European Resuscitation Council Guidelines for Resuscitation 2010 Section 5. Initial management of acute coronary syndromes

Prognostic implications and outcomes of cardiac arrest among contemporary patients with STEMI treated with PCI

Background

Cardiac arrest (CA) complicating ST-elevation myocardial infarction (STEMI) is associated with a disproportionately higher risk of mortality. We described the contemporary presentation, management, and outcomes of CA patients in the era of primary percutaneous coronary intervention (PCI).

Methods

We reviewed 1,272 consecutive STEMI patients who underwent PCI between 1/1/2011-12/31/2016 and compared characteristics and outcomes between non-CA (N = 1,124) and CA patients (N = 148), defined per NCDR definitions as pulseless arrest requiring cardiopulmonary resuscitation and/or defibrillation within 24-hr of PCI.

Results

Male gender, cerebrovascular disease, chronic kidney disease, in-hospital STEMI, left main or left anterior descending culprit vessel, and initial TIMI 0 or 1 flow were independent predictors for CA. CA patients had longer door-to-balloon-time (106 [83,139] vs. 97 [74,121] minutes, p = 0.003) and greater incidence of cardiogenic shock (48.0% vs. 5.9%, p < 0.001), major bleeding (25.0% vs. 9.4%, p < 0.001), and 30-day mortality (16.2% vs. 4.1%, p < 0.001). Risk score for 30-day mortality based on presenting characteristics provided excellent prognostic accuracy (area under the curve = 0.902). However, over long-term follow-up of 4.5 ± 2.4 years among hospital survivors, CA did not portend any additional mortality risk (HR: 1.01, 95% CI: 0.56–1.82, p = 0.97).

Conclusions

In a contemporary cohort of STEMI patients undergoing primary PCI, CA occurs in >10% of patients and is an important mechanism of mortality in patients with in-hospital STEMI. While CA is associated with adverse outcomes, it carries no additional risk of long-term mortality among survivors highlighting the need for strategies to improve the in-hospital care of STEMI patients with CA.

Identification of return of spontaneous circulation during cardiopulmonary resuscitation via pulse oximetry in a porcine animal cardiac arrest model

In this prospective study we investigated whether the pulse oximetry plethysmographic waveform (POP) could be used to identify return of spontaneous circulation (ROSC) during cardio-pulmonary resuscitation (CPR). Tweleve pigs (28 ± 2 kg) were randomly assigned to two groups: Group I (non-arrested with compressions) (n = 6); Group II (arrested with CPR and defibrillation) (n = 6). Hemodynamic parameters and POP were collected and analyzed. POP was analyzed using both a time domain method and a frequency domain method. In Group I, when compressions were carried out on subjects with a spontaneous circulation, a hybrid fluctuation or "envelope" phenomenon appeared in the time domain method and a "double" or "fusion" peak appeared in the frequency domain method. In Group II, after the period of ventricular fibrillation was induced, the POP waveform disappeared. With compressions, POP showed a regular compression wave. After defibrillation, ROSC, and continued compressions, a hybrid fluctuation or "envelope" phenomenon appeared in the time domain method and a "double" or "fusion" peak appeared in the frequency domain method, similar to Group I. Analysis of POP using the time and frequency domain methods could be used to identify ROSC during CPR.

A five-year retrospective study of out-of-hospital cardiac arrest in a north-east Italian urban area

BACKGROUND

The reporting and analysing of data of out-of-hospital cardiac arrests encourages the quality improvement of the emergency medical services. For this reason, the establishment of a sufficiently large patient database is intended to allow analysis of resuscitation treatments for out-of-hospital cardiac arrests and performances of different emergency medical services.

AIMS

The aim of this study was to describe the demographics, characteristics, outcomes and determinant factors of survival for patients who suffered an out-of-hospital cardiac arrest.

METHODS

this was a retrospective study including all out-of-hospital cardiac arrest cases treated by the emergency medical service in the district of Udine (Italy) from 1 January 2010-31 December 2014.

RESULTS

A total of 1105 out-of-hospital cardiac arrest patients were attended by the emergency medical service. Of these, 489 (44.2%) underwent cardiopulmonary resuscitation, and return of spontaneous circulation was achieved in 142 patients (29%). There was a male predominance overall, and the main age was 72.6 years (standard deviation 17.9). Cardiopulmonary resuscitation before emergency medical service arrival was performed on 62 cases (44%) in the return of spontaneous circulation group, and on 115 cases (33%) in the no return of spontaneous circulation group ( p<0.024). Among the 142 cases of return of spontaneous circulation, 29 (5.9%) survived to hospital discharge. There was a smaller likelihood of return of spontaneous circulation when patients were female (odds ratio 0.61, 0.40-0.93). Patients who had an out-of-hospital cardiac arrest with an initial shockable rhythm (odds ratio 6.33, 3.86-10.39) or an age <60 years (odds ratio 2.91, 1.86-4.57) had a greater likelihood of return of spontaneous circulation. In addition, bystander cardiopulmonary resuscitation (odds ratio 1.56, 1.04-2.33) was associated with an increased chance of return of spontaneous circulation.

CONCLUSION

The incidence of out-of-hospital cardiac arrest and survival rate lies within the known range. A wider database is necessary to achieve a better knowledge of out-of-hospital cardiac arrest and to drive future investments in the healthcare system.

Guideline adherence in acute coronary syndromes between telemedically supported paramedics and conventional on-scene physician care: A longitudinal pre-post intervention cohort study

Health informatics applications reduce time intervals in acute coronary syndromes, but their impact on guideline adherence is unknown. This pre-post intervention study compared guideline adherence between telemedically supported (n = 101, April 2014-July 2015) and conventional on-scene care (n = 120, January 2014-March 2014) in acute coronary syndrome. A multivariate logistic regression was performed for dependent variables: adverse events 0 versus 0, p = NA; electrocardiogram 101 versus 120, p = NA; acetylic salicylic acid 91 versus 102, p = 0.21; heparin 92 versus 112, p = 0.99; morphine 96 versus 107, p = 0.33; oxygen 83 versus 102, p = 0.92; glyceroltrinitrate 55 versus 90, p = 0.038; correct destination: 100 versus 119, p = 1.0. The time from ambulance arrival to hospital arrival was prolonged with telemedicine: 48.7 ± 11 min versus 35.5 ± 8.1 min, p < 0.001. Guideline adherence showed no differences except for glyceroltrinitrate. Prolonged time requirements are critical, though explainable. However, this approach enables a timely and high-quality backup strategy if only paramedics are on-scene.

The effect of a national web course "Help-Brain-Heart" as a supplemental learning tool before CPR training: a cluster randomised trial

BACKGROUND

The effectiveness of cardiopulmonary resuscitation (CPR) learning methods is unclear. Our aim was to evaluate whether a web course before CPR training, teaching the importance of recognition of symptoms of stroke and acute myocardial infarction (AMI) and a healthy lifestyle, could influence not only theoretical knowledge but also practical CPR skills or willingness to act in a cardiac arrest situation.

METHODS

Classes with 13-year-old students were randomised to CPR training only (control) or a web course plus CPR training (intervention). Data were collected (practical test and a questionnaire) directly after training and at 6 months. CPR skills were evaluated using a modified Cardiff test (12-48 points). Knowledge on stroke symptoms (0-7 points), AMI symptoms (0-9 points) and lifestyle factors (0-6 points), and willingness to act were assessed by the questionnaire. The primary endpoint was CPR skills at 6 months. CPR skills directly after training, willingness to act and theoretical knowledge were secondary endpoints. Training and measurements were performed from December 2013 to October 2014.

RESULTS

Four hundred and thirty-two students were included in the analysis of practical skills and self-reported confidence. The mean score for CPR skills was 34 points after training (control, standard deviation [SD] 4.4; intervention, SD 4.0; not significant [NS]); and 32 points at 6 months for controls (SD 3.9) and 33 points for intervention (SD 4.2; NS). At 6 months, 73% (control) versus 80% (intervention; P = 0.05) stated they would do compressions and ventilation if a friend had a cardiac arrest, whereas 31% versus 34% (NS) would perform both if the victim was a stranger. One thousand, two hundred and thirty-two students were included in the analysis of theoretical knowledge; the mean scores at 6 months for the control and intervention groups were 2.8 (SD 1.6) and 3.2 (SD 1.4) points (P < 0.001) for stroke symptoms, 2.6 (SD 2.0) and 2.9 (SD 1.9) points (P = 0.008) for AMI symptoms and 3.2 (SD 1.2) and 3.4 (SD 1.0) points (P < 0.001) for lifestyle factors, respectively.

DISCUSSION

Use of online learning platforms is a fast growing technology that increases the flexibility of learning in terms of location, time and is available before and after practical training.

CONCLUSIONS

A web course before CPR training did not influence practical CPR skills or willingness to act, but improved the students' theoretical knowledge of AMI, stroke and lifestyle factors.

The effect of high-risk ST elevation myocardial infarction transfer patients on risk-adjusted in-hospital mortality: A report from the American Heart Association Mission: Lifeline program

BACKGROUND

Hospital mortality is an important quality measure for acute myocardial infarction care. There is a concern that despite risk adjustment, percutaneous coronary intervention hospitals accepting a greater volume of high-risk ST elevation myocardial infarction (STEMI) transfer patients may have their reported mortality rates adversely affected.

METHODS

The STEMI patients in the National Cardiovascular Data RegistryAcute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines from April 2011 to December 2013 were included. High-risk STEMI was defined as having either cardiogenic shock or cardiac arrest on first medical contact. Receiving hospitals were divided into tertiles based on the ratio of high-risk STEMI transfer patients to the total number of STEMI patients treated at each hospital. Using the Action Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines in-hospital mortality risk model, we calculated the difference in risk-standardized in-hospital mortality before and after excluding high-risk STEMI transfers in each tertile.

RESULTS

Among 119,680 STEMI patients treated at 539 receiving hospitals, 37,028 (31%) were transfer patients, of whom 4,500 (12%) were highrisk. The proportion of high-risk STEMI transfer patients ranged from 0% to 12% across hospitals. Unadjusted mortality rates in the low-, middle-, and high-tertile hospitals were 6.0%, 6.0%, and 5.9% among all STEMI patients and 6.0%, 5.5%, and 4.6% after excluding high-risk STEMI transfers. However, risk-standardized hospital mortality rates were not significantly changed after excluding high-risk STEMI transfer patients in any of the 3 hospital tertiles (low, -0.04%; middle, -0.05%; and high, 0.03%).

CONCLUSIONS

Risk-adjusted in-hospital mortality rates were not adversely affected in STEMI-receiving hospitals who accepted more high-risk STEMI transfer patients when a clinical mortality risk model was used for risk adjustment.

Controversies in Out of Hospital Cardiac Arrest?

Cardiac arrest is a major cause of morbidity and mortality and accounts for nearly 500,000 deaths annually in the United States. In patients suffering out-of-hospital cardiac arrest, survival is less than 15%, with considerable regional variation. Although most deaths occur during the initial resuscitation, an increasing proportion occur in patients hospitalized after initially successful resuscitation. In these patients, the significant subsequent morbidity and mortality is due to "post cardiac arrest syndrome." Until recently, most single interventions have yielded little improvement in rates of survival; however, there is growing recognition that optimal treatment strategies during the postresuscitation phase may improve outcomes.

Platelet inhibition with prasugrel in patients with acute myocardial infarction undergoing therapeutic hypothermia after cardiopulmonary resuscitation

Acute myocardial infarction (AMI) is the leading cause for out-of-hospital cardiac arrest. Therapeutic hypothermia improves neurological outcome in combination with early revascularisation, but seems to affect clopidogrel responsiveness. The more potent thienopyridine prasugrel has not yet been sufficiently evaluated during therapeutic hypothermia. We investigated 23 consecutive AMI patients (61 ± 11 years) following out-of-hospital resuscitation undergoing revascularisation and therapeutic hypothermia. Prasugrel efficacy was assessed by the platelet-reactivity-index (PRI) before and 2, 4, 6, 12, 24, 48, and 72 hours (h) following a loading dose of 60 mg via a gastric tube. Mean PRI (± SD) was 70 ± 12 % prior to loading and 60 ± 16 % (2 h, ns), 52 ± 21 % (4 h, p< 0.01), 42 ± 26 % (6 h, p< 0.01), 37 ± 21 % (12 h, p< 0.01), 27 ± 23 % (24 h, p< 0.01), 18 ± 14 % (48 h, p< 0.01), and 13 ± 10 % (72 h, p< 0.01) after loading. Sufficient platelet inhibition occurred later compared to stable AMI patients (6 h vs 2 h); however, high on-treatment platelet reactivity significantly decreased over time and was non-existent after 72 h (PRI> 50 %: 2 h: 72 %, 4 h: 52 %, 6 h: 43 %, 12 h: 29 %, 24 h: 17 %, 48 h: 5 %, 72 h: 0 %). There was no relation between 30-day mortality rate (26 %) and PRI values. Prasugrel significantly reduced platelet reactivity even during vasopressor use, analgosedation and therapeutic hypothermia. Despite a significant delay compared to stable AMI patients, sufficient platelet inhibition was reached in 83 % of patients within 24 h. Therefore, prasugrel administration via gastric tube might be a useful therapeutic strategy in these patients at high risk, providing potent and effective P2Y12 inhibition.

Hyperoxia in intensive care, emergency, and peri-operative medicine: Dr. Jekyll or Mr. Hyde? A 2015 update

This review summarizes the (patho)-physiological effects of ventilation with high FiO₂ (0.8–1.0), with a special focus on the most recent clinical evidence on its use for the management of circulatory shock and during medical emergencies. Hyperoxia is a cornerstone of the acute management of circulatory shock, a concept which is based on compelling experimental evidence that compensating the imbalance between O₂ supply and requirements (i.e., the oxygen dept) is crucial for survival, at least after trauma. On the other hand, “oxygen toxicity” due to the increased formation of reactive oxygen species limits its use, because it may cause serious deleterious side effects, especially in conditions of ischemia/reperfusion. While these effects are particularly pronounced during long-term administration, i.e., beyond 12–24 h, several retrospective studies suggest that even hyperoxemia of shorter duration is also associated with increased mortality and morbidity. In fact, albeit the clinical evidence from prospective studies is surprisingly scarce, a recent meta-analysis suggests that hyperoxia is associated with increased mortality at least in patients after cardiac arrest, stroke, and traumatic brain injury. Most of these data, however, originate from heterogenous, observational studies with inconsistent results, and therefore, there is a need for the results from the large scale, randomized, controlled clinical trials on the use of hyperoxia, which can be anticipated within the next 2–3 years. Consequently, until then, “conservative” O₂ therapy, i.e., targeting an arterial hemoglobin O₂ saturation of 88–95 % as suggested by the guidelines of the ARDS Network and the Surviving Sepsis Campaign, represents the treatment of choice to avoid exposure to both hypoxemia and excess hyperoxemia.

Pulse Oximetry: A Non-Invasive, Novel Marker for the Quality of Chest Compressions in Porcine Models of Cardiac Arrest

Objective

Pulse oximetry, which noninvasively detects the blood flow of peripheral tissue, has achieved widespread clinical use. We have noticed that the better the quality of cardiopulmonary resuscitation (CPR), the better the appearance of pulse oximetry plethysmographic waveform (POP). We investigated whether the area under the curve (AUC) and/or the amplitude (Amp) of POP could be used to monitor the quality of CPR.

Design

Prospective, randomized controlled study.

Setting

Animal experimental center in Peking Union Medical Collage Hospital, Beijing, China.

Subjects

Healthy 3-month-old male domestic swine.

Interventions

34 local pigs were enrolled in this study. After 4 minutes of untreated ventricular fibrillation, animals were randomly assigned into two resuscitation groups: a “low quality” group (with a compression depth of 3cm) and a “high quality” group (with a depth of 5cm). All treatments between the two groups were identical except for the depth of chest compressions. Hemodynamic parameters [coronary perfusion pressure (CPP), partial pressure of end-tidal carbon dioxide (P_ETCO₂)] as well as AUC and Amp of POP were all collected and analyzed.

Measurements and Findings

There were statistical differences between the “high quality” group and the “low quality” group in AUC, Amp, CPP and P_ETCO₂ during CPR (P<0.05). AUC, Amp and CPP were positively correlated with P_ETCO₂, respectively (P<0.01). There was no statistical difference between the heart rate calculated according to the POP (F_CPR) and the frequency of mechanical CPR at the 3^rd minute of CPR. The F_CPR was lower than the frequency of mechanical CPR at the 6^th and the 9^th minute of CPR.

Conclusions

Both the AUC and Amp of POP correlated well with CPP and P_ETCO₂ in animal models. The frequency of POP closely matched the CPR heart rate. AUC and Amp of POP might be potential noninvasive quality monitoring markers for CPR.

Post resuscitation care of out-of-hospital cardiac arrest patients in the Nordic countries: a questionnaire study

Background

Aim of this study was to compare post resuscitation care of out-of-hospital cardiac arrest (OHCA) patients in Nordic (Denmark, Finland, Iceland, Norway, Sweden) intensive care units (ICUs).

Methods

An online questionnaire was sent to Nordic ICUs in 2012 and was complemented by an additional one in 2014.

Results

The first questionnaire was sent to 188 and the second one to 184 ICUs. Response rates were 51 % and 46 %. In 2012, 37 % of the ICUs treated all patients resuscitated from OHCA with targeted temperature management (TTM) at 33 °C. All OHCA patients admitted to the ICU were treated with TTM at 33 °C more often in Norway (69 %) compared to Finland (20 %) and Sweden (25 %), p 0.02 and 0.014. In 2014, 63 % of the ICUs still use TTM at 33 °C, but 33 % use TTM at 36 °C. Early coronary angiography (CAG) and possible percutaneous coronary intervention (PCI) was routinely provided for all survivors of OHCA in 39 % of the hospitals in 2012 and in 28 % of the hospitals in 2014. Routine CAG for all actively treated victims of OHCA was performed more frequently in Sweden (51 %) and in Norway (54 %) compared to Finland (13 %), p 0.014 and 0.042.

Conclusions

Since 2012, TTM at 36 °C has been implemented in some ICUs, but TTM at 33 °C is used in majority of the ICUs. TTM at 33 or 36 °C and primary CAG are not routinely provided for all OHCA survivors and the criteria for these and ICU admission are variable. Best practices as a uniform approach to the optimal care of the resuscitated patient should be sought in the Nordic Countries.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-015-0141-z) contains supplementary material, which is available to authorized users.

Criteria of the German Society of Cardiology for the establishment of chest pain units: update 2014

Since 2008, the German Cardiac Society (DGK) has been establishing a network of certified chest pain units (CPUs). The goal of CPUs was and is to carry out differential diagnostics of acute or newly occurring chest pain of undetermined origin in a rapid and goal-oriented manner and to take immediate therapeutic measures. The basis for the previous certification process was criteria that have been established and published by the task force on CPUs. These criteria regulate the spatial and technical requirements and determine diagnostic and therapeutic strategies in patients with chest pain. Furthermore, the requirements for the organization of CPUs and the training requirements for the staff of a CPU are defined. The certification process is carried out by the DGK; currently, 225 CPUs are certified and 139 CPUs have been recertified after running for a period of 3 years. The certification criteria have now been revised and updated according to new guidelines.

Cardiac arrest and clinical characteristics, treatments and outcomes among patients hospitalized with ST-elevation myocardial infarction in contemporary practice: A report from the National Cardiovascular Data Registry

BACKGROUND

Cardiac arrest (CA) is a major complication of patients with ST-elevation myocardial infarction (STEMI). Its prevalence and prognostic impact in contemporary US practice has not been well assessed.

METHODS

We evaluated STEMI patients included in the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines (ACTION Registry-GWTG) from 4/1/11 to 6/30/12. Patient clinical characteristics, treatments, and inhospital outcomes were compared by the presence or absence of CA on first medical contact-either before hospital arrival or upon presentation to the ACTION hospital.

RESULTS

Of the 49,279 STEMI patients included, 3,716 (7.5%) had CA. Cardiac arrest patients were more likely to have heart failure (15.5% vs 6.9%) and shock (42.9% vs 4.9%) on presentation and higher median (25th and 75th percentiles) ACTION Registry-GWTG mortality risk scores (42 [32, 54] vs 32 [26, 38]) than non-CA patients (all P < .001). Primary percutaneous coronary intervention was performed in most patients with and without CA (76.7% vs 79.1%). Inhospital mortality was significantly higher in patients with than without CA (28.8% vs 4.0%; P < .001), both in patients who presented with cardiogenic shock (46.9% vs 27.1%; P < .001) and those without shock (15.4% vs 2.9%; P < .001). The ACTION Registry-GWTG inhospital mortality model underestimated mortality risk in CA patients; however, prediction significantly improved after adding CA to the model.

CONCLUSIONS

Almost 8% of STEMI patients present with CA. More than 25% die during the hospitalization, despite high use of primary percutaneous coronary intervention. Cardiogenic shock and CA frequently coexist. Our results suggest that development of systems of care and treatments for both STEMI and CA is needed to reduce the high mortality in these patients.

Prognostic implication of out-of-hospital cardiac arrest in patients with cardiogenic shock and acute myocardial infarction

OBJECTIVES

To compare outcome in patients with acute myocardial infarction (MI) and cardiogenic shock (CS) presenting with and without out-of-hospital cardiac arrest (OHCA).

BACKGROUND

Despite general improvement in outcome after acute MI, CS remains a leading cause of death in acute MI patients with a high 30-day mortality rate. OHCA on top of cardiogenic shock may further increase mortality in these patients resulting in premature withdrawal of supportive therapy, but this is not known.

METHODS AND RESULTS

In a retrospective study from 2008 to 2013, 248 consecutive patients admitted alive to a tertiary centre with the diagnosis of CS and acute MI were enrolled, 118 (48%) presented with OHCA and 130 (52%) without (non-OHCA patients). Mean lactate level at admission was significantly higher in OHCA patients compared with non-OCHA patients (9mmol/l (SD 6) vs. 6mmol/l (SD 4) p<0.0001). Co-morbidities were more prevalent in the non-OHCA group. By univariate analysis age (Hazard ratio (HR)=1.02 [CI 1.00-1.03], p=0.01) and lactate at admission (HR=1.06 [CI 1.03-1.09], p<0.001), but not OHCA (HR=1.1 [CI 0.8-1.4], p=NS) was associated with mortality. In multivariate analysis, only age (HR=1.02 [CI 1.01-1.04], p=0.003) and lactate level at admission (HR=1.06 [1.03-1.09], p<0.001) were independent predictors of mortality. One-week mortality was 63% in the OHCA group and 56% in the non-OHCA group, p=NS.

CONCLUSION

OHCA is not an independent predictor of mortality in patients with acute MI complicated by cardiogenic shock. This should encourage active intensive treatment of CS patients regardless of OHCA.

Out-of-hospital cardiac arrest -optimal management

Out-of-hospital cardiac arrest (OHCA) has attracted increasing attention over the past years because outcomes have improved impressively lately. The changes for neurological intact outcomes has been poor but several areas have achieved improving survival rates after adjusting their cardiac arrest care. The pre-hospital management is certainly key and decides whether a cardiac arrest patient can be brought back into a spontaneous circulation. However, the whole chain of resuscitation including the in-hospital care have improved also. This review describes aetiologies of OHCA, risk and potential protective factors and recent advances in the pre-hospital and in-hospital management of these patients.

Routine angiography in survivors of out of hospital cardiac arrest with return of spontaneous circulation: a single site registry

BACKGROUND

Coronary revascularization in resuscitated out of hospital cardiac arrest (OOHCA) patients has been associated with improved survival.

METHODS

This was a retrospective review of patients with OOHCA between 01/07/2007 and 31/03/2009 surviving to hospital admission. Cardiac risk factors, demographics, treatment times, electrocardiogram (ECG), angiographic findings and in-hospital outcomes were recorded.

RESULTS

Of the 78 patients, 63 underwent coronary angiography. Traditional cardiac risk factors were common in this group. Chest pain occurred in 33.3% pre-arrest, 59.0% were initially treated at a peripheral hospital, 83.3% had documented ventricular tachycardia or ventricular fibrillation, 55.1% had specific ECG changes, 65.4% had acute myocardial infarction (AMI) as the cause of OOHCA and the majority had multi-vessel disease. ST elevation strongly predicted AMI. The in-hospital survival was 67.9% with neurological deficit in 13.2% of survivors. The group of patients who had an angiogram were more likely to have AMI as a cause of cardiac arrest (71.4% vs 40.0%, p = 0.01) and more likely to have survived to discharge (74.6% vs 40.0%, p < 0.01). Poor outcome was associated with older age, cardiogenic shock, longer transfer times, diabetes, renal impairment and a long duration to return of spontaneous circulation.

CONCLUSIONS

Acute myocardial infarction was the commonest cause of OOHCA and a high rate of survival to discharge was seen with a strategy of routine angiography and revascularization.

HEMS in Slovenia: one country, four models, different quality outcomes

OBJECTIVE

The objective of this study was to determine the quality of patient care using quality indicators in 4 different Slovenian helicopter emergency medical service (HEMS) models.

METHODS

This was a cross-sectional study of all 4 HEMS in Slovenia. We collected data on quality for the period from July 2003 to August 2008, in a sample of all eligible patients that were managed by HEMS during the study period (N = 833). We obtained the following data on emergency operations: the time and organizational features of the operation; the description of the patients' condition; and the on-site diagnostic and treatment procedures. We used the following as quality indicators: the number of resuscitated patients that were intubated; the number of patients with a Glasgow Coma Scale (GCS) score of # 8 that were intubated; the number of patients with acute coronary syndrome that received treatment with morphine, oxygen, nitroglycerine, and aspirin (MONA); the number of patients with a National Advisory Committee on Aeronautics (NACA) scale score of $ 4 with an intravenous line; the number of patients with a NACA score of $ 5 that were given oxygen; and the number of patients with a NACA score of $ 4 that were given appropriate analgesic treatment.

RESULTS

Across all HEMS bases, 36 (87.8%) resuscitated patients were intubated; 122 (81.9%) patients with GCS # 8 were intubated; 149 (89.2%) patients with ACS were given MONA treatment; 52 (92.9%) patients with a NACA score of $ 4 were given an intravenous line; 254 (92.7%) patients with a NACA score of $ 5 were given oxygen; and 18 (32.7%) trauma patients with a NACA score of $ 4 were given intravenous analgesics. The quality of patient management in HEMS in Slovenia is affected by the callout procedure, the presence or absence of a fixed rope, the type of helicopter operator, and the provider of the doctor in the helicopter team.

CONCLUSIONS

The data from our study indicates that the quality of patient management in HEMS in Slovenia is high. It also seems that organizational factors play a role in the quality management of patients in HEMS as well, but their effect remains unclear and needs further evaluation.

Cardiac aetiology of cardiac arrest: percutaneous coronary interventions during and after cardiopulmonary resuscitation

Management and prevention of cardiac arrest in the setting of heart disease is a challenge for modern cardiology. After reviewing the aetiology of sudden cardiac death and discussing the way to identify candidates at risk, we emphasise the role of percutaneous coronary interventions during and after cardiopulmonary resuscitation in the treatment of patients with return of spontaneous circulation after cardiac arrest.

Evidence-based Management of Cardiogenic Shock After Acute Myocardial Infarction

Guidelines for evidence-based management of patients with cardiogenic shock after acute myocardial infarction focuses on early revascularisation of the occluded coronary artery as well as on support of cardiac failure and improvement of impaired organ perfusion. Also of great importance is effective treatment of shock complications, especially acute respiratory failure and other forms of multiple organ dysfunction syndrome (MODS). Cardiovascular therapy has to be accompanied by best general intensive care of these critically ill patients with high mortality. Most lives can be saved by early revascularisation, and this class I recommendation has a high level of evidence. So far, most of the other guideline recommendations are of low evidence level, in most cases based on expert opinions. Recently, the Intra-aortic Balloon Pump in Cardiogenic Shock II (IABP SHOCK II) trial with 600 patients has shown that adjunctive IABP therapy - for long a class I recommendation - does not reduce 30-day and six-month motality.

Ischaemic heart disease: accuracy of the prehospital diagnosis-a retrospective study

Purpose. Correct prehospital diagnosis of ischaemic heart disease (IHD) may accelerate and improve the treatment. We sought to evaluate the accuracy of prehospital diagnoses of ischemic heart diseases assigned by physicians. Methods. The Mobile Emergency Care Unit (MECU) in Odense, Denmark, services a population of 260.000. All admissions in 2009 concerning patients diagnosed in the IHD category were assessed. Outcome and diagnosis of each patient were manually validated in accordance to the final diagnosis established following admission to hospital, using the discharge summary from the relevant department as reference. Results. 428 MECU runs with a prehospital diagnosis of IHD were registered. 422 of these were included in the study and 354 of those patients were suitable for this analysis. 73,4% of the patients hospitalized with a prehospital diagnosis of IHD were initially admitted to the relevant ward. Of these patients, 40,0% had their preliminary diagnosis of IHD confirmed. 14,1% of all patients admitted to the hospital were diagnosed with nonheart conditions. Preliminary diagnoses of STEMI had an accuracy of 87,5%. Conclusions. The preliminary IHD diagnoses assigned by the MECU physicians were acceptable. In case of STEMI patients the diagnostic accuracy was excellent. In this study there was an apparent overtriage.

Acute coronary angiography in patients resuscitated from out-of-hospital cardiac arrest--a systematic review and meta-analysis

INTRODUCTION

Out-of-hospital cardiac arrest has a poor prognosis. The main aetiology is ischaemic heart disease.

AIM

To make a systematic review addressing the question: "In patients with return of spontaneous circulation following out-of-hospital cardiac arrest, does acute coronary angiography with coronary intervention improve survival compared to conventional treatment?"

METHODS

Peer reviewed articles written in English with relevant prognostic data were included. Comparison studies on patients with and without acute coronary angiography were pooled in a meta-analysis.

RESULTS

Thirty-two non-randomised studies were included of which 22 were case-series without patients with conservative treatment. Seven studies with specific efforts to control confounding had statistical evidence to support the use of acute coronary angiography following resuscitation from out-of-hospital cardiac arrest. The remaining 25 studies were considered neutral. Following acute coronary angiography, the survival to hospital discharge, 30 days or six months ranged from 23% to 86%. In patients without an obvious non-cardiac aetiology, the prevalence of significant coronary artery disease ranged from 59% to 71%. Electrocardiographic findings were unreliable for identifying angiographic findings of acute coronary syndrome. Ten comparison studies demonstrated a pooled unadjusted odds ratio for survival of 2.78 (1.89; 4.10) favouring acute coronary angiography.

CONCLUSION

No randomised studies exist on acute coronary angiography following out-of-hospital cardiac arrest. An increasing number of observational studies support feasibility and a possible survival benefit of an early invasive approach. In patients without an obvious non-cardiac aetiology, acute coronary angiography should be strongly considered irrespective of electrocardiographic findings due to a high prevalence of coronary artery disease.

Cardiogenic shock due to myocardial infarction: diagnosis, monitoring and treatment: a German-Austrian S3 Guideline

INTRODUCTION

Infarction-related cardiogenic shock (ICS) is usually due to left-ventricular pump failure. With a mortality of 30% to 80%, ICS is the most common cause of death from acute myocardial infarction. The S3 guideline presented here characterizes the current evidence-based treatment of ICS: early revascularization, treatment of shock, and intensive care treatment of multi-organ dysfunction syndrome (MODS) if it arises. The success or failure of treatment for MODS determines the outcome in ICS.

METHODS

Experts from eight German and Austrian specialty societies analyzed approximately 3600 publications that had been retrieved by a systematic literature search. Three interdisciplinary consensus conferences were held, resulting in the issuing of 111 recommendations and algorithms for this S3 guideline.

RESULTS

Early revascularization of the occluded vessel, usually with a percutaneous coronary intervention (PCI), is of paramount importance. The medical treatment of shock consists of dobutamine as the inotropic agent and norepinephrine as the vasopressor of choice and is guided by a combination of pressure and flow values, or by the cardiac power index. Levosimendan can be given in addition to treat catecholamine-resistant shock. For patients with ICS who are treated with PCI, the current S3 guideline differs from the European and American myocardial infarction guidelines with respect to the recommendation for intra-aortic balloon pulsation (IABP): Whereas the former guidelines give a class I recommendation for IABP, this S3 guideline states only that IABP "can" be used in this situation, in view of the poor state of the evidence. Only for patients being treated with systemic fibrinolysis is IABP weakly recommended (IABP "should" be used in such cases). With regard to the optimal intensive-care interventions for the prevention and treatment of MODS, recommendations are given concerning ventilation, nutrition, erythrocyte-concentrate transfusion, prevention of thrombosis and stress ulcers, follow-up care, and rehabilitation.

DISCUSSION

The goal of this S3 guideline is to bring together the types of treatment for ICS that lie in the disciplines of cardiology and intensive-care medicine, as patients with ICS die not only of pump failure, but also (and even more frequently) of MODS. This is the first guideline that adequately emphasizes the significance of MODS as a determinant of the outcome of ICS.

Optimizing outcome after cardiac arrest

PURPOSE OF REVIEW

To discuss recent data relating to survival rates after cardiac arrest and interventions that can be used to optimize outcome.

RECENT FINDINGS

A recent analysis of 70 studies indicates that following out-of-hospital cardiac arrest (OHCA), 7.6% of patients will survive to hospital discharge (95% confidence interval 6.7-8.4). Following in-hospital cardiac arrest, 18% of patients will survive to hospital discharge. Survival may be optimized by increasing the rate of bystander cardiopulmonary resuscitation (CPR), which can be achieved by improving recognition of cardiac arrest, simplifying CPR and training more of the community. Feedback systems improve the quality of CPR but this has yet to be translated into improved outcome. One study has shown improved survival following OHCA with active compression-decompression CPR combined with an impedance-threshold device. In those who have no obvious extracardiac cause of OHCA, 70% have at least one significant coronary lesion demonstrable by coronary angiography. Although generally reserved for those with ST-elevation myocardial infarction, primary percutaneous coronary intervention may also benefit OHCA survivors with ECG patterns other than ST elevation. The term 'mild therapeutic hypothermia' has been replaced by the term 'targeted temperature management'; its role in optimizing outcome after cardiac arrest continues to be defined.

SUMMARY

In several centres, survival rates following OHCA are increasing. All links in the chain of survival must be optimized if a good-quality neurological outcome is to be achieved.

[Coronary revascularization during cardiopulmonary resuscitation. The bridge code]

Cardiac arrest is one of the major current challenges, due to both its high incidence and mortality and the fact that it leads to severe brain dysfunction in over half of the survivors. The so-called coronary origin Bridge Code is presented, based on the international resuscitation recommendations (2005, 2010). In accordance with a series of strict predictive criteria, this code makes it possible to: (1) select refractory CPR patients with a high or very high presumption of underlying coronary cause; (2) evacuate the patient using mechanical chest compressors [LucasTM, Autopulse®], maintaining coronary and brain perfusion pressures; (3) allow coronary revascularization access during resuscitation maneuvering (PTCA during ongoing CPR); (4) induce early hypothermia; and (5) facilitate post-cardiac arrest intensive care. In the case of treatment failure, the quality of hemodynamic support makes it possible to establish a second bridge to non-heart beating organ donation.

The impact of response time reliability on CPR incidence and resuscitation success: a benchmark study from the German Resuscitation Registry

Introduction

Sudden cardiac arrest is one of the most frequent causes of death in the world. In highly qualified emergency medical service (EMS) systems, including well-trained emergency physicians, spontaneous circulation may be restored in up to 53% of patients at least until admission to hospital. Compared with these highly qualified EMS systems, markedly lower success rates are observed in other systems. These data clearly show that there are considerable differences between EMS systems concerning treatment success following cardiac arrest and resuscitation, although in all systems international guidelines for resuscitation are used. In this study, we investigated the impact of response time reliability (RTR) on cardiopulmonary resuscitation (CPR) incidence and resuscitation success by using the return of spontaneous circulation (ROSC) after cardiac arrest (RACA) scores and data from seven German EMS systems participating in the German Resuscitation Registry.

Methods

Anonymised patient data after out-of-hospital cardiac arrest gathered from seven EMS systems in Germany from 2006 to 2009 were analysed with regard to socioeconomic factors (population, area and EMS unit-hours), process quality (RTR, CPR incidence, special CPR measures and prehospital cooling), patient factors (age, gender, cause of cardiac arrest and bystander CPR). End points were defined as ROSC, admission to hospital, 24-hour survival and hospital discharge rate. χ² tests, odds ratios and the Bonferroni correction were used for statistical analyses.

Results

Our present study comprised 2,330 prehospital CPR patients at seven centres. The incidence of sudden cardiac arrest ranged from 36.0 to 65.1/100,000 inhabitants/year. We identified two EMS systems (RTR < 70%) that reached patients within 8 minutes of the call to the dispatch centre 62.0% and 65.6% of the time, respectively. The other five EMS systems (RTR > 70%) reached patients within 8 minutes of the call to the dispatch centre 70.4% up to 95.5% of the time. EMS systems arriving relatively later at the patients side (RTR < 70%) initiate CPR less frequently and admit fewer patients alive to hospital (calculated per 100,000 inhabitants/year) (CPR incidence (1/100,000 inhabitants/year) RTR > 70% = 57.2 vs RTR < 70% = 36.1, OR = 1.586 (99% CI = 1.383 to 1.819); P < 0.01) (admitted to hospital with ROSC (1/100,000 inhabitants/year) RTR > 70% = 24.4 vs RTR < 70% = 15.6, OR = 1.57 (99% CI = 1.274 to 1.935); P < 0.01). Using ROSC rate and the multivariate RACA score to predict outcomes, we found that the two groups did not differ, but ROSC rates were higher than predicted in both groups (ROSC RTR > 70% = 46.6% vs RTR < 70% = 47.3%, OR = 0.971 (95% CI = 0.787 to 1.196); P = n.s.) (ROSC RACA RTR > 70% = 42.4% vs RTR < 70% = 39.5%, OR = 1.127 (95% CI = 0.911 to 1.395); P = n.s.)

Conclusion

This study demonstrates that, on the level of EMS systems, faster ones more often initiate CPR and increase the number of patients admitted to hospital alive. Furthermore, we show that, with very different approaches, all centres that adhere to and are intensely trained according to the 2005 European Resuscitation Council guidelines are superior and, on the basis of international comparisons, achieve excellent success rates following CPR.

[Rational use of oxygen in anesthesiology and intensive care medicine]

Oxygen (O(2)) is the most frequently used pharmaceutical in anesthesiology and intensive care medicine: Every patient receives O(2) during surgery or during a stay in the intensive care unit. Hypoxia and hypoxemia of various origins are the most typical indications which are mentioned in the prescribing information of O(2): the goal of the administration of O(2) is either an increase of arterial O(2) partial pressure in order to treat hypoxia, or an increase of arterial O(2) content in order to treat hypoxemia. Most of the indications for O(2) administration were developed in former times and have seldom been questioned from that time on as the short-term side-effects of O(2) are usually considered to be of minor importance. As a consequence only a small number of controlled randomized studies exist, which can demonstrate the efficacy of O(2) in terms of evidence-based medicine. However, there is an emerging body of evidence that specific side-effects of O(2) result in a deterioration of the microcirculation. The administration of O(2) induces arteriolar constriction which will initiate a decline of regional O(2) delivery and subsequently a decline of tissue oxygenation. The aim of the manuscript presented is to discuss the significance of O(2) as a pharmaceutical in the clinical setting.

B-type natriuretic peptide blood levels identify patients with non-ST elevation acute coronary syndromes at high risk for complications during intravenous beta-blocker infusion

BACKGROUND

We hypothesized that measurement of B-type natriuretic peptide could identify patients with non-ST elevation acute coronary syndromes at high risk for complications during beta-blocker (esmolol) infusion.

METHODS

We reviewed the records of 340 consecutive patients admitted with a non-ST elevation acute coronary syndrome. Seventy three (47 males, aged 62 ± 14 years) received esmolol up to a maximum dose of 300 μg/ kg/min until the symptoms were relieved or an adverse event occurred.

RESULTS

The median infusion rate at steady state was 175 μg/kg/min (median infusion time 18 h). Infusion was halted in 14 patients. The frequency of drug discontinuation increased across admission BNP quartiles. BNP > 141 pg/ml at admission had a 95% predictive value for subsequent withdrawal of esmolol. The presence of BNP > 141 pg/ml in combination with systolic blood pressure < 130 mmHg and left ventricular ejection fraction < 50% identified a group of patients at high risk for drug interruption (interruption frequency = 83%, 95% CI: 55-95%).

CONCLUSIONS

In conclusion, BNP measurement in combination with systolic blood pressure and 2D echocardiography may identify patients with non-ST elevation acute coronary syndromes at high risk for adverse events during esmolol infusion.

[Cardiopulmonary resuscitation, new recommendations]

A procedure for telephone CPR must be started since the call centres do the diagnosis of cardiac arrest. All the rescuers, trained or not, have to realize quality chest compressions (depths 5 in 6cm, rhythm from 100 to 120 per minute) to the victims of cardiac arrest. Chest compressions must be interrupted only briefly in case of indispensable specific interventions. The trained rescuers have to realize insufflations during the CPR, with a ratio compression-ventilation of 30/2. The development of AE programs is encouraged. A more important deployment of AED is necessary in public places and residential areas. The use of the acetylsalicylic acid by witnesses, in case of cardiac arrest, is authorized with or without the assistance of the medical dispatcher of the EMS. The administration of medicines by endotracheal tube is not any more recommended. If the intravenous access cannot be used, it is the intra-osseous, which would be privileged. In case of children cardiac arrest, the non-professional rescuer have to use a ratio of 30 compressions for two ventilations if he is alone and 15/2 if they are working in team. All the citizens, and all the healthcare providers, should be trained in CPR and to keep their skills should follow all three to six months refresher courses to upgrade their knowledge.