Verbesserung der Zusammenarbeit zwischen Notärzten und Kardiologen zur Optimierung der frühen Therapie bei akutem ST-Hebungs-Infarkt

In cases of ST elevation myocardial infarction (MI), the aim is to reduce the time to reperfusion. Together with delay in contacting the emergency doctor, time is also commonly lost because the emergency site diagnosis is often queried in the hospital and a new diagnosis made. Building trust between cardiologists and emergency doctors, such as at common workshops, can lead to better cooperation. Another problem is the financing of prehospital thrombolysis. This early therapy can improve the prognosis for patients with acute ST elevation MI. However, the cost carrier has not yet been clearly determined.     

Frequency of rib and sternum fractures associated with out-of-hospital cardiopulmonary resuscitation is underestimated by conventional chest X-ray

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.     

NACA-Scoringsystem

Background

Objectification of the spread of National Advisory Committee for Aeronautics (NACA) scoring system for selected homogeneous groups based on retrospective data, and diagnosis and analysis of the influence of a given validatation date to the valuation accuracy based on prospective data.

Material and Methods

Records of emergency operations from the data pool of the NACA-X database of emergency medical systems (EMS) Innsbruck and surroundings with a retrospective study period over 6?years and a prospective study period of 9?months with the possibility to record the NACA score on three different time points.

Results

All diagnostic groups with 2596?records show a striking retrospective dispersion in the NACA evaluation. Prospectively ??hypoglycemia?? (n=31) and ??intoxication?? (n=93) show a highly (p <0.01) while ??acute coronary syndroms (ACS)?? (n=87) and ??cardiopulmonary resuscitation/arrest (CPR)?? (n=68) show a significant change (p <0.05) in the distribution of NACA evaluation between the evaluation time points.

Conclusions

Depending on the classification stage partly significantly different NACA-values are assigned. The NACA system requires a clear definition of the classification time. For the intended aim of being used as a severity score, the time of maximum threat to emergency patients should be chosen.     

Patientenzufriedenheit in der pr?klinischen Notfallmedizin

Introduction

The study primarily aimed to develop a standardized, psychometrically tested and validated questionnaire to assess patient satisfaction with out-of hospital emergency care. The second aim was to analyze the quality of care provided by emergency medical services (EMS).

Methods

Accomplishment of tasks was designed in three sections a) interviews of focus groups to specify four quality categories (emergency call, emergency treatment, transport, admission to hospital) and development of a questionnaire, b) conduction of the main study and c) psychometric analysis and evaluation of the questionnaire regarding practicability, validity and reliability.

Results

A total of 437 questionnaires were evaluated and the four quality categories showed high satisfaction rates (means: 84?C94 points on a 0?C100 scale). The values correlated with the total quality score (r=0.6-0.81). In the main study transport showed the highest impact in total satisfaction, followed by emergency treatment. The item social support showed high dissatisfaction scores.

Conclusions

The psychometrically tested and validated questionnaire proved to be valuable for benchmarking studies. From the patient point of view satisfaction with out-of hospital emergency care can be improved regarding social environment and training of social and emotional skills of rescue personnel.     

Evaluierung der Maßnahmen zur Reduktion von Notarzteinsätzen in Tirol während der COVID-19-Pandemie

Die Anaesthesiologie - Die COVID-19-Hochphase im österreichischem Bundesland Tirol war für den Rettungs- und Notarztdienst sehr herausfordernd. Hauptziel war, unter Aufrechterhaltung der...     

Strong corruption of electrocardiograms caused by cardiopulmonary resuscitation reduces efficiency of two-channel methods for removing motion artefacts in non-shockable rhythms

AimCardiopulmonary resuscitation (CPR) artefact removal methods provide satisfactory results when the rhythm is shockable but fail on non-shockable rhythms. We investigated the influence of the corruption level on the performance of four different two-channel methods for CPR artefact removal.Materials and methods395 artefact-free ECGs and 13 pure CPR artefacts with corresponding blood pressure readings as a reference channel were selected. Using a simplified additive data model we generated CPR-corrupted signals at different signal-to-noise ratio (SNR) levels from ?10 to +10 dB. The algorithms were optimized on learning data with respect to SNR improvement and then applied to testing data. Sensitivity and specificity were derived from the shock/no-shock advice of an automated external defibrillator before CPR corruption and after artefact removal.ResultsSensitivity for the filtered data (>95%) was significantly superior to that for the unfiltered data (76%), p < 0.001. However, specificity was similar for the filtered and unfiltered data (<90% vs 89.3%). For large artefacts (?10 dB) specificity decreased below 70%. No important difference in the performance of the four algorithms was found.ConclusionUsing a simplified data model we showed that, when the ECG rhythm is non-shockable, two-channel methods could not reduce CPR artefacts without affecting the rhythm analysis for shock recommendation. The reason could be poor reconstruction when the artefacts are large. However, poor reconstruction was not a hindrance to re-identifying shockable rhythms. Future investigations should both include the refinement of filter methods and also focus on reducing motion artefacts already at the recording stage.     

The new 2005 resuscitation guidelines of the European Resuscitation Council: comments and supplements

The new CPR guidelines are based on a scientific consensus which was reached by 281 international experts. Chest compressions (100/min, 4-5 cm deep) should be performed in a ratio of 30:2 with ventilation (tidal volume 500 ml, Ti 1 s, FIO2 if possible 1.0). After a single defibrillation attempt (initially biphasic 150-200 J, monophasic 360 J, subsequently with the respective highest energy), chest compressions are initiated again immediately for 2 min. Endotracheal intubation is the gold standard; other airway devices may be employed as well depending on individual skills. Drug administration routes for adults and children: first choice IV, second choice intraosseous, third choice endobronchial [epinephrine dose 2-3x (adults) or 10x (pediatric patients) higher than IV]. Vasopressors: 1 mg epinephrine every 3-5 min IV. After the third unsuccessful defibrillation attempt amiodarone IV (300 mg); repetition (150 mg) possible. Sodium bicarbonate (1 ml/kg 8.4%) only in excessive hyperkalemia, metabolic acidosis, or intoxication with tricyclic antidepressants. Consider atropine (3 mg) and aminophylline (5 mg/kg). Thrombolysis during spontaneous circulation only in myocardial infarction or massive pulmonary embolism; during CPR only during massive pulmonary embolism. Cardiopulmonary bypass only after cardiac surgery, hypothermia or intoxication. Pediatrics: best improvement in outcome by preventing cardiocirculatory collapse. Alternate chest thumps and chest compression (infants), or abdominal compressions (>1-year-old) in foreign body airway obstruction. Initially five breaths, followed by chest compressions (100/min; approximately 1/3 of chest diameter): ventilation ratio 15:2. Treatment of potentially reversible causes (4 "Hs", "HITS": hypoxia, hypovolemia, hypo- and hyperkaliemia, hypothermia, cardiac tamponade, intoxication, thrombo-embolism, tension pneumothorax). Epinephrine 10 microg/kg IV or intraosseously, or 100 microg (endobronchially) every 3-5 min. Defibrillation (4 J/kg; monophasic oder biphasic) followed by 2 min CPR, then ECG and pulse check. Newborns: inflate the lungs with bag-valve mask ventilation. If heart rate<60/min chest compressions:ventilation ratio 3:1 (120 chest compressions/min). Postresuscitation phase: initiate mild hypothermia [32-34 degrees C for 12-24 h; slow rewarming (<0.5 degrees C/h)]. Prediction of CPR outcome is not possible at the scene; determining neurological outcome within 72 h after cardiac arrest with evoked potentials, biochemical tests and physical examination. Even during low suspicion for an acute coronary syndrome, record a prehospital 12-lead ECG. In parallel to pain therapy, aspirin (160-325 mg PO or IV) and in addition clopidogrel (300 mg PO). As antithrombin, heparin (60 IU/kg, max. 4000 IU) or enoxaparine. In ST-segment elevation myocardial infarction, define reperfusion strategy depending on duration of symptoms until PCI (prevent delay>90 min until PCI). Stroke is an emergency and needs to be treated in a stroke unit. A CT scan is the most important evaluation, MRT may replace a CT scan. After hemorrhage exclusion, thrombolysis within 3 h of symptom onset (0.9 mg/kg rt-PA IV; max 90 mg within 60 min, 10% of the entire dosage as initial bolus, no aspirin, no heparin within the first 24 h). In severe hemorrhagic shock, definite control of bleeding is the most important goal. For successful CPR of trauma patients, a minimal intravascular volume status and management of hypoxia are essential. Aggressive fluid resuscitation, hyperventilation, and excessive ventilation pressure may impair outcome in severe hemorrhagic shock. Despite bad prognosis, CPR in trauma patients may be successful in select cases. Any CPR training is better than nothing; simplification of contents and processes remains important.     

Telephone-assisted CPR

Introduction

Despite numerous efforts, out-of-hospital cardiac arrest (OHCA) survival has not significantly increased in recent decades. The first telephone-assisted cardiopulmonary resuscitation (T-CPR) studies were published in the 1980s, but only in the last decade has T?CPR been implemented in dispatch centers. T?CPR is still not available in all dispatch centers and no national or international T?CPR recommendations are available.

Methods

Studies from PubMed were identified and evaluated. Preliminary information from the European Dispatch Center Survey (EDiCeS) is also included.

Results

In all, 42 studies were included. T?CPR is implemented in 87.6?% of those dispatch centers which have joined the not-yet published EDiCeS. According to German Resuscitation Registry data, about 10?% of OHCA patients received T?CPR in 2014. Agonal breathing is the leading cause for nonrecognition of OHCA by the dispatcher. Sensitivity of OHCA recognition by the dispatcher is about 75?%, whereby 8–45?% of these patients were not in cardiac arrest. The time interval from call to first compression is 140–328 s. Instructing rescue breathing by telephone is time consuming, leads to extensive hands-off times, and often to ineffective ventilation; therefore, rescue breathing is not indicated in adults with primary cardiac arrest. Studies showed improved survival with standardized T?CPR implementation.

Conclusion

T-CPR is established in many dispatch centers. However, emergency call interrogation and T?CPR vary between dispatch centers and are often performed without evaluation. International recommendations with standardized quality control are necessary and may lead to improved survival.

     

Die neuen internationalen Richtlinien zur kardiopulmonalen Reanimation

In August 2000, the American Heart Association and the European Resuscitation Council published the conclusions of the International Guidelines 2000 Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care which contains both the new recommendations and an in-depth review. The discussions and drafting began at a conference in March 1999, followed by a second conference in September 1999, both attended by approx. 250 participants and another conference in February 2000 which was attended by approx. 500 participants. Review of the current state of science, discussion and final consensus continued subsequently via email, conference calls, fax, and personal conversation. During the entire process, scientists and resuscitation councils from all over the world participated, with participants from the United States comprising approx.60%, and scientists from outside of the United States comprising approx. 40%. In order to ensure that the CPR recomendations are not dominated by any given nation or resuscitation council, most topics were reviewed and interpretated by two scientists from the United States and two scientists from outside of the United States. Accordingly, changes in these new CPR recommendations are the result of an evidence-based review by worldwide experts. The most important changes in the recommendations according to the authors are discontinuation of the pulse-check for lay people, 500 ml instead of 800–1200 ml tidal volume during bag-valve-mask ventilation (FiO₂ >0.4) of a patient with an unprotected airway, verifying correct endotracheal intubation with capnography and an esophageal detector, employing mechanical devices such as interposed abdominal compression CPR, vest CPR, active-compression-decompression CPR, and the inspiratory threshold valve (ITV) CPR as alternatives or adjuncts to standard manual chest compressions, defibrillation with <200 Joule biphasic instead of with 200–360 Joule monophasic impulses, vasopressin (40 units) and epinephrine (1 mg) as comparable drugs to treat patients with ventricular fibrillation, amiodarone (300 mg) for shock-refractory ventricular fibrillation and intravenous lysis for patients who have suffered a stroke.