[Sonography of the liver following CT staging of patients with lung cancer: a retrospective analysis]. / Sonografie der Leber nach CT-Staging von Patienten mit Bronchialkarzinom: eine retrospektive Analyse.

PURPOSE: Liver lesions are frequently detected in the CT staging of lung cancer patients and may require further investigation. The aim of our study was to assess the value of an ultrasound (US) examination of the liver in addition to routine CT staging. MATERIALS AND METHODS: In this retrospective study we included 174 consecutive patients with lung cancer who underwent US of the liver in addition to contrast-enhanced CT of the thorax and upper abdomen. The reports of the examinations were evaluated for the presence of liver lesions. Based on CT and US standard criteria, liver lesions were grouped into unequivocal cysts, hemangiomas, metastases and undefined lesions. RESULTS: With CT, liver lesions were detected in 56 / 174 patients (32 %). These included 24 cysts in 11 patients, 2 hemangiomas in 2 patients and 18 patients with liver metastases. In 31 patients, 66 small (< 1.5 cm) hypodense lesions were detected, which could not be further defined by CT. Using US, 21 of these 66 liver lesions were confirmed as benign (cysts, hemangiomas), and two lesions were diagnosed as metastases. In 2 patients US revealed metastases that were not visible on the CT scans. CONCLUSION: The study demonstrates that a complementary US of the liver in patients with lung cancer may reveal information relevant for treatment. Therefore, liver US may play an important role in the staging of lung cancer. When equivocal small liver lesions are detected with CT, a complementary US examination may help to diagnose these lesions or detect metastases not visible on the single-phase staging CT of the liver.

Cervical ultrasound (US) and US-guided lymph node biopsy as a routine procedure for staging of lung cancer.

PURPOSE: To assess the value of routine ultrasound evaluation and US-guided fine-needle aspiration biopsy of supraclavicular lymph nodes for the diagnosis, staging and treatment of patients with lung cancer. MATERIALS AND METHODS: 300 consecutive patients with lung cancer were evaluated with high-resolution ultrasound for the presence of pathological lymph nodes (criteria: short-axis >or= 5 mm, rounded shape, missing echogenic hilum). Suspicious lymph nodes were biopsied under ultrasound guidance if the result could influence further patient management RESULTS: In 41 of 257 NSCLC patients (16 %) and 15 of 43 (35 %) SCLC patients, enlarged lymph nodes were detected, in particular in patients with a CT stage N2 or N3 (NSCLC) or extensive disease (SCLC). 16 lymph node biopsies were positive for malignancy, 4 biopsies were negative for malignancy or not diagnostic. US had a higher sensitivity for the detection of pathological lymph nodes than CT. CONCLUSION: Routine ultrasound evaluation of supraclavicular lymph nodes reveals suspicious lymph nodes in a high number of patients with lung cancer. High-resolution US is superior to CT in the detection of pathological lymph nodes. Ultrasound-guided biopsy proves malignancy and thereby a N3 or M1 stage. Thus, more invasive and expensive diagnostic procedures can be avoided.

Case report: Gluteal injection site granulomas: false positive finding on FDG-PET in patients with non-small cell lung cancer.

Positron-emission-tomography (PET) with fludeoxyglucose F-18 ([(18)F] fluoro-2-deoxy-D-glucose, FDG) has become an established imaging modality in patients with lung cancer for mediastinal lymph node staging and the detection of extrathoracic metastases. However, tracer accumulations are not limited to malignant tissue but are also found in muscles and benign inflammatory processes. We report on two patients with lung cancer in whom FDG-PET revealed suspicious tracer accumulations in the buttock. Ultrasound (US) revealed a hyperechogenic nodule with poorly defined margins in both patients. On specific inquiry both patients reported on repeated "intramuscular" gluteal injections. Histology after US guided biopsy showed an accumulation of macrophages within fibrous tissue, compatible with injection site granulomas. The reported cases underline that (18)F-FDG may accumulate in benign, ancillary processes that have to be distinguished from distant metastases. Tracer accumulation in the buttocks may be highly suggestive of injection site granulomas, especially if the patient reports on "intramuscular" injections. In this setting, US is a widely available modality to distinguish metastasis from adipose tissue necrosis.

[Evaluation of a portable ultrasound device immediately after spiral computed tomography]. / Einsatz eines tragbaren Ultraschallgeräts unmittelbar nach Spiral-Computertomographie.

AIM: Portable ultrasound devices are an established diagnostic tool. They are frequently used in trauma and emergency wards. Multidetector computed tomography (MD-CT) represents the standard imaging method for many diagnostic questions. In some patients, however, there are findings on CT which remain unspecific. In these cases, a complementary ultrasound (US) examination may help to obtain a specific diagnosis. Aim of this study is the evaluation of a portable US device immediately after MD-CT for further work-up of unclear lesions. METHODS: 257 MD-CT examinations were performed during a 3-week period. A portable US device (LogiqBook, GE Medical Systems, Solingen, Deutschland) was used when a lesion found at MD-CT remained unclear. Time intervals between CT and US as well as US examination times were registered. RESULTS: US was used in 23 of 257 CT examinations (8.9 %), but 3 of these examinations had to be terminated due to unfavourable US conditions. Thus, there remained 19 questions regarding parenchymal lesions in the liver (n = 13), kidney (n = 1) or suprarenal gland (n = 2). Pleural empyema was suspected in the 4 remaining patients. In all of the 20 patients, US helped to narrow down the differential diagnosis of MD-CT results. The mean time span between CT and US was 2.5 min, and the mean US examination time was 6.5 min. CONCLUSION: Portable US immediately after MD-CT helps to narrow down the differential diagnosis of hepatic and pleural lesions with minimal additional effort in time and organization.

["Disappearance" of retroperitoneal vessels - a case report]. / Die "verschwundenen" Retroperitonealen Gefässe: ein Fallbericht.

We report the ultrasound findings in a case of pneumo-retroperitoneum. The 74-year-old patient was admitted because of severe dyspnoea. Chest X-ray revealed a left-sided pleural effusion, and a drainage was performed. Later on the patient for the first time complained about severe pain in the lower abdomen. Ultrasound of the abdomen was performed. Sonographically, it was remarkably difficult to obtain images of the right kidney and the retroperitoneal vessels, as massive reverberation artifacts in the retroperitoneum were present. Plain radiography of the abdomen revealed free retroperitoneal and intraabdominal gas. At laparotomy a perforated diverticulitis of the sigma was discovered. Postoperative follow-up was uneventful, but the recurrent pleural effusion was later confirmed to be due to a malignant mesothelioma. This article discusses the characteristic sonomorphologic features of pneumo-retroperitoneum and its differential diagnosis. Although free retroperitoneal air is a rare condition, it is crucial for the examiner to be aware of the characteristic sonographic findings in order to initiate appropriate therapy.

[Imaging in collagen-vascular diseases with special emphasis on fibrotic lung alterations]. / Radiologische Bildgebung bei Kollagenosen unter besonderer Berücksichtigung fibrotischer Lungenparenchymveränderungen.

This review presents the wide spectrum of radiological abnormalities seen in patients with collagen-vascular disorders. It provides an overview of both common and uncommon findings observed in this group of diseases. Moreover, diagnostic imaging algorithms used in conjunction with clinical tests are presented. In addition to conventional radiography and computed tomography (CT), these diagnostic algorithms also include more recent radiological modalities, such as thin section CT and multislice CT.

[MR arthrography of the hip joint]. / MR-Arthrographie des Hüftgelenks.

MR arthrography of the hip joint is usually performed after a conventional MRI has been obtained to rule out other pathologies of the hip joint as for instance bone marrow edema or osteonecrosis of the hip. MR arthrography is mainly performed as a very special investigation, and it is executed in most cases if the clinician asks for the diagnosis of a labral lesion. In very rare cases, MR arthrography of the hip is performed to image cartilage disease or osteochondrosis dissecans or free intraarticular bodies. In this paper, the indications, the technique, and the most important pathology of the hip joint--labral lesions--will be described as well as variants of the normal acetabular labrum. After a conventional MRI of the hip joint has been performed, a MR arthrography of the hip will be obtained to search for labral pathology or cartilage disease. MR arthrography is obtained after the intraarticular injection of 10-20 ml of a 0.1 mmol solution of gadopentate-dimeglumine has been performed. The intraarticular injection can either be fluoroscopic-guided or CT-guided or directly MR-guided. After the intraarticular injection, MR arthrography will be performed by the use of paracoronal and parasagittal T1-weighted spin echo or gradient echo sequences. In cases of labral lesions (degeneration, labral tear, labral detachment) or cartilage disease MR arthrography proved to be more sensitive as conventional MRI as shown in the literature. The sensitivity of MRI to detect labral pathology was reported to be about 65%, and that of MR arthrography was reported to be about 92-95% compared to surgical results. According to the current literature, MR arthrography is the most sensitive method to delineate these kind of pathologies. Therefore, the invasive technique of MR arthrography may be justified for the correct diagnosis of these kind of pathologies after other pathologic entities have been ruled out by conventional MRI.

Clinical application of rapid quantitative determination of cardiac troponin-T in an emergency department setting.

OBJECTIVES: We analysed the clinical use of Troponin-T compared to creatine kinase MB in a non-trauma emergency department setting. BACKGROUND: A newly established single specimen quantitative Troponin T assay allows the clinical application of this parameter. METHODS. Five-hundred Troponin T tests were provided for use by emergency physicians who could combine them with the routine laboratory tests without restriction as to the indication or number of tests per patient. The number of tests per patient, time frame, final diagnosis and additional clinical information gained were recorded. All patients were followed for at least 6 months to verify the diagnosis and to assess the occurrence of cardiac events (nonfatal AMI or cardiac death). The ability of Troponin T and creatine kinase MB tests to predict cardiac events within 6 months were compared. RESULTS: The 500 Troponin T tests were used in 249 patients (median two tests per patient (range 1-5)) within 41 days. The final diagnosis revealed coronary heart disease in 85, non-coronary heart disease in 39, non-cardiac chest pain in 86 and other diagnoses in 39 of the patients. In 14 patients with an elevated creatine kinase MB, myocardial damage could safely be ruled out by a negative Troponin T, in six patients with a normal creatine kinase MB minor myocardial damage could be detected by a positive Troponin T. During follow up 28 cardiac events were recorded. Troponin T had a significantly higher specificity, positive predictive value and proportion of correct prediction for cardiac events within 6 months compared to creatine kinase MB. CONCLUSIONS: Troponin T has proved to be an useful method for diagnosing myocardial damage in routine clinical use in the non-trauma emergency department.

Effects of bystander first aid, defibrillation and advanced life support on neurologic outcome and hospital costs in patients after ventricular fibrillation cardiac arrest.

OBJECTIVE: To evaluate the effects of basic life support, time to first defibrillation and emergency medical service arrival time on neurologic outcome and expenses for hospital care in patients after cardiac arrest. SETTING: Large urban emergency medical services system and emergency department in a 2000-bed university hospital. DESIGN: Outcome and cost benefit analysis of patients admitted to the hospital after witnessed, out-of-hospital, ventricular fibrillation cardiac arrest from October 1, 1991, until December 31, 1997. PATIENTS: Out of 1054 patients with out-of-hospital cardiac arrest, 276 were eligible. MEASUREMENTS AND RESULTS: The effects of basic and advanced life support measures on neurologic outcome and hospital expenses were evaluated. In contrast to intubation (odds ratio 1.08; 95% CI: 0.51-2.31; p=0.84), basic life support (odds ratio 0.44; 95% CI: 0.24-0.77; p=0.004) and time to first defibrillation (odds ratio 1.08; 95% CI: 1.03-1.13; p=0.001) were significantly correlated with good neurologic outcome. Among the patients who did not receive basic life support, the average cost per patient with good neurologic outcome significantly increased with the delay of the first defibrillation (p<0.001). CONCLUSIONS: In contrast to intubation, bystander basic life support and time to first defibrillation were significantly associated with good neurologic outcome and resulted in fewer expenses spent on in-hospital efforts.

Cardiopulmonary resuscitation performed by bystanders does not increase adverse effects as assessed by chest radiography.

UNLABELLED: Important adverse effects of bystander cardiopulmonary resuscitation (CPR) are well known. We describe the number of nonmedical professional CPR-related complications in patients surviving cardiac arrest, as assessed by chest radiograph. Within 2 yr, all consecutive patients admitted to the department of emergency medicine at a university hospital who had a witnessed, nontraumatic, normothermic cardiac arrest were studied. Radiologically evaluated adverse effects were compared with Mann-Whitney U-tests between patients who received bystander basic life support (Bystander group) and patients who did not receive bystander basic life support before advanced life support was started (ALS group). For assessment of bystander CPR-associated complications, chest radiographs were used. Of 224 patients, 173 were eligible. The median age was 58 yr (interquartile range, 51-71 yr), and 126 patients (73%) were men. The incidence of adverse effects associated with assisted-ventilation maneuvers and external chest compressions did not differ significantly between groups (severe gastric insufflation, 17% vs 18% between the Bystander group [n = 59] and the ALS group [n = 96], respectively; suspicion of aspiration, 22% vs 17%, respectively; soft tissue emphysema, 2% vs 1%, respectively; and serial rib fractures, 8% vs 8%, respectively). CPR administered by nonmedical personnel did not increase the number of life support-related adverse effects in patients surviving cardiac arrest as assessed by means of chest radiograph on admission. IMPLICATIONS: Complications related to cardiopulmonary bypass (CPR) are not increased when CPR is administered by nonmedical personnel, as assessed by chest radiograph. These data may be valuable in motivating lay people to perform basic life support.

Sepsis-associated purpura fulminans in adults.

Sepsis-associated purpura fulminans is defined as septicemia, shock, disseminated intravascular coagulation and circulatory failure leading to multiple organ dysfunction. 40-70% of patients with sepsis-associated purpura fulminans die. Early prognostic factors in adults have not been well delineated yet. Aim of our study was 1) to evaluate currently used scoring systems for meningococcal septicemia in the setting of sepsis-associated purpura fulminans and 2) to assess if other parameters are feasible as early prognostic factors. From 1.1 1994-31.12.1998 twelve patients (female: 7; mean age: 31 (21; 43) years) were studied. Six patients (50%) died within 2 hours and 7 days after admission despite standard intensive treatment. On admission non-survivors had a more pronounced degree of disseminated intravascular coagulation compared to survivors (platelet count 18000 (15000; 45000) G/l vs. 119.000 (111000; 152000) G/l, (p = 0.03); fibrinogen 67 (50; 108) mg/dl vs. 356 (234; 483) mg/dl, (p = 0.02); PTZ 28% (20%; 30%) vs. 44% (35%; 51%), (p = 0.05); aPTT 120 (120; 128) sec vs. 46 (44; 69) sec, (p = 0.001). Severity of lactic acidosis was significantly higher in non-survivors than in survivors (pH 7.08 (6.92; 7.21) vs. pH 7.4 (7.25; 7.4), (p = 0.02); lactate 13.5 (11; 15) mval/l vs. 6.0 (4.4; 6) mval/l, (p = 0.02); data presented as median (25-75% interquartile range). In our patients the Glasgow Meningococcal Septicemia Prognostic Score (GMSPS) and the Niklasson-Score failed to distinguish between survivors and non-survivors (GMSPS 7 (6; 11) vs 7.5 (7; 9) out of 15; predicted mortality according to Niklasson-Score 73% vs 88%). There was no difference in the APACHE II Score (22 (18.5, 24) vs 22 (20.25, 26)). The severity of disseminated intravascular coagulation assessed by routine laboratory parameters and the degree of lactic acidosis on admission were the strongest predictors of outcome in patients with sepsis-associated purpura fulminans. Scoring systems developed for patients with meningococcal septicemia are of limited value in the setting of sepsis-associated purpura fulminans.

Out-of-hospital diagnosis of cerebral infarction versus intracranial hemorrhage.

OBJECTIVE: To establish a model based on clinical and anamnestic data easily available in the out-of-hospital setting, which facilitates the differential diagnosis between cerebral infarction and intracranial hemorrhage. DESIGN: Retrospective study that simulates a prospective approach. SETTING: Emergency Department of the University Hospital in Vienna, Austria. PATIENTS AND PARTICIPANTS: Data of 224 patients with either intracranial hemorrhage or cerebral infarction were prospectively collected. Uni-and multivariate analysis was performed to identify neurological symptoms and anamnestic data, which were associated with either intracranial hemorrhage or cerebral infarction. MEASUREMENTS AND RESULTS: Unilateral weakness or sensory loss was observed more frequently in patients with infarction compared to hemorrhage (69.8 % vs 11.9 %, P < 0.001). The frequency of patients with impaired level of consciousness was significantly higher in the hemorrhage group compared to the infarction group (59.3 % vs 3.8 %, P < 0.001). A multivariate logistic regression analysis showed that hypertension (OR = 0.31, 95 % CI = 0.12-0.76, P = 0.01), diabetes (OR = 0.17, 95% CI = 0.04-0.68, P = 0.01), and unilateral weakness or sensory loss (OR = 0.10, 95 % CI = 0.04-0.26, P < 0.001) were significantly associated with cerebral infarction. Impaired level of consciousness was significantly related to hemorrhage (OR = 13.41, 95 % CI = 3.92-45.91, P < 0.001). On the basis of the logistic regression analysis, we generated a scoring system for the out-of-hospital diagnosis between infarction and hemorrhage. The values of the score lay between -3 and +3. The probability of infarction increases when the score becomes negative, and the probability for hemorrhage increases when the score becomes positive. CONCLUSION: Our model is a useful guideline for the differential diagnosis between cerebral infarction and intracranial hemorrhage in the out-of-hospital setting, as it is based on easily available clinical and anamnestic parameters.

Simultaneous comparison of thoracic bioimpedance and arterial pulse waveform-derived cardiac output with thermodilution measurement.

OBJECTIVE: To compare the accuracy and reliability of thoracic electrical bioimpedance (TEB) and the arterial pulse waveform analysis with simultaneous measurement of thermodilution cardiac output (TD-CO) in critically ill patients. DESIGN: Prospective data collection. SETTING: Emergency department and critical care unit in a 2,000-bed inner-city hospital. PATIENTS: A total of 29 critically ill patients requiring invasive hemodynamic monitoring for clinical management were prospectively studied. INTERVENTIONS: Noninvasive cardiac output was simultaneously measured by a TEB device and by analysis of the arterial pulse waveform derived from the finger artery. Invasive cardiac output was determined by the thermodilution technique. MEASUREMENTS AND MAIN RESULTS: A total of 175 corresponding TD-CO and noninvasive hemodynamic measurements were collected in 30-min intervals. They revealed an overall bias of 0.34 L/min/m2 (95% confidence interval, 0.24-0.44 L/min/m2; p < .001) for the arterial pulse waveform analysis and of 0.61 L/min/m2 (95% confidence interval, 0.50-0.72 L/min/m2; p < .001) for the TEB. In 39.4% (n = 69) of all measurements, the discrepancy between arterial pulse waveform analysis and TD-CO was >0.50 L/min/m2. The discrepancies of the arterial pulse waveform analysis correlated positively with the magnitude of the cardiac index (r2 = 0.29; p < .001). In 56.6% (n = 99) of all measurements, the discrepancy between TEB and TD-CO was >0.50 L/min/m2. The magnitude of the discrepancies of the TEB was significantly correlated with age (r2 = 0.17; p = .02). Measurements were in phase in 93.2% of all arterial pulse waveform analysis and in 84.9% of all TEB readings (p < .001). CONCLUSIONS: The arterial pulse waveform analysis exhibits a greater accuracy and reliability as compared with the TEB with regard to overall bias, number of inaccurate readings, and phase lags. The arterial pulse waveform analysis may be useful for the monitoring of hemodynamic changes. However, both methods fail to be a substitute for the TD-CO because of a substantial percentage of inaccurate readings.

The association between C-reactive protein on admission and mortality in patients with acute myocardial infarction.

OBJECTIVE: In patients presenting with acute myocardial infarction the pathophysiologic and prognostic value of serum C-reactive protein is not well defined. This study assessed the association between serum C-reactive protein levels on admission and mortality in patients admitted because of acute myocardial infarction. DESIGN: Retrospective cohort study. SETTING: Tertiary care centre. PATIENTS: A total of 729 patients with acute myocardial infarction admitted within a period of 3 years. MAIN OUTCOME MEASURES: C-reactive protein levels on admission, cardiovascular risk factors and survival within the observational period. RESULTS: Within the 3-year observational period, 118 patients died of a cardiovascular cause. With increasing serum C-reactive protein levels (<0.5, 0.5 to <2, 2 to <5, 5-10 and >10 mg dL-1) mortality also increased (14%, 19%, 20%, 39% and 28%, respectively). When controlling for the confounding effect of age, thrombolytic treatment, the time interval between onset of pain and admission, smoking, diabetes mellitus, hypercholesterolemia, hypertension, and elevated creatine kinase on admission in a multivariate Cox regression model, there was only a weak and nonsignificant association between increased serum C-reactive protein and the risk of death. CONCLUSIONS: Patients with elevated concentrations of serum C-reactive protein admitted to the hospital because of acute myocardial infarction are at an increased risk of dying. This association is however, largely explained by other baseline variables, in particular by an estimate of the duration of myocardial ischaemia. If C-reactive protein measured by means of an ultra-sensitive assay is more suitable for risk stratification of unselected patients with acute myocardial infarction, needs further study.

Accuracy of oscillometric blood pressure measurement according to the relation between cuff size and upper-arm circumference in critically ill patients.

OBJECTIVE: To evaluate the accuracy of oscillometric blood pressure measurement according to the relation between cuff size and upper-arm circumference in critically ill patients. DESIGN: Prospective data collection. SETTING: Emergency department in a 2,000-bed inner city hospital. PATIENTS: Thirty-eight patients categorized into three groups according to their upper-arm circumference (group I: 18-25 cm; group II: 25.1-33 cm; and group III: 33.1-47.5 cm) were enrolled in the study protocol. INTERVENTIONS: In each patient, all three cuff sizes (Hewlett-Packard Cuff 40401 B, C, and D) were used to perform an oscillometric blood pressure measurement at least within 3 mins until ten to 20 measurements for each cuff size were achieved. Invasive mean arterial blood pressure measurement was done by cannulation of the contralateral radial artery with direct transduction of the systemic arterial pressure waveform. The corresponding invasive blood pressure value was obtained at the end of each oscillometric measurement. MEASUREMENT AND MAIN RESULTS: Overall, 1,494 pairs of simultaneous oscillometric and invasive blood pressure measurements were collected in 38 patients (group I, n = 5; group II, n = 23; and group III, n = 10) over a total time of 72.3 hrs. Mean arterial blood pressure ranged from 35 to 165 mm Hg. The overall discrepancy between oscillometric and invasive blood pressure measurement was -6.7+/-9.7 mm Hg (p<.0001), if the recommended cuff size according to the upper-arm circumference was used (539 measurements). Of all the blood pressure measurements, 26.4% (n = 395) had a discrepancy of > or =10 mm Hg and 34.2% (n = 512) exhibited a discrepancy of > or =20 mm Hg. No differences between invasive and noninvasive blood pressure measurements were noted in patients either with or without inotropic support (-6.6 + 7.2 vs. -8.6 + 6.8 mm Hg; not significant). CONCLUSION: The oscillometric blood pressure measurement significantly underestimates arterial blood pressure and exhibits a high number of measurements out of the clinically acceptable range. The relation between cuff size and upper-arm circumference contributes substantially to the inaccuracy of the oscillometric blood pressure measurement. Therefore, oscillometric blood pressure measurement does not achieve adequate accuracy in critically ill patients.

Multiple organ failure and prognosis in adult patients with diabetic ketoacidosis.

OBJECTIVE: Evaluation of prognostic factors of patients presenting with diabetic ketoacidosis (DKA) at an emergency department. DESIGN: Retrospective cohort study. SETTING: The Emergency Department of the Vienna General Hospital, a 2000-bed tertiary care hospital. PATIENTS AND PARTICIPANTS: Patients with DKA admitted from January 1, 1994 to September 30, 1998. INTERVENTIONS: Treatment of DKA in accordance with a predefined regimen. MEASUREMENTS AND RESULTS: History, clinical findings, biochemical parameters, blood gas analysis, multiorgan failure score (MOF) and treatment modalities were assessed. Patients were followed until death or hospital discharge. For group comparison the Mann Whitney U-test was used. Within the study period 21 patients were admitted because of diabetic ketoacidosis (female: 10, median age: 42 years; 31 to 58). All patients suffered from insulin-dependent diabetes mellitus and were treated according to a standardised protocol. Six patients (29%) died in hospital. The non-survivors had significantly higher MOF-scores on admission (5 vs. 2, p < 0.001) and after 24 hours (4 vs. 0, p < 0.01) of intensive care treatment. Additionally, non-survivors had significantly higher levels of GOT (64 vs. 8 U/l), GPT (28 vs. 11 U/l), BUN (34.63 vs. 12.14 mmol/l), creatinine (291.7 vs. 150.3 mmol/l), amylase (315 vs. 78 U/l) and lipase (573 vs. 122 U/l) on admission than did survivors (p < 0.05), and also had a significantly higher net positive fluid balance after 24 hours (8.0 vs. 4.75 l, p < 0.05). All other parameters were not significantly different between the groups. CONCLUSION: Multiple organ failure may develop in patients with diabetic ketoacidosis and is associated with poor prognosis.

The influence of chest compressions and external defibrillation on the release of creatine kinase-MB and cardiac troponin T in patients resuscitated from out-of-hospital cardiac arrest.

OBJECTIVES: This study sought to determine the influence of resuscitative procedures, such as chest compressions and external defibrillation, on the release of creatine kinase (CK)-MB and cardiac troponin T (cTnT). METHODS: In 87 patients with out-of-hospital cardiac arrest and successful cardiopulmonary resuscitation (CPR), the initial ECG rhythm, the duration of cardiac arrest and CPR, and the number of defibrillations were assessed on arrival in the hospital. The serum CK-MB and cTnT were measured 12 h after the event. We also assessed whether the patient developed cardiogenic shock within 12 h, and if the patient had acute myocardial infarction (AMI), which was confirmed or eliminated by of typical ECG findings, thallium-201 myocardial scintigraphy, or autopsy within the hospital stay. A backward stepwise linear regression model was applied to assess the association between the markers of myocardial injury (CK-MB and cTnT) and the above clinical variables. RESULTS: CK-MB concentrations were independently associated with the presence of AMI [B 68.5 (SE 28.5, P = 0.018)], the duration of CPR (as a measure of trauma to the chest by means of chest compressions) [B 2.07 (SE 1.01, P = 0.045)] and cardiogenic shock [B 52.3 (SE 23.4, P = 0.03)]. The remaining clinical variables listed were excluded by the model. Cardiac troponin T concentrations were only associated with the presence of AMI [B 4.86 (SE 1.34, P = 0.0005)]. There was a non-significant association between increasing serum cTnT concentrations and the presence of cardiogenic shock [B 2.51 (SE 1.46, P = 0.09)]. The remaining clinical variables were excluded by the model. CONCLUSION: The release of CK-MB appears to be influenced by the duration of resuscitation and the presence of cardiogenic shock. This has to be considered when interpreting serum CK-MB concentrations after CPR. The release of cTnT seems to be only associated with acute myocardial infarction, but not with the duration of chest compressions, or with the number of defibrillations administered.

Successful automatic external defibrillator operation by people trained only in basic life support in a simulated cardiac arrest situation.

OBJECTIVE: To show whether in an in-hospital cardiac arrest, early defibrillation can also be performed by hospital staff trained only in basic life support. BACKGROUND: The International Liaison Committee on Resuscitation (ILCOR) endorses the concept that in many settings non-medical individuals should be allowed and encouraged to use defibrillators. METHODS: Five different groups of hospital staff were evaluated whether they were able to correctly operate an automatic external defibrillator in a simulated sudden cardiac arrest situation without any prior instruction. The participants were assigned either to the 'basic life support-trained' group (BLS, n = 40, or to the 'advanced life support-trained' group (ALS, n = 40). RESULTS: All persons of the 'only BLS-trained' group delivered the three sequential ('stacked') shocks with the automatic external defibrillator when persistent ventricular fibrillation was simulated. The 'ALS-trained' persons successfully delivered the three shocks with the automatic external defibrillator in 98% of the cases. When this group used a conventional defibrillator, only 88% were able to deliver the three shocks, however they were able to do it significantly more quickly. CONCLUSION: Using an automatic defibrillator without any prior instruction, even persons trained only in BLS were able to deliver three sequential shocks in a simulated persistent ventricular fibrillation cardiac arrest.