Transport with ongoing cardiopulmonary resuscitation may not be futile.

BACKGROUND: Despite it being generally regarded as futile, patients are regularly brought to the emergency department with ongoing cardiopulmonary resuscitation (CPR). METHODS: Long-term outcome and its predictors in patients who were transported during ongoing CPR were evaluated in an observational study. Adult patients with non-traumatic cardiac arrest admitted to the Department of Emergency Medicine of a tertiary-care facility after transport with ongoing chest compression were retrospectively analysed. Multivariate analysis of epidemiological variables, treatment, blood gas values on admission, cause of arrest, and location of arrest was performed to find factors that were predictive for favourable long-term outcome (6-month survival, best cerebral performance category 1 or 2). RESULTS: Over 15 yr (1991-2006), a total of 2643 patients were treated after cardiac arrest. Of these, 327 patients received chest compressions during transport and were analysed (out-of-hospital cardiac arrest: n=244, in-hospital: n=83; the remaining 2316 patients were either stabilized before transport or suffered their arrest in our department). Return of spontaneous circulation was achieved in 31% of patients (n=102). Of these, 19 (19%) had favourable long-term outcome (6% of total). Independent predictors of good outcome were age, witnessed arrest, amount of epinephrine, and initial shockable rhythm. Among the patients with cardiac origin of arrest, 11 out of 197 patients (6%) survived; pulmonary origin, 4 out of 46 patients (9%); hypothermic arrest, 1 of 10 patients (10%); and intoxications, one out of nine patients (11%). CONCLUSIONS: Post-resuscitation care in patients who receive CPR during transport is not futile. Once restoration of spontaneous circulation is established, one out of five patients will have good long-term outcome.

Hyperthermia after cardiac arrest is associated with an unfavorable neurologic outcome.

BACKGROUND: Moderate elevation of brain temperature, when present during or after ischemia, may markedly worsen the resulting injury. OBJECTIVE: To evaluate the impact of body temperature on neurologic outcome after successful cardiopulmonary resuscitation. METHODS: In patients who experienced a witnessed cardiac arrest of presumed cardiac cause, the temperature was recorded on admission to the emergency department and after 2, 4, 6, 12, 18, 24, 36, and 48 hours. The lowest temperature within 4 hours and the highest temperature during the first 48 hours after restoration of spontaneous circulation were recorded and correlated to the best-achieved cerebral performance categories' score within 6 months. RESULTS: Over 43 months, of 698 patients, 151 were included. The median age was 60 years (interquartile range, 53-69 years); the estimated median no-flow duration was 5 minutes (interquartile range, 0-10 minutes), and the estimated median low-flow duration was 14.5 minutes (interquartile range, 3-25 minutes). Forty-two patients (28%) underwent bystander-administered basic life support. Within 6 months, 74 patients (49%) had a favorable functional neurologic recovery, and a total of 86 patients (57%) survived until 6 months after the event. The temperature on admission showed no statistically significant difference (P =.39). Patients with a favorable neurologic recovery showed a higher lowest temperature within 4 hours (35.8 degrees C [35.0 degrees C-36.1 degrees C] vs 35.2 degrees C [34.5 degrees C-35.7 degrees C]; P =.002) and a lower highest temperature during the first 48 hours after restoration of spontaneous circulation (37.7 degrees C [36.9 degrees C-38.6 degrees C] vs 38.3 degrees C [37.8 degrees C-38.9 degrees C]; P<.001) (data are given as the median [interquartile range]). For each degree Celsius higher than 37 degrees C, the risk of an unfavorable neurologic recovery increases, with an odds ratio of 2.26 (95% confidence interval, 1.24-4.12). CONCLUSION: Hyperthermia is a potential factor for an unfavorable functional neurologic recovery after successful cardiopulmonary resuscitation.

Acute renal failure after successful cardiopulmonary resuscitation.

OBJECTIVE: To assess the frequency and independent predictors of severe acute renal failure in patients resuscitated from out-of-hospital ventricular fibrillation cardiac arrest. DESIGN: A cohort study with a minimum follow-up of 6 months. SETTING: Emergency department of a tertiary care 2200-bed university hospital. PATIENTS AND PARTICIPANTS: Consecutive adult (> 18 years) patients admitted from 1 July 1991 to 31 October 1997 after witnessed ventricular fibrillation out-of-hospital cardiac arrest and successful resuscitation. MEASUREMENTS AND RESULTS: Acute renal failure was defined as a 25% decrease of creatinine clearance within 24 h after admission. Out of 187 eligible patients (median age 57 years, 146 male), acute renal failure occurred in 22 patients (12%); in 4 patients (18%) renal replacement therapy was performed. Congestive heart failure (OR 6.0, 95% CI 1.6-21.7; p = 0.007), history of hypertension (OR 4.4, 95% CI 1.3-14.7; p = 0.02) and total dose of epinephrine administered (OR 1.1, 95% CI 1.0-1.2; p = 0.009) were independent predictors of acute renal failure. Duration of cardiac arrest, pre-existing impaired renal function and blood pressure at admission were not independently associated with renal outcome. CONCLUSIONS: Severe progressive acute renal failure after cardiopulmonary resuscitation (CPR) is rare. Pre-existing haemodynamics seem to be more important for the occurrence of acute renal failure than actual hypoperfusion during resuscitation.

Hemodynamic effects of active compression-decompression after prolonged CPR.

BACKGROUND: This study was designed to test the effects of active compression-decompression (ACD) versus standard (STD) cardiopulmonary resuscitation (CPR) on hemodynamics after prolonged cardiac arrest (CA). METHODS AND RESULTS: After nontraumatic prehospital CA, 21 patients were resuscitated in a prospective nonblinded setting sequentially with STD and ACD CPR at the emergency department, if it had not been possible to achieve restoration of spontaneous circulation (ROSC) before admission. The compression rate was 80/min with a 50% duty cycle, and 1 mg epinephrine was given every 5th min. Invasive arterial, central venous pressure and end tidal CO2 (ETCO2) were monitored. Comparing coronary perfusion pressure (CoPP) and ETCO2, no significant differences between STD and ACD CPR were found. In 3 cases ROSC could be achieved for a short time. CONCLUSIONS: In our study, a comparison of STD and ACD CPR revealed no significant differences in coronary perfusion pressures and ETCO2. We conclude that after prolonged CA, ACD CPR does not provide an apparent hemodynamic advantage over STD CPR.

Mild resuscitative hypothermia and outcome after cardiopulmonary resuscitation.

Recovery without residual neurological damage after cardiac arrest with global cerebral ischemia is still a rare event. Severe impairment of bodily or cognitive functions is often the result. The individual, emotional, and social aspects of brain damage and rehabilitation are seldom taken into account. Efforts to improve the prevention of brain damage immediately after successful resuscitation of patients are missing. The efficacy of hypothermia in preserving neurologic function when instituted before and during certain no-flow cardiovascular states has been well documented both clinically and experimentally since the 1950s. Most studies have used moderate (28-33 degrees C) to deep (20-28 degrees C) hypothermia to demonstrate these protective effects. Considering the use of hypothermia for preservation and resuscitation, the lack of controlled outcome trials, the long period of time required to reach therapeutic hypothermia, and the incidence of rewarming complications such as infection, arrhythmia, and coagulopathy have made it difficult to apply these methods to emergency situations such as cardiac arrest. Recent experimental evidence in dogs has shown that hypothermia induced after cardiac arrest does indeed mitigate the effects of the postresuscitation syndrome and improves neurologic function and reduces histologic brain damage. More importantly, such benefits can be demonstrated with mild (34-36 degrees C) hypothermia, thus minimizing complications and requiring less time for induction of hypothermia. Ice water nasal lavage, direct carotid infusion of cold fluids, use of a cooling helmet, and peritoneal cooling are promising techniques for clinical cerebral cooling. External auditory canal temperature (e.g., tympanic membrane temperature changes) could provide an approximation to brain temperatures. For accurate temperature monitoring, however, a central pulmonary artery thermistor probe should be inserted. Temperature monitoring is needed to avoid temperature < 30 degrees C. Mild hypothermia may prove to be an important and secure component for cerebral preservation and resuscitation during and after global ischemia; it may also prove to be a useful method of cerebral resuscitation after global ischemic states, thereby promoting the prevention of neuromental diseases.

Treatment of alcoholism and concomitant drugs of abuse.

It has been proposed that concomitant substances of abuse may have additive or synergistic properties such that alcoholics using other substances of abuse concurrently may have a harder time giving up alcohol than alcoholics abusing only alcohol. The present study surveyed 291 alcoholics in an alcohol treatment program and 86 social drinker controls matched on age, education, SES and gender. Alcohol consumption, smoking, coffee intake, other substances of abuse. Beck depression and Spielberger Anxiety (State) were measured. Alcoholics drank significantly more alcohol than did social drinkers per day (350.19 cc versus 28.08 cc, p less than 0.001), consumed more caffeine/day (486.3 mg versus 339.9 mg, p less than 0.002), smoked more cigarettes/day (27.8 versus 12.8, p less than 0.001), were more depressed (16.8 versus 4.4 (Beck), p less than 0.0001), had lower internal locus of control scores (37.6 versus 39.7, p less than 0.005), had higher scores on control by chance (22.7 versus 20.2, p less than 0.03) and were significantly more anxious (52.5 versus 33.9 on Spielberger's State Inventory p less than 0.0001). Some patients used stimulants, tranquilizers, depressants, narcotics or toluene. Only 3/258 abused alcohol without using other drugs. Results support earlier studies showing strong associations between alcohol and smoking and between alcohol and caffeine consumption. The alcoholic abusing only alcohol is very rare. Treatment programs need to pay attention to concomitant drugs of abuse.

Tribal affiliation and prevalence of alcohol problems.

Differences in tribal culture, history and settlement may explain why Indians in eastern Oklahoma have lower rates of alcohol-related arrests and deaths than do Indians in the western part of the state.

Systemic and cerebral oxygen extraction after human cardiac arrest.

The aim of this study was to observe cerebral and systemic oxygen extraction after human cardiac arrest with return of spontaneous circulation. Eight adult patients after non-traumatic, cardiac arrest were included. Cerebral and systemic oxygen extraction ratios were measured together with haemodynamic variables beginning 2 hours after cardiac arrest and every 4 hours thereafter until 24 hours. Between 2 and 12 hours after cardiac arrest cerebral oxygen extraction values ranged from very low over normal to very high. In the further course these values were reduced until 24 hours in six patients. Two patients who were still alive after 6 months, both severely mentally disabled, had a higher cerebral oxygen extraction ratios in comparison with non-survivors. Systemic oxygen extraction seemed to vary more than the cerebral oxygen extraction. The two long-term survivors had normal to supranormal values from 8 to 24 hours. In conclusion cerebral oxygen extraction was higher in long-term cardiac arrest survivors than in non-survivors between 12 and 24 hours after the event. Further, a better quality of neurological recovery was associated with higher cerebral oxygen extraction. Systemic oxygen extraction was also impaired, but to a lesser extent, especially in long-term survivors.

Asystole during dipyridamole infusion in patients without coronary artery disease or beta-blocker therapy.

The authors report two patients without coronary artery disease who experienced asystole during the IV infusion of dipyridamole on routine TI-201 myocardial perfusion imaging and review the literature for possible explanations of this rare side effect. Until now, this side effect was only reported in patients with coronary artery disease or beta-blocker therapy. Yet, the cases lacked both concomitant factors and autonomic dysregulation is suggested as a cause for asystole.

[Intravenous urapidil versus sublingual nifedipine in the treatment of hypertensive emergencies]. / Urapidil per via endovenosa verso nifedipina sublinguale nel trattamento delle urgenze ipertensive.

In a 6-month prospective study, the efficacy and safety of urapidil and nifedipine in an out-patient population with hypertensive urgencies (systolic blood pressure > 200 mmHg; diastolic blood pressure > 110 mmHg) was investigated. Response to treatment was defined as a stable reduction of systolic blood pressure below 180 mmHg and diastolic blood pressure below 100 mmHg 15 minutes after application of a single dose of either 25 mg urapidil intravenously (N = 26) or 10 mg nifedipine sublingually (N = 27). If the blood pressure was still elevated, a second dose of 10 mg nifedipine or 12.5 mg urapidil was given, and blood pressure response was evaluated 15 minutes after application of the second dose according to the aforementioned criterias. After the first application of nifedipine, 19 (70%) responders have been observed. Eight patients needed an additional 10 mg of nifedipine. In four of these patients, no reduction of blood pressure was observed after a second dose of nifedipine. In contrast, 24 (92%) patients responded well to the first application of 25 mg of urapidil. Two patients required a second dose of 12.5 mg of urapidil, but no nonresponder to urapidil was observed. No severe side-effects were noted in both groups. Intravenous urapidil is a highly effective drug in the treatment of hypertensive urgencies and is more effective than sublingual nifedipine, because the number of patients treated successfully was significantly higher.

Reaction time performance with and without backscatter from intense pulse light.

Twenty male graduate students, 22-30 years of age, were asigned by a table of randome numbers to two groups, and visual reaction time performance with and without backscatter was measured. The subjects' task was to observe a 5 cm dial face whose needle deflected 2 mm either left or right of center. Meter deflections were either preceded by 10 light pulse from a Grimes "360 strobe or they were not preceded by light pulses. Two measures of performance were recorded: 1) voice reaction time in milliseconds, and 2) errors. Error rate (3.5%) did not discriminate between groups or conditions. Reaction time was almost twice as long with backscatter than without backscatter (1,556 ms and 854 ms, respectively). This RT increase was highly reliable statistically. Variability of RT performance increased markedly with backscatter. In practical terms, the results suggest that the effects of backscatter could induce a cumulative performace decrement in instrument scanning which might endanger air safety.

[Bladder dysfunction due to spinal cord compression. Treatment modes and results]. / Blasendysfunktion bei spinaler Kompression.Therapieformen und Ergebnisse.

Bladder dysfunction is often observed in cases of spinal compression and is commonly caused by spinal tumors, trauma, or degenerative spine disease. Microsurgical decompression is the most important therapy. The earlier microsurgery is performed, the better the chances are for recovery of bladder function.

Effects of sex steroids on ethanol pharmacokinetics and autonomic reactivity.

Several lines of evidence indicate that female sex steroids, especially estrogen, interact with ethanol pharmacokinetics. Both animal and human studies are consistent in indicating that voluntary intake of alcohol decreases with increasing estrogen concentrations. Such effects are equivocal with progesterone and nonexistent with testosterone. There is some suggestion that estrogen modulates monoamine oxidase activity and via that mechanism alters sympathetic nervous system tone. Alterations in sympathetic nervous system tone, in turn, can alter gastric motility and absorption of alcohol from stomach and intestines. Several types of studies, both animal and human, indicate that high estrogen concentrations also impair ethanol metabolism. At present the exact mechanism of action for this effect is not known. Future studies investigating this aspect are indicated. At present the effect of sex steroids on performance and its interaction with alcohol do not show a clear relationship. There are contrary pieces of information both for and against the view that menstrual cycle, performance and alcohol interact.

Bidirectional changes in digital skin temperature using biofeedback in a cold room.

The ability to increase digital skin temperature (DST) of cold extremities or to prevent decreases in DST in a cold environment may be useful clinically in the treatment of Raynaud's disease or in the alleviation of the effects of stressful stimuli. Ten Ss, each of whom participated in five sessions, were studied in a room at 20 degrees C. Each session was divided into 5-minute trials during which Ss either received auditory biofeedback of DST and tried to increase or decrease DST or received no feedback and merely sat quietly (Baseline trials). There were significant changes in DST during Baseline trials; these changes were different at different times during the session. The difference between Increase and Decrease trials was significant. The DST decrease during Decrease trials was significantly different from the change during corresponding Baseline trials, while the Increase trials, while the Increase trial DST, although of the same magnitude as the decrease trial, did not differ significantly from its corresponding Baseline trials DST.

Effects of elevated female sex steroids on ethanol and acetaldehyde metabolism in humans.

Two groups (n = 20 each for pill and no pill groups) of young female social drinkers were tested with an acute ethanol dose (0.52 g/kg) as a 20% solution in water. Ethanol pharmacokinetics and acetaldehyde were repeatedly assayed from breath by a gas chromatograph. Cardiovascular indices were concurrently recorded. Groups did not differ on ethanol pharmacokinetics. However, the group on birth control pills reached a significantly higher acetaldehyde concentration than did the group of normally cycling females not on birth control pills (3.26 ng/ml vs. 1.45 ng/ml). Further, the pill (P) group showed significantly greater vasodilation 20 min postdrink as indexed by ear lobe plethysmography than did the no pill (NP) group (P = 160.3% vs. NP = 113.9%). Results are consistent with the interpretation that female sex steroids modulate aldehyde dehydrogenase function. Practical implications are that females with elevated steroids (either pregnant or on birth control pills) may be at greater risk for toxic effects of ethanol consumption.

Menstrual cycle and oral contraceptive effects on alcohol pharmacokinetics in caucasian females.

We investigated the relationship between oral contraceptives, day of menstrual cycle and alcohol pharmacokinetics in 20 Caucasian females. Peak blood alcohol concentration was higher and clearance rates were faster on Day 1 (when hormonal levels were low) than on Day 24. No pill subjects reached a higher BAC than did pill subjects on Day 24 but not on Day 1. Clearance rates of no pill subjects were faster on Day 24 than for pill subjects. Results suggest that female sex steroids, directly or indirectly, reduce peak BAC and slow clearance rates.

Racial differences in circadian variation of ethanol metabolism.

In two experiments, independent groups of male social drinkers were administered equal doses of ethanol per unit of body weight (0.66 ml/kg) at different times during the day. Peak blood alcohol concentration (BAC) was achieved, and the time taken to return to a BAC of 20 mg/100 ml and the rate of ethanol metabolism per hour were determined.