Effect of calcium vs. placebo on long-term outcomes in patients with out-of-hospital cardiac arrest.

OBJECTIVE: The Calcium for Out-of-hospital Cardiac Arrest (COCA) trial was a randomized, placebo-controlled, double-blind trial of calcium for out-of-hospital cardiac arrest. The primary and secondary outcomes have been reported previously. This article describes the long-term outcomes of the trial. METHODS: Patients aged ≥18 years were included if they had a non-traumatic out-of-hospital cardiac arrest during which they received adrenaline. The trial drug consisted of calcium chloride (5 mmol) or saline placebo given after the first dose of adrenaline and again after the second dose of adrenaline for a maximum of two doses. This article presents pre-specified analyses of 6-month and 1-year outcomes for survival, survival with a favorable neurological outcome (modified Rankin Scale of 3 or less), and health-related quality of life. RESULTS: A total of 391 patients were analyzed. At 1 year, 9 patients (4.7%) were alive in the calcium group while 18 (9.1%) were alive in the placebo group (risk ratio 0.51; 95% confidence interval 0.24, 1.09). At 1 year, 7 patients (3.6%) were alive with a favorable neurological outcome in the calcium group while 17 (8.6%) were alive with a favorable neurological outcome in the placebo group (risk ratio 0.42; 95% confidence interval 0.18, 0.97). Outcomes for health-related quality of life likewise suggested harm of calcium but results were imprecise with wide confidence intervals. CONCLUSIONS: Effect estimates remained constant over time suggesting harm of calcium but with wide confidence intervals. The results do not support calcium administration during out-of-hospital cardiac arrest. TRIAL REGISTRATION: ClinicalTrials.gov-number, NCT04153435.

Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial.

Importance: It is unclear whether administration of calcium has a beneficial effect in patients with cardiac arrest. Objective: To determine whether administration of calcium during out-of-hospital cardiac arrest improves return of spontaneous circulation in adults. Design, Setting, and Participants: This double-blind, placebo-controlled randomized clinical trial included 397 adult patients with out-of-hospital cardiac arrest and was conducted in the Central Denmark Region between January 20, 2020, and April 15, 2021. The last 90-day follow-up was on July 15, 2021. Interventions: The intervention consisted of up to 2 intravenous or intraosseous doses with 5 mmol of calcium chloride (n = 197) or saline (n = 200). The first dose was administered immediately after the first dose of epinephrine. Main Outcomes and Measures: The primary outcome was sustained return of spontaneous circulation. The secondary outcomes included survival and a favorable neurological outcome (modified Rankin Scale score of 0-3) at 30 days and 90 days. Results: Based on a planned interim analysis of 383 patients, the steering committee stopped the trial early due to concerns about harm in the calcium group. Of 397 adult patients randomized, 391 were included in the analyses (193 in the calcium group and 198 in the saline group; mean age, 68 [SD, 14] years; 114 [29%] were female). There was no loss to follow-up. There were 37 patients (19%) in the calcium group who had sustained return of spontaneous circulation compared with 53 patients (27%) in the saline group (risk ratio, 0.72 [95% CI, 0.49 to 1.03]; risk difference, -7.6% [95% CI, -16% to 0.8%]; P = .09). At 30 days, 10 patients (5.2%) in the calcium group and 18 patients (9.1%) in the saline group were alive (risk ratio, 0.57 [95% CI, 0.27 to 1.18]; risk difference, -3.9% [95% CI, -9.4% to 1.3%]; P = .17). A favorable neurological outcome at 30 days was observed in 7 patients (3.6%) in the calcium group and in 15 patients (7.6%) in the saline group (risk ratio, 0.48 [95% CI, 0.20 to 1.12]; risk difference, -4.0% [95% CI, -8.9% to 0.7%]; P = .12). Among the patients with calcium values measured who had return of spontaneous circulation, 26 (74%) in the calcium group and 1 (2%) in the saline group had hypercalcemia. Conclusions and Relevance: Among adults with out-of-hospital cardiac arrest, treatment with intravenous or intraosseous calcium compared with saline did not significantly improve sustained return of spontaneous circulation. These results do not support the administration of calcium during out-of-hospital cardiac arrest in adults. Trial Registration: ClinicalTrials.gov Identifier: NCT04153435.

A Case of an Advanced Chain of Survival in Penetrating Cardiac Injury.

The survival rate of penetrating cardiac trauma is dismal, with only a few patients reaching the hospital with any signs of life. Short transport time and close proximity to the trauma center are positive factors for survival. We report the successful case of a 21-year-old male with penetrating cardiac injury and tension-pneumothorax with long distance to a trauma facility. The patient was stabbed twice in the anterior left side of the thorax. The emergency services found the patient with suspicion of left tension-pneumothorax. Urgent left mini-thoracotomy was established resulting in spontaneous respiration and clinical improvement. Due to rapid clinical deterioration and clinical suspicion of pericardial tamponade, patient was transported to the local regional hospital only minutes away. Echocardiography confirmed tamponade, and urgent ultrasound-guided pericardiocentesis was performed. During the transport blood was intermittently drained from the pericardial sack until arrival at the trauma center where a penetrating injury to the left ventricle was repaired during urgent cardiac surgery. The patient was discharged 8 days after the incident. Conclusion. Well organized emergency medical transport systems increase the chance of survival in penetrating cardiac injuries. Urgent pericardiocentesis with continuous drainage can help stabilize a patient until arrival at trauma facility.

Prehospital triage of patients suffering severe dyspnoea using N-terminal pro-brain natriuretic peptide, the PreBNP trial: a randomised controlled clinical trial.

PURPOSE: The purpose of this study was to examine whether the addition of brain natriuretic peptide measurement to the routine diagnostic work-up by prehospital critical care team physicians improves triage in patients with severe dyspnoea. METHODS: Prehospital critical care team physicians randomly assigned patients older than 18 years with severe dyspnoea to routine diagnostic work-up or diagnostic work-up with incorporated point-of-care N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement. The primary endpoint was the proportion of patients with dyspnoea of primary cardiac origin triaged directly to a department of cardiology. RESULTS: A total of 747 patients were randomly assigned and 711 patients consented to participate, 350 were randomly assigned to the NT-proBNP group and 361 to the routine work-up group. NT-proBNP was measured in 90% (315/350) of patients in the NT-proBNP group and in 19% (70/361) of patients in the routine work-up group. There was no difference in the proportion of patients with dyspnoea of primary cardiac origin triaged directly to a department of cardiology between the NT-proBNP group and the routine work-up group (75% vs. 69%, P=0.22) in the intention-to-treat analysis. Sensitivity analysis according to the de facto diagnostics performed showed results consistent with this. No differences in hospital length of stay, intensive care unit admission rates or mortality between the NT-proBNP group and the routine work-up group were observed. CONCLUSION: Routine supplementary point-of-care measurement of NT-proBNP in patients with severe dyspnoea did not improve triage of patients with dyspnoea primarily caused by heart disease. ClinicalTrials.gov identifier NCT02050282.

[Fatal intoxication with the new designer drug 25C-NBOMe]. / Fatalt forløb efter intoksikation med det nye designerdrug 25C-NBOMe.

This is a case report of a 22-year-old man, who snorted the content of three capsules of the new designer drug 25C-NBOMe (2-(4-chloro-2,5-dimethoxyphenyl)-N-[(2-methoxyphenyl)methyl]ethanamine). 1-2 hours after the intake he became unconscious with generalized seizures, so he was intubated prehospitally and brought to the local hospital. At admission he had acute renal failure and was severely metabolic acidotic with potassium 8.6 mmol/l, lactate 28 mmol/l and pH 6.69. Despite maximal therapy he died ten hours after admission. 25C-NBOMe is currently legal in most parts of the world, and fatal intoxication with the drug has not yet been described in Scandinavia.

[Fentanyl tea]. / Fentanylte

Fentanyl is a potent synthetic opioid. Abuse of fentanyl patches is rarely occurring, but has been described. In this case a patient had been drinking hot tea mixed with two fentanyl patches. He was found unconscious, with convulsions and respiratory insufficiency. He was intubated and he responded to naloxone treatment, which was repeated several times during the observation. When fentanyl patches are abused this way large quantities of fentanyl are absorbed, giving severe and prolonged effect - exceeding the antidote. The patient must be observed for several hours in an intensive care unit.

Lower versus higher hemoglobin threshold for transfusion in septic shock.

BACKGROUND: Blood transfusions are frequently given to patients with septic shock. However, the benefits and harms of different hemoglobin thresholds for transfusion have not been established. METHODS: In this multicenter, parallel-group trial, we randomly assigned patients in the intensive care unit (ICU) who had septic shock and a hemoglobin concentration of 9 g per deciliter or less to receive 1 unit of leukoreduced red cells when the hemoglobin level was 7 g per deciliter or less (lower threshold) or when the level was 9 g per deciliter or less (higher threshold) during the ICU stay. The primary outcome measure was death by 90 days after randomization. RESULTS: We analyzed data from 998 of 1005 patients (99.3%) who underwent randomization. The two intervention groups had similar baseline characteristics. In the ICU, the lower-threshold group received a median of 1 unit of blood (interquartile range, 0 to 3) and the higher-threshold group received a median of 4 units (interquartile range, 2 to 7). At 90 days after randomization, 216 of 502 patients (43.0%) assigned to the lower-threshold group, as compared with 223 of 496 (45.0%) assigned to the higher-threshold group, had died (relative risk, 0.94; 95% confidence interval, 0.78 to 1.09; P=0.44). The results were similar in analyses adjusted for risk factors at baseline and in analyses of the per-protocol populations. The numbers of patients who had ischemic events, who had severe adverse reactions, and who required life support were similar in the two intervention groups. CONCLUSIONS: Among patients with septic shock, mortality at 90 days and rates of ischemic events and use of life support were similar among those assigned to blood transfusion at a higher hemoglobin threshold and those assigned to blood transfusion at a lower threshold; the latter group received fewer transfusions. (Funded by the Danish Strategic Research Council and others; TRISS ClinicalTrials.gov number, NCT01485315.).

[Fatal pulmonary embolism after acute bilateral minor surgery].

Venous thromboembolism (VTE) is a quite common and well-documented complication after major surgery. The causes are multifactorial, but prophylactic antithrombotic treatment reduces the risk of VTE. In Denmark, all hospitals have prophylactic antithrombotic regimes for major surgery. There is no such standard regime for minor surgery. We describe a case of a 79-year-old otherwise healthy woman, who was operated for eight hours in her upper extremities after trauma. The operation was labelled as minor surgery. Prophylactic antithrombotic treatment was never discussed. The patient died 14 hours post-operatively due to pulmonary embolism.

[Pneumomediastinum induced by sniffed cocaine]. / Pneumomediastinum efter snifning af kokain.

The increasing availability and use of cocaine stresses the importance that physicians are aware of the medical complications of the abuse. This case report describes a 24 year-old man who got chest pain after the snorting of 6 g of cocaine. A chest X-ray revealed a pneumomediastinum, which was confirmed by a computed tomography of the thorax. Pneumomediastinum secondary to cocaine insufflations is described as a benign condition. Adequate therapy is painkillers and observation, when life-threatening condition such as oesophageal rupture is excluded.

[Chronic obstructive pulmonary disease as frequent secondary diagnosis at medical department]. / Kronisk obstruktiv lungesygdom er hyppig som bidiagnose i en medicinsk afdeling.

INTRODUCTION: Patients with Chronic Obstructive Pulmonary Disease (COPD) often suffer from comorbidities. This study evaluates the need for hospitalization due to comorbidity in COPD patients and the diagnoses these patients have, and it investigates whether COPD comorbidity prolongs the hospital stay. MATERIAL AND METHODS: A cross-sectional study performed at a department of internal medicine. A total of 66 of the 101 possible participants were included. They performed a spirometry and filled-in a questionnaire. Furthermore, patients' case records were studied for evaluation of final diagnoses and length of stay. RESULTS: 39% (26/66) suffered from COPD. 54% (14/26) were diagnosed at our examination. 35% had moderate COPD, 26% severe COPD and 19% very severe COPD. 43% (6/14) of the patients with no former knowledge of their COPD had severe or very severe COPD. The COPD patients had accumulated significantly more pack years (p < 0.005) and there were significantly more smokers (p = 0.05) among them compared with patients with no COPD. 38% (10/26) had several concurrent chronic diseases. The admission period was not significantly longer for patients with COPD than for those with no COPD (p = 0.07). CONCLUSION: The need for hospitalization due to comorbidity in COPD patients significantly exceeded the 20% expected to suffer from COPD in comparative age-groups of the general Danish population (p < 0.05).