Markku Kuisma

Paediatric out-of-hospital cardiac arrests — epidemiology and outcome

OBJECTIVE To determine the epidemiology and aetiology of out-of-hospital paediatric cardiac arrest and the outcome of resuscitation and to apply the Utstein template for the paediatric cardiac arrest population. DESIGN Retrospective cohort study. SETTING A middle-sized urban city (population 516,000) served by a single emergency medical services (EMS) system. PATIENTS 79 consecutive paediatric (age under 16 years) prehospital cardiac arrest patients between January 1, 1985 and December 31, 1994. No patient was excluded. INTERVENTION Advanced paediatric life support according to the recommendations of American Heart Association. MAIN OUTCOME MEASURES Survival from cardiac arrest to discharge and factors associated with favourable outcome defined as alive 1 year after discharge with Bloom category I or II. RESULTS 79 patients had cardiac arrest. The incidence of paediatric out-of-hospital cardiac arrest and sudden unexpected out-of-hospital death was 9.8 and 8.9/100,000/inhabitants aged under 16, respectively. The mean age was 2.9 years, 72.2% were under 18 months. SIDS was the leading cause of cardiac arrest followed by trauma, airway related cardiac arrest and (near)drowning. Fifty-two patients were considered for resuscitation in whom asystole was the most common initial rhythm (78.9%) followed by pulseless electrical activity (13.5%) and ventricular fibrillation (3.8%). Resuscitation was attempted in 34 patients. The overall survival rate was 9.6%, for attempted resuscitation 14.7%, for attempted resuscitation when cardiac arrest was witnessed 25.0% and for attempted resuscitation with witnessed arrest of cardiac origin 0%. Favourable outcome was registered in four of five survivors. Factors associated with favourable outcome were collapse in a public place, the near-drowning aetiology of arrest, bystander initiated CPR and short duration of resuscitation. Multivariate regression analysis showed no factor related to favourable outcome, but MICU time interval < 10 min was related with survival. Due to the retrospective nature of this study all core times could not be obtained. In spite of this, the Utstein template was applicable also in our paediatric cardiac arrest population. CONCLUSIONS Survival from paediatric cardiac arrest has remained low. The overall survival rate was 9.6%, survival after attempted resuscitation 14.7% and 0% when resuscitation was attempted in witnessed arrest of cardiac origin. Asystole was the most common initial rhythm and the four leading causes for cardiac arrest were SIDS, trauma, airway related arrest and (near)drowning. The Utstein template adopted for adult out-of-hospital cardiac arrests was was found applicable also in paediatric cardiac arrests.

Resuscitation in Europe: a tale of five European regions.

AIM To describe cardiac arrest data from five emergency medical services (EMS) systems in Europe with regard to survival from an out-of-hospital cardiac arrest. METHODS Based on recommendations from various countries in Europe EMS systems were approached with regard to survival from out-of-hospital cardiac arrest. Five EMS systems were asked to report their cardiac arrest data according to the Utstein style. RESULTS The five selected EMS systems were: Bonn (Germany), Göttingen (Germany), Helsinki (Finland), Reykjavik (Iceland) and Stavanger (Norway). For patients with a bystander witnessed arrest of cardiac aetiology the percentage of patients being discharged alive from hospital in these regions were: 21, 33, 23, 23 and 35. The corresponding percentages for patients fulfilling criteria as above and being found in ventricular fibrillation were: 32, 42, 32, 27 and 55. CONCLUSIONS Many EMS systems in Europe show extremely good results in terms of survival after an out-of-hospital cardiac arrest. Some of the results should be interpreted with caution since they were based on relatively small sample sizes. Furthermore, the results from one of the regions (Stavanger) was unit based and not community based.

Door to thrombolysis: ER reorganization and reduced delays to acute stroke treatment

The authors reorganized the emergency room (ER) by moving CT to the ER and streamlining triage by prenotification by emergency medical services (EMS), which reduced in-hospital delays and enhanced access to stroke thrombolysis. CT delay dropped from 1 hour 3 minutes ± 14 minutes in 1999 to 7 ± 2 minutes in 2004 (p < 0.0001). Door-to-needle time dropped from 1 hour 28 minutes ± 7 minutes to 50 ± 3 minutes (p < 0.001), while symptom-to-needle time dropped from 2 hours 44 minutes ± 6 minutes to 2 hours 5 minutes ± 4 minutes (p < 0.0001). From 23 patients in 1999, thrombolysis access was increased to 100 patients in 2004 and 183 patients in 2005.

The incidence of out-of-hospital ventricular fibrillation in Helsinki, Finland, from 1994 to 1999

Early defibrillation by emergency medical services has been a success story in the treatment of ventricular fibrillation. This success has been followed by recommendations to allow public access to defibrillation equipment. We tracked the changes in incidence of ventricular fibrillation from prospectively collected data from the Helsinki Cardiac Arrest Register. We found that the incidence of out-of-hospital ventricular fibrillation of cardiac origin fell by 48% from 1994 to 1999 (p=0.0036). The primary and secondary prevention of coronary artery disease may not be the only reasons for this change and so new public-access defibrillation programmes should be delayed until our findings are confirmed.

Community-Based Thrombolytic Therapy of Acute Ischemic Stroke in Helsinki

Background and Purpose— Thrombolysis with alteplase is used in acute ischemic stroke within 3 hours after symptom onset in many stroke centers, but experience remains limited in Europe. Methods— Using eligibility and management criteria similar to those published by the American Heart Association, we treated 75 consecutive patients aged 21 to 83 years (mean age, 63.6 years; median Scandinavian Stroke Scale score, 32/58) with hemispheric infarction with alteplase in 1998–2001. Their neuroradiological findings (ischemic and hemorrhagic changes) and functional outcome at 3 months were evaluated. Results— Sixty-one percent of the patients had recovered functional independence (Barthel Index 95 to 100) at the 3-month follow-up. On the modified Rankin Scale (mRS), 37% (28/75) of patients had no or minimal symptoms (mRS 0 to 1), while 17% (13/75) remained dependent (mRS 4 to 5) and 5% (4/75) died. Cerebral parenchymal hematomas occurred in 8% (6/75) and hemorrhagic transformation in 8% (6/75) of the patients. Low initial diastolic blood pressure and administration of intravenous antihypertensive medication were associated with unfavorable outcome (mRS 3 to 6). Conclusions— We conclude that our management protocol for thrombolytic therapy is safe. These rates of functional outcome, case fatality, and hemorrhagic cerebral events compare favorably with those of other published series of stroke thrombolysis with similar time windows and management guidelines. Associations between blood pressure and its treatment during thrombolysis with functional outcome deserve further analysis.

T HE U SE OF P REHOSPITAL C ONTINUOUS P OSITIVE A IRWAY P RESSURE T REATMENT IN P RESUMED A CUTE S EVERE P ULMONARY E DEMA

Objective. To describe the prehospital use of a continuous positive airway pressure (CPAP) system for the treatment of presumed acute severe pulmonary edema (ASPE). Methods. The efficacy of prehospital CPAP treatment was analyzed in terms of changes in oxygen saturation, need for intubation or ventilatory support, and possible morbidity associated with the CPAP therapy. This was a retrospective cohort study conducted in the mobile intensive care unit of a university hospital. Participants included all consecutive patients with a clinical picture of ASPE treated by a mobile intensive care unit between January 1, 1998, and December 31, 1999. Results. 121 patients were included in this study. 116 patients received prehospital CPAP therapy. Two patients (1.7%) from the CPAP-treated patients were intubated in the field. A total of six patients required endotracheal intubation before hospital, and six other patients after that. After the beginning of CPAP treatment, there was statistically significant elevation in blood oxygen saturation (mean and standard deviation [SD] before CPAP 77% ± 11% and after CPAP 90% ± 7%) (p < 0.0001) as well as reductions in the respiratory rate (mean and SD before CPAP 34 ± 8 breaths/min and after CPAP 28 ± 8 breaths/min) (p < 0.0001), systolic blood pressure (mean and SD before CPAP 173 ± 39 mm Hg and after CPAP 166 ± 37 mm Hg) (p = 0.0002), and heart rate (mean and SD before CPAP 108 ± 25 beats/min and after CPAP 100 ± 20 beats/min) (p = 0.0017). The main reason for in-hospital death (8%) was myocardial infarction. No technical problems or complications occurred during CPAP treatment. Conclusions. Prehospital CPAP treatment in patients with ASPE improved oxygenation significantly and lowered respiratory rate, heart rate, and systolic blood pressure. Because of the retrospective nature of this study, the hemodynamic effects of nitroglycerine and morphine cannot be excluded. The mortality rate was low, which needs to be confirmed in a controlled, prospective study.

The use of undiluted amiodarone in the management of out‐of‐hospital cardiac arrest

Introduction:  The Resuscitation 2000 Guidelines recommends amiodarone as the antiarrhythmic drug of choice in treatment of resistant ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Amiodarone has been associated with side‐effects and difficulty of administration, due to recommended dilution, rendering it suboptimal for out‐of‐hospital cardiac arrest (CA) management. In the present study we report experiences and side‐effects of the use of undiluted amiodarone in CA management in Helsinki Emergency Medical Service (EMS) during a 2‐year period.

Paediatric cardiac arrest and resuscitation provided by physician-staffed emergency care units

Background:Most paediatric cardiac arrest studies have been conducted in the USA, where paramedics provide prehospital emergency care. We wanted to study the outcome of paediatric cardiac arrest patients in an emergency medical system which is based on physician staffed emergency care units.

Serious overdoses involving buprenorphine in Helsinki.

Background:  Buprenorphine is used as maintenance therapy for opioid‐dependent patients. In comparison with other opioids it is thought to be safer because it is less likely to cause serious respiratory depression. However, concomitant use of psychotropics, especially benzodiazepines, and intravenous injection of dissolved buprenorphine tablets increase the risk of a serious overdose.

Thrombolytic treatment of acute myocardial infarction after out-of-hospital cardiac arrest

OBJECTIVE To investigate the safety and efficacy of thrombolytic treatment for an acute myocardial infarction (AMI) immediately after resuscitation in the out-of-hospital setting. DESIGN Retrospective. SETTING A middle-sized urban city (population 540000) served by a single emergency medical system using a tiered response with physicians in field. PATIENTS AND METHODS Sixty-eight patients with an initial diagnosis of AMI who received thrombolytic treatment in an out-of-hospital setting after cardiac arrest and cardiopulmonary resuscitation (CPR) between January 1st 1994 and December 31st 1998. An ECG and the myocardial enzymes (CK, CK-MB, Troponin-T) were used to diagnose AMI. Myocardial reperfusion was assessed by resolution of the ST-segment elevation. Side effects and complications were studied. The quality of secondary survival was evaluated. The Utstein style was used for a uniform style of reporting the cardiac arrest data. RESULTS The accuracy of prehospital diagnosis was found to be excellent. Retrospective analysis revealed that thrombolytic therapy had been appropriately administered in 64 (94%) of the 68 patients actually treated. Reperfusion was achieved in 71% of the patients. Haemorrhagic complications were few, and included intracranial haemorrhage (one patient), gastrointestinal bleeding (two patients), bleeding from the puncture site (one patient) and epistaxis (one patient). The incidence of hypotension during streptokinase infusion was 22%. Sixty-three (93%) of the patients were admitted alive to the hospital, with 36 subsequently surviving to discharge. CONCLUSIONS Thrombolytic treatment is a safe and effective treatment in AMI even after out-of-hospital cardiopulmonary resuscitation.