Computed Tomography to Exclude Cardiac Thrombus in Atrial Fibrillation-An 11-Year Experience from an Academic Emergency Department.

BACKGROUND: Computed tomography (CT) could be a suitable method for acute exclusion of left atrial appendage thrombus (LAAT) prior to cardioversion of atrial fibrillation (AF) and atrial flutter (AFL) at the emergency department. Our aim was to present our experiences with this modality in recent years. METHODS: This registry-based observational study was performed at the Department of Emergency Medicine at the Medical University of Vienna, Austria. We studied all consecutive patients with AF and AFL who underwent CT between January 2012 and January 2023 to rule out LAAT before cardioversion to sinus rhythm was attempted. Follow-ups were conducted by telephone and electronic medical records. The main variables of interest were the rate of LAAT and ischemic stroke at follow-up. RESULTS: A total of 234 patients (143 [61%] men; median age 68 years [IQR 57-76], median CHA2DS2-VASc 2 [IQR 1-4]) were analyzed. Follow-up was completed in 216 (92%) patients after a median of 506 (IQR 159-1391) days. LAAT was detected in eight patients (3%). A total of 163 patients (72%) in whom LAAT was excluded by CT were eventually successfully cardioverted to sinus rhythm. No adverse events occurred during their ED stay. All patients received anticoagulation according to the CHA2DS2-VASc risk stratification, and no patient had suffered an ischemic stroke at follow-up, resulting in an incidence risk of ischemic strokes of 0% (95% CI 0.0-1.2%). CONCLUSION: LAAT was rare in patients admitted to the ED with AF and AFL who underwent cardiac CT prior to attempted cardioversion. At follow-up, no patient had suffered an ischemic stroke. Prospective studies need to show whether this strategy is suitable for the acute treatment of symptomatic AF in the emergency setting.

[Layperson basic life support education in Austria: An overview]. / Laienreanimationstraining in Österreich: Eine Übersicht und Annäherung.

Early interventions of laypersons can improve the survival and neurological outcome in patients with out-of-hospital cardiac arrest. There are several organizations in Austria which train lay people in basic life support and raise awareness for sudden cardiac death. To obtain an overview of the various initiatives, a questionnaire was sent to 26 organizations, and 15 of the organizations (58%) replied. The geographical distribution of the organizations between rural and urban areas was illustrated in a map. Most of them are situated in a university city, resulting in accessibility disparities for individuals in urban and rural settings. Layperson resuscitation education in Austria is largely dependent on the individual commitments of volunteers. The time spent practicing chest compressions in resuscitation courses ranges from 25% to 90% of the total course time. Furthermore, reasons for a lack of scientific endeavours could be identified, and solutions are suggested. Through better networking between organizations and initiatives, more laypersons could be trained in the future, which would lead to improved survival chances for persons suffering from out-of-hospital cardiac arrest in Austria. Appropriate support by political bodies and public authorities is and will remain a key element.

Outcomes and potential for improvement in the prehospital treatment of penetrating chest injuries in a European metropolitan area: A retrospective analysis of 2009 - 2017.

BACKGROUND: Trauma is the leading cause of death in patients <45 years living in high-resource settings. However, penetrating chest injuries are still relatively rare in Europe - with an upwards trend. These cases are of particular interest to emergency medical services (EMS) due to available invasive treatment options like chest tube placement or resuscitative thoracotomy. To date, there is no sufficient data from Austria regarding penetrating chest trauma in a metropolitan area, and no reliable source to base decisions regarding further skill proficiency training on. METHODS: For this retrospective observational study, we screened all trauma emergency responses of the Viennese EMS between 01/2009 and 12/2017 and included all those with a National Advisory Committee for Aeronautics (NACA) score ≥ IV (= potentially life-threatening). Data were derived from EMS mission documentations and hospital files, and for those cases with the injuries leading to cardiopulmonary resuscitation (CPR), we assessed the EMS cardiac arrest registry and consulted a forensic physician. RESULTS: We included 480 cases of penetrating chest injuries of NACA IV-VII (83% male, 64% > 30 years old, 74% stab wounds, 16% cuts, 8% gunshot wounds, 56% inflicted by another party, 26% self-inflicted, 18% unknown). In the study period, the incidence rose from 1.4/100,000 to 3.5/100,000 capita, and overall, about one case was treated per week. In the cases with especially severe injury patterns (= NACA V-VII, 43% of total), (tension-)pneumothorax was the most common injury (29%). The highest mortality was seen in injuries to pulmonary vessels (100%) or the heart (94%). Fifty-eight patients (12% of total) deceased, whereas in 15 cases, the forensic physician stated survival could theoretically have been possible. However, only five of these CPR patients received at least unilateral thoracostomy. Regarding all penetrating chest injuries, thoracostomy had only been performed in eight patients. CONCLUSIONS: Severe cases of penetrating chest trauma are rare in Vienna and happened about once a week between 2009 and 2017. Both incidence and case load increased over the years, and potentially life-saving invasive procedures were only reluctantly applied. Therefore, a structured educational and skill retention approach aimed at both paramedics and emergency physicians should be implemented. TRIAL REGISTRATION: Retrospective analysis without intervention.

Prehospital emergency medicine research by additional teams on scene - Concepts and lessons learned.

While the initial minutes of acute emergencies significantly influence clinical outcomes, prehospital research often receives inadequate attention due to several challenges. Retrospective chart reviews carry the risk of incomplete and inaccurate data. Furthermore, prehospital intervention trials frequently encounter difficulties related to extensive training requirements, even during the planning phase. Consequently, we have implemented prospective research concepts involving additional paramedics and physicians directly at the scene during major emergency calls. Three concepts were used: (I) Paramedic field supervisor units, (II) a paramedic + physician field supervisor unit, (III) a special physician-based research car. This paper provides insights into our historical perspective, the current situation, and the lessons learned while overcoming certain barriers and using existing and novel facilitators. Our objective is to support other research groups with our experiences in their planning of upcoming prehospital trials.

Disparities in layperson resuscitation education: A scoping review.

BACKGROUND: The aim of this scoping review was to identify factors that would enable or hinder the opportunity for laypersons to undertake resuscitation education. METHODS: We searched PubMed, Ovid EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) to identify studies published from January 1, 1966 to December 31, 2022 including factors that could influence laypersons to undertake resuscitation education. Data regarding participant characteristics, interventions, and design and outcomes of included studies were extracted. RESULTS: Of the initially identified 6627 studies, 23 studies (20 cross-sectional and 3 cohort studies) were finally included. Among them, a wide variety of enablers and barriers were identified. High heterogeneity among studies was observed. We categorized factors into three themes: personal factors (age, sex, race, family status, language, prior experience of resuscitation, and immigration status), socioeconomic and educational factors (income, societal status, occupation and legislation, and educational attainment), and geographic factors (birthplace and habitancy). Several barriers were identified that affect laypersons from participating in resuscitation training, such as personal factors like advanced age, lower socioeconomic and educational status, as well as being part of marginalized groups due to race or language barriers. On the other hand, several enablers identified in the study included prior experiences of witnessing someone collapsing, awareness of automated external defibrillators in public locations, certain occupations, or legal requirements for training. CONCLUSIONS: Various barriers and enablers were found to influence laypersons to participate in resuscitation training. To enhance layperson response to cardiac arrest, targeted initiatives that aim to eliminate barriers need to be initiated, and further research is required to explore factors relating to populations with special needs.

Cardiopulmonary resuscitation in low-resource settings: a statement by the International Liaison Committee on Resuscitation, supported by the AFEM, EUSEM, IFEM, and IFRC.

Most recommendations on cardiopulmonary resuscitation were developed from the perspective of high-resource settings with the aim of applying them in these settings. These so-called international guidelines are often not applicable in low-resource settings. Organisations including the International Liaison Committee on Resuscitation (ILCOR) have not sufficiently addressed this problem. We formed a collaborative group of experts from various settings including low-income, middle-income, and high-income countries, and conducted a prospective, multiphase consensus process to formulate this ILCOR Task Force statement. We highlight the discrepancy between current cardiopulmonary resuscitation guidelines and their applicability in low-resource settings. Successful existing initiatives such as the Helping Babies Breathe programme and the WHO Emergency Care Systems Framework are acknowledged. The concept of the chainmail of survival as an adaptive approach towards a framework of resuscitation, the potential enablers of and barriers to this framework, and gaps in the knowledge are discussed, focusing on low-resource settings. Action points are proposed, which might be expanded into future recommendations and suggestions, addressing a large diversity of addressees from caregivers to stakeholders. This statement serves as a stepping-stone to developing a truly global approach to guide resuscitation care and science, including in health-care systems worldwide.

PULS - Austrian Cardiac Arrest Awareness Association: An overview of a multi-tiered and multi-facetted regional initiative to save lives.

Background: Out-of-hospital cardiac arrest with subsequent cardiopulmonary resuscitation (CPR) still leads to dismal outcomes worldwide. The crucial gap between cardiac arrest and advanced life support can only be filled by bystander-CPR. However, knowledge and willingness of the public towards basic life support (BLS) remain low. Global and national initiatives for awareness building and CPR training have produced promising improvements, but an additional focus on regional initiatives might be necessary to truly implement change. Methods and results: In order to support other like-minded groups, we present a "coming of age" narrative review of PULS - Austrian Cardiac Arrest Awareness Association, along with a future outlook and "lessons learned". Interviews with past and present employees, members, and functionaries were conducted by the authors. Additionally, the organization's archives were assessed. Conclusion: Following current guidelines and the Utstein formula of survival, building a system to save lives is essential to achieve progress concerning cardiac arrest survival and outcomes. As kinds of "regional offices" of global resuscitation efforts, a network of individual local initiatives and organizations such as PULS can carry the respective messages, engage with local key figures of implementation, and keep up perpetual work for cardiac arrest awareness and BLS education.

Out of sight - Out of mind? The need for a professional and standardized peri-mission first responder support model.

First responders are an essential part of the chain (-mail) of survival as they bridge and reduce the time to first chest compressions and defibrillation substantially. However, in the peri-mission phase before and after being sent to a cardiac arrest, these first responders are in danger of being forgotten and taken for granted, and the potential psychological impact has to be remembered. We propose a standardized first responder support system (FRSS) that needs to ensure that first responders are valued and cared for in terms of psychological safety and continuing motivation. This multi-tiered program should involve tailored education and standardized debriefing, as well as actively seeking contact with the first responders after their missions to facilitate potentially needed professional psychological support.

Hemodynamic and Rhythmologic Effects of Push-Dose Landiolol in Critical Care-A Retrospective Cross-Sectional Study.

BACKGROUND: The highly ß1-selective beta-blocker Landiolol is known to facilitate efficient and safe rate control in non-compensatory tachycardia or dysrhythmia when administered continuously. However, efficacy and safety data of the also-available bolus formulation in critically ill patients are scarce. METHODS: We conducted a retrospective cross-sectional study on a real-life cohort of critical care patients, who had been treated with push-dose Landiolol due to sudden-onset non-compensatory supraventricular tachycardia. Continuous hemodynamic data had been acquired via invasive blood pressure monitoring. RESULTS: Thirty patients and 49 bolus applications were analyzed. Successful heart rate control was accomplished in 20 (41%) cases, rhythm control was achieved in 13 (27%) episodes, and 16 (33%) applications showed no effect. Overall, the heart rate was significantly lower (145 (130-150) vs. 105 (100-125) bpm, p < 0.001) in a 90 min post-application observational period in all subgroups. The median changes in blood pressure after the bolus application did not reach clinical significance. Compared with the ventilation settings before the bolus application, the respiratory settings including the required FiO2 after the bolus application did not differ significantly. No serious adverse events were seen. CONCLUSIONS: Push-dose Landiolol was safe and effective in critically ill ICU patients. No clinically relevant impact on blood pressure was noted.

The Impact of Preclinical High Potent P2Y12 Inhibitors on Decision Making at Discharge and Clinical Outcomes in Patients with Acute Coronary Syndrome.

BACKGROUND: Purinergic signaling receptor Y12 (P2Y12) inhibitors are a fundamental part of pharmacological therapy in acute coronary syndrome (ACS) for preventing recurrent ischemic events. Current guidelines support the use of prasugrel over ticagrelor-however, ticagrelor is widely used for preclinical loading during ACS due to its ease of administration. In this regard, it remains unknown whether the preclinical loading with P2Y12 inhibitors impacts decision-making for the long-term dual antiplatelet strategy, as well as cardiovascular outcomes, including re-percutaneous coronary intervention in real-world settings. METHODS: Within this population-based prospective observational study, all patients with ACS who received medical care via the Emergency Medical Service (EMS) in the city of Vienna between January 2018 and October 2020 were enrolled. Patients were stratified according to their P2Y12 inhibitor loading regimen. Subsequently, the association of P2Y12 inhibitor loading on long-term prescription at discharge and outcome was assessed. RESULTS: The entire study cohort consisted of 1176 individuals with ST-elevation myocardial infarction (STEMI), of whom 47.5% received prasugrel and 52.5% ticagrelor. The likelihood of adhering to the initial P2Y12 inhibitor strategy during the clinical stay was high for both ticagrelor (84%; OR: 10.00; p < 0.001) and prasugrel (77%; OR: 21.26; p < 0.001). During patient follow-up (median follow-up time three years), 84 (7.1%) patients died due to cardiovascular causes, and 82 (7.0%) patients required re-PCI. Notably, there was no difference in cardiovascular mortality (6.6% ticagrelor vs. 7.7% prasugrel) or re-PCI rates (6.6% ticagrelor vs. 7.3% prasugrel) addressing the P2Y12 inhibition strategy. CONCLUSION: We observed that, regardless of the initial antiplatelet inhibitor strategy, the in-hospital P2Y12 adherence was exceedingly high, and there was a minimal occurrence of switching to another P2Y12 inhibitor. Most importantly, no significant difference in cardiovascular death/re-PCI between ticagrelor and prasugrel-based preclinical loading has been observed. Consequently, the choice of high potent P2Y12 did not influence the cardiac outcome from a long-term perspective.

Differences in Automated External Defibrillator Types in Out-of-Hospital Cardiac Arrest Treated by Police First Responders.

Background: Police first responder systems also including automated external defibrillation (AED) has in the past shown considerable impact on favourable outcomes after out-of-hospital cardiac arrest (OHCA). While short hands-off times in chest compressions are known to be beneficial, various AED models use different algorithms, inducing longer or shorter durations of crucial timeframes along basic life support (BLS). Yet, data on details of these differences, and also of their potential impact on clinical outcomes are scarce. Methods: For this retrospective observational study, patients with OHCA of presumed cardiac origin and initially shockable rhythm treated by police first responders in Vienna, Austria, between 01/2013 and 12/2021 were included. Data from the Viennese Cardiac Arrest Registry and AED files were extracted, and exact timeframes were analyzed. Results: There were no significant differences in the 350 eligible cases in demographics, return of spontaneous circulation, 30-day survival, or favourable neurological outcome between the used AED types. However, the Philips HS1 and -FrX AEDs showed immediate rhythm analysis after electrode placement (0 [0-1] s) and almost no shock loading time (0 [0-1] s), as opposed to the LP CR Plus (3 [0-4] and 6 [6-6] s, respectively) and LP 1000 (3 [2-10] and 6 [5-7] s, respectively). On the other hand, the HS1 and -FrX had longer analysis times of 12 [12-16] and 12 [11-18] s than the LP CR Plus (5 [5-6] s) and LP 1000 (6 [5-8] s). The duration from when the AED was turned on until the first defibrillation were 45 [28-61] s (Philips FrX), 59 [28-81] s (LP 1000), 59 [50-97] s (HS1), and 69 [55-85] s (LP CR Plus). Conclusion: In a retrospective analysis of OHCA-cases treated by police first responders, we could not find significant differences in clinical patient outcomes concerning the respective used AED model. However, various differences in time durations (e.g., electrode placement to rhythm analysis, analysis duration, or AED turned on until first defibrillation) along the BLS algorithm were seen. This opens up the question of AED-adaptations and tailored training methods for professional first responders.

Association Between Postresuscitation 12-Lead ECG Features and Early Mortality After Out-of-Hospital Cardiac Arrest: A Post Hoc Subanalysis of the PEACE Study.

Background Once the return of spontaneous circulation after out-of-hospital cardiac arrest is achieved, a 12-lead ECG is strongly recommended to identify candidates for urgent coronary angiography. ECG has no apparent role in mortality risk stratification. We aimed to assess whether ECG features could be associated with 30-day survival in patients with out-of-hospital cardiac arrest. Methods and Results All the post-return of spontaneous circulation ECGs from January 2015 to December 2018 in 3 European centers (Pavia, Lugano, and Vienna) were collected. Prehospital data were collected according to the Utstein style. A total of 370 ECGs were collected: 287 men (77.6%) with a median age of 62 years (interquartile range, 53-70 years). After correction for the return of spontaneous circulation-to-ECG time, age >62 years (hazard ratio [HR], 1.78 [95% CI, 1.21-2.61]; P=0.003), female sex (HR, 1.5 [95% CI, 1.05-2.13]; P=0.025), QRS wider than 120 ms (HR, 1.64 [95% CI, 1.43-1.87]; P<0.001), the presence of a Brugada pattern (HR, 1.49 [95% CI, 1.39-1.59]; P<0.001), and the presence of ST-segment elevation in >1 segment (HR, 1.75 [95% CI, 1.59-1.93]; P<0.001) were independently associated with 30-day mortality. A score ranging from 0 to 26 was created, and by dividing the population into 3 tertiles, 3 classes of risk were found with significantly different survival rate at 30 days (score 0-4, 73%; score 5-7, 66%; score 8-26, 45%). Conclusions The post-return of spontaneous circulation ECG can identify patients who are at high risk of mortality after out-of-hospital cardiac arrest earlier than other forms of prognostication. This provides important risk stratification possibilities in postcardiac arrest care that could help to direct treatments and improve outcomes in patients with out-of-hospital cardiac arrest.

Associations between nailfold capillary aberrations and autoantibodies in children and adults with Raynaud's phenomenon.

OBJECTIVE: To characterise associations between individual nailfold capillary aberrations with autoantibodies in a cross-sectional study on children and adults with Raynaud's phenomenon (RP). METHODS: Consecutive children and adults with RP and without previously known connective tissue disease (CTD) systemically underwent nailfold capillaroscopy and laboratory tests for the presence of antinuclear antibodies (ANA). The prevalence of individual nailfold capillary aberrations and ANA was assessed, and the associations between individual nailfold capillary aberrations and ANA were analysed separately in children and adolescents. RESULTS: In total, 113 children (median age 15 years) and 2858 adults (median age 48 years) with RP and without previously known CTD were assessed. At least one nailfold capillary aberration was detected in 72 (64%) of included children and in 2154 (75%) of included adults with RP (children vs adults p<0.05). An ANA titre ≥1:80, ≥1:160 or≥1:320 was observed in 29%, 21% or 16% of included children, and in 37%, 27% or 24% of screened adults, respectively. While the occurrence of individual nailfold capillary aberrations was related to the presence of an ANA titre of ≥1:80 in adults (reduced capillary density, avascular fields, haemorrhages, oedema, ramifications, dilations and giant capillaries: each p<0.001), no comparable association between nailfold capillary aberrations and ANA was observed in children with RP without previously known CTD. CONCLUSION: In contrast to adults, the association between nailfold capillary aberrations and ANA might be less pronounced in children. Further studies are warranted to validate these observations in children with RP.

The Epidemiology of Pre-Hospital EMS Treatment of Geriatric Patients in the City of Vienna-An Overview.

Background: The city of Vienna, Austria, has a gradually aging population. Elderly people, over 65 years old and living at home or in nursing homes, frequently use Emergency Medical Services (EMS). However, there is no previous data comparing the EMS utilization of elderly- and non-elderly patients in Vienna. Methods: We retrospectively analyzed all EMS incidents in Vienna from 2012 to 2019. Transport- and emergency physician treatment rates, annual fluctuations, and the number of non-transports were compared between elderly (≥65 years) and non-elderly (18−64 years) patients. Results: Elderly people accounted for 42.6% of the total EMS responses in adult patients, representing an annual response rate of 223 per 1000 inhabitants ≥ 65 years. Compared to 76 per 1000 inhabitants in patients 18−64 years old, this results in an incidence rate ratio (IRR) of 2.93 [2.92−2.94]. Elderly people were more likely (OR 1.68 [1.65−1.70]) to need emergency physicians, compared to 18−64 year-olds. Nursing home residents were twice (OR 2.11 [2.06−2.17]) as likely to need emergency physicians than the rest of the study group. Non-transports were more likely to occur in patients over 65 years than in non-elderlies (14% vs. 12%, p < 0.001). Conclusions: The elderly population ≥ 65 years in Vienna shows higher EMS response rates than younger adults. They need emergency physicians more often, especially when residing in nursing homes. The economical and organizational strain this puts on the emergency response system should trigger further research and the development of solutions, such as specific response units dedicated to elderly people.

Arterial stiffness in acute coronary syndrome as a potential triage tool: a prospective observational study.

BACKGROUND: Diagnosis and percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS) are time-sensitive. Triage and algorithms identify patients at high-risk. However, additional prediction tools are warranted for prioritized care based on predicted coronary pathologies and PCI complexity. Pulse-wave velocity (PWV) is a non-invasive measurement related to cardiovascular morbidity, and their exact value in ACS evaluation is unclear. METHODS: In patients undergoing coronary angiography (CA) and - if warranted - PCI for ACS evaluation at a tertiary university hospital in Vienna, Austria, brachial-ankle (ba)PWV and carotid-femoral (cf)PWV were prospectively measured from January 2020 to January 2021. RESULTS: PWV was measured in 58 patients (60.3% male; 65 [61-69] years). Risk prediction scores (GRACE, CRUSADE, TIMI), cardiac enzymes, and fraction of patients with a three-vessel disease were significantly higher in the pathological PWV ranges. Adjusted for age and comorbidities, baPWV independently predicted the LAD being relevantly stenotic (crude OR=1.416 [1.143-1.755], P=0.001; adjusted OR=1.340 [1.039-1.727], P=0.024; cut-off 15.5 m/s in CART-analysis), being the culprit lesion (crude OR=1.320 [1.094-1.594], P=0.004; adjusted OR=1.311 [1.037-1.657], P=0.024; cut-off 15.5 m/s), and being totally occluded (crude OR=1.422 [1.113-1.818], P=0.005; adjusted OR=1.677 [1.189-2.366], P=0.003; cut-off 19.6 m/s). Moreover, CA or PCI complexity were associated with higher PWV. CONCLUSIONS: Pathological PWV as a surrogate for arterial stiffness, polyvascular disease and a larger atherosclerotic burden was associated with GRACE, CRUSADE, and TIMI scores, and PCI duration and complexity. BaPWV independently predicted relevant LAD pathologies, and is suggested as a potential novel triage and prioritization tool for suspected NSTE-ACS in emergency departments.