Aktuelle Literatur aus der Notfallmedizin

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1 Aktuelle Literatur aus der Notfallmedizin prä- und innerklinisch Aktuelle Publikationen aus 2012 / 2013 PubMed hits zu emergency medicine 12,599

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3 Abstract OBJECTIVES: Current American Heart Association guidelines recommend standardized interval administration of epinephrine for patients in cardiac arrest. The objective of this study was to compare short-term survival using a hemodynamic directed resuscitation strategy versus chest compression depth-directed cardiopulmonary resuscitation in a porcine model of cardiac arrest. After 7 minutes of ventricular fibrillation, pigs were randomized to receive one of three resuscitation strategies: 1) Hemodynamic directed care (coronary perfusion pressure-20): chest compressions with depth titrated to a target systolic blood pressure of 100 mm Hg and titration of vaso pressors to maintain coronary perfusion pressure greater than 20 mm Hg; 2) Depth 33 mm: target chest compression depth of 33 mm with standard American Heart Association epinephrine dosing; or 3) Depth 51 mm: target chest compression depth of 51 mm with standard American Heart Association epinephrine dosing. RESULTS: Forty-five-minute survival was higher in the coronary perfusion pressure-20 group (8 of 8) compared to depth 33 mm (1 of 8) or depth 51 mm (3 of 8) groups; p equals to Coronary perfusion pressures were higher in the coronary perfusion pressure-20 group compared to depth 33 mm (p =0.004) and depth 51 mm (p = 0.006) and in survivors compared to nonsurvivors (p <0.01). Total epinephrine dosing and defibrillation attempts were not different. CONCLUSIONS: Hemodynamic directed resuscitation targeting coronary perfusion pressures greater than 20 mm Hg during 10 minutes of cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest improves short-term survival, when compared to resuscitation with depth of compressions guided to33 mm or 51 mm and standard American Heart Association vaso pressor dosing.

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5 Abstract BACKGROUND: In emergency medicine intraosseous access (IOA) has been established as an alternative to conventional intravenous access. Originally the use of IOA was strictly limited to children up to 6 years of age and to adults for cardiopulmonary resuscitation. These limitations have been relaxed and the indications for IOA have been expanded. MATERIAL AND METHODS: A retrospective nationwide analysis of rescue missions by all helicopter emergency medical services of the German Automobile Club (ADAC) Air Rescue Service as well as the German Air Rescue (DRF) over a 7-year period was carried out. RESULTS: A total of 466,813 patients were treated during the study period and an IOA was established in 1,498 (0.32 %) patients. There was a significant increase in using an IOA from % (p < 0.05) from 2005 to Furthermore, there was an increase in using an IOA in elderly patients and in patients with lower degrees of severity according to the National Advisory Committee for Aeronautics (NACA) scales ( ): decreased use of IOA in patients up to 6 years of age from 92.4 % to 19.7 % (p < 0.05) and in patients with NACA grades VII/VI from 74.4 % to 46.6 % (p < 0.05) and temporarily limited increase of non-indicated IOA use in patients with NACA grade III between 2008 and Furthermore, there was an increase in the number of the different drug groups used for intraosseous infusion over the study period. CONCLUSION: The current guidelines and recommendations for the use of IOA in the prehospital setting are reflected more and more in mission reality for helicopter emergency medical services.

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7 Abstract BACKGROUND: Airway management and prehospital emergency medicine are of particular interest as both categories frequently show very dynamic developments. Incidents in this particular area can lead to serious injury but at the same time it has never been analyzed what kind of incidents might harm patients during prehospital airway management. MATERIALS AND METHODS: The German website (CIRS critical incident reporting systems) offers anonymous reporting of critical incidents in prehospital emergency medicine. All incidents reported between 2005 and 2012 were screened to identify those which were concerned with airway management and four experts in this field analyzed the incidents and performed a root cause analysis. RESULTS: The database contained 845 reports. The authors considered 144 reports to be airway management related and identified 10 root causes: indications for intubation but no intubation performed (n = 8), no indications for intubation but intubation attempt performed (n = 7), wrong medication (n = 25), insufficient practical skills (n = 46), no use of alternative airway management (n = 7),insufficient handling before or after intubation (n = 27), defect equipment (n = 28), lack of equipment (n = 31), others (n = 18) and factors that cannot be influenced (n = 12). CONCLUSIONS: The incidents that were reported via the website and that occurred during airway management in prehospital emergency medicine are described. To improve practical airway management skills of emergency physicians are one of the most important tasks in order to prevent critical incidents and are discussed in the article.

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9 Abstract BACKGROUND: Given the benefit of early recognition of STEMI and resulting ability to decrease reperfusion times and improve mortality. OBJECTIVES: We sought to determine the effect of wireless transmission of prehospital ECGs on STEMI recognition and reperfusion times. METHODS: We conducted a retrospective, observational study of patients who presented to our suburban, tertiary care, teaching hospital emergency department with STEMI on a prehospital ECG. RESULTS: Ninety-nine patients underwent reperfusion therapy. Patients with prehospital ECGs had a mean time to angioplasty suite of 43 min (95% confidence interval [CI] 31-54). Compared to patients with no prehospital ECG, mean time to angioplasty suite was 49 min (95% CI 41-57), p = Patients with prehospital STEMI identification and catheterization laboratory activation had a mean time to angioplasty suite of 33 min (95% CI 25-41), p = Patients with prehospital ECGs had a mean door-to-balloon time of 66 min (95% CI 53-79), whereas the control group had a mean door-to-balloon time of 79 min (95% CI 67-90),p = Patients with prehospital STEMI identification and catheterization laboratory activation had a mean door-to-balloon time of 58 min (95% CI 48-68),p = CONCLUSIONS: Prehospital STEMI identification allows for prompt catheterization laboratory activation, leading to decreased reperfusion times.

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11 Abstract Objective. Early restoration of coronary perfusion by thrombolysis or percutaneous coronary intervention is the main modality of treatment to salvage the ischemic myocardium. The aim of the study is to compare the door-to-needle time (DNT) in acute ST elevation myocardial infarction (STEMI) in the period prior to December 2008 when the site of thrombolysis was in coronary care unit (CCU) and the period after that when the site was shifted to emergency department (ED). Methods. A retrospective,descriptive study was conducted in patients with acute STEMI who underwent thrombolysis at CCU and ED from April 2005 until December 2011, to compare the DNT, duration of hospitalization, and mortality. Results. A total of 211 patients with acute STEMI were eligible for thrombolysis; 58 patients were thrombolysed in the CCU and 153 in ED. The median DNT was reduced from 33.5 minutes in the CCU to 17 minutes in the ED representing a reduction of more than 50% with a P value of < Conclusion. The transfer of the thrombolysis site from CCU to the ED was associated with a dramatic and significant reduction in median door-to-needle time by more than half.

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13 Abstract INTRODUCTION: Recently, we have questioned the validity of the Advanced Trauma Life Support (ATLS) classification of hypovolemic shock by demonstrating that the suggested combination of heart rate, systolic blood pressure and Glasgow Coma Scale displays substantial deficits in reflecting clinical reality. The aim of this study was to introduce and validate a new classification of hypovolemic shock based upon base deficit (BD) at emergency department (ED) arrival. METHODS: Between 2002 and 2010, 16,305 patients were retrieved from the TraumaRegister DGU database, classified into four strata of worsening BD [class I (BD 2 mmol/l), class II (BD > 2.0 to 6.0 mmol/l), classiii (BD > 6.0 to 10 mmol/l) and class IV (BD > 10 mmol/l)]. This new BD-based classification was validated to the current ATLS classification of hypovolemic shock. RESULTS: With worsening of BD, injury severity score (ISS) increased in a step-wise pattern from 19.1 (± 11.9) in class I to 36.7 (± 17.6) in class IV, while mortality increased in parallel from 7.4%to 51.5%. Decreasing hemoglobin and prothrombin ratios as well as the amount of transfusions and fluid resuscitation paralleled the increasing frequency of hypovolemic shock within the four classes. Massive transfusion rates increased from 5% in class I to 52% in class IV. The new introduced BD-based classification of hypovolemic shock discriminated transfusion requirements, massive transfusion and mortality rates significantly better compared to the conventional ATLS classification of hypovolemic shock (p <0.001). CONCLUSIONS: BD may be superior to the current ATLS classification of hypovolemic shock in identifying the presence of hypovolemic shock and in risk stratifying patients in need of early blood product transfusion.

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15 BACKGROUND: This study aimed to examine whether blood component transfusion and hemostatic drug administration during acute trauma care have changed in daily practice during the recent years. METHODS: The multicenter trauma registry of the German Society for Trauma was retrospectively analyzed for primarily admitted patients older than 16 years with an Injury Severity Score 16, who had received at least five red blood cell (RBC) units between emergency room arrival and intensive care unit admission. RESULTS: From 2002 until 2009 (n = 2,813), the fresh frozen plasma : RBC ratio increased from 0.65 to 0.75 (p = 0.02) and the platelet : RBC ratio from 0.04 to 0.09 (p < ). A constant increase was also observed regarding the over all use of hemostatic drugs (n = 1,811; ) as these were administered to 43.4% of the patients in 2005 and to 60.7% in 2009 (p < ). Especially, the administration of fibrinogen concentrate (2005: 17.0%, 2009: 45.6%; p < ) and recombinant factor VIIa (2005: 1.9%, 2009: 6.3%; p = 0.04) showed a marked increase. However, mortality rates remained unchanged during the 8-year study period. CONCLUSIONS: The therapy of bleeding trauma patients has changed in Germany during the recent years toward more aggressive coagulation support. This development continues although grades of evidence are still low regarding most of the changes reported in our study. Randomized controlled trials are needed with respect to blood component therapy using predefined ratios and to the administration of hemostatic drugs commonly used for the severely injured.

16 FAZIT Aktuelle Literatur weiterhin umfangreich Bekannte Methoden und Strategien werden neu evaluiert, weiter entwickelt, Indikationen teilweise erweitert Erkenntnisse sind fachbezogen erarbeitet