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PubMed2004

[Therapeutic hypothermia after cardiac arrest saves more lives!].

To treat patients suffering from cardiac arrest after restoration of spontaneous circulation has been difficult and discouraging, with a high mortality rate. Two independent studies have, however, shown that early treatment with hypothermia increases survival and protects from neurological sequelae after out-of-hospital cardiac arrest. Recently the International Liaison Committee on Resuscitation (ILCOR) has published an advisory statement recommending therapeutic hypothermia after out-of-hospital cardiac arrest. In this paper the issue is discussed and the therapy recommended.

Cardiopulmonary Resuscitation↗
PubMed1994

Case definition in survival studies of out-of-hospital cardiac arrest.

The purpose of this investigation was to determine problems with case definition and selection biases in studies of survival from out-of-hospital cardiac arrest, by comparing characteristics of subjects with cardiac arrest who entered the emergency medical services (EMS) system and those who did not enter the system. Data for 143 prehospital cardiac arrest patients in Johnson County, Iowa, were obtained from death certificates and EMS reports. Approximately one half of cardiac arrest patients entered the EMS system. Mean total number of causes of death listed on death certificates was significantly higher in subjects who did not enter the EMS system. Several factors, including age, sex, and number of causes of death listed on death certificates were significant univariate factors in whether a cardiac arrest victim entered the EMS system, but multivariate logistic regression indicated age by itself was the most significant factor. These results indicate there are possible initial biases determining who will enter the EMS system, which affects the generalizability of previous studies.

Age Factors↗
PubMed1986

Effect of nifedipine on cerebral high-energy phosphates after cardiac arrest and resuscitation in the rat.

We studied the effect of nifedipine, a calcium entry blocker, on the recovery of cerebral adenosine triphosphate (ATP), creatine phosphate (CP), and lactate levels following resuscitation from cardiac arrest. Using the cardiac arrest and resuscitation model of de Garavilla, Babbs, and Tacker with an arrest time of eight minutes, 76% of the animals arrested were resuscitated with an average intermittent abdominal compression-CPR time of 3.3 minutes. Rats were assigned randomly to the following groups: nonischemic; eight minutes of arrest without resuscitation; and postresuscitation treatment with either IV normal saline; 3 micrograms/kg nifedipine; 10 micrograms/kg nifedipine; or 30 micrograms/kg nifedipine. Treated animals were sacrificed at either 20 or 120 minutes thereafter. As expected, after eight minutes of cardiac arrest, the levels of ATP and CP dropped to near 0 and rebounded in all resuscitated animals. By 120 minutes after resuscitation, rats given the 10-micrograms/kg dose of nifedipine had levels of ATP equivalent to nonischemic values. Return of CP values to nonischemic levels was seen only at the 3-micrograms/kg dose and was independent of time of measurement. The ATP and CP levels in these nifedipine-treated groups were significantly better when compared to saline-treated controls. There were no treatment-dependent differences in lactate levels. We conclude that clinically appropriate doses of nifedipine had a beneficial effect on the recovery of cerebral high-energy phosphates after cardiac arrest and resuscitation.

Adenosine Triphosphate↗
PubMed2004

Trends in treated ventricular fibrillation out-of-hospital cardiac arrest: a 17-year population-based study.

OBJECTIVES: The aims of this study were to describe the trends of ventricular fibrillation (VF) out-of-hospital cardiac arrest in Rochester, Minnesota, since 1985 and to determine coexistent trends in implantable cardioverter defibrillator (ICD) placement and termination of potentially lethal ventricular arrhythmias that might explain, at least in part, a declining incidence trend. BACKGROUND: The incidence of VF out-of-hospital cardiac arrest treated by emergency medical services (EMS) personnel has declined over the past decade. Because VF out-of-hospital cardiac arrest occurs primarily in the setting of severe coronary artery disease, primary and secondary prevention strategies may account in part for the decline. In particular, ICD use in large primary and secondary prevention clinical trials in patients at high risk of sudden death has demonstrated that these devices improve survival. METHODS: All residents of the City of Rochester, Minnesota, who presented with a VF out-of-hospital cardiac arrest from 1985 to 2002, identified and treated by EMS, were included in the study. In addition, residents of the City of Rochester who received their first ICD implant from 1989 to 2002 were identified. From the ICD records, general demographics, etiology of heart disease, comorbid medical disease, and indication for ICD placement were abstracted. Follow-up data obtained from this population included ICD shocks, the underlying rhythm disturbance, and death. RESULTS: The overall incidence of EMS-treated VF out-of-hospital cardiac arrest in Rochester during the study period was 17.1 per 100,000 [95% confidence interval (CI) 15.1-19.4]. The incidence has decreased significantly (P < 0.001) over the study period: 1985-1989: 26.3/100,000 (95% CI 21.0-32.6), 1990-1994: 18.2/100,000 (95% CI 14.1-23.1), 1995-1999: 13.8/100,000 (95% CI 10.4-17.9), 2000-2002: 7.7/100,000 (95% CI 4.7-11.9). One hundred ten patients received an ICD. The placement of ICDs also has increased dramatically over the past 10 years: 1990-1994: 5.0/100,000 to 2000-2002: 20.7/100,000 (P < 0.001). ICDs terminated VF or fast ventricular tachycardia (<270 ms) in 22 patients. Termination of these potentially fatal arrhythmias has shown a trend toward an increase over the study period: 1990-1994: 1.1/100,000 to 2000-2002: 3.5/100,000 (P = 0.06). CONCLUSIONS: The incidence of VF out-of-hospital cardiac arrest is declining. In contrast, the rates of ICD placement and ICD termination of ventricular tachycardia or VF are markedly increasing. Sudden death preventive strategies are multifactorial. These observations suggest that ICD termination of potentially lethal ventricular arrhythmias may contribute to the lower incidence of VF out-of-hospital cardiac arrest.

Aged↗
PubMed1982

Effects of atropine on the cardiac arrest induced by propranolol and digitoxin in dogs.

The present study examines the hypothesis that vagal activity can accelerate the onset of cardiac arrest produced by administering a beta-adrenergic blocking dose of propranolol to digitoxin-intoxicated dogs. In 11 experiments, intravenous injection of 0.75 mg/kg propranolol into digitoxin intoxicated dogs induced a sustained ventricular asystole (early-phase cardiac arrest). In six of these eleven experiments, intermittent pacing of the ventricles for as long as 150 min to maintain blood pressure after the onset of asystole, led to the resumption of spontaneous heart beats in only one dog. In five other experiments, injection of atropine (1 mg/kg) three min after the onset of early-phase cardiac arrest elicited sustained spontaneous junctional rhythms. In another four experiments the injection of atropine prior to or simultaneously with propranolol prevented the occurrence of asystole and caused the emergence of a junctional pacemaker. In eight experiments in which the cardiac arrest was reversed or prevented, injection of maintenance doses of atropine and propranolol caused eventual failure of the junctional pacemaker (late-phase cardiac arrest). This failure could not be prevented or reversed by atropine. The results suggest that early-phase cardiac arrest is due to vagal suppression of cardiac pacemakers and therefore supports the above hypothesis.

Animals↗
PubMed1993

Survival in the elderly after out-of-hospital cardiac arrest.

OBJECTIVES: To evaluate the survival prognosis for the elderly (> or = 70 yrs of age) after out-of-hospital cardiac arrest in a large urban center, and to identify any specific differences in survival factors relative to those adults < 70 yrs of age. DESIGN: The study was a prospective, inception cohort study. SETTING: An urban population of approximately 2,000,000, served by one centralized municipal emergency medical services system. PATIENTS: All 986 adult victims (367 elderly and 619 younger patients) of primary cardiac arrest attended by the emergency medical services system over a 12-month period. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: All victims of out-of-hospital cardiac arrest occurring within a single, large, urban municipality were studied over a 12-month period. Each event was analyzed for age, sex, witnesses, bystander cardiopulmonary resuscitation, presenting electrocardiographic rhythm, paramedic response time, scene time, return of spontaneous circulation (pulses), and electrocardiographic rhythm on hospital arrival. Outcomes evaluated included inhospital admission (resuscitation) and successful discharge from the hospital (survival). Patients were followed until death or discharge from the hospital. Of 367 elderly cardiac arrest victims, 81 (22%) patients were successfully resuscitated and 24 (7%) patients survived. However, of 119 (32% of all elderly patients) patients who presented with ventricular fibrillation/tachycardia, 48 (40%) patients were resuscitated and 17 (14%) patients survived. These 17 patients with ventricular fibrillation/tachycardia accounted for 71% of all elderly survivors. During the same study period, there were 619 adult primary cardiac arrest victims < 70 yrs of age, 160 (26%) of whom were resuscitated and 73 (12%) of whom survived. Among the younger patients, 296 (48%) patients presented with ventricular fibrillation/tachycardia, of whom 110 (37%) were resuscitated and of whom 60 patients (20%) survived. Within the context of this study, survival rates for younger and older ventricular fibrillation/tachycardia patients were not significantly different. Also, among survivors, there were no other major differences in terms of established survival determinants. CONCLUSIONS: Survival chances for the elderly after out-of-hospital cardiac arrest are not bleak, and are reasonable if ventricular fibrillation/tachycardia is the presenting rhythm. Survival determinants are similar for younger and older adults.

Age Factors↗
PubMed2004

Serial lactate determinations for prediction of outcome after cardiac arrest.

We investigated the relationship between lactate clearance and outcome in patients surviving the first 48 hours after cardiac arrest. We conducted the study in the emergency department of an urban tertiary care hospital. We analyzed the data for all 48-hour survivors after successful resuscitation from cardiac arrest during a 10-year period. Serial lactate measurements, demographic data, and key cardiac arrest data were correlated to survival and best neurologic outcome within 6 months after cardiac arrest. Parameters showing significant results in univariate analysis were tested for significance in a logistic regression model. Of 1502 screened patients, 394 were analyzed. Survivors (n = 194, 49%) had lower lactate levels on admission (median, 7.8 [interquartile range, 5.4-10.8] vs 9 [6.6-11.9] mmol/L), after 24 hours (1.4 [1-2.5] vs 1.7 [1.1-3] mmol/L), and after 48 hours (1.2 [0.9-1.6] vs 1.5 [1.1-2.3] mmol/L). Patients with favorable neurologic outcome (n = 186, 47%) showed lower levels on admission (7.6 [5.4-10.3] vs 9.2 [6.7-12.1] mmol/L) and after 48 hours (1.2 [0.9-1.6] vs 1.5 [1-2.2] mmol/L). In multivariate analysis, lactate levels at 48 hours were an independent predictor for mortality (odds ratio [OR]: 1.49 increase per mmol/L, 95% confidence interval [CI]: 1.17-1.89) and unfavorable neurologic outcome (OR: 1.28 increase per mmol/L, 95% CI: 1.08-1.51). Lactate levels higher than 2 mmol/L after 48 hours predicted mortality with a specificity of 86% and poor neurologic outcome with a specificity of 87%. Sensitivity for both end points was 31%. Lactate at 48 hours after cardiac arrest is an independent predictor of mortality and unfavorable neurologic outcome. Persisting hyperlactatemia over 48 hours predicts a poor prognosis.

Age Factors↗
PubMed1995

Combined continuous monitoring of systemic and cerebral oxygen metabolism after cardiac arrest.

Cerebral oxygenation was assessed in 8 patients in cardiac arrest during the 24 h after resuscitation, by continuous fiber-optic monitoring of jugular bulb venous oxygen saturation (SjO2), in conjunction with continuous monitoring of mixed venous oxygen saturation (SvO2). Three patients survived and 5 died. SjO2 and SvO2 patterns were compared between surviving and non-surviving patients with regard to their prognostic and therapeutic implications. The mean SjO2 of the survivors (67%) was significantly lower than that of the non-survivors (80%) (P < 0.001), whereas the corresponding SvO2 value was higher in the survivor group (74%) than in the non-survivor group (64%) (P < 0.001). Three of the non-survivors died of brain death within 5 days after resuscitation, and then the others died of respiratory or cardiovascular failure without recovering from deep coma. The high SjO2 of the non-survivors suggests that an inability of damaged neurons to use oxygen may be an indicator of poor neurological outcome in resuscitated patients after cardiac arrest. When SjO2 was < 45%, Sv-O2 was extremely low, reflecting cardiovascular failure after resuscitation. SjO2 may thus serve to warn of deterioration in cardiopulmonary function and serve as a predictor of outcome in cardiac arrest survivors.

Brain↗
PubMed1993

Pulsatile versus nonpulsatile reperfusion improves cerebral blood flow after cardiac arrest.

Cardiopulmonary bypass using nonpulsatile flow (NF) is currently advocated for treating refractory cardiac arrest. Although the heart can be revived using cardiopulmonary bypass support, the brain must recover if such therapy is to be considered successful. Previous studies have demonstrated that pulsatile flow (PF) reperfusion can improve neurologic outcome compared with NF reperfusion after cardiac arrest. The purpose of this study was to assess cerebral perfusion and oxygen consumption during either PF or NF reperfusion after cardiac arrest. Dogs (n = 22) underwent a 15-minute cardiac arrest followed by 1 hour of either PF or NF reperfusion. Microsphere techniques were used to assess cerebral perfusion and oxygen consumption at 3, 15, and 60 minutes of reperfusion. Mean arteriovenous gradients and total brain flows were similar in both groups. However, cerebral oxygen consumption was significantly improved at 3 minutes of reperfusion with PF versus NF (1.8 +/- 0.3 versus 0.9 +/- 0.3 mL O2.dL-1.min-1, respectively; p < 0.05). These results were coincident with improved gray-to-white flow ratios at 3 minutes of PF versus NF reperfusion (5.2 +/- 1.0 versus 2.0 +/- 0.3, respectively; p < 0.05). There were no statistically significant differences in brain perfusion variables by 15 minutes of reperfusion. However, a relative hyperemia was exhibited at 15 minutes of NF versus PF reperfusion, which suggests nutrient flow was insufficient during early NF versus PF reperfusion. In conclusion, PF reperfusion can better restore cerebral blood flow and oxygen consumption than can NF reperfusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed2006

Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions.

BACKGROUND: Prospective and retrospective studies have shown that empiric use of fibrinolytic agents in sudden cardiac arrest is safe and may improve outcomes in sudden cardiac arrest. Use of fibrinolytic agents for this indication is increasing in response to these data. METHODS: A prospective multicenter observational trial was performed in three emergency departments (EDs) to determine the proportion of patients that respond to empiric fibrinolysis with tenecteplase (TNK) after failing to respond to Advanced Cardiac Life Support (ACLS) measures. Cardiac arrest patients unresponsive to ACLS, who were given TNK by their treating physician, were enrolled in an outcome registry. Return of spontaneous circulation (ROSC), survival, complications, and neurological outcomes were recorded. RESULTS: Fifty patients received TNK after a mean of 30min of cardiac arrest and eight doses of ACLS medications. One hundred and thirteen concurrent control patients received standard ACLS measures. ROSC occurred in 26% of TNK patients (95% confidence interval (CI) 16-40%) compared to 12.4% (95% CI 6.9-20%) among ACLS controls (p=.04); 12% (4.5-24%) of TNK patients survived to admission compared to none in the control group (p=.0007); 4% (0.5-14%) survived to 24h (p=NS); and 4% (0.5-14%) survived to hospital discharge (p=NS). All survivors had a good neurological outcome (Cerebral Performance Category (CPC) 1-2). One intracranial hemorrhage (ICH) occurred. No other significant bleeding complications were observed. CONCLUSIONS: Empiric fibrinolysis with TNK in cardiac arrest is associated with increased ROSC and short term survival, and with survival to hospital discharge with good neurological function in patients who fail to respond to ACLS. Results may improve with earlier administration. Prospective controlled interventional trials are indicated to evaluate this promising new therapy.

Advanced Cardiac Life Support↗
PubMed1996

Response to cardiac arrests in a hospital setting: delays in ventilation.

The outcome following a cardiac arrest is affected by the length of time that elapses before cardiopulmonary resuscitation is initiated. Only 10-15% of patients experiencing cardiac arrest in hospital settings survive to discharge. Therefore, the time between cardiac arrest and administration of cardiopulmonary resuscitation in a metropolitan hospital was examined. All cardiac and respiratory arrests that occurred in the adult non-intensive care areas of a medical center over a period of 16 months were evaluated within 12 h to determine how much time had elapsed before resuscitation was initiated, the devices utilized for initial airway management, and the outcome. To initiate ventilation, bag-valve-masks (BVMs) were used in the majority (76%) of the efforts to resuscitate while mouth-to-mask resuscitation was performed in another 18%; however, in only 37% of the codes was ventilation initiated within 1 min and in 18% ventilation was started after 3 min. Mouth-to-mask resuscitation resulted in more rapid time to onset of ventilation than BVM. In only 18% of the arrests studied was a 'lay-on' mask available in the room and utilized. In 11%, a bag-valve-mask was at the patient's bedside, and in 53% a BVM was taken from the crash cart outside the room. In 63% of the cases where using a lay-on mask was appropriate, it was either not looked for or not present in the patient's room. Also in 37% of the cases where a BVM was needed, one was not readily present because of difficulty in locating the crash cart immediately. Although initiation of cardiopulmonary resuscitation within a minute of a cardiac or respiratory arrest is the standard of care, in the non-intensive care in-patient cases surveyed, typically more than a minute elapsed, and frequently 3 or more minutes, before resuscitation was started. If the time elapsing before an arresting in-patient is ventilated can be shortened, which is easily and effectively achieved by mouth-to-mouth or mouth-to-mask resuscitation, an increase in both the survival rate and the number of good neurological outcomes should be expected.

Adult↗
PubMed1989

[Cardiac arrest outside of hospital. A retrospective study in Odense].

During the period 1.10.1986-30.9.1987, all patients with cardiac arrest outside hospital brought to the casualty department in Odense Hospital were registered. Out of 160 patients, 133 (83%) could be primarily resuscitated, 19 (12%) were resuscitated but died later in hospital and eight patients (5%) were resuscitated and could be discharged alive from hospital. Out of the eight patients who were discharged alive, only two (1%) had retained reasonable cerebral function as assessed by dementia testing. Treatment of the cardiac arrest prior to the arrival of the ambulance, duration of the cardiac arrest for less than six minutes and staffing of the ambulance with three first-aid men were factors of decisive importance for survival of the patients. The results of this investigation demonstrate that treatment of cardiac arrest outside hospital is unsatisfactory. Proposals for improvement of treatment include: 1. Information to the population. 2. Training of first-aid staff in treatment of cardiac arrest. 3. Quicker arrival of ambulances and 4. Better staffing and training of ambulance staff in the use of a defibrillator possibly with participation of a doctor.

Denmark↗
PubMed2005

Factors associated with an increased chance of survival among patients suffering from an out-of-hospital cardiac arrest in a national perspective in Sweden.

AIM: To describe factors associated with an increased chance of survival among patients suffering from an out-of-hospital cardiac arrest in Sweden. PATIENTS AND METHODS: All patients suffering from an out-of-hospital cardiac arrest, which were not crew witnessed, in Sweden and in whom cardiopulmonary resuscitation (CPR) was attempted and who were registered in the Swedish Cardiac Arrest Registry. This registry covers about 85% of the Swedish population and has been running since 1990. RESULTS: In all, 33,453 patients, 71% of whom had a cardiac etiology, were included in the survey. The following were independent predictors for an increased chance of survival in order of magnitude: (1) patients found in ventricular fibrillation (odds ratio [OR] 5.3, 95% confidence limits [CL] 4.2-6.8), (2) the interval between call for and arrival of the ambulance less than or equal to the median (OR 3.6, 95% CL 2.9-4.6), (3) cardiac arrest occurred outside the home (OR 2.2, 95% CL 1.9-2.7), (4) cardiac arrest was witnessed (OR 2.0, 95% CL 1.6-2.7), (5) bystanders performing CPR before the arrival of the ambulance (OR 2.0, 95% CL 1.7-2.4), and (6) age less than or equal to the median (OR 1.6, 95% CL 1.4-2.0). When none of these factors were present, survival to 1 m was 0.4%; when all factors were present, survival was 23.8%. CONCLUSION: Among patients suffering from an out-of-hospital cardiac arrest, which were not crew witnessed, in Sweden and in whom CPR was attempted, 6 factors for an increased chance of survival could be defined. These include (1) initial rhythm, (2) delay to arrival of the rescue team, (3) place of arrest, (4) witnessed status, (5) bystander CPR, and (6) age.

Age Factors↗
PubMed1992

Effect of epinephrine on the ability of end-tidal carbon dioxide readings to predict initial resuscitation from cardiac arrest.

OBJECTIVE: To determine if the administration of epinephrine changes the partial pressure of end-tidal CO2 during cardiac arrest, as previously reported. Such a change could diminish the demonstrated ability of end-tidal CO2 measurements to predict resuscitation from cardiac arrest. DESIGN: The partial pressures of end-tidal CO2 of adult cardiac arrest patients who received i.v. epinephrine in doses from 1 to 15 mg were monitored throughout arrest. SETTING: Emergency department of a university hospital. PATIENTS: Adults (n = 64) in cardiac arrest with a mean age of 70 +/- 12 yrs, of whom 35 were males and 15 had a mean time of return of spontaneous circulation of 6.5 +/- 11 hrs. INTERVENTIONS: End-tidal CO2 (in torr) was analyzed on arrival, before the first dose of epinephrine, and 4 mins after epinephrine was administered in varying doses chosen by the supervising physician. MEASUREMENTS AND RESULTS: The end-tidal CO2 decreased an average of 0.3 torr (0.04 kPa) after epinephrine was administered. Patients with a return of pulse had a decrease of -2 torr (-0.3 kPa) vs. an increase of 0.3 torr (0.04 kPa) for those patients with no return of pulse (p = .07). In 33% of patients, there was no change; in 28%, the partial pressure of end-tidal CO2 increased, and in 39%, it decreased. There was no correlation between the change in end-tidal CO2 after epinephrine and whether or not patients regained a pulse (r2 = .08, p = .07), although a decrease in end-tidal CO2 was most often associated with return of pulse. At a threshold of 10 torr (1.3 kPa), the first end-tidal CO2 had a positive predictive value for return of pulse of 50% and a negative predictive value of 82%. Just before epinephrine administration, the positive predictive value was 71% and the negative predictive value was 83%; 4 mins after epinephrine administration, the positive predictive value was 64% and the negative predictive value was 86%. A decrease in end-tidal CO2 after epinephrine had a positive predictive value of 53% and a negative predictive value of 92%. End-tidal CO2 readings predicted resuscitation most accurately when taken after initial stabilization and before administration of epinephrine. CONCLUSIONS: Although epinephrine administration may decrease end-tidal CO2 tensions in cardiac arrest, it does so unpredictably in individual patients, and it does not eliminate the predictive value of this measurement.

Aged↗
PubMed1995

The AMPA antagonist NBQX provides partial protection of rat cerebellar Purkinje cells after cardiac arrest and resuscitation.

Purkinje cell loss in adult rats resuscitated following cardiac arrest is analogous to that seen following human cardiac arrest. Administration of the competitive AMPA antagonist NBQX to rats resuscitated after 10 min duration cardiac arrest rescued 21.5% of the vulnerable Purkinje cell population. These results support the hypothesis that sustained postischemic overexcitation of AMPA receptors may be a driving force in the process of Purkinje cell degeneration.

Animals↗
PubMed1994

Outcome of out-of-hospital cardiac arrest in New York City. The Pre-Hospital Arrest Survival Evaluation (PHASE) Study.

OBJECTIVE: To determine survival from out-of-hospital cardiac arrest in New York City and to compare this with other urban, suburban, and rural areas. DESIGN: Observational cohort study. SETTING: New York City. PARTICIPANTS: Consecutive out-of-hospital cardiac arrests occurring between October 1, 1990, and April 1, 1991. INTERVENTION: Trained paramedics performed immediate postarrest interviews with care providers, using a standardized questionnaire. MAIN OUTCOME MEASURES: Entry criteria, elapsed time intervals, and nodal events conformed to Utstein recommendations. The single target end point was death or discharge home. RESULTS: Of 3243 consecutive cardiac arrests on which resuscitation was attempted, 2329 (72%) met entry criteria as primary cardiac events. Overall survival was 1.4% (99% confidence interval [CI], 0.9% to 2.3%). No patients were lost to follow-up. Survival from witnessed ventricular fibrillation was 5.3% (99% CI, 2.9% to 8.8%). Using survival from witnessed ventricular fibrillation for intersystem comparison, our survival rate was similar to that of Chicago, Ill (4.0%; 99% CI, 1.9% to 7.5%; P = .41), the only other large city on which data were available. However, it was significantly lower than that reported from midsized urban/suburban areas (33.0%; 99% CI, 30.4% to 35.6%; P < .0001) and suburban/rural areas (12.6%; 99% CI, 8.9% to 16.3%; P < .0001). Survival rate among arrests occurring after arrival of emergency medical services personnel (8.5%; 99% CI, 4.7% to 14.0%) was comparable with Chicago (6.6%; 99% CI, 3.3% to 11.5%; P = .41) but markedly lower than King County, Washington (36%; 99% CI, 28.6% to 43.8%; P < .0001). CONCLUSIONS: Survival from out-of-hospital cardiac arrest in New York City was poor. This was partly attributable to lengthy elapsed time intervals at every step in the chain of survival. However, examination of survival among arrests occurring after emergency medical services arrival suggests that other features may predispose residents of large cities to higher cardiac arrest mortality than individuals living in more suburban or rural settings. Since half the US population resides in large metropolitan areas, this represents a public health problem of considerable magnitude.

Aged↗
PubMed2005

["Highlights" in emergency medicine -- severe head trauma, polytrauma and cardiac arrest].

According to scientific publications focusing on emergency medicine and published in international journals in the past few months, new and clinically important results can be identified. In patients with severe head trauma (SHT), application of hypertonic solutions is possible; long term outcome, however, is not improved by this measure. Prehospital capnometry is important, because otherwise up to 40 % of all mechanically ventilated patients are hypoventilated. In a study in 200 patients with prehospital cardiac arrest and ventricular fibrillation as initial cardiac rhythm, subgroup analysis (alarm-response time > 5 min) showed an increase in survival rate (14 % vs. 2 %), if defibrillation was proceeded by 3 min of conventional cardiopulmonary resuscitation (CPR) for reperfusion. If ACD ("active compression decompression")-CPR is combined with a specific ventilatory valve ("inspiratory impedance threshold device", ITD) which does not allow passive inspiration, survival rate after cardiac arrest is increased for up to 24 h. Such a device facilitates an increase in venous return to the heart during decompression of the thorax. High-dose adrenalin for intrahospital CPR in children is not associated with better survival but with worse outcome. Comparison of an emergency medical service (EMS) system from U.K. with paramedics and a physician-staffed German EMS system demonstrated that survival rate following prehospital cardiac arrest is markedly increased with doctors on board. The European multicentre trial comparing vasopressin vs. adrenalin as first vasopressor during CPR in 1219 patients did not reveal any differences between both groups. In subgroup analyses of patients with asystoly and prolonged CPR, vasopressin was superior without being associated with a benefit on neurological outcome. Further subgroup analyses revealed beneficial effects of amiodarone and thrombolysis during CPR. Thrombolysis during CPR apears to be associated with an increased rate of haemodynamic stabilisation without increased risk of bleeding complications. In a very clear advisory statement, the "International Liaison Committee on Resuscitation" (ILCOR) has recommended mild therapeutic hypothermia (i. e., cooling of cardiac arrest victims to 32 - 34 degrees C central body temperature for 12 - 24 h following cardiac arrest of cardiac etiology) not only for unconciuous patients with ventricular fibrillation as initial prehospital rhythm, but also for all other adult patients (other rhythms, intrahospital CPR) following cardiac arrest. In randomised controlled clinical trials, this therapy has markedly improved survival rate and neurological outcome. Such therapeutic cooling can be initiated nearly everywhere and with simple methods - like the infusion of ice-cold cristalloid solutions.

Cardiopulmonary Resuscitation↗
PubMed1998

A comparison of near-infrared spectroscopy and jugular bulb oximetry in comatose patients resuscitated from a cardiac arrest.

One cause of cerebral damage in comatose patients resuscitated from a cardiac arrest is cerebral ischaemia occurring during the postresuscitation period. Near-infrared spectroscopy has been advocated as a useful monitor of brain oxygenation, but data on clinical use in comatose postarrest patients are not available. Therefore, we compared regional oxygen saturation measured with the INVOS 3100 with global oxygen saturation measured using jugular bulb oximetry in 10 comatose patients successfully resuscitated from an out-of-hospital cardiac arrest. Our data show that, in most patients, there is a significant difference between the two methods. The INVOS 3100 over-read at low jugular bulb saturations (< 60%) and under-read at high jugular bulb saturations (> or = 60%). During hypoventilation we found a significant increase in regional oxygen saturation. This increase was significantly correlated with the rise in cerebral blood flow and cardiac index, indicating that regional oxygen saturation is influenced by both cerebral and extracerebral components. We conclude that regional cerebral oxygen saturation measured with the INVOS 3100 cannot be compared with global cerebral oxygen saturation measured with jugular bulb oximetry in comatose patients resuscitated from a cardiac arrest. This may be due to characteristics of the INVOS 3100 or to the distribution of cerebral blood flow after cardiac arrest.

Aged↗