Abstract: AIM: Mild therapeutic hypothermia improves survival and neurologic recovery in primary comatose survivors of cardiac arrest. Cooling effectivity, safety and feasibility of nasopharyngeal cooling with the RhinoChill device (BeneChill Inc., San Diego, USA) were determined for induction of therapeutic hypothermia. METHODS: Eleven emergency departments and intensive care units participated in this multi-centre, single-arm descriptive study. Eighty-four patients after successful resuscitation from cardiac arrest were cooled with nasopharyngeal delivery of an evaporative coolant for 1h. Subsequently, temperature was controlled with systemic cooling at 33 degrees C. Cooling rates, adverse events and neurologic outcome at hospital discharge using cerebral performance categories (CPC; CPC 1=normal to CPC 5=dead) were documented. Temperatures are presented as median and the range from the first to the third quartile. RESULTS: Nasopharyngeal cooling for 1h reduced tympanic temperature by median 2.3 (1.6; 3.0) degrees C, core temperature by 1.1 (0.7; 1.5) degrees C. Nasal discoloration occurred during the procedure in 10 (12%) patients, resolved in 9, and was persistent in 1 (1%). Epistaxis was observed in 2 (2%) patients. Periorbital gas emphysema occurred in 1 (1%) patient and resolved spontaneously. Thirty-four of 84 patients (40%) patients survived, 26/34 with favorable neurological outcome (CPC of 1-2) at discharge. CONCLUSIONS: Nasopharyngeal evaporative cooling used for 1h in primary cardiac arrest survivors is feasible and safe at flow rates of 40-50L/min in a hospital setting.
Abstract: AIM OF THE STUDY: The admission blood glucose level after cardiac arrest is predictive of outcome. However the blood glucose levels in the post-resuscitation period, that are optimal remains a matter of debate. We wanted to assess an association between blood glucose levels at 12h after restoration of spontaneous circulation and neurological recovery over 6 months. MATERIALS AND METHODS: A total of 234 patients from a multi-centre trial examining the effect of mild hypothermia on neurological outcome were included. According to the serum glucose level at 12h after restoration of spontaneous circulation, quartiles (Q) were generated: Median (range) glucose concentrations were for QI 100 (67-115 mg/dl), QII 130 (116-143 mg/dl), QIII 162 (144-193 mg/dl) and QIV 265 (194-464 mg/dl). RESULTS: In univariate analysis there was a strong non-linear association between blood glucose and good neurological outcome (odds ratio compared to QIV): QI 8.05 (3.03-21.4), QII 13.41 (4.9-36.67), QIII 1.88 (0.67-5.26). After adjustment for sex, age, "no-flow" and "low-flow" time, adrenaline (epinephrine) dose, history of coronary artery disease and myocardial infarction, and therapeutic hypothermia, this association still remained strong: QI 4.55 (1.28-16.12), QII 13.02 (3.29-49.9), QIII 1.37 (0.38-5.64). CONCLUSION: There is a strong non-linear association of survival with good neurological outcome and blood glucose levels 12h after cardiac arrest even after adjusting for potential confounders. Not only strict normoglycaemia, but also blood glucose levels from 116 to 143 mg/dl were correlated with survival and good neurological outcome, which might have an important therapeutic implication.
Abstract: INTRODUCTION: Advances in early defibrillation access, key to the "Chain of Survival", will depend on innovations in defibrillation waveforms, because of their impact on device size and weight. This study compared standard monophasic waveform automatic external defibrillators (AEDs) to an innovative biphasic waveform AED. MATERIAL AND METHODS: Impedance-compensated biphasic truncated exponential (ICBTE) and either monophasic truncated exponential (MTE) or monophasic damped sine (MDS) AEDs were prospectively, randomly assigned by date in four emergency medical services. The study design compared ICBTE with MTE and MDS combined. This subset analysis distinguishes between the two classes of monophasic waveform, MTE and MDS, and compares their performance to each other and to the biphasic waveform, contingent on significant overall effects (ICBTE vs. MTE vs. MDS). Primary endpoint: Defibrillation efficacy with < or =3 shocks. Secondary endpoints: shock efficacy with < or =1 shock, < or =2 shocks, and survival to hospital admission and discharge. Observations included return of spontaneous circulation (ROSC), refibrillation, and time to first shock and to first successful shock. RESULTS: Of 338 out-of-hospital cardiac arrests, 115 had a cardiac aetiology, presented with ventricular fibrillation, and were shocked by an AED. Defibrillation efficacy for the first "stack" of up to 3 shocks, for up to 2 shocks and for the first shock alone was superior for the ICBTE waveform than for either the MTE or the MDS waveform, while there was no difference between the efficacy of MTE and MDS. Time from the beginning of analysis by the AED to the first shock and to the first successful shock was also superior for the ICBTE devices compared to either the MTE or the MDS devices, while again there was no difference between the MTE and MDS devices. More ICBTE patients achieved ROSC pre-hospital than did MTE patients. While the rates of ROSC were identical for MTE and MDS patients, the difference between ICBTE and MDS was not significant. Rates of refibrillation and survival to hospital admission and discharge did not differ among the three populations. CONCLUSIONS: ICBTE was superior to MTE and MDS in defibrillation efficacy and speed and to MTE in ROSC. MTE and MDS did not differ in efficacy. There were no differences among the waveforms in refibrillation or survival.
Abstract: BACKGROUND: In the present study, we compared an automatic external defibrillator (AED) that delivers 150-J biphasic shocks with traditional high-energy (200- to 360-J) monophasic AEDs. METHODS AND RESULTS: AEDs were prospectively randomized according to defibrillation waveform on a daily basis in 4 emergency medical services systems. Defibrillation efficacy, survival to hospital admission and discharge, return of spontaneous circulation, and neurological status at discharge (cerebral performance category) were compared. Of 338 patients with out-of-hospital cardiac arrest, 115 had a cardiac etiology, presented with ventricular fibrillation, and were shocked with an AED. The time from the emergency call to the first shock was 8.9+/-3.0 (mean+/-SD) minutes. CONCLUSIONS: The 150-J biphasic waveform defibrillated at higher rates, resulting in more patients who achieved a return of spontaneous circulation. Although survival rates to hospital admission and discharge did not differ, discharged patients who had been resuscitated with biphasic shocks were more likely to have good cerebral performance.
Abstract: BACKGROUND AND PURPOSE: The aim of our study was to assess the use of S-100 protein (S-100) and neuron-specific enolase (NSE) in serum and cerebrospinal fluid (CSF) for the prediction of patients' regaining consciousness after acute global cerebral ischemia. METHODS: Sixty-four unconscious patients were followed until the return of consciousness or until death/vegetative state. Serum and CSF samples for measurement of S-100 and NSE using an immunoradiometric assay technique were obtained 24 hours (serum) and 48 hours (CSF) after the acute event and correlated with patient outcome. RESULTS: Values for serum S-100 protein, serum NSE, CSF S-100, and CSF NSE were significantly different in the 2 outcome groups. A serum S-100 value of >0.7 micrograms/L was found to be a predictor of not regaining consciousness, with a high positive predictive value (95%) and high specificity (96%). CONCLUSIONS: S-100 protein used as serum marker 24 hours after acute global cerebral ischemia gives reliable and independent information on the outcome of the patient that is comparable or superior to that obtained with CSF markers. Therefore, S-100 may be a serum marker of brain cell damage useful for clinical assessment of these patients.
Abstract: OBJECTIVE: To assess the use of serum neuron-specific enolase (S-NSE) level as a noninvasive predictor of CNS injury irreversibility in comatose cardiac arrest survivors. METHODS: An observational, prospective clinical study was performed in a community hospital ED and intensive care unit. All cardiac arrest survivors (n = 52) with impaired neurologic status admitted between February 1994 and May 1995 were followed until return of consciousness (1) or death due to CNS failure (0). Serum samples for S-NSE determination (ng/mL) using the radioimmunoassay technique were obtained 24 hours after cardiac arrest. Data were analyzed using stepwise logistic regression with dichotomized predictors to validate the correlation between S-NSE (X) and outcome (Y), where X = 0 if < or = median and 1 if > median S-NSE level. Adjustment was made for the following variables: glucose level on admission, total epinephrine dose used before return of spontaneous circulation, and best Glasgow Coma Scale score on admission. These data were all available in 34 cases. In 16 cases, CSF enzymes at 48 hours postarrest were obtained and compared with S-NSE. RESULTS: The logistic equation determining the influence of S-NSE (X) on outcome (Y) was: Y = 0.606-1.785X (odds ratio = 6; p = 0.020). There was no confounding effect of the other variables related to survival. The mean S-NSE value for all the patients was 34 (7.9-188). All the patients recovering consciousness (n = 15) had an S-NSE mean +/- SEM value of 17.5 +/- 2.4, with a maximum of 47. CONCLUSION: These data support the conclusion that measurement of S-NSE at 24 hours post-cardiac arrest may supplement clinical assessment of hypoxic-ischemic encephalopathy after cardiac arrest.
Abstract: OBJECTIVE: To determine whether in a larger data base call for sudden cardiac death exhibits a specific circadian rhythm similar to that recently demonstrated by Levine et al. DESIGN AND SETTING: The time of the day of calls received for out-of-hospital cardiac arrests (OOHCA) prospectively registered between 1983 and '90 by 7 major Belgian pre-hospital EMS-MICU services. Chrono-biologic assessment was made by two-harmonic linear regression analysis of the data tabulated by hour of the day. The hourly distribution of calls for OOHCAs was subjected to Fourier transformation resulting in a periodogram. PATIENTS: 3471 OOHCAs with presumed cardiac etiology and age of more than 18 years versus 2007 inpatients registered in the same period. MEASUREMENTS AND RESULTS: Significant and remarkably similar circadian patterns were found (R-square = 0.84) for the cardiac origin OOHCAs and the ventricular fibrillation OOHCAs. There is a low incidence during the night and an increased incidence from 6 a.m. until noon with an additional early afternoon-peak. The data were always better fitted when applying sinusoids with periods of 8 and 24 h instead of 12 and 24 h. Our observed circadian distribution resembles the reported circadian variation of ischaemic episodes, ventricular tachycardia and acute myocardial infarction in the awake hours. The time distribution of OOHCA (cardiac origin) differs significantly from OOHCA (non-cardiac origin) and from in-hospital cardiac arrests. The in-hospital CA pattern shows less deviation. The age dependent variation in the incidence of cardiac origin OOHCAs, was not obvious for the ventricular fibrillation subgroup. CONCLUSION: Knowledge about the cyclical nature of incidence of cardiac arrests is useful to improve intersystem comparisons and make sound decisions about prophylaxis, treatment and allocation of resources.
Abstract: Sudden non-traumatic death in young people (< 30 years old) has been discussed both in systematic studies and anecdotal reports. After presenting three remarkable cases, a global survey of the incidence with special reference to the Belgian CPCR database, ethiopathogenesis and prognosis of sudden non-traumatic death in this specific age group is given. The atherosclerotic coronary artery disease (CAD) related and especially the non-CAD related causes are extensively discussed as well as the role of intoxication and increasing drug and substance abuse. After conventional cardiopulmonary resuscitation with restoration of spontaneous circulation and a favourable neurological outcome, a thorough search for the underlying disease is mandatory. The involvement of drugs or other toxins has to be excluded in the first place. Apart from transoesophageal echocardiography and coronary angiography, electrophysiological testing, serological exams, myocardial biopsy and magnetic resonance imaging should be considered.
Abstract: The cause of the 'sudden infant death syndrome' (SIDS) remains unknown. We describe a case in which a benzodiazepine unadvisedly taken by a mother might have been at least in part responsible for the death of her breast-fed 'at risk' daughter. Moreover, in this case, home monitoring as a preventive measure was not effective.
Abstract: Frequent criticism concerning the investigation of near-death-experiences (NDEs) has been the lack of uniform nomenclature and the failure to control the studied population with an elimination of interfering factors such as administration of sedatives and nonspecific stress responses. Greyson's NDE Scale is a 16-item questionnaire developed to standardize further research into mechanisms and effects of NDEs. Using this scale, we interviewed good out-of-hospital cardiac arrest survivors, with documented time-intervals between call for help and restoration of spontaneous circulation, yet without obvious brain damage or known, psychiatric history. The incidence of such experiences appeared to be extremely low among survivors of genuine cardiac arrest events. Alteration of information processing under the influence of hypoxia and hypercarbia only occurs after several minutes of brain ischaemia. International multicentric data collection within the framework for standardized reporting of cardiac arrest events will be the only satisfying method to address this fascinating and intriguing issue.
Abstract: A preliminary comparison of out-of-hospital cardiac arrest (CA) data registered with a common software program (Utstein style) in two different European EMS centers is presented. Rather than attempting independently several small-scale trials, we prefer to develop in a committed effort a coordinated program of active and passive surveillance. Hopefully, this will allow us to determine the true European profile and outcome of our out-of-hospital CA victims.
Abstract: The successful supportive management of an acute combined strychnine and aconitine poisoning is described. The clinical features including initially resistant ventricular fibrillation and biochemical findings are reported. Occurrence, signs, symptoms, mechanisms of action of both strychnine and aconitine and treatment particularly with regard to the life-threatening arrhythmia induced by aconitine are briefly reviewed.
Abstract: The exact impact of the 'interval between cardiac arrest (CA) and the start of basic cardiopulmonary resuscitation (CPR) performed by bystanders' on outcome is not fully established. We retrospectively evaluated data with regard to response intervals of 1195 out-of-hospital CA interventions where bystander CPR was performed and continued by the eight mobile intensive care units (MICUs) participating in the Belgian Cerebral Resuscitation Registry between 1982 and 1990. Partial correlations between time elapsed from CALL to CPR by lay public and outcome were determined when the effect of response times of 1st and 2nd tier were removed. The following groups were studied: ventricular fibrillation (VF), asystole and electromechanical dissociation (EMD), non-witnessed and witnessed. Good outcome was represented by initial restoration of spontaneous circulation (ROSC successes) and by prolonged survival (CPR successes) being 22.7 and 9.7%, respectively. The mean time +/- S.E.M. between CALL and CPR initiated by lay people for the studied population (n = 1195) was 2.5 +/- 0.1 min. The partial correlation coefficient between prolonged survival and time passed between CALL and bystander CPR was negative for all types of CA, yet significance was reached only in the non-witnessed group. Using ROSC as the endpoint significance is achieved in all groups except the VF patients, where the intervention times were shorter. In our population, prolonged survival was independently and negatively influenced by a delay between CALL and any CPR in the non-witnessed CA group (n = 421).
Abstract: A total of 6178 persons with out-of-hospital (70%) and in hospital (30%) cardiac arrests from the first of January 1982 until the end of 1989 were reviewed retrospectively with respect to 4 variables, contributing to a score for specific prediction of poor prognosis (cut-off point: greater than 3 points). These included age, initial ECG, type of respiratory arrest and bystander resuscitation. Presence of ventricular fibrillation, gasping and bystander resuscitation contributes nothing to the score, while presence of asystole or EMD (electromechanical dissociation), apnoea and absence of bystander resuscitation adds one point to it. Of patients scoring 4 or 5 points 44 were awake 14 days post CPR (Class 3). The positive predictive value of the score was 97% (95% CI 96-98%) for the out-of-hospital group and 92.2% (95% CI 88-95%) for the in-hospital group. The specificity was respectively 92.3% (95% CI 89-95%) and 94.2% (95% CI 91-96%). Although the score can weigh the likelihood of no success against that of success, we cannot recommend it for decision making as far as abandoning or continuing cardiopulmonary resuscitation efforts.
Abstract: The optimal dose of epinephrine in human cardiac arrest remains an area of continuing controversy. Apart from animal data some anecdotal reports in humans suggest that the dose currently recommended by the AHA may be insufficient for resuscitation of spontaneous circulation during prolonged cardiac arrest (CA). Since 1982, 1610 CA patients registered in Bruges have been evaluated under the following variables: prolonged survival (class 3 CPCR successes); solely restoration of spontaneous circulation (ROSC): class 2a, 2b and 3); epinephrine dose used during cardiopulmonary resuscitation (CPR); duration of advanced life support (ALS) and duration of complete CA. Because these variables affect the dose of epinephrine and each other simultaneously, we determined the partial correlation between outcome and epinephrine dose, independently of the other two variables (R12.34). Secondly we retrospectively assessed the effect of the availability of 10 mg epinephrine vials since March 1st, 1989 on outcome. Thus we made a separate assessment of the 114 patients registered after March 1st, 1989. The mean epinephrine dose (+/- S.E.M.) for the total population (n = 1724) was 2.53 +/- 0.06 mg; for patients since March 1989 (n = 114) this number was 5.58 +/- 0.36 mg. In contrast to the period before March 1989, we found a non-significant positive correlation between the survival of class 3 and epinephrine dose by limiting the influence of CPR times in the asystole and electromechanical dissociation (EMD) arrest groups.
Abstract: We report a case of bilateral injury to the ulnar nerve above the level of the elbow due to a particular retractor used for high abdominal surgery. Possible mechanisms of pathogenesis and predestinating conditions are discussed.
