Effect of Austrian COVID-19 lockdowns on acute myocardial infarction frequency and long-term mortality: a multicentre observational study.

OBJECTIVES: The aim of this study was to find out if the decrease in acute myocardial infarction (AMI) admissions during the first COVID-19 lockdowns (LD), which was described by previous studies, occurred equally in all LD periods (LD1, LD2, LD2021), which had identical restrictions. Further, we wanted to analyse if the decrease of AMI admission had any association with the 1-year mortality rate. DESIGN AND SETTING: This study is a prospective observational study of two centres that are participating in the Vienna ST-elevation myocardial infarction network. PARTICIPANTS: A total of 1732 patients who presented with AMI according to the 4th universal definition of myocardial infarction in 2019, 2020 and the LD period of 2021 were included in our study. Patients with myocardial infarction with non-obstructive coronary arteries were excluded from our study. MAIN OUTCOME MEASURES: The primary outcome of this study was the frequency of AMI during the LD periods and the all-cause and cardiac-cause 1-year mortality rate of 2019 (pre-COVID-19) and 2020. RESULTS: Out of 1732 patients, 70% (n=1205) were male and median age was 64 years. There was a decrease in AMI admissions of 55% in LD1, 28% in LD2 and 17% in LD2021 compared with 2019.There were no differences in all-cause 1-year mortality between the year 2019 (11%; n=110) and 2020 (11%; n=79; p=0.92) or death by cardiac causes [10% (n=97) 2019 vs 10% (n=71) 2020; p=0.983]. CONCLUSION: All LDs showed a decrease in AMI admissions, though not to the same extent, even though the regulatory measures were equal. Admission in an LD period was not associated with cardiac or all-cause 1-year mortality rate in AMI patients in our study.

Laryngeal Tube Practice in a Metropolitan Ambulance Service: A Five-year Retrospective Observational Study (2009-2013).

Background: The endotracheal tube (ETT) is considered the gold standard in emergency airway management, although supraglottic airway devices, especially the laryngeal tube (LT), have recently gained in importance. Although regarded as an emergency device in case of failure of endotracheal intubation in most systems, we investigated the dynamics of the use of the LT in a metropolitan ambulance service without any regulations on the choice of airway device. Methods: A retrospective, observational study on all patients from the Municipal Ambulance Service, Vienna in need of advanced airway management over a 5-year period. Differences between years were compared; influencing factors for the use of the LT were analyzed using multivariable logistic regression. Results: In total 5,175 patients (mean age 62 ± 20 years, 36.6% female) underwent advanced airway management. Of these, 15.6% received the LT. LT use increased from 20 out of 1,001 (2.0%) in 2009 to 292 of 1,085 (26.9%) in 2013 (p < 0.001). The increase between each consecutive year was also significant. Paramedics more frequently inserted the LT than physicians (RR 1.80 (95%CI 1.48-2.16); p < 0.001). Female patients received a LT less frequently (RR 0.84 (95%CI 0.72-0.97), p = 0.013). There was no difference regarding airway device due to underlying causes requiring airway management and no relationship to the NACA-score. Conclusion: In a European EMS system of physician and paramedic response, the proportion of airway managed by LT over ETT rose considerably over five years. Although the ET is still the gold standard, the LT is gaining in importance for EMS physicians and paramedics.

Initial end-tidal carbon dioxide as a predictive factor for return of spontaneous circulation in nonshockable out-of-hospital cardiac arrest patients: A retrospective observational study.

BACKGROUND: Early outcome prediction in out-of-hospital cardiac arrest is still a challenge. End-tidal carbon dioxide (ETCO2) has been shown to be a reliable parameter to reflect the quality of cardiopulmonary resuscitation and the chance of return of spontaneous circulation (ROSC). OBJECTIVES: This study assessed the validity of early capnography as a predictive factor for ROSC and survival in out-of-hospital cardiac arrest victims with an underlying nonshockable rhythm. DESIGN: Retrospective observational study. SETTING/PATIENTS: During a 2-year observational period, data from 2223 out-of-hospital cardiac arrest victims within the city of Vienna were analysed. The focus was on the following patients: age more than 18 years, an underlying nonshockable rhythm, and advanced airway management within the first 15 min of advanced life support with subsequent capnography. INTERVENTION: No specific intervention was set in this observational study. MAIN OUTCOME MEASURES: The first measured ETCO2, assessed immediately after placement of an advanced airway, was used for further analysis. The primary outcome was defined as sustained ROSC, and the secondary outcome was 30-day survival. RESULTS: A total of 526 patients met the inclusion criteria. These were stratified into three groups according to initial ETCO2 values (<20, 20 to 45, >45 mmHg). Baseline data and resuscitation factors were similar among all groups. The odds of sustained ROSC and survival were significantly higher for patients presenting with higher values of initial ETCO2 (>45 mmHg): 3.59 [95% CI, 2.19 to 5.85] P = 0.001 and 5.02 [95% CI, 2.25 to 11.23] P = 0.001, respectively. On the contrary ETCO2 levels less than 20 mmHg were associated with significantly poorer outcomes. CONCLUSION: Patients with a nonshockable out-of-hospital cardiac arrest who presented with higher values of initial ETCO2 had an increased chance of sustained ROSC and survival. This finding could help decision making as regards continuation of resuscitation efforts.

Age-dependent effect of targeted temperature management on outcome after cardiac arrest.

BACKGROUND: In elder patients after out-of-hospital cardiac arrest, diminished neurologic function as well as reduced neuronal plasticity may cause a low response to targeted temperature management (TTM). Therefore, we investigated the association between TTM (32-34°C) and neurologic outcome in cardiac arrest survivors with respect to age. MATERIAL AND METHODS: This retrospective cohort study included patients 18 years of age or older suffering a witnessed out-of-hospital cardiac arrest with presumed cardiac cause, which remained comatose after return of spontaneous circulation. Patients were a priori split by age into four groups (<50 years (n = 496); 50-64 years (n = 714); 65-74 years (n = 395); >75 years (n = 280)). Subsequently, within these groups, patients receiving TTM were compared to those not treated with TTM. RESULTS: Out of 1885 patients, 921 received TTM for 24 hours. TTM was significantly associated with good neurologic outcome in patients <65 years of age whereas showing no effect in elders (65-74 years: OR: 1.49 (95% CI: 0.90-2.47); > 75 years: OR 1.44 (95% CI 0.79-2.34)). CONCLUSION: In our cohort, it seems that TTM might not be able to achieve the same benefit for neurologic outcome in all age groups. Although the results of this study should be interpreted with caution, TTM was associated with improved neurologic outcome only in younger individuals, patients with 65 years of age or older did not benefit from this treatment.

The impact of airway strategy on the patient outcome after out-of-hospital cardiac arrest: A propensity score matched analysis.

BACKGROUND: While guidelines mentioned supraglottic airway management in the case of out-of- hospital cardiac arrest, robust data of their impact on the patient outcome remain scare and results are inconclusive. METHODS: To assess the impact of the airway strategy on the patient outcome we prospectively enrolled 2224 individuals suffering cardiac arrest who were treated by the Viennese municipal emergency medical service. To control for potential confounders, propensity score matching was performed. Patients were matched in four groups with a 1:1:1:1 ratio ( n=210/group) according to bag-mask-valve, laryngeal tube, endotracheal intubation and secondary endotracheal intubation after primary laryngeal tube ventilation. RESULTS: The laryngeal tube subgroup showed the lowest 30-day survival rate among all tested devices ( p<0.001). However, in the case of endotracheal intubation after primary laryngeal tube ventilation, survival rates were comparable to the primary endotracheal tube subgroup. The use of a laryngeal tube was independently and directly associated with mortality with an adjusted odds ratio of 1.97 (confidence interval: 1.14-3.39; p=0.015). Additionally, patients receiving laryngeal tube ventilation showed the lowest rate of good neurological performance (6.7%; p<0.001) among subgroups. However, if patients received endotracheal intubation after initial laryngeal tube ventilation, the outcome proved to be significantly better (9.5%; p<0.001). CONCLUSION: We found that the use of a laryngeal tube for airway management in cardiac arrest was significantly associated with poor 30-day survival rates and unfavourable neurological outcome. A primary endotracheal airway management needs to be considered at the scene, or an earliest possible secondary endotracheal intubation during both pre-hospital and in-hospital post-return of spontaneous circulation critical care seems crucial and most beneficial for the patient outcome.

Outcome of in- and out-of-hospital cardiac arrest survivors with liver cirrhosis.

BACKGROUND: Organ failure increases mortality in patients with liver cirrhosis. Data about resuscitated cardiac arrest patients with liver cirrhosis are missing. This study aims to assess aetiology, survival and functional outcome in patients after successful cardiopulmonary resuscitation (CPR) with and without liver cirrhosis. METHODS: Analysis of prospectively collected cardiac arrest registry data of consecutively hospital-admitted patients following successful CPR was performed. Patient's characteristics, admission diagnosis, severity of disease, course of disease, short- and long-term mortality as well as functional outcome were assessed and compared between patients with and without cirrhosis. RESULTS: Out of 1068 patients with successful CPR, 47 (4%) had liver cirrhosis. Acute-on-chronic liver failure (ACLF) was present in 33 (70%) of these patients on admission, and four patients developed ACLF during follow-up. Mortality at 1 year was more than threefold increased in patients with liver cirrhosis (OR 3.25; 95% CI 1.33-7.96). Liver cirrhosis was associated with impaired neurological outcome (OR for a favourable cerebral performance category: 0.13; 95% CI 0.04-0.36). None of the patients with Child-Turcotte-Pugh (CTP) C cirrhosis survived 28 days with good neurological outcome. Overall nine (19%) patients with cirrhosis survived 28 days with good neurological outcome. All patients with ACLF grade 3 died within 28 days. CONCLUSION: Cardiac arrest survivors with cirrhosis have worse outcome than those without. Although one quarter of patients with liver cirrhosis survived longer than 28 days after successful CPR, patients with CTP C as well as advanced ACLF did not survive 28 days with good neurological outcome.

Feasibility of profound hypothermia as part of extracorporeal life support in a pig model.

OBJECTIVE: To investigate the feasibility of a refined aortic flush catheter and pump system to induce emergency preservation and resuscitation before extracorporeal cardiopulmonary resuscitation in a normovolemic cardiac arrest swine model simulating near real size/weight conditions of adults. METHODS: In this feasibility study, 8 female Large White breed pigs weighing 70 to 80 kg underwent ventricular fibrillation cardiac arrest for 15 minutes, followed by 4°C aortic flush (150 mL/kg for the brain; 50 mL/kg for the spine) via a new hardware ensued by resuscitation with extracorporeal cardiopulmonary resuscitation. RESULTS: Brain temperature was lowered from 39.9°C (interquartile range [IQR] 39.6-40.3) to 24.0°C (IQR 20.8-28.9) in 12 minutes (IQR 11-16) with a median cooling rate of 1.3°C (IQR 0.7-1.6) per minute. A median of 776 mL (IQR 673-840) per minute with a median pump pressure of 1487 mm Hg (IQR 1324-1545) were pumped to the brain. CONCLUSIONS: With the new hardware, we were able to cool the brain within a few minutes in a large pig cardiac arrest model. The exact position; the design, diameter, and length of the flush catheter; and the brain perfusion pressure seem to be critical to effectively reduce brain temperature. Redistribution of peripheral blood could lead to sterile inflammation again and might be avoided.

Age-specific prognostication after out-of-hospital cardiac arrest - The ethical dilemma between 'life-sustaining treatment' and 'the right to die' in the elderly.

BACKGROUND: While prognostic values on survival after out-of-hospital cardiac arrest have been well investigated, less attention has been paid to their age-specific relevance. Therefore, we aimed to identify suitable age-specific early prognostication in elderly patients suffering out-of-hospital cardiac arrest in order to reduce the burden of unnecessary treatment and harm. METHODS: In a prospective population-based observational trial on individuals suffering out-of-hospital cardiac arrest, a total of 2223 patients receiving resuscitation attempts by the local emergency medical service in Vienna, Austria, were enrolled. Patients were stratified according to age as follows: young and middle-aged individuals (<65 years), young old individuals (65-74 years), old individuals (75-84 years) and very old individuals (>85 years). RESULTS: There was an increasing rate of 30-day mortality (+21.8%, p < 0.001) and unfavourable neurological outcome (+18.8%, p < 0.001) with increasing age among age groups. Established predictive variables lost their prognostic potential with increasing age, even after adjusting for potential confounders. Independently, an initially shockable electrocardiogram proved to be directly associated with survival, with an adjusted hazard ratio (HR) of 2.04 (95% confidence interval (CI) 1.89-2.38, p = 0.003) for >85-year-olds. Frailty was directly associated with mortality (HR 1.22, 95% CI 1.01-1.51, p = 0.049), showing a 30-day survival of 5.6% and a favourable neurological outcome of 1.1% among elderly individuals. CONCLUSION: An initially shockable electrocardiogram proved to be a suitable tool for risk assessment and decision making in order to predict a successful outcome in elderly victims of out-of-hospital cardiac arrest. However, the outcomes of elderly patients seemed to be exceptionally poor in frail individuals and need to be considered in order to reduce unnecessary treatment decisions.

Is hypothermia indicated during cardiopulmonary resuscitation and after restoration of spontaneous circulation?

PURPOSE OF REVIEW: Targeted temperature management (TTM) after cardiac arrest has become a standard therapy in postresuscitation care. However, many questions addressing the optimum treatment protocol remain unanswered. RECENT FINDINGS: The positive influence of intra-arrest cooling on survival and neurologic outcome, seen in animal studies, was not revealed in clinical trials so far. By contrast, the evidence of TTM after restoration of circulation is based on both experimental and clinical data. The mechanisms of cerebral injury unfold different time windows for cooling initiation. Immediate cooling and early achievement of a target temperature less than 34°C seems to be beneficial, although clinical data on preclinical cooling failed to detect a positive correlation. Despite previous beneficial experimental and clinical data, the benefit of a lower body temperature was recently called into question by a recent study. Regardless of the preferred temperature range, the main focus must lie in active cooling and prevention of hyperthermic conditions. There are many factors that influence the effect of TTM, which should therefore be tailored to the specific patient's needs. SUMMARY: To maximize its beneficial potential, TTM should be customized to resuscitation covariates. Despite open questions on the optimum treatment protocol, active cooling should be started as soon as possible and hyperthermic conditions should be prevented in any case. To answer the question if intra-arrest cooling or prehospital cooling induction is indicated, additional studies are needed.

Limited effect of mild therapeutic hypothermia on outcome after prolonged resuscitation.

BACKGROUND: Mild therapeutic hypothermia interferes with multiple cascades of the ischaemia/reperfusion injury that is known as primary mechanism for brain damage after cardiac arrest. First resuscitation attempts and the duration of resuscitation efforts will initiate and aggravate this pathophysiology. Therefore we investigated the interaction between the duration of basic and advanced life support and outcome after cardiac arrest in patients treated with or without mild therapeutic hypothermia. METHODS: This retrospective cohort study included patients 18 years of age or older suffering a witnessed out-of-hospital cardiac arrest with presumed cardiac cause, which remained comatose after restoration of spontaneous circulation. The basic and advanced life support 'low-flow' time, categorized into four quartiles (0-11, 12-17, 18-28, ≥ 29 min), was correlated with neurological outcome. RESULTS: Out of 1103 patients 613 were cooled to a target temperature of 33 ± 1 °C for 24h. In the three quartiles with 'low-flow' time up to 28 min cooling was associated with >2-fold odds of favourable neurological outcome. In the fourth quartile with 'low-flow' time of ≥ 29 min cooling had no influence on neurological outcome (OR: 0.73; 95% CI: 0.38-1.4, test for interaction p<0.01). CONCLUSION: The duration of resuscitation efforts, defined as 'low-flow' time, influences the effectiveness of mild therapeutic hypothermia in terms of neurologic outcome. Patients with low to moderate 'low-flow' time benefit most from this treatment.

Surveillance of Patients in the Waiting Area of the Department of Emergency Medicine.

Many patients visiting an emergency department are in reduced general condition of health and at risk of suffering further deterioration during their stay. We wanted to test the feasibility of a new monitoring system in a waiting area of an emergency department.In an observational cross-sectional single-center study, patients with acute cardiac or pulmonary symptoms or in potentially life-threatening conditions were enrolled. Monitoring devices providing vital signs via short range radio (SRR) at certain time points and compliance evaluation forms were used.Out of 230 patients, 4 wanted to terminate their participation prematurely. No data was lost due to technical difficulties. Over a median monitoring period of 178 (118-258) min per patient, 684 h of vital sign data were collected and used to assist managing those patients. Linear regression analysis between clinical symptom category groups of patients showed significant differences in the respiratory rate and noninvasive blood pressure courses. Feedback from patients and users via questionnaires showed overall very good acceptance and patients felt that they were given better care.To assist medical staff of an emergency department waiting area to rapidly response to potentially life-threatening situations of its patients, a new monitoring system proved to be feasible and safe.

Quality of post arrest care does not differ by time of day at a specialized resuscitation center.

Previous studies suggest worse outcomes after out-of-hospital cardiac arrest (OHCA) at night. We analyzed whether patients admitted after nontraumatic OHCA to a resuscitation center received the same quality post arrest care at day and night and whether quality of care affected clinical outcomes. We analyzed data of OHCA patients with return of spontaneous circulation admitted to the Vienna general hospital emergency department between January 2006 and May 2013. Data reported include admission time (day defined from 8 AM to 4 PM based on staffing), time to initiation of hypothermia, and door-to-balloon time in patients with ST-elevation myocardial infarction. Survival and cognitive performance at 12 months were assessed. In this retrospective observational study, 1059 patients (74% males, n = 784) with a mean age of 58 ±â€Š16 years were analyzed. The vast majority was treated with induced hypothermia (77% of day vs. 79% of night admissions, P = 0.32) within 1 hour of admission (median time admission to cooling 27 (confidence interval [CI]: 10-60) vs. 23 (CI: 11-59) minutes day vs. night, P = 0.99). In 298 patients with ST-elevation myocardial infarction, median door-to-balloon time did not differ between day and night admissions (82 minutes, CI: 60 to 142 for day vs. 86 minutes, CI: 50 to 135 for night, P = 0.36). At 12 months, survival was recorded in 238 of 490 day and 275 of 569 night admissions (49% vs. 48%, P = 0.94%), and a good neurologic outcome was recorded in 210 of 490 day and 231 of 569 night admissions (43% vs. 41%, P = 0.46). Patients admitted to our department after OHCA were equally likely to receive timely high-quality postresuscitation care irrespective of time of day. Survival and good neurologic outcome at 12 months did not differ between day and night admissions. Our results may support the concept of specialized post arrest care centers.

Prehospital surface cooling is safe and can reduce time to target temperature after cardiac arrest.

PURPOSE: Mild therapeutic hypothermia proved to be beneficial when induced after cardiac arrest in humans. Prehospital cooling with i.v. fluids was associated with adverse side effects. Our primary objective was to compare time to target temperature of out-of hospital cardiac arrest patients cooled non-invasively either in the prehospital setting vs. the in-hospital (IH) setting, to assess surface-cooling safety profile and long term outcome. METHODS: In this retrospective, single center cohort study, a group of adult patients with restoration of spontaneous circulation (ROSC) after out-of hospital cardiac arrest were cooled with a surface cooling pad beginning either in the prehospital or IH setting for 24h. Time to target temperature (33.9°C), temperature on admission, time to admission after ROSC and outcome were compared. Also, rearrests and pulmonary edema were assessed. Neurologic outcome at 12 months was evaluated (Cerebral Performance Category, CPC 1-2, favorable outcome). RESULTS: Between September 2005 and February 2010, 56 prehospital cooled patients and 54 IH-cooled patients were treated. Target temperature was reached in 85 (66-117)min (prehospital) and in 135 (102-192)min (IH) after ROSC (p<0.001). After prehospital cooling, hospital admission temperature was 35.2 (34.2-35.8)°C, and in the IH-cooling patients initial temperature was 35.8 (35.2-36.3)°C (p=0.001). No difference in numbers of rearrests and pulmonary edema between groups was observed. In both groups, no skin lesions were observed. Favorable outcome was reached in 26.8% (prehospital) and in 37.0% (IH) of the patients (p=0.17). CONCLUSIONS: Using a non-invasive prehospital surface cooling method after cardiac arrest, target temperature can be reached faster without any major complications than starting cooling IH. The effect of early non-invasive cooling on long-term outcome remains to be determined in larger studies.

Novel treatment techniques for recanalization of femoral-popliteal deep venous occlusion from chronic thrombosis.

Patients with postthrombotic syndrome due to previous femoral-popliteal deep venous thrombosis often experience lifestyle-limiting lower-extremity pain and swelling. Conservative treatment options include compression stockings and lymphedema massage, but in many cases these treatments only temporarily and partially improve symptoms. Ultrasound and venography in patients with postthrombotic syndrome often show only partial recanalization of the femoral vein with significant collateral vein formation. These abnormal veins are insufficient for adequate venous drainage from the lower extremity as evidenced by the patient's continued symptoms. Recanalization of the occluded or partially occluded femoral vein using prolonged venoplasty, with or without chemical thrombolysis, combined with optimizing anticoagulation and conservative treatment measures, results in lasting improvement in symptoms for a high percentage of patients.

Cardiac arrest caused by acute intoxication-insight from a registry.

INTRODUCTION: The aim of the study was to evaluate the epidemiology and outcome after cardiac arrest caused by intoxication. METHODS: A retrospective analysis of 1991 to 2010 medical record of patients experiencing cardiac arrest caused by self-inflicted, intentional intoxication was performed. The setting was an emergency department of a tertiary care university hospital. The primary end point was the presentation of epidemiologic data in relation to favorable neurologic outcome, defined as cerebral performance categories 1 or 2 and 180-day survival. Furthermore, the patients were subdivided into a single-substance and polysubstance group, depending on the substances causing the intoxication. RESULTS: Of 3644 patients admitted to our department, 99 (2.7%) with a median age of 26 (interquartile range, 19-42) years (37% female) were included. Cardiac arrest was witnessed in 62 cases (63%). Eleven patients (11%) received basic life support by bystanders, and 11 (11%) had a shockable rhythm in the initial electrocardiogram. The combined end point "good survival" was achieved by 34 patients (34%). Cardiac arrest occurred out of hospital in 73 patients (74%) and in-hospital in 26 patients (26%). A single substance causing the intoxication was found in 56 patients (56%). Opiates were the leading substance, with 25 patients (25%) using them. CONCLUSION: Cardiac arrest caused by intoxication is found predominately in young patients. Overall, favorable neurologic survival was achieved in 34%. Opiate-related cardiac arrest was associated with poor survival and a high incidence of neurologic deficits.

Strategic target temperature management in myocardial infarction--a feasibility trial.

OBJECTIVE: The purpose of this study was to demonstrate the feasibility of a combined cooling strategy started out of hospital as an adjunctive to percutaneous coronary intervention (PCI) in the treatment of ST-elevation acute coronary syndrome (STE-ACS). DESIGN: Non-randomised, single-centre feasibility trial. SETTING: Department of emergency medicine of a tertiary-care facility, Medical University of Vienna, Vienna, Austria. In cooperation with the Municipal ambulance service of the city of Vienna. PATIENTS: Consecutive patients with STE-ACS presenting to the emergency medical service within 6 h after symptom onset. INTERVENTIONS: Cooling was initiated with surface cooling pads in the out-of-hospital setting, followed by the administration of 1000-2000 mL of cold saline at hospital arrival and completed by endovascular cooling in the catheterisation laboratory. MAIN OUTCOME MEASURES: Feasibility of lowering core temperature below 35.0°C prior to immediately performed revascularisation. Safety and tolerability of the cooling procedure. RESULTS: In enrolled 19 patients (one woman, median age 51 years (IQR 45-59)), symptom onset to first medical contact (FMC) was 45 min (IQR 31-85). A core temperature below 35.0°C at reperfusion of the culprit lesion was achieved in 11 patients (78%) within 100 min (IQR 90-111) after FMC without any cooling-related serious adverse event. Temperature could be lowered from baseline 36.4°C (IQR 36.2-36.5°C) to 34.4°C (IQR 34.1-35.0°C) at the time of reperfusion. CONCLUSIONS: With limitations an immediate out-of-hospital therapeutic hypothermia strategy was feasible and safe in patients with STE-ACS undergoing primary PCI. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov/ct2/show/NCT01864343; clinical trials unique identifier: NCT01864343.

Airway management of adult patients without trauma in an ED led by internists.

BACKGROUND: Airway management is a key competence in emergency medicine. Patients heavily differ from those in the operating room. They are acutely ill by definition and usually not fasting. Evaluation of risk factors is often impossible. Current literature primarily originates from countries where emergency medicine is an independent specialty. We evaluated intubations in a high-volume emergency department run by internists and comprising its own distinctive intensive care unit. METHODS: In this prospective, noncontrolled, observational study, we continuously documented all intubations performed at the emergency department. We analyzed demographic, medical, and staff-related factors predicting difficulties during intubation using logistic regression models. RESULTS: For 73 months, 660 cases were included, 69 (10.5%) of them were without any induction therapy. Two hundred fifty-two (38.2%) patients were female, and their mean age was 59 ± 17 years. Three hundred four (49.9%) had an initial Glasgow Coma Scale of 3. Leading indications were respiratory insufficiency (n = 246; 37.3%), resuscitation (n = 172; 26.1%), and intracranial hemorrhage (n = 75; 11.4%). First attempt was successful in 465 cases (75.1%); alternative airway devices were used in 22 cases (3.3%). Time from the first intubation attempt to a validated airway was 1 minute (interquartile range, 0-2 minutes). Physicians' experience and anatomical risk factors were associated with failure at the first attempt, prolonged intubation, and the need for alternative devices. CONCLUSIONS: Airway management at the emergency department possesses a high potential of failure. Experience seems to be the key to success.

Rapid induction of mild therapeutic hypothermia by extracorporeal veno-venous blood cooling in humans.

AIM: Mild therapeutic hypothermia is beneficial in patients successfully resuscitated from non-traumatic out-of-hospital cardiac arrest. The effect of fast induction of hypothermia in these patients remains to be investigated. The aim of this study was to evaluate the efficacy and safety of extracorporeal veno-venous blood cooling in humans successfully resuscitated from cardiac arrest. METHODS: We performed an interventional study in patients after successful resuscitation from cardiac arrest admitted to the emergency department of a tertiary care centre. The extracorporeal veno-venous circulation was established via a percutaneously introduced double lumen dialysis catheter in the femoral vein, and a tubing circuit and heat exchanger. A paediatric cardiopulmonary bypass roller pump and a heater-cooler system were used to circulate the blood. Main outcome measures were feasibility, efficacy, and safety. RESULTS: We included eight consecutive cardiac arrest patients with a median oesophageal temperature of 35.9°C (interquartile range 34.9-37.0). A median time of 8 min elapsed (interquartile range 5-15 min) to reach oesophageal temperatures below 34°C, which reflects a cooling rate of 12.2°C/h (interquartile range 10.8°C/h to 14.1°C/h). The predefined target temperature of 33.0°C was reached after 14 min (interquartile range 8-21 min). No device or method related adverse events were reported. CONCLUSION: Extracorporeal veno-venous blood cooling is a feasible, safe, and very fast approach for induction of mild therapeutic hypothermia in patients successfully resuscitated from cardiac arrest.

Frequency of external iliac artery branch injury in blunt trauma: improved detection with selective external iliac angiography.

PURPOSE: To assess the utility of selective external iliac artery (EIA) angiography and the frequency of injury to branches of the EIA in cases of blunt pelvic trauma. MATERIALS AND METHODS: A retrospective review of pelvic angiograms in 66 patients with blunt pelvic trauma was conducted over a 12-month period. Pelvic and femur fracture patterns were correlated to the presence of EIA injury. Pelvic arteriography was compared versus selective EIA angiography for the detection of arterial injury. RESULTS: Fifty-four of 66 patients (82%) exhibited pelvic arterial injury or elicited enough suspicion for injury to warrant embolization. Internal iliac artery embolization was performed in 50 of 66 (76%). EIA branch injury was identified in 11 of 66 patients (17%), and 10 were successfully embolized. EIA branch vessel injury was identified more frequently when there was ipsilateral intertrochanteric fracture (P = .07) or ipsilateral ilium fracture (P = .07). The sensitivity of nonselective pelvic angiography in the detection of EIA branch vessel injury was 45%. CONCLUSIONS: EIA branch injury occurs in a substantial fraction of patients with blunt pelvic trauma who undergo pelvic angiography. Selective EIA angiography should be considered in all patients undergoing pelvic angiography in this situation.

Emergency cardio-pulmonary bypass in cardiac arrest: seventeen years of experience.

AIM: Emergency cardiopulmonary bypass (E-CPB) is an advanced and rarely used procedure for patients in cardiac arrest that do not regain restoration of spontaneous circulation with standard resuscitation methods. The feasibility, safety and outcome of the intervention with E-CPB in cardiac arrest situations at our department have been evaluated. METHODS: Clinical presentation, time intervals, diagnosis and outcome of all patients who received E-CPB at an emergency department of a tertiary care university hospital were evaluated. Patient charts were reviewed regarding cardiac arrest variables and treatment data of all patients from 1993 to 2010. RESULTS: E-CPB was performed in 55 patients. Of all patients, 33 (60%) were male and the median age was 32 years (IQR 24-44). In all cases cardiac arrest was witnessed. The first recorded ECG rhythm showed pulseless electric activity in 23 (42%), ventricular fibrillation in 21 (38%) and asystole in 11 (20%) patients. Cardiac arrest occurred out-of-hospital in 33 (60%) patients. The median duration of CPR before performing E-CPB was 86 min (IQR 69-121). The median 'cannulation'-time was 33 min (IQR 21-45) and the duration on bypass was 311 min (IQR 161-953). Cardiac causes of arrest were found in 19 (35%) patients. Eight patients (15%) survived to 6 months with good neurological outcome. CONCLUSION: E-CPB for cardiac arrest is feasible and safe. In this seemingly desperate patient population after prolonged cardiac arrest, we observed a high survival rate of 15%. E-CPB is a meaningful treatment option, which should be considered more often and earlier.