ILCOR- Konsensuskonferenz in Dallas, 1.–4.2.2010

The consensus conference for elaboration of the International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR) of the International Liaison Committee on Resuscitation (ILCOR) took place from 1^st–4^th February 2010 in Dallas. The American Heart Association (AHA) and European Resuscitation Council (ERC) presided over the development of this consensus. The new guidelines for resuscitation 2010 are anticipated to be published in October 2010. The official German language translation document, which is ratified by the German Resuscitation Council (GRC), is planned to be published by the end of 2010.     

Stellenwert der Beatmung bei der Laienreanimation

The latest scientific advisory note of the American Heart Association (AHA), which was published online-first on March 31 2008, includes a call to action for bystanders witnessing an adult out-of-hospital sudden collapse probably of cardiac origin, and who are not or not sufficiently trained in cardiopulmonary resuscitation (CPR), to provide chest compression alone without ventilation (so-called compression-only CPR). Both the German Resuscitation Council (GRC) as well as the European Resuscitation Council (ERC) do not see any need for change or amendment of the actual ERC Resuscitation Guidelines in Adult Basic Life Support: “Laypeople should be encouraged to perform compression-only CPR if they are unable or unwilling to provide rescue breaths”. This statement is already included in the official Resuscitation Guidelines published by the ERC in November 2005. Bystanders, who have been trained and are confident with CPR, however, should perform resuscitation applying chest compression-ventilation until arrival of the emergency team. The training of young lay rescuers and the establishment of training programs through emergency medical organisations and in schools should be substantially promoted.     

CPR--guidelines 2000. New international guidelines for cardiopulmonary resuscitation

The "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. An International Consensus an Science" are the first true international CPR guidelines in the history of resuscitation medicine. Experts from major international resuscitation organizations (International Liaison Committee on Resuscitation, ILCOR) achieved a consensus of recommendations which had to pass a rigorous review procedure applying the tools of evidence-based medicine: all proposed guidelines or guideline changes had to be based on critically appraised pieces of evidence which had to be integrated into a final class of recommendations. The most important changes compared to previous recommendations from either the European Resuscitation Council or the American Heart Association are presented and commented upon.     

Reanimation des Neugeborenen

Although almost 10% of all newborn infants need some form of respiratory assistance after birth, only 1% will require more advanced forms of resuscitation. Because these rare events cannot always be anticipated, pediatricians and neonatologists may not be readily available and resuscitation will have to be performed by anesthesiologists. In recent years, international guidelines for neonatal resuscitation have been revised by the International Liaison Committee on Resuscitation (ILCOR), the American Academy of Pediatrics (AAP) and the American Heart Association (AHA), as well as the European Resuscitation Council (ERC). The revised guidelines describe a simplified resuscitation algorithm which emphasizes the central role of respiratory support and an increase in heart rate is judged to be the best marker for successful ventilation. In deliveries complicated by meconium-stained amniotic fluid, intrapartum suctioning of the oropharynx is no longer recommended and endotracheal suctioning is restricted to severely depressed babies. The new guidelines mention the use of the laryngeal mask airway (LMA) and CO(2) detectors without, however, making firm recommendations. The use of 100% oxygen in neonatal resuscitation is increasingly being challenged. In the rare event of a newborn whose heart rate drops below 60 beats/min, more advanced resuscitation (chest compressions using the 2-thumb-encircling-hands technique, epinephrine 10-30 mug/kgBW i.v.) will be required. Finally, the guidelines mention the possible neuroprotective effect of therapeutic hypothermia after asphyxia, but finally only recommend that hyperthermia should be avoided.     

Atemwegsmanagement

Managing the difficult airway poses an enormous challenge for anaesthesiologists, intensivists and A&E physicians, particularly because of the high probability of a potentially fatal outcome. Development and (pre-) clinical distribution of supraglottic airway devices (e.g. LMA, LT) and their enhancements, as well as the broad acceptance of awake fibre-optic intubation, led to a profound change in the strategy for managing the difficult airway. This is reflected in the revised ASA guidelines, implementing the use of the laryngeal mask airway and fibre-optic intubation. In view of the utmost importance of this topic the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) framed an independent German guideline, considering German national terms and conditions. In analogy algorithms and guidelines of the ILCOR, ERC and ATLS were revised as well as those of many other national anaesthesiological boards. Nevertheless, massive national and international deficits exist in implementing these guidelines into practice and the implicated structural requirements with respect to education, reflection, team building and equipment concerning the individual institution.     

Airway management

Managing the difficult airway poses an enormous challenge for anaesthesiologists, intensivists and A&E physicians, particularly because of the high probability of a potentially fatal outcome. Development and (pre-) clinical distribution of supraglottic airway devices (e.g. LMA, LT) and their enhancements, as well as the broad acceptance of awake fibre-optic intubation, led to a profound change in the strategy for managing the difficult airway. This is reflected in the revised ASA guidelines, implementing the use of the laryngeal mask airway and fibre-optic intubation. In view of the utmost importance of this topic the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) framed an independent German guideline, considering German national terms and conditions. In analogy algorithms and guidelines of the ILCOR, ERC and ATLS were revised as well as those of many other national anaesthesiological boards. Nevertheless, massive national and international deficits exist in implementing these guidelines into practice and the implicated structural requirements with respect to education, reflection, team building and equipment concerning the individual institution.     

Thoraxkompression ohne Beatmung bei der Laienreanimation?

Basic life support (BLS) refers to maintaining airway patency and supporting breathing and the circulation, without the use of equipment other than infection protection measures. The scientific advisory committee of the American Heart Association (AHA) published recommendations (online-first) on March 31 2008, which promote a call to action for bystanders who are not or not sufficiently trained in cardiopulmonary resuscitation (CPR) and witness an adult out-of-hospital sudden collapse probably of cardiac origin. These bystanders should provide chest compression without ventilation (so-called compression-only CPR). If bystanders were previously trained and thus confident with CPR, they should decide between conventional CPR (chest compression plus ventilation at a ratio of 30:2) and chest compression alone. However, considering current evidence-based medicine and latest scientific data both the European Resuscitation Council (ERC) and the German Resuscitation Council (GRC) do not at present intend to change or supplement the current resuscitation guidelines "Basic life support for adults". Both organisations do not see any need for change or amendments in central European practice and continue to recommend that only those lay rescuers that are not willing or unable to give mouth-to-mouth ventilation should provide CPR solely by uninterrupted chest compressions until professional help arrives. It is also stressed that the training of young people especially teenagers as lay rescuers should be promoted and the establishment of training programs through emergency medical organizations and in schools should be encouraged.     

Modifizierter Zweihelferreanimationsalgorithmus

Background

The aim of this study was to examine whether it is possible to perform resuscitation according to the present European Resuscitation Council (ERC) guidelines with a modified algorithm in the case of special, e.g. military, circumstances. On international missions of the German Armed Forces a rescue team only consists of an emergency physician and a paramedic. As the German Armed Forces require the same means of medical aid for all soldiers on every type of mission worldwide the algorithm must meet the ERC requirements.

Material and methods

In the study 20 medical teams specialized in resuscitation were examined. Of these teams 10 were from the German Armed Forces (the physician is a certified emergency physician) and 10 were civilian (the emergency physicians had up to 28 years experience). Each team was monitored as they performed resuscitation on a simulator for a period of 10?min. The patient??s airway was secured by a laryngeal tube (LT) and over-the-head chest compressions were performed by the emergency physician. During resuscitation both team members held their position. In addition to comparing all results to the ERC guidelines both groups were analyzed separately and compared to each other.

Results

The median time needed for securing the airway was 17?s without any differences between the 2 groups. In 75% of the cases the time needed for successfully securing the airway on the first attempt was less than the allowed 30?s. In 5 cases (25%) the teams did not manage to successfully install the LT during the first attempt (4 failed attempts were performed by civilian teams and 1 by the military emergency teams); however, all 5 teams were successful at the second attempt. In the cases where the placement of the LT was not successful at the first attempt the time required for the final and successful placement was nevertheless less than 40?s. During the 10?min resuscitation procedure the hands-off fraction was on average 22.4%. No differences between the two groups were noted concerning the hands-off time (133.5?s for the civilian teams and 134.5?s for the teams of the German Armed Forces). The frequency of chest compressions was above the required 100/min (for the civilian teams 110/min and for the teams of the German Armed Forces 116.5/min).

Conclusion

During military missions of the German Armed Forces there are no other options to perform resuscitation than by performing this procedure with only two rescuers. Using the algorithm in a modified way securing of the airway with an LT, the performance of over-the-head chest compressions and an effective resuscitation with advanced cardiac life support according to the ERC guidelines of 2005 are feasible even with 2 rescuers. Using the LT instead of endotracheal intubation to secure the airway particularly contributed to shortening the hands-off time.     

Leitlinien zur Reanimation 2005 – Was haben sie bewirkt, was gibt es Neues?

Under coordination of the International Liason Committee on Resuscitation (ILCOR) for several years experts all over the world allocated resuscitation measures by their level of evidence, that would lead to improved survival after cardiac arrest. Derived from the “Consensus of Science” in 2005 the European Resuscitation Council (ERC) published the reedited guidelines for cardiopulmonary resuscitation. The most important effect of the guideline changes is that external cardiac compressions can be performed for longer periods without interruptions. This has been possible since resuscitation measures that have not shown to improve survival now have to be done less frequently. Hereby it seems to be easier to perform cardiopulmonary resuscitation more efficiently and structured. But it also had to be noticed that some changes, e.g. immediate continuation of external cardiac compressions following defibrillation, are more difficult to teach. New conclusions indicate that further guideline changes can be expected.     

Kardiopulmonale Reanimation bei schwerer Hypothermie

Background

Although recent findings show that the routine use of mechanical resuscitation devices in out-of-hospital cardiac arrest showed no benefit, such devices have found widespread use by emergency services in recent years.

Method

Case report and review of the literature.

Objective

In the 2015 Guidelines for Resuscitation from the European Resuscitation Council (ERC), the use of mechanical resuscitation devices is only described for specific situations. Starting with a case report, we discuss possible meaningful scenarios for use, taking into consideration the current literature and resuscitation guidelines.

     

The workshop of cardiopulmonary resuscitation for medical doctors in Jichi Medical Hospital

The Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (ECC) established in 2000 (Guidelines 2000) are the standard for cardiopulmonary resuscitation (CPR) all over the world. Written guidelines based on Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) are widely available throughout Japan and are studied by physicians but ACLS training courses have been made available only recently. In 2003, our hospital formed a committee to address standards of patient safety and one of the recommendations of the committee was the attendance of standardized BLS by health care workers and of ACLS by physicians. In May, 2003 a total of 447 physicians from our hospital participated in a workshop on BLS which provided lectures, demonstrations and a written examination. After completion of this workshop, it has been concluded that standardization in the area of resuscitation is mandatory, and efforts to disseminate this workshop to health care practitioners are to be undertaken.     

Leitlinien zur Reanimation 2005 – Umsetzung im Rettungsdienst

Guidelines become effective only when they are adhered to during the course of everyday work. The question that then arises is how current scientific knowledge of cardiopulmonary resuscitation is put into practice by the professionals involved in emergency medical services. To begin with, a German translation of the complete text of the 2005 guidelines issued by the European Resuscitation Council was published promptly. Subsequently the guidelines had to be adopted nationwide by the German Medical Association as well as locally. At the regional level new concepts for organization and process structures had to be established. Theoretical and practical courses acquainted participants with the changes in resuscitation workflows. As part of quality management, documentation was instituted, analysis performed, and feedback gathered regarding implementation of the new clinical guidelines into practice, especially during the first year. By constantly updating the workflow, the goal of improving the patients’ outcome after resuscitation will continue to be pursued.     

Ausbildungskonzepte des European Resuscitation Council (ERC)

The European Resuscitation Council (ERC) is the interdisciplinary professional association in Europe for resuscitation and medical emergencies. The mission of the ERC is to save lives by continuously improving the standard in resuscitation. Based on international consensus, the ERC thus formulates guidelines for cardiopulmonary resuscitation, which conform to current scientific knowledge and European requirements. In addition, it offers programs for basic and advanced training and continuing education for anyone who may be confronted by a situation in which resuscitation is needed.     

Erstversorgung, Reanimation und Transport von Neugeborenen

The primary care of neonate poses a particular challenge to those unpracticed in administering first aid. In most cases it suffices to dry off the newborn child after birth, stimulate respiration, and provide warm towels. Expert measures are necessary for a minority of full-term neonates, and for premature infants this need increases in direct relation to the degree of immaturity. The international Liaison Committee on Resuscitation (ILCOR) has developed internationally valid guidelines. These recommendations are not usually based on data from controlled studies but rather on currently recognized experience and teaching theory. Well-trained personnel should be available during every delivery to provide basic care of neonates. For full-scale resuscitation measures, a specialized team is indispensable. The subsequent transport to a clinic represents a strain on the neonate and is associated with special risks. This report presents the ILCOR recommendations and clinical/practical aspects of transporting a newborn child.     

Intraossäre Fehlpunktion

In cases of emergency it can sometimes be difficult or even impossible to achieve peripheral venous access. However, intraosseous (IO) devices enable vascular access even under adverse conditions due to the abundant, non-collapsible intramedullary vessels which are able to rapidly transport drugs and infusions to the central circulation. Therefore, the current European Resuscitation Council (ERC) guidelines favour IO access even in adults if rapid peripheral venous catheterization is not possible. Appropriate training in homologous IO devices is imperative for successfully achieving vascular access. Lacking or insufficient training may lead to complications. The present article describes a case of incorrect IO device application on a severely injured patient in the resuscitation room. Flawed patient positioning and incorrect handling of the IO device led to displacement of the device. Therefore, the intraosseous administration of drugs or infusions was not possible.     

Akutes Koronarsyndrom

BACKGROUND: The acute coronary syndrome (ACS) with 16% is one of the most common indication for emergency missions. Care of ACS patients in the Heidelberg emergency service region has been carried out since the beginning of 2005 following an interdisciplinary developed concept based on the current guidelines of the German Society for Cardiology (DGK), the American College of Cardiology (ACC), the American Heart Association (AHA), the European Society of Cardiology (ESC) and the European Resuscitation Council (ERC).MATERIALS AND METHODS: Evaluation of the emergency diagnostic and therapeutic measures for the diagnosis of ACS before and after the introduction of the ACS care concept, was carried out retrospectively for the years 2004 (group 1) and 2005 (group 2) by electronic data processing of the records stored in the emergency medical services documentaion system (NADOK).RESULTS: In the years 2004 before (group 1, n=633) and 2005 after (group 2, n=628) introduction of the ACS care concept, there was a comparable basic diagnostic consisting of a 3-lead electrocardiogram (ECG; 95 versus 97%), manual blood pressure measurement (93 versus 95%) and pulse oxymetry (94 versus 91%) as well as a comparable proportion of patients who received a peripheral vene access (99 versus 100%). There were no significant differences between the two groups. However, after the introduction of the ACS concept, the 12-lead ECG was used significantly more often (49 versus 71%, p=0.0001). Furthermore, a guideline-conform medicinal treatment of ACS patients was used inceasingly more often for anticoagulation with heparin/acetylsalicylic acid (75 versus 84%,p=0.0001) and the use of beta-receptor blockers (32 versus 39%, p=0.009) after introduction of the ACS concept.CONCLUSIONS: The introduction of a regional care concept leads to an optimisation of guideline-conform prehospital treatment for ACS patients.     

Der Einsatz des intraoss?ren Zugangs im pr?klinischen Notarztdienst

Background

Since 2005 the European Resuscitation Council (ERC) has recommended an intraosseous access as an early alternative for difficult vein situations in the guidelines for emergency medical services. But how does the theory succeed in routine practice? Using a survey of rescue assistants and physicians, the authors found that the intraosseous infusion technique is still a rarity in the Berlin emergency medical service and therefore presumably nationwide, 5?years after a revision of its importance.

Materials and methods

Within a preclinical prospective observational study with before and after analyses, it was shown that use of an intraosseous access according to the guidelines can be reasonably and efficiently integrated into treatment algorithms of preclinical emergency medical services by the use of modern products.

Results

During a period of 10.5?months an intraosseous access was established in a very short time in 100?patients with no complications and independent of the experience of the operator, because the timely placement of a peripheral venous access was not possible. This corresponds to an average frequency of 2.2?per week or 9.5?per month and a proportion of 4.5% of the total patient collective or 22.7% of patients estimated to be in a life-threatening situation. The application of the intraosseous technique increased accordingly by a factor of 7 to 27.2?per 1,000?alarm calls by the implementation of the guidelines.

Conclusions

Intraosseous access is a simple aid to minimize the therapy-free time even with limited personnel resources. Its use in preclinical emergency medical services seems, however, to be more of a rarity than a standard and does not therefore correspond to the evidence-based recommendations of the professional societies.     

What cardioversion protocol for ventricular fibrillation should be followed for patients who arrest shortly post-cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was how many cardioversion attempts should be performed for patients who have gone into ventricular fibrillation post-cardiac surgery prior to performing chest reopening. Using the reported search, 1183 papers were identified. Fifteen papers represented the best evidence on the subject. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. The quality and level of evidence was assessed using the International Liaison Committee of Resuscitation guideline recommendations. The most recent European Resuscitation Council guidelines suggest single attempts at cardioversion, spaced at 2-min intervals, for all patients going into ventricular fibrillation or pulseless ventricular tachycardia. Cardiac surgery presents a unique challenge for these guidelines in that emergency re-sternotomy may provide additional lifesaving interventions once it is deemed that external cardioversion is unlikely to succeed. The 15 papers identified demonstrated that the success of the first attempt at cardioversion for VF/VT was around 78%. The chance of the second shock succeeding was around 35%. The chance of a third shock succeeding was 14%. Very little data were found on the chance of further shocks succeeding. Of note none of these papers were in patients on the intensive care after cardiac surgery. We conclude that, due to the importance of minimising the delay to chest reopening, three shocks should be quickly delivered. If these do not succeed the chance of a 4th shock succeeding is likely to be <10% and, thus, immediate chest reopening should be performed. (This is a Class-IIa recommendation using ILCOR guideline recommendations.).     

Psychopharmakotherapie im Notarztdienst

Part two of the CME article Psychotropic agents and psychopharmacotherapy in emergency medicine aims to give an understanding of the pharmacotherapy of psychiatric disorders in emergency medicine. In contrast to somatic emergencies, many emergency physicians are not familiar with the treatment of psychiatric emergencies, although there are guidelines and recommendations. In the following article, treatment recommendations for the 5 most common and relevant syndromes in emergency medicine (i.e., suicide, delirium, agitation, stupor, and syndromes due to psychopharmaceutical use) are described based on the German S2-Guideline Emergency Psychiatry that will be published soon.     

Ethische Aspekte der präklinischen Notfallversorgung

Ethical problems take on a special character in preclinical emergency medicine.Decisions are characterized by the acute need for action and the lacking possibility to consult with colleagues.This makes it all the more urgent to analyze ethically problematic situations beforehand to support the emergency staff in their decisions.This review tries to help in this task by analyzing three fields of special importance in the preclinical context: “The lived experience of patients and relatives”,“Patient autonomy and advance directives” and “Futile therapy”.Additionally we will discuss the ethical part of the Guidelines 2000 and the recommendations of the German national board of physicians (Bundesärztekammer) on these topics and propose some ethical indications for the practice of preclinical emergency medicine.