Browsing by Author "Wenzel, V."

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.

Inducing anaesthesia outside the hospital is an important therapeutic intervention in emergency medicine; it is much more difficult to accomplish than inside the hospital. Its primary goals include hypnosis and analgesia which enable airway management to achieve mechanical ventilation and adequate oxygenation. Secondary goals of emergency anaesthesia include amnesia, anxiolysis, reduced oxygen consumption and work of breathing, and thus protection of vital organs and avoidance of secondary myocardial injury or cerebral injuries. Prior to prehospital induction of anaesthesia, patient-, scene- and operator-specific factors need to be considered. The rapid sequence induction includes basic monitoring, pre-oxygenation, standardized preparation of drugs and equipment, administration of drugs, removal of the cervical collar and manual in-line stabilization during intubation attempt (if needed), intubation and confirmation of endotracheal intubation. Every spontaneously breathing emergency patient should receive pre-oxygenation for at least 3-4 min with 12-15 l oxygen per min and a tight-sealing facemask, or a demand valve. The standardized preparation process includes preparation and labeling drugs/syringes, checking the bag-valve mask, preparing the endotracheal tube with a stylet and blocking syringe, as well as having a stethoscope and material to secure the tube at hand, as well as alternative airway devices. It also includes immediate access to alternative means of airway management, as well as a suction unit, ventilator and monitoring devices including capnography. Basic monitoring for prehospital emergency anaesthesia includes ECG, an automatic/manual blood pressure cuff, and pulse oximetry. Continuous capnography is used without exception to confirm ventilation, to detect possible disconnections/dislocations, and for indirect monitoring of hemodynamics. Prior to induction of prehospital emergency anaesthesia, two peripheral intravenous catheters should be placed if possible.

For poison related emergencies German ambulances are equipped with a big number of antidotes. However most intoxications are not treated specifically out of hospital by ambulance physicians. Ambulances are requested, when vital functions of a patient are jeopardised. In most cases symptomatic treatment is sufficient; including mechanical ventilation, whereas need for administration of a specific antidote is extremely rare. On behalf of the Working Group of Northern German Emergency Physicians (AGNN) the authors, all of them emergency physicians and toxicologists, developed a list of antidotes necessary in the out-of-hospital emergency setting. The results are based on the experience of thousands of treated emergencies and on the calls to the GIZ-Nord Poisons Centre Gottingen from 1996 to 2010. The list was discussed by the Board of Continuing Education of the AGNN as well as at a meeting of Medical Directors of Emergency Services. Both boards supported the list of antidotes. Without reduction of quality of care antidotes held available in an ambulance car can be reduced to 5 substances: atropine, 4-DMAP, naloxone, tolonium chloride, activated charcoal. This general recommendation has to be adjusted to local conditions. A list of antidotes that need to be carried by an ambulance car is proposed. Due to a lack of studies the list has a low evidence level (expert judgement). It is based on the experience of emergency physicians and toxicologists. The list is thought to provoke a discussion among experts and to prompt further studies on the use and usefulness of antidotes.

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, F1O2 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 2-3 x (adults) or 10 x (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; similar to 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 mu g/kg IV or intraosseously, or 100 mu g (endobronchially) every 3 5 min. Defibrillation (4 J/kg; monophasic or 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 ventilaton 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.