Background Haemoadsorption has been described as an effective way to control increased pro- and anti-inflammatory mediators (“cytokine storm”) in septic shock patients. No prospective or randomised clinical study has yet confirmed these results. However, no study has yet prospectively specifically investigated patients in severe septic shock with sepsis-associated acute kidney injury (SA-AKI). Therefore, we aimed to examine whether haemoadsorption could influence intensive care unit (ICU) and hospital mortality in these patients. Furthermore, we examined the influence of haemoadsorption on length of stay in the ICU and therapeutic support. Methods Retrospective control group and prospective intervention group design in a tertiary hospital in central Europe (Germany). Intervention was the implementation of haemoadsorption for patients in septic shock with SA-AKI. 76 patients were included in this analysis. Results Severity of illness as depicted by APACHE II was higher in patients treated with haemoadsorption. Risk-adjusted ICU mortality rates (O/E ratios) did not differ significantly between the groups (0.80 vs. 0.83). We observed in patients treated with haemoadsorption a shorter LOS and shorter therapeutic support such as catecholamine dependency and duration of RRT. However, in multivariate analysis (logistic regression for mortality, competing risk for LOS), we found no significant differences between the two groups. Conclusions The implementation of haemoadsorption for patients in septic shock with acute renal failure did not lead to a reduction in ICU or hospital mortality rates. Despite univariate analysis delivering some evidence for a shorter duration of ICU-related treatments in the haemoadsorption group, these results did not remain significant in multivariate analysis. Trial registration CytoSorb® registry https://clinicaltrials.gov/ct2/show/NCT02312024. December 9, 2014. Database: https://www.cytosorb-registry.org/ (registration for content acquisition is necessary)

Zusammenfassung Hintergrund Die stetig wachsende Zahl der Notarztanforderungen und der geringe Anteil indizierter Einsätze führen zum Attraktivitätsverlust des Notarztdienstes, was sich vielerorts bereits durch nichtbesetzbare Notarztdienste bemerkbar macht. Vorliegende retrospektive Analyse evaluiert die Häufigkeit notärztlicher und medizinischer Maßnahmen in einem bodengebundenen Notarztsystem. Methode Retrospektive Analyse anonymisierter Daten aus der Datenbank des Notarztstützpunkts LKH Univ.-Klinikum Graz. Die von Notärztinnen und Notärzten zwischen 2010 und 2018 absolvierten Einsätze wurden extrahiert, durchgeführte Maßnahmen evaluiert und je nach Schwierigkeitsgrad in 3 Kategorien aufgeschlüsselt: spezifische notärztliche Maßnahmen (Kategorie I), allgemein-medizinische Maßnahmen (Kategorie II), keine ärztliche Tätigkeit (Kategorie III). Die Häufigkeiten des Auftretens dieser Kategorien zwischen den Jahren wurden verglichen und Inzidenzen einzelner Maßnahmen pro 100.000 Einwohner errechnet. Ergebnisse Im Beobachtungszeitraum wurden 15.409 Primäreinsätze und 322 Sekundärtransporte extrahiert und analysiert. Die jährliche Einsatzrate stieg beinahe kontinuierlich von 1442 Einsätzen 2010 auf 2301 Einsätze 2018. Bei 3687 (23,4 %) Stornierungen kam es zu 12.044 Patientenkontakten. Insgesamt wurden 2842 (18 %) Einsätze der Kategorie I, 7371 (47 %) Einsätze der Kategorie II sowie 5518 (35 %) Einsätze der Kategorie III verzeichnet. Die Häufigkeit für notärztliche Maßnahmen kann daher auf 157/100.000 Einwohner, die medizinischer Maßnahmen auf 409/100.000 Einwohner geschätzt werden. Schlussfolgerung In einem Großteil aller Alarmierungen ist keine spezifisch notärztliche Maßnahme erforderlich. Somit erscheint das aktuelle Modell der präklinischen Versorgung nicht patientenorientiert und effizient. Der niedrige Anteil kritisch kranker bzw. schwer verletzter Patientinnen und Patienten führt bereits merkbar zum Attraktivitätsverlust bei den Notärzten und auch zu einer drohenden Qualitätsproblematik durch zu geringe Einsatzerfahrung und fehlendem Training.

This study seeks to identify factors that are associated with decisions of prehospital physicians to start (continue, if ongoing) or withhold (terminate, if ongoing) CPR in patients with OHCA. We conducted a retrospective study using anonymised data from a prehospital physician response system. Data on patients attended for cardiac arrest between January 1st, 2010 and December 31st, 2018 except babies at birth were included. Logistic regression analysis with start of CPR by physicians as the dependent variable and possible associated factors as independent variables adjusted for anonymised physician identifiers was conducted. 1525 patient data sets were analysed. Obvious signs of death were present in 278 cases; in the remaining 1247, resuscitation was attempted in 920 (74%) and were withheld in 327 (26%). Factors significantly associated with higher likelihood of CPR by physicians (OR 95% CI) were resuscitation efforts by EMS before physician arrival (60.45, 19.89–184.29), first monitored heart rhythm (3.07, 1.21–7.79 for PEA; 29.25, 1.93–442. 51 for VF / pVT compared to asystole); advanced patient age (modelled using cubic splines), physician response time (0.92, 0.87–0.97 per minute) and malignancy (0.22, 0.05–0.92) were significantly associated with lower odds of CPR. We thus conclude that prehospital physicians make decisions to start or withhold resuscitation routinely and base those mostly on situational information and immediately available patient information known to impact outcomes.

Background Atlanto-occipital dislocation is a rare and severe injury of the upper spine associated with a very poor prognosis. Case presentation We report the case of a 59-year-old European man who suffered from out-of-hospital cardiac arrest following a motor vehicle accident. Cardiopulmonary resuscitation was initiated immediately by bystanders and continued by emergency medical services. After 30 minutes of cardiopulmonary resuscitation with a total of five shocks following initial ventricular fibrillation, return of spontaneous circulation was achieved. An electrocardiogram recorded after return of spontaneous circulation at the scene showed signs of myocardial ischemia as a possible cause for the cardiac arrest. No visible signs of injury were found. He was transferred to the regional academic trauma center. Following an extended diagnostic and therapeutic workup in the emergency room, including extended focused assessment with sonography for trauma ultrasound, whole-body computed tomography, and magnetic resonance imaging (of his head and neck), a diagnosis of major trauma (atlanto-occipital dislocation, bilateral serial rip fractures and pneumothoraces, several severe intracranial bleedings, and other injuries) was made. An unfavorable outcome was initially expected due to suspected tetraplegia and his inability to breathe following atlanto-occipital dislocation. Contrary to initial prognostication, after 22 days of intensive care treatment and four surgical interventions (halo fixation, tracheostomy, intracranial pressure probe, chest drains) he was awake and oriented, spontaneously breathing, and moving his arms and legs. Six weeks after the event he was able to walk without aid. After 2 months of clinical treatment he was able to manage all the activities of daily life on his own. It remains unclear, whether cardiac arrest due to a cardiac cause resulted in complete atony of the paravertebral muscles and caused this extremely severe lesion (atlanto-occipital dislocation) or whether cardiac arrest was caused by apnea due the paraplegia following the spinal injury of the trauma. Conclusions A plausible cause for the trauma was myocardial infarction which led to the car accident and the major trauma in relation to the obviously minor trauma mechanism. With this case report we aim to familiarize clinicians with the mechanism of injury that will assist in the diagnosis of atlanto-occipital dislocation. Furthermore, we seek to emphasize that patients presenting with electrocardiographic signs of myocardial ischemia after high-energy trauma should primarily be transported to a trauma facility in a percutaneous coronary intervention-capable center rather than the catheterization laboratory directly.

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