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Patients discovered recumbent, helpless and incapacitated, awake or unresponsive are referred to as "long lie trauma" (LLT) in the German medical jargon. Yet, a characterization of this cohort is missing.We retrospectively analyzed all LLT patients admitted to the emergency department of the University Hospital Cologne from July 2018 to December 2020.A total of 50 LLT patients (median age 76 years, median time on the ground 13.5 h) were identified. The FD was most often attributed to primary cerebral causes in 40% of the cases (20% ischemic stroke, 16% intracranial hemorrhage, 4% epilepsy), intoxication/overdose (12%), and trauma (10%). It was often associated with infection (52%), injury (22%), hypovolemia (66%), acute kidney injury (20%), and severe rhabdomyolysis (creatine kinase ≥ 5000 U/l, 21%) as well as severe hypothermia 32 °C (20%). Overall, 69% of the patients were admitted to an intensive care unit and in-hospital mortality was 50%.The term "long lie trauma" describes a complex clinical situation, in which various conditions lead to an incapacitated state with acute onset, which then causes further adverse health effects. Trauma or tissue damage were no obligatory requirement in this syndrome. Considering the high morbidity and in-hospital mortality, patients should initially be treated in the emergency room by an interdisciplinary team.HINTERGRUND: Bisher fehlen Versorgungsdaten für Patienten mit Liegetrauma (LT).Deskriptive retrospektive Analyse aller rettungsdienstlich mit einem LT der Notaufnahme des Universitätsklinikums Köln von 07.2018 bis 12.2020 zugeführten Patienten.Insgesamt konnten 50 Patienten mit LT (Altersmedian 76 Jahre, Liegedauer im Median 13,5 h) im Untersuchungszeitraum identifiziert werden. Die zugrunde liegende Ursache für das LT war in 40 % primär neurologisch (ischämischer Schlaganfall: 20 %, intrakranielle Blutung: 16 %, Epilepsie: 4 %), in 12 % eine Intoxikation und in 10 % ein häusliches Trauma. Häufige assoziierte Diagnosen waren Infektionen (52 %), Traumafolgen (22 %), Exsikkose (66 %), akute Nierenfunktionsstörung (20 %), schwere Rhabdomyolyse (Kreatininkinase ≥ 5000 U/l, 21 %) und schwere Hypothermie 32 °C (20 %). Insgesamt wurden 69 % der Patienten auf einer Intensivstation aufgenommen und die Krankenhausletalität betrug 50 %.Das LT beschreibt einen Patientenzustand, bei dem infolge vielfältiger Ursachen plötzlich die eigenständige Mobilisierung und ein selbstständiges Hilfeholen verhindert werden und dadurch weitere Gesundheitsschäden entstehen. Bei diesem Syndrom sind Gewebsschäden als Folge des Liegens keine notwendige Voraussetzung für das Vorliegen eines LT. Aufgrund der hohen Morbidität und Letalität sollten diese Patienten in einem nichttraumatologischen Schockraum aufgenommen werden.

Der auserklinische Herz-Kreislauf-Stillstand (OHCA) betrifft jedes Jahr ca. 75.000 Menschen in Deutschland und ist mit einer eingeschrankten Prognose und hoher Mortalitat verbunden. Die extrakorporale kardiopulmonale Reanimation (eCPR) unter Verwendung venoarterieller ECMO-Systeme (va-ECMO) stellt eine zusatzliche und zunehmend verbreitete und im Leitlinienalgorithmus seit 2020 verankerte Moglichkeit der Therapie dar. Es erfolgte eine selektive Literaturrecherche in PubMed und Embase, fokussiert auf Studien, die die eCPR bei OHCA untersuchen. Auserdem werden aktuell in Rekrutierung und Durchfuhrung befindliche klinische Studien zu diesem Thema zusammengefasst. Die bisherige Datenlage zum Nutzen von eCPR bei OHCA basiert hauptsachlich auf retrospektiven Kohortenstudien. Ein Uberlebensvorteil bzw. Vorteil im neurologischen Outcome fur selektierte eCPR-therapierte Patienten vs. „konventionell“ reanimierten Patienten (CPR) konnte aus diesen Daten abgeleitet werden. Zwei aktuelle randomisierte und kontrollierte Studien konnten diesen Effekt bestatigen. Aktuelle in der Durchfuhrung befindliche Studien untersuchen, inwiefern eine fruhestmogliche extrahospitale ECMO-Kanulierung noch am Auffindeort des Patienten mit einem besseren Uberleben einhergehen konnte. Trotz einer bisher sparlichen Datenlage muss fur selektierte OHCA-Patienten von einem Uberlebensvorteil bei eCPR-Therapie ausgegangen werden. Sollten weitere qualitativ hochwertige Studien dies untermauern, erscheint es indiziert zu evaluieren, inwiefern und in welchem Umfang ressourcenintensive eCPR-Programme flachendeckend etabliert werden konnen.

Objectives Simultaneous mechanical circulatory support (MCS) with intra-aortic balloon pump (IABP) to extracorporeal membrane oxygenation (ECMO) is common in postcardiotomy cardiogenic shock (PCS). This study aimed to analyse the effect of concomitant ECMO and IABP therapy on the short-term outcomes of patients with PCS. Methods Between March 2006 and March 2017, 172 consecutive patients with central (c) or peripheral (p) veno-arterial ECMO therapy due to PCS were identified at the current institution and included in this retrospective analysis. Patients were divided into ECMO+IABP and ECMO alone groups. Further, the impact of ECMO flow direction was analysed for the groups. Results A total of 129 patients received ECMO+IABP support and 43 patients were treated with ECMO alone. Median ECMO duration did not differ between the groups (68 [34; 95] hours ECMO+IABP vs 44 [20; 103] hours ECMO; p=0.151). However, a trend toward a higher weaning rate was evident in ECMO+IABP patients (75 [58%] ECMO+IABP vs 18 [42%] ECMO; p=0.078). Concomitant IABP support with either cECMO (73% [n=24] cECMO+IABP vs 50% [n=11] ECMO; p=0.098) or pECMO (57% [n=55] ECMO+IABP vs 33% [n=7] ECMO; p=0.056) was also associated with a trend toward a higher weaning rate off ECMO. In-hospital mortality did not differ between the groups. Conclusion This analysis found that, independent of ECMO type, additional IABP support might increase ECMO weaning; however, it did not influence survival in PCS patients. Larger studies are necessary to further analyse the impact of this concomitant MSC therapy on clinical outcomes.

Objectives To test if the early kinetics of neurofilament light (NFL) in blood adds to the absolute values of NFL in the prediction of outcome, and to evaluate if NFL can discriminate individuals with severe hypoxic–ischemic brain injury (sHIBI) from those with other causes of poor outcome after out-of-hospital cardiac arrest (OHCA). Design and setting Monocentric retrospective study involving individuals following non-traumatic OHCA between April 2014 and April 2016. NFL concentrations were determined on a SiMoA HD-1 device using NF-Light Advantage Kits. Participants Of 73 patients screened, 53 had serum samples available for NFL measurement at three timepoints (after 3, 24, and 48 h of admission). Of these 53 individuals, 43.4% had poor neurologic outcome at discharge as assessed by Glasgow–Pittsburgh cerebral performance categories, and, according to a current prognostication algorithm, poor outcome due to sHIBI in 20.7%. Main outcome measure Blood NFL and its early kinetics for prognostication of outcome and prediction of sHIBI after OHCA. Results An absolute NFL > 508.6 pg/ml 48 h after admission, or a change in NFL > 494 pg/ml compared with an early baseline value predicted outcome, and discriminated severe sHIBI from other causes of unfavorable outcome after OHCA with high sensitivity (100%, 95%CI 70.0–100%) and specificity (91.7%, 95%CI 62.5–100%). Conclusions Not only absolute values of NFL, but also early changes in NFL predict the outcome following OHCA, and may differentiate sHIBI from other causes of poor outcome after OHCA with high sensitivity and specificity. Our study adds to published data, overall corroborating that NFL measured in blood should be implemented in prognostication algorithms used in clinical routine.

Objectives: Out-of-hospital cardiac arrest (OHCA) is associated with excessively high mortality rates. Recent studies suggest benefits from extracorporeal cardiopulmonary resuscitation (ECPR) performed in selected patients. We sought to present the first results from our interdisciplinary ECPR program with a particular focus on early outcomes and potential risk factors associated with in-hospital mortality. Methods: Between January 2016 and December 2019, 44 patients who underwent ECPR selected according to our institutional ECPR protocol were retrospectively analyzed regarding pre-hospital, in-hospital, and early outcome parameters. Patients were divided into survivors (S) and non-survivors (NS). Statistical analysis of risk factors regarding in-hospital mortality of the patient cohort analyzed was performed. Results: The mean age of the population was 53 ± 12 years, with most patients being male ( n = 40). The leading cause of cardiac arrest (CA) was myocardial infarction ( n = 24, 55%). The median hospital stay was 1 (1;13) day. Twenty-three percent of patients ( n = 10) were discharged from hospital including eight patients (18%) with CPC 1–2. Survivors showed a trend toward shorter pre-hospital CPR duration (60 (59;60) min (S) vs 60 (55;90) min (NS), p = 0.07). Conclusion: Establishing ECPR programs in large population areas offers the option to improve survival rates for OHCA patients. Stringent compliance of institutional criteria (mainly age, witnessed arrest, and time of pre-hospital resuscitation) and providing ECPR to strictly selected patients seems to be a vital factor for such programs’ success. Pre-clinical settings and therapeutic measures must be adjusted in this regard to improve outcomes for this highly demanding patient cohort.

In the situation of a shortage of ventilation beds, ethically justifiable, transparent and comprehensible decisions must be made. This concept proposes that all patients are first intubated depending on necessity and then assessed by a triage team afterwards. In this situation newly admitted COVID patients compete with newly admitted Non-COVID patients as well as patients already treated in intensive care units for a ventilator. The combination of short-term and long-term prognoses should enable the interprofessional triage team to make comprehensible decisions. The aim of the prioritization concept is to save as many human lives as possible and to relieve the treatment team of the difficult decision on prioritization.In der Situation des Beatmungsbettenmangels sind ethisch begründbare, transparente und nachvollziehbare Entscheidungen zu treffen. Dieses Konzept sieht vor, dass zunächst alle Patienten nach Notwendigkeit intubiert und dann von einem Triage-Team beurteilt werden. Dabei stehen neu aufgenommene COVID-Patienten mit neu aufgenommenen Nicht-COVID-Patienten und bereits intensivmedizinisch behandelte Patienten in Konkurrenz um ein Beatmungsgerät. Die Kombination der kurz- und langfristigen Prognose soll dem interprofessionellen Triage-Team ermöglichen, nachvollziehbare Entscheidungen zu treffen. Ziel des Priorisierungskonzeptes ist es, möglichst viele Menschenleben zu retten und die Behandlungsteams von der schwierigen Entscheidung der Priorisierung zu entlasten.

Extracorporeal cardiopulmonary resuscitation (eCPR) is a rapidly growing treatment strategy due to significant improvement in selected patients' survival rates. Gender-related differences might impact the outcome of therapeutic measures. Therefore, we sought to investigate patients with eCPR at our interdisciplinary extracorporeal membrane oxygenation center regarding sex-related differences with the view to potentially adjusting current selection criteria. From January 2016 to December 2019, 71 patients underwent eCPR at our institution. Data before eCPR and early outcome parameters were analyzed comparing male and female patients. The cohort analyzed consisted of 60 male (84%) and 11 female (15%) patients. Comparing both groups, male patients significantly more frequently suffered out-of-hospital cardiac arrest (68% male vs. 36% female, P = .04), whereas female patients were associated with more in-hospital cardiac arrest (32% male vs. 64% female, P = .04). Creatinine levels differed significantly (1.5 (1.1;2.1) mg/dL in male vs. 1.0 (0.7;1.5) mg/dL in female patients, P = .03). Also, several hepatic parameters showed a significant difference between the groups: aspartate aminotransferase 423 (249;804) U/L in male vs. 115 (61;408) U/L in female patients, P = .01; alanine aminotransferase 174 (102;446) U/L in male vs. 86 (36;118) U/L in female patients, P = .01). Renal failure requiring hemodialysis occurred more frequently in men than in women (P

The aim of this study was to evaluate the incidence and determinants of malignant arrhythmias (MA) in patients with shock following out-of-hospital cardiac arrest (OHCA) treated with targeted temperature management. Risk factors for the development of MA were prospectively analyzed in patients after OHCA. MA were defined as ventricular tachycardia or fibrillation with a duration30 seconds, which had to be terminated by defibrillation. All patients were treated with therapeutic hypothermia for 24 hours. Demographics, OHCA details, interventions, and intensive care unit (ICU) treatment were recorded. A total of 55 patients were included, 11 (20%) of whom developed MA during the ICU stay. All MA occurred within the first 18 hours after admission. Patients who developed MA showed a stronger decrease in body temperature (Δ -2.4°C ± 0.8°C vs. Δ -1.3°C ± 1.3°C

In Germany, 70,000-100,000 persons per year suffer from out-of-hospital cardiac arrest (OHCA). Despite medical progress, survival rates with good neurological outcome remain low. For many important clinical issues, no or only insufficient evidence from randomised trials is available. Therefore, a systemic and standardised acquisition of the treatment course and of the outcome of OHCA patients is warranted.The German Cardiac Arrest Registry (G-CAR) is an observational, prospective, multicentre registry. It will determine the characteristics, initial treatment strategies, invasive procedures, revascularisation therapies and the use of mechanical circulatory support devices with a focus on extracorporeal cardiopulmonary resuscitation. A special feature is the prospective 12-month follow-up evaluating mortality, neurological outcomes and several patient-reported outcomes in the psychosocial domain (health-related quality of life, cognitive impairment, depression/anxiety, post-traumatic stress disorder and social reintegration). In a pilot phase of 24 months, 15 centres will include approximately 400 consecutive OHCA patients ≥ 18 years. Parallel to and after the pilot phase, scaling up of G-CAR to a national level is envisaged.G-CAR is the first national registry including a long-term follow-up for adult OHCA patients. Primary aim is a better understanding of the determinants of acute and long-term outcomes with the perspective of an optimised treatment.NCT05142124. German Cardiac Arrest Registry (G-CAR).

LAA occlusion has become a favourable option in patients with atrial fibrillation not eligible for oral anticoagulation therapy. Proof of effectiveness of LAA closure devices in a midterm follow-up period. This retrospective single-center cohort study analysed outcome in patients treated with AMPLATZER Cardiac Plug or AMPLATZER Amulet device. A standardized follow-up by phone call focusing on data of death, stroke and bleeding events was performed. Routine antiplatelet strategy was DAPT for 3 months post procedural. 212 patients (mean age 77 ± 6 years) were included. Follow up was performed in 197 (93%) patients. Patients were at high risk for thromboembolic or bleeding events (prior stroke/TIA 29%; prior bleeding 54%. Overall, there was a mean follow-up period of 1244.2 days (± 756.7) and a total of 674 patient years. We observed 25 events later than day 8 post procedure. We were able to demonstrate a high effectiveness of the AMPLATZER Cardiac Plug/AMPLATZER Amulet devices regarding the prevention of stroke and bleedings in a high-risk real-world cohort during a midterm follow-up period. Overall, we observed remarkably lower rates of stroke and bleedings as predicted with CHA2DS2–VASc and HASBLED scores.

Bei der Differenzialdiagnostik zur Kausalitat eines praklinischen Kreislaufstillstands („out-of-hospital cardiac arrest“ [OHCA]) muss zwingend auch eine Perikardtamponade als mogliche Ursache erwogen werden. Diese ist im Notarztdienst in der Regel traumatisch bedingt oder tritt als lebensbedrohliche Komplikation einer akuten thorakalen Aortendissektion auf. Die Detektion ist mithilfe miniaturisierter Ultraschallgerate im Zuge einer fokussierten Echokardiographie zumeist problemlos moglich. Wird die Tamponade als Ursache fur den OHCA evident, sollte konsequenterweise mit einem geeigneten Set eine Perikardpunktion durchgefuhrt werden. Hierfur bieten sich unterschiedliche sonographisch gestutzte Techniken an.

Objectives Central or peripheral venoarterial extracorporeal membrane oxygenation (va ECMO) is widely used in postcardiotomy cardiogenic shock (PCS). Available data suggest controversial results for both types. Our aim was to investigate PCS patients treated with either peripheral (pECMO) or central ECMO (cECMO) concerning their outcome. Methods Between April 2006 and October 2016, 156 consecutive patients with va ECMO therapy due to PCS were identified and included in this retrospective analysis. Patients were divided into cECMO and pECMO groups. Statistical analysis of risk factors concerning 30-day mortality of the mentioned patient cohort was performed using IBM SPSS Statistics. Results Fifty-six patients received cECMO and 100 patients were treated with pECMO due to PCS. In the group of cECMO peripheral vascular disease was significantly more present (cECMO 19 [34%] vs pECMO 14 [14%]; P < .01). On-site ECMO complications occurred significantly more frequent in patients treated with cECMO (cECMO 44 [79%] vs pECMO 54 [54%] g/dL; P < 0.01). More often cECMO patients required a second look operation due to mediastinal bleeding (cECMO 52 [93%] vs pECMO 61 [61%] g/dL; P < .01). Thirty-day mortality was comparable with nearly 70% in both cohorts (cECMO 39 [70%] vs pECMO 69 [69%]; P = .93). Conclusion Patients supported by cECMO or pECMO due to refractory PCS did not show significant differences in 30-day mortality, despite a lower incidence of on-site ECMO complications and re-exploration in pECMO patients. PCS itself is associated with high mortality and peripheral cannulation might help to save resources compared with central cannulation.

Aims This network meta-analysis aimed to assess the effect of early coronary angiography (CAG) compared with selective CAG (late and no CAG) for patients after out-of-hospital cardiac arrest without ST-elevation myocardial infarction (NSTE-OHCA). Methods and results A systematic literature search was performed using the EMBASE, MEDLINE and Web of Science databases without restrictions on publication date. The last search was performed on 15 July 2022. Randomized controlled trials (RCTs) and non-randomized studies (NRS) comparing the effect of early CAG to selective CAG after NSTE-OHCA on survival and/or neurological outcomes were included. Meta-analyses were performed based on a DerSimonian-Laird random effects model. A total of 18 studies were identified by the literature search. After the exclusion of two studies due to high risk of bias, 16 studies (six RCTs, ten NRS) were included in the final analyses. Meta-analyses showed a statistically significant increase in survival after early CAG compared with selective CAG in the overall analysis [OR: 1.40, 95% confidence interval (CI): (1.12–1.76), P < 0.01, I2 = 68%]. This effect was lost in the subgroup analysis of RCTs [OR: 0.89, 95% CI: (0.73–1.10), P = 0.29, I2 = 0%]. Random effects model network meta-analysis of NRS based on a Bayesian method showed statistically significant increased survival after late compared with early CAG [OR: 4.20, 95% CI: (1.22, 20.91)]. Conclusion The previously reported superiority of early CAG after NSTE-OHCA is based on NRS at high risk of selection and survivorship bias. The meta-analysis of RCTs does not support routinely performing early CAG after NSTE-OHCA.

The effect of respiratory infectious diseases on STEMI incidence, but also STEMI care is not well understood. The Influenza 2017/2018 epidemic and the COVID-19 pandemic were chosen as observational periods to investigate the effect of respiratory virus diseases on these outcomes in a metropolitan area with an established STEMI network. We analyzed data on incidence and care during the COVID-19 pandemic, Influenza 2017/2018 epidemic and corresponding seasonal control periods. Three comparisons were performed: (1) COVID-19 pandemic group versus pandemic control group, (2) COVID-19 pandemic group versus Influenza 2017/2018 epidemic group and (3) Influenza 2017/2018 epidemic group versus epidemic control group. We used Student’s t-test, Fisher’s exact test and Chi square test for statistical analysis. 1455 patients were eligible. The daily STEMI incidence was 1.49 during the COVID-19 pandemic, 1.40 for the pandemic season control period, 1.22 during the Influenza 2017/2018 epidemic and 1.28 during the epidemic season control group. Median symptom-to-contact time was 180 min during the COVID-19 pandemic. In the pandemic season control group it was 90 min (p = 0.183), and in the Influenza 2017/2018 cohort it was 90 min, too (p = 0.216). Interval in the epidemic control group was 79 min (p = 0.733). The COVID-19 group had a door-to-balloon time of 49 min, corresponding intervals were 39 min for the pandemic season group (p = 0.038), 37 min for the Influenza 2017/2018 group (p = 0.421), and 38 min for the epidemic season control group (p = 0.429). In-hospital mortality was 6.1% for the COVID-19 group, 5.9% for the Influenza 2017/2018 group (p = 1.0), 11% and 11.2% for the season control groups. The respiratory virus diseases neither resulted in an overall treatment delay, nor did they cause an increase in STEMI mortality or incidence. The registry analysis demonstrated a prolonged door-to-balloon time during the COVID-19 pandemic.

Out-of-hospital cardiac arrest (OHCA) affects ca. 75,000 people each year in Germany and is associated with a limited prognosis and a high mortality. Extracorporeal cardiopulmonary resuscitation (eCPR) using arteriovenous extracorporeal membrane oxygenation (av-ECMO) systems is an additional option for treatment, which is increasingly more widespread and since 2020 anchored in the guideline algorithm.A selective search of the literature was carried out in PubMed and Embase focusing on studies that investigated eCPR for OHCA. Furthermore, clinical studies on this topic that are currently recruiting and running are summarized.The available data on the benefits of eCPR for OHCA are mostly based on retrospective cohort studies. A survival advantage and an advantage in the neurological outcome could be derived from these data for selected patients treated with eCPR vs. conventionally resuscitated patients (CPR). This effect could be confirmed by two current randomized controlled studies. Studies which are currently running are investigating if out-of-hospital ECMO cannulation at the earliest time possible at the site of OHCA of patients could be associated with a better survival.Despite a current scarcity of data, a survival advantage for eCPR treatment in selected OHCA patients must be assumed. If this can be substantiated by other high-quality studies, it seems to be indicated to evaluate if and to what extent resource-intensive eCPR programs can be comprehensively established.HINTERGRUND: Der außerklinische Herz-Kreislauf-Stillstand (OHCA) betrifft jedes Jahr ca. 75.000 Menschen in Deutschland und ist mit einer eingeschränkten Prognose und hoher Mortalität verbunden. Die extrakorporale kardiopulmonale Reanimation (eCPR) unter Verwendung venoarterieller ECMO-Systeme (va-ECMO) stellt eine zusätzliche und zunehmend verbreitete und im Leitlinienalgorithmus seit 2020 verankerte Möglichkeit der Therapie dar.Es erfolgte eine selektive Literaturrecherche in PubMed und Embase, fokussiert auf Studien, die die eCPR bei OHCA untersuchen. Außerdem werden aktuell in Rekrutierung und Durchführung befindliche klinische Studien zu diesem Thema zusammengefasst.Die bisherige Datenlage zum Nutzen von eCPR bei OHCA basiert hauptsächlich auf retrospektiven Kohortenstudien. Ein Überlebensvorteil bzw. Vorteil im neurologischen Outcome für selektierte eCPR-therapierte Patienten vs. „konventionell“ reanimierten Patienten (CPR) konnte aus diesen Daten abgeleitet werden. Zwei aktuelle randomisierte und kontrollierte Studien konnten diesen Effekt bestätigen. Aktuelle in der Durchführung befindliche Studien untersuchen, inwiefern eine frühestmögliche extrahospitale ECMO-Kanülierung noch am Auffindeort des Patienten mit einem besseren Überleben einhergehen könnte.Trotz einer bisher spärlichen Datenlage muss für selektierte OHCA-Patienten von einem Überlebensvorteil bei eCPR-Therapie ausgegangen werden. Sollten weitere qualitativ hochwertige Studien dies untermauern, erscheint es indiziert zu evaluieren, inwiefern und in welchem Umfang ressourcenintensive eCPR-Programme flächendeckend etabliert werden können.

Objectives Right ventricular (RV) failure is associated with poor outcome and increased mortality in cardiac surgery. Aim of our study was to analyze the outcome of veno arterial extracorporeal membrane oxygenation (va ECMO) therapy in patients with isolated RV failure in postcardiotomy cardiogenic shock (PCS) and to evaluate risk factors associated with 30-day-mortality. Methods Between August 2006 until August 2016, 64 consecutive patients with va ECMO therapy due to fulminant RV failure in PCS were identified and included in this retrospective observation. Further, outcome data and a comparison of va ECMO survivors and nonsurvivors was conducted. Results The mean age of the patient cohort was 63 ± 14 years. Patients were treated with va ECMO for 79 ± 61 hours. Twenty-eight patients (44%) were successfully weaned off ECMO support. Overall 30-day-mortality was 88% (56/64). Hemoglobin concentration before ECMO implantation, maximum rise of muscle-brain type creatine kinase during ECMO therapy, as well as lactic acid concentration 24 hours after initiation of va ECMO therapy were predictive for 30-day mortality. Conclusion ECMO therapy in RV failure due to PCS is shown to be associated with an excessive mortality. Regarding our data, va ECMO might only be an appropriate short-term mechanical assist device separating patients form cardiopulmonary bypass with an acceptable weaning rate. Particularly, in case of failed hemodynamic recovery of the right heart on va ECMO, direct RV bypass systems might function as a bailout option. Additionally, cardiac enzymes and lactic acid might provide valuable information in meeting therapy-related decisions.

The determination of high-sensitivity troponin remains the gold standard in patients with acute chest pain and allows the early diagnosis and therapy of patients with acute myocardial infarction (AMI). Increased cardiac troponin levels are highly specific for myocardial damage. However, elevated troponin levels are not equivalent to AMI and therefore the clinical presentation and the electrocardiogram of each patient must be taken into account. Elevated troponin levels are found in numerous diseases but not every patient needs invasive coronary angiography.

The determination of the cardiac preload is still a challenge for intensive care physicians. In addition to clinical assessment, both non-invasive and invasive methods exist for evaluating fluid responsiveness. The following article demonstrates one possible approach for systematic assessment of fluid responsiveness using a practical algorithm for critical care patients.

BackgroundSince December 2019 the novel coronavirus (SARS-CoV-2) is the center of global attention due to its rapid transmission and toll on health care systems and global economy. Population-based serosurveys measuring antibodies for SARS-CoV-2 provide one method for estimating infection rates and monitoring the progression of the epidemic.MethodsIn June 2020 we succeeded in testing almost half of the population of an Austrian township (n=835 of 1359 inhabitants) with a reported higher incidence for COVID-19 infections. We determined the level of prevalence for SARS-CoV-2 in this population, factors affecting, and symptoms correlated with prior infection.ResultsWe found a high prevalence of 9% positive antibodies among the town population in comparison to 6% of the neighboring villages. Only 20% of SARS-CoV-2 cases self-declared being asymptomatic. In contrast, we identified six single major symptoms, including anosmia/ageusia, weight loss, anorexia, general debility, dyspnea, and fever, and especially their combination to be of high prognostic value for predicting SARS-CoV-2 infection in a patient. Our comparison of the gold standard lab-based ELISA test and the on-site antibody test demonstrated a lack of accuracy for the latter test form.ConclusionsThis population study demonstrated a high prevalence of antibodies to SARS-CoV-2 as a marker of both active and past infections in an Austrian township. Several symptoms revealed a diagnostic value especially in combination. Results from self-administered antibody tests should be considered with caution.

Objectives: Extracorporeal cardiopulmonary resuscitation (eCPR) is a rapidly growing treatment strategy due to increasing survival rates in selected patients. Additional left ventricular mechanical unloading, using a transfemoral micro-axial blood pump (Impella®), might improve patients’ outcomes. In this regard, we sought to investigate patients who suffered OHCA (out- of hospital cardiac arrest) or IHCA (in-hospital cardiac arrest) with subsequent eCPR (extracorporeal cardiopulmonary resuscitation) via VA-ECMO (veno-arterial extracorporeal membrane oxygenation) and concomitant Impella® implantation. Methods: From January 2016 until December 2019, 71 patients underwent eCPR at our institution. Data prior eCPR and early outcome parameters were analyzed comparing patients who were supported with an additional transfemoral micro-axial blood pump (ECMO+Impella®, n= 7) and patients without additional (ECMO, n=64) support during VA-ECMO therapy. Results: Baseline data did not significantly differ between groups. All-cause mortality was significantly lower in the ECMO+Impella® group (83% vs. 29%, p= 0.01). The time of circulatory support was shorter in the ECMO+Impella® cohort (3.16±2.09 vs. 6.5±2.79, p=0.01). Additionally, ECMO weaning was significantly more feasible in patients with ECMO+Impella® (71% vs. 29%, p =0.02). Patients treated with additional Impella® showed more acute kidney injury (AKI) with the need for dialysis (71% vs. 21%, p=0.09). Conclusion: From our data, concomitant Impella® support might increase survival and successful ECMO weaning in eCPR patients. Treatment associated complications such as AKI were more common in this highly selected patient group. Further studies with larger numbers are necessary to evaluate concomitant LV-unloading’s clinical relevance in eCPR patients, using an Impella® device.

BackgroundWith the “Artemis”-mission mankind will return to the Moon by 2024. Prolonged periods in space will not only present physical and psychological challenges to the astronauts, but also pose risks concerning the medical treatment capabilities of the crew. So far, no guideline exists for the treatment of severe medical emergencies in microgravity. We, as a international group of researchers related to the field of aerospace medicine and critical care, took on the challenge and developed a an evidence-based guideline for the arguably most severe medical emergency – cardiac arrest.MethodsAfter the creation of said international group, PICO questions regarding the topic cardiopulmonary resuscitation in microgravity were developed to guide the systematic literature research. Afterwards a precise search strategy was compiled which was then applied to “MEDLINE”. Four thousand one hundred sixty-five findings were retrieved and consecutively screened by at least 2 reviewers. This led to 88 original publications that were acquired in full-text version and then critically appraised using the GRADE methodology. Those studies formed to basis for the guideline recommendations that were designed by at least 2 experts on the given field. Afterwards those recommendations were subject to a consensus finding process according to the DELPHI-methodology.ResultsWe recommend a differentiated approach to CPR in microgravity with a division into basic life support (BLS) and advanced life support (ALS) similar to the Earth-based guidelines. In immediate BLS, the chest compression method of choice is the Evetts-Russomano method (ER), whereas in an ALS scenario, with the patient being restrained on the Crew Medical Restraint System, the handstand method (HS) should be applied. Airway management should only be performed if at least two rescuers are present and the patient has been restrained. A supraglottic airway device should be used for airway management where crew members untrained in tracheal intubation (TI) are involved.DiscussionCPR in microgravity is feasible and should be applied according to the Earth-based guidelines of the AHA/ERC in relation to fundamental statements, like urgent recognition and action, focus on high-quality chest compressions, compression depth and compression-ventilation ratio. However, the special circumstances presented by microgravity and spaceflight must be considered concerning central points such as rescuer position and methods for the performance of chest compressions, airway management and defibrillation.

Purpose of review Pulmonary hypertension is a common phenomenon in heart failure patients that is highly relevant for morbidity and outcome. Although postcapillary in nature, the pathophysiology of pulmonary hypertension in patients with heart failure with reduced or preserved ejection fraction is complex, and decisions about management strategies remain challenging. Recent findings Recently, the hemodynamic definitions and subclassification of postcapillary pulmonary hypertension have been revisited. The distinction between isolated postcapillary pulmonary hypertension (IpcPH) and combined post and precapillary pulmonary hypertension (CpcPH) and their definition are essential. Novel data on the prognostic impact of hemodynamic variables and right ventricular function highlight the importance of cardiopulmonary interaction in patients with left-sided heart failure (LHF). Furthermore, the impact of management strategies including medical therapy, remote hemodynamic monitoring, and interventional approaches on hemodynamics and outcome has recently been investigated. Here, we critically review recent developments and future considerations in this field, and highlight distinct treatment strategies targeting the underlying left heart condition, the pulmonary circulation, and/or impaired right ventricular function. Summary Detailed hemodynamic characterization and proper phenotyping are essential for prognostication and the management of patients with pulmonary hypertension associated with LHF, both in clinical practice and when addressing research questions.

Background Medical emergencies frequently occur in commercial airline flights, but valid data on causes and consequences are rare. Therefore, optimal extent of onboard emergency medical equipment remains largely unknown. Whereas a minimum standard is defined in regulations, additional material is not standardized and may vary significantly between airlines. Methods European airlines operating aircrafts with at least 30 seats were selected and interviewed with a 5-page written questionnaire including 81 items. Besides pre-packed and required emergency medical material, drugs, medical devices, and equipment lists were queried. If no reply was received, airlines were contacted up to three times by email and/or phone. Descriptive analysis was used for data interpretation. Results From a total of 305 European airlines, 253 were excluded from analysis (e.g., no passenger transport). 52 airlines were contacted and data of 22 airlines were available for analysis (one airline was excluded due to insufficient data). A first aid kit is available on all airlines. 82% of airlines (18/22) reported to have a “doctor's kit” (DK) or an “Emergency Medical Kit” (EMK) onboard. 86% of airlines (19/22) provide identical equipment in all aircraft of the fleet, and 65% (14/22) airlines provide an automated external defibrillator. Conclusions Whereas minimal required material according to European aviation regulations is provided by all airlines for medical emergencies, there are significant differences in availability of the additional material. The equipment of most airlines is not sufficient for treatment of specific emergencies according to published in-flight medical guidelines (e.g., for CPR or acute myocardial infarction).

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in clinical practice and is known to be associated with significant morbidity and mortality. Previous studies suggested a link between inflammation and AF by findings of increased inflammatory markers in AF patients. However, it has not been finally clarified whether inflammation is a systemic or a local phenomenon reflecting an active inflammatory process in the heart. To address this subject, human left atrial appendage tissues were obtained from 10 patients who underwent cardiac surgery and subjected to immunohistochemical analysis. The number of inflammatory CD3-positive T cells significantly increased from patients with sinus rhythm to paroxysmal AF and persistent AF, respectively. Interestingly, in patients with persistent AF, these cells were frequently arranged in small clusters. Subsequently, the number of inflammatory CD3-positive T cells decreased and was significantly lower in patients with permanent AF than in patients with persistent AF. Inflammatory CD20-positive B cells could only be detected very occasionally in all AF subgroups and were not locatable in patients with SR. Hence, our data emphasize the potential prominent role of the cellular component of the immune system in the development and perpetuation of AF.

Despite all efforts, mortality of out of hospital cardiac arrest (OHCA) remains high. Patients with OHCA due to a primary shockable rhythm typically have a better prognosis. However, outcome worsens if return of spontaneous circulation (ROSC) cannot be achieved quickly. There is insufficient evidence for maximum duration of resuscitation in these patients and it is unclear, which patients profit from transport under ongoing CPR. Investigate predictors for favourable neurologic outcome in OHCA patients with presumed cardiac cause due to refractory shockable rhythm (rSR). Retrospective analysis of OHCA patients that presented to a tertiary hospital due to a rSR. One hundred seventy-five OHCA patients with presumed cardiac cause due to rSR were included. Overall hospital mortality was 50% and 83% of initial survivors were discharged with a good neurologic outcome [cerebral performance category (CPC) 1–2]. In patients with a time from cardiac arrest to ROSC of > 45 min, 18% survived to CPC 1–2. Independent predictors for good neurologic outcome were age, lower no-flow time and lower serum lactate levels at hospital arrival. In an urban setting, a significant proportion of OHCA patients with rSR can survive to a good neurologic outcome, despite very long time to ROSC.

Zusammenfassung Hintergrund Im Jahr 2017 wurden weltweit etwa 4 Milliarden Menschen mit einem Flugzeug transportiert. Die International Air Transport Association (IATA) prognostiziert für Europa bis zum Jahr 2034 eine durchschnittliche jährliche Steigerung der Passagierzahlen von 2,7%. In der zivilen Luftfahrt treten Notfälle an Bord (sogenannte In-Flight Medical Emergencies, IFME) mit einer Häufigkeit von 1 pro 14 000 bis 1 pro 50 000 transportierte Passagiere auf. Belastbare Daten über die exakte Häufigkeit und Art von medizinischen Notfällen an Bord von Flugzeugen existieren nicht. Ein Herz-Kreislauf-Stillstand tritt statistisch gesehen nur in 0,3% der Notfälle an Bord auf. Dieses Ereignis ist jedoch mit einer Mortalität von 86% assoziiert und stellt daher Passagiere und Crew zugleich vor eine große Herausforderung. Mit der Leitlinie zum In-Flight Cardiac Arrest (IFCA) wurden 28 spezifische Empfehlungen erarbeitet. Ziel der Leitlinie war es, spezifische Handlungsempfehlungen für mitfliegende Ärzte, Kabinenpersonal (Cabin Crew) und auch Fluglinien zur Behandlung des Herz-Kreislauf-Stillstands an Bord von Luftfahrzeugen zu generieren.

Die Detektion und die konsequente Behandlung potenziell reversibler Ursachen eines Herz-Kreislauf-Stillstandes sind integrale Bestandteile der aktuellen Reanimationsleitlinien. Wir berichten von einem 68-jahrigen Patienten mit plotzlich einsetzenden thorakalen Schmerzen und Dyspnoe. In Anwesenheit des Rettungsteams kam es zu einem Herz-Kreislauf-Stillstand. Durch den praklinischen Einsatz der fokussierten Ultraschalldiagnostik konnte dessen reversible Ursache unmittelbar erkannt und therapiert werden. Nachfolgend wird die Anwendung der Ultraschalldiagnostik im praklinischen Bereich diskutiert.

Die Sterblichkeit bei Patienten mit prahospitalem Herz-Kreislauf-Stillstand („out-of-hospital cardiac arrest“, OHCA) bleibt trotz der Fortschritte bei den Wiederbelebungsmasnahmen sehr hoch. Die Mehrzahl der betroffenen Patienten erreicht nicht das Krankenhaus, sondern verstirbt noch an der Einsatzstelle. Welcher Patient von einem Transport unter laufender kardiopulmonaler Reanimation (CPR) in die Klinik profitiert, ist gegenwartig unklar. Detektion von Einflussfaktoren auf Morbiditat und Mortalitat bei Patienten mit laufender CPR unter Transport nach OHCA. Retrospektive Analyse von 70 konsekutiven Patienten (mittleres Alter: 54,7 ± 15 Jahre) mit therapierefraktarem OHCA, die unter laufender CPR in die Klinik transportiert worden sind. Das neurologische Outcome der Patienten wurde 30 Tage nach OHCA, basierend auf der Glasgow-Pittsburgh Cerebral Performance Category (CPC), erhoben. Dreisig Tage nach Indexereignis waren 82,9 % der analysierten Patienten verstorben. Von den 12 Uberlebenden (17,1 %) wiesen 8 Patienten (11,4 % vom Gesamtkollektiv) ein gutes neurologisches Outcome (CPC 1–2) und 4 Patienten (5,7 % vom Gesamtkollektiv) ein schlechtes neurologisches Outcome (CPC 3–4) auf. Einflussfaktoren fur ein gunstiges neurologisches Outcome waren ein beobachteter Herz-Kreislauf-Stillstand, das Vorliegen eines defibrillierbaren Rhythmus und der Serumlaktatspiegel bei Aufnahme im Krankenhaus. Bei allen Patienten mit guter neurologischer Erholung war das Indexereignis auf eine kardiale Genese zuruckzufuhren. Ein selektiertes Patientenkollektiv kann von einem Transport unter laufender CPR in die Klinik profitieren.