Browsing by Author "Bahr, Jan"

Background: Survival rate after out-of-hospital cardiac arrest (OHCA) has not significantly increased over the last decade. However, survival rate has been used as a quality benchmark for many emergency medical services. A uniform resuscitation registry may be advantageous for quality management of cardiopulmonary resuscitation (CPR). This study was conducted to evaluate the establishment of a national CPR registry in Germany. Materials and methods: A prospective cohort study was performed that included 469 patients who experienced CHCA requiring CPR in the metropolitan area of Dortmund, Germany. Cardiac arrest was defined as concomitant appearance of unconsciousness, apnoea or gasping and pulselessness. All data were collected via a secure and confidential paper-based method as the data set 'Preclinical care'. Results: Quality of data was classified as 'good' in 33.4%, 'moderate' in 48.4%, and 'bad' in 18.2% of the patients, respectively. Sixty-two percent had CHCA in private residences, 24% of the patients had a first monitored rhythm of ventricular fibrillation (VF) or ventricular tachycardia (VT), 35.2% had return of spontaneous circulation (ROSC) on scene, and patients presenting VF/VT as the first monitored rhythm had higher ROSC rates (51.3%) compared to patients with asystole (22.6%). Conclusion: The data set 'Preclinical care' proved to be congruent with the Utstein style, provided further information for national and international comparisons, and enabled a detailed analysis. Optimisation of data collection and introduction of strict control mechanisms may further improve data quality. (c) 2008 Elsevier Ireland Ltd. All rights reserved.

Aim: We studied the course and success rate of cardiopulmonary resuscitation (CPR) attempted on nursing home residents by a physician-staffed pre-hospital advanced cardiac life support (ACLS) team. Methods: Ambulance records of nursing home residents from Goettingen/Germany who had a cardiac arrest were examined retrospectively. Results: During a seven-year period (1992-1998) the ACLS team was called to 71 residents (mean age 81.8 years) who sustained cardiac arrest. In 25 patients no CPR was attempted: 20 were pronounced dead by the arriving emergency physician, though only in 7 patients obvious clinical signs of death were present. Five patients suffered from a continuous deterioration of their health status and the ACLS team arrived after the process of dying had already started. No CPR attempt was initiated. The ACLS team performed CPR on 46 nursing home residents. In 33 patients (72% of CPR attempts) no return of spontaneous circulation (ROSC) was achieved. in three patients (6%) palpable pulse returned only transiently. Ten patients (22%) who showed ROSC were transported to the hospital. Six patients died within 24 hours after having been admitted to the hospital, two patients within the next 8 days. Two patients survived to hospital discharge. The first was a 79-year old woman who returned to the nursing home after three weeks and survived severely mentally disabled another five days. The second was an 83-year-old man who was hospitalised for 20 days, returned in a persistent vegetative state to the nursing home and died 10 months later. A comparison of the arrest characteristics demonstrated that in patients with successful CPR there was a higher incidence of a witnessed collapse, bystander CPR, ventricular fibrillation and cardiac aetiology of arrest. Conclusion: In a high rate (35%) the ACLS team with the emergency physician at the scene withheld CPR efforts in nursing home residents. Even if CPR was initiated, the benefits were very limited with only two patients (4,3%) surviving severely disabled to hospital discharge.

From 1985-1989 a community project on bystander CPR was carried out, including about 20.000 citizens; most of them were male, more than 60% younger than 30 years old. Evaluation of knowledge and skills among former participants in a realistic setting showed that six months after the course 66,7% performed according to AHA standards, after 12 and 24 months 23,5 % and 21,1%. Using a more practical method of interpreting the data with emergency medicine based criteria it could be found that after 6 months 90% of the test persons were able to improve the chances of survival in a real emergency, after 12 and 24 months each time 70%. The CPR data bank which has been established with the start of the project actually includes 1.825 cases. 70% of the patients on whom resuscitation has been attempted were male, mean age was 62 years. 60% of the emergencies occurred in the patients' home, 84% were witnessed, and 74% of cardiac origin. In 28% bystanders initiated resuscitation prior to the arrival of the EMS. Out of all 1.825 CPR attempts 35,8% were primarily successful, that means patients could be admitted to hospital with a spontaneous circulation. Following bystander CPR 42,4% of patients had VF in the first ECG compared with 29,1% in the non-bystander group. Corresponding to this out of the bystander group 43,6% of patients could be admitted to hospital with a spontaneous circulation, out of the non-bystander group only 32,7%. The positive effects of bystander CPR continued during the clinical course: 31,8% out of this group could be discharged without neurologic damage compared with 7,2% out of the non-bystander group. As far as long-term survival is concerned five years after discharge 53% of patients in whom bystanders had initiated resuscitation were alive and 31 % out of the non-bystander group. As an attempt to increase the rate of bystander initiated CPR and thus to bridge the interval without therapy a project on telephone CPR has started just recently.

Administer chest compressions (minimum 100/min, minimum 5 cm depth) at a ratio of 30:2 with ventilation (tidal volume 500-600 ml, inspiration time 1 s, F(I)O(2) if possible 1.0). Avoid any interruptions in chest compressions. After every single defibrillation attempt (initially biphasic 120-200 J, monophasic 360 J, subsequently with the respective highest energy), chest compressions are initiated again immediately for 2 min independent of the ECG rhythm. Tracheal intubation is the optimal method for securing the airway during resuscitation but should be performed only by experienced airway management providers. Laryngoscopy is performed during ongoing chest compressions; interruption of chest compressions for a maximum of 10 s to pass the tube through the vocal cords. Supraglottic airway devices are alternatives to tracheal intubation. Drug administration routes for adults and children: first choice IV, second choice intraosseous (IO). Vasopressors: 1 mg epinephrine every 3-5 min IV. After the third unsuccessful defibrillation amiodarone (300 mg IV), repetition (150 mg) possible. Sodium bicarbonate (50 ml 8.4%) only for excessive hyperkaliemia, metabolic acidosis, or intoxication with tricyclic antidepressants. Consider aminophylline (5 mg/kgBW). Thrombolysis during spontaneous circulation only for myocardial infarction or massive pulmonary embolism; during on-going cardiopulmonary resuscitation (CPR) only when indications of massive pulmonary embolism. Active compression-decompression (ACD-CPR) and inspiratory threshold valve (ITV-CPR) are not superior to good standard CPR. Most effective improvement of outcome by prevention of full cardiorespiratory arrest. Basic life support: initially five rescue breaths, followed by chest compressions (100-120/min depth about one third of chest diameter), compression-ventilation ratio 15:2. Foreign body airway obstruction with insufficient cough: alternate back blows and chest compressions (infants), or abdominal compressions (children > 1 year). Treatment of potentially reversible causes: ("4 Hs and 4 Ts") hypoxia and hypovolaemia, hypokalaemia and hyperkalaemia, hypothermia, and tension pneumothorax, tamponade, toxic/therapeutic disturbances, thrombosis (coronary/pulmonary). Advanced life support: adrenaline (epinephrine) 10 A mu g/kgBW IV or IO every 3-5 min. Defibrillation (4 J/kgBW; monophasic or biphasic) followed by 2 min CPR, then ECG and pulse check. Initially inflate the lungs with bag-valve mask ventilation (p(AW) 20-40 cmH(2)O). If heart rate remains < 60/min, start chest compressions (120 chest compressions/min) and ventilation with a ratio 3:1. Maintain normothermia in preterm babies by covering them with foodgrade plastic wrap or similar. Early protocol-based intensive care stabilization; initiate mild hypothermia early regardless of initial cardiac rhythm [32-34A degrees C for 12-24 h (adults) or 24 h (children); slow rewarming (< 0.5A degrees C/h)]. Consider percutaneous coronary intervention (PCI) in patients with presumed cardiac ischemia. Prediction of CPR outcome is not possible at the scene, determine neurological outcome < 72 h after cardiac arrest with somatosensory evoked potentials, biochemical tests and neurological examination. Even if only a weak suspicion of an acute coronary syndrome is present, record a prehospital 12-lead ECG. In parallel to pain therapy, administer aspirin (160-325 mg PO or IV) and clopidogrel (75-600 mg depending on strategy); in ST-elevation myocardial infarction (STEMI) and planned PCI also prasugrel (60 mg PO). Antithrombins, such as heparin (60 IU/kgBW, max. 4000 IU), enoxaparin, bivalirudin or fondaparinux depending on the diagnosis (STEMI or non-STEMI-ACS) and the planned therapeutic strategy. In STEMI define reperfusion strategy depending on duration of symptoms until PCI, age and location of infarction. In severe hemorrhagic shock, definitive 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 patients with severe hemorrhagic shock. Any CPR training is better than nothing; simplification of contents and processes is the main aim.

Early in February of this year the 3rd meeting of the scientific groups of the Working Group on Emergency Medicine of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) took place in Kiel. The participants were informed about current results of emergency medicine research. In addition to ongoing individual projects, several multicenter studies were also presented. Besides the fields of education and training, the topics included basic research in emergency medicine and quality management. Current clinical trials address in the particular the subject of ventilation, especially alternative methods of ensuring patent airways. Other current issues of emergency medicine research pertain to inhospital emergencies, use of vasopressin, and thrombolysis in cardiac arrest.

On February 12-13, 2006, the Working Committee on Emergency Medicine of the German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft fur Anasthesiologie und Intensivmedizin, DGAI) held the second meeting of scientifically active working groups in Kiel. The current state of research in emergency medicine in Germany and Austria was described in 36 brief reports providing information on training, theory, quality management, clinical studies, and basic research. This meeting attended by more than 50 participants again illustrated the numerous activities in our special field. The following article presents an overview of the projects dealt with.

The American Heart Association changed the Guidelines for Adult Basic Life Support on 31(st) March 2008 online: Lay rescuers should perform Compression only CPR omitting mouth-to-mouth-ventilation. The ERC didn't judge it necessary to change European Guidelines that are based on the same common "Consensus of Science" (Dallas 2005), since ERC recommended even 2005 for lay rescuers to perform only chest Compressions if he or she is not able or willing to perform mouth-to-mouth-ventilation. The recent change of AHA Guidelines and also the ongoing ERC recommendation (ALS guidelines 2005) aims on bringing as many lay rescuers as possible to action and on achieving a better outcome for victims of a sudden circulatory arrest. The remaining question is: Are there good arguments for "Compression only CPR"?

Background: In 1999, the laryngeal tube (VBM Medizintechnik, Sulz, Germany) was introduced as a new supraglottic airway. It was designed to allow either spontaneous breathing or controlled ventilation during anaesthesia; additionally it may serve as an alternative to endotracheal intubation, or bag-mask ventilation during resuscitation. Several variations of this supraglottic airway exist. In our study, we compared ventilation with the laryngeal tube suction for single use (LTS-D) and a bag-mask device. One of the main points of the revised ERC 2005 guidelines is a low no-flow-time (NFT). The NFT is defined as the time during which no chest compression occurs. Traditionally during the first few minutes of resuscitation NFT is very high. We evaluated the hypothesis that utilization of the LTS-D could reduce the NFT compared to bag-mask ventilation (BMV) during simulated cardiac arrest in a single rescuer manikin study. Results: Utilization of the LTS-D reduced NFT significantly (p < 0.01). Adherence to the time frame of ERC guidelines was 96% in the LTS-D group versus 30% in the BMV group. Two participants in the LTS-D group required more than one attempt to establish the LTS-D correctly. Once established, ventilation was effective in 100%. In a subjective evaluation all participants preferred the LTS-D over BMV to provide ventilation in a cardiac arrest scenario. Conclusion: In our manikin study, NFT was reduced significantly when using LTS-D compared to BMV. During cardiac arrest, the LTS-D might be a good alternative to BMV for providing and maintaining a patent airway. For personnel not experienced in endotracheal intubation it seems to be a safe airway device in a manikin use.

Background: In 2005 the European Resuscitation Council (ERC) published a revised version of the guidelines for Advanced Life Support (ALS). One of the aims was to reduce the time without chest compression in the first period of cardiac arrest (no-flow-time; NFT). We evaluated in a manikin study the influence on NFT using the single use laryngeal tube with suction option (LTS-D) compared to single use I-gel for emergency airway management. Methods: A randomised prospective study with 200 paramedics who performed standardised simulated cardiac arrest management in a manikin. Results: The use of the LTS-D did not significantly reduce NFT compared with the I-gel (104.7 s vs. 105.1 s; p > 0.05). The LTS-D was inserted as fast as the I-gel (10.4 s vs. 9.3 s; p > 0.05). The LTS-D was correctly positioned by 98% of the participants on the first attempt compared to 96% with the I-gel. During the cardiac arrest simulation, establishing and performing first ventilation took an average of 40.5 s with the LTS-D compared to 40.9 s with the I-gel. Conclusion: In our manikin study, NFT was comparable using the LTS-D and the I-gel. Therefore, for personnel not experienced in tracheal intubation, the LTS-D and the I-gel seem to be equal alternatives in establishing the airway during cardiac arrest. However, relevant clinical studies are appropriate because any change in guidelines in this area must be based on clinical evidence. (C) 2008 Elsevier Ireland Ltd. All rights reserved.

During the stay in hospital intrahospital transports (IHT) of critically ill patients are often necessary for optimal patient care. The transport of intensive care patients within the hospital may be associated with many potential complications and risks. It is therefore necessary to minimize risk factors before the onset of transport. Intensive Care Unit (ICU) patients should be transported safely when adequate time is provided, preparations are made prior to IHT, and human resources and technical support are sufficiently available. Patients should be stabilized as good as possible. The standard monitoring equipment of ICUs should be used over the whole time of transport. This article focuses on the transport of critically ill patients inside the hospital. We discuss the reasons for such transports, possible complications during transports, and show how to avoid complications.

Backround and objectives: In 2005 the European Resuscitation Council (ERC) published a revised version of the guidelines for Advanced Life Support (ALS). One of the aims was to reduce the time without chest compression in the first period of cardiac arrest. We evaluated in a manikin study whether using the single use laryngeal tube (LT-D) instead of single use laryngeal mask (LMA) for emergency airway management could reduce the "No Flow Time" (NFT). The NFT is defined as the time during which no chest compressions take place. Methods: Randomised prospective study with 200 volunteers who performed a standardised simulated cardiac arrest management in a manikin following one-day cardiac arrest training (simulation scenario 430 s). Two supraglottic airway devices were compared (LT-D and LMA). Endpoints were the total "no flow time" during the scenario, and the successful airway management with the used airway device. Results: In the present manikin study the use of the LT-D significantly reduced NFT compared with the LMA (104.2s vs. 124.0 s; p < 0.01). The LT-D was correctly positioned by 98% of the participants on the first attempt compared to 74% with the LMA. The LT-D was inserted significantly faster than the LMA (12.4 s vs. 29.1 s, p < 0.01). During the cardiac arrest simulation establishing and performing first ventilation took an average of 40.5 s with the LT-D compared to 47.9 s with LMA. Conclusions: In this manikin study data showed that the LT-D may be a good alternative airway device compared to LMA for providing and maintaining a patent airway during resuscitation.

To bridge the time gap without therapeutic intervention until the EMS team arrives, lay rescuers should be trained in performing adequate cardiopulmonary resuscitation (CPR). About 2 million people attend CPR courses each year in Germany. However, it has been observed that the skills acquired by the attendees already begin to deteriorate shortly thereafter. As an alternative, efforts are currently underway to assess telephone-guided resuscitation performed by bystanders on site following instruction received via telephone. Use of automated external defibrillators by helpers first on the scene is considered to be another option. Initial experience has shown, however, that little use is made of the equipment located at heavily frequented areas (airports, railroad stations, etc.). At these locations it seems to make more sense to train the first responders (police force, fire department). Further measures need to be implemented to improve the actual assistance rendered in terms of quality and quantity.

Background. The published 2005 guidelines of the European Resuscitation Council (ERC) emphasize that first aid by bystanders is an essential part in the care of emergency patients but also seems to be the weakest link in the "chain of survival". Methods. During a 3-month period we investigated participants in a standardized course of "immediate life-saving procedures", mandatory for people applying for a driving license. We also investigated the theoretical knowledge of participants using a self-developed questionnaire. Results. A total of 100 participants were included during the defined study period and of these 65% passed the theoretical knowledge test directly following the course. Significantly better results in the test were reached by participants who had repeated the course several times in the past. Discussion. It could be shown that repeating first-aid courses can improve test results for theoretical knowledge of lay persons. Thus, repeating first-aid courses may strengthen this essential part of the "chain of survival".

The purpose of this study is to evaluate the demographic characteristics of patients who suffered cardiac arrest in our intensive care units (ICUs) as well. as to identify those factors influencing outcome after resuscitation following cardiac arrest. Methods: We reviewed the records of all patients who underwent cardiopulmonary resuscitation (CPR) in our ICUs at the Georg-August University Hospital, Goettingen, Germany, from January 1, 1999 to December 31, 2003. Results: One hundred and sixty-nine patients underwent CPR. Severity of illness assessed by SAPS 11 score on admission was 51.8 +/- 18.5 (predicted mortality 46.6%). The initially monitored rhythm at the time of arrest was asystote in 51 (30.2%) patients. Ventricular tachycardia/fibrillation (VT/VF) was recorded in 65 (38.5%) and pulseless electrical activity in 49 (29.0%) patients. Twenty (23.8%), 28 (33.3%) and 33 (39.3%) patients with initially recorded asystote, VT/VF and putseless electrical activity (PEA) rhythms, respectively, survived to ICU discharge. Eighty of the 169 patients survived to hospital discharge giving a survival rate of 47.3%. The highest ICU mortality was seen in patients admitted for neurosurgery (80%) followed by major vascular surgery (77.8%), non-surgical patients (67.4%) and patients with severe sepsis (66.7%). The occurrence of cardiac arrest within the first 24 h was associated with a significantly lower ICU mortality compared to a later incident. At hospital discharge 66 patients (82.5% of the survivors) achieved good cerebral recovery, 12 patients (15.0%) were severely disabled (CPC 3) while 2 (2.5%) remained unconscious. Conclusion: Several factors affect the outcome from CPR. However, quicker triage to ICU, closer monitoring along with prompt intervention might minimise the consequences of cardiac arrest and its complications. (c) 2006 Elsevier Ireland Ltd. All rights reserved.

Background. First aid by bystanders is an essential part in the care for emergency patients. Till now it seemed to be the weakest part of the "chain of survival" and for that first-aid defines the strength of this concept. Methods: We investigated 118 participants of a standardized course of immediate life-saving treatment. That type of course is addressed to lay people and is mandatory to get the German driving license. We looked for the practical skills directly following the course by a standardized basic life scenario for evaluation using a recording CPR manikin (Laerdal(TM)). Results: Most of the participants failed the practical test directly following the course (64.4%). Significant better results in performing CPR were reached by participants having taken part in such training courses frequently in the past. Discussion:We could show that repeating first-aid courses may improve better practical results by lay people. This repeating of first-aid courses may strengthen an essential part of the chain of survival. The mandatory first aid course seems not to be appropriate to create or increase the motivation of participants to initiate CPR in a real emergency situation [5,6,14].