Abstract Aim of the study Application of mild hypothermia (32–33 °C) has been shown to improve neurological outcome in patients with cardiac arrest. However, hypothermia affects hemostasis, and even ...mild hypothermia is associated with bleeding and increased transfusion requirements in surgery patients. On the other hand, crystalloid hemodilution has been shown to induce a hypercoagulable state. The study aim was to elucidate in which way the induction of mild therapeutic hypothermia by a bolus infusion of cold crystalloids affects the coagulation system of patients with cardiac arrest. Methods This was a prospective pilot study in 18 patients with cardiac arrest and return of spontaneous circulation (ROSC). Mild hypothermia was initiated by a bolus infusion of cold 0.9% saline fluid (4 °C; 30 ml/kg/30 min) and maintained for 24 h. At 0 h (before hypothermia), 1, 6 and 24 h we assessed coagulation parameters (PT, APPT), platelet count and performed thrombelastography (ROTEM) after in vitro addition of heparinase. Results A total amount of 2528 (±528) ml of 0.9% saline fluid was given. Hematocrit ( p < 0.01) and platelet count (−27%; p < 0.05) declined, whereas APTT increased (2.7-fold; p < 0.01) during the observation period. All ROTEM parameters besides clotting time (CT) after 1 h (−20%; p < 0.05) did not significantly change. Conclusion Mild hypothermia only slightly prolonged clotting time as measured by rotation thrombelastography. Therefore, therapeutic hypothermia initiated by cold crystalloid fluids has only minor overall effects on coagulation in patients with cardiac arrest.
Abstract Background Carbon monoxide (CO) is regarded as a leading cause of morbidity and mortality. It endangers not only patients, but also health care professionals, especially emergency medical ...services (EMS) personnel because CO exposure is often unknown at the time EMS is called. Objective Our objective was to report a case of unrecognized CO exposure during the treatment of a patient that finally led to the hospitalization of 11 EMS personnel. Case Report A 71-year-old man was found unconscious in the basement of his house. EMS was called and, due to ST-segment elevations on electrocardiogram, the patient was treated for acute coronary syndrome. Unknown to EMS personnel, ongoing CO exposure was the cause of the patient's symptoms. EMS staff finally had to be evacuated by firefighters, and a total of 12 persons, including the initial patient, had to be hospitalized. Conclusions In the prehospital setting, hazardous environments always have to be considered as potential causes of a patient's altered status. Together with the correct use of modern equipment, such as permanently switched-on CO detectors, this can help avoid harm to both patients and staff.
Background and Purpose —Recent animal studies showed that mild resuscitative hypothermia improves neurological outcome when applied after cardiac arrest. In a 3-year randomized, prospective, ...multicenter clinical trial, we hypothesized that mild resuscitative cerebral hypothermia (32°C to 34°C core temperature) would improve neurological outcome after cardiac arrest. Methods —We lowered patients’ temperature after admission to the emergency department and continued cooling for at least 24 hours after arrest in conjunction with advanced cardiac life support. The cooling technique chosen was external head and total body cooling with a cooling device in conjunction with a blanket and a mattress. Infrared tympanic thermometry was monitored before a central pulmonary artery thermistor probe was inserted. Results —In 27 patients (age 58 interquartile range IQR 52 to 64 years; 7 women; estimated “no-flow” duration 6 IQR 1 to 11 minutes and “low-flow” duration 15 IQR 9 to 23 minutes; admitted to the emergency department 36 IQR 24 to 43 minutes after return of spontaneous circulation), we could initiate cooling within 62 (IQR 41 to 75) minutes and achieve a pulmonary artery temperature of 33±1°C 287 (IQR 42 to 401) minutes after cardiac arrest. During 24 hours of mild resuscitative hypothermia, no major complications occurred. Passive rewarming >35°C was accomplished within 7 hours. Conclusions —Mild resuscitative hypothermia in patients is feasible and safe. A clinical multicenter trial might prove that mild hypothermia is a useful method of cerebral resuscitation after global ischemic states.
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 12h after restoration of spontaneous circulation and neurological recovery over 6 months.
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 12h 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).
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).
There is a strong non-linear association of survival with good neurological outcome and blood glucose levels 12h 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.
OBJECTIVETo determine whether patients with hypertensive urgency have a higher risk for subsequent cardiovascular events compared with hypertensive patients without this event.
METHODSOverall, 384 ...patients with hypertensive urgency and 295 control patients were followed up for at least 2 years. Hypertensive urgency was defined as a systolic blood pressure above 220 mmHg and/or a diastolic blood pressure above 120 mmHg without any evidence of acute end-organ damage. The control group consisted of patients admitted to the emergency department with a systolic blood pressure between 135 to 180 mmHg and a diastolic blood pressure between 85–110 mmHg. The number of cardiovascular events defined as acute coronary syndrome, acute stroke, atrial fibrillation, acute left ventricular failure and aortic aneurysm were consecutively analyzed during follow-up. The median follow-up time was 4.2 years (interquartile range 2.9–5.7 years). Twenty-six patients of the urgency group and 23 patients of the control group were lost for follow-up.
RESULTSOverall, 117 (17%) patients had nonfatal clinical cardiovascular events and 13 had (2%) fatal cardiovascular events. The frequency of cardiovascular events was significantly higher in patients with hypertensive urgencies (88 vs. 42; P = 0.005). The Cox regression analysis identified age (P < 0.001) and hypertensive urgencies (P = 0.035) as independent predictors for subsequent cardiovascular events.
CONCLUSIONSHypertensive urgencies are associated with an increased risk for subsequent cardiovascular events in patients with arterial hypertension.
OBJECTIVEComparison of oscillometric blood pressure measurement with two different devices (M3000A using a new algorithm and M1008A using an established algorithm, both Hewlett Packard) and ...evaluation of current recommendations concerning the relation between cuff size and upper arm circumference in critically ill patients.
DESIGNProspective data collection.
SETTINGEmergency department in a 2000-bed inner-city hospital.
PATIENTSA total of 30 patients categorized into three groups according to their upper arm circumference (I, 18–25 cm; II, 25.1–33 cm; III, 33.1–47.5 cm) were enrolled in the study protocol.
INTERVENTIONSIn each patient, two noninvasive blood pressure devices with three different cuff sizes were used to perform oscillometric blood pressure measurement. Invasive mean arterial blood pressure measurement was done by cannulation of the radial artery.
MEASUREMENT AND MAIN RESULTSOverall, 1,011 pairs of simultaneous oscillometric and invasive blood pressure measurements were collected in 30 patients (group I, n = 10; group II, n = 10; group III, n = 10). The overall discrepancy between both methods with the M3000A was −2.4 ± 11.8 mm Hg (p < .0001) and, with the M1008A, −5.3 ± 11.6 mm Hg (p < .0001) if the recommended cuff size according to the upper arm circumference was used (352 measurements). If smaller cuff sizes than recommended were used (308 measurements performed in group II and III), the overall discrepancy between both methods with the M3000A was 1.3 ± 13.4 mm Hg (p < .024) and, with the M1008A, −2.3 ± 11.5 mm Hg (p < .0001).
CONCLUSIONThe new algorithm reduced the overall bias of the oscillometric method but still showed a significant discrepancy between both methods of blood pressure measurement, primarily due to the mismatch between upper arm circumference and cuff size. The improvement of the algorithm alone could not result in a sufficient improvement of oscillometric blood pressure measurement. A reevaluation of the recommendations concerning the relation between upper arm circumference and cuff size are urgently required if oscillometric blood pressure measurement should become a reasonable alternative to intra-arterial blood pressure measurement in critically ill patients.
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 or >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.
Objectivo: A terapêutica trombolı́tica no contexto de tromboembolismo pulmonar maciço (TEPM) e reanimação cardiorespiratória prolongada (RCP) é alvo de debate. Este estudo foi realizado com o objectivo de clarificar se: (1) O tratamento trombolı́tico aumenta as complicações hemorrágicas, (2) se o risco hemorrágico é influenciado pela duração da RCR e se (3) os trombolı́ticos melhoram o prognóstico.
Desenho: Estudo cohort retrospectivo.
Contexto: Departamento de Emergência dum hospital terciário e universitário.
Doentes e métodos: 66 doentes em PCR associada a TEPM admitidos entre Julho de 1993 e Dezembro de 2001. 36 doentes receberam trombólise (TL) e foram comparados com 30 doentes que não foram alvo de TL. As complicações hemorrágicas foram avaliadas por evidência clı́nica ou por autópsia.
Resultados: As complicações hemorrágicas significativas parecem ocorrer com maior frequência em doentes que receberam TL (9/36 (25%) vs. 3/30 (10%) embora a diferença não tenha significado estatı́stico (
P=0.15). Parece que a duração > 10 minutos da RCR não tem impacto negativo nas complicações hemorrágicas. Não se verificou nenhuma diferença significativa na taxa de complicações hemorrágicas, entre o grupo que recebeu TL e que tiveram RCR com duração ≤10 ou >10 minutos (2/8(25%) vs. 7/28 (25,
P=0.99). A recuperação de circulação espontânea ocorreu com maior frequência nos doentes que receberam TL (24/36 (67%) vs. 13/30 (43%) no grupo controlo,
P=0.06) a sobrevivência ás 24 horas foi igualmente superior (19/36 (53%) vs. 7/30 (23%),
P=0.01. A sobrevivência até a alta hospitalar foi igualmnete mais elevada no grupo que recebeu TL (7/36 (19%) vs. 2/30 (7%), mas sem significado estatı́stico (
P=0.15).
Conclusão: Apesar das complicações hemorrágicas significativas ocorrerem com maior frequência em doentes que fizeram TL, o benefı́cio deste tipo de tratamento pode ultrapassar os riscos hemorrágicos.
Objetivo: La terapia trombolı́tica en pacientes con embolı́a pulmonar masiva (MPE) y reanimación cardiopulmonar (RCP) prolongada es objeto de debate. Este estudio se realizó para determinar (1) si acaso el tratamiento trombolı́tico aumenta el riesgo de complicaciones hemorrágicas, (2) si el riesgo de sangrado es influenciado por la duración de la RCP y (3) si la terapia trombolı́tica mejora el resultado.
Diseño: Estudio retrospectivo de cohorte.
Ambiente: Departamento de emergencias de un hospital universitario de cuidados de nivel terciario.
Pacientes y métodos: sesenta y seis pacientes con paro cardı́aco (CA) debido a embolı́a pulmonar masiva, admitidos entre julio 1993 y diciembre 2001. 36 pacientes recibieron trombolisis (TL) y fueron comparados con 30 que no recibieron terapia trombolı́tica. Las complicaciones hemorrágicas fueron evaluadas por evidencia clı́nica o autopsia.
Resultados: Las complicaciones hemorrágicas mayores parecen ocurrir mas frecuentemente en pacientes tratados con trombolı́ticos (9/36 (25%) vs. 3/30 (10%)) aun cuando la diferencia fue estadı́sticamente no significativa (
P=0.15). La RCP de >10 minutos de duración no parece tener impacto adverso en las complicaciones hemorrágicas mayores No se observó diferencia en la tasa complicaciones hemorrágicas mayores entre pacientes trombolizados que recibieron RCP ≤10 ó >10 minutos (2/8 (25%) vs. 7/28 (25%),
P=0.99). En los pacientes trombolizados se alcanzó retorno a circulación espontánea mas frecuentemente (24/36 (67%) vs. 13/30 (43%) en los controles,
P=0.06) y la sobrevida después de 24 horas fue mas alta (19/36 (53%) vs. 7/30 (23%),
P=0.01). La sobrevida al alta fue mas alta en el grupo TL (7/36 (19%) vs 2/30(7%)), pero no es estadı́sticamente significativa (
P=0.15).
Conclusión: Aunque las complicaciones hemorrágicas severas tienden a ocurrir con mayor frecuencia en pacientes con terapia trombolı́tica, el beneficio de este tratamiento puede prevalecer sobre el riesgo de sangrado.
The prediction of neurological outcome in comatose cardiac arrest survivors has enormous ethical and socioeconomic implications. The purpose of the present study was to investigate the prognostic ...relevance of the time course of serum neuron-specific enolase (NSE) as a biochemical marker of hypoxic brain damage.
Serial analysis of serum NSE levels was performed in 56 patients resuscitated from witnessed, nontraumatic, normothermic, in- or out-of-hospital cardiac arrest. The neurological outcome was evaluated with the use of the cerebral performance category (CPC) within 6 months after restoration of spontaneous circulation (ROSC). The Mann-Whitney U test was used to compare patients with good (CPC 1 to 2) and bad (CPC 3 to 4) neurological outcome. The diagnostic performance at different time points after ROSC was described in terms of areas under receiver operating characteristic curves according to standard methods.
Patients with a bad neurological outcome (CPC 3 to 4) had significantly higher NSE levels than those with a good neurological outcome at 12 (P=0.004), 24 (P=0.04), 48 (P<0.001), and 72 hours (P<0.001) after ROSC. The maximum NSE level measured within 72 hours after ROSC was also significantly higher in patients with a bad neurological outcome (P<0.001). The NSE value at 72 hours after ROSC was the best predictor of neurological outcome (area under the curve=0.92+/-0.04). In addition, we also found a significant difference in the time course of NSE concentrations during the first 3 days after ROSC.
Serum NSE levels are valuable adjunctive parameters for assessing neurological outcome after cardiac arrest.
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