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Introduction: The outcome after out of hospital cardiac arrest is dismal. Thrombolysis during CPR has been advocated. Our hypothesis was that early administration of bolus thrombolysis could lead to improved survival from out of hospital cardiac arrest.Methods: A prospective, randomised, double blind placebo controlled trial. All victims of out of hospital cardiac arrest brought to the Emergency Department (ED) by the emergency medical system were eligible for inclusion. All patients received standard advanced cardiac life support, except that the first drug the patient received was either tenecteplase 50 mg or placebo. The primary end point was return of spontaneous circulation (ROSC).Results: Of 35 patients enrolled, 19 received tenecteplase and 16 placebo. The tenecteplase group was younger (63 vs 72 years P = 0.04) and had significantly more ventricular fibrillation as the initial rhythm (63% versus 19%, 44% difference, 95% CI 15-73%). There was no difference in rhythm on arrival at the ED. ROSC occurred in 8 (42%) patients receiving tenecteplase and one (6%) placebo (36% difference, 95% CI 11-61%). Two tenecteplase and one placebo patient survived to leave ED, and one in each group survived to hospital discharge. Autopsy results were available on eight patients, five of whom had a thrombotic cause of death.Conclusion: In this pilot study, we found the use of early bolus tenecteplase for OHCA to be feasible, and that it appears to increase the rate of ROSC. Larger studies are required to determine if this translates into a survival benefit. Appropriate patient selection for OHCA studies remains problematic. [ABSTRACT FROM AUTHOR]

Background: It is recommended that eligible patients receive thrombolytic treatment within 90 min of alerting medical or ambulance services. The Donegal Area Rapid Treatment Study (DARTS) showed that pre-hospital thrombolysis reduces “call to needle” times for patients living remote from the hospital base [Donegal Area Rapid Treatment Study (DARTS): Final Report. North Western Health Board]. Aim: To review DARTS data to describe the potential impact of pre-hospital thrombolysis on a defined population. Method: Data from the DARTS project was reviewed to describe cases where thrombolysis was not administered, cases where thrombolysis was administered in hospital but not in the community, and to extrapolate these findings to other rural regions in the area to identify the potential for additional pre-hospital thrombolysis. Results: Eighty-four patients from DARTS practices presented to the district hospital with AMI during the study period with 35% (29/84) receiving thrombolysis. Of the 29 who received thrombolysis, 87% (25) were referred from the general practitioner. Of these, 32% (8/25) were administered thrombolysis by the general practitioner. Of the general practitioner referrals that did not receive pre-hospital thrombolysis (n=17), 65% (11/17) were not thrombolysed in the community for appropriate clinical reasons and 35% (6/17) could have been potentially eligible for pre-hospital thrombolysis. Inclusion of these patients suggests a potential pre-hospital thrombolysis rate in the region of 56%. For the rural Donegal areas this would result in a potential 17 cases per year being eligible for pre-hospital thrombolysis. Conclusions: Currently, 35% of the 240 AMIs that occur annually in the region receive thrombolysis. Broad implementation of DARTS in the region would provide pre-hospital thrombolysis to approximately an additional 25 patients each year, with a potential for further gains. For this to become a reality, support and encouragement must be provided to all rural general practitioners, the ambulance services, receiving hospitals and policy makers to implement a pre-hospital thrombolysis policy. [Copyright &y& Elsevier]

Objective: The long-term outcome in patients who received recombinant tissue plasminogen activator during cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OHCA) of non-traumatic aetiology was assessed. Methods: The neurological outcome in survivors and their level of performance, subjective well-being and quality of life were evaluated. Results: A follow-up study of 27 cardiac arrest survivors was conducted; four patients (15%) died during the first year, a total of seven patients (26%) within 5 years. Twenty-two patients (81%) were discharged from hospital without neurological deficit (cerebral performance category (CPC) score: 1), three patients scored CPC 2 and two patients CPC 3. Heart failure classification on discharge was, according to the New York Heart Association (NYHA) criteria 2.1±0.9. Fifteen patients (56%) managed to return to their previous level of activity. At the time of follow-up 18 patients (67%) were still alive, of whom 15 responded to a survey regarding life satisfaction. Thirteen patients (87%) judged their situation to be worth living and twelve (80%) considered their survival a second chance, while five (33%) feared they could suffer another cardiac arrest. Reactions from close relatives included fear/anxiety (n=14; 78%), a sustained burden on family life (n=12; 67%), and occasional depression (n=7; 39%). Conclusions: Thrombolytic therapy during cardiopulmonary resuscitation may produce a favourable neurological outcome. The majority of long-term survivors reported a good subjective quality of life. In one-third of close family members some negative factors had a lasting impact on the quality of daily living. [Copyright &y& Elsevier]

Objective: Fractured ribs and sternum are frequent complications of thoracic compression during CPR in adults. This study was conducted to determine whether findings of plain chest radiography (CXR) correlate with post-mortem findings in patients who underwent cardiopulmonary resuscitation (CPR) after out-of-hospital cardiac arrest. Methods: CXR findings and autopsy results of CPR-related chest injuries comprising rib and sternum fractures were compared prospectively in 19 patients. Results: Fractures were diagnosed in nine of 19 patients by means of radiology and in 18 of 19 patients by autopsy (rib fractures in 6/19 versus 17/19, P=0.002; sternum fractures in 5/19 versus in 9/19, P=0.227). The total number of isolated bone fractures detected by CXR was 18 (12 rib and six sternum fractures) and by autopsy 92 (83 rib and nine sternum fractures). The majority of rib fractures was located in the anterior part of the thoracic cage. Sternum fractures predominantly occurred in the lower third. Eight of 19 patients received either thrombolytic or antithrombotic treatment during CPR but no major bleeding complication associated with CPR was detected by autopsy. Conclusions: The findings of this study indicate that fractures associated with CPR are underreported in conventional radiographic investigations. No major bleeding complications related to CPR-associated fractures was detected. [Copyright &y& Elsevier]

Thrombotic disease of the vertebrobasilar circulation is associated with a poor prognosis. It may occur in trauma patients, especially those with neck injuries and even several months after the initial insult. We report on the case of a young polytrauma patient, victim of a traffic accident, with associated cervical and thoracic spinal injuries resulting in paraplegia. Consciousness was not impaired initially, but during transfer to our hospital he became suddenly unconscious. An occluded basilar artery was found on angiography, but unfortunately we were unable to reopen the vessel with thrombolytic therapy. This case again proves that lesions of the vertebro-basilar system must always be suspected in neck injuries. Even after minor whiplash injuries, fatal basilar thrombosis may occur. A review of all reported cases of traumatic basilar artery thrombosis is given and the use of thrombolytic therapy is discussed. [Copyright &y& Elsevier]

Objective: To compare the speed and reliability of electrocardiogram (ECG) transmissions from the prehospital setting to a conventional table facsimile device and to an advanced mobile phone in a Helicopter Emergency Medical Service System (HEMS). Methods: Eighteen authentic ECGs stored in the memory module of a monitor defibrillator were used. The ECGs were (1) sent directly from the monitor defibrillator to a table fax and an advanced mobile phone at the HEMS base; (2) printed out and sent from a mobile fax connected to an ordinary mobile phone to the table fax and the advanced mobile phone at the HEMS base; (3) printed out and sent from an ordinary table fax as well as from a table fax connected to a satellite phone system to the receiving devices at the HEMS base. Results: When the ECGs were sent from the table fax via satellite, the transmission times were longer to the advanced mobile phone than to the table fax at the HEMS base (1 min 54 s±0 min 21 s vs. 1 min 37 s±0 min 20 s, (mean±SD), (P<0.01). Regarding transmission from the other fax devices, there were no differences in transmission times between the two receiving devices. The fastest way to transmit ECGs to the advanced mobile phone was to send it from conventional table fax (1 min 22 s±0 min 18 s) and the longest transmission times were with mobile fax connected to mobile phone (5 min 23 s±3 min 5 s). In all ECGs transmitted except one the cardiac rhythm and ST-changes could be recognised. Conclusion: An advanced mobile phone is as fast and reliable as a conventional table fax in receiving ECGs. A mobile phone with advanced features is a practical tool for HEMS physicians who need to evaluate ECGs in the prehospital setting. [Copyright &y& Elsevier]

Objective: Thrombolytic therapy in patients with massive pulmonary embolism (MPE) and prolonged cardiopulmonary resuscitation (CPR) is subject to debate. This study was performed to determine whether (1) thrombolytic treatment increases the risk of bleeding complications, (2) if the risk of bleeding is influenced by the duration of CPR and if (3) thrombolytic therapy improves outcome. Design: Retrospective cohort study. Setting: Emergency department of a tertiary care university hospital. Patients and methods: Sixty-six patients with cardiac arrest (CA) due to MPE admitted between July 1993 and December 2001. Thirty-six patients received thrombolysis (TL) and were compared with 30 patients without thrombolytic therapy. Bleeding complications were assessed by clinical evidence or autopsy. Results: Major bleeding complications appear to occur more frequently in patients treated with thrombolytics (9/36 (25%) vs. 3/30 (10%)) even though the difference was statistically not significant (P=0.15). It appears that CPR duration >10 min has no adverse impact on major bleeding complications. No difference in the rate of major bleeding complications between thrombolyzed patients who had a CPR duration of ≤10 or >10 min could be observed (2/8 (25%) vs. 7/28 (25%), P=0.99). In thrombolyzed patients a return of spontaneous circulation could be achieved more frequently (24/36 (67%) vs.13/30 (43%) in controls, P=0.06) and survival after 24 h was higher (19/36 (53%) vs. 7/30 (23%), P=0.01). Survival to discharge was also higher in the TL group (7/36 (19%) vs. 2/30 (7%)), but not statistically significant (P=0.15). Conclusion: Although severe bleeding complications tend to occur more frequently in patients undergoing TL, the benefit of this treatment might outweigh the risk of bleeding. [Copyright &y& Elsevier]