Eligibility and efficacy of a CPC- and CHX-based antiviral mouthwash for the elimination of SARS-CoV-2 from the saliva: A randomized, double-blind, controlled clinical trial.

AIM: This study aimed at investigating the efficacy of a 0.05% cetylpyridinium chloride-0.05% chlorhexidine (CPC-CHX) mouthwash in reducing viral load in the saliva as compared with sterile water. MATERIALS AND METHODS: Forty SARS-CoV-2 positive patients were asked to dispense 4 mL of saliva. Half the patients rinsed for 60 s with 15 mL CPC-CHX, and the remaining patients rinsed with sterile water (control). Four millilitres of saliva were collected after 15, 30 and 60 min after rinsing. Quantitative reverse transcriptase polymerase chain reaction (RT-qPCR) and enzyme-linked immunosorbent assay (ELISA) specific for SARS-CoV-2 nucleocapsid protein were performed. For ELISA, the intact (representing the active virus) to total virus load (I/T) was calculated. RESULTS: SARS-CoV-2 copy numbers/mL from RT-qPCR tended to decrease in the control group, whereas in the CPC-CHX group, an increase was observed after T30. However, mixed linear model analysis revealed no statistical differences between groups (p = .124), time points (p = .616) and vaccinated or non-vaccinated patients (p = .953). Similarly, no impact of group (p = .880), time points (p = .306) and vaccination (p = .711) was observed for I/T ratio values. CONCLUSIONS: Within the limitation of this study, there was no evidence that the intervention reduced salivary SARS-CoV-2 viral load during the course of 60 min. Therefore, commonly used pre-procedural rinsing might not be clinically relevant.

Possible effect of the early administration of tranexamic acid on myocardial injury in patients with severe trauma.

Hemodynamic stabilization plays a crucial role in the treatment of patients suffering from severe trauma. Current guidelines recommend the early administration of tranexamic acid (TXA) for bleeding control. While less blood loss can result in less end-organ damage, including myocardial injury, TXA also exhibits prothrombotic effects with potentially adverse myocardial effects. The aim of this study was to investigate the association between the administration of TXA and myocardial injury in patients with severe trauma. We conducted a monocentric cohort study including severely injured patients ≥ 18 years [defined by Injury severity score (ISS) ≥ 16], who were admitted to a tertiary care hospital between 2016 and 2019. Primary outcome measure was myocardial injury according to the fourth Universal Definition (= high sensitive troponin T ≥ 14 ng/l). Secondary endpoints were in-hospital major adverse cardiovascular events (MACE) and mortality. Main exposure was defined as administration of TXA during prehospital period. We conducted multivariate logistic regression models including predefined covariables. A total of 368 patients were screened. Among the 297 included patients (72% male, age. 55?21 years), 119 (40%) presented myocardial injury at hospital arrival. TXA was administered to 20/297 (7%) patients in the prehospital setting, and in 96/297 (32%) patients during pre-or in-hospital period. MACE incidence was 9% (26/297) and in-hospital mortality was 26% (76/297). The adjusted odds ratios (OR) for prehospital TXA and myocardial injury, MACE and mortality were 0.75 [95% confidence interval (CI): 0.25-2.23], 0.51 [95%CI: 0.06-4.30] and 0.84 [0.21-3.33], respectively. In the present cohort of patients suffering from severe trauma, prehospital TXA did not affect the incidence of myocardial injury.

Triage Performance Across Large Language Models, ChatGPT, and Untrained Doctors in Emergency Medicine: Comparative Study.

BACKGROUND: Large language models (LLMs) have demonstrated impressive performances in various medical domains, prompting an exploration of their potential utility within the high-demand setting of emergency department (ED) triage. This study evaluated the triage proficiency of different LLMs and ChatGPT, an LLM-based chatbot, compared to professionally trained ED staff and untrained personnel. We further explored whether LLM responses could guide untrained staff in effective triage. OBJECTIVE: This study aimed to assess the efficacy of LLMs and the associated product ChatGPT in ED triage compared to personnel of varying training status and to investigate if the models' responses can enhance the triage proficiency of untrained personnel. METHODS: A total of 124 anonymized case vignettes were triaged by untrained doctors; different versions of currently available LLMs; ChatGPT; and professionally trained raters, who subsequently agreed on a consensus set according to the Manchester Triage System (MTS). The prototypical vignettes were adapted from cases at a tertiary ED in Germany. The main outcome was the level of agreement between raters' MTS level assignments, measured via quadratic-weighted Cohen κ. The extent of over- and undertriage was also determined. Notably, instances of ChatGPT were prompted using zero-shot approaches without extensive background information on the MTS. The tested LLMs included raw GPT-4, Llama 3 70B, Gemini 1.5, and Mixtral 8x7b. RESULTS: GPT-4-based ChatGPT and untrained doctors showed substantial agreement with the consensus triage of professional raters (κ=mean 0.67, SD 0.037 and κ=mean 0.68, SD 0.056, respectively), significantly exceeding the performance of GPT-3.5-based ChatGPT (κ=mean 0.54, SD 0.024; P<.001). When untrained doctors used this LLM for second-opinion triage, there was a slight but statistically insignificant performance increase (κ=mean 0.70, SD 0.047; P=.97). Other tested LLMs performed similar to or worse than GPT-4-based ChatGPT or showed odd triaging behavior with the used parameters. LLMs and ChatGPT models tended toward overtriage, whereas untrained doctors undertriaged. CONCLUSIONS: While LLMs and the LLM-based product ChatGPT do not yet match professionally trained raters, their best models' triage proficiency equals that of untrained ED doctors. In its current form, LLMs or ChatGPT thus did not demonstrate gold-standard performance in ED triage and, in the setting of this study, failed to significantly improve untrained doctors' triage when used as decision support. Notable performance enhancements in newer LLM versions over older ones hint at future improvements with further technological development and specific training.

Mild therapeutic hypothermia after cardiac arrest - effect on survival with good neurological outcome outside of randomised controlled trials: A registry-based analysis.

BACKGROUND: For nearly 20 years, in international guidelines, mild therapeutic hypothermia (MTH) was an important component of postresuscitation care. However, recent randomised controlled trials have questioned its benefits. At present, international guidelines only recommend actively preventing fever, but there are ongoing discussions about whether the majority of cardiac arrest patients could benefit from MTH treatment. OBJECTIVE: The aim of this study was to compare the outcome of adult patients treated with and without MTH after cardiac arrest. DESIGN: Observational cohort study. SETTING: German Resuscitation Registry covering more than 31 million inhabitants of Germany and Austria. PATIENTS: All adult patients between 2006 and 2022 with out-of-hospital or in-hospital cardiac arrest and comatose on admission. MAIN OUTCOME MEASURES: Primary endpoint: hospital discharge with good neurological outcome [cerebral performance categories (CPC) 1 or 2]. Secondary endpoint: hospital discharge. We used a multivariate binary logistic regression analysis to identify the effects on outcome of all known influencing variables. RESULTS: We analysed 33 933 patients (10 034 treated with MTH, 23 899 without MTH). The multivariate regression model revealed that MTH was an independent predictor of CPC 1/2 survival and of hospital discharge with odds ratio (95% confidence intervals) of 1.60 (1.49 to 1.72), P < 0.001 and 1.89 (1.76 to 2.02), P < 0.001, respectively. CONCLUSION: Our data indicate the existence of a positive association between MTH and a favourable neurological outcome after cardiac arrest. It therefore seems premature to refrain from giving MTH treatment for the entire spectrum of patients after cardiac arrest. Further prospective studies are needed.

Resuscitation room management of patients with non-traumatic critical illness in the emergency department (OBSERvE-DUS-study).

BACKGROUND: Few studies address the care of critically ill non-traumatic patients in the emergency department (ED). The aim of this study was to assess the epidemiology, management, and outcome of these patients. METHODS: In this retrospective study, we identified and analyzed data from all consecutive adult critically ill non-traumatic ED patients treated from March 2018 to February 2019. Patient characteristics, major complaint leading to admission, out-of-hospital, and in-hospital interventions and 30-day mortality were extracted from medical records of the electronic patient data management system. RESULTS: During the study period, we analyzed 40,764 patients admitted to the ED. Of these, 621 (1.5%) critically ill non-traumatic patients were admitted for life-threatening emergencies to the resuscitation room (age: 70 ± 16 years, 52% male). Leading problem on admission was disability/unconsciousness (D), shock (C), respiratory failure (B), airway obstruction (A), and environment problems (E) in 41%, 31%, 25%, 2%, and 1%, respectively. Out-of-hospital and in-hospital measures included: intravenous access (61% vs. 99%), 12-lead ECG (55% vs. 87%), invasive airway management (21% vs. 34%) invasive ventilation (21% vs. 34%), catecholamines (9% vs. 30%), arterial access (0% vs. 52%), and cardiopulmonary resuscitation (11% vs. 6%). The underlying diagnoses were mainly neurological (29%), followed by cardiological (28%), and pulmonological (20%) emergencies. The mean length of stay (LOS) in the resuscitation room and ED was 123 ± 122 and 415 ± 479 min, respectively. The 30-day mortality was 18.5%. CONCLUSION: The data describe the care of critically ill non-traumatic patients in the resuscitation room. Based on these data, algorithms for the structured care of critically ill non-traumatic patients need to be developed.

["B problems" in non-traumatic resuscitation room management]. / "B-Probleme" des nichttraumatologischen Schockraummanagements.

In the primary survey of resuscitation room management in critically ill nontrauma patients, the ABCDE (airway, breathing, circulation, disability, exposure) approach is used for immediate recognition and treatment of life-threatening conditions. "B problems" are associated with respiratory failure and require immediate treatment. The pathogenesis is diverse, especially in the nontrauma resuscitation room. Clinical examination, emergency sonography and knowledge of oxygenation techniques and ventilation are important components of diagnosis and therapy. Standardized procedures and regular training in the emergency room are of fundamental importance.

[SEPSIS-3.0-Is intensive care medicine ready for ICD-11?] / SEPSIS-3.0 ­ Ist die Intensivmedizin bereit für die ICD-11?

BACKGROUND: The 11th revision of the International Classification of Diseases (ICD-11) will come into effect in January 2022. Among other things, The Third International Consensus Definitions for Sepsis and Septic Shock (SEPSIS­3 definition) will be implemented in it. This defines sepsis as a "life-threatening organ dysfunction caused by a dysregulated host response to infection". The aim of the present secondary analysis of a survey on the topic of "sepsis-induced coagulopathy" was to evaluate whether the SEPSIS­3 definition, 4 years after its international introduction, has arrived in everyday clinical practice of intensive care units (ICU) run by anesthesiologists in Germany and thus the requirements for its use of the ICD-11 are given. METHODS: Between October 2019 and May 2020, we carried out a nationwide survey among German medical directors of ICUs. In a separate block of questions we asked about the definition of sepsis used in daily practice. In addition, we asked whether the quick-sequential (sepsis-related) organ failure assessment (qSOFA) score is used in screening for sepsis in the hospital to which to the participating ICU belongs. RESULTS: A total of 50 medical directors from anesthesiological ICUs took part in the survey. In total, the ICUs evaluated stated that they had around 14% of the high-care beds registered in Germany. The SEPSIS­3 definition is integrated into everyday clinical practice at 78.9% of the university hospitals and 84.0% of the participating teaching hospitals. In contrast, the qSOFA screening test is only used by 26.3% of the participating university hospitals, but at least 52% of the teaching hospitals and 80% of the other hospitals. CONCLUSION: The data show that both SEPSIS­3 and qSOFA have become part of everyday clinical practice in German hospitals. The cautious use of qSOFA at university hospitals with simultaneous broad acceptance of the SEPSIS­3 definition can be interpreted as an indication that the search for a suitable screening test for sepsis has not yet been completed.

Sublingual microcirculation predicts survival after out-of-hospital cardiac arrest.

BACKGROUND: Despite successful resuscitation with return of spontaneous circulation (ROSC), the prediction of survival in patients suffering out-of-hospital cardiac arrest (OHCA) remains difficult. Several studies have shown alterations in sublingual microcirculation in the critical ill. We hypothesized that early alterations in sublingual microcirculation may predict short-term survival after OHCA. METHODS: We prospectively included all adults admitted to our university hospital between April and September 2019 with ROSC following OHCA. Sidestream dark-field microscopy to obtain sublingual microcirculation was performed at admission and after 6, 12 and 24 hours. Primary outcome was survival until discharge. RESULTS: Twenty-five patients were included. Six hours after ROSC, the proportion of perfused small vessels (PPVsmall ) was lower in non-survivors than in survivors (85 ± 7.9 vs. 75 ± 6.6%; p = .01). PPVsmall did not correlate with serum lactate. Stratification for survival with cutoff values >78.4% for PPVsmall 6 h post-admission and <5.15 mmol/l for initial serum lactate as suggested by ROC-Analyses results in a positive predictive value of 100% and a negative one of 67% for our study population. CONCLUSION: Estimating short-term prognosis of OHCA patients with ROSC may be supported by measuring the PPVsmall at the sublingual microcirculation 6 hours after admission.

Admission Blood Glucose in the Emergency Department is Associated with Increased In-Hospital Mortality in Nontraumatic Critically Ill Patients.

BACKGROUND: Abnormal admission blood glucose was reported as a useful predictor of outcome in critically ill patients. OBJECTIVES: To identify patients at higher risk, this study aimed to evaluate the relationship between admission blood glucose levels and patient mortality during the management of nontraumatic critically ill patients in the emergency department (ED). METHODS: In this prospective, single-center observational study in a German university ED, all adult patients admitted to the resuscitation room of the ED were included between September 1, 2014 and August 31, 2015. Directly after resuscitation room admission, blood samples for admission blood glucose were taken, and adult patients were divided into groups according to predefined cut-offs between the admission blood glucose. Study endpoint was in-hospital mortality. RESULTS: During the study period, 532 patients were admitted to the resuscitation room. The data of 523 patients (98.3%) were available for analysis. The overall in-hospital mortality was 34.2%. In comparison with an in-hospital mortality of 25.2% at an admission blood glucose of 101-136 mg/dL (n = 107), admission blood glucose of ≤ 100 mg/dL (n = 25, odds ratio [OR] 6.30, 95% confidence interval [CI] 2.44-16.23, p < 0.001), 272-361 mg/dL (n = 63, OR 2.53, 95% CI 1.31-4.90, p = 0.007), and ≥ 362 mg/dL (n = 44, OR 2.96, 95% CI 1.42-6.18, p = 0.004) were associated with a higher mortality. CONCLUSIONS: Abnormal admission blood glucose is associated with a high in-hospital mortality. Admission blood glucose is an inexpensive and rapidly available laboratory parameter that may predict mortality and help to identify critically ill patients at risk in a general nontraumatic critically ill ED patient cohort. The breakpoint for in-hospital mortality may be an admission blood glucose ≤ 100 and ≥ 272 mg/dL.

[Commercial soda lime ingestion during a dive]. / Akzidentelle Atemkalkingestion im Rahmen eines Tauchganges.

Breathing lime is used in closed circuit and semi-closed circuit rebreathers (CCR/SCR) for technical diving. Similar to the use in anesthesia systems, the lime usually contains hydroxycarbamide, which can react to caustic soda under the influence of water. The ingestion of components of the soda lime can lead to burns of the esophageal mucosa with the formation of colliquation necrosis and the danger of esophageal perforation. Early endoscopy is essential in this case to assess the consequences of ingestion.

[Acute Abdominal Pain in the Emergency Department]. / Vom Leitsymptom zur Diagnose: abdominelle Beschwerden.

Abdominal pain is a common leading symptom in emergency medicine. This symptom complex includes a variety of different causes, ranging from intra-abdominal to extra-abdominal and retroperitoneal pathologies, which can affect all age groups. Abdominal complaints can include diseases ranging from trivialities to life-threatening emergencies. The acute abdominal condition is an interdisciplinary emergency in which interdisciplinary teamwork is mandatory. A rapid initial assessment and risk stratification is necessary in order to detect critically ill patients with an acute need for intervention at an early stage and to provide them with a suitable emergency therapy. A structured approach can identify the most important differential diagnoses.

Association between rapid weather changes and incidence of chiefly cardiovascular complaints in the emergency department.

INTRODUCTION: Studies suggest that there is an association between weather and cardiovascular disease (CVD) related visits in emergency departments (ED). METHODS: We used a case-crossover study design to investigate the association between ED visits for CVD and changes in temperature, atmospheric pressure, and relative humidity. Patient and weather data from the years 2014 and 2015 were used to investigate relevance of changes associated with weather in the frequency of CVD-related ED visits. They were correlated to overall variability of the visits adjusted to day of the week. RESULTS: In the study period 20,558 ED visits were related to CVD (mean per day: 28.3). Significant associations were identified for all three variables (temperature, atmospheric pressure, and relative humidity). Significant odds ratio (OR) was found for a large decrease in temperature 1.29 (95%-CI, 1.1-1.52). However, the related effects, although significant, were small compared to overall variability of visits. CONCLUSION: We found an association between rapid weather changes on the day before ED admission and ED visits due to CVD. In conclusion, a drop in temperature and an increase or decrease in atmospheric pressure and relative humidity are associated with a slight increase in CVD admissions. However, the observed significant effects seem to be too small to draw any conclusions in terms of ED capacity due to weather changes.

[Lactate in emergency medicine]. / Lactat in der Notfallmedizin.

The basis of all metabolic processes in the human body is the production and metabolism of carriers of energy. Lactate is the end-product of anaerobic glycolysis. Lactate can serve as a substrate for gluconeogenesis and as an oxidation substrate. Hyperlactatemia can be detected as the result of a multitude of acute events (e.g. shock, sepsis, cardiac arrest, trauma, seizure, ischemia, diabetic ketoacidosis, thiamine deficiency, liver failure and intoxication). Hyperlactatemia can be associated with increased mortality, therefore in emergency medicine the search for the cause of hyperlactatemia is just as important as an effective causal treatment. Repetitive measurements of lactate are components of several treatment algorithms as observation of the dynamic development of blood lactate concentrations can help to make a better assessment of the acute medical condition of the patient and to evaluate the effectiveness of the measures undertaken.

Post-mortem in situ stability of serum markers of cerebral damage and acute phase response.

The aim of the given study was to test the in situ stability of biochemical markers of cerebral damage and acute phase response in the early post-mortem interval to assess their usability for forensic pathology. A monocentric, prospective study investigated post-mortem femoral venous blood samples at four time points obtained within 48 h post-mortem starting at the death of 20 deceased, using commercial immunoassays for the ten parameters: S100 calcium-binding protein B (S100B), glial fibrillary acidic protein (GFAP), neuron-specific enolase (NSE), brain-derived neurotrophic factor (BDNF), interleukin-6 (IL-6), C-reactive protein (CRP), procalcitonin (PCT), ferritin, soluble tumor necrosis factor receptor type 1 (sTNFR1), and lactate dehydrogenase (LDH). Significant changes in serum levels were observed only later than 2 h after death for all markers. Inter-laboratory comparability was high, and intra-assay precision was sufficient for most markers. Most of the biomarker levels depended on the severity of hemolysis and lipemia but were robust against freeze-thaw cycles. Serum levels increased with longer post-mortem intervals for S100B, NSE, ferritin, sTNFR1, and LDH (for all p < 0.001) but decreased over this period for CRP (p = 0.089) and PCT (p < 0.001). Largely unchanged median values were found for GFAP (p = 0.139), BDNF (p = 0.106), and IL-6 (p = 0.094). Serum levels of CRP (p = 0.059) and LDH (p = 0.109) did not differ significantly between the final ante-mortem (resuscitation) and the first post-mortem sample (moment of death). Collecting the post-mortem blood sample as soon as possible will reduce the influence of post-mortem blood changes. Serum GFAP for detection of cerebral damage as well as serum IL-6 and CRP as proof of acute phase response seemed to be preferable due to their in situ stability in the first 2 days after death.

Early Lactate Dynamics in Critically Ill Non-Traumatic Patients in a Resuscitation Room of a German Emergency Department (OBSERvE-Lactate-Study).

BACKGROUND: Management of critically ill non-trauma patients in the resuscitation room of an emergency department (ED) is very challenging, and it is difficult to identify patients with a higher risk of death. Previous studies have shown that lactate indices can predict survival for selected diseases and syndromes. OBJECTIVE: As reported for other patient populations, we set out to determine whether admission lactate or lactate dynamics (LD) within 24 h can predict 30-day mortality in unselected critically ill non-traumatic patients. METHODS: In this retrospective study over a 1-year period, admission lactate, time weighted average lactate (LacTW) and LD of all critically ill adult patients admitted from ED to intensive care unit were analyzed. A linear regression model was implemented to estimate lactate data 1 h after admission. RESULTS: The admission lactate, LacTW, and LD within 24 h were analyzed from 392 critically ill patients. The overall 30-day mortality rate was around 29%. Admission lactate (4.1 ± 4.0 mmol/L vs. 6.6 ± 6.1 mmol/L; p < 0.01) and LacTW (1.8 ± 1.7 mmol/L vs. 4.1 ± 4.8 mmol/L; p < 0.01) were different between survivors and non-survivors. LD between survivors and non-survivors did not differ at 1 h, 6 h, 12 h, or 24 h. After excluding patients with out-of-hospital or in-hospital cardiac arrest during resuscitation room management, admission lactate and LD between survivors and non-survivors did not differ at 1 h, 12 h, and 24 h. LD at 6 h (44% ± 42% vs. 33% ± 58%; p = 0.042) and LacTW (1.7 ± 1.6 mmol/L vs. 2.6 ± 3.0 mmol/L; p < 0.01) did differ. CONCLUSIONS: In critically ill ED patients initially requiring treatment in a resuscitation room setting, LD at 6 h and LacTW may predict their survival beyond 30 days. These findings need to be confirmed in a prospective study design.

[Diagnostic Approaches in Sepsis - Part 1: General Diagnostic Principles, Focus Identification and Source Control]. / Diagnostik der Sepsis ­ Teil 1: allgemeine Diagnostik und Fokussuche-/sanierung.

Sepsis and septic shock represent medical emergencies with persistently high mortality rates. According to the lately revised Surviving Sepsis Campaign (SSC) guidelines, focus identification/pathogen detection and the initial administration of broad-spectrum antibiotics are to be secluded within one hour after recognition of the symptoms of sepsis. However, there is dispute concerning the so called hour-1 bundle. Being a core aspect of focus identification, imaging modalities mainly depend on the suspected site of infection and the individual patient. Contrast agent-enhanced computed tomography (CT) is the modality usually used in critically ill patients. The microbiological pathogen detection still largely remains culture-based. This emphasizes the significance of microbiological specimen obtained from easily accessible body compartments and at least 2 blood culture sets. If possible, blood cultures should be drawn prior to antibiotic administration. Intraoperatively obtained swabs of otherwise sterile body compartments are of utmost importance with regard to microbiological pathogen detection. Catheters and implanted medical devices (i.e. cardiac pacemakers or defibrillators) suspicious of infection should be explanted and sent in for microbiological workup as soon as possible. All necessary source control measures should be realized as soon as medically possible but at least within 6 - (12) hours after the onset of symptoms. There is no specific biomarker for sepsis so far. Procalcitonin (PCT) and C-reactive protein (CRP) are crucial biomarkers in terms of infectious disease management and guidance of antimicrobial therapy in the ICU. Positive clinical trials showed that biomarkers like the midregional pro-adrenomedullin (MR-proADM) or presepsin might be promising candidates in the diagnosis of sepsis in the future. As an important marker of microcirculatory failure and disrupted cell metabolism, lactate serum concentrations (and lactate-clearance, respectively) are of prognostic value in septic patients.

[Diagnostic Approaches in Sepsis - Part 2: Pathogen Detection]. / Diagnostik der Sepsis ­ Teil 2: Erregeridentifikation.

Despite the dissemination of innovative, molecular biology-based and commercially available devices for pathogen detection, culture-based methods with susceptibility testing remain the key principles for guiding antimicrobial treatment of patients suffering from sepsis or septic shock on the ICU. Culture-based methods are able to facilitate pathogen detection from a diversity of specimen (respiratory secretion, intraoperatively obtained smears, aspirates, and so forth). However, the latency from obtainment of the specimen up to pathogen detection with susceptibility testing is a major disadvantage of culture-based methods in critical illness. Molecular biology-based methods like Polymerase Chain Reaction (PCR) and especially Next-Generation Sequencing (NGS) based methods promise faster pathogen and resistance detection, but are not used in clinical routine yet. With more clinical trials to come, these innovative diagnostic tools may have the potential to lead to a paradigm shift within the context of pathogen identification in sepsis.

Frequency and intensity of pulmonary bone marrow and fat embolism due to manual or automated chest compressions during cardiopulmonary resuscitation.

Iatrogenic consequences of cardiopulmonary resuscitation (CPR) include sternal or rib fractures, pulmonary bone marrow embolisms (BME) and fat embolisms (FE). This report aimed to analyze the frequency and intensity of pulmonary BME and FE in fatal cases receiving final CPR efforts with the use of automated chest compression devices (ACCD) or manual chest compressions (mCC). The study cohort (all cardiac causes of death, no ante-mortem fractures) consisted of 15 cases for each group 'ACCD', 'mCC' and 'no CPR'. Lung tissue samples were retrieved and stained with hematoxylin eosin (n = 4 each) and Sudan III (n = 2 each). Evaluation was conducted microscopically for any existence of BME or FE, the frequency of BME-positive vessels, vessel size for BME and the graduation according to Falzi for FE. The data were compared statistically using non-parametric analyses. All groups were matched except for CPR duration (ACCD > mCC) but this time interval was linked to the existence of pulmonary BME (p = 0.031). Both entities occur in less than 25% of all cases following unsuccessful CPR. BME was only detectable in CPR cases, but was similar between ACCD and mCC cases for BME frequency (p = 0.666), BME intensity (p = 0.857) and the size of BME-affected pulmonary vessels (p = 0.075). If any, only mild pulmonary FE (grade I) was diagnosed without differences in the CPR method (p = 0.624). There was a significant correlation between existence of BME and FE (p = 0.043). Given the frequency, intensity and size of pulmonary BME and FE following CPR, these conditions may unlikely be considered as causative for death in case of initial survival but can be found in lower frequencies in autopsy histology.

Chest compression-associated injuries in cardiac arrest patients treated with manual chest compressions versus automated chest compression devices (LUCAS II) - a forensic autopsy-based comparison.

The aim of this autopsy study was to investigate chest-compression associated injuries to the trunk in out-of-hospital and in-hospital non-traumatic cardiac arrest patients treated with automated external chest compression devices (ACCD; all with LUCAS II devices) versus exclusive manual chest compressions (mCC). In this retrospective single-center study, all forensic autopsies between 2011 and 2017 were included. Injuries following cardiopulmonary resuscitation (CPR) in patients treated with mCC or ACCD were investigated and statistically compared using a bivariate logistic regression. In the seven-year period with 4433 autopsies, 614 were analyzed following CPR (mCC vs. ACCD: n = 501 vs. n = 113). The presence of any type of trunk injury was correlated with longer resuscitation intervals (30 ± 15 vs. 44 ± 25 min, p < 0.05). In comparison with mCC, treatment with ACCD led to more frequent skin emphysema (5 vs 0%, p = 0.012), pneumothorax (6 vs. 1%, p = 0.008), lung lesions (19 vs. 4%, p = 0.008), hemopericardium (3 vs 1%, p = 0.025) and liver lesions (10 vs. 1%, p = 0.001), all irrespective of confounding aspects. Higher age and longer CPR durations statistically influenced frequency of sternal and rib fractures (p < 0.001). The mean number of fractured ribs did not vary significantly between the groups (6 ± 3 vs. 7 ± 2, p = 0.09). In this cohort with unsuccessful CPR, chest compression-related injuries were more frequent following ACCD application than in the mCC group, but with only minutely increased odds ratios. The severity of injuries did not differ between the groups, and no iatrogenic injury was declared by the forensic pathologist as being fatal. In the clinical routine after successful return of spontaneous circulation a computed tomography scan for CPR-associated injuries is recommended as soon as possible.