Safety and effectiveness of the short (0-1h) high sensitive troponin protocol in real-life practice.

AIM: Recent guidelines recommend the use of a short 0-1h high sensitive cardiac troponin (hs-cTn) algorithm in patients presenting with chest pain at the emergency department (ED). This retrospective observational study evaluates the safety and effectiveness of the new 0-1h hs-cTn I protocol in comparison with the standard 0-3h cTn I protocol for the diagnosis of acute myocardial infarction (AMI). METHODS: A total of two times 100 consecutive chest pain patients presenting at the ED in November/December 2018 (standard 0-3h cTn I group) and in November/December 2020 (short 0-1h hs-cTn I group) were enrolled. Decision making was based upon validated assay-specific cut-off values. RESULTS: The new 0-1h hs-cTn I protocol had a sensitivity of 100% (95% CI 83.2-100) and a negative predictive value of 100% to rule out AMI. The accuracy of rule-in was slightly lower with a specificity of 92.5% (95% CI 84.4-97.2). The overall protocol accuracy was 94% (95% CI 87.4-97.8) in the short 0-1h hs-cTn I group compared to 88% (95% CI 80.0-93.6) in the standard 0-3h cTn I group (p-value 0.14). The 0-1h hs-cTn I protocol was associated with a numerically higher rate of early hospital discharge compared to the conventional 0-3h cTn I protocol (47% versus 59%; p-value 0.09) and with a shorter median length of stay for those patients (mean 316 min versus 289 min; p-value 0.09). CONCLUSION: The abbreviated protocol based on the 0-1h hs-cTn I assays is effective and safe for the exclusion of AMI at the ED.

Early administration of Vitamin C in patients with sepsis or septic shock in emergency departments: A multicenter, double blinded, randomized controlled trial: The C-EASIE trial protocol.

BACKGROUND: Sepsis is a potentially life-threatening condition characterized by a deregulated body's response to infection causing injury to its own tissues and organs. Sepsis is the primary cause of death from infection. If not recognized and treated timely, it can evolve within minutes/hours to septic shock. Sepsis is associated with an acute deficiency of Vitamin C. Despite the proof-of-concept of the benefit of administering Vitamin C in patients with sepsis or septic shock, Vitamin C administration is not yet current practice. OBJECTIVE: To investigate the potential benefit of early administration of high doses of Vitamin C in addition to standard of care in patients with sepsis or septic shock. METHODS: This phase 3b multi-center trial is conducted in 8 hospitals throughout Belgium. In total 300 patients will be randomly assigned to one of two groups in a 1:1 allocation ratio. The intervention group will receive 1.5 g Vitamin C 4 times a day during 4 days, started within 6 hours after admission. The primary outcome is the average post-baseline patient SOFA score. CONCLUSION: This trial will determine whether the early administration of Vitamin C in patients with sepsis or septic shock can lead to a more rapid solution of shock and less deterioration from sepsis to septic shock, hereby reducing morbidity and mortality as well as the length of hospital stay in this patient population. TRIAL REGISTRATION: The C-EASIE trial has been registered on the ClinicalTrials.gov website on 10 February 2021 with registration number NCT04747795. TRIAL SPONSOR: UZ Leuven (sponsor's reference S63213).

Changing resuscitation strategies during a pandemic: lessons from the consecutive surges in New York and global challenges.

PURPOSE OF REVIEW: To provide a framework for resuscitation of COVID-19 critical illness for emergency and intensive care clinicians with the most up to date evidence and recommendations in the care of COVID-19 patients in cardiac arrest or in extremis. RECENT FINDINGS: Performing cardiopulmonary resuscitation (CPR) on COVID-19 patients requires the clinicians to adopt infection mitigation strategies such as full personal protective equipment, mechanical chest compression devices, and restricting the number of people present during the resuscitation. The time of intubation is a subject of ongoing research and clinicians should use their best judgment for each patient. Clinicians should prepare for CPR in prone position. Particular attention should be given to the psychological well-being of the staff. Point of care ultrasound has proved to be an invaluable diagnostic tool in assessing ventricular dysfunction and parenchymal lung disease. Although novel therapies to supplant the function of diseased lungs have shown promise in select patients the evidence is still being collected. The end-of-life discussions have been negatively impacted by prognostic uncertainty as well as barriers to in person meetings with families. SUMMARY: The resuscitation of critically ill COVID-19 patients poses new challenges, but the principles remain largely unchanged.

[Executive summary]. / Kurzfassung: Leitlinien des European Resuscitation Council 2021.

Informed by a series of systematic reviews, scoping reviews and evidence updates from the International Liaison Committee on Resuscitation, the 2021 European Resuscitation Council Guidelines present the most up to date evidence-based guidelines for the practice of resuscitation across Europe. The guidelines cover the epidemiology of cardiac arrest; the role that systems play in saving lives, adult basic life support, adult advanced life support, resuscitation in special circumstances, post resuscitation care, first aid, neonatal life support, paediatric life support, ethics and education.

European Resuscitation Council Guidelines 2021: Executive summary.

Informed by a series of systematic reviews, scoping reviews and evidence updates from the International Liaison Committee on Resuscitation, the 2021 European Resuscitation Council Guidelines present the most up to date evidence-based guidelines for the practice of resuscitation across Europe. The guidelines cover the epidemiology of cardiac arrest; the role that systems play in saving lives, adult basic life support, adult advanced life support, resuscitation in special circumstances, post resuscitation care, first aid, neonatal life support, paediatric life support, ethics and education.

Role of oxidative stress, angiogenesis and chemo-attractant cytokines in the pathogenesis of ischaemic protection induced by remote ischaemic conditioning: Study of a human model of ischaemia-reperfusion induced vascular injury.

AIMS: We explored the effect of remote ischaemic conditioning (RIC) on endothelial function and on circulating mediators. METHODS AND RESULTS: In 20 healthy male volunteers (mean age 31 ± 10 years), flow-mediated dilation (FMD) was measured before and after 20 min of arm ischaemia, followed by reperfusion. Remote ischaemic conditioning (RIC) was performed by applying 3 cycles of 5 min of ischaemia of the leg at the onset of index arm ischaemia. Each volunteer underwent the IR-induced vascular injury protocol with and without RIC in a crossover study design. In the control group, IR significantly reduced FMD (5.9 ± 2.9% before IR vs. 2.2 ± 3.7% after IR; p < 0.001). This effect was significantly attenuated by performing RIC (FMD of 5.5 ± 3.1% before IR vs. 4.0 ± 3.4% % after IR; p for interaction = 0.01). Serum levels of SOD and ADMA increased significantly whereas MCP-1 and VEGF levels decreased significantly. Only changes in SOD levels were significantly related to the degree of RIC induced protection (r² = 0.34; p = 0.018). CONCLUSION: RIC has protective effects against endothelial IR injury. Our biomarker study suggests that anti-oxidative stress mediators, such as SOD, seem to be more involved in the pathogenesis of RIC-induced protection in humans than angiogenesis factors or chemo-attractant cytokines.

Fournier's gangrene: a fulminant subcutaneous infection.

A 73-year-old man with a history of diabetes was urgently referred to our emergency department because of severe pain of his genitalia and pubical region. Physical examination revealed an extensive subcutaneous emphysema and edema of his abdomen. Computer tomography confirmed an extensive necrotizing fasciitis, diagnosed as Fournier's gangrene. Despite the efforts made, the patient did not survive. And a review of the medical approach of this short of a life-threatening form of necrotizing soft tissue infection with a high mortality rate.

U-Shape Kissing Chimney Thoracic Endovascular Aneurysm Repair for a Traumatic Arch Rupture in a Polytraumatized Patient.

An 18-year-old male patient was admitted to our hospital because of a high impact trauma. A computed tomography scan showed massive mediastinal bleeding due to a posteriorly located rupture of the aortic arch with formation of a pseudoaneurysm. Although urgent repair was indicated, open cardiac surgery was not feasible, as this would involve full heparinization in a patient with subarachnoid bleeding. The chosen solution was to perform a percutaneous thoracic endovascular aneurysm repair (TEVAR) and a kissing chimney procedure using a U-shape configuration.

The formula for survival in resuscitation.

The International Liaison Committee on Resuscitation (ILCOR) Advisory Statement on Education and Resuscitation in 2003 included a hypothetical formula--'the formula for survival' (FfS)--whereby three interactive factors, guideline quality (science), efficient education of patient caregivers (education) and a well-functioning chain of survival at a local level (local implementation), form multiplicands in determining survival from resuscitation. In May 2006, a symposium was held to discuss the validity of the formula for survival hypothesis and to investigate the influence of each of the multiplicands on survival. This commentary combines the output from this symposium with an updated illustration of the three multiplicands in the FfS using rapid response systems (RRS) for medical science, therapeutic hypothermia (TH) for local implementation, and bystander cardiopulmonary resuscitation (CPR) for educational efficiency. International differences between hospital systems made it difficult to assign a precise value for the multiplicand medical science using RRS as an example. Using bystander CPR as an example for the multiplicand educational efficiency, it was also difficult to provide a precise value, mainly because of differences between compression-only and standard CPR. The local implementation multiplicand (exemplified by therapeutic hypothermia) is probably the easiest to improve, and is likely to have the most immediate improvement in observed survival outcome in most systems of care. Despite the noted weaknesses, we believe that the FfS will be useful as a mental framework when trying to improve resuscitation outcome in communities worldwide.

AED in Europe. Report on a survey.

INTRODUCTION: Based on the strategies for community defibrillation defined by a joint policy conference of ESC and ERC, we have conducted a survey to identify the current status of AED programmes in Europe. METHODS: All registered visitors to the website of the ERC were contacted by e-mail and invited to participate in a web-based survey. RESULTS: Of the 983 usable responses, 899 came from 36 European countries, representing a total of 748 million inhabitants. In 11 countries AED use by non-physicians has been implemented partially. All but 3 countries reported that first-tier ambulances are equipped with defibrillators. In 13 countries everybody is allowed to use an AED and in 11 countries anybody who has been trained. In 14 countries there are a few community responder programmes, in 14 countries there are hardly any, and in 7 countries there are none. Thirteen countries have implemented a few on-site responder programmes; in 16 countries there are hardly any such programmes, and in 7 countries none. Programmes for home responders can hardly be found in 19 countries; in-hospital programmes exist in 7 countries nearly everywhere. Only 1 country reported that epidemiologic and/or economic evaluations are carried out nearly everywhere when planning AED programmes. Nationwide registries to collect data from resuscitation attempts have been set up in 4 countries. In 27 countries inventories for AEDs can be found here and there. CONCLUSION: Much has been achieved concerning the provision and use of AEDs in Europe, but there is still a long way to go.