[When should we stop cardiopulmonary resuscitation in patients brought to the emergency room in cardiac arrest without pre-hospital care?]. / Quando interromper, na sala de emergência, as manobras de ressuscitação cardiopulmonar na parada cardiorrespiratória sem atendimento pré-hospitalar?

PURPOSE: The decision of stopping cardiopulmonary resuscitation (CPR) in patients brought to emergency room in arrest remains a challenge. Such decision is even more difficult when someone is brought by bystanders, after an acute loss of consciousness without any out-of-hospital care. To evaluate the probability of survival of these patients we reviewed retrospectively charts in our institution, during a period of five years. METHODS: One hundred and one patients that fulfilled these characteristics came to our emergency in arrest. The time to arrival since symptoms started, cardiac rhythm at first electrocardiogram (EKG), age, gender, initial CPR success, late outcomes and previous diseases were obtained. Patients were divided in two groups regarding which cardiac rhythms they had at first EKG: A-patients arriving in asystole; and VF-patients arriving in ventricular fibrillation. To evaluate time to arrival, we arbitrarily choose 15 min as a reference point. RESULTS: In these 101 subjects the mean age was 62 +/- 13.7 years and 63 (62.3%) were men. Previous heart disease was documented in 74 [dilated cardiomyopathy in 22 (21.7%), coronary heart disease in 41 (40.6%), arterial hypertension in 25 (24.7%) and others in 6 (5.6%)]. In 66 episodes we were sure of the time patients spent before arrival (mean 2.5 +/- 11 min). Only in 63 subjects we had no doubts about the rhythm at entrance: VF in 37 (58.7%), A in 22 (34.9%) and an accelerated idioventricular rhythm (AIR) in four (6.3%). Time to arrival was 18.6 +/- 10.6 in VF vs 32.5 +/- 11.7 min in A (p = 0.012). Fourteen (13.8%) subjects resumed a supraventricular rhythm with systolic pressure > or = 90 mmHg after CPR and all of them were in VF (13) or AIR (one). Nine patients (8.9%) evolved in coma. Only five (4.9%) were discharged from the hospital without any neurological disturbance and their time to arrival ranged from one to 15 (9 +/- 5.8) min. CONCLUSION: Delayed arrival to the emergency room (> 15 min) associated with asystole were predictors of unsuccessful CPR, and both data are helpful in deciding when to stop CPR in subjects arriving at the emergency department with no out-of-hospital care.

[Acute atrial fibrillation in the emergency room. Which is the best drug for a rapid sinus rhythm conversion?]. / Fibrilação atrial aguda na unidade de emergência. Qual a droga ideal para rápida reversão ao ritmo sinusal?

PURPOSE: To evaluate differences between amiodarone, procainamide and quinidine in the time delay necessary to convert acute atrial fibrillation (AF) to sinus rhythm. METHODS: Sixty patients with acute AF were randomized in three groups (G) and treated with: quinidine (QG)-(21 patients) i.v. digital + quinidine up to 600 mg; procainamide (PG)-(23 patients) i.v. digital + i.v. procainamide, 10 mg/kg; amiodarone (AG)-(16 patients) i.v. amiodarone, 5 mg/kg. To evaluate time delay to conversion, all patients have their rhythm recorded by Holter system during four hours. Statistics were done with x2, considering significant a p < 0.05. RESULTS: There were no differences between groups regarding to age, gender and delay from symptoms initiation and medical assistance. Conversion to sinus rhythm occurred, in QG-71.4% cases; PG-47.8% and AG-50% (p > 0.05). Time delay in minutes to conversion were, respectively (media +/- SD): QG-112 +/- 43; PG-44.1 +/- 28; AG-20 +/- 13, significantly lower in PG and AG related to QG (p = 0.001). Although not significant, side effects were observed mostly in PG. CONCLUSION: Amiodarone is a good choice to convert, very quickly, acute AF. Otherwise, quinidine has the best rate of conversion but with a longer time delay.