Delayed return of spontaneous circulation (the Lazarus phenomenon) after cessation of out-of-hospital cardiopulmonary resuscitation.

INTRODUCTION: The delayed return of spontaneous circulation (ROSC) after cessation of cardiopulmonary resuscitation (CPR), also known as the Lazarus phenomenon, is a rare event described in several case reports. This study aims to determine the incidence and the time of occurrence of the Lazarus phenomenon after cessation of out-of-hospital CPR. METHODS: This prospective observational cohort study was conducted in the Helsinki Emergency Medical Service in Finland from 1 January 2011 through 31 December 2016. All out-of-hospital CPR attempts were carefully monitored for 10min after the cessation of CPR in order to detect delayed ROSC. RESULTS: Altogether, 2102 out-of-hospital cardiac arrests occurred during the six-year study period. CPR was attempted in 1376 (65.5%) cases. In 840 cases (61.0% of all attempts) CPR attempts were terminated on site. The Lazarus phenomenon occurred five times, with an incidence of 5.95/1000 (95% CI 2.10-14.30) in field-terminated CPR attempts. Time to delayed ROSC from the cessation of CPR varied from 3 to 8min. Three of the five patients with delayed ROSC died at the scene within 2-15min while two died later in hospital within 1.5 and 26h, respectively. CONCLUSIONS: We observed that the Lazarus phenomenon is a real albeit rare event and can occur a few minutes after the cessation of out-of-hospital CPR. We suggest a 10-min monitoring period before diagnosing death. CPR guidelines should be updated to include information of the Lazarus phenomenon and appropriate monitoring for it.

Cutting the Prehospital On-Scene Time of Stroke Thrombolysis in Helsinki: A Prospective Interventional Study.

BACKGROUND AND PURPOSE: Significant portion of the prehospital delay consists of minutes spent on the scene with the patient. We implemented a training program for the emergency medical services personnel with the aim to optimize the on-scene time (OST) and to study the impact of different elements of prehospital practice to the OST duration. METHODS: In this prospective interventional study, key operational emergency medical service performance variables were analyzed from all thrombolysis candidates transported to the Helsinki University Hospital emergency department. The catchment period was 4 months before and 4 months after the implementation. RESULTS: One hundred and forty-one patients were managed as thrombolysis candidates before and 148 patients after the training program implementation. The OST duration for the groups was 25 (20.5-31) and 22.5 (18-28.5) minutes, respectively (P<0.001). Physician consultations via telephone were associated with a longer (odds ratio 0.546 [0.333-0.893]) and advanced life support training with a shorter OST (odds ration 1.760 [1.070-2.895]). CONCLUSIONS: Implementation of the emergency medical services training program successfully decreased the OST of thrombolysis candidates by 10%. Higher expertise level of the ambulance crew was associated with shorter OST, and decisions to consult a physician via telephone were reflected by longer OST.

Ultra-acute increase in blood glucose during prehospital phase is associated with worse short-term and long-term survival in ST-elevation myocardial infarction.

BACKGROUND: The current study was to investigate the blood glucose changes in ultra-acute phase in patients with ST-elevation myocardial infarction (STEMI) and its associations with patient outcome. METHODS: This study was a retrospective population-based observational study utilizing prospectively collected registry data complemented with laboratory data. All adult patients with STEMI treated by emergency medical services (EMS) in the city of Helsinki from January 2006 to December 2010 were included in the study. Both prehospital and hospital admission glucose values were available from 152 (32%) of all STEMI patients (n = 469). RESULTS: Change in blood glucose from prehospital phase to emergency department admission was significantly higher in non-survivors within 30 days compared to survivors (+1.2 ± 5.1 vs. -0.3 ± 2.4 mmol/l [mean ± SD], P = 0.03). Furthermore, the 3-year survival rate was significantly lower in patients with an evident (≥2 mmol/l) rise in blood glucose (P = 0.02). In patients with impaired left ventricle function (best ejection fraction < 40%), blood glucose increased more compared to patients without it (1.2 ± 2.9 vs. 0.4 ± 2.7 mmol/l, P = 0.01). Increase in glucose was correlated with peak myocardial creatinine kinase (r = 0.17, P = 0.04) as a marker of increased size of infarct, but not with glycosylated haemoglobin A1C as a marker of chronic hyperglycaemia (r = -0.12, P = 0.27). CONCLUSIONS: In patients with STEMI, ultra-acute hyperglycaemia during prehospital phase is associated with increased mortality, impaired cardiac function and increased size of infarct.

Warfarin and fibrinolysis--a challenging combination: an observational cohort study.

BACKGROUND: Patients presenting with ST-segment elevation myocardial infarction (STEMI) frequently use warfarin. Fibrinolytic agents and warfarin both increase bleeding risk, but only a few studies have been published concerning the bleeding risk of warfarin-prescribed patients receiving fibrinolysis. The objective of this study was to define the prevalence for intracranial haemorrhage (ICH) or major bleeding in patients on warfarin treatment receiving pre-hospital fibrinolysis. METHODS: This was an observational cohort study. Data for this retrospective case series were collected in Helsinki Emergency Medical Service catchment area from 1.1.1997 to 30.6.2010. All warfarin patients with suspected ST-segment elevation myocardial infarction (STEMI), who received pre-hospital fibrinolysis, were included. Bleeding complications were detected from Medical Records and classified as ICH, major or minor bleeding. RESULTS: Thirty-six warfarin patients received fibrinolysis during the study period. Fourteen patients had bleeding complications. One (3%, 95% CI 0-15%) patient had ICH, six (17%, 95% CI 7-32%) had major and seven (19%, 95% CI 9-35%) had minor bleeding. The only fatal bleeding occurred in a patient with ICH. Patients' age, fibrinolytic agent used or aspirin use did not predispose to bleeding complications. High International Normalized Ratio (INR) seemed to predispose to bleedings with values over 3, but no statistically significant difference was found. CONCLUSIONS: Bleedings occur frequently in warfarin patients treated with fibrinolysis in the real world setting, but they are rarely fatal.