Currently, the decision to initiate extracorporeal life support for patients who suffer cardiac arrest due to accidental hypothermia is essentially based on serum potassium level. Our goal was to ...build a prediction score in order to determine the probability of survival following rewarming of hypothermic arrested patients based on several covariates available at admission.
We included consecutive hypothermic arrested patients who underwent rewarming with extracorporeal life support. The sample comprised 237 patients identified through the literature from 18 studies, and 49 additional patients obtained from hospital data collection. We considered nine potential predictors of survival: age; sex; core temperature; serum potassium level; mechanism of hypothermia; cardiac rhythm at admission; witnessed cardiac arrest, rewarming method and cardiopulmonary resuscitation duration prior to the initiation of extracorporeal life support. The primary outcome parameter was survival to hospital discharge.
Overall, 106 of the 286 included patients survived (37%; 95% CI: 32–43%), most (84%) with a good neurological outcome. The final score included the following variables: age, sex, core temperature at admission, serum potassium level, mechanism of cooling, and cardiopulmonary resuscitation duration. The corresponding area under the receiver operating characteristic curve was 0.895 (95% CI: 0.859–0.931) compared to 0.774 (95% CI: 0.720–0.828) when based on serum potassium level alone.
In this large retrospective study we found that our score was superior to dichotomous triage based on serum potassium level in assessing which hypothermic patients in cardiac arrest would benefit from extracorporeal life support. External validation of our findings is required.
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment ...Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
The HOPE score, based on covariates available at hospital admission, predicts the probability of in-hospital survival after extracorporeal life support (ECLS) rewarming of a given hypothermic cardiac ...arrest patient with accidental hypothermia. Our goal was to externally validate the HOPE score.
We included consecutive hypothermic arrested patients who underwent rewarming with ECLS. The sample comprised 122 patients. The six independent predictors of survival included in the HOPE score were collected for each patient: age, sex, mechanism of hypothermia, core temperature at admission, serum potassium level at admission and duration of CPR. The primary outcome parameter was survival to hospital discharge.
Overall, 51 of the 122 included patients survived, resulting in an empirical (global) probability of survival of 42% (95% CI = 33–51%). This was close to the average HOPE survival probability of 38% calculated for patients from the validation cohort, while the Hosmer–Lemeshow test comparing empirical and HOPE (i.e. estimated) probabilities of survival was not significant (p = 0.08), suggesting good calibration. The corresponding area under the receiver operating characteristic curve was 0.825 (95% CI = 0.753–0.897), confirming the excellent discrimination of the model. The negative predictive value of a HOPE score cut-off of <0.10 was excellent (97%).
This study provides the first external validation of the HOPE score reaching good calibration and excellent discrimination. Clinically, the prediction of the HOPE score remains accurate in the validation sample. The HOPE score may replace serum potassium in the future as the triage tool when considering ECLS rewarming of a hypothermic cardiac arrest victim.
Autoresuscitation describes the return of spontaneous circulation after termination of resuscitation (TOR) following cardiac arrest (CA). We aimed to identify phenomena that may lead to ...autoresuscitation and to provide guidance to reduce the likelihood of it occurring.
We conducted a literature search (Google Scholar, MEDLINE, PubMed) and a scoping review according to PRISMA-ScR guidelines of autoresuscitation cases where patients undergoing CPR recovered circulation spontaneously after TOR with the following criteria: 1) CA from any cause; 2) CPR for any length of time; 3) A point was reached when it was felt that the patient had died; 4) Staff declared the patient dead and stood back. No further interventions took place; 5) Later, vital signs were observed. 6) Vital signs were sustained for more than a few seconds, such that staff had to resume active care.
Sixty-five patients with ROSC after TOR were identified in 53 articles (1982-2018), 18 (28%) made a full recovery.
Almost a third made a full recovery after autoresuscitation. The following reasons for and recommendations to avoid autoresuscitation can be proposed: 1) In asystole with no reversible causes, resuscitation efforts should be continued for at least 20 min; 2) CPR should not be abandoned immediately after unsuccessful defibrillation, as transient asystole can occur after defibrillation; 3) Excessive ventilation during CPR may cause hyperinflation and should be avoided; 4) In refractory CA, resuscitation should not be terminated in the presence of any potentially-treatable cardiac rhythm; 5) After TOR, the casualty should be observed continuously and ECG monitored for at least 10 min.
Throughout history, accidental hypothermia has accompanied natural disasters in cold, temperate, and even subtropical regions. We conducted a non-systematic review of the causes and means of ...preventing accidental hypothermia after natural disasters caused by avalanches, earthquakes, tsunamis, and floods. Before a disaster occurs, preventive measures are required, such as accurate disaster risk analysis for given areas, hazard mapping and warning, protecting existing structures within hazard zones to the greatest extent possible, building structures outside hazard zones, and organising rapid and effective rescue. After the event, post hoc analyses of failures, and implementation of corrective actions will reduce the risk of accidental hypothermia in future disasters.
Hypothermia has notable effects on platelets, platelet function, fibrinogen, and coagulation factors. Common laboratory techniques cannot identify those effects, because blood samples are usually ...warmed to 37°C before analysis and do not fully reflect the
situation. Multiple aspects of the pathophysiological changes in humoral and cellular coagulation remain obscure. This
experimental study aimed to compare the measurements of thromboelastometry (TEM), multiple-electrode aggregometry (MEA) and Real Time Live Confocal Imaging for the purpose of identifying and characterizing hypothermia-associated coagulopathy.
Blood samples were drawn from 18 healthy volunteers and incubated for 30 min before being analyzed at the target temperatures (37, 32, 24, 18, and 13.7°C). At each temperature thromboelastometry and multiple-electrode aggregometry were measured. Real Time Live Confocal Imaging was performed at 4, 24, and 37°C. The images obtained by Real Time Live Confocal Imaging were compared with the functional results of thromboelastometry and multiple-electrode aggregometry.
Thromboelastometry standard parameters were impaired at temperatures below baseline 37°C (ANOVA overall effect,
< 0.001): clotting time was prolonged by 27% at 13.7°C and by 60% at 18°C (
< 0.044); clot formation time was prolonged by 157% (
< 0.001). A reduction in platelet function with decreasing temperatures was observed (
< 0.001); the area under the curve at 13.7°C was reduced by 96% (ADP test), 92% (ASPI test), and 91% (TRAP test) of the baseline values. Temperature-associated changes in coagulation were visualized with Real Time Live Confocal Imaging. Molecular changes such as the temperature-associated decrease in the fibrin network are paralleled by cellular effects like the lesser activity of the platelets as a result of decreased temperature. The maximum clot firmness (MCF) in TEM only changed slightly within the temperature range tested.
The inhibitory effects of temperature on clot formation were visualized with Real Time Live Confocal Microscopy and compared with standard point-of-care testing. Inhibition of clotting factors and impaired platelet function are probably a result of hypothermia-induced impairment of thrombin. Measurement of MCF in TEM does not fully concur with Real Time Live Confocal Microscopy or MEA in hypothermia.
Recent technical and strategical developments have increased the survival chances for avalanche victims. Still hundreds of people, primarily recreationists, get caught and buried by snow avalanches ...every year. About 100 die each year in the European Alps-and many more worldwide. Refining concepts for avalanche rescue means to optimize the procedures such that the survival chances are maximized in order to save the greatest possible number of lives. Avalanche rescue includes several parameters related to terrain, natural hazards, the people affected by the event, the rescuers, and the applied search and rescue equipment. The numerous parameters and their complex interaction make it unrealistic for a rescuer to take, in the urgency of the situation, the best possible decisions without clearly structured, easily applicable decision support systems. In order to analyse which measures lead to the best possible survival outcome in the complex environment of an avalanche accident, we present a numerical approach, namely a Monte Carlo simulation. We demonstrate the application of Monte Carlo simulations for two typical, yet tricky questions in avalanche rescue: (1) calculating how deep one should probe in the first passage of a probe line depending on search area, and (2) determining for how long resuscitation should be performed on a specific patient while others are still buried. In both cases, we demonstrate that optimized strategies can be calculated with the Monte Carlo method, provided that the necessary input data are available. Our Monte Carlo simulations also suggest that with a strict focus on the "greatest good for the greatest number", today's rescue strategies can be further optimized in the best interest of patients involved in an avalanche accident.
ObjectivesTo elucidate gender differences in snowboarding accidents.DesignRetrospective registry analysis within the Austrian National Registry of Mountain Accidents.SettingSnowboard-related ...emergencies between November 2005 and October 2018.ParticipantsAll injured snowboarders with documented injury severity and gender (3536 men; 2155 women).Primary and secondary outcome measuresGender-specific analysis of emergency characteristics and injury patterns.ResultsOver time, the number of mild, severe and fatal injuries per season decreased in men but not in women. Accidents most frequently were interindividual collisions (>80%) and occurred when heading downhill on a slope. Men more often suffered injuries to the shoulder (15.1% vs 9.2%) and chest (6.8% vs 4.4%), were involved in accidents caused by falling (12.9% vs 9.6%) or obstacle impact (4.3% vs 1.5%), while on slopes with higher difficulty levels (red: 42.6% vs 39.9%; black: 4.2% vs 2.5%), while snowboarding in a park (4.8% vs 2.1%) and under the influence of alcohol (1.6% vs 0.5%). Women more often sustained injuries to the back (10.2% vs 13.1%) and pelvis (2.9% vs 4.2%), on easier slopes (blue: 46.1% vs 52.4%) and while standing or sitting (11.0% vs 15.8%). Mild injuries were more frequent in women (48.6% vs 56.4%), severe and fatal injuries in men (36.0% vs 29.7% and 0.9% vs 0.4%). Male gender, age and the use of a helmet were risk factors for the combined outcome of severe or fatal injuries (OR (99% CI): 1.22 (1.00 to 1.48), 1.02 (1.02 to 1.03) and 1.31 (1.05 to 1.63)). When wearing a helmet, the relative risk (RR) for severe injuries increased while that for mild injuries decreased in male snowboarders only (RR (95% CI): 1.21 (1.09 to 1.34) and 0.88 (0.83 to 0.95)).ConclusionsSnowboard injuries are proportionally increasing in women and the observed injury patterns and emergency characteristics differ substantially from those of men. Further gender-specific research in snowboard-related injuries should be encouraged.Trial registration numberNCT03755050.
Background As pediatric patients are typically rare among helicopter emergency medical systems (HEMS), children might be at risk for oligo-analgesia due to the rescuer's lack of experience and the ...fear of side effects. Methods In this retrospective analysis, data was obtained from the üAMTC HEMS digital database including 14 physician staffed helicopter bases in Austria over a 12-year timeframe. Primary missions involving pediatric trauma patients (< 15 years) not mechanically ventilated on-site were included. Analgesia was assessed and compared between the age groups 0-5, 6-10 and 11-14 years. Results Of all flight missions, 8.2% were dedicated to children < 15 years. Analgetic drugs were administered in 31.4% of all primary missions (3874 of 12,324), wherefrom 2885 were injured and non-ventilated (0-5 yrs.: n = 443; 6-10 yrs.: n = 902; 11-14 yrs.: n = 1540). The majority of these patients (> 75%) suffered moderate to severe pain, justifying immediate analgesia. HEMS physicians typically chose a monotherapy with an opioid (n = 1277; 44.3%) or Esketamine (n = 1187; 41.1%) followed by the combination of both (n = 324; 11.2%). Opioid use increased (37.2% to 63.4%) and Esketamine use decreased (66.1% to 48.3%) in children < 6 vs. > 10 years. Esketamine was more often administered in extremity (57.3%) than in head (41.5%) or spine injuries (32.3%). An intravenous access was less often established in children < 6 years (74.3% vs. 90.8%; p < 0.001). Despite the use of potent analgesics, 396 missions (13.7%) were performed without technical monitoring. Particularly regarding patient data at handover in hospital, merely < 10% of all missions featured complete documentation. Therefore, sufficient evaluation of the efficacy of pain relief was not possible. Yet, by means of respiratory measures required during transport, severe side effects such as respiratory insufficiency, were barely noted. Conclusions In the physician-staffed HEMS setting, pediatric trauma patients liberally receive opioids and Esketamine for analgesia. With regard to severe respiratory insufficiency during transport, the application of these potent analgesics seems safe. Keywords: Children, Air ambulance, Analgesia, Accident, Emergency medicine services, Wounds and injuries
Currently, healthcare management fosters a maximization of performance despite a relative shortage of specialists. We evaluated anaesthesiologists' workload, physical health, emotional well-being, ...job satisfaction and working conditions under increased pressure from consolidated working hours. A nationwide cross-sectional survey was performed in Austrian anaesthesiologists (overall response rate 41.0%). Three hundred and ninety four anaesthesiologists (280 specialists, 114 anaesthesiology trainees) participated. Anaesthesiologists reported frequently working under time pressure (95%CI: 65.6-74.6), at high working speed (95%CI: 57.6-67.1), with delayed or cancelled breaks (95%CI: 54.5-64.1), and with frequent overtime (95%CI: 42.6-52.4). Perceived work climate correlated with task conduct (manner of work accomplishment, the way in which tasks were completed), participation (decision-making power in joint consultation and teamwork), psychosocial resources, uncertainty, task variability and time tolerance (authority in time management and control over operating speed) (all P <0.001). Having not enough time for oneself (95%CI: 47.6-57.4), for sleep (95%CI: 45.6-55.4) or for one's partner and children (95%CI: 21.8-30.4) was common. One-third of the participants reported frequent feelings of being unsettled (95%CI: 33.4-43.0) and difficulty talking about their emotions (95%CI: 27.3-36.5). Frequent dissatisfaction with life was reported by 11.4% (95%CI: 8.7-14.9) of the respondents. Strong time pressure and little decision-making authority during work along with long working hours and frequent work interruptions constitute the basis for occupational stress in anaesthesiologists. We conclude that increased pressure to perform during work hours contributes to emotional exhaustion and poor work-life balance. Changes in the work schedule of anaesthesiologists are required to avoid negative effects on health and emotional well-being.
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