Lars Ekström

Effect of bystander initiated cardiopulmonary resuscitation on ventricular fibrillation and survival after witnessed cardiac arrest outside hospital.

OBJECTIVE--To describe the proportion of patients who were discharged from hospital after witnessed cardiac arrest outside hospital in relation to whether a bystander initiated cardiopulmonary resuscitation. PATIENTS--All patients with witnessed cardiac arrest outside hospital before arrival of the ambulance and in whom cardiopulmonary resuscitation was attempted by the emergency medical service in Gothenburg during 1980-92. RESULTS--Cardiopulmonary resuscitation was initiated by a bystander in 18% (303) of 1,660 cases. In this group 69% had ventricular fibrillation at first recording compared with 51% in the remaining patients (P < 0.001). Among patients in whom cardiopulmonary resuscitation had been initiated by a bystander 25% were discharged alive versus 8% of the remaining patients (P < 0.001). Independent predictors of survival were in order of significance: initial arrhythmia (P < 0.001), interval between collapse and arrival of first ambulance (P < 0.001), cardiopulmonary resuscitation initiated by a bystander (P < 0.001), and age (P < 0.01). Among patients who were admitted to hospital alive 30% of patients in whom cardiopulmonary resuscitation had been initiated by a bystander compared with 58% of remaining patients (P < 0.001) had brain damage and died in hospital. Corresponding figures for death in association with myocardial damage were 18% and 29% respectively (P < 0.01). CONCLUSIONS--Cardiopulmonary resuscitation initiated by a bystander maintains ventricular fibrillation and triples the chance of surviving a cardiac arrest outside hospital. Furthermore, it seems to protect against death in association with brain damage as well as with myocardial damage.

Experimental disc degeneration due to endplate injury.

The aim of this study was to create an experimental model of disc degeneration that closely mimicked human disc degeneration. In six domestic pigs, an L4 cranial endplate perforation into the nucleus pulposus was made. Three months postoperatively, compressive testing was performed on the L2–L4 motion segments, and intradiscal pressure was measured in the intervening discs. Histochemical and morphologic examinations were made on the excised degenerated and adjacent discs. A significant reduction in water content was observed in the outer anterior annulus of the degenerated disc. In the nucleus, the proteoglycan content was significantly reduced, as well as the cellularity, although not significantly. The nucleus lost its gel-like structure and was discolored, and there was delamination of annular layers. Intradiscal pressure in the nucleus was significantly lower in the degenerated disc. In conclusion, experimental degeneration of the intervertebral disc induced by endplate penetration resembled human disc degeneration, as exemplified by biochemical and structural changes.

Characteristics and outcome among patients suffering in-hospital cardiac arrest in monitored and non-monitored areas

AIM To describe the characteristics and outcome among patients suffering in-hospital cardiac arrest in relation to whether the arrest took place in a ward with monitoring facilities. METHODS All patients who suffered an in-hospital cardiac arrest during a 4-year period in Sahlgrenska Hospital, Göteborg, Sweden and in whom resuscitative efforts were attempted, were prospectively recorded and described in terms of characteristics and outcome. RESULTS Among 557 patients, 292 (53%) had a cardiac arrest in wards with monitoring facilities. Those in a monitored location more frequently had a confirmed or possible acute myocardial infarction (AMI) as judged to be the cause of arrest (P < 0.0001), and the arrest was witnessed more frequently (96 vs. 79%; P < 0.0001). Ventricular fibrillation/tachycardia was observed more often as initial arrhythmia in monitored wards (56 vs. 44%; P = 0.006). The median interval between collapse and first defibrillation was 1 min in monitored wards and 5 min in non-monitored wards (P < 0.0001). Among patients with arrest in monitored wards 43.2% were discharged alive compared with 31.1% of patients in non-monitored wards (P = 0.004). Cerebral performance category (CPC-score) at discharge was somewhat better among survivors in monitored wards. CONCLUSION In a Swedish University Hospital 47% of in-hospital cardiac arrests in which resuscitation was attempted took place in wards without monitoring facilities. These patients differed markedly from those having arrest in wards with monitoring facilities in terms of characteristics, interval to defibrillation and outcome. A shortening of the interval between collapse and defibrillation in these patients might increase survival even further.

Effect of a media campaign on delay times and ambulance use in suspected acute myocardial infarction

The early phase in suspected acute myocardial infarction (AMI) is particularly critical. More than 50% of deaths from coronary artery disease occur outside the hospital mainly due to ventricular fibrillation.1 Recent experiences strongly indicate that early intervention with thrombolysis2–4 and β blockers5,6 can limit myocardial damage and thereby improve prognosis. Delay times in suspected AMI have remained stable over the years. Therefore, a media campaign was started in the urban area of Goteborg, Sweden, with the intention to shorten delay times and to increase ambulance use in patients with suspected AMI.

Adrenaline in out-of-hospital ventricular fibrillation. Does it make any difference?

BACKGROUND A large proportion of cardiac arrests outside hospital are caused by ventricular fibrillation. Although it is frequently used, the exact role of treatment with adrenaline in these patients remains to be determined. AIM To describe the proportion of patients with witnessed out-of-hospital cardiac arrest found in ventricular fibrillation who survived and were discharged from hospital in relation to whether they were treated with adrenaline prior to hospital admission. PATIENTS AND TREATMENT All the patients with out-of-hospital cardiac arrest found in ventricular fibrillation in Göteborg between 1981 and 1992 in whom cardiopulmonary resuscitation (CPR) was initiated by our emergency medical service (EMS). During the observation period, some of the EMS staff were authorized to give medication and some were not. RESULTS In all, 1360 patients were found in ventricular fibrillation and detailed information was available in 1203 cases (88%). Adrenaline was given in 417 cases (35%). Among patients with sustained ventricular fibrillation, those who received adrenaline experienced the return of spontaneous circulation more frequently (P < 0.001) and were hospitalized alive more frequently (P < 0.01). However, the rate of discharge from hospital did not differ significantly between the 2 groups. Among patients who converted to asystole or electromechanical dissociation, those who received adrenaline experienced the return of spontaneous circulation more frequently (P < 0.001) and were hospitalised alive more frequently (P < 0.001). However, the rate of discharge from hospital did not differ significantly between the 2 groups. CONCLUSIONS On the basis of 2 treatment regimens during a 12-year survey, we explored the usefulness of adrenaline in out-of-hospital ventricular fibrillation. Both patients with sustained ventricular fibrillation and those who converted to asystole or electromechanical dissociation had an initially more favourable outcome if treated with adrenaline. However, the final outcome was not significantly affected. This study does not confirm the hypothesis that adrenaline increases survival among patients with out-of-hospital cardiac arrest who are found in ventricular fibrillation.

Characteristics and outcome among patients with a suspected in-hospital cardiac arrest

AIM To describe the characteristics and outcome among patients with a suspected in-hospital cardiac arrest. METHODS All the patients who suffered from a suspected in-hospital cardiac arrest during a 14-months period, where the cardiopulmonary resuscitation (CPR) team was called, were recorded and described prospectively in terms of characteristics and outcome. RESULTS There were 278 calls for the CPR team. Of these, 216 suffered a true cardiac arrest, 16 a respiratory arrest and 46 neither. The percentage of patients who were discharged alive from hospital was 42% for cardiac arrest patients, 62% for respiratory arrest and 87% for the remaining patients. Among patients with a cardiac arrest, those found in ventricular fibrillation/ventricular tachycardia had a survival rate of 64%, those found in asystole 24% and those found in pulseless electrical activity 10%. Among patients who were being monitored at the time of arrest, the survival rate was 52%, as compared with 27% for non-monitored patients (P= 0.001). Among survivors of cardiac arrest, a cerebral performance category (CPC) of 1 (no major deficit) was observed in 81% at discharge and in 82% on admission to hospital prior to the arrest. CONCLUSION We conclude that, during a 14-month period at Sahlgrenska University Hospital in Göteborg, almost half the patients with a cardiac arrest in which the CPR team was called were discharged from hospital. Among survivors, 81% had a CPC score of 1 at hospital discharge. Survival seems to be closely related to the relative effectiveness of the resuscitation organisation in different parts of the hospital.

Lidocaine in out-of-hospital ventricular fibrillation. Does it improve survival?

BACKGROUND A large proportion of cardiac arrests outside hospital are caused by ventricular fibrillation. Although it is frequently used, the exact role for treatment with lidocaine in these patients remains to be determined. AIM To describe the proportion of patients with witnessed out-of-hospital cardiac arrest found in ventricular fibrillation who survived and were discharged from hospital in relation to whether they were treated with lidocaine prior to hospital admission. PATIENTS AND TREATMENT All the patients with out-of-hospital cardiac arrest found in ventricular fibrillation in Göteborg between 1980 and 1992 in whom cardiopulmonary resuscitation (CPR) was initiated by our emergency medical service (EMS). During the observation period, some of the EMS staff were authorized to give medication and some were not. RESULTS In all, 1,360 patients were found in ventricular fibrillation, with detailed information being available in 1,212 cases (89%). Lidocaine was given in 405 of these cases (33%). Among patients with sustained ventricular fibrillation, those who received lidocaine had a return of spontaneous circulation (ROSC) more frequently (P < 0.001) and were hospitalized alive more frequently (38% vs. 18%, P < 0.01). However, the rate of discharge from hospital did not significantly differ between the two groups. Among patients who were converted to a pulse-generating rhythm, those who received lidocaine on that indication were more frequently alive than those who did not receive such treatment (94% vs. 84%; P < 0.05). However, the rate of discharge did not significantly differ between the two groups. CONCLUSION In a retrospective analysis comparing patients who received lidocaine with those who did not in sustained ventricular fibrillation and after conversion to a pulse-generating rhythm, such treatment was associated with a higher rate at ROSC and hospitalization but was not associated with an increased rate of discharge from hospital.

Survival after cardiac arrest outside hospital over a 12-year period in Gothenburg

BACKGROUND A two-tiered ambulance system with a mobile coronary care unit and standard ambulance has operated in Gothenburg (population 434,000) since 1980. Mass education in cardiopulmonary resuscitation (CPR) commenced in 1985 and in 1988 semiautomatic defibrillators were introduced. AIM To describe early and late survival after cardiac arrest outside hospital over a 12-year period. TARGET POPULATION All patients with prehospital cardiac arrest in Gothenburg reached by mobile coronary care unit or standard ambulance between 1980 and 1992. RESULTS The number of patients with cardiac arrest remained fairly steady over time. Among patients with witnessed ventricular fibrillation, the time to defibrillation decreased over time. The proportion of patients in whom bystander initiated CPR was increased only moderately over time. The proportion of patients given medication such as lignocaine and adrenaline successively increased. The number of patients with cardiac arrest who were discharged from hospital per year remained steady between 1981 and 1990 (20 per year), but increased during 1991 and 1992 to 41 and 31 respectively. CONCLUSIONS Improvements in the emergency medical service in Gothenburg over a 12-year period have lead to: (1) a shortened delay time between cardiac arrest and first defibrillation and (2) an improved survival of patients with cardiac arrest outside hospital probably explained by this shortened delay time.

A comparison between patients suffering in-hospital and out-of-hospital cardiac arrest in terms of treatment and outcome

Abstract. Herlitz J, Bång A, Ekström L, Aune S, Lundström G, Holmberg S, Holmberg M, Lindqvist J (Sahlgrenska University Hospital, Göteborg, Sweden). A comparison between patients suffering in‐hospital and out‐of‐hospital cardiac arrest in terms of treatment and outcome. J Intern Med 2000; 248: 53–60.

Laser angioplasty of restenosed coronary stents: Results of a multicenter surveillance trial

OBJECTIVES This study evaluated safety and efficacy of excimer laser angioplasty for treatment of restenosed or occluded coronary stents. BACKGROUND Balloon angioplasty of in-stent restenosis is limited by a high recurrence rate. Debulking by laser angioplasty is a novel concept to treat in-stent restenosis. METHODS A total of 440 patients with restenoses or occlusions in 527 stents were enrolled for treatment with concentric or eccentric laser catheters and adjunctive balloon angioplasty. RESULTS Laser angioplasty success (< or =50% diameter stenosis after laser treatment or successful passage with a 2.0-mm or 1.7-mm eccentric laser catheter) was achieved in 92% of patients. Adjunctive balloon angioplasty was performed in 99%. Procedural success (laser angioplasty success followed by < or =30% stenosis with or without balloon angioplasty) was 91%. There was neither a significant difference in success with respect to lesion length, nor were there differences between small and large vessels or native vessels and vein grafts. Success was higher and residual stenosis lower using large or eccentric catheters. Serious adverse events included death (1.6%, not directly laser catheter related), Q-wave myocardial infarction (0.5%), non-Q-wave infarction (2.7%), cardiac tamponade (0.5%) and stent damage (0.5%). Perforations after laser treatment occurred in 0.9% of patients and after balloon angioplasty in 0.2%. Dissections were visible in 4.8% of patients after laser treatment and in 9.3% after balloon angioplasty. Reinterventions during hospitalization were necessary in 0.9% of patients; bypass surgery was performed in 0.2%. CONCLUSIONS Excimer laser angioplasty with adjunctive balloon angioplasty is a safe and efficient technology to treat in-stent restenoses. These data justify a randomized comparison with balloon angioplasty.