Evaluierung der NEF-Fehl- und Übergabeeinsätze im Raum Innsbruck

Die Anaesthesiologie - Die Qualität eines Rettungssystems zeichnet sich auch durch den effizienten Einsatz seiner personellen und Fahrzeugressourcen aus. So können im berechtigten Fall...     

Hands-off-Zeiten durch AED-Sprachanweisungen

Background

Hands-off intervals during cardiopulmonary resuscitation (CPR) diminish the likelihood of success. The influence of voice prompts from an automated external defibrillator (AED) on the length of CPR interruption was investigated.

Material and methods

In a randomized, one-way blinded manikin CPR study we prospectively assessed intervals between the start of voice prompting and the start of execution by participants for a shockable and a non-shockable rhythm. Difficulties with executing AED voice prompts were assessed by a questionnaire. The influence on the length of CPR interruptions was evaluated in a post hoc analysis.

Results

Mean hands-off intervals measured in 57 voluntary participants accounted for 38.5?% of the total CPR time. Hands-off intervals between defibrillation and chest compressions were significantly shorter when CPR started with a non-shockable rhythm (6.5?±?3.5 s versus 9.0?±?5.5 s, p?<?0.043) and when participants rated the voice prompts as very good or good compared to middle or bad (7.1?±?4.5 s versus 11.3?±?4.7 s, p?<?0.020).

Conclusions

Confusing voice prompts that potentially delay CPR need to be identified and modified.     

Recombinant tissue plasminogen activator during cardiopulmonary resuscitation in 108 patients with out-of-hospital cardiac arrest.

BACKGROUND: Thrombolytic therapy during cardiopulmonary resuscitation (CPR) is a controversial issue in emergency medicine practice. This study was conducted to determine whether administration of recombinant tissue plasminogen activator (rt-PA) in out-of-hospital cardiac arrest of non-traumatic aetiology improves CPR outcome. METHODS AND RESULTS: A retrospective chart review of 401 patients with out-of-hospital cardiac arrest who were resuscitated by the emergency medical services (EMS) during a 6 year period was performed. A total of 108 patients received rt-PA during CPR and were compared to 216 controls, closely matched according to baseline characteristics, arrival status and ECG findings. Administration of rt-PA was optional. Return of spontaneous circulation (ROSC) occurred in 76 patients under rt-PA treatment (70.4 vs. 51.0% in controls; P=0.001). Fifty-two patients from the lysis group survived the first 24 h (48.1 vs. 32.9% in controls; P=0.003), while 27 (25.9%) survived to discharge. Autopsy reports revealed major bleeding complications in six patients receiving rt-PA treatment. Fulminant intracranial haemorrhage was observed in one patient who received rt-PA and in two cases from the control group. CONCLUSIONS: Thrombolytic therapy may improve frequency of return of spontaneous circulation substantially and increase primary survival in patients with non-traumatic cardiac arrest. Serious bleeding complications are not frequently observed under rt-PA treatment.     

Chest injuries after active compression-decompression cardiopulmonary resuscitation (ACD-CPR) in cadavers

In a prospective study of 38 cadavers of patients older than 18 without previous chest injury or cardiopulmonary resuscitation (CPR), active compression-decompression (ACD) resuscitation manoeuvres were performed to determine possible factors influencing sternal and/or rib fractures. ACD was performed for 60 s, with compression and decompression forces being continuously recorded. A stepwise logistic regression analysis was applied. Factors analyzed were age, gender, use of a compression cushion beneath the piston of the ACD device (Ambu CardioPump), and maximal compression and decompression forces. After ACD, the cadavers were autopsied and thoracic injuries were assessed. There was a significant correlation between sternal fractures and gender (P = 0.008), and between rib fractures and age (P = 0.008). Women were found to have a higher risk for sternal fractures, whereas older patients had a higher risk for rib fractures. Maximal compression force was another factor in sternal and/or rib fracture (P = 0.048). Even though a significantly higher incidence of sternal fractures was observed when the compression cushion was used (P = 0.045), inclusion of this variable in the regression analysis only marginally improved the prediction for correct classification of sternal fractures. In conclusion, when well controlled ACD-CPR is performed in cadavers, age is the most important factor determining the incidence of rib fracture. Sternal fractures were more common in female cadavers.     

The prognostic significance of coma-rating, duration of anoxia and cardiopulmonary resuscitation in out-of-hospital cardiac arrest

Early determination of outcome after successful prehospital cardiopulmonary resuscitation (CPR) is a common problem with great ethical, economic, social, and legal consequences. We prospectively investigated 112 adult patients who had been resuscitated after out-of-hospital cardiac arrest (CA). The aim of our study was to determine whether coma rating by the mobile intensive care unit (MICU) is a useful tool for outcome prediction. For neurological assessment the Innsbruck Coma Scale (ICS) was used initially and after return of spontaneous circulation (ROSC) or 20–30 min after the start of CPR, before any sedating drugs were given. The duration of anoxia and CPR were determined with the automatically recorded emergency call protocol of the dispatch centre and the protocol of the MICU. For estimation of cerebral outcome at the time of discharge from hospital we used the Glasgow-Pittsburgh Cerebral Performance Categories (CPC). Restoration of spontaneous circulation was achieved in 42 patients (37%), and 15 (13%) were discharged from hospital. The first coma rating performed immediately at the time of arrival on scene had no significant prognostic value for prediction of neurological outcome (P = 0.204) and survival (P = 0.103). The second coma rating (performed after ROSC or 20–30 min after the start of CPR), however, demonstrated a significant correlation with neurological outcome (P = 0.0000) and survival (P = 0.0000), a correlation which was comparable to both duration of anoxia and duration of CPR. In patients with out-of-hospital cardiac arrest prognostic information could be obtained with the ICS as early as 20– 30 min after the start of cardiopulmonary resuscitation. Received: 27 November 1996 Received in revised form: 10 July 1997 Accepted: 26 July 1997     

Notfallmedizin in Tirol und Innsbruck

Ohne Zusammenfassung     

Kommentar zu den Leitlinien 2010 zur kardiopulmonalen Reanimation des European Resuscitation Council

Adults

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_IO₂ 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.

Children

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 µg/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.

Newborns

Initially inflate the lungs with bag-valve mask ventilation (p_AW 20–40 cmH₂O). 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.

Postresuscitation phase

Early protocol-based intensive care stabilization; initiate mild hypothermia early regardless of initial cardiac rhythm [32–34°C for 12–24 h (adults) or 24 h (children); slow rewarming (<0.5°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.

Acute coronary syndrome

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.

Trauma

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.

Training

Any CPR training is better than nothing; simplification of contents and processes is the main aim.