Gunnar Kroesen

Recombinant tissue plasminogen activator during cardiopulmonary resuscitation in 108 patients with out-of-hospital cardiac arrest

BACKGROUND Thrombolytic therapy during cardiopulmonary resuscitation (CPR) is a controversial issue in emergency medicine practice. This study was conducted to determine whether administration of recombinant tissue plasminogen activator (rt-PA) in out-of-hospital cardiac arrest of non-traumatic aetiology improves CPR outcome. METHODS AND RESULTS A retrospective chart review of 401 patients with out-of-hospital cardiac arrest who were resuscitated by the emergency medical services (EMS) during a 6 year period was performed. A total of 108 patients received rt-PA during CPR and were compared to 216 controls, closely matched according to baseline characteristics, arrival status and ECG findings. Administration of rt-PA was optional. Return of spontaneous circulation (ROSC) occurred in 76 patients under rt-PA treatment (70.4 vs. 51.0% in controls; P=0.001). Fifty-two patients from the lysis group survived the first 24 h (48.1 vs. 32.9% in controls; P=0.003), while 27 (25.9%) survived to discharge. Autopsy reports revealed major bleeding complications in six patients receiving rt-PA treatment. Fulminant intracranial haemorrhage was observed in one patient who received rt-PA and in two cases from the control group. CONCLUSIONS Thrombolytic therapy may improve frequency of return of spontaneous circulation substantially and increase primary survival in patients with non-traumatic cardiac arrest. Serious bleeding complications are not frequently observed under rt-PA treatment.

Unexpected return of cardiac action after termination of cardiopulmonary resuscitation.

Application of sodium bicarbonate is still an option when resuscitation efforts remain unsuccessful. Despite this, there are no recommendations on how long resuscitation should be performed after administration of this drug. Here we describe a case in which prehospital resuscitation efforts were terminated about 35 min after cardiac arrest. Seven minutes after all efforts had been discontinued, spontaneous sinus rhythm appeared from a zero-line ECG, giving normal hemodynamic values. The underlying reason might be unexpected and unrecognized hyperkalemia, which was diminished by administration of sodium bicarbonate, even under the conditions of cardiocirculatory arrest.

Epidemiology and outcome of pediatric trauma treated by an emergency-physician-staffed advanced life-support unit.

SummaryBackgroundThe aim of this study was to describe the epidemiology and outcome of pediatric trauma in the setting of an emergency-physician-staffed mobile advanced life support (ALS) unit serving a predominantly urban area in Austria.MethodsIn this retrospective chart review, all pediatric trauma patients (0–14 years of age) who were treated by a physician-staffed ALS unit in Innsbruck within a 3-year period were analyzed. In addition, hospital charts were assessed to determine the clinical course and the outcome of these patients.Results113 injured children were treated by the physician-staffed ALS unit (1.5% of all runs) during the study period; a frequency of three pediatric trauma patients per month. On average, injuries were of moderate severity (2.6±1.3 on the NACA severity scale). Thirteen children (11.5%) sustained severe to life-threatening injuries and two of whom underwent out-of-hospital resuscitation. The majority of the injuries were caused by vehicular accidents and sports/recreation-related trauma; head trauma was the most frequent injury. Violence-related trauma including weapon-inflicted injuries was uncommon. 40% of the children were hospitalized. The overall outcome was favorable: 78% of the hospitalized children had no impairment at the time of discharge. By comparing the prehospital trauma diagnosis with the final diagnosis, we found that the vast majority of emergency-physician trauma diagnoses were accurate.ConclusionBecause the frequency of pediatric trauma is so low, ALS units may not gain adequate experience in the management of (severe) pediatric trauma, thus rendering regular training of paramount importance.

Cardiopulmonary resuscitation after thoracic surgery: echocardiographic observations

We report echocardiographic observations during external chest compression in a patient with marked abnormalities in thoracic anatomy following emergency surgery of aortic arch aneurysm. Transesophageal echocardiography demonstrated direct right ventricular, aortic and left atrial compression, only minimal left ventricular compression and an open mitral valve during closed chest heart massage. Colour flow doppler demonstrated forward blood flow across the mitral valve and along the left ventricular outflow tract during the compression phase. Echocardiographic findings indicate that factors apart from simple cardiac pump mechanism contributed to blood flow during cardiopulmonary resuscitation (CPR) in this postoperative patient after a major thoracic surgical intervention.

Active compression–decompression cardiopulmonary resuscitation in standing position over the patient: pros and cons of a new method

Active compression-decompression cardiopulmonary resuscitation (ACD-CPR) has been introduced to improve outcome of CPR after cardiac arrest. Usually, ACD-CPR is performed with the rescuer kneeling beside the patient (ACD-B), but ACD-CPR with the rescuer in standing position (ACD-S) has been taught and applied in some centres in addition to conventional ACD-CPR (ACD-B). The aim of this randomised and cross-over study was to evaluate the new technique of ACD-S and to compare it with conventional ACD-B. Twelve professional rescuers (aged 30.8 +/- 7.9 years) applied both methods of ACD-CPR on a manikin. We obtained the following results. (1) Duration of CPR performance was comparable for ACD-S (13.2 +/- 7.1 min) and ACD-B (15.5 +/- 10.2 min, P = 0.48). (2) Pain in the upper extremity and pain in the vertebral column were the main reasons for break-off by the rescuers. Exhaustion was judged to be similar during ACD-S (5.3 +/- 2.3) and ACD-B (6.2 +/- 2.1; on a rating scale with 1 = no and 9 = complete exhaustion). (3) Oxygen consumption was significantly higher during ACD-S (P < 0.005), whereas heart rate and lactate levels did not differ. (4) Decompression forces were lower than compression forces. The averaged decompression forces in both methods were similar during the first 2 min and the last min. Compression forces decreased in ACD-S from 55.1 to 48.9 kp (P = 0.002) and in ACD-B from 52.8 to 47.0 kp (P = 0.069). We conclude that ACD-CPR in standing position can be considered equal to ACD-B in view of maximal duration of CPR, exhaustion of the rescuers and decompression forces. The decrease of compression forces in ACD-S and ACD-B as well as the difference between compression forces in ACD-S and ACD-B seem to be of no clinical relevance, and exhaustion was judged to be similar despite oxygen consumption being higher in ACD-S than in ACD-B.

Studies on hypo-and hypercoagulability II. Coagulation and fibrin analyses in severe infectious and toxic conditions

SummaryPlasma phospholipids were elevated in patients with severe infections with renal complications (except for pyelonephritis) without shock in comparison with normals and with patients with severe infectionswithout renal complications. In contrast, in patients with toxic conditions with and without shock, total phospholipids were decreased. The percentages of phosphatidyl-ethanolamine and of lecithin were increased and those of lysolecithin decreased in all patient groups.By incubation of citrate plasma, partial thromboplastin or thromboplastin and Ca++ fibrins were produced, washed out, homogenized and phospholipids were estimated. In the patient groups with infections with renal complications and with peritoneal toxic conditions total phospholipids in the fibrins produced with partial thromboplastin reagent were significantly increased both in comparison to normals and to the corresponding amounts of reagent. Phospholipids in thromboplastinproduced fibrins were significantly elevated only in the patients with infections with renal complications.The results suport the view that plasma phospholipids-and herewith lipoproteins-are not simply trapped by the fibrin network, but play a role in the coagulation process, particularly under pathological conditions:1)In the patient groups with the most severe conditions the amount of total phospholipids in the PTT*-produced fibrins was significantly augmented in comparison to normals and the corresponding amount of reagent.2)Total phospholipids in the PTT-produced fibrins were independent of the amount of phospholipids in the plasma.3)They were also independent of fibrinogen or any of the coagulation factors.4)There were significant differences in the complexing of phospholipids between PTT-and thromboplastin-produced fibrins within the same groups. Routine coagulation parameters (fibrinogen, one-stage prothrombin time, partial thromboplastin time, platelets, thrombelastography, factors II, V, VII, VIII, IX, X) varied greatly. PT* and factor II and VII were significantly decreased in patients with toxic conditions. Fibrinogen was augmented, but the platelet count decreased in patients with infections with renal complications. Of all parameters tested, the increases of percentages of phosphatidylethanolamine in plasma and of total phospholipids in PTT-produced fibrins were most closely connected with clinical signs of hypercoagulability (i.e. of intravascular coagulation without excessive consumption of clotting factors leading to bleeding).ZusammenfassungPlasmaphospholipide waren bei Patienten mit schweren Infekten mit renalen Komplikationen (mit Ausnahme der Pyelonephritis) ohne Schock signifikant im Vergleich mit unkomplizierten Infekten und mit Normalen vermehrt. Im Gegensatz dazu waren sie bei infektiös-toxischen Zustandsbildern deutlich erniedrigt. Die Prozentwerte von Phosphatidyläthanolamin und von Lecithin waren bei allen Patientengruppen signifikant vermehrt, während die von Lysolecithin vermindert waren.Durch inkubation von Zitratplasma, partiellem Thromboplastin oder Thromboplastin und Ca++ wurden Fibrine erzeugt, ausgewaschen, homogenisiert und die Phospholipide im Homogenat bestimmt. In allen Patientengruppen mit Ausnahme der unkomplizierten schweren Infekte waren die in den Fibrinen gefundenen Phospholipide beträchtlich im Vergleich mit Normalen und mit der entsprechenden Menge Reagens vermehrt. Phospholipide in mit Thromboplastin erzeugten Fibrinen waren nur bei schweren Infekten mit renalen Komplikationen erhöht.Die Ergebnisse unterstützen die Ansicht, daß die Plasmaphospholipide — und damit Lipoproteine — sich nicht einfach im Fibrinnetzwerk verfangen sondern eine eigenständige Rolle im Gerinnungsprozeß, besonders unter pathologischen Bedingungen spielen, und zwar aus folgenden Gründen.1.In den Patientengruppen mit den schwersten Zustandsbildern waren die Gesamtphospholipide in den mit PTT-Reagens produzierten Fibrinen signifikant im Vergleich zu Normalen und zur entsprechenden Menge Reagens vermehrt.2.Die Gesamtphospholipide in den PTT-produzierten Fibrinen waren unabhängig von den Gesamtphospholipiden.3.Sie waren auch unabhängig von Fibrinogen oder einem anderen der geprüften Gerinnungsfaktoren im Plasma.4.In der Bindung der Phospholipide bestanden signifikante Unterschiede zwischen PTT-und Thromboplastin-produzierten Fibrinen innerhalb der gleichen Gruppen. Die Routinegerinnungsparameter zeigten große Schwankungen. PT und die Faktoren II und VII waren signifikant bei Patienten mit infektiös-toxischen Zustandsbildern vermehrt. In der Gruppe der Infektionen mit renalen Komplikationen war Fibrinogen vermehrt, jedoch die Thrombozyten vermindert.Von allen geprüften Parametern waren die Vermehrung der Prozentwerte von Phosphatidyläthanolamin im Plasma und der Gesamtphospholipide in den PTT-produzierten Fibrinen am ausgeprägtesten mit klinischen Zeichen von Hyperkoagulabilität (intravasale Fibrinbildung ohne massiven, zu Blutungen führenden Verbrauch von Gerinnungsfaktoren) verbunden.

Studies on hypo- and hypercoagulability I. Evidence for the occurence of “incomplete” consumption coagulopathy

SummaryIn patients with consumption coagulopathy (CCO) with and without mass transfusions, in patients who had received mass transfusions and in normal persons coagulation studies were carried out and phospholipids were examined in plasmata and fibrins produced under standardized conditions. In fibrins of all groups the percentage of lecithin was significantly increased indicating a participation of plasmatic phospholipids. Phospholipids in fibrins produced with thromboplastin were decreased in patients with CCO compared to normals. Phospholipids of fibrins made with partial thromboplastins were, however, increased in the group with incomplete CCO in comparison with all other groups and with the corresponding amount of reagent.In evaluating the parameters examined statistically we found it justified to establish a separate group — incomplete CCO — for the following reasons: In incomplete CCO fibrinogen and factor IX were significantly higher than in the other CCO-groups, whereas factor X was significantly lower. Total plasma phospholipids were significantly elevated compared to the other CCO-groups. Absolute amounts and percentages of phosphatidylethanolamine were 2 to 3 times higher than in normals or in the other CCO groups: In the fibrins produced with partial thromboplastin reagent total phospholipids were significantly higher than in all other groups and also in the reagent.ZusammenfassungBei Patienten mit Verbrauchskoagulopathie (VK) mit und ohne Massentransfusionen, bei Patienten, die Massentransfusionen erhalten hatten sowie bei Normalen wurden Gerinnungsuntersuchungen durchgeführt und die Phospholipide (PL) im Plasma und in unter standardisierten Bedingungen erzeugten Fibrinen untersucht. Die prozentuellen Anteile von Lezithin waren in Fibrinen aller Gruppen erhöht, was auf eine Beteiligung plasmatischer PL bei der Fibrinbildung hinweist. PL in mit Thromboplastin erzeugten Fibrinen waren bei Patienten mit VK im Vergleich zu Normalen vermindert. Die PL der mit partiellem Thromboplastin erzeugten Fibrine waren jedoch bei Patienten mit inkompletter VK deutlich im Vergleich zu Normalen und zu den anderen Patienten mit VK sowie mit der entsprechenden Menge Reagens erhöht.Bei der statistischen Auswertung der Daten fanden wir es berechtigt, eine eigene Gruppe — inkomplette VK — zu bilden, und zwar aus den folgenden Gründen: Bei inkompletter VK waren Fibrinogen und Faktor IX signifikant höher als bei den anderen VK, während Faktor X signifikant niedriger war. Im Plasma waren die Gesamtphospholipide sowie die Absolut- und Relativwerte von Phosphatidyl-äthanolamin wesentlich höher als bei den anderen VK.: In den mit partiellem Thromboplastinreagens erzeugten Fibrinen waren die PL signifikant höher als bei Normalen, als bei den anderen Patienten mit VK und als in der entsprechenden Menge Reagens.

Basic life-support kit in an out-of-hospital emergency.

An 8-year-old boy suffered a skull fracture and severe brain injury while attending a skiing event. A physician, equipped with his private emergency kit accomplished placement of a venous access line enabling administration of analgesic and sedating medication with ketamine and midazolam. When the helicopter emergency medical service arrived on the scene the patient’s peripheral circulation had decreased to such an extent that further attempts to place a second peripheral venous line were impossible. Securing the airways by tracheal intubation was not considered necessary; the spine was stabilised with a cervical collar and a vacuum mattress. Transport to the trauma centre and intensive care were uneventful. The importance of a specially adjusted emergency kit for first aid by experienced medical personnel is discussed.