We investigated the relationship between lactate clearance and outcome in patients surviving the first 48 hours after cardiac arrest. We conducted the study in the emergency department of an urban ...tertiary care hospital. We analyzed the data for all 48-hour survivors after successful resuscitation from cardiac arrest during a 10-year period. Serial lactate measurements, demographic data, and key cardiac arrest data were correlated to survival and best neurologic outcome within 6 months after cardiac arrest. Parameters showing significant results in univariate analysis were tested for significance in a logistic regression model. Of 1502 screened patients, 394 were analyzed. Survivors (n = 194, 49%) had lower lactate levels on admission (median, 7.8 interquartile range, 5.4-10.8 vs 9 6.6-11.9 mmol/L), after 24 hours (1.4 1-2.5 vs 1.7 1.1-3 mmol/L), and after 48 hours (1.2 0.9-1.6 vs 1.5 1.1-2.3 mmol/L). Patients with favorable neurologic outcome (n = 186, 47%) showed lower levels on admission (7.6 5.4-10.3 vs 9.2 6.7-12.1 mmol/L) and after 48 hours (1.2 0.9-1.6 vs 1.5 1-2.2 mmol/L). In multivariate analysis, lactate levels at 48 hours were an independent predictor for mortality (odds ratio OR: 1.49 increase per mmol/L, 95% confidence interval CI: 1.17-1.89) and unfavorable neurologic outcome (OR: 1.28 increase per mmol/L, 95% CI: 1.08-1.51). Lactate levels higher than 2 mmol/L after 48 hours predicted mortality with a specificity of 86% and poor neurologic outcome with a specificity of 87%. Sensitivity for both end points was 31%. Lactate at 48 hours after cardiac arrest is an independent predictor of mortality and unfavorable neurologic outcome. Persisting hyperlactatemia over 48 hours predicts a poor prognosis.
Summary Aim of the study Cold infusions have proved to be effective for induction of therapeutic hypothermia after cardiac arrest but so far have not been used for hypothermia maintenance. This study ...investigates if hypothermia can be induced and maintained by repetitive infusions of cold fluids and muscle relaxants. Material and methods Patients were eligible, if they had a cardiac arrest of presumed cardiac origin and no clinical signs of pulmonary oedema or severely reduced left ventricular function. Rocuronium (0.5 mg/kg bolus, 0.5 mg/kg/h for maintenance) and crystalloids (30 ml/kg/30 min for induction, 10 ml/kg every 6 h for 24 h maintenance) were administered via large bore peripheral venous cannulae. If patients failed to reach 33 ± 1 °C bladder temperature within 60 min, endovascular cooling was applied. Results Twenty patients with a mean age of 57 (±15) years and mean body mass index of 27 (±4) kg/m2 were included (14 males). Mean temperature at initiation of cooling (median 27 (IQR 16; 87) min after admission) was 35.4 (±0.9) °C. In 13 patients (65%) the target temperature was reached within 60 min, 7 patients (35%) failed to reach the target temperature. Maintaining the target temperature was possible in three (15%) patients and no adverse events were observed. Conclusion Cold infusions are effective for induction of hypothermia after cardiac arrest, but for maintenance additional cooling techniques are necessary in most cases.
Abstract Background In CPR, sufficient compression depth is essential. The American Heart Association (“at least 5 cm”, AHA-R) and the European Resuscitation Council (“at least 5 cm, but not to ...exceed 6 cm”, ERC-R) recommendations differ, and both are hardly achieved. This study aims to investigate the effects of differing target depth instructions on compression depth performances of professional and lay-rescuers. Methods 110 professional-rescuers and 110 lay-rescuers were randomized (1:1, 4 groups) to estimate the AHA-R or ERC-R on a paper sheet (given horizontal axis) using a pencil and to perform chest compressions according to AHA-R or ERC-R on a manikin. Distance estimation and compression depth were the outcome variables. Results Professional-rescuers estimated the distance according to AHA-R in 19/55 (34.5%) and to ERC-R in 20/55 (36.4%) cases ( p = 0.84). Professional-rescuers achieved correct compression depth according to AHA-R in 39/55 (70.9%) and to ERC-R in 36/55 (65.4%) cases ( p = 0.97). Lay-rescuers estimated the distance correctly according to AHA-R in 18/55 (32.7%) and to ERC-R in 20/55 (36.4%) cases ( p = 0.59). Lay-rescuers yielded correct compression depth according to AHA-R in 39/55 (70.9%) and to ERC-R in 26/55 (47.3%) cases ( p = 0.02). Conclusion Professional and lay-rescuers have severe difficulties in correctly estimating distance on a sheet of paper. Professional-rescuers are able to yield AHA-R and ERC-R targets likewise. In lay-rescuers AHA-R was associated with significantly higher success rates. The inability to estimate distance could explain the failure to appropriately perform chest compressions. For teaching lay-rescuers, the AHA-R with no upper limit of compression depth might be preferable.
National authorities have introduced measures as lockdowns against spreading of COVID-19 and documented incidences of multiple non-COVID-19 diseases have dropped. Yet, data on workload dynamics ...concerning atrial fibrillation and electrical cardioversion whilst a national lockdown are scarce and may assist in future planning.
Documented cases of atrial fibrillation and respective electrical cardioversion episodes at the Emergency Department of the Medical University of Vienna, Austria, from 01/01/2020 to 31/05/2020 were assessed. As reference groups, those incidences were calculated for the years 2017, 2018, and 2019. Inter- and intra-year analyses were conducted through Chi-square test and Poisson regression.
A total of 2,310 atrial fibrillation-, and 511 electrical cardioversion episodes were included. We found no significant incidence differences in inter-year analyses of the time periods from January to May, or of the weeks pre- and post the national lockdown due to the COVID-19 pandemic. However, the intra-year analysis of the year 2020 showed a trend toward decreased atrial fibrillation incidences (rate-ratio 0.982, CI 0.964-1.001,
= 0.060), and significantly increased electrical cardioversion incidences in the post-lockdown period (rate ratio 1.051, CI 1.008-10.96,
= 0.020).
The decreased atrial fibrillation incidences are in line with international data. However, an increased demand of electrical cardioversions during the lockdown period was observed. A higher threshold to seek medical attention may produce a selected group with potentially more severe clinical courses. In addition, lifestyle modifications during isolation and a higher stress level may promote atrial fibrillation episodes to be refractory to other therapeutic approaches than electrical cardioversion.
IMPORTANCE: Whether the simultaneous intravenous administration of potassium and magnesium is associated with the probability of spontaneous conversion to sinus rhythm (SCV) in the acute treatment of ...atrial fibrillation (AF) and atrial flutter (AFL) is unknown. OBJECTIVE: To assess potassium and magnesium administration and SCV probability in AF and AFL in the emergency department. DESIGN, SETTING, AND PARTICIPANTS: A registry-based cohort study was conducted in the Department of Emergency Medicine of the Medical University of Vienna, Austria. All consecutive patients with AF or AFL were screened between February 6, 2009, and February 16, 2020. INTERVENTIONS: Intravenous administration of potassium, 24 mEq, and magnesium, 145.8 mg. MAIN OUTCOMES AND MEASURES: The primary outcome was the probability of SCV during the patient’s stay in the emergency department. Multivariable cluster-adjusted logistic regression was used to estimate the association between potassium and magnesium administration and the probability of SCV. RESULTS: A total of 2546 episodes of nonpermanent AF (median patient age, 68 IQR, 58-75 years, 1411 55.4% men) and 573 episodes of nonpermanent AFL (median patient age, 68 IQR, 58-75 years; 332 57.9% men) were observed. In AF episodes, intravenous potassium and magnesium administration vs no administration was associated with increased odds of SCV (19.2% vs 10.4%; odds ratio OR, 1.98; 95% CI, 1.53-2.57). In AFL episodes, in contrast, no association was noted for the probability of SCV with potassium and magnesium vs no administration (13.0% vs 12.5%; OR, 1.05; 95% CI, 0.65-1.69). CONCLUSIONS AND RELEVANCE: The findings of this registry-based cohort study on intravenous administration of potassium and magnesium suggest an increased probability of SCV in nonpermanent AF, but not AFL, during a patients’ stay in the emergency department.
Hypokalemic paralysis in a professional bodybuilder Mayr, Florian B., MD, MPH; Domanovits, Hans, MD; Laggner, Anton N., MD
The American journal of emergency medicine,
09/2012, Letnik:
30, Številka:
7
Journal Article
Recenzirano
Severe hypokalemia is a potentially life-threatening disorder and is associated with variable degrees of skeletal muscle weakness, even to the point of paralysis. On rare occasions, diaphragmatic ...paralysis from hypokalemia can lead to respiratory arrest. There may also be decreased motility of smooth muscle, manifesting with ileus or urinary retention. Rarely, severe hypokalemia may result in rhabdomyolysis. Other manifestations of severe hypokalemia include alteration of cardiac tissue excitability and conduction. Hypokalemia can produce electrocardiographic changes such as U waves, T-wave flattening, and arrhythmias, especially if the patient is taking digoxin. Common causes of hypokalemia include extrarenal potassium losses (vomiting and diarrhea) and renal potassium losses (eg, hyperaldosteronism, renal tubular acidosis, severe hyperglycemia, potassium-depleting diuretics) as well as hypokalemia due to potassium shifts (eg, insulin administration, catecholamine excess, familial periodic hypokalemic paralysis, thyrotoxic hypokalemic paralysis). Although the extent of diuretic misuse in professional bodybuilding is unknown, it may be regarded as substantial. Hence, diuretics must always be considered as a cause of hypokalemic paralysis in bodybuilders.
Background:
While contributors to system delay in ST-elevation myocardial infarction (STEMI) are well described, predictors of patient-related delays are less clear. The aim of this study was to ...identify predictors that cause delayed diagnosis of STEMI in a metropolitan system of care (VIENNA STEMI network) and to investigate a possible association with long-term mortality.
Methods:
The study population investigated consisted of 2366 patients treated for acute STEMI in the Vienna STEMI registry from 2003–2009. Multivariable regression modelling was performed for (a) onset of pain to first medical contact (FMC) as a categorical variable (pain-to-FMC⩽60 min versus >60 min: ‘early presenters’ versus ‘late presenters’); and for (b) onset of pain-to-FMC (min) as a continuous variable.
Results:
After multivariable adjustment, female sex (odds ratio (OR) 1.348; 95% confidence interval (CI) 1.013–1.792; p=0.04) and diabetes mellitus (OR 1.355; 95% CI 1.001–1.835; p=0.05) were independently associated with late presentation in STEMI patients, whereas cardiogenic shock (OR 0.582; 95% CI 0.368–0.921; p=0.021) was a predictor of early diagnosis. When onset of pain-to-FMC was treated as a continuous variable, female sex (p=0.003), anterior infarction (p=0.004) and diabetes mellitus (p=0.035) were independently associated with longer delay, while hyperlipidaemia (p=0.002) and cardiogenic shock (p=0.017) were strong predictors of short pain-to-FMC times. Three-year-all cause mortality was 9.6% and 11.3% (p=0.289) for early and late presenters, respectively. After adjustment for clinical factors (sex, age, diabetes, current smoking, hypertension, hyperlipidaemia, cardiogenic shock and location of myocardial infarction) only a trend for increased risk of all-cause death was observed for longer pain-to-FMC times in a cox regression model (hazard ratio (HR) 1.012; 95% CI 0.999–1.025 for every 10 min of delay; p=0.061). Interestingly, early presentation within one hour of symptom onset was not associated with three-year mortality survival (HR 1.031; 95% CI 0.676–1.573; p=0.886).
Conclusion:
In this all-comers study of STEMI patients in the VIENNA STEMI network, cardiogenic shock was the strongest predictor of short patient-related delays, whereas a history of diabetes and female sex were independent associated with late diagnosis in STEMI. After adjustment for clinical confounders, patient related delay did not significantly impact on long-term all-cause mortality.
Right ventricular function is an important prognostic factor for pulmonary embolism. 1 Massive pulmonary embolism may lead to right ventricular failure, reduced left ventricular output, and even ...death. 2 Cardiac troponins are routinely applied markers of minor and major myocardial damage in patients with acute coronary syndromes. Participants, methods, and results We assessed 136 consecutive patients who were admitted to the emergency department of a tertiary care university hospital between December 1999 and November 2001 with pulmonary embolism, confirmed by computed tomography or scintigraphy.
Summary Aim of the study The admission blood glucose level after cardiac arrest is predictive of outcome. However the blood glucose levels in the post-resuscitation period, that are optimal remains a ...matter of debate. We wanted to assess an association between blood glucose levels at 12 h after restoration of spontaneous circulation and neurological recovery over 6 months. Materials and methods A total of 234 patients from a multi-centre trial examining the effect of mild hypothermia on neurological outcome were included. According to the serum glucose level at 12 h after restoration of spontaneous circulation, quartiles (Q) were generated: Median (range) glucose concentrations were for QI 100 (67–115 mg/dl), QII 130 (116–143 mg/dl), QIII 162 (144–193 mg/dl) and QIV 265 (194–464 mg/dl). Results In univariate analysis there was a strong non-linear association between blood glucose and good neurological outcome (odds ratio compared to QIV): QI 8.05 (3.03–21.4), QII 13.41 (4.9–36.67), QIII 1.88 (0.67–5.26). After adjustment for sex, age, “no-flow” and “low-flow” time, adrenaline (epinephrine) dose, history of coronary artery disease and myocardial infarction, and therapeutic hypothermia, this association still remained strong: QI 4.55 (1.28–16.12), QII 13.02 (3.29–49.9), QIII 1.37 (0.38–5.64). Conclusion There is a strong non-linear association of survival with good neurological outcome and blood glucose levels 12 h after cardiac arrest even after adjusting for potential confounders. Not only strict normoglycaemia, but also blood glucose levels from 116 to 143 mg/dl were correlated with survival and good neurological outcome, which might have an important therapeutic implication.
PDF
