Randomized placebo controlled trial of furosemide on subjective perception of dyspnoea in patients with pulmonary oedema because of hypertensive crisis.

BACKGROUND: To compare the administration of furosemide with placebo on the subjective perception of dyspnoea in patients with acute pulmonary oedema because of hypertensive crisis. Design Randomized, controlled and double-blinded clinical trial. SETTING: Municipal emergency medical service system and university-based emergency department. PARTICIPANTS: Fifty-nine patients with pulmonary oedema because of hypertensive crisis. INTERVENTIONS: Additional to administration of oxygen, morphine-hydrochloride and urapidil until the systolic blood pressure was below 160mmHg, the patients were randomized to receive furosemide 80mg IV bolus (furosemide group) or saline placebo (placebo group). MAIN OUTCOME MEASURES: The primary outcome was the subjective perception of dyspnoea as measured with a modified BORG scale at one hour after randomization. Secondary outcome parameters were the subjective perception of dyspnoea of patients as measured with a modified BORG scale and a visual analogue scale at 2, 3 and 6h after randomization of the patient; course of the systolic arterial pressure and peripheral oxygen saturation and lactate at admission and at 6h after admission. RESULTS: In 25 patients in the furosemide group and in 28 patients in the placebo group, a BORG score could be obtained. There was no statistically significant difference in the severity of dyspnoea at one hour after randomization (P=0·40). The median BORG score at 1h after randomization in the furosemide group was 3 (IQR 2 to 4) compared to 3 (IQR 2 to 7) in the placebo group (P=0·40). Those patients who were randomized to the placebo group needed higher doses of urapidil at 20min after randomization. There were no significant differences in the rate of adverse events, nonfatal cardiac arrests or death between the two groups. CONCLUSIONS: The subjective perception of dyspnoea in patients with hypertensive pulmonary oedema was not influenced by the application of a loop-diuretic. Therefore, additional furosemide therapy needs to be scrutinized in the therapy of these patients.

Platelet hyperfunction is decreased by additional aspirin loading in patients presenting with myocardial infarction on daily aspirin therapy.

OBJECTIVE: Currently 162-325 mg aspirin is recommended for the treatment of acute coronary syndrome. We tested the effect of an additional loading dose of 250 mg aspirin at the onset of acute coronary syndrome in patients who were already on chronic therapy with 100 mg aspirin. DESIGN: This was a prospective trial in patients presenting with symptoms suggestive of acute coronary syndrome that included a randomized, double-blind, placebo-controlled trial subgroup. SETTING: An emergency department in a tertiary care center. PATIENTS: Consecutive patients with symptoms suggestive of acute coronary syndrome were enrolled, including a cohort already on chronic aspirin therapy. INTERVENTIONS: Patients received an intravenous infusion of 250 mg aspirin. MEASUREMENTS AND MAIN RESULTS: Platelet function was measured with a platelet function analyzer in 234 patients before and after aspirin infusion. Aspirin infusion prolonged collagen epinephrine closure times in almost all patients. Aspirin infusion further lowered thromboxane B(2) levels in patients with acute coronary syndrome who were on chronic aspirin therapy before admission. Concomitantly, collagen epinephrine closure times increased by 22% from 223 secs (95% confidence interval, 192-255 secs) before to 273 secs (95% confidence interval, 252-294 secs) after aspirin infusion (p < .01). Eleven patients with ST-elevation myocardial infarction on daily aspirin therapy (53%) displayed platelet hyperfunction (collagen epinephrine closure times <193 secs). Additional aspirin infusion further decreased platelet function in these patients with ST-elevation myocardial infarction (30% prolongation of collagen epinephrine closure times; p < .01), and only two patients with ST-elevation myocardial infarction still displayed platelet hyperfunction (p = .02). CONCLUSION: Aspirin loading in the emergency room further reduced thromboxane B(2) levels and further inhibited platelet function in many patients with acute coronary syndrome already on 100 mg aspirin.

Physical strain on advanced life support providers in different out of hospital environments.

OBJECTIVES: To examine to what extent the type of emergency medical transportation influences the physical response of advanced life support providers. BACKGROUND: Providing external chest compression during resuscitation is physically exhausting. If the decision is made to bring the patient to a hospital undergoing resuscitation procedures, there are usually two options for transportation: ambulance vehicles or helicopters. There should be discussion on deciding which means of transportation should be preferred, because there is evidence that the quality of rescuers performance influences patient's outcome. METHODS: The study was a randomised crossover trial comparing physical strain on 11 European Resuscitation Council (ERC) approved healthcare professionals during external chest compression in different environments: (a) moving ambulance vehicle vs. (b) flying helicopter, and both compared to (c) staying at the scene (control). MAIN OUTCOME MEASURES: Difference in heart rate to systolic blood pressure ratio after 8 min of external chest compression. Secondary outcomes were BORG-rate of perceived exertion scale, blood pressure, serum lactate, and a Nine Hole Peg Test. RESULTS: Mean heart rate to systolic blood pressure ratio was 0.89+/-0.21 in the ambulance vehicle compared to 1.01+/-0.21 in the flying helicopter (p=0.04) There were no significant differences in the secondary outcome parameters. Perceived exertion increased by resuscitation time in all groups. CONCLUSION: External chest compression CPR is possible in a flying helicopter as it is in a moving ambulance vehicle. There is no clinical relevant difference in physical strain during ALS between a flying helicopter and a moving ambulance car. As would be expected, the exertion increases with duration of CPR.

Quality of closed chest compression in ambulance vehicles, flying helicopters and at the scene.

CONTEXT: Transport of patients during resuscitation is a critical procedure. In both, ambulances and helicopters the quality of resuscitation is potentially hampered due to the movement of the vehicle and confined space. To date, however, no direct comparison of the quality of resuscitation at the scene, during a helicopter flight and in a moving ambulance has been made. OBJECTIVE: Direct comparison of the quality of resuscitation at the scene, during a helicopter flight and in a moving ambulance. DESIGN: The study was performed in July 2005 as a randomised cross-over trial comparing different environments for resuscitation. SETTING: Medical University of Vienna. PARTICIPANTS: Eleven European Resuscitation Council (ERC) approved health care professionals. INTERVENTIONS: Interventions during resuscitation: (a) in a moving ambulance, (b) in a flying helicopter, were compared to those staying at the (c) scene (control). Each participant performed resuscitation in all three environments. MAIN OUTCOME MEASURES: Quality of chest compression during resuscitation. RESULTS: Compared to resuscitation at the scene, efficiency of chest compressions during a helicopter flight was 86% and 95% in the moving ambulance 95%. There were no differences in secondary outcomes (time without chest compression, total number of incorrect hand position relative to total compressions, and total number of incorrect pressure release relative to total compressions). CONCLUSIONS: Resuscitation during transport is feasible and relatively efficient. There is some difference between the environments, but there is no relevant difference between helicopters and ambulances regarding the effectiveness of CPR.

Major bleeding complications in cardiopulmonary resuscitation: the place of thrombolytic therapy in cardiac arrest due to massive pulmonary embolism.

OBJECTIVE: Thrombolytic therapy in patients with massive pulmonary embolism (MPE) and prolonged cardiopulmonary resuscitation (CPR) is subject to debate. This study was performed to determine whether (1) thrombolytic treatment increases the risk of bleeding complications, (2) if the risk of bleeding is influenced by the duration of CPR and if (3) thrombolytic therapy improves outcome. DESIGN: Retrospective cohort study. SETTING: Emergency department of a tertiary care university hospital. PATIENTS AND METHODS: Sixty-six patients with cardiac arrest (CA) due to MPE admitted between July 1993 and December 2001. Thirty-six patients received thrombolysis (TL) and were compared with 30 patients without thrombolytic therapy. Bleeding complications were assessed by clinical evidence or autopsy. RESULTS: Major bleeding complications appear to occur more frequently in patients treated with thrombolytics (9/36 (25%) vs. 3/30 (10%)) even though the difference was statistically not significant (P=0.15). It appears that CPR duration >10 min has no adverse impact on major bleeding complications. No difference in the rate of major bleeding complications between thrombolyzed patients who had a CPR duration of 10 min could be observed (2/8 (25%) vs. 7/28 (25%), P=0.99). In thrombolyzed patients a return of spontaneous circulation could be achieved more frequently (24/36 (67%) vs.13/30 (43%) in controls, P=0.06) and survival after 24 h was higher (19/36 (53%) vs. 7/30 (23%), P=0.01). Survival to discharge was also higher in the TL group (7/36 (19%) vs. 2/30 (7%)), but not statistically significant (P=0.15). CONCLUSION: Although severe bleeding complications tend to occur more frequently in patients undergoing TL, the benefit of this treatment might outweigh the risk of bleeding.

[Surgical reduction of fat surplus leading to pulmonary embolism]. / Pulmonalembolie nach chirurgischer Fettreduktion.

Surgical reduction of fat surplus is usually performed on healthy individuals and is reported as a safe procedure as it is not associated with a lethal outcome. Due to the anticipation of peri- and postoperative bleeding as a result of the large wound area, which may have a negative influence on the cosmetic result, patients often receive no or only inadequate anticoagulation. We report three cases in which surgical reduction of fat surplus led to sudden collapse and cardiac arrest. In all of our patients, fatal pulmonary embolism was the cause of cardiac arrest. These patients received only inadequate or no anticoagulation. Early postoperative mobilization, elastic stockings and compressive wound-dressing did not prevent pulmonary embolism. In addition to early postoperative mobilization of the patient and even though there is a risk of perioperative bleeding complications, the use of anticoagulation is highly recommended in surgical procedures like abdominoplasty or dermolipectomy. If sudden dyspnea, chest pain, collapse or cardiac arrest occurs after surgical interventions like these, pulmonary embolism should be considered and further diagnostic steps should be initiated.

Arterial puncture closing devices compared with standard manual compression after cardiac catheterization: systematic review and meta-analysis.

CONTEXT: Arterial puncture closing devices (APCDs) were developed to replace standard compression at the puncture site and to shorten bed rest following percutaneous coronary intervention. OBJECTIVE: To assess the safety and efficacy of APCDs (Angioseal, Vasoseal, Duett, Perclose, Techstar, Prostar) compared with standard manual compression in patients undergoing coronary angiography or percutaneous vascular interventions. DATA SOURCES: A systematic literature search of MEDLINE (1966-January 2003), EMBASE (1989-January 2003), PASCAL (1996-January 2003), BIOSIS (1990-January 2003), and CINHAL (1982-January 2003) databases and the Cochrane Central Register of Controlled Trials for relevant articles in any language. STUDY SELECTION: Included randomized controlled trials reporting vascular complications at the puncture site (hematoma, bleeding, arteriovenous fistula, pseudoaneurysm) and efficacy (time to hemostasis, time to ambulation, time to discharge from hospital). DATA EXTRACTION: Two reviewers abstracted the data independently and in duplicate. Disagreements were resolved by discussion among at least 3 reviewers. The most important criteria were adequacy of allocation concealment, whether the analysis was according to the intention-to-treat principle, and if person assessing the outcome was blinded to intervention group. Random-effects models were used to pool the data. DATA SYNTHESIS: Thirty trials met the selection criteria and included up to 4000 patients. When comparing any APCD with standard compression, the relative risk (RR) of groin hematoma was 1.14 (95% confidence interval [CI], 0.86-1.51; P =.35); bleeding, 1.48 (95% CI, 0.88-2.48; P =.14); developing an arteriovenous fistula, 0.83 (95% CI, 0.23-2.94; P =.77); and developing a pseudoaneurysm at the puncture site, 1.19 (95% CI, 0.75-1.88; P =.46). Time to hemostasis was shorter in the group with APCD compared with standard compression (mean difference, 17 minutes; range, 14-19 minutes), but there was a high degree of heterogeneity among studies. Only 2 studies explicitly reported allocation concealment, blinded outcome assessment, and intention-to-treat analysis. When limiting analyses to only trials that used explicit intention-to-treat approaches, APCDs were associated with a higher risk of hematoma (RR, 1.89; 95% CI, 1.13-3.15) and a higher risk of pseudoaneurysm (RR, 5.40; 95% CI, 1.21-24.5). CONCLUSIONS: Based on this meta-analysis of 30 randomized trials, many of poor methodological quality, there is only marginal evidence that APCDs are effective and there is reason for concern that these devices may increase the risk of hematoma and pseudoaneurysm.

Quality of closed chest compression on a manikin in ambulance vehicles and flying helicopters with a real time automated feedback.

CONTEXT: Automated verbal and visual feedback improves quality of resuscitation in out-of-hospital cardiac arrest and was proven to increase short-term survival. Quality of resuscitation may be hampered in more difficult situations like emergency transportation. Currently there is no evidence if feedback devices can improve resuscitation quality during different modes of transportation. OBJECTIVE: To assess the effect of real time automated feedback on the quality of resuscitation in an emergency transportation setting. DESIGN: Randomised cross-over trial. SETTING: Medical University of Vienna, Vienna Municipal Ambulance Service and Helicopter Emergency Medical Service Unit (Christophorus Flugrettungsverein) in September 2007. PARTICIPANTS: European Resuscitation Council (ERC) certified health care professionals performing CPR in a flying helicopter and in a moving ambulance vehicle on a manikin with human-like chest properties. INTERVENTIONS: CPR sessions, with real time automated feedback as the intervention and standard CPR without feedback as control. MAIN OUTCOME MEASURES: Quality of chest compression during resuscitation. RESULTS: Feedback resulted in less deviation from ideal compression rate 100 min(-1) (9+/-9 min(-1), p<0.0001) with this effect becoming steadily larger over time. Applied work was less in the feedback group compared to controls (373+/-448 cm x compression; p<0.001). Feedback did not influence ideal compression depth significantly. There was some indication of a learning effect of the feedback device. CONCLUSIONS: Real time automated feedback improves certain aspects of CPR quality in flying helicopters and moving ambulance vehicles. The effect of feedback guidance was most pronounced for chest compression rate.