[Aspects of intensive care medicine in emergency medicine]. / Intensivmedizinische Aspekte in der Notfallmedizin.

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.

A novel PCR-based point-of-care method facilitates rapid, efficient, and sensitive diagnosis of influenza virus infection.

OBJECTIVE: 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. PATIENTS AND METHODS: 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. RESULTS: 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 (p <0.01). 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; p <0.01). CONCLUSION: 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.

Point-of-care PT and aPTT in patients with suspected deficiencies of coagulation factors.

INTRODUCTION: There are several clinical settings and patient conditions especially in intensive care units, emergency departments, and operating theaters, where the coagulation status of a patient must be known immediately and point-of-care (POC) systems are beneficial due to low time to result. METHODS: This noninterventional, single-blinded, multicenter study with prospectively collected whole blood samples was performed to evaluate the diagnostic accuracy of the CoaguChek PT Test (POC PT) and CoaguChek aPTT Test (POC aPTT) compared to standard laboratory testing in patients with suspected deficiencies of coagulation factors. RESULTS: In total, 390 subjects were included. Both POC PT and POC aPTT showed concordance with the laboratory PT and aPTT. Lot-to-lot variation was below 2% both for POC PT and for POC aPTT. The mean relative difference of capillary blood compared to venous blood was 0.2 % with POC PT and 8.4% with POC aPTT. The coefficients of variation for repeatability of POC PT using whole blood were found to be between 2% and 3.6%. CONCLUSION: Our findings suggest reliable quantitative results with this POC system to support on-site decision-making for patients with suspected deficiencies of coagulation factors in acute and intensive care.

Cerebral and Peripheral Metabolism to Predict Successful Reperfusion After Cardiac Arrest in Rats: A Microdialysis Study.

BACKGROUND: In clinical practice, monitoring of the efficacy of resuscitation can be challenging. The prediction of cerebral and overall outcome in particular is an unmet medical need. Microdialysis is a minimally invasive technique for the continuous determination of metabolic parameters in vivo. Using this technique, we set out to establish a model allowing for concomitant determination of cerebral and peripheral metabolism in a cardiac arrest setting in rodents. METHODS: Microdialysis settings were optimized in vitro and then used in male Sprague-Dawley rats. Probes were implanted into the CA1 region of the right hippocampus and the right femoral vein. With a time interval of 8 min, glucose, lactate, pyruvate, and glutamate levels were determined during baseline conditions, untreated ventricular fibrillation cardiac arrest, cardiopulmonary resuscitation (CPR), reperfusion, and death. RESULTS: In 16 rodents, restoration of spontaneous circulation was achieved in seven animals. Characteristic metabolic changes were evident during cardiac arrest and reperfusion with both probes. Ischemic patterns in peripheral compartments were delayed and more variable compared to the changes in cerebral metabolism highlighting the importance of cerebral metabolic monitoring. Microdialysis allowed distinguishing between survivors and non-survivors 8 min after termination of CPR. Cerebral glutamate showed a trend toward higher levels in non-survivors during CPR. CONCLUSIONS: We established a new rodent model for research in hypoxic ischemic encephalopathy. This setting allows to investigate the impact of resuscitation methods on cerebral and peripheral metabolism simultaneously. The present model may be used to evaluate different resuscitation strategies in order to optimize brain survival in future studies.

A prediction tool for initial out-of-hospital cardiac arrest survivors.

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 circulation 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 variables. 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.

Cardiac arrest due to accidental hypothermia--a 20 year review of a rare condition in an urban area.

BACKGROUND: Accidental hypothermic cardiac arrest is associated with unfortunate prognosis and large studies are rare. We therefore have performed an outcome analysis in patients that were admitted to Vienna University Hospital with the diagnosis of accidental hypothermic cardiac arrest. METHODS: This study employed a retrospective outcome analysis of prospectively collected data in a selected cohort of hypothermic cardiac arrest patients. We screened 3800 cardiac arrest patients, treated at our department between 1991 and 2010, for eligibility. Inclusion criteria were cardiac arrest with a body core temperature ≤28 °C and return of spontaneous circulation. RESULTS: A total of 18 patients who achieved return of spontaneous circulation were analysed. Nine patients (50%) achieved survival in good neurologic condition (defined as cerebral performance category CPC 1 or 2). Accidental hypothermia with consecutive cardiac arrest was caused by intoxication in most cases (67%). These patients had a better outcome than patients with other causes of accidental hypothermic cardiac arrest (OR=28; 95%KI 2-37.9; p<0.01). Hypothermia associated typical ECG changes after return of spontaneous circulation (Osborne waves) were more frequent in the surviving population (OR 16; 95%KI 1.3-19.5; p=0.05). CONCLUSIONS: Accidental hypothermic cardiac arrest in a central European urban area is rare. Prognosis was excellent in patients where hypothermic cardiac arrest was caused by intoxication.

Massive pulmonary embolism leading to cardiac arrest is associated with consumptive coagulopathy presenting as disseminated intravascular coagulation.

SUMMARY BACKGROUND: A consumptive coagulopathy resembling disseminated intravascular coagulation (DIC) has been seen in patients with massive pulmonary embolism (PE). We hypothesized that a DIC-like condition is relevant in patients whose pulmonary embolism leads to cardiopulmonary arrest and cardiopulmonary resuscitation (CPR). METHODS: This hypothesis was tested by the use of a database consisting of all cases of PE diagnosed at the Department of Emergency Medicine from June 1993 to October 2007. Out of 1018 cases with PE, 113 patients underwent CPR. In this cohort study, the resuscitated patients were compared with those with PE but without CPR. RESULTS: Patients with PE and CPR had 3-fold higher D-dimer, prolonged prothrombin time (PT), reduced platelet counts and lower fibrinogen and antithrombin (AT) levels compared with PE patients without cardiac arrest (P < 0.001 for all). Among patients with PE and CPR, D-dimer was abnormal in 100%, PT in 44%, AT in 53%, fibrinogen in 19% and platelets in 25%. In comparison, PE without CPR was associated with abnormal D-dimer in 99%, abnormal PT in 15%, low AT in 6%, low fibrinogen in 1% and low platelets in 2%. Nine per cent of the resuscitated patients had a DIC score >or= 5, indicating overt DIC. The DIC score highly correlated with 1-year and in-hospital mortality. CONCLUSIONS: Massive PE leading to CPR is associated with consumptive coagulopathy and overt DIC. In resuscitated patients, DIC markers may indicate pulmonary embolism as the underlying cause of arrest.

Troponin T predicts in-hospital and 1-year mortality in patients with pulmonary embolism.

We aimed to determine the prognostic value of troponin T (TNT) for in-hospital and 1-yr mortality in a large sample of patients with pulmonary embolism (PE). Patients presenting at the emergency department of a tertiary care centre from January 1998 to December 2006 with PE were included. A blood sample was taken at the time of presentation. To determine in-hospital and 1-yr mortality, data from the hospital records and the national death register were used. TNT was determined in 563 out of 737 patients with proven PE. TNT was elevated (>0.03 ng x mL(-1)) in 27%. In-hospital survival was 79% in TNT-positive patients compared with 94% in TNT-negative patients (p<0.001). 1-yr survival was 71% in TNT-positive patients compared with 90% in TNT-negative patients (p<0.001). Elevated TNT levels meant a four-times higher risk of in-hospital death and a three-times higher risk of 1-yr mortality, even after adjustment for the other most important risk factors of death in this population. Elevated TNT independently predicts in-hospital and 1-yr mortality in patients with acute PE.

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.

Human heart-type fatty-acid-binding protein as a point-of-care test in the early diagnosis of acute myocardial infarction.

BACKGROUND: At very early stages of acute myocardial infarction (AMI), highly sensitive biomarkers are still lacking. AIM: To evaluate the utility of human heart-type fatty acid-binding protein (h-FABP) for early diagnosis of AMI. DESIGN: Prospective diagnostic study. METHODS: Consecutive patients presenting to the emergency department with chest pain or dyspnoea within 24 h of symptom onset were included. At presentation, the h-FABP test result was compared to the standard diagnostic work-up, including repeated ECG and troponin T measurements. Sensitivity analysis was performed for inconclusive tests. RESULTS: We enrolled 280 patients presenting to hospital with a median symptom onset of 3 h (IQR 2-6 h): 109 (39%) had AMI. At presentation, h-FABP had a sensitivity of 69% (95%CI 59-77) and specificity of 74% (95%CI 66-80); 45 tests were false-positive and 34 were false-negative. Omitting inconclusive tests increased sensitivity and specificity only slightly. AMI was identified significantly earlier by h-FABP than by troponin T (24 vs. 8 patients, p=0.005). DISCUSSION: Although h-FABP can help to detect myocardial damage at an early stage in patients with chest pain or dyspnoea, it appears unsuitable as a stand-alone test for ruling out AMI.

Compromising bradycardia: management in the emergency department.

AIM OF THE STUDY: Bradycardia may represent a serious emergency. The need for temporary and permanent pacing is unknown. METHODS: We analysed a registry for the incidence, symptoms, presenting rhythm, underlying mechanism, management and outcome of patients presenting with compromising bradycardia to the emergency department of a university hospital retrospectively during a 10-year period. RESULTS: We identified 277 patients, 173 male (62%), median age 68 (IQR 58-78), median ventricular rate 33 min(-1) (IQR 30-40). The leading symptoms were syncope [94 (33%)], dizziness [61 (22%)], collapse [46 (17%)], angina [46 (17%)] and dyspnoea/heart failure [30 (11%)]. The initial ECG showed high grade AV block [134 (48%)], sinus bradycardia/AV block [46 (17%)], sinuatrial arrest [42 (15%)], bradycardic atrial fibrillation [39 (14%)] and pacemaker-failure [16 (6%)]. The underlying mechanisms were primary disturbance of cardiac automaticity and/or conduction [135 (49%)], adverse drug effect [58 (21%)], acute myocardial infarction [40 (14%)], pacemaker failure [16 (6%)], intoxication [16 (6%)] and electrolyte disorder [12 patients (4%)]. In 107 (39%) patients bed rest resolved the symptoms. Intravenous drugs to increase ventricular rate were given to 170 (61%) patients, 54 (20%) required additional temporary transvenous/transcutaneous pacing. Two severely intoxicated patients could be stabilised only by cardiopulmonary bypass. A permanent pacemaker was implanted in 137 patients (50%). Mortality was 5% at 30 days. CONCLUSION: In our cohort, about 20% of the patients presenting with compromising bradycardia required temporary emergency pacing for initial stabilisation, in 50% permanent pacing had to be established.

Platelet function in patients with acute coronary syndrome (ACS) predicts recurrent ACS.

BACKGROUND: Platelet hyperfunction contributes to acute coronary syndromes (ACS). Thus, we hypothesized that platelet function under high shear stress predicts recurrent ACS during long-term follow-up of ACS patients. PATIENTS AND METHODS: Consecutive ACS patients (n = 208) were prospectively followed-up for an average of 28 months. Platelet function was measured with the platelet function analyzer (PFA-100; Dade Behring, Marburg, Germany) at baseline for collagen/adenosine diphosphate closure times (CADP-CT) and for collagen/epinephrine closure times (CEPI-CT) after infusion of a uniform dose of 250 mg aspirin. RESULTS: Of the conventional risk factors, only the prevalence of diabetes was higher in ACS patients with re-events. However, use of clopidogrel and use of beta blockers were also slightly lower in patients with re-events (P < 0.05). The unadjusted risk hazard ratio (HR) for re-events was 3.3 [95% confidence interval (95% CI): 1.4-7.4; P = 0.005] in those patients with the shortest CADP-CT values (lowest quartile). Similarly, the risk was 2.0-fold higher (95% CI: 1.1-3.6; P = 0.02) in ACS patients with CEPI-CT < 300 s as compared with CEPI-CT >or = 300 s. Inclusion of diabetes, clopidogrel and beta blockers in a multivariate Cox regression model enhanced the predictive value of CEPI-CT (HR: 2.7). Inclusion of von Willebrand factor levels did not alter the HR for recurrent ACS (HR: 2.1; 95% CI: 1.1-5.2; P = 0.03) for CEPI-CT < 300 s, but reduced the HR for CADP-CT (HR: 2.8, 95% CI: 0.8-9.8; P = 0.11). CONCLUSION: Shortened CT values reflect biologically relevant platelet hyperfunction in patients with ACS because they predict recurrent ACS.

The role of Chlamydia pneumoniae in human aortic disease-a hypothesis revisited.

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

Assessment of the safety and efficacy of the novel tetrapeptide ITF-1697 on infarct size after primary PTCA in acute myocardial infarction: a randomised, placebo-controlled pilot trial.

OBJECTIVE AND DESIGN: ITF-1697 is a chemically modified LYS-Pro tetrapeptide that corresponds to sequence 113-116 of C-reactive protein. Previous studies have demonstrated significant anti-ischaemic and antithrombotic activity of this tetrapeptide. The aim of this prospective, randomised, double-blind study in patients with acute myocardial infarction undergoing coronary revascularisation was to investigate the safety and efficacy of prolonged intravenous (i.v.) infusion of ITF-1697 at different doses on reduction of infarct size, as assessed by radionuclide imaging. PATIENTS AND METHODS: Injection of technetium-99m (Tc99m) was followed by injection of ITF-1697 or placebo bolus and 24-hour infusion in patients with acute myocardial infarction. Percutaneous transluminal coronary angioplasty (PTCA) was performed and succeeded by radionuclide imaging. A second Tc99m injection and radionuclide imaging was performed 7 days after the PTCA or at hospital discharge. The primary efficacy variable was set as the ratio between the myocardial salvage (size of the initial perfusion defect minus the final size of the infarct) and the initial area at risk (myocardial salvage index). Twenty-three patients were included in the study protocol, of whom nine were randomised to the ITF-1967 dose 1 group (loading dose 55 microg/kg i.v., infusion 0.5 microg/kg/min for 24 hours), a further nine to the ITF-1697 dose 2 group (loading dose 110 microg/kg i.v., infusion 1.0 microg/kg/min for 24 hours), and the remaining five to the placebo group. RESULTS: The defined safety variables (adverse events, laboratory parameters, vital signs and clinical outcome) exhibited no relationship to the application of ITF-1697. Comparison of myocardial salvage index revealed no statistical difference within the three groups (p = 0.65). Hypothesis testing on the myocardial salvage as well as the empirical and bias-correct confidence intervals (CIs) revealed significant differences between the ITF-1697 dose 2 group and the placebo group (95% CI 2.75, 18.07). CONCLUSION: The application of the tetrapeptide ITF-1697 during acute myocardial infarction to reduce infarct size was found to be feasible and safe in this pilot trial.

[Patients in circulatory shock in emergency and intensive care units]. / Der Schockpatient in der Notaufnahme und auf der Intensivstation.

Patients in circulatory shock are being treated in emergency as well as in intensive care units. Despite different resources in personnel and technical equipment in both areas, patient management has to follow standardized protocols. Diagnosis of shock has to be based upon objective parameters (lactate, pH, standard bicarbonate, arterial blood pressure, central venous pressure, cardiac output). Aim of shock treatment is restoration of adequate tissue perfusion with the use of fluid and red blood cell replacement, vasoconstrictors, inotropics, substances improving microcirculation, and mechanical circulatory support. Target values are: mean arterial blood pressure >80 mmHg, central venous pressure >6 mmHg, hemoglobin >8.0 g/dl, cardiac index >3.5 l/min/m(2). New concepts for optimization of hemodynamics and hematocrit, cortisone, intraaortic balloon counterpulsation, mechanical ventilation with low tidal volumes, and intensive insulin therapy are discussed. However, as shock reversal is dependent on its reason, clarification and treatment of the shock causing event has to be performed with highest priority.

Life after death: posttraumatic stress disorder in survivors of cardiac arrest--prevalence, associated factors, and the influence of sedation and analgesia.

OBJECTIVE: Cardiac arrest is possibly one of the most traumatizing conditions for patients, but to date, its influence on psychic morbidity remains unknown. Posttraumatic stress disorder is a unique symptom configuration after an extreme event consisting of intrusion re-experiencing, avoidance and numbness, and hyperarousal symptoms. We studied a) the prevalence of posttraumatic stress disorder (PTSD) in long term survivors of cardiac arrest; b) the role of specific stress factors related to cardiac arrest for the development of PTSD; and c) the influence of sedation and analgesia during or after cardiac arrest on the occurrence of PTSD. DESIGN: Prospective, cohort study. SETTING: University teaching hospital. PATIENTS: Analysis was performed in cardiac arrest survivors who were discharged with favorable neurologic outcome during an 8-yr period (1991-1999). INTERVENTIONS: All patients received the Davidson Trauma Score for the assessment of PTSD and a modified German version of the EuroQol questionnaire for assessment of quality of life. Cardiac arrest circumstances and administration of sedation and analgesia were assessed. MEASUREMENTS AND MAIN RESULTS: Of 1,630 initially resuscitated patients, 270 patients were discharged with good neurologic outcome. A total of 226 patients were contacted, and 143 patients (63% of all eligible patients) completed the study. Mean time from cardiac arrest to follow up was 45 months (range, 24-66). Thirty-nine patients (27%; 95% confidence interval, 21% to 35%) had a Davidson Trauma Score >40 and fulfilled criteria for PTSD. Patients with PTSD had a significantly lower quality of life. The only independent risk factor for the development of PTSD was younger age. There was no difference between patients with or without PTSD regarding the use of sedation and analgesia during or after cardiac arrest. CONCLUSION: The prevalence of PTSD in cardiac arrest survivors is high. Besides younger age, neither clinical factors nor the use of sedation and analgesia were associated with development of PTSD.

Major bleeding complications after cardiopulmonary resuscitation: impact of thrombolytic treatment.

OBJECTIVE: The risk of bleeding complications caused by thrombolysis in patients with cardiac arrest and prolonged cardiopulmonary resuscitation is unclear. We evaluate the complication rate of systemic thrombolysis in patients with out-of-hospital cardiac arrest caused by acute myocardial infarction, especially in relation to duration of cardiopulmonary resuscitation. DESIGN: The study was designed as retrospective cohort study, the risk factor being systemic thrombolysis and the end-point major haemorrhage, defined as life-threatening and/or need for transfusion. Over 10.5 years, emergency cardiac care data, therapy, major haemorrhage and outcome of 265 patients with acute myocardial infarction admitted to an emergency department after successful cardiopulmonary resuscitation were registered. RESULTS: We observed major haemorrhage in 13 of 132 patients who received thrombolysis (10%, 95% confidence interval 5-15%), five of these survived to discharge, none died because of this complication. Major haemorrhage occurred in seven of 133 patients in whom no thrombolytic treatment had been given (5%, 95% confidence interval 1-9%), two of these survived to discharge. Taking into account baseline imbalances between the groups, the risk of bleeding was slightly increased if thrombolytics were used (odds ratio 2.5, 95% confidence interval 0.9-7.4) but this was not significant (P = 0.09). There was no clear association between duration of resuscitation and bleeding complications (z for trend = 1.52, P = 0.12). Survival was not significantly better in patients receiving thrombolysis (odds ratio 1.6, 0.9-3.0, P = 0.12). CONCLUSIONS: Bleeding complications after cardiopulmonary resuscitation are frequent, particularly in patients with thrombolytic treatment, but do not appear to be related to the duration of resuscitation. In the light of possible benefits on outcome, thrombolytic treatment should not be withheld in carefully selected patients.

Acute phase reactants in patients with abdominal aortic aneurysm.

BACKGROUND: There is increasing evidence that an inflammatory process is present in abdominal aortic aneurysms (AAAs) to varying degrees. The aim of this study was to compare acute phase reactants in patients with asymptomatic AAA, symptomatic AAA without rupture and ruptured AAA. METHOD: Two hundred and twenty-five consecutive patients treated because of AAA were included in this case-control study. Polynomial logistic regression analysis was applied to compare admission C-reactive protein (CRP) and white blood count (WBC) measured in 111 asymptomatic outpatients, 52 symptomatic patients without rupture and 62 patients with rupture of the aneurysm. We adjusted for the potentially confounding effect of age, sex, haemoglobin levels and aneurysm diameter. RESULTS: Patients with symptomatic AAA and patients with ruptured AAA had significantly elevated CRP (p=0.002) and WBC (p<0.0001) levels compared to asymptomatic patients. There was no statistically significant difference in CRP and WBC between patients with symptomatic AAA and ruptured AAA. Median CRP values of asymptomatic, symptomatic and ruptured AAA were <0.5 (interquartile range (IQR) <0.5-0.85), 1.1(IQR <0.5-4.0) and 2.4 mg/dl (IQR 0.65-8.6), respectively, and median WBC values were 6.5 (IQR 5.5-8.0), 8.7 (IQR 6.8-11.2) and 13.2 (IQR 10.5-17.0), respectively. CONCLUSION: A significant elevation of CRP and WBC could be found in patients who presented with symptoms or rupture of an AAA. These indicators of inflammation were not observed in asymptomatic patients with AAA.