[Drowning versus cardiac ischemia: Cardiac arrest of an 11-year-old boy at a swimming lake]. / Ertrinken vs. kardiale Ischämie: Elfjähriger Junge mit Herz-Kreislauf-Stillstand am Badesee.

This report describes a case of sudden cardiac arrest and subsequent attempted cardiopulmonary resuscitation of an 11-year-old child on the shores of a swimming lake. Reports of eyewitnesses excluded the obviously suspected diagnosis of a drowning accident. The result of the autopsy was sudden cardiac death due to a congenital coronary anomaly (abnormal left coronary artery, ALCA). Favored by vigorous physical activity, this anomaly can lead to malignant arrhythmias because the ectopic coronary artery with its intramural course through the aortic wall is compressed during every systole. This pathology was not known to the boy or his family; in fact he liked sports but had suffered of a syncope once which was not followed up. Without a strong suspicion it is difficult to diagnose a coronary artery anomaly and it is often missed even in college athletes. Tragically, sudden cardiac arrest may be the first symptom of an undiagnosed abnormal coronary artery. Following syncope or chest pain during exercise with a normal electrocardiogram (ECG) cardiac imaging, such as computed tomography (CT) or angiography should be initiated in order to enable surgical repair of an abnormal coronary artery.

[Out-of-hospital emergency medicine in Germany, Austria and Switzerland : randomized prospective studies from 1990 to 2012]. / Außerklinische Notfallmedizin in Deutschland, Österreich und der Schweiz : Randomisierte, prospektive Studien von 1990 bis 2012.

BACKGROUND: Only randomized clinical trials can improve the outcome of life-threatening injuries or diseases but observations from England and North America suggest that the number of such randomized clinical trials is decreasing. In this study contributions from German speaking countries with regards to randomized clinical trials in emergency medicine over the last 22 years were investigated. METHODS: The Medline database was searched from January 1990 to December 2012 for prospective randomized clinical trials in the prehospital setting using the criteria "cardiac arrest", "cardiopulmonary resuscitation", "multiple trauma", "hemorrhagic shock", "head trauma", "stroke" as well as myocardial infarction and emergency medical service. Only studies originating from Germany, Austria or Switzerland were included. RESULTS: A total of 474 studies were found and 25 studies (5.3 %) fulfilled the inclusion criteria. In the last 22 years German speaking countries have published approximately one prospective, randomized, clinical trial per year on prehospital emergency medicine. The median number of patients included in the trials was 159 (minimum 16, maximum 1,219). Most (80 %) studies originated from Germany and most (64 %) studies were conducted by anesthesiology departments. Cardiac arrest was the most frequent subject of the investigated studies. Approximately 50 % of the studies had financial support from industrial companies. CONCLUSION: A significant increase or decrease in the number of prospective randomized clinical trials in the out-of-hospital setting could not be found in German speaking countries despite the fact that the absolute numbers of studies had increased. Only about one prospective, randomized clinical trial with an emergency medicine core tracer diagnosis originated from Germany, Austria and Switzerland per year.

Oscillation frequency of skin microvascular blood flow is associated with mortality in critically ill patients.

BACKGROUND: Microcirculatory dysfunction has been hypothesized to play a key role in the pathophysiology of multiple organ failure and, consequently, patient outcome. The objective of this study was to investigate the differences in reactive hyperemia response and oscillation frequency in surviving and non-surviving patients with multiple organ dysfunction syndrome. METHODS: Twenty-nine patients (15 survivors; 14 non-survivors) with two or more organ failures were eligible for study entry. All patients were hemodynamically stabilized, and demographic and clinical data were recorded. A laser Doppler flowmeter was used to measure the cutaneous microcirculatory response. Reactive hyperemia and oscillatory changes in the Doppler signal were measured during 3 min before and after a 5-min period of forearm ischemia. RESULTS: Non-survivors demonstrated a significantly higher multiple organ dysfunction score when compared with survivors (P= 0.004). Norepinephrine administration was higher in non-survivors (P= 0.018). Non-survivors had higher arterial lactate levels (P= 0.046), decreased arterial pH levels (P= 0.001) and decreased arterial Po(2) values (P= 0.013) when compared with survivors. A higher oscillation frequency of the skin microvasculature at rest (P= 0.033) and after an ischemic stimulus (P= 0.009) was observed in non-survivors. The flow motion frequency observed in reactive hyperemia was associated with the severity of multiple organ dysfunction (P= 0.009) and, although not statistically significant, with the arterial lactate concentration (P= 0.052). CONCLUSION: Increased skin microvascular oscillation frequency at rest and in the hyperemic state after an ischemic stimulus is associated with increased mortality in patients suffering from multiple organ dysfunction. The underlying mechanism could be a response of the skin microvasculature to an impaired oxygen utilization of the skin tissue.

Monitoring of cerebral oxygenation with near infrared spectroscopy and tissue oxygen partial pressure during cardiopulmonary resuscitation in pigs.

BACKGROUND AND OBJECTIVE: The present study was designed to compare cerebral oxygenation measured with near infrared spectroscopy and local brain tissue oxygen partial pressure, respectively, in pigs during cardiopulmonary resuscitation. Since tissue overlying the brain may have an impact on near infrared spectroscopy readings, we tested whether optode placement on intact skin or on the skull yielded comparable results. METHODS: Twelve healthy pigs were anaesthetized and subjected to continuous haemodynamic, near infrared spectroscopy and brain tissue oxygen partial pressure monitoring. After 4 min of untreated ventricular fibrillation, cardiopulmonary resuscitation was started and arginine vasopressin was administered repeatedly three times. Near infrared spectroscopy values recorded were both the tissue oxygenation index and the tissue haemoglobin index as well as relative changes of chromophores (haemoglobin and cytochrome oxidase). Four animals served as control and were measured with both near infrared spectroscopy optodes mounted on the intact skin of the forehead, while in the remaining eight animals, one near infrared spectroscopy optode was implanted directly on the skull. RESULTS: Near infrared spectroscopy readings at the skin or at the skull differed consistently throughout the study period. After arginine vasopressin administration, near infrared spectroscopy values at the different locations showed a transient dissociation. In contrast to near infrared spectroscopy measured on intact skin, near infrared spectroscopy readings obtained from skull showed a significant correlation to brain tissue oxygen partial pressure values (r = 0.67, P < 0.001). CONCLUSION: Near infrared spectroscopy readings obtained from skin and skull differed largely after vasopressor administration. Near infrared spectroscopy optode placement therefore may have an important influence on the tissue region investigated.

Arginine vasopressin reduces cerebral oxygenation and cerebral blood volume during intact circulation in swine---a near infrared spectroscopy study.

BACKGROUND AND OBJECTIVE: The aim of the present study was to investigate the impact of arginine vasopressin (AVP), a drug currently under investigation for use during cardiopulmonary resuscitation, on cerebral oxygenation and cerebral blood volume (CBV) in pigs with intact systemic circulation using near infrared spectroscopy. METHODS: Nine healthy pigs were anaesthetized and subjected to invasive haemodynamic monitoring as well as to non-invasive determination (with near infrared spectroscopy) of changes in the Tissue Oxygenation Index (TOI is the ratio of oxygenated to total tissue haemoglobin), Tissue Haemoglobin Index (THI, representing CBV) and cytochrome oxidase (deltaCytOx, representing the balance of intracellular oxygen supply). RESULTS: At both 3 and 5 min after AVP administration, TOI, THI and deltaCytOx were significantly (P < 0.001) reduced compared to baseline, while cerebral perfusion pressure increased significantly (P < 0.001). The effects of AVP on TOI and THI lasted longer than on deltaCytOx. There were no significant changes with respect to the intracranial pressure throughout the study period. CONCLUSIONS: No improvement of cerebral oxygenation was detected after AVP administration in swine with an intact systemic circulation. In contrast to recently published investigations, AVP provoked a sustained drop in indices of cerebral oxygenation and CBV.

Changes of local brain tissue oxygen pressure after vasopressin during spontaneous circulation.

BACKGROUND: Brain tissue oxygen pressure (PbtO2) correlates to cerebral blood flow (CBF) during spontaneous circulation, with one important regulator being nitric oxide (NO). Although it is established that arginine vasopressin (AVP) improves CBF and global cerebral oxygenation during cardiopulmonary resuscitation, it is unknown whether similar beneficial effects are present during spontaneous circulation. The purpose of this study was to investigate the effects of AVP with and without pre-treatment with the NO synthase inhibitor N-omega-nitro-L-arginine methyl ester (L-NAME) on local brain tissue oxygenation in a beating heart model. METHODS: Following approval of the Animal Investigational Committee, nine healthy piglets underwent general anaesthesia, and were instrumented with a probe in the cerebral cortex to measure PbtO2. Each animal was assigned to receive AVP (0.4 U . kg(-1)), and after a wash-out period, L-NAME (25 mg x kg(-1) over 20 min) followed by AVP (0.4 U x kg(-1)). After each AVP administration, nitroglycerine (25 microg x kg(-1) over 1 min) as a NO donor was infused to test the vascular reactivity independently from NOS inhibition. FINDINGS: Three minutes after administration of AVP, PbtO2 increased significantly (P < .05; mean +/- SEM, 31 +/- 11 versus 43 +/- 14 mm Hg, +39%), compared with baseline. After pre-treatment with L-NAME, the changes of PbtO2 after AVP were not significant (32 +/- 11 versus 28 +/- 10, -13%) when compared with the baseline. CONCLUSION: In this beating heart porcine model, local brain tissue oxygenation was improved after AVP alone, but not after inhibition of NO synthesis with L-NAME.

Employing vasopressin as an adjunct vasopressor in uncontrolled traumatic hemorrhagic shock. Three cases and a brief analysis of the literature.

Resuscitation of patients in hemorrhagic shock remains one of the most challenging aspects of trauma care. We showed in experimental studies that vasopressin, but not fluid resuscitation, enabled short-term and long-term survival in a porcine model of uncontrolled hemorrhagic shock after penetrating liver trauma. In this case report, we present two cases with temporarily successful cardiopulmonary resuscitation (CPR) using vasopressin and catecholamines in uncontrolled hemorrhagic shock with subsequent cardiac arrest that was refractory to catecholamines and fluid replacement. In a third patient, an infusion of vasopressin was started before cardiac arrest occurred; in this case, we were able to stabilize blood pressure thus allowing further therapy. The patient underwent multiple surgical procedures, developed multi-organ failure, but was finally discharged from the critical care unit without neurological damage.

[Stem cell therapy for urinary incontinence]. / Stammzelltherapie der Harninkontinenz.

Experimental and clinical studies investigated whether urinary incontinence can be effectively treated with transurethral ultrasound-guided injections of autologous myoblasts and fibroblasts.This new therapy was performed in eight female pigs. It could be shown that the injected cells survived well and that new muscle tissue was formed. Next, 42 patients (29 women, 13 men) suffering from urinary stress incontinence were treated. The fibroblasts were mixed with a small amount of collagen as carrier material and injected into the urethral submucosa to treat atrophies of the mucosa. The myoblasts were directly injected into the rhabdosphincter to reconstruct the muscle and to heal morphological and functional defects. In 35 patients urinary incontinence could be completely cured. In seven patients who had undergone multiple surgical procedures and radiotherapy urinary incontinence improved. No side effects or complications were encountered postoperatively. The experimental as well as the clinical data clearly demonstrate that urinary incontinence can be treated effectively with autologous stem cells. The present data support the conclusion that this new therapeutic concept may represent a very promising treatment modality in the future.

Neither vasopressin nor amiodarone improve CPR outcome in an animal model of hypothermic cardiac arrest.

BACKGROUND: Aim of this experimental animal study was to investigate the influence of vasopressin and amiodarone on cardiopulmonary resuscitation (CPR) outcome in a pig model of hypothermic cardiac arrest. METHODS: After surface cooling to a core temperature of 26 degrees C, ventricular fibrillation was induced in 14 12-16-week-old domestic pigs. After 15 min of untreated cardiac arrest, a manual closed chest CPR was started and pigs were randomly assigned to two treatment groups: Group 1 pigs (n = 7) received vasopressin 0.4 U kg-1 as initial drug therapy, followed by a combination vasopressin (0.4 U kg-1) and amiodarone (4 mg kg-1) as subsequent drug therapy. Subsequent drug therapy was administered in animals without permanent restoration of spontaneous circulation after a first series of electrical countershocks 10 min after drug administration. Group 2 pigs (n = 7) received saline placebo as initial drug therapy and saline placebo and amiodarone (4 mg kg-1) as subsequent drug therapy. RESULTS: Vasopressin significantly increased coronary perfusion pressure and defibrillation success (successful defibrillation in five of seven Group 1 vs. none of seven Group 2 pigs, P = 0.02). Due to refibrillation within 30-150 s, the 60-min survival rate was not improved by vasopressin. Subsequent drug therapy with amiodarone had no further effect on defibrillation success or the refibrillation rate. CONCLUSIONS: Data from this experimental animal model suggest that vasopressin and amiodarone may not be beneficial for treatment of ventricular fibrillation associated with severe hypothermia when concomitant measures at core rewarming are not applied.