Aim: Prior studies suggest that the use of personal protective equipment might impair the quality of critical care. We investigated the influence of personal protective equipment on out-of-hospital cardiopulmonary resuscitation. Methods: Randomised controlled non-inferiority triple-crossover study. Forty-eight emergency medical service providers, randomized into teams of two, performed 12 min of basic life support (BLS) on a manikin after climbing 3 flights of stairs. Three scenarios were completed in a randomised order: Without personal protective equipment, with personal protective equipment including a filtering face piece (FFP) 2 mask with valve, and with personal protective equipment including an FFP2 mask without valve. The primary outcome was mean depth of chest compressions with a pre-defined non-inferiority margin of 3.5 mm. Secondary outcomes included other measurements of CPR quality, providers' subjective exhaustion levels, and providers' vital signs, including end-tidal CO 2. Results: Differences regarding the primary outcome were well below the pre-defined non-inferiority margins for both control vs. personal protective equipment without valve (absolute difference 1 mm, 95% CI [À1, 2]) and control vs. personal protective equipment with valve (absolute difference 1 mm, [À0.2, 2]). This was also true for secondary outcomes regarding quality of chest compressions and providers' vital signs including etCO 2. Subjective physical strain after BLS was higher in the personal protective equipment groups (Borg 4 (SD 3) without valve, 4 (SD 2) with valve) than in the control group (Borg 3 (SD 2)). Conclusion: PPE including masks with and without expiration valve is safe for use without concerns regarding the impairment of CPR quality.

Background The COVID-19 pandemic led to widespread use of personal protection equipment (PPE), including filtering face piece (FFP) masks, throughout the world. PPE. Previous studies indicate that PPE impairs neurocognitive performance in healthcare workers. Concerns for personnel safety have led to special recommendations regarding basic life support (BLS) in patients with a potential SARS-CoV-2 infection, including the use of PPE. Established instruments are available to assess attention and dexterity in BLS settings, respectively. We aimed to evaluate the influence of PPE with different types of FFP masks on these two neuropsychological components of EMS personnel during BLS. Methods This was a randomized controlled non-inferiority triple-crossover study. Teams of paramedics completed three 12-min long BLS scenarios on a manikin after having climbed three flights of stairs with equipment, each in three experimental conditions: (a) without pandemic PPE, (b) with PPE including a FFP2 mask with an expiration valve and (c) with PPE including an FFP2 mask without an expiration valve. The teams and intervention sequences were randomized. We measured the shift in concentration performance using the d2 test and dexterity using the nine-hole peg test (NHPT). We compared results between the three conditions. For the primary outcome, the non-inferiority margin was set at 20 points. Results Forty-eight paramedics participated. Concentration performance was significantly better after each scenario, with no differences noted between groups: d2 shift control versus with valve − 8.3 (95% CI − 19.4 to 2.7) points; control versus without valve − 8.5 (− 19.7 to 2.7) points; with valve versus without valve 0.1 (− 11.1 to 11.3) points. Similar results were found for the NHPT: + 0.3 (− 0.7 to 1.4), − 0.4 (− 1.4 to 0.7), 0.7 (− 0.4 to 1.8) s respectively. Conclusion Attention increases when performing BLS. Attention and dexterity are not inferior when wearing PPE, including FFP2 masks. PPE should be used on a low-threshold basis.

Objective Risk assessment plays a decisive role in the management of acute coronary syndrome (ACS). The GRACE and the CRUSADE scores are among the most frequently used risk assessment tools.
We aimed to compare the performance of the GRACE and CRUSADE risk scores to predict in‐hospital mortality and major bleeding in a contemporary ACS population at a high‐volume academic hospital. Methods All patients treated for ACS from January 1, 2006 to December 31, 2015 at a tertiary care centre were prospectively enrolled. We calculated GRACE and CRUSADE risk scores. We compared the discrimination capacity of both scores for in‐hospital mortality and major bleeding. Results In total 4087 patients (1151 [28.2%] female; age 62 ± 14 years) were included. Among these 2218 (54.3%) were diagnosed with ST‐elevation myocardial infarction, 113 (2.8%) died in hospital and major bleeding occurred in 65 (1.6%). Discrimination capacity for in‐hospital mortality of the GRACE score was superior to the CRUSADE score (receiver operator characteristic area under the curve (AUC) 0.91 (95% CI 0.89‐0.93) vs 0.83 (95% CI 0.80‐0.86); P < .01). Performance for major bleeding differed but was poor for both scores (AUC 0.71 [0.65‐0.76] for GRACE vs 0.61 [0.55‐0.68] for CRUSADE; P < .01). Conclusion The GRACE score appears to be superior over CRUSADE to predict in‐hospital mortality. Major bleeding is rare in the era of primary PCI and performance of both scores for this outcome was poor.

Background: High quality cardiopulmonary resuscitation is a key factor in survival with good overall quality of life after out-of-hospital cardiac arrest. Current evidence is predominantly based on studies conducted at low altitude, and do not take into account the special circumstances of alpine rescue missions. We therefore aimed to investigate the influence of physical strain at high altitude on the quality of cardiopulmonary resuscitation. Methods: Alpine field study. Twenty experienced mountaineers of the Austrian Mountain Rescue Service trained in Basic Life Support (BLS) performed BLS on a manikin in groups of two for 16 min. The scenario was executed at baseline altitude and immediately after a quick ascent over an altitude difference of 1200 m at 3454 m above sea level. The sequence of scenarios was randomised for a cross over analysis. Quality of CPR and exhaustion of participants (vital signs, Borg-Scale, Nine hole peg test) were measured and compared between high altitude and baseline using random-effects linear regression models. Results: The primary outcome of chest compression depth significantly decreased at high altitude compared to baseline by 1 cm (95% CI 0.5 to 1.3 cm, p < 0.01). There was a significant reduction in the proportion of chest compressions in the target depth (at least 5 cm pressure depth) by 55% (95% CI 29 to 82%, p < 0.01) and in the duration of the release phase by 75 ms (95% CI 48 to 101 ms, p < 0.01). No significant difference was found regarding hands-off times, compression frequency or exhaustion. Conclusion: Physical strain during a realistic alpine rescue mission scenario at high altitude led to a significant reduction in quality of resuscitation. Resuscitation guidelines developed at sea level are not directly applicable in the mountain terrain.

Background: Acute coronary syndrome is a disease with high prevalence and high mortality. Exposure to heat or cold increases the risks of myocardial infarction significantly. Gender-specific effects of this have not yet been examined. Our goal was to determine whether extreme weather conditions, which become more and more frequent, are gender-specific risk factors for myocardial infarction, in order to help provide faster diagnosis and revascularization therapy for patients. Methods: We analysed the incidence of ST-elevation myocardial infarction (STEMI) in a large urban area over a 65-months period in a cohort study. A day was the unit of analysis. Incidence rate ratios (IRR) with Poisson regression models were calculated. All patients with STEMI on Saturdays and Sundays were included. Gender, high or low perceived temperatures (PT), a function of temperature, wind speed and humidity, and meteorological cold and heat warnings by the Austrian Central Institute for Meteorology and Geodynamics (ZAMG) were considered as risk factors. Results: During the 562 days of the study period, a total of 1109 patients with STEMI (803; 72% men, mean age 61;14 years) were included. The gender difference between men and women was much more pronounced on cold (0°C) days (85% of patients male; 1.8 per day) than on hot (20°C) days (71% male; 1.4 per day) or days without extreme temperatures (72% male; 1.4 per day). We found significant interaction between gender and cold days (IRR of the interaction term 2.3 (95% CI 1.2-4.6), p = 0.02). No gender-specific effect was observed on warm days (IRR for interaction 0.9 (95% CI 0.6-1.3), p = 0.3). Conclusion: Low perceived temperature pronouncedly increases the already elevated risk for STEMI in males. Whether this effect is based on gender alone, or on one of the cardiovascular risk factors which are more common in men, is up to further study.