The observed cardiovascular complications were not severe. Most probably, the observed reactions were vasavagal presyncopes. Supine positioning led to immediate recovery in all of these patients. A complete hemodynamic monitoring and the placement of an intravenous line do not seem to be absolute necessities in the routine cervical nerve root infiltration.

Endothelial function in the forearm circulation of patients with the metabolic syndrome--effect of different lipid-lowering regimens.

We compared the effect of statin therapy (either alone or combined with ezetimibe) on the inhibition of cholesterol resorption and endothelial function by measuring forearm blood flow in male patients with the metabolic syndrome. Compared to 40 mg atorvastatin alone, combination therapy with 10 mg ezetimibe and 10 mg atorvastatin for 8 weeks resulted in significantly decreased total serum cholesterol and triglycerides levels (n = 14). Endothelium-dependent, acetylcholine-mediated vasodilation was significantly better with combination therapy (p < 0.05). In contrast, endothelium-independent forearm blood flow response to sodium nitroprusside was comparable in both groups. Our data suggest a more effective restoration of endothelial function with the statin/ezetimibe combination compared to statin monotherapy in patients with the metabolic syndrome.

[Effects of lumbar spinal nerve analgesia on the cardiovascular system]. / Auswirkungen der lumbalen Spinalnervenanalgesie (LSPA) auf das Herz-Kreislauf-System.

AIM: The frequency of cardiovascular adverse effects of lumbar paravertebral nerve root infiltration was investigated. METHOD: 117 patients with sciatic pain were included prospectively. 60 % of these suffered from known cardiovascular diseases. In 50 patients, cardiac rhythm was investigated by Holter monitoring. In 100 patients blood pressure, heart rate, respiratory rate and oxygen saturation were registered continuously from 5 minutes before to 15 minutes after the administration of a paravertebral nerve root infiltration by means of a non-invasive monitoring system. RESULTS: A minor rise in systolic and diastolic blood pressure, heart rate and respiratory rate as well as a normalization of these parameters after the nerve root infiltration, were found. These findings were similar for patients with and without pre-existing cardiovascular diseases. No relevant cardiac arrhythmias could be determined. 5 of the 117 patients suffered from presyncope after the nerve root infiltration. These individuals were significantly (p = 0.002) younger than those without presyncope (32.4 +/- 9.3 vs. 55.8 +/- 14.6 years). Presyncope was more frequent during the first treatment with lumbar paravertebral nerve root infiltration in comparison to repeated application of this therapy [4/27 (14.8 %) vs. 1/90 (1.1 %), p = 0.003]. 80 % of the patients who had experienced a presyncope reported a history of similar events. CONCLUSION: According to our findings, cardiovascular monitoring for lumbar paravertebral nerve root infiltrations in the treatment of sciatica does not appear to be required. Patients with a presyncope seem to be characterized by age, first treatment and a history of (pre-)syncopes. In these cases, intravenous fluid substitution might be of help in counteracting vasovagal circulatory reactions.

Human coronary morphology after beta radiation brachytherapy of in-stent restenosis.

This case report discusses the human coronary morphological findings 18 hours after brachytherapy (beta radiation) of an in-stent restenosis. Brachytherapy produced aseptic inflammation of the periadventitial connective tissue integrating the vasa vasorum in the acute phase. The stent neointima eight months after stenting and acutely 18 hours after radiation consisted of the same cellular components as human stent neointima of specimen not additionally treated with radiation. No evidence of necrosis or excessive fibrotic alterations of the arterial vessel wall have been found.

Impaired vasodilator responses to atrial natriuretic peptide in essential hypertension.

BACKGROUND: Atrial natriuretic peptide (ANP) has vasodilating and diuretic/natriuretic properties, both of which contribute to lower blood pressure. These effects are mediated by binding of ANP to a cell-surface receptor [type A guanylyl cyclase (GC-A)]. It has been demonstrated by studies in monogenetic mouse models that the ANP/GC-A system participates in the maintenance of blood pressure homeostasis. METHODS: In male patients with essential hypertension (EH; n = 36) as the only cardiovascular risk factor and normotensive controls (n = 12), blood flow was measured in the forearm circulation in response to i.a. infusion of synthetic human ANP, acetylcholine, orciprenaline, and sodium nitroprusside by strain-gauge venous plethysmography. In blood samples, cyclic guanosine'5-monophosphate (cGMP) and ANP concentrations were measured at resting conditions and during exogenous ANP infusion. In 200 patients with EH, genomic DNA was screened for an inhibitory deletion mutation of the GC-A gene, which has been recently linked to EH in a Japanese cohort. RESULTS: The vasodilatations in response to ANP and acetylcholine were impaired in the forearm circulation of patients with EH, whereas the responses to orciprenaline and nitroprusside were preserved. Plasma ANP and cGMP concentrations were increased in the patients with EH both at resting conditions and during ANP infusion; the resting plasma cGMP levels correlated significantly with the plasma ANP levels (r = 0.68). A specific deletion mutation of the GC-A gene did not account for the diminished relaxant effects of ANP in our study population. CONCLUSIONS: The vascular ANP/GC-A pathway is altered in patients with EH, in addition to the known defects on the nitric oxide/cGMP pathway. Attenuation of the vasodilative responses to ANP suggests impaired receptor or postreceptor responsiveness of GC-A. It is possible that this dysfunction participates in the pathomechanism of EH.