A rare case of neuroleptic malignant syndrome presenting with serious hyperthermia treated with a non-invasive cooling device: a case report

<p>Abstract</p> <p>Introduction</p> <p>A rare side effect of antipsychotic medication is neuroleptic malignant syndrome, mainly characterized by hyperthermia, altered mental state, haemodynamic dysregulation, elevated serum creatine kinase and rigor. There may be multi-organ dysfunction including renal and hepatic failure as well as serious rhabdomyolysis, acute respiratory distress syndrome and disseminated intravascular coagulation. The prevalence of neuroleptic malignant syndrome is between 0.02% and 2.44% for patients taking neuroleptics and it is not necessary to fulfil all cardinal features characterizing the syndrome to be diagnosed with neuroleptic malignant syndrome. Because of other different life-threatening diseases matching the various clinical findings, the correct diagnosis can sometimes be hard to make. A special problem of intensive care treatment is the management of severe hyperthermia. Lowering of body temperature, however, may be a major clinical problem because hyperthermia in neuroleptic malignant syndrome is typically unresponsive to antipyretic agents while manual cooling proves difficult due to peripheral vasoconstriction.</p> <p>Case presentation</p> <p>A 22-year-old Caucasian man was admitted unconscious with a body temperature of 42°C, elevated serum creatine phosphokinase, tachycardia and hypotonic blood pressure. In addition to intensive care standard therapy for coma and shock, a non-invasive cooling device (Arctic Sun 2000^®, Medivance Inc., USA), originally designed to induce mild therapeutic hypothermia in patients after cardiopulmonary resuscitation, was used to lower body temperature. After successful treatment it became possible to obtain information from the patient about his recent ambulant treatment with Olanzapin (Zyprexa®) for schizophrenia.</p> <p>Conclusion</p> <p>Numerous case reports have been published about patients who developed neuroleptic malignant syndrome due to Olanzapin (Zyprexa®) medication. Frequently hyperthermia has been observed in these cases with varying outcomes. In our case the only residual impairment for the patient is dysarthria with corresponding symmetric cerebellar pyramidal cell destruction demonstrated by increased signal intensity in T2-weighted magnetic resonance imaging, most likely caused by the excessive hyperthermia.</p

Establishment of an extracorporeal cardio-pulmonary resuscitation program in Berlin – outcomes of 254 patients with refractory circulatory arrest

Objective: Optimal management of out of hospital circulatory arrest (OHCA) remains challenging, in particular in patients who do not develop rapid return of spontaneous circulation (ROSC). Extracorporeal cardiopulmonary resuscitation (eCPR) can be a life-saving bridging procedure. However its requirements and feasibility of implementation in patients with OHCA, appropriate inclusion criteria and achievable outcomes remain poorly defined. Design: Prospective cohort study. Setting: Tertiary referral university hospital center. Patients: Here we report on characteristics, course and outcomes on the first consecutive 254 patients admitted between August 2014 and December 2017. Intervention: eCPR program for OHCA. Mesurements and main results: A structured clinical pathway was designed and implemented as 24/7 eCPR service at the Charité in Berlin. In total, 254 patients were transferred with ongoing CPR, including automated chest compression, of which 30 showed or developed ROSC after admission. Following hospital admission predefined in- and exclusion criteria for eCPR were checked; in the remaining 224, 126 were considered as eligible for eCPR. State of the art postresuscitation therapy was applied and prognostication of neurological outcome was performed according to a standardized protocol. Eighteen patients survived, with a good neurological outcome (cerebral performance category (CPC) 1 or 2) in 15 patients. Compared to non-survivors survivors had significantly shorter time between collaps and start of eCPR (58 min (IQR 12–85) vs. 90 min (IQR 74–114), p = 0.01), lower lactate levels on admission (95 mg/dL (IQR 44–130) vs. 143 mg/dL (IQR 111–178), p <  0.05), and less severe acidosis on admission (pH 7.2 (IQR 7.15–7.4) vs. 7.0 (IQR6.9–7.2), p <  0.05). Binary logistic regression analysis identified latency to eCPR and low pH as independent predictors for mortality. Conclusion: An eCPR program can be life-saving for a subset of individuals with refractory circulatory arrest, with time to initiation of eCPR being a main determinant of survival

Vulnerabilität der Metropolregion Bremen-Oldenburg gegenüber dem Klimawandel (Synthesebericht)

Der nordwest2050-Bericht Nr. 2 führt die von 'nordwest2050' durchgeführten Verwundbarkeitsanalysen für eine Vielzahl gesellschaftlicher Sektoren, die Wirtschaftsbereiche Tourismus, Ernährung, Energie sowie Hafen und Logistik sowie für die regionale Governance in der Metropolregion Bremen-Oldenburg in einem Bericht zur regionalen Verwundbarkeit zusammen. Schwerpunkte dieses so genannten Syntheseberichts sind eine vergleichende Darstellung der Höhe der jeweiligen Verwundbarkeiten durch den Klimawandel und mögliche Wechselwirkungen zwischen den Sektoren und Wirtschaftsbereichen, die z.B. Flächennutzungs- oder Zielkonflikte in der Region verstärken können. Weitere Aspekte sind: An welcher Stelle könnten aufgrund von Klimaanpassungsmaßnahmen zukünftig Konflikte und Konkurrenzen um Fläche auftreten? Welche Aussagen machen die regionalen Klimaszenarien über das zukünftige Auftreten von Extremereignissen und wie wirken sich diese auf die Verwundbarkeit im Nordwesten aus? Wie wirken die globalen Folgen des Klimawandels auf die Wertschöpfungsketten der Wirtschaftsbereiche in der Region? Die Ergebnisse der Synthese der Verwundbarkeitsanalyse erlauben einen Überblick über die zu erwartenden Auswirkungen des Klimawandels und des resultierenden Anpassungsbedarfs in der Region in einer mittelfristigen (bis 2050) und einer langfristigen Perspektiven (bis 2100). Aus ihnen lassen sich auch Hinweise auf sinnvolle Handlungsstrategien ableiten, die in einer regionalen Klimaanpassungsstrategie berücksichtigt werden sollten

Bivalirudin is superior to heparins alone with bailout GP IIb/IIIa inhibitors in patients with ST-segment elevation myocardial infarction transported emergently for primary percutaneous coronary intervention:a pre-specified analysis from the EUROMAX trial

AIMS: In the HORIZONS trial, in-hospital treatment with bivalirudin reduced bleeding and mortality in primary percutaneous coronary intervention (PCI) compared with heparin and routine glycoprotein IIb/IIIa inhibitors (GPI). It is unknown whether this advantage of bivalirudin is observed in comparison with heparins only with GPI used as bailout. METHODS AND RESULTS: In the EUROMAX study, 2198 patients with ST-segment elevation myocardial infarction (STEMI) were randomized during transport for primary PCI to bivalirudin or to heparins with optional GPI. Primary and principal outcome was the composites of death or non-CABG-related major bleeding at 30 days. This pre-specified analysis compared patients receiving bivalirudin (n = 1089) with those receiving heparins with routine upstream GPI (n = 649) and those receiving heparins only with GPI use restricted to bailout (n = 460). The primary outcome death and major bleeding occurred in 5.1% with bivalirudin, 7.6% with heparin plus routine GPI (HR 0.67 and 95% CI 0.46–0.97, P = 0.034), and 9.8% with heparins plus bailout GPI (HR 0.52 and 95% CI 0.35–0.75, P = 0.006). Following adjustment by logistic regression, bivalirudin was still associated with significantly lower rates of the primary outcome (odds ratio 0.53, 95% CI 0.33–0.87) and major bleeding (odds ratio 0.44, 95% CI 0.24–0.82) compared with heparins alone with bailout GPI. Rates of stent thrombosis were higher with bivalirudin (1.6 vs. 0.6 vs. 0.4%, P = 0.09 and 0.09). CONCLUSION: Bivalirudin, started during transport for primary PCI, reduces major bleeding compared with both patients treated with heparin only plus bailout GPI and patients treated with heparin and routine GPI, but increased stent thrombosis

[Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin.]

Chest pain and acute dyspnoea are frequent causes of emergency medical services activation. The pre-hospital management of these conditions is heterogeneous across different regions of the world and Europe, as a consequence of the variety of emergency medical services and absence of specific practical guidelines. This position paper focuses on the practical aspects of the pre-hospital treatment on board and transfer of patients taken in charge by emergency medical services for chest pain and dyspnoea of suspected cardiac aetiology after the initial assessment and diagnostic work-up. The objective of the paper is to provide guidance, based on evidence, where available, or on experts' opinions, for all emergency medical services' health providers involved in the pre-hospital management of acute cardiovascular care