Extracorporeal cardiopulmonary resuscitation after out-of-hospital cardiac arrest in a Danish health region.

BACKGROUND: Extracorporeal Cardiopulmonary Resuscitation (ECPR) has emerged as a feasible rescue therapy for refractory, normothermic out-of-hospital cardiac arrest (OHCA). Reported survival rates vary and comparison between studies is hampered by heterogeneous study populations, differences in bystander intervention and in pre-hospital emergency service organisation. We aimed to describe the first experiences, treatment details, complications and outcome with ECPR for OHCA in a Danish health region. METHODS: Retrospective study of adult patients admitted at Aarhus University Hospital, Denmark between 1 January 2011 and 1 July 2015 with witnessed, refractory, normothermic OHCA treated with ECPR. OHCA was managed with pre-hospital advanced airway management and mechanical chest compression during transport. Relevant pre-hospital and in-hospital data were collected with special focus on low-flow time and ECPR duration. Survival to hospital discharge with Cerebral Performance Category (CPC) of 1 and 2 at hospital discharge was the primary endpoint. RESULTS: Twenty-one patients were included. Median pre-hospital low-flow time was 54 min [range 5-100] and median total low-flow time was 121 min [range 55-192]. Seven patients survived (33%). Survivors had a CPC score of 1 or 2 at hospital discharge. Five survivors had a shockable initial rhythm. In all survivors coronary occlusion was the presumed cause of cardiac arrest. CONCLUSION: Extracorporeal cardiopulmonary resuscitation is feasible as a rescue therapy in normothermic refractory OHCA in highly selected patients. Low-flow time was longer than previously reported. Survival with favourable neurological outcome is possible despite prolonged low-flow duration.

Time to treatment-door-to-balloon time is not everything.

International guidelines for the management of patients with ST-elevation myocardial infarction (STEMI) recommend various performance measures to monitor the quality of STEMI systems of care. Door-to-balloon (D2B) time (arrival at hospital to percutaneous coronary intervention, PCI) and overall health care system delay (first medical contact to reperfusion) are acknowledged as valuable performance measures when treating patients with primary percutaneous coronary intervention (PPCI). However, there is confusion regarding the exact definition of these performance measures, and moreover system delay and PCI-related delay (the extra delay acceptable to perform PPCI instead of fibrinolysis) are often used synonymously, which add confusion when considering reperfusion strategy. The present paper calls for a consensus regarding the use and definition of objective performance measures when treating patients with STEMI, and exemplifies why it is insufficient just to focus on D2B time.

Left ventricular contractile function after distal protection in primary percutaneous coronary intervention: results from the Drug Elution and Distal Protection in ST-Elevation Myocardial Infarction trial.

BACKGROUND: Coronary intervention (PCI) may result in an increased infarct size. We evaluated the effect of distal protection during PCI for ST-segment elevation myocardial infarction (STEMI) on myocardial function. METHODS: Patients with STEMI were randomly referred within 12 h for PCI with (N = 312) or without distal protection (N = 314). Left ventricular (LV) contractile function was assessed with echocardiography 8 months after PCI. Global LV myocardial wall motion index (WMI) was calculated as the average wall motion score of all myocardial segments. The occurrence of death, nonfatal re-infarction, and stroke 8 months after PCI were also recorded. RESULTS: The occurrence of death, nonfatal re-infarction, and stroke 8 months after PCI was 7.1% after distal protection and 5.7% after conventional treatment (p = 0.17). WMI improved by 4.1% at 8 months in patients treated with distal protection compared to patients receiving conventional PCI (p < 0.01). In myocardium supplied by a culprit artery treated by distal protection regional LV function was 9-11% higher than myocardial regions treated conventionally ( p < 0.02). CONCLUSIONS: Routine use of distal protection during primary PCI is associated with a significant improvement in LV contractile function, with no detectable impact on intermediate term clinical outcome.

Primary PCI as the preferred reperfusion therapy in STEMI: it is a matter of time.

There is a continuing controversy about the acceptable time-window for primary percutaneous coronary intervention (PPCI) in patients with ST-elevation myocardial infarction (STEMI). Recent American and European guidelines recommend PPCI if the delay in performing PPCI instead of administering fibrinolysis (PCI-related delay) is <60 min and the presentation delay is more than 3 h. Based on a review of the literature, this viewpoint recommends a revision of the guidelines. The evidence supports an acceptable PCI-related delay of 80-120 min and PPCI as the better reperfusion strategy also in the early incomers. Furthermore, the previous assumption that PPCI is less time-dependent than fibrinolysis is questioned. To maximise the number of patients with STEMI eligible for PPCI the optimal logistic may be to establish the diagnosis in the prehospital phase, to bypass local hospitals and re-route patients directly to catheterisation laboratories running 24/7.

Myocardial infarction centres: the way forward.

In the era of primary PCI, a strategy of admitting patients to the nearest hospital should be obsolete. Instead, a prehospital diagnostic strategy should be implemented in order to: (1) refer patients directly to interventional centres, thereby eliminating delay at local hospitals; (2) alert the interventional centre, thereby reducing door to balloon times; (3) initiate adjunctive medication in the prehospital phase.

Are we underestimating the full potential of early thrombolytic treatment in patients with acute myocardial infarction?

Use of the Boersma curve in order to describe the beneficial effect of thrombolytic treatment at different treatment delays seems questionable, because the curve may underestimate the favourable prognostic effects of early thrombolysis in patients with acute myocardial infarction

Telemedicine used for remote prehospital diagnosing in patients suspected of acute myocardial infarction.

INTRODUCTION: In patients with acute myocardial infarction (AMI), considerable time elapses from symptom onset until initiation of thrombolytic therapy or primary percutaneous coronary intervention. Prehospital diagnosing can reduce time delays, and remote diagnosing using telemedicine may be appropriate in areas and countries where ambulances are not staffed with physicians. OBJECTIVES: To evaluate whether it was technically feasible for physicians at a remote university hospital to diagnose ST-segment-elevation-AMI (AMI(STelev)) in patients suspected of AMI, who were transported by ambulances to a local hospital. To determine associated prehospital delays and in-hospital treatment delays. METHODS: Patients carried in telemetry equipped ambulances had 12-lead electrocardiograms (ECGs) acquired as soon as possible. En route to the local hospital the ECGs were transmitted to a remote university hospital, by use of the GSM-system. The physician on call at the university hospital interviewed the patients, who were provided with cellular phone headsets, and alerted the local hospital if signs of AMI(STelev), bundle-branch-block-AMI or malignant arrhythmia were detected. Patients transported by traditional ambulances were included in a prospective control group. RESULTS: In 214 (86%) of 250 patients prehospital diagnosing was successful. Geographically related transmission problems were the primary reason for failure. Ninety-eight per cent of transmitted electrocardiograms and obtained history takings were technically acceptable for diagnostic purposes. Door-to-needle times were shorter amongst patients with AMI(STelev) who were subjected to prehospital diagnosing (n = 13) as compared with patients transported by traditional ambulances (n = 14) (38 vs. 81 min) (P = 0.004). CONCLUSIONS: It was technically feasible to use telemedicine for remote prehospital diagnosing of patients suspected of AMI. Patients subjected to prehospital diagnosing had shorter door-to-needle times compared with a prospective control group.

Badminton injuries--a prospective epidemiological and socioeconomic study.

During a 1-year period 100 badminton players were registered and treated in the casualty ward of Randers City Hospital, Denmark. The injuries to the badminton players constituted 5% of all sports injuries registered during the same period in the casualty ward. At follow-up questionnaires were sent to all participants. Replies were received from 89 patients. Over the same period all sports participants in the hospital catchment area (30,254) were registered according to their sport affiliation (2620 badminton players-1650 men and 970 women). Of those injured 58% were men (mean age 31 years) and 42% were women (mean age 25 years). Of the injuries 55% occurred in club players, the remainder occurring during company and school sports activities. The active players were classified into three groups according to age: Group 1 under 18 years (31%); Group 2 18-25 years (16%); Group 3 more than 25 years (53%). According to the Abbreviated Injury Scale (AIS) 17% of the injuries were classified as minor, 56% as moderate, and 27% as severe, respectively. Of the severe injuries (AIS = 3) 56% were found in the oldest age group. AIS correlated with time absent from sport (P < 0.001). Nine players (9%) reported that earlier injuries had influenced the actual accident. Most players (96%) trained one to three times a week. Sprains were the injury most commonly diagnosed (56%), fractures accounted for 5%, torn ankle ligaments were found in 10%, and 13% had ruptures to the Achilles tendon. Overall, 21% were admitted to hospital. None of the patients treated as inpatients was kept in hospital for more than 7 days. The injury caused 56% of players to be absent from work of whom 23% were absent for more than 3 weeks. After the injury 12% of the players gave up their sport, and only 4% restarted their training/sport within 1 week. As many as 28% had to avoid training and playing in matches for 8 weeks or more.

[Handball injuries. An epidemiological and socioeconomic study]. / Håndboldskader. En epidemiologisk og socioøkonomisk undersøgelse.

A total of 570 injuries in handball players were prospectively registered in a well-defined geographical area of 124,321 inhabitants. The incidence of handball injuries was 46/10,000 inhabitants/year and in females (61/10,000/year) double that for males (31/10,000/year). Sixty-two percent of the injuries were distortions and sprains and 12% were fractures. A total of 7% were hospitalised and the loss of income because of sick leave was in total $3870. Sixty-eight percent of the injured handball players did not play for more than one week. Surprisingly, 8% of the minor injuries resulted in a risk leave of more than six days. Five percent of these injured quit a tournament of training after sustaining a handball injury.

[Soccer injuries. A prospective epidemiological and socioeconomic study]. / Fodboldskader. En prospektiv epidemiologisk og socioøkonomisk undersøgelse.

In one year 715 soccer injuries were registered and treated in the casualty ward of Randers City Hospital. We conducted a prospective study of these patients, using a questionnaire in order to determine the most common locations, types, mechanisms and treatments of injury. Financial costs to society and the individual were also examined. Finally, we compared the most common types of injury definition in sports medicine. According to the Abbreviated Injury Scale, A.I.S., 44% of the injuries were classified as minor, 46% as moderate injury and 9% as severe. Fractures accounted for 17% of all injuries. Sprains and contusions were the most frequent injuries, accounting for 46% and 25% respectively. Most injuries (63%) were treated in the casualty ward, whilst 20% were treated as outpatients. 7% were admitted to the hospital immediately, and a further 2% were later admitted from the outpatient clinic. A total of 88% of those hospitalized were treated as inpatients for 1-7 days, and 12% for more than two weeks. 31% of all the soccer players seen in the casualty ward were absent from work, and 12% were absent from work for more than three weeks. 8% of the injured soccer players suffered loss of income. 40% had financial losses between $0-250, 40% between $250-750, seven per cent between $750-1,250, and 14% more than $1,250. From the data presented in this study, we conclude that the injury rate among soccer players increases with age, and the severity of the injuries is greatest in the oldest age groups. Soccer injuries constitute the major part of sports injuries seen in the casualty ward.(ABSTRACT TRUNCATED AT 250 WORDS)

Handball injuries. An epidemiologic and socioeconomic study.

A total of 570 injuries in handball players were prospectively registered in a well-defined geographic area of 124,321 inhabitants. The incidence of handball injuries was 46 per 10,000 inhabitants per year. The incidence in women (61 per 10,000 per year) was double that of men (31 per 10,000 per year). Sixty-two percent of the injuries were ligament sprains and tears and 12% were fractures. A total of 7% of the patients were hospitalized and the total loss of income because of sick leave was $3870. Sixty-eight percent of the injured handball players were absent from handball more than 1 week. Surprisingly, 8% of the minor injuries resulted in a sick leave of more than 6 days.

European soccer injuries. A prospective epidemiologic and socioeconomic study.

In 1 year, 715 patients with soccer injuries were registered and treated in the emergency department of Randers City Hospital. We did a prospective study of these patients using a questionnaire to determine the most common locations, types, mechanisms, and treatments of injury. Financial costs for society and the individual were also examined. Forty-nine percent of the injuries were to the joints; sprains and contusions were the most common types of injury, accounting for 46% and 25%, respectively. The majority of patients (64% of the men and 58% of the women) were injured during physical contact with another player. Most (63%) of the patients were treated in the emergency department and then released. Thirty-one percent had to be absent from work, but only 8% of the patients had a loss of income because of their injury. The average amount of work time lost was 5 days.

Product-related home accidents in children. A survey of 1590 accidents.

In a well defined geographical area a total of 1590 accidents related to home products in children 0-15 years of age were prospectively registered. The incidence of product-related accidents was 279 per 10,000 children per year. A higher incidence in boys and a decreasing incidence of accidents with age was found. The most common localization of lesions was upper extremities 41% and face and skull 30%. In children 0-4 years of age household and child furniture, constructional features of the house and corrosives, hot liquids and heating equipment were the most common products causing accidents, whereas in children 5-15 years of age playthings and sports equipment as well as constructional features of the house were involved in a higher percentage of accidents.

Product-related childhood accidents. A survey of 1590 cases.

Over a one-year period prospectively a total of 1,590 product-related accidents in the home in children (0-15 years), presented at the two hospitals, were registered in a well defined geographical area to analyze injury mechanisms, injury panorama and potential risk products. The incidence of accidents in children was 279 per 10,000 inhabitants per year. A tendency of a smaller incidence with age and a significant higher incidence in boys were found. The most common localization of lesion was upper extremities (41%) and face and skull (30%). Household furniture and constructional features of the house caused most accidents and an alarming high number of burns was registered.

Domestic burns among children.

Out of 338 domestic burn injuries 134 affected children below 16 years of age. The investigation was prospective over a 1-year period. The highest incidence occurred in the age-group 0-2 years and was most often caused by contact, secondly by scalds. The sex ratio girls/boys was 1/1.6. The most vulnerable areas were the hands, head and fingers. Activities related to cooking and in the kitchen caused most of the burns.

[Home accidents involving children. An epidemiologic investigation]. / Børneulykker i hjemmet. En epidemiologisk undersøgelse.

During a period of 1 year, 1,590 product-related domestic accidents among 0-15 year-olds were registered prospectively at the casualty wards of Aarhus County Hospital and Randers Central Hospital. This registration was carried out as a part of the Danish participation in the E.E.C.'s pilot project. A significant predominance of boys and a larger frequency of accidents in boys was discovered; the sex ratio girl/boy being 1:1.6. The frequency of accidents was high among the one year olds. The greatest number of accidents was demonstrated to occur during weekends and in the months of April, May and August. An accumulation of accidents (48%) among a few main groups of products was discovered; constructional features of the house, do-it-yourself tools, furniture, toy- and sports equipment and vehicles for baby and child transport. Dangerous accidents in the age group 0-4 years were caused by hot objects, chemicals and kitchen utensils. Most of the lesions were localized to the hands and fingers (31%) and the face and head (30%), which is alarming.

[Scalding accidents among children--an epidemiologic study]. / Skoldningsulykker blandt børn--en epidemiologisk undersøgelse.

During the periods March 1 1983 to February 29, 1984 in the Aarhus County Hospital and from November 1 1982 to November 30 1983 in the Central Hospital in Randers, a total of 47 scalding accidents in children were registered among 338 burns resulting from accidents in the home. The incidence of scalds was greatest in the age group 0-2 years. The number of scalds was greater during winter and no less than five children were admitted to intensive care units in hospital, one of these being transferred to the Burns Unit of Hvidovre Hospital, Copenhagen. The commonest accident mechanism was scalding when the child pulled a cloth or electric cable attached to a coffee machine, thereby upsetting a container of hot water. This explains why the most frequent localizations of scalding were the face, head, neck, trunk and upper limbs.

Epidemiology of domestic burns related to products.

Of 4357 home accidents in a 1-year period related to products, a total of 338 burn injuries were prospectively studied with respect to age, sex, the time and cause of the burn accident and the product involved in the burn injury. The survey showed the highest incidence (26 per cent) in the age group 0-5 years and that most burns were caused by scalds or contact. The male to female ratio was 1:1. Activities related to cooking and making/drinking hot beverages constitute the majority of the domestic burns. A trend of more burns occurring during the weekends and the dark winter was found, but monthly or seasonal differences were not significant (0.10 less than P less than 0.20 and 0.20 less than P less than 0.30).