Prehospital misdiagnosis of acute cerebral disease for acute coronary syndrome: a retrospective study.

OBJECTIVE: In cerebrovascular accidents symptoms, laboratory results and electrocardiogram (ECG) changes can mimic acute coronary syndrome (ACS) and is subsumed as neurogenic stunned myocardium. So far, data regarding the frequency of cerebrovascular accidents misdiagnosed for ACS in a prehospital setting are missing. This study aims to quantify misdiagnoses and discover discriminating features. METHODS: In a retrospective cohort study, prehospital and hospital medical records of all patients treated by physician-staffed emergency medical teams in the city of Bonn (Germany) with suspected ACS in 2018 were evaluated regarding medical history, prehospital symptoms and findings as well as hospital diagnoses. RESULTS: From 758 patients admitted for presumed ACS, 9 patients (1.2%, 95% CI: 0.5-2.2%) suffered from acute cerebral disease (ACD group). Mainly, diagnoses were cerebrovascular accidents and one case of neuroborreliosis. A history of intracranial haemorrhage was found more often in the ACD group compared to the remaining cohort (OR 19, p = 0.01), while a history of arterial hypertension was less frequent (OR 0.22, p = 0.03). Presentation with headaches (OR 10.1, p = 0.03) or neurological symptoms (OR 16.9, p = 0.01) occurred more frequent in the ACD group. ECG changes were similar between groups. CONCLUSION: Acute cerebral disease misdiagnosed for ACS seems more common than assumed. Out of 758 patients with presumed ACS, 9 patients (1.2%) suffered from ACD, which were cerebrovascular accidents mainly. This is highly relevant, since prehospital treatment with heparin and acetylsalicylic acid is indicated in ACS but contraindicated in cerebrovascular accidents without further diagnostics. Thus, discriminating these patients is crucial. An attentive patient history and examination may be the key to differentiating ACD. Due to small ACD group size, further studies are needed.

Aneurysmal Subarachnoid Hemorrhage during the Shutdown for COVID-19.

The aim was to evaluate hospitalization rates for aneurysmal subarachnoid hemorrhage (SAH) within an interdisciplinary multicenter neurovascular network (NVN) during the shutdown for the COVID-19 pandemic along with its modifiable risk factors. In this multicenter study, admission rates for SAH were compared for the period of the shutdown for the COVID-19 pandemic in Germany (calendar weeks (cw) 12 to 16, 2020), the periods before (cw 6-11) and after the shutdown (cw 17-21 and 22-26, 2020), as well as with the corresponding cw in the years 2015-2019. Data on all-cause and pre-hospital mortality within the area of the NVN were retrieved from the Department of Health, and the responsible emergency medical services. Data on known triggers for systemic inflammation, e.g., respiratory viruses and air pollution, were analyzed. Hospitalizations for SAH decreased during the shutdown period to one-tenth within the multicenter NVN. There was a substantial decrease in acute respiratory illness rates, and of air pollution during the shutdown period. The implementation of public health measures, e.g., contact restrictions and increased personal hygiene during the shutdown, might positively influence modifiable risk factors, e.g., systemic inflammation, leading to a decrease in the incidence of SAH.

Hospital admissions during Covid-19 lock-down in Germany: Differences in discretionary and unavoidable cardiovascular events.

BACKGROUND: A decline in hospitalization for cardiovascular events and catheter laboratory activation was reported for the United States and Italy during the initial stage of the Covid-19 pandemic of 2020. We report on the deployment of emergency services for cardiovascular events in a defined region in western Germany during the government-imposed lock-down period. METHODS: We examined 5799 consecutive patients who were treated by emergency services for cardiovascular events during the Covid-19 pandemic (January 1 to April 30, 2020), and compared those to the corresponding time frame in 2019. Examining the emergency physicians' records provided by nine locations in the area, we found a 20% overall decline in cardiovascular admissions. RESULTS: The greatest reduction could be seen immediately following the government-imposed social restrictions. This reduction was mainly driven by a reduction in discretionary admissions for dizziness/syncope (-53%), heart failure (-38%), exacerbated COPD (-28%) and unstable angina (-23%), while unavoidable admissions for ST-elevation myocardial infarction (STEMI), cardiopulmonary resuscitation (CPR) and stroke were unchanged. There was a greater decline in emergency admissions for patients ≥60 years. There was also a greater reduction in emergency admissions for those living in urban areas compared to suburban areas. CONCLUSIONS: During the Covid-19 pandemic, a significant decline in hospitalization for cardiovascular events was observed during the government-enforced shutdown in a predefined area in western Germany. This reduction in admissions was mainly driven by "discretionary" cardiovascular events (unstable angina, heart failure, exacerbated COPD and dizziness/syncope), but events in which admission was unavoidable (CPR, STEMI and stroke) did not change.

Diagnostic accuracy of physician-staffed emergency medical teams: a retrospective observational cohort study of prehospital versus hospital diagnosis in a 10-year interval.

BACKGROUND: In Germany, emergency medical teams are staffed with physicians but evidence regarding their prehospital diagnostic accuracy remains poor. OBJECTIVE: To evaluate the out-of-hospital diagnostic accuracy of physician-staffed emergency medical teams (PEMTs). METHODS: A retrospective observational cohort study involving the Emergency Medical Service Bonn, Germany, from January to December 2004 and 2014 respectively. A total of 8346 patients underwent medical treatment by PEMTs, of which 1960 adult patients (inclusion criteria: ≥18 years of age, hospital diagnosis available) were included for further analysis. Reasons for non-inclusion: death on scene, outpatient, interhospital transfer, mental illness, false alarm, no hospital medical history available. The overall diagnostic accuracy (correct or false) of PEMTs was measured after matching the prehospital diagnosis with the corresponding diagnosis of the hospital. Secondary outcome measures were incidence of common PEMT diagnoses (acute coronary syndrome (ACS), dyspnea, stroke/intracerebral bleeding), recognition rate of a given disease by PEMTs, and prehospital diagnostic accuracy in elderly patients. RESULTS: PEMT calls increased 2-fold over a decade (2004: n = 3151 vs. 2014: n = 5195). Overall diagnostic accuracy of PEMTs increased from 87.5% in 2004 to 92.6% in the year 2014. The incidence of common PEMT diagnoses such as ACS, dyspnea or stroke/intracerebral bleeding increased 2-fold from 2004 to 2014. The recognition rate of a given disease by the PEMT varied between 2004 and 2014: an increase was observed when a stroke/intracerebral bleeding was diagnosed (2004: 67% vs. 2014: 83%; p = 0.054), a decreased rate of recognition occurred when a syncope/collapse was diagnosed (2004: 81% vs. 2014: 56%; p = 0.007) and a sepsis appears to be a rare event for EMS personnel (2004: 0% vs. 2014: 23%). Linear regression analysis revealed that the prehospital diagnostic accuracy decreases in the elderly patient. CONCLUSIONS: The overall prehospital diagnostic accuracy of PEMTs improved between the year 2004 and 2014 respectively. Our findings suggest that the incidence of common diseases (ACS, dyspnea stroke/intracerebral bleeding, sepsis) increased over a 10-year period. Diagnostic accuracy of different diseases varied but generally decreased in the elderly patient. Regular training of EMS personnel and public campaigns should be implemented to improve the diagnostic accuracy in the future.

Outcome of out-of-hospital cardiac arrest over a period of 15 years in comparison to the RACA score in a physician staffed urban emergency medical service in Germany.

BACKGROUND: Patient outcome after out of hospital cardiac arrest (OHCA) depends on the cardiopulmonary resuscitation (CPR) performance and might also be influenced by organisation of the emergency medical service (EMS) and implementation of guidelines. AIM: To assess the rate of return of spontaneous circulation (ROSC) after cardiac arrest to the predicted rate by the ROSC after cardiac arrest (RACA) score over a 15-year period reflecting three different implemented ALS-guidelines in a physician-staffed EMS. METHODS: All adult patients with non-traumatic OHCA in the EMS of Bonn from 1996 to 2011 were included. Utstein data from three 5-years time periods (1996-2001, 2001-2006, 2006-2011) representing different ALS-guideline implementations were collected. Group comparisons were made in terms of incidence, epidemiology and short-term outcome of CPR with emphasis on changes over time and factors of importance. In each group observed ROSC rate were compared to the predicted ROSC rates (the RACA score). RESULTS: CPR by the ALS unit was attempted in a total of 1989 patients (735, 666, and 588 patients in the first, second and third period, respectively). Average crude incidence of CPR per 100,000 person-years decreased over time (61.3; 55.5; 49.0/100,000/years) while patients treated were significantly older (65.5 ± 16.5; 67.9 ± 15; 68.9 ± 15.7 (p<0.001)). Observed ROSC rates were higher than predicted by the RACA score in all time periods, however, admittance to ICU decreased significantly from 50% in the first five-year period to 38% last five-year period (p<0.001). From first to third period the proportion of arrests with first observed rhythm of VT/VF arrests did not change (29% vs. 27%, p=0.323) nor there were changes in bystander CPR rates (17% vs. 17%, p=0.520). CONCLUSIONS: In a 15-years period and in the setting of a physician-staffed EMS the ROSC rates remain higher than predicted by the RACA score but the admittance to the ICU after OHCA declined significantly. This finding was accompanied by a decrease in CPR incidence and an increase in age of patients.

Monitoring of cerebral oxygen saturation during resuscitation in out-of-hospital cardiac arrest: a feasibility study in a physician staffed emergency medical system.

BACKGROUND: Despite recent advances in resuscitation algorithms, neurological injury after cardiac arrest due to cerebral ischemia and reperfusion is one of the reasons for poor neurological outcome. There is currently no adequate means of measuring cerebral perfusion during cardiac arrest. It was the aim of this study to investigate the feasibility of measuring near infrared spectroscopy (NIRS) as a potential surrogate parameter for cerebral perfusion in patients with out-of-hospital resuscitations in a physician-staffed emergency medical service. METHODS: An emergency physician responding to out-of-hospital emergencies was equipped with a NONIN cerebral oximetry device. Cerebral oximetry values (rSO2) were continuously recorded during resuscitation and transport. Feasibility was defined as >80% of total achieved recording time in relation to intended recording time. RESULTS: 10 patients were prospectively enrolled. In 89.8% of total recording time, rSO2 values could be recorded (213 minutes and 20 seconds), thus meeting feasibility criteria. 3 patients experienced return of spontaneous circulation (ROSC). rSO2 during manual cardiopulmonary resuscitation (CPR) was lower in patients who did not experience ROSC compared to the 3 patients with ROSC (31.6%, ± 7.4 versus 37.2% ± 17.0). ROSC was associated with an increase in rSO2. Decrease of rSO2 indicated occurrence of re-arrest in 2 patients. In 2 patients a mechanical chest compression device was used. rSO2 values during mechanical compression were increased by 12.7% and 19.1% compared to manual compression. CONCLUSIONS: NIRS monitoring is feasible during resuscitation of patients with out-of-hospital cardiac arrest and can be a useful tool during resuscitation, leading to an earlier detection of ROSC and re-arrest. Higher initial rSO2 values during CPR seem to be associated with the occurrence of ROSC. The use of mechanical chest compression devices might result in higher rSO2. These findings need to be confirmed by larger studies.

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, in other systems markedly lower success rates are observed. 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. This study investigates the impact of response time reliability (RTR) on cardio pulmonary resuscitation (CPR) incidence and resuscitation success using return of spontaneous circulation (ROSC) after cardiac arrest (RACA) score and data from seven German EMS systems participating in the German Resuscitation Registry. METHODS: Anonymized patient data after out of hospital cardiac arrest from 2006 to 2009 of seven EMS systems in Germany were analysed to socioeconomic factors (population, area, EMS unit hours), process quality (response time reliability, CPR incidence, special CPR measures, prehospital cooling), patient factors (age, gender, cause of cardiac arrest, bystander CPR). Endpoints were defined as ROSC, admission to hospital, 24 hour survival and hospital discharge rate. For statistical analyses, chi-square, odds-ratio and Bonferroni correction were used. RESULTS: 2,330 prehospital CPR from seven centres were included in this analysis. Incidence of sudden cardiac arrest differs from 36.0 to 65.1/100,000 inhabitants/year. We identified two EMS systems (RTR < 70%) reaching the patients within eight minutes in 62.0% and 65.6% while the other five EMS systems (RTR > 70%) achieved 70.4 up to 95.5%. EMS systems arriving relatively later at the patients side (RTR < 70%) less frequently initiate CPR 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 outcome, 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 will more often initiate CPR and will increase number of patients admitted to hospital alive. Furthermore it is shown that with very different approaches, all adhering to and intensely training in the ERC guidelines 2005, superior and, according to international comparison, excellent success rates following resuscitation may be achieved.

[Transport with ongoing cardiopulmonary resuscitation - when does is it make sense?]. / Kardiopulmonale Reanimation (CPR) - Transport Unter CPR - Wann macht es Sinn?

The currently valid guidelines for resuscitation of the European Resuscitation Council (ERC) do not give any unambiguous recommendations for "transport with ongoing cardiopulmonary resuscitation". Furthermore, up to now there are no generally accepted criteria for terminating cardiopulmonary resuscitation, apart from certain signs of death. In spite of the generally poor outcome of patients being transported with ongoing cardiopulmonary resuscitation, there are a number of positive case reports and undisputable indications (e.g., in cases with a potentially reversible cause of cardiac arrest). The increase observed over the past few years in the number of patients being transported under cardiopulmonary resuscitation has as yet not been reflected in an improved prognosis for these patients. The use of mechanical chest compression devices with a better quality of chest compression, also under transport conditions, may have an influence on the number transports but this has not yet been evaluated sufficiently with regard to patient outcome. However, the decision to transport a patient resides with the responsible emergency physician who has to evaluate the prognosis for the patient on an individual basis.

Out-of-hospital cardiopulmonary resuscitation with the AutoPulse system: a prospective observational study with a new load-distributing band chest compression device.

OBJECTIVE: To evaluate the effectiveness, the safety, and the practicability of the new automated load-distributing band resuscitation device AutoPulse in out-of-hospital cardiac arrest in the midsized urban emergency service of Bonn city. STUDY DESIGN: Prospective, observational study. METHODS: Measurements of effectiveness were the proportion of patients with a return of spontaneous circulation (ROSC) and end-tidal carbon-dioxide (etCO(2)) values during cardiopulmonary resuscitation (CPR). The indications of safety was the proportion of injuries caused by the device, and practicability was assessed by the measurement of the time taken to setup the AutoPulse. RESULTS: Forty-six patients were resuscitated with the device from September 2004 to May 2005. In 25 patients (54.3%) ROSC was achieved, 18 patients (39.1%) were admitted to intensive care unit (ICU), and 10 patients (21.8%) were discharged from ICU. End-tidal capnography showed significantly higher etCO(2) values in patients with ROSC than in patients without ROSC. The mean time to setup the AutoPulse was 4.7+/-5.9 min, but activation of the device after arrival at the scene in 2 min or less was possible in 67.4%. No injuries were detected after use of the AutoPulse-CPR. CONCLUSION: The AutoPulse system is an effective and safe mechanical CPR device useful in out-of-hospital cardiac arrest CPR. Automated CPR devices may play an increasingly important role in CPR in the future because they assure continuous chest compressions of a constant quality.

Hypertonic saline during CPR: Feasibility and safety of a new protocol of fluid management during resuscitation.

BACKGROUND AND PURPOSE: In experimental studies infusion of hypertonic saline during cardiopulmonary resuscitation (CPR) increased resuscitation success rate and improved myocardial and cerebral reperfusion during CPR. We tested the feasibility and the safety of this new therapeutic measure in a randomised, preclinical pilot study. METHODS: The study was performed in the EMS system of Bonn after approval of the local ethical committee. Study inclusion criteria were out-of-hospital cardiac arrest (CA) of non-traumatic origin, age > or =18 years, application of adrenaline (epinephrine) during CPR, duration of CA < or = 15 min, and estimated body weight < or = 125 kg. Patients randomly received 2 ml/kg/10 min HHS (7.2% NaCl with 6% hydroxy ethyl starch 200,000/0.5 [HES]) or HES alone. Haemoglobin, blood gases, plasma sodium and potassium concentrations were measured before and 10 min after infusion, and after admission to hospital. Feasibility and safety of the new fluid management was evaluated by looking for side effects and determination of resuscitation success and admission rates. RESULTS: Sixty-six patients were included. After infusion of HHS, plasma sodium concentration increased to 168+/-29 mmol/l at 10 min after application but already decreased to near normal (147+/-5.5 mmol/l) at admission to hospital. Patients receiving HHS showed a trend to higher resuscitation success and hospital admission rates (ROSC: HHS 66.7%, HES 51.5%, p = 0.21; admission: HHS 57.6%, HES 39.4%, p = 0.14). The benefit of HHS was more pronounced if duration of untreated CA was >6 min or if initial rhythm was asystole or pulseless electrical activity (PEA). Negative side-effects were not observed after HHS. CONCLUSIONS: HHS after CA is feasible and safe and might improve short term survival after CPR. However, whether giving HHS could be a useful measure to increase resuscitation success after out-of-hospital CA requires a larger preclinical trial.