Einfluss der Basisreanimationsma?nahmen durch Laien auf das überleben nach pl?tzlichem Herztod

Background

Bystander cardiopulmonary resuscitation (CPR) is mandatory to shorten no-flow time. The present study aimed to evaluate the factors age, gender, etiology and location of out-of-hospital cardiac arrest (OHCA) in relation to bystander CPR based on the German resuscitation registry (GRR) database.

Methods

Retrospective analyses from the German resuscitation registry including data from adult OHCA patients registered from 01/2004 to 07/2011 (n?=?11,788). The data set preclinical care included demographic factors, presumed etiology, location of collapse, any return of spontaneous circulation (ROSC) and survival to hospital admission.

Results

Patients with OHCA witnessed by bystanders (n?=?5,659) received bystander CPR significantly more often compared with non-witnessed OHCA (p?<?0.01; OR: 4.19; CI 95% 3.70–4.67) and had significantly increased ROSC (p?<?0.01) and survival to hospital admission (p?<?0.01). The incidence of bystander CPR was highest in younger patients (18–20 years; 25%) and lowest in elderly patients (>?80 years; 12%). Bystander CPR of witnessed OHCA was performed significantly less often at private homes compared with public areas (p?<?0.01, OR: 0.37; CI95% 0.33–0.42).

Conclusions

Lay people initiate CPR independently from witnessing in OHCA patients who are younger than 20 years and where OHCA occurred at the workplace. Considering the high number of OHCA witnessed by lay persons but the generally poor incidence of bystander CPR in the case of witnessing, in particular at non-public areas, modifications in bystander CPR training strategy are needed.     

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.

     

Mechanische Reanimationshilfen

In Germany 100,000–160,000 people suffer from out-of-hospital cardiac arrest (OHCA) annually. The incidence of cardiopulmonary resuscitation (CPR) after OHCA varies between emergency ambulance services but is in the range of 30–90 CPR attempts per 100,000 inhabitants per year. Basic life support (BLS) involving chest compressions and ventilation is the key measure of resuscitation. Rapid initiation and quality of BLS are the most critical factors for CPR success. Even healthcare professionals are not always able to ensure the quality of CPR measures. Consequently in recent years mechanical resuscitation devices have been developed to optimize chest compression and the resulting circulation. In this article the mechanical resuscitation devices currently available in Germany are discussed and evaluated scientifically in context with available literature. The ANIMAX CPR device should not be used outside controlled trials as no clinical results have so far been published. The same applies to the new device Corpuls CPR which will be available on the market in early 2014. Based on the current published data a general recommendation for the routine use of LUCAS? and AutoPulse® CPR cannot be given. The preliminary data of the CIRC trial and the published data of the LINC trial revealed that mechanical CPR is apparently equivalent to good manual CPR. For the final assessment further publications of large randomized studies must be analyzed (e.g. the CIRC and PaRAMeDIC trials). However, case control studies, case series and small studies have already shown that in special situations and in some cases patients will benefit from the automatic mechanical resuscitation devices (LUCAS?, AutoPulse®). This applies especially to emergency services where standard CPR quality is far below average and for patients who require prolonged CPR under difficult circumstances. This might be true in cases of resuscitation due to hypothermia, intoxication and pulmonary embolism as well as for patients requiring transport or coronary intervention when cardiac arrest persists. Three prospective randomized studies and the resulting meta-analysis are available for active compression-decompression resuscitation (ACD-CPR) in combination with an impedance threshold device (ITD). These studies compared ACD-ITD-CPR to standard CPR and clearly demonstrated that ACD-ITD-CPR is superior to standard CPR concerning short and long-term survival with good neurological recovery after OHCA.     

Improved survival after an out-of-hospital cardiac arrest using new guidelines

Background: An out-of-hospital cardiac arrest (OHCA) is associated with a poor prognosis. We hypothesized that the implementations of 2005 European Resuscitation Council resuscitation guidelines were associated with improved 30-day survival after OHCA.
Methods: We prospectively recorded data on all patients with OHCA treated by the Mobile Emergency Care Unit of Copenhagen in two periods: 1 June 2004 until 31 August 2005 (before implementation) and 1 January 2006 until 31 March 2007 (after implementation), separated by a 4-month period in which the above-mentioned change took place.
Results: We found that 30-day survival increased after the implementation from 31/372 (8.3%) to 67/419 (16%), P =0.001. ROSC at hospital admission, as well as survival to hospital discharge, were obtained in a significantly higher proportion from 23.4% to 39.1%, P <0.0001, and from 7.9% to 16.3%, P =0.0004, respectively. Treatment after implementation was confirmed as a significant predictor of better 30-day survival in a logistic regression analysis.
Conclusion: The implementation of new resuscitation guidelines was associated with improved 30-day survival after OHCA.     

Welcher Patient profitiert von einem Transport unter laufender kardiopulmonaler Reanimation?

Background

Mortality in patients with out-of-hospital cardiac arrest (OHCA) remains very high despite advances in resuscitation algorithms. Most of these patients die at the scene and do not reach hospital. It is currently the subject of discussion whether transport to hospital with ongoing cardiopulmonary resuscitation (CPR) improves survival and neurological outcome in patients with OHCA.

Objective

The aim of this study was to identify predictors of survival and good neurological outcome in patients after OHCA who were transported to hospital with ongoing CPR.

Patients and methods

A total of 70 consecutive patients with refractory OHCA (mean age 54.7?±?15 years) transported to hospital with ongoing CPR were retrospectively analyzed. Neurological outcome was assessed after 30 days based on the Glasgow-Pittsburgh cerebral performance category (CPC).

Results

After 30 days 82.9% of the patients enrolled in the trial died (CPC score of 5), 8 patients (11.4%) showed a good neurological recovery with CPC scores of 1–2 and 4 patients (5.7%) had a poor neurological outcome with CPC scores of 3–4. Predictors of good neurological outcome were witnessed arrest, initial defibrillatable rhythm and serum lactate levels on admission. In all patients with good outcome, the index event for OHCA was from cardiac causes.

Conclusion

Selected patient collectives can benefit from transport to hospital with ongoing cardiopulmonary resuscitation (CPR).

     

Importance of comorbidities in comatose survivors of shockable and non-shockable out-of-hospital cardiac arrest treated with target temperature management

Objective. Comorbidity prior to out-of-hospital cardiac arrest (OHCA) and primary rhythm in relation to survival is not well established. We aimed to assess the prognostic importance of comorbidity in relation to primary rhythm in OHCA-patients treated with Target Temperature Management (TTM). Design. Consecutive comatose survivors of OHCA treated with TTM in hospitals in the Copenhagen area between 2002–2011 were included. Utstein-based pre- and in-hospital data collection was performed. Data on comorbidity was obtained from The Danish National Patient Register and patient charts, assessed by the Charlson Comorbidity Index (CCI). Results. A total of 666 patients were included. A third (n?=?233, 35%) presented with non-shockable rhythm, and they were less often male (64% vs. 82%, p?p?p?p?p?p?=?.34). No significant interaction between primary rhythm and comorbidity in terms of mortality was present. Conclusion. A higher comorbidity burden was independently associated with a higher 30-day mortality rate in patients presenting with non-shockable primary rhythm but not in patients with shockable rhythm.     

In-hospital resuscitation

A recent world expert conference on resuscitation and emergency cardiac care led to evidence-based international guidelines for cardiopulmonary resuscitation (CPR). Several changes to CPR interventions were recommended, and will have to be implemented into clinical practice. The poor prognosis of patients who suffer in-hospital cardiac arrest may be improved with developments in CPR interventions. In the present review the most important changes recommended by the new CPR guidelines and the latest promising CPR investigations are described, focusing on their impact on in-hospital resuscitation.     

Adrenaline administration during cardiopulmonary resuscitation: poor adherence to clinical guidelines

BACKGROUND: Adrenaline does not appear to improve the outcome after cardiac arrest in clinical trials in spite of beneficial effects in experimental studies. The objective of this study was to determine whether adrenaline was administered in accordance with advanced cardiac life support (ACLS) guidelines during adult cardiopulmonary resuscitation (CPR). METHODS: From 15 January to 31 December 2000, all patients at Uppsala University Hospital in whom CPR was attempted were registered prospectively. The duration of CPR was documented in the register and the total dose of adrenaline was retrieved retrospectively from patient records. From these data the average interval between adrenaline doses was calculated. RESULTS: Data for evaluation of the between-dose interval of adrenaline was available in 53 of 107 registered cardiac arrests. In 68% (36/53) the average between-dose interval was longer than the 3-5 min recommended in the guidelines, and 8% (4/53) received no adrenaline. The median interval between adrenaline doses during CPR was 6.5 min (25th-75th percentile: 5.1-10.4). Adherence to guidelines was lower in out-of-hospital cardiac arrest than in in-hospital cardiac arrest (P = 0.01). CONCLUSIONS: In the majority of cases adrenaline did not appear to be administered according to current ACLS guidelines.     

Temporal variation in out-of-hospital cardiac arrest with validated cardiac cause

Objective. Temporal variations in the occurrence of out-of-hospital cardiac arrest (OHCA) have been shown. Most previous studies have in common that they include individuals whom have received cardiopulmonary resuscitation (CPR) and thus excluding a great number of all the actual cases of OHCA when conducting a study. Therefore the aim of this study was to describe temporal variations of OHCA, regardless of whether CPR was performed or not. Design. All individuals aged 25–74 years in northern Sweden, 1989–2009, who suffered an out-of-hospital cardiac arrest with validated myocardial infarction aetiology (OHCA-V), regardless of whether CPR was performed or not, were included in this study, which resulted in 3357 individuals. Results. Regarding the diurnal variation, a daytime excess of OHCA-V was seen, with most occurring between 12:00–17:59 (29%) closely followed by the 06:00–11:59 time block (27%). In terms of the weekly variation, most OHCA-V was seen on Saturdays (17%), while January (11%), followed by December (9%), saw the highest incidence of the months. Conclusion. A temporal variation in OHCA-V is seen even when including cases where no CPR is attempted. However, this variation differs in some aspects to what some previous studies have shown, in that no clear morning or Monday peaks were seen. In order to explore potential triggers and underlying factors that influence OHCA, more studies like these are needed, preferably following standardized inclusion criteria and definitions of OHCA to better be able to compare results, all in order to develop the best possible preventive strategies.     

Quality of clinical care provided during simulated pediatric cardiac arrest: a simulation-based study

We sought to assess compliance to resuscitation guidelines during pediatric simulated cardiac arrests in a pediatric intensive care unit (PICU) and to identify performance gaps to target with future training. In a prospective observational study in a PICU, ten cardiac arrest scenarios were developed for resuscitation training and video recorded. The video recordings were examined for times to start cardiopulmonary resuscitation (CPR), delivery of first shock, CPR quality (rate, depth), length of pauses, chest compression fraction (CCF), ventilation, pulse/rhythm assessment, compressors’ rotation, and leader’s behaviours. The primary outcome was percentage of events compliant to Pediatric Advance Life Support guidelines. Compliance to guidelines was poor in the 23 simulation events studied. The median [interquartile range] time to start CPR was 29 [16–76] sec and 320 [245–421] sec to deliver the first shock. A total of 306 30-sec epochs of CPR were analyzed; excellent CPR (≥ 90% compressions in target for rate and depth) was achieved in 22 (7%) epochs. More than a quarter of the CPR pauses lasted > 10 seconds (33/127, 26%) with just one task performed in most of them; CCF was ≥ 80% in 19/23 (82.6%) events. Ventilation rate for intubated patients was greater than 10 breaths·min−1 in 15/27 (56%) of one-minute epochs observed. Review of simulated resuscitation events found suboptimal compliance with resuscitation guidelines, particularly the times to starting CPR and delivering the first shock, as well as compression rate and depth.     

Emergency medicine and myocardial ischaemia - thrombolysis during cardiopulmonary resuscitation - available data and recommendations

Patients suffering cardiac arrest still have a poor prognosis. Up to the present, no drug therapy has shown to improve longterm survival after cardiac arrest. Acute myocardial infarction (AMI) or massive pulmonary embolism (PE) are the underlying causes for sudden cardiac arrest in 50-70 % of patients. Thrombolysis is an effective and causal therapy in patients with AMI or PE. Therefore, combining cardiopulmonary resuscitation (CPR) with thrombolysis may be a promising therapeutic approach. Experimental studies have demonstrated that thrombolytic therapy during CPR is not only a causal treatment for coronary or pulmonary arterial thrombi, but may also improve microcirculatory reperfusion after cardiac arrest. Although numerous case series and small clinical studies showed evidence for the success of thrombolytic therapy during CPR, a large randomised study did not confirm these results. Thrombolysis during CPR today can not be recommended as a standard therapy in patients suffering cardiac arrest. However, it should be considered if a massive PE is supposed to be the cause of cardiac arrest or if conventional CPR has not been successful in a patient with presumed thrombotic cause of cardiac arrest. The expected bleeding risk is outweighed by the potential benefit of this therapy in selected patients.     

肝素预抗凝对窒息性心跳骤停大鼠心肺脑复苏效果的影响

目的 评价肝素预抗凝对窒息性心脏停搏大鼠心肺脑复苏效果的影响。方法 SD雄性大鼠70只，8-9周龄，体重350-450 g，随机分为4组：正常对照组（组Ⅰ，n=10）、假手术组（组Ⅱ， n=10）、心跳骤停-复苏组（组Ⅲ，n=25）和预抗凝组（组Ⅳ，n=25），组Ⅳ窒息前静脉注射肝素50 IU／100 g。组Ⅲ、组Ⅳ窒息导致大鼠心脏停搏后5 min开始心肺复苏术。于窒息前（基础值）、复苏成功后即刻、10、30、60min时记录大鼠平均动脉压（MAP）、心率（HR）、直肠温度（RT）和呼气末二氧化碳分压（PETCO2）。记录大鼠心脏停搏、心肺复苏及气管导管拔除的时间。于麻醉前、复苏成功后2、24、48、72 h对大鼠神经系统损伤进行行为学评分（ND评分）。光学显微镜下对复苏成功后72 h大鼠海马、皮层、丘脑、小脑以及壳-尾核进行组织病理损伤评分（HD评分）。结果 MAP、HR、BT和PETCO2基础值组间相比差异无统计学意义（P〉0．05）。与组Ⅲ相比，组Ⅳ复苏成功后即刻MAP明显升高，心脏停搏时间延长，复苏时间以及气管导管拔除时间明显缩短（P〈0．01），心肺复苏成功率及72 h存活率明显升高（P〈0．05），ND和HD评分明显降低（P〈0．05）。结论 肝素预抗凝可明显提高窒息性心跳骤停大鼠心肺复苏的效果，减轻复苏后脑组织损伤，改善心肺脑复苏的转归。     

Cardiopulmonary resuscitation: when guidelines provide no answers

Die Anaesthesiologie - Out of hospital cardiac arrest (OHCA) is encountered on a&nbsp;regular basis in prehospital care. Specific guidelines exist for cardiopulmonary resuscitation. Guidelines...     

大鼠窒息性心跳骤停-心肺复苏改良模型的评价

目的 评价大鼠窒息性心跳骤停-心肺复苏改良模型.方法 雄性SD大鼠15只,2～3月龄,体重350～400 g,麻醉后经口气管插管,机械通气,连续监测心电图、MAP、HR、PETCO2和直肠温度,并维持在正常范围内.静脉注射维库溴铵2 ms/kg后机械通气,5～8 min后再次静脉注射维库溴铵1 mg/kg,1 min后停止机械通气,制备窒息性心跳骤停模型.窒息8 min后,开始药物和标准胸外按压进行心肺复苏(CPR).记录从窒息到心跳骤停的时间、CPR到自主循环恢复的时间、拔管时间,并记录CPR成功及复苏成功后3 d生存的情况.结果 窒息8 min可造成至少4～5 min心跳骤停.CPR开始后2 min内可逆转心跳骤停,使自主循环恢复(MAP>60 mm Hg).从窒息到心跳骤停的时间为(116±12)s,从CPR到自主循环恢复的时间为(42±12)s,拔管时间为(6.9±1.4)h.CPR成功率93%,复苏成功后3 d生存率86%.与窒息前比较,自主循环恢复后即刻、10 min时MAP、HR和PETCO2升高(P<0.05或0.01).结论 大鼠窒息性心跳骤停-心肺复苏改良模型成功率及复苏成功后3 d生存率高,模型稳定,可重复性好,可作为CPR研究的实验动物模型.     

Comparable Outcome of Out‐of‐Hospital Cardiac Arrest and In‐Hospital Cardiac Arrest Treated With Extracorporeal Life Support

Extracorporeal life support (ECLS) has shown benefits in the management of refractory in‐hospital cardiac arrest (IHCA) by improving survival. Nonetheless, the results concerning out‐of‐hospital refractory cardiac arrests (OHCA) remain uncertain. The aim of our investigation was to compare survival between the two groups. We realized a single‐center retrospective, observational study of all patients who presented IHCA or OHCA treated with ECLS between 2011 and 2015. Multivariate analysis was realized to determine independent factors associated with mortality. Over the 4‐year period, 65 patients were included, 43 in the IHCA group (66.2%), and 22 (33.8%) in the OHCA group. The duration of low flow was significantly longer in the OHCA group (60 vs. 90 min, P = 0.004). Survival to discharge from the hospital was identical in the two groups (27% in the OHCA group vs. 23% in the IHCA group, P = 0.77). All surviving patients in the OHCA group had a cerebral performance categories score of 1–2. In multivariate analysis, we found that the initial lactate level and baseline blood creatinine were independently associated with mortality. We found comparable survival and neurological score in patients who presented IHCA and OHCA treated with ECLS. We believe that appropriate selection of patients and optimization of organ perfusion during resuscitation can lead to good results in patients with OHCA treated with ECLS.     

Use of renal replacement therapy after out-of-hospital cardiac arrest in Denmark 2005–2013

Abstract

Objectives: Renal replacement therapy (RRT) is used to treat acute kidney injury as part of multi organ failure. Use and prognostic implications after out-of-hospital cardiac arrest (OHCA) is not well known.

This study aims to assess incidence and use of RRT and whether RRT post-arrest was associated with 30-day mortality in Denmark in the years 2005–2013. Methods: The Danish Cardiac Arrest Registry holds information on all OHCA patients in Denmark from 2005 to 2013. We identified 3,012 one-day survivors of OHCA ≥18 years, with presumed cardiac aetiology of arrest, admitted to ICU without previous RRT. Change in use of RRT during the study period was assessed using competing risk analysis. Mortality was assessed with Cox regression. Results: On average, RRT was performed in 6% of the patient population with an average annual 1% increase, HR: 1.01, CI: 0.95–1.07, p?=?.69. Hazard of RRT was lower in patients receiving bystander cardiopulmonary resuscitation (CPR) (p?<?.001), patients with a shockable primary rhythm (p?=?.009) and elderly patients (p?=?.03). Socioeconomic factors did not influence hazard of RRT, but patients admitted to tertiary centres had higher hazard of RRT (p?=?.009).

Use of RRT was associated with increased mortality in multivariate Cox regression (HR: 1.28, CI: 1.06–1.55, p?=?.01). Conclusion: Use of RRT as part of post resuscitation care following OHCA did not increase from 2005 to 2013; use was more common in tertiary centres and in patients with negative prehospital predictors (no bystander CPR, non-shockable rhythm). RRT was associated with increased mortality.     

ILCOR hot topics

Cardiovascular disease is the world’s leading cause of death. Extrapolation of a representative incidence and survival analysis from cardiac arrest in all rhythms treated by the emergency medical services (out-of-hospital cardiac arrest, OHCA) leads to numbers of 350,000 persons who experience OHCA in Europe [10]. The number mentioned above and the fact that the impact of single therapeutic measures on improvement of individual survival is unclear requires standard procedures that lead to the best possible outcome for as many patients as possible. Beyond the actions of basic life support, only a few advanced life support measures have definitely proven to be of value for ROSC (return of spontaneous circulation) and improved neurological outcome: defibrillation, some pharmacological interventions and hypothermia. ILCOR (International Liaison Committee on Resuscitation) is co-ordinating again an evidence-based review of resuscitation science, which will culminate in a Consensus Conference in February 2010. This will provide material for the ERC to write the new resuscitation guidelines. What changes can we expect?     

ERC 2010 guidelines for adult and pediatric resuscitation: summary of major changes

The new European Resuscitation Council (ERC) guidelines for cardiopulmonary resuscitation (CPR) published on October 18th, 2010, replace those published in 2005 and are based on the latest International Consensus on CPR Science with Treatment Recommendations (CoSTR). For both adult and pediatric resuscitation, the most important general changes include: the introduction of chest compression-only CPR in primary cardiac arrest as an option for rescuers who are unable or unwilling to perform expired-air ventilation; increased emphasis on uninterrupted, good-quality CPR and minimisation of both pre- and post-shock pauses during defibrillation. For adult resuscitation, the recommended chest compression depth and rate are 5-6 cm and 100-120 compressions per minute, respectively. Both a specific period of CPR before defibrillation during out-of-hospital resuscitation and use of endotracheal route for drug delivery during advanced life support are no longer recommended. During postresuscitation care, inspired oxygen should be titrated to obtain an arterial oxygen saturation of 94-98%, to avoid possible damage from hyperoxemia. In pediatric resuscitation, the role of pulse palpation for the diagnosis of cardiac arrest has been de-emphasised. The compression-to-ventilation ratio depends on the number of rescuers available, and a 30:2 ratio is acceptable even for rescuers with a duty to respond if they are alone. Chest compression depth should be at least 1/3 of the anterior-posterior chest diameter. The use of automated external defibrillators for children under one year of age should be considered.     

Paediatric cardiac arrest and resuscitation provided by physician-staffed emergency care units

Background: Most paediatric cardiac arrest studies have been conducted in the USA, where paramedics provide prehospital emergency care. We wanted to study the outcome of paediatric cardiac arrest patients in an emergency medical system which is based on physician staffed emergency care units.
Methods: We analysed retrospectively the files of 100 prehospital cardiac arrest patients from Southern Finland during a 10-year study period. The patients were less than 16 years of age.
Results: Fifty patients were declared dead on the scene (DOS) without attempted resuscitation, and cardiopulmonary resuscitation (CPR) was initiated in 50 patients. The sudden infant death syndrome was the most common cause of arrest in the DOS patients (68%) as well as in those receiving CPR (36%). Asystole was the initial cardiac rhythm in 70% of the patients in whom CPR was attempted. Resuscitation was successful in 13 patients, 8 of whom were ultimately discharged. Six of the patients survived with mild or no disability and 4 of them had near-drowning aetiology. In multivariate analysis, the short duration of CPR (≤15 min) was the only factor significantly associated with better survival.
Conclusions: Although prehospital care was provided by physicians, the overall rate of survival was found to be equally poor as reported from systems with paramedics. The only major difference between physician- and paramedic-staffed emergency care units is the ability of physicians to refrain from resuscitation already on the scene when prognosis is poor.