"Highlights" in emergency medicine -- severe head trauma, polytrauma and cardiac arrest

According to scientific publications focusing on emergency medicine and published in international journals in the past few months, new and clinically important results can be identified. In patients with severe head trauma (SHT), application of hypertonic solutions is possible; long term outcome, however, is not improved by this measure. Prehospital capnometry is important, because otherwise up to 40 % of all mechanically ventilated patients are hypoventilated. In a study in 200 patients with prehospital cardiac arrest and ventricular fibrillation as initial cardiac rhythm, subgroup analysis (alarm-response time > 5 min) showed an increase in survival rate (14 % vs. 2 %), if defibrillation was proceeded by 3 min of conventional cardiopulmonary resuscitation (CPR) for reperfusion. If ACD ("active compression decompression")-CPR is combined with a specific ventilatory valve ("inspiratory impedance threshold device", ITD) which does not allow passive inspiration, survival rate after cardiac arrest is increased for up to 24 h. Such a device facilitates an increase in venous return to the heart during decompression of the thorax. High-dose adrenalin for intrahospital CPR in children is not associated with better survival but with worse outcome. Comparison of an emergency medical service (EMS) system from U.K. with paramedics and a physician-staffed German EMS system demonstrated that survival rate following prehospital cardiac arrest is markedly increased with doctors on board. The European multicentre trial comparing vasopressin vs. adrenalin as first vasopressor during CPR in 1219 patients did not reveal any differences between both groups. In subgroup analyses of patients with asystoly and prolonged CPR, vasopressin was superior without being associated with a benefit on neurological outcome. Further subgroup analyses revealed beneficial effects of amiodarone and thrombolysis during CPR. Thrombolysis during CPR apears to be associated with an increased rate of haemodynamic stabilisation without increased risk of bleeding complications. In a very clear advisory statement, the "International Liaison Committee on Resuscitation" (ILCOR) has recommended mild therapeutic hypothermia (i. e., cooling of cardiac arrest victims to 32 - 34 degrees C central body temperature for 12 - 24 h following cardiac arrest of cardiac etiology) not only for unconciuous patients with ventricular fibrillation as initial prehospital rhythm, but also for all other adult patients (other rhythms, intrahospital CPR) following cardiac arrest. In randomised controlled clinical trials, this therapy has markedly improved survival rate and neurological outcome. Such therapeutic cooling can be initiated nearly everywhere and with simple methods - like the infusion of ice-cold cristalloid solutions.