Optimal Chest Compression Point During Pediatric Resuscitation: Implications for Pediatric Resuscitation Practice by CT Scans.

OBJECTIVES: Current European guidelines for pediatric cardiopulmonary resuscitation (CPR) recommend the lower half of the sternum as the chest compression point (CP). In this study, we have used thoracic CT scans to evaluate recommended and optimal CP in relation to cardiac anatomy and structure. DESIGN: Analysis of routinely acquired thoracic CT scans acquired from 2000 to 2020. SETTING: Single-center pediatric department in a German University Hospital. PATIENTS: Imaging data were obtained from 290 patients of 3-16 years old. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We measured and analyzed 14 thoracic metrics in each thoracic CT scan. In 44 of 290 (15.2%) scans, the recommended CP did not match the level of the cardiac ventricles. Anatomically, the optimal CP was one rib or one vertebral body lower than the recommended CP, that is, the optimal CP was more caudal to the level of the body of the sternum in 67 of 290 (23.1%) scans. The recommended compression depth appeared reasonable in children younger than 12 years old. At 12 years old or older, the maximum compression depth of 6 cm is less than or equal to one-third of the thoracic depth. CONCLUSIONS: In this study of thoracic CT scans in children 3-16 years old, we have found that optimal CP for CPR appears to be more caudal than the recommended CP. Therefore, it seems reasonable to prefer to use the lower part of the sternum for CPR chest compressions. At 12 years old or older, a compression depth similar to that used in adults-6 cm limit-may be chosen.

The German Resuscitation Registry - Epidemiological data for out-of-hospital and in-hospital cardiac arrest.

Introduction: The German Resuscitation Registry was started in 2007 and collects data on out-of-hospital as well as in-hospital cardiac arrest and resuscitation. It has collected more than 400.000 datasets till today. Methods: The German Resuscitation Registry (GRR) is a voluntary quality improvement tool and research tool for out-of-hospital and in-hospital resuscitation as well as in-hospital emergency treatment. It collects data for initial treatment, in-hospital care as well as long-term outcome in an online database. For risk stratification two scores have been developed, published, and implemented. The participants are getting annual and monthly or quarterly reports in addition to the standardized online, 24/7 available analyzing options. An annual public report is published as well. We are reporting on the OHCA annual report of 2022. Results: In 2022 the incidence of CPR started or continued by EMS was 77.6/100.000 inhabitants/year. The mean age was 70.2 years and 66.7% were male bystanders who started CPR in 51.3%. The average response time for the first EMS vehicle to arrive on scene was 6:55 min.In 57.9% of the cases, they had a presumed cardiac cause. The primary outcome, return-of-spontaneous circulation (ROSC) was achieved in 42.1%. Discussion: With its more than 450.000 included datasets, the GRR is an established tool for quality improvement and research in Germany and internationally. The results for the incidence of OHCA and outcome from 2022 are compared to EuReCa TWO data ranging in the upper third of European countries. Furthermore, the GRR has contributed to increasing knowledge of OHCA by conducting and publishing research e.g. on epidemiology, airway management, and medication of OHCA.

[Physician-assisted interhospital transfer-an analysis from Schleswig-Holstein]. / Arztbegleitete Interhospitaltransporte ­ eine Analyse aus Schleswig-Holstein.

BACKGROUND: The need for interhospital transport (IHT) of intensive care patients is increasing due to changes in the hospital environment. Interhospital transports are challenging and require careful operational planning of personnel and rescue vehicles. OBJECTIVE: To investigate the need for IHT, an analysis was conducted in the service area of the emergency medical service central dispatch center (IRLS) in Schleswig-Holstein. MATERIAL AND METHODS: Emergency physician-assisted IHT were analyzed in the period from 01.10.2021 to 30.09.2022. RESULTS: Of a total of 158,823 documented IRLS missions, 2264 (1.4%) records could be identified and included as IHT: 1389 IHT (61.4%) were managed by specialized ambulances, 875 (38.6%) by primary care ambulances. Primary care ambulances were mainly used for time-critical transfers and outside the duty hours of the intensive care ambulances, 21.2 % were by air. Of all IHT, 43.1% were required to hospitals with a higher level of medical care. CONCLUSION: Emergency physician-assisted IHT are a relevant part of the emergency service's operational spectrum and concern both primary care and specialized rescue vehicles. A relevant number of urgent IHT were recorded outside the duty hours of the intensive care ambulances. For emergency transports during nighttime, an expansion of air-based transfer capacities should be considered due to the time advantage. For less urgent IHT, an adjustment of the capacities of specialized ground-based vehicles in Schleswig-Holstein seems reasonable.

Gender-related differences in adults concerning frequency, survival and treatment quality after out-of-hospital cardiac arrest (OHCA): An observational cohort study from the German resuscitation registry.

BACKGROUND: In Germany approximately 20,500 women and 41,000 men were resuscitated after out-of-hospital cardiac arrest (OHCA) each year. We are currently experiencing a discussion about the possible undersupply of women in healthcare. The aim of the present study was to examine the prevalence of OHCA in Germany, as well as the outcome and quality of resuscitation care for both women and men. METHODS: We present a cohort study from the German Resuscitation Registry (2006-2022). The quality of care was assessed for both EMS and hospital care based on risk-adjusted survival rates with the endpoints: "hospital admission with return of spontaneous circulation" (ROSCadmission) for all patients and "discharge with favourable neurological recovery" (CPC1/2discharge) for all admitted patients. Risk adjustment was performed using logistic regression analysis (LRA). If sex was significantly associated with survival, a matched-pairs-analysis (MPA) followed to explore the frequency of guideline adherence. RESULTS: 58,798 patients aged ≥ 18 years with OHCA and resuscitation were included (men = 65.2%, women = 34.8%). In the prehospital phase the male gender was associated with lower ROSCadmission-rate (LRA: OR = 0.79, CI = 0.759-0.822). A total of 27,910 patients were admitted. During hospital care, men demonstrated a better prognosis (OR = 1.10; CI = 1.015-1.191). MPA revealed a more intensive therapy for men both during EMS and hospital care. Looking at the complete chain of survival, LRA revealed no difference for men and women concerning CPC1/2discharge (n = 58,798; OR = 0.95; CI = 0.888-1.024). CONCLUSION: In Germany, 80% more men than women experience OHCA. The prognosis for CPC1/2discharge remains low (men = 10.5%, women = 7.1%), but comparable after risk adjustment. There is evidence of undersupply of care for women during hospital treatment, which could be associated with a worse prognosis. Further investigations are required to clarify these findings.

Out-of-hospital cardiac arrest in children: an epidemiological study based on the German Resuscitation Registry identifying modifiable factors for return of spontaneous circulation.

AIM: This work provides an epidemiological overview of out-of-hospital cardiac arrest (OHCA) in children in Germany between 2007 and 2021. We wanted to identify modifiable factors associated with survival. METHODS: Data from the German Resuscitation Registry (GRR) were used, and we included patients registered between 1st January 2007 and 31st December 2021. We included children aged between > 7 days and 17 years, where cardiopulmonary resuscitation (CPR) was started, and treatment was continued by emergency medical services (EMS). Incidences and descriptive analyses are presented for the overall cohort and each age group. Multivariate binary logistic regression was performed on the whole cohort to determine the influence of (1) CPR with/without ventilation started by bystander, (2) OHCA witnessed status and (3) night-time on the outcome hospital admission with return of spontaneous circulation (ROSC). RESULTS: OHCA in children aged < 1 year had the highest incidence of the same age group, with 23.42 per 100 000. Overall, hypoxia was the leading presumed cause of OHCA, whereas trauma and drowning accounted for a high proportion in children aged > 1 year. Bystander-witnessed OHCA and bystander CPR rate were highest in children aged 1-4 years, with 43.9% and 62.3%, respectively. In reference to EMS-started CPR, bystander CPR with ventilation were associated with an increased odds ratio for ROSC at hospital admission after adjusting for age, sex, year of OHCA and location of OHCA. CONCLUSION: This study provides an epidemiological overview of OHCA in children in Germany and identifies bystander CPR with ventilation as one primary factor for survival. Trial registrations German Clinical Trial Register: DRKS00030989, December 28th 2022.

[Ultrasound diagnostics in prehospital emergency care-do we need a standardized educational approach?] / Ultraschalldiagnostik in der prähospitalen Notfallmedizin ­ brauchen wir eine standardisierte Ausbildung?

BACKGROUND: Limited diagnostic capabilities represent an ongoing obstacle in out-of-hospital emergency settings. Prehospital deployment of ultrasound might reduce this particular diagnostic gap. So far, little is known about the availability and usage of ultrasound in emergency medical services (EMS) or about the level of education of EMS physicians regarding prehospital ultrasound (point-of-care ultrasound, POCUS). METHODS: A nationwide survey was conducted among emergency physicians in Germany focusing on POCUS education and experience. RESULTS: Between 02/2022 and 05/2022, 1079 responses were registered, of which 853 complete responses were analyzed. Of the emergency physicians, 71.9% consider POCUS beneficial for out-of-hospital diagnostics and 43.8% had participated in a certified POCUS training prior to the survey. The self-evaluation of POCUS skills among emergency physicians depended significantly on their participation in a certified training (p < 0.001) and frequent ultrasound routine (p < 0.001). CONCLUSION: The majority of participating emergency physicians in Germany consider POCUS to improve out-of-hospital diagnostic capabilities. Participation in a certified POCUS training and frequent use of ultrasound facilitated higher self-confidence in POCUS skills.

Pre-hospital analgesia in pediatric trauma and critically ill patients: An analysis of a German air rescue service.

BACKGROUND: Pain management in the pre-hospital setting remains a particular challenge for paramedics and emergency physicians, especially in children. This study evaluates the pre-hospital use and effect of analgesics in children with trauma or pain due to other reasons. METHODS: This study is a retrospective analysis of the database of a German air rescue service and was conducted over a period of 9 years (2012-2020) to assess pain in general and whether patients with trauma pain due to other reasons received treatment with analgesics. We included all patients in the registry under the age of 16 years. Patients with a Glasgow Coma Scale of 3 at hospital admission and incomplete records were excluded. The intensity of pain was determined by the emergency physician on scene at arrival and hospital admission in a ten-point rating scale (0 = no pain). Effective pain reduction was analyzed. RESULTS: Out of 227,458 cases, a total of 22,025 emergency cases involved pediatric patients aged 0-16 years. 20,405 cases were included in the study. 12,000 (58.8%) children had suffered a trauma, 8108 (39.7%) had pain due to other reasons and 297 (1.5%) had both. In total, 4,608 (38.4%) of the children with trauma were assessed having a numerical rating scale (NRS) > 4 at EMS arrival. These patients received mainly ketamine (34.5%) and the opioids fentanyl (38.7%) and piritramide (19.1%). The value on the NRS was significantly lower at admission to hospital (mean 1.9) compared with the EMS arrival (mean 6.9). In 4.9% the NRS at hospital admission was still > 4. 282 patients within the non-trauma group had a pre-hospital NRS of > 4. The pain therapy consisted of opioids (35.8%) and ketamine (2.8%). 28.4% patients in the non-trauma group received no pain medication. In 16.0% the NRS at hospital admission was still > 4. CONCLUSIONS: German emergency physicians achieved a sufficient pain therapy in pediatric patients with a NRS > 4 after trauma. In case of non-trauma, the pain management by the emergency physicians is restrained and less successful. The most common analgesic medications administered were ketamine and fentanyl, followed by piritramide. TRIAL REGISTRATION: The study has been retrospectively registered at DRKS (DRKS00026222).

[Ethical aspects of mechanical resuscitation in a child : Results of an expert workshop within the BMBF project CLAIRE-Children's Automated Intelligent Resuscitation]. / Ethische Aspekte mechanischer Reanimationshilfen beim Kind : Ergebnisse eines Expertenworkshops im Rahmen des BMBF-Projekts CLAIRE ­ Children's Automated Intelligent Resuscitation.

BACKGROUND: While the use of mechanical resuscitation devices can be considered for adult resuscitation, the European Resuscitation Council guidelines do not yet mention their use for pediatric resuscitation. Only one device has been partially approved for use in children; further pediatric appliances are currently being used off-label. Ethical considerations arising from the use of mechanical resuscitation devices have not yet been presented in a structured way. OBJECTIVE: To elaborate ethical considerations in the development phase of mechanical resuscitation devices for children. METHODS: Based on several fictitious case reports, an interdisciplinary expert focus group discussion was conducted. This was followed by a moderated discussion, summarizing the results. Guiding principles and research desiderata were formulated using these results as well as existing literature. RESULTS: According to the group of experts, ethical considerations regarding mechanical resuscitation devices in pediatrics predominantly concern the subject of indication and discontinuation criteria. Ethical aspects concerning psychosocial impacts on affected families and intervention teams cannot be generalized and need to be analyzed on a case-by-case basis. CONCLUSION: The considerations presented regarding the use of mechanical resuscitation devices in the pediatric context, which is still in its developmental stage, could also have practical implications for adult out-of-hospital resuscitation decisions. Concerning ethical aspects of out-of-hospital resuscitation decisions, especially using mechanical resuscitation devices, the need for accompanying empirical research is substantial.

Indications and measures of medical emergency teams: a retrospective evaluation of in-hospital emergency operations of the German Resuscitation Register.

BACKGROUND: The present study examines characteristics and interventions of medical emergency teams (MET) in in-hospital emergency care. METHODS: Analysis of all in-hospital emergencies in patients ≥18 years at 62 hospitals with established MET from the database of the German Resuscitation Registry between 2014-2019. The evaluation covered indications for activation using the ABCDE-scheme, time intervals of arrival and patient care as well as the performed invasive/medical interventions. RESULTS: Out of 62 hospitals 14,166 in-hospital emergencies (male: 8033 [56.7%]; mean age: 64±18 years) were included. Causes of activation were circulation (5760 [40.7%]), disability (4076 [28.8%]), breathing (3649 [25.8%]) and airway-problems (1589 [11.2%]). Average arrival time at the emergency scene was 4±3 minutes, supply time of MET was 24±23 minutes. Endotracheal intubation was required in 1757 (12.4%) and difficult intubation occurred in 201 (11.4%) patients with the necessity for cricothyroidotomy in eight cases (3.9%). Invasive blood-pressure-measurement was indicated in 1074 (7.6%) patients. Catecholamines were required for hemodynamic stabilization in 2421 (17.1%) patients (norepinephrine: 1520 [10.7%], epinephrine: 430 [3.0%], dobutamine: 26 [0.2%]). CONCLUSIONS: Current in-hospital emergency care requires special skills in invasive hemodynamic and airway interventions. Recommendations from professional societies are necessary to optimize equipment (e.g. videolaryngoscopy, invasive blood pressure management), training, care algorithms and staff composition against the background of an increasing shortage of resources in the healthcare system.

Survival after traumatic cardiac arrest is possible-a comparison of German patient-registries.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) due to trauma is rare, and survival in this group is infrequent. Over the last decades, several new procedures have been implemented to increase survival, and a "Special circumstances chapter" was included in the European Resuscitation Council (ERC) guidelines in 2015. This article analysed outcomes after traumatic cardiac arrest in Germany using data from the German Resuscitation Registry (GRR) and the TraumaRegister DGU® (TR-DGU) of the German Trauma Society.  METHODS: In this study, data from patients with OHCA between 01.01.2014 and 31.12.2019 secondary to major trauma and where cardiopulmonary resuscitation (CPR) was started were eligible for inclusion. Endpoints were return of spontaneous circulation (ROSC), hospital admission with ROSC and survival to hospital discharge. RESULTS: 1.049 patients were eligible for inclusion. ROSC was achieved in 28.7% of the patients, 240 patients (22.9%) were admitted to hospital with ROSC and 147 (14.0%) with ongoing CPR. 643 (67.8%) patients were declared dead on scene. Of all patients resuscitated after traumatic OHCA, 27.3% (259) died in hospital. The overall mortality was 95.0% and 5.0% survived to hospital discharge (47). In a multivariate logistic regression analysis; age, sex, injury severity score (ISS), head injury, found in cardiac arrest, shock on admission, blood transfusion, CPR in emergency room (ER), emergency surgery and initial electrocardiogram (ECG), were independent predictors of mortality. CONCLUSION: Traumatic cardiac arrest was an infrequent event with low overall survival. The mortality has remained unchanged over the last decades in Germany. Additional efforts are necessary to identify reversible cardiac arrest causes and provide targeted trauma resuscitation on scene. TRIAL REGISTRATION: DRKS, DRKS-ID DRKS00027944. Retrospectively registered 03/02/2022.

Impact of COVID-19 on out-of-hospital cardiac arrest: A registry-based cohort-study from the German Resuscitation Registry.

INTRODUCTION: The global COVID-19 pandemic effects people and the health system. Some international studies reported an increasing number of out-of-hospital cardiac arrest (OHCA). Comparable studies regarding the impact of COVID-19 on incidence and outcome of OHCA are not yet available for Germany. MATERIALS AND METHODS: This epidemiological study from the German Resuscitation Registry (GRR) compared a non-pandemic period (01.03.2018-28.02.2019) and a pandemic period (01.03.2020-28.02.2021) regarding the pandemic-related impact on OHCA care. RESULTS: A total of 18,799 cases were included. The incidence of OHCA (non-pandemic 117.9 vs. pandemic period 128.0/100,000 inhabitants) and of OHCA with resuscitation attempted increased (66.0 vs. 69.1/100,000). OHCA occurred predominantly and more often at home (62.8% vs. 66.5%, p<0.001). The first ECG rhythm was less often shockable (22.2% vs. 20.3%, p = 0.03). Fewer cases of OHCA were observed (58.6% vs. 55.6% p = 0.02). Both the bystander resuscitation rate and the proportion of telephone guided CPR remained stable (38.6% vs. 39.8%, p = 0.23; and 22.3% vs. 22.5%, p = 0.77). EMS arrival times increased (08:39 min vs. 09:08 min, p<0.001). Fewer patients reached a return of spontaneous circulation (ROSC) (45.4% vs. 40.9%, p<0.001), were admitted to hospital (50.2% vs. 45.0%, p<0.001), and discharged alive (13.9% vs. 10.2%, p<0.001). DISCUSSION: Survival after OHCA significantly decreased while the bystander resuscitation rate remained stable. However, longer EMS arrival times and fewer cases of witnessed OHCA may have contributed to poorer survival. Any change to EMS systems in the care of OHCA should be critically evaluated as it may mean a real loss of life-regardless of the pandemic situation.

Mechanical chest compression devices under special circumstances.

AIM: According to the current resuscitation guidelines, the use of mechanical chest compression devices could be considered under special circumstances like transport with ongoing resuscitation or long-term resuscitation. The aim of this study was to investigate whether survival is improved using mechanical devices under such circumstances. METHODS: Out-of-hospital cardiac arrests from all high-quality data centres of the German Resuscitation Registry from 2007 to 2020 were investigated. The use of mechanical devices was compared separately for transport with ongoing resuscitation, prolonged resuscitation (>45 min), and resuscitation with fibrinolytic agents applied. Baseline characteristics, 30-day survival/discharged alive, and neurological function at discharge were analysed descriptively; and 30-day survival/discharged alive was additionally analysed using multivariate logistic regression. RESULTS: Overall, patients who were treated with a mechanical device tended to be younger and were significantly more likely to have a witnessed cardiac arrest and a shockable initial rhythm. During the study period, 4,851 patients were transported to hospital with ongoing resuscitation (devices used in 44.2%). The 30-day survival was equal (odds ratio, OR: 1.13, 95%-CI: 0.79-1.60). In 3,920 cases, a resuscitation duration > 45 min was documented (9.5% with device). When a device was used, 30-day survival was significantly increased (OR 2.33, 95%-CI: 1.30-4.15). Fibrinolytic agents were used in 2,106 patients (22.2% with device). Here, 30-day survival was significantly worse with a device (OR: 0.52, 95%-CI: 0.30-0.91). CONCLUSION: Mechanical devices are not associated with better survival when used during transport, but rescuer safety could still be an important argument for their use. Devices are associated with better survival in prolonged resuscitation, but worse survival when a fibrinolytic was used.

Higher chance of survival in patients with out-of-hospital cardiac arrest attributed to poisoning.

AIM OF THE STUDY: Description and comparison of cohort characteristics and outcome of adult patients with out-of-hospital cardiac arrest (OHCA) attributed to poisoning (P-OHCA) versus patients with OHCA attributed to other medical causes (NP-OHCA). METHODS: We included all patients who received cardiopulmonary resuscitation after OHCA between January 2011 and December 2020 from German emergency medical services with good data quality in the German Resuscitation Registry. EXCLUSION CRITERIA: patients < 18 years of age or OHCA attributed to trauma, drowning, intracranial bleeding or exsanguination. RESULTS: Patients with P-OHCA (n = 574) were significantly younger compared to NP-OHCA (n = 40,146) (median age of 43 (35-54) years vs. 73 (62-82) years; p < 0.001). Cardiac arrest in P-OHCA patients was significantly less often witnessed by bystanders (41.8 % vs. 66.2 %, p < 0.001). Asystole was the predominant initial rhythm in P-OHCA patients (73.5% vs. 53.7%, p < 0.001) while ventricular fibrillation (VF) and pulseless electrical activity (PEA) were less common (9.2% vs. 25.1% and 16.2 % vs. 20.5%, p < 0.001). P-OHCA had a higher chance of survival with good neurological outcome at hospital discharge (15.2 vs. 8.8 % p < 0.001) and poisoning was an independent protective prognostic factor in multivariate analysis (OR 2.47, 95%-CI [1.71-3.57]). P-OHCA patients with initial PEA survival with good neurological outcome was comparable to initial VF (34.3 % vs. 37.7%). CONCLUSION: Patients in the P-OHCA group had a significantly higher chance of survival with good neurological outcome and PEA as initial rhythm was as favourable as initial VF. Therefore, in P-OHCA patients resuscitation efforts should be extended.

Importance of reporting survival as incidence: a cross-sectional comparative study on out-of-hospital cardiac arrest registry data from Germany and Norway.

OBJECTIVES: Health registries are a unique source of information about current practice and can describe disease burden in a population. We aimed to understand similarities and differences in the German Resuscitation Registry (GRR) and the Norwegian Cardiac Arrest Registry (NorCAR) and compare incidence and survival for patients resuscitated after out-of-hospital cardiac arrest. DESIGN: A cross-sectional comparative analysis reporting incidence and outcome on a population level. SETTING: We included data from the cardiac arrest registries in Germany and Norway. PARTICIPANTS: Patients resuscitated between 1 January 2015 and 31 December 2019 were included, resulting in 29 222 cases from GRR and 16 406 cases from NorCAR. From GRR, only emergency medical services (EMS) reporting survival information for patients admitted to the hospital were included. PRIMARY AND SECONDARY OUTCOME MEASURES: This study focused on the EMS systems, the registries and the patients included in both registries. The results compare the total incidence, incidence of patients resuscitated by EMS, and the incidence of survival. RESULTS: We found an incidence of 68 per 100 000 inhabitants in GRR and 63 in NorCAR. The incidence of patients treated by EMS was 67 in GRR and 53 in NorCAR. The incidence of patients arriving at a hospital was higher in GRR (24.3) than in NorCAR (15.1), but survival was similar (8 in GRR and 7.8 in NorCAR). CONCLUSION: GRR is a voluntary registry, and in-hospital information is not reported for all cases. NorCAR has mandatory reporting from all EMS and hospitals. EMS in Germany starts treatment on more patients and bring a higher number to hospital, but we found no difference in the incidence of survival. This study has improved our knowledge of both registries and highlighted the importance of reporting survival as incidence when comparing registries.

[Prehospital treatment of tension pneumothorax in children-which decisions do we make? : Results of a survey among German emergency physicians]. / Die prähospitale Therapie eines Spannungspneumothorax bei Kindern ­ welche Entscheidungen treffen wir? : Ergebnisse einer Umfrage unter deutschen Notärzten.

BACKGROUND: The preclinical treatment of a traumatic or spontaneous tension pneumothorax remains a particular challenge in pediatric patients. Currently recommended interventions for decompression are either finger thoracostomy or needle decompression. Due to the tiny intercostal spaces, finger thoracostomy may not be feasible in small children and surgical preparation may be necessary. In needle decompression, the risk of injuring underlying vital structures is increased because of the smaller anatomic structures. As most emergency physicians do not regularly work in pediatric trauma care, decompression of tension pneumothorax is associated with significant uncertainty; however, in this rare emergency situation, consistent and goal-oriented action is mandatory and lifesaving. An assessment of pre-existing experience and commonly used techniques therefore seems necessary to deduce the need for future education and training. OBJECTIVE: In this study an online survey was created to evaluate the experience and the favored prehospital treatment of tension pneumothorax in children among German emergency physicians. MATERIAL AND METHODS: An online survey was conducted with 43 questions on previous experience with tension pneumothorax in children, favored decompression technique and anatomical structures in different age groups. Surveyed were the emergency physicians of the ground-based emergency medical service of the University Medical Center Mannheim, the German Air Rescue Service (DRF) and the pediatric emergency medical service of the City of Munich. RESULTS: More than half of all respondents stated that there was uncertainty about the procedure of choice. Needle decompression was favored in smaller children and mini-thoracostomy in older children. In comparison with the literature, the thickness of the chest wall was mostly estimated correctly by the emergency medical physicians. The depth of the vital structures was underestimated at most of the possible insertion sites in all age groups. At the lateral insertion sites on the left hemithorax, however, the distance to the left ventricle was overestimated. The caliber of the needle selected for decompression tended to be too large, especially in younger children. CONCLUSION: Even though having interviewed an experienced group of prehospital emergency physicians, the experience in decompression of tension pneumothorax in children is relatively scant. Knowledge of chest wall thickness and depth to vital structures is sufficient, the choice of needle calibers tends to be too large but still reasonable. For many providers a large amount of uncertainty about the right choice of technique and equipment arises from the challenge of decompressing a tension pneumothorax in children and therefore further theoretical education and regular training are required for safe performance of the procedure.

Automated mechanical cardiopulmonary resuscitation devices versus manual chest compressions in the treatment of cardiac arrest: protocol of a systematic review and meta-analysis comparing machine to human.

INTRODUCTION: Cardiac arrest is a leading cause of death in industrialised countries. Cardiopulmonary resuscitation (CPR) guidelines follow the principles of closed chest compression as described for the first time in 1960. Mechanical CPR devices are designed to improve chest compression quality, thus considering the improvement of resuscitation outcomes. This protocol outlines a systematic review and meta-analysis methodology to assess trials investigating the therapeutic effect of automated mechanical CPR devices at the rate of return of spontaneous circulation, neurological state and secondary endpoints (including short-term and long-term survival, injuries and surrogate parameters for CPR quality) in comparison with manual chest compressions in adults with cardiac arrest. METHODS AND ANALYSIS: A sensitive search strategy will be employed in established bibliographic databases from inception until the date of search, followed by forward and backward reference searching. We will include randomised and quasi-randomised trials in qualitative analysis thus comparing mechanical to manual CPR. Studies reporting survival outcomes will be included in quantitative analysis. Two reviewers will assess independently publications using a predefined data collection form. Standardised tools will be used for data extraction, risks of bias and quality of evidence. If enough studies are identified for meta-analysis, the measures of association will be calculated by dint of bivariate random-effects models. Statistical heterogeneity will be evaluated by I2-statistics and explored through sensitivity analysis. By comprehensive subgroup analysis we intend to identify subpopulations who may benefit from mechanical or manual CPR techniques. The reporting follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. ETHICS AND DISSEMINATION: No ethical approval will be needed because data from previous studies will be retrieved and analysed. Most resuscitation studies are conducted under an emergency exception for informed consent. This publication contains data deriving from a dissertation project. We will disseminate the results through publication in a peer-reviewed journal and at scientific conferences. PROSPERO REGISTRATION NUMBER: CRD42017051633.

Effect of airway management strategies during resuscitation from out-of-hospital cardiac arrest on clinical outcome: A registry-based analysis.

AIM: An effective airway management is pivotal for treating hypoxia and to ensure reoxygenation during cardiopulmonary resuscitation (CPR). This matched-pair analysis from the German Resuscitation Registry (GRR) investigates the outcomes of various methods of airway management used on out-of-hospital cardiac arrest (OHCA) patients. METHODS: 89,220 OHCA patients were reported between 01/01/2007 and 12/31/2017. After applying exclusion and inclusion criteria, the resulting 19,196 patient's data were analyzed. Endpoints were return of spontaneous circulation (ROSC), hospital admission, 24-h survival, hospital discharge, and discharge with cerebral performance categories 1,2 (CPC1,2). Three categories of airway management were defined: endotracheal tube ("ETT"), laryngeal tube ("LT_only"), and laryngeal to endotracheal tube exchange ("LTEX"). The groups were matched with respect to age, gender, aetiology or location of OHCA, witnessing or CPR by lay people, initial rhythm, and use of epinephrine and amiodarone. RESULTS: "ETT" versus "LT_only" was associated with higher short- and long-term outcome rates and better neurological recovery (CPC_1.2: 7.7 vs. 5.8%, OR = 1.35, 95%-CI = 1.09-1.67, n = 5552). "LTEX" versus "LT_only" showed significantly higher ROSC- and 24-h survival rate (33.7 vs. 21.8%, OR = 1.82, 95%-CI = 1.51-2.2, n = 2302). "LTEX" versus "ETT" revealed significantly higher ROSC- and 24-h survival rate (34.6 vs. 30.4%, OR = 1.21, 95%-CI = 1.03-1.42, n = 2608). CONCLUSION: "ETT" was associated with higher survival rates and better neurological outcomes in comparison to "LT_only". The strategy of "LTEX" versus "LT_only" or "ETT" was only associated with better short-term outcomes. Our observational registry data suggests that endotracheal intubation by physician staffed EMS is the optimal airway strategy for OHCA in our system.