Prehospital anesthesia in postcardiac arrest patients: a multicenter retrospective cohort study.

BACKGROUND: Currently, the data regarding the impact of prehospital postcardiac arrest anesthesia on target hemodynamic and ventilatory parameters of early postresuscitation care and recommendations on its implementation are rare. The present study examines the incidence and impact of prehospital postcardiac arrest anesthesia on hemodynamic and ventilatory target parameters of postresuscitation care. METHODS: In this multicentre observational study between 2019 and 2021 unconscious adult patients after out-of-hospital-cardiac arrest with the presence of a return-of-spontaneous circulation until hospital admission were included. Primary endpoint was the application of postarrest anesthesia. Secondary endpoints included the medication group used, predisposing factors to its implementation, and its influence on achieving target parameters of postresuscitation care (systolic blood pressure: ≥ 100 mmHg, etCO2:35-45 mmHg, SpO2: 94-98%) at hospital handover. RESULTS: During the study period 2,335 out-of-hospital resuscitations out of 391,305 prehospital emergency operations (incidence: 0.58%; 95% CI 0.54-0.63) were observed with a return of spontaneous circulation to hospital admission in 706 patients (30.7%; 95% CI 28.8-32.6; female: 34.3%; age:68.3 ± 14.2 years). Postcardiac arrest anesthesia was performed in 482 patients (68.3%; 95% CI 64.7-71.7) with application of hypnotics in 93.4% (n = 451), analgesics in 53.7% (n = 259) and relaxants in 45.6% (n = 220). Factors influencing postcardiac arrest sedation were emergency care by an anesthetist (odds ratio: 2.10; 95% CI 1.34-3.30; P < 0.001) and treatment-free interval ≤ 5 min (odds ratio: 1.59; 95% CI 1.01-2.49; P = 0.04). Although there was no evidence of the impact of performing postcardiac arrest anesthesia on achieving a systolic blood pressure ≥ 100 mmHg at the end of operation (odds ratio: 1.14; 95% CI 0.78-1.68; P = 0.48), patients with postcardiac arrest anesthesia were significantly more likely to achieve the recommended ventilation (odds ratio: 1.59; 95% CI 1.06-2.40; P = 0.02) and oxygenation (odds ratio:1.56; 95% CI 1.04-2.35; P = 0.03) targets. Comparing the substance groups, the use of hypnotics significantly more often enabled the target values for etCO2 to be reached alone (odds ratio:2.79; 95% CI 1.04-7.50; P = 0.04) as well as in combination with a systolic blood pressure ≥ 100 mmHg (odds ratio:4.42; 95% CI 1.03-19.01; P = 0.04). CONCLUSIONS: Postcardiac arrest anesthesia in out-of-hospital cardiac arrest is associated with early achievement of respiratory target parameters in prehospital postresuscitation care without evidence of more frequent hemodynamic complications.

A comparison of Simplified Acute Physiology Score II and Sepsis-related Organ Failure Assessment Score for prediction of mortality after Intensive Care Unit cardiac arrest.

BACKGROUND: This study investigates the predictive value and suitable cutoff values of the Sepsis-related Organ Failure Assessment Score (SOFA) and Simplified Acute Physiology Score II (SAPS-II) to predict mortality during or after Intensive Care Unit Cardiac Arrest (ICU-CA). METHODS: In this secondary analysis the ICU database of a German university hospital with five ICU was screened for all ICU-CA between 2016-2019. SOFA and SAPS-II were used for prediction of mortality during ICU-CA, hospital-stay and one-year-mortality. Receiver operating characteristic curves (ROC), area under the ROC (AUROC) and its confidence intervals were calculated. If the AUROC was significant and considered "acceptable," cutoff values were determined for SOFA and SAPS-II by Youden Index. Odds ratios and sensitivity, specificity, positive and negative predictive values were calculated for the cutoff values. RESULTS: A total of 114 (78 male; mean age: 72.8±12.5 years) ICU-CA were observed out of 14,264 ICU-admissions (incidence: 0.8%; 95% CI: 0.7-1.0%). 29.8% (N.=34; 95% CI: 21.6-39.1%) died during ICU-CA. SOFA and SAPS-II were not predictive for mortality during ICU-CA (P>0.05). Hospital-mortality was 78.1% (N.=89; 95% CI: 69.3-85.3%). SAPS-II (recorded within 24 hours before and after ICU-CA) indicated a better discrimination between survival and death during hospital stay than SOFA (AUROC: 0.81 [95% CI: 0.70-0.92] vs. 0.70 [95% CI: 0.58-0.83]). A SAPS-II-cutoff-value of 43.5 seems to be suitable for prognosis of hospital mortality after ICU-CA (specificity: 87.5%, sensitivity: 65.6%; SAPS-II>43.5: 87.5% died in hospital; SAPS-II<43.5: 65.6% survived; odds ratio:13.4 [95% CI: 3.25-54.9]). Also for 1-year-mortality (89.5%; 95% CI: 82.3-94.4) SAPS-II showed a better discrimination between survival and death than SOFA: AUROC: 0.78 (95% CI: 0.65-0.91) vs. 0.69 (95% CI: 0.52-0.87) with a cutoff value of the SAPS-II of 40.5 (specificity: 91.7%, sensitivity: 64.3%; SAPS-II>40.5: 96.4% died; SAPS-II<40.5: 42.3% survived; odd ratio: 19.8 [95% CI: 2.3-168.7]). CONCLUSIONS: Compared to SOFA, SAPS-II seems to be more suitable for prediction of hospital and 1-year-mortality after ICU-CA.

The European Trauma Course: Transforming systems through training.

The European Trauma Course (ETC) exemplifies an innovative approach to multispecialty trauma education. This initiative was started as a collaborative effort among the European Society for Emergency Medicine, the European Society for Trauma and Emergency Surgery, and the European Society of Anaesthesiology under the auspices of the European Resuscitation Council. With the robust support of these societies, the project has evolved into the independent European Trauma Course Organisation. Over the past 15 years, the ETC has transcended traditional training by integrating team dynamics and non-technical skills into a scenario-based simulation course, helping to shape trauma care practice and education. A distinctive feature of the ETC is its training of doctors and allied healthcare professionals, fostering a collaborative and holistic approach to trauma care. The ETC stands out for its unique team-teaching approach, which has gained widespread recognition as the standard for in-hospital trauma care training not only in Europe but also beyond. Since its inception ETC has expanded geographically from Finland to Sudan and from Brazil to the Emirates, training nearly 20,000 healthcare professionals and shaping trauma care practice and education across 25 countries. Experiencing exponential growth, the ETC continues to evolve, reflecting its unmet demand in trauma team education. This review examines the evolution of the ETC, its innovative team-teaching methodology, national implementation strategies, current status, and future challenges. It highlights its impact on trauma care, team training, and the effect on other life support courses in various countries.

Effects of COVID-19 on a mature citizen first responder system in the German district of Gütersloh: an observational study.

BACKGROUND: The aim of this study was to examine the impact of COVID-19 on the response rate of community-first-responders (CFR) and other out-of-hospital-cardiac-arrest (OHCA) outcomes using the smartphone-first-responder-system (SFRS) "Mobile Retter." METHODS: All adult non-traumatic OHCA in the district of Gütersloh between 01.01.2018-31.12.2021 were included. Periods of interest were 1) prior to the first COVID-19-lockdown; to 2) both lockdowns; and 3) the time in between, as well as after the COVID-19-lockdowns (pre-COVID-19, COVID-19-lockdown and COVID-19-pandemic respectively). The primary outcome was the CFR response rate defined as proportion of CFR alerts that were accepted by a CFR and in which at least one CFR arrived on scene of the emergency out of all CFR alerts. Secondary outcomes included the rate of CFR alerts, defined as proportion of OHCA to which CFR were summoned by the emergency medical dispatcher, as well as the rate of return-of-spontaneous-circulation (ROSC) and rate of survival until hospital discharge. We also examined the incidence COVID-19-infection of CFR in context of the SFRS. RESULTS: A total of 1064 OHCA-patients (mean age: 71.4±14.5 years; female: 33.8%) were included in the study (Pre-COVID-19: 539; COVID-19-lockdown: 109; COVID-19-pandemic: 416). The response rate was 64.0% (pre-COVID-19: 58.7%; COVID-19-lockdown: 63.5%; COVID-19-pandemic: 71.8%, P=0.002 vs. pre-COVID-19). The alert rate was 52.7% (pre-COVID-19: 56.2%; COVID-19-lockdown: 47.7%, P=0.04 vs. Pre-COVID-19; COVID-19-Pandemic: 49.5%, P=0.02 vs. pre-COVID-19). The ROSC-rate was 40.4% (pre-COVID-19: 41.0%; COVID-19-lockdown: 33.9%; COVID-19-pandemic: 41.4%) and hospital discharge rate 31.2% (Pre-COVID-19: 33.0%; COVID-19-lockdown: 36.8%; COVID-19-pandemic: 28.7%). The use of CFR was associated with favorable effects in terms of hospital admission (odds ratio [OR]: 0.654 (CI95: 0.444-0.963), P=0.03), hospital discharge (OR: 2.343 (CI95: 1.002-5.475), P=0.04). None of the CFR became infected with COVID-19. CONCLUSIONS: "Mobile-Retter" was associated with high response rates, improved outcome in OHCA patients and no COVID-19-infections of CFR during the COVID-19-pandemic and -lockdowns.

Midazolam for Post-Arrest Sedation in Pre-Hospital Emergency Care.

BACKGROUND: An out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) may need to be treated with airway management, emergency ventilation, invasive interventions, and post-arrest sedation. We investigated the influence of the use of midazolam for post-arrest sedation on achieving postresuscitation care targets and the associated risk of hemodynamic complications. METHODS: All emergency rescue missions of the Dresden, Gütersloh, and Lippe medical rescue services in the years 2019-2021 were reviewed to identify adult patients who had OHCA, unconsciousness, and sustained ROSC with spontaneous circulation until arrival at the hospital; the findings were supplemented with data from the German Resuscitation Registry. Patients who received midazolam (alone or in combination with other anesthetic agents) for post-arrest sedation were compared with those who did not. The endpoints were the regaining of a systolic blood pressure ≥ 100 mmHg, end-tidal pCO2 35-45 mmHg, and oxygen saturation (SpO2) 94-98%. A propensity score analysis was used to adjust for age, sex, and variables potentially affecting hemodynamic status or the targets for oxygenation and ventilation. RESULTS: There were 2335 cases of OHCA among 391 305 emer - gency rescue missions. 571 patients had ROSC before arrival in the hospital (24.5%; female, 33.6%; age, 68 ± 14 years). Of the 395 among them (69.2%) who were treated with postarrest sedation, 249 (63.0%) received midazolam. Patients who received midazolam reached the guideline- recommended targets for oxygenation, ventilation, and blood pressure more frequently than those who were not sedated: the respective odds ratios and 95% confidence intervals were 2.00 [1.20; 3.34], 1.57 [0.99; 2.48], and 1.41 [0.89; 2.21]. CONCLUSION: The pre-hospital administration of midazolam leads to more frequent pre-hospital attainment of the oxygenation and ventilation targets in post-resuscitation care, without any evidence of an elevated risk of hemodynamic complications.

From tradition to innovation: a comparison of the traditional 4-step approach versus a blended learning modification for technical skills teaching.

BACKGROUND: This experimental study was performed to evaluate the role of blended learning for technical skill teaching on the European Trauma Course (ETC). While online modules are extensively used for theoretical teaching, their role in skills training remains less well explored. The ETC currently relies on the established 4-step technique for teaching technical skills. However, the required large cohort of skilled instructors and the time intensity prove increasingly challenging in a current climate of staff shortages and funding constraints. This study assesses if blended learning, combining pre-course online elements with face-to-face training matches the effectiveness of the traditional 4-step approach whilst being more time-efficient. METHODS: In a randomised, multi-centre trial, the conventional face-to-face 4-step technique for teaching a skill of medium complexity, the application of a pelvic binder, was compared with an innovative blended approach. It was hypothesised that the blended approach was non-inferior for skill performance measured after the teaching session and after two days (skill retention) with the time needed for teaching and student/teacher satisfaction as secondary outcomes. RESULTS: Ninety participants, divided into 44 traditional and 46 blended method students, were analysed. Independent-samples t-test showed no significant difference in performance scores and non-inferiority of the blended approach with a half of one standard deviation margin. A statistically significant difference in mean retention scores favored the blended approach. A Mann-Whitney U Test revealed no significant difference in candidate satisfaction levels but a statistically significant difference in instructors' satisfaction levels in favour of the blended approach. Analysis with Welch' t-test demonstrated that the face-to-face teaching time needed for the blended approach was significantly shorter (by 6 min). CONCLUSIONS: The integration of a blended approach with the 4-step technique for teaching pelvic binder application in the ETC streamlined teaching without compromising skill acquisition quality. This innovative approach addresses traditional limitations and shows promise in adapting medical education to modern learning and teaching demands. We suggest that blended learning could also be applied for other skills taught on life support courses. TRIAL REGISTRATION: University of Dundee (Schools of Medicine and Life sciences Research Ethics Committee, REC number 22/59, 28th June 2022).

Efficacy of in-bed chest compressions depending on provider position during in-hospital cardiac arrest: a controlled manikin study.

BACKGROUND: In contrast to the pre-hospital environment, patients with in-hospital cardiac arrest are usually lying in a hospital bed. Interestingly, there are no current recommendations for optimal provider positioning. The present study evaluates in bed chest compression quality in different provider positions during in-hospital-cardiac-arrest. METHODS: Paramedics conducted four resuscitation scenarios: manikin lying on the floor with provider position kneeling next to the manikin (control group), manikin lying in a hospital bed with the provider kneeling astride, kneeling beside or standing next to the manikin. A resuscitation board was not used according to the current guideline recommendations. Quality of resuscitation, compression depth, compression rate and percentage of compressions with complete chest rebound were recorded. Afterwards, the paramedics were asked about subjective efficiency and fatigue. Data were analyzed using Generalized-Linear-Mixed-Models and, in addition, by non-parametric Friedman test. RESULTS: A total of 60 participants were recruited. The total quality of chest compressions was significantly higher in floor-based control position compared to the standing (P<.001) and both kneeling positions (P<.05). Also, the compression depth was significantly more guideline compliant in the control (P<.001) and the kneeling position (P<.05) compared to the standing position. The compression frequency as well as the complete chest wall recoil did not differ significantly. The standing position was rated as more fatiguing than the other positions (p≤0.001), kneeling beside as subjectively more efficient than the standing position (P<0.001). CONCLUSIONS: In case of an in-bed resuscitation, high quality chest compressions are possible. Kneeling astride or beside the patient should be preferred because these positions demonstrated a good chest compression quality and were more efficient and less exhausting.

Prevalence and severity of pediatric emergencies in a German helicopter emergency service: implications for training and service configuration.

This study primarily aims to determine the frequency of life-threatening conditions among pediatric patients served by the DRF, a German helicopter emergency service (HEMS) provider. It also seeks to explore the necessity of invasive procedures in this population, discussing the implications for HEMS crew training and service configuration based on current literature. We analyzed the mission registry from 31 DRF helicopter bases in Germany, focusing on 7954 children aged 10 or younger over a 5-year period (2014-2018). Out of 7954 identified children (6.2% of all primary missions), 2081 (26.2%) had critical conditions. Endotracheal intubation was needed in 6.5% of cases, while alternative airway management methods were rare (n = 14). Half of the children required intravenous access, and 3.6% needed intraosseous access. Thoracostomy thoracentesis and sonography were only performed in isolated cases.  Conclusions: Critically ill or injured children are infrequent in German HEMS operations. Our findings suggest that the likelihood of HEMS teams encountering such cases is remarkably low. Besides endotracheal intubation, life-saving invasive procedures are seldom necessary. Consequently, we conclude that on-the-job training and mission experience alone are insufficient for acquiring and maintaining the competencies needed to care for critically ill or injured children. What is Known: • Pediatric emergencies are relatively rare in the prehospital setting, but their incidence is higher in helicopter emergency medical services (HEMS) compared to ground-based emergency services. What is New: • On average, HEMS doctors in Germany encounter a critically ill or injured child approximately every 1.5 years in their practice, establish an IV or IO access in infants or toddlers every 2 years, and intubate an infant every 46 years. • This low frequency highlights the insufficiency of on-the-job training alone to develop and maintain pediatric skills among HEMS crews. Specific interdisciplinary training for HEMS crews is needed to ensure effective care for critically unwell pediatric patients.

Impact of COVID-19-adapted guidelines using different airway management strategies on resuscitation quality in out-of-hospital-cardiac-arrest - a randomised manikin study.

BACKGROUND: Although airway management for paramedics has moved away from endotracheal intubation towards extraglottic airway devices in recent years, in the context of COVID-19, endotracheal intubation has seen a revival. Endotracheal intubation has been recommended again under the assumption that it provides better protection against aerosol liberation and infection risk for care providers than extraglottic airway devices accepting an increase in no-flow time and possibly worsen patient outcomes. METHODS: In this manikin study paramedics performed advanced cardiac life support with non-shockable (Non-VF) and shockable rhythms (VF) in four settings: ERC guidelines 2021 (control), COVID-19-guidelines using videolaryngoscopic intubation (COVID-19-intubation), laryngeal mask (COVID-19-Laryngeal-Mask) or a modified laryngeal mask modified with a shower cap (COVID-19-showercap) to reduce aerosol liberation simulated by a fog machine. Primary endpoint was no-flow-time, secondary endpoints included data on airway management as well as the participants' subjective assessment of aerosol release using a Likert-scale (0 = no release-10 = maximum release) were collected and statistically compared. Continuous Data was presented as mean ± standard deviation. Interval-scaled Data were presented as median and Q1 and Q3. RESULTS: A total of 120 resuscitation scenarios were completed. Compared to control (Non-VF:11 ± 3 s, VF:12 ± 3 s) application of COVID-19-adapted guidelines lead to prolonged no-flow times in all groups (COVID-19-Intubation: Non-VF:17 ± 11 s, VF:19 ± 5 s;p ≤ 0.001; COVID-19-laryngeal-mask: VF:15 ± 5 s,p ≤ 0.01; COVID-19-showercap: VF:15 ± 3 s,p ≤ 0.01). Compared to COVID-19-Intubation, the use of the laryngeal mask and its modification with a showercap both led to a reduction of no-flow-time(COVID-19-laryngeal-mask: Non-VF:p = 0.002;VF:p ≤ 0.001; COVID-19-Showercap: Non-VF:p ≤ 0.001;VF:p = 0.002) due to a reduced duration of intubation (COVID-19-Intubation: Non-VF:40 ± 19 s;VF:33 ± 17 s; both p ≤ 0.01 vs. control, COVID-19-Laryngeal-Mask (Non-VF:15 ± 7 s;VF:13 ± 5 s;p > 0.05) and COVID-19-Shower-cap (Non-VF:15 ± 5 s;VF:17 ± 5 s;p > 0.05). The participants rated aerosol liberation lowest in COVID-19-intubation (median:0;Q1:0,Q3:2;p < 0.001vs.COVID-19-laryngeal-mask and COVID-19-showercap) compared to COVID-19-shower-cap (median:3;Q1:1,Q3:3 p < 0.001vs.COVID-19-laryngeal-mask) or COVID-19-laryngeal-mask (median:9;Q1:6,Q3:8). CONCLUSIONS: COVID-19-adapted guidelines using videolaryngoscopic intubation lead to a prolongation of no-flow time. The use of a modified laryngeal mask with a shower cap seems to be a suitable compromise combining minimal impact on no-flowtime and reduced aerosol exposure for the involved providers.

State of implementation of the Corona-Virus-Disease-2019 resuscitation guidelines : An online-based survey one year after publication in Germany.

BACKGROUND: The present study evaluated the implementation of the European Resuscitation Council Corona-Virus-Disease 2019 (COVID-19) resuscitation guidelines in Germany 1 year after publication. AIM OF THE WORK: To evaluate the practical implementation of the COVID-19 resuscitation guidelines in Germany one year after their publication. MATERIAL AND METHODS: In an online survey between April and May 2021 participants were asked about awareness of COVID-19 resuscitation guidelines, corresponding training, the resuscitation algorithm used and COVID-19 infections of emergency medicine personnel associated with COVID-19 resuscitation. RESULTS: A total of 961 (8%) of the 11,000 members took part in the survey and 85% (818/961) of questionnaires were fully completed. While 577 (70%) of the respondents were aware of the COVID-19 guidelines, only 103 (13%) had received respective training. A specific COVID-19 resuscitation algorithm was used by 265 respondents (32%). Adaptations included personal protective equipment (99%), reduction of staff caring for the patient, or routine use of video laryngoscopy for endotracheal intubation (each 37%), securing the airway before rhythm analysis (32%), and pausing chest compressions during endotracheal intubation (30%). Respondents without a specific COVID-19 resuscitation algorithm were more likely to use mouth-nose protection (47% vs. 31%; p < 0.001), extraglottic airway devices (66% vs. 55%; p = 0.004) and have more than 4 team members close to the patient (45% vs. 38%; p = 0.04). Use of an Filtering-Face-Piece(FFP)-2 or FFP3 mask (89% vs. 77%; p < 0.001; 58% vs. 70%; p ≤ 0.001) or performing primary endotracheal intubation (17% vs. 31%; p < 0.001) were found less frequently and 9% reported that a team member was infected with COVID-19 during resuscitation. CONCLUSION: The COVID-19 resuscitation guidelines are still insufficiently implemented 1 year after publication. Future publication strategies must ensure that respective guideline adaptations are implemented in a timely manner.

Can drones save lives and money? An economic evaluation of airborne delivery of automated external defibrillators.

BACKGROUND: Out-of-hospital cardiac arrest is one of the most frequent causes of death in Europe. Emergency medical services often struggle to reach the patient in time, particularly in rural areas. To improve outcome, early defibrillation is required which significantly increases neurologically intact survival. Consequently, many countries place Automated External Defibrillators (AED) in accessible public locations. However, these stationary devices are frequently not available out of hours or too far away in emergencies. An innovative approach to mustering AED is the use of unmanned aerial systems (UAS), which deliver the device to the scene. METHODS: This paper evaluates the economic implications of stationary AED versus airborne delivery using scenario-based cost analysis. As an example, we focus on the rural district of Vorpommern-Greifswald in Germany. Formulae are developed to calculate the cost of stationary and airborne AED networks. Scenarios include different catchment areas, delivery times and unit costs. RESULTS: UAS-based delivery of AEDs is more cost-efficient than maintaining traditional stationary networks. The results show that equipping cardiac arrest hot spots in the district of Vorpommern-Greifswald with airborne AEDs with a response time < 4 min is an effective method to decrease the time to the first defibrillation The district of Vorpommern-Greifswald would require 45 airborne AEDs resulting in annual costs of at least 1,451,160 €. CONCLUSION: In rural areas, implementing an UAS-based AED system is both more effective and cost-efficient than the conventional stationary solution. When regarding urban areas and hot spots of OHCA, complementing the airborne network with stationary AEDs is advisable.

[AED drones on the rise? : Use of drones to improve public access defibrillation]. / Kommt die Defi-Drohne? : Einsatz von Drohnen zur Verbesserung der Frühdefibrillationsrate.

BACKGROUND: The poor availability of automatic external defibrillators (AED) and the modest knowledge of lay persons in handling these devices has led to an insufficient spread of public access defibrillation in Germany. OBJECTIVE: This article examines whether the automated deployment of AED drones to out-of-hospital cardiac arrest can help to remedy this situation. METHODS: Narrative literature review, evaluation of statistics, analysis of relevant media reports, and discussion of key research. RESULTS: The present investigations are mainly located in the experimental field and demonstrate the feasibility and safety of drone use, as well as shorter times to first defibrillation, which is confirmed by initial clinical studies. Mathematical models also indicate cost-effectiveness of airborne AED delivery compared to ground dispatch. Integration into the chain of survival appears to be possible but adaptations to existing emergency medical service structures and close cooperation with regional first responder and AED schemes as well as local authorities is required to optimise patient benefit and efficiency. CONCLUSION: The use of AED drones could probably contribute to improving public access defibrillation in Germany. This applies to both rural and urban regions. The technological requirements are met but flight regulations still have to be amended. In order to explore the full potential of this novel technology, further field trials are required to achieve smooth integration into existing emergency medical services.

Incidence, characteristics and predictors of mortality following cardiac arrest in ICUs of a German university hospital: A retrospective cohort study.

BACKGROUND: Cardiac arrest in intensive care is a rarely studied type of in-hospital cardiac arrest. OBJECTIVE: This study examines the incidence, characteristics, risk factors for mortality as well as long-term prognosis following cardiac arrest in intensive care. DESIGN: Retrospective cohort study. SETTING: Five noncardiac surgical ICUs (41 surgical and 37 medical beds) at a German university hospital between 2016 and 2019. PATIENTS: Adults experiencing cardiac arrest defined as the need for chest compressions and/or defibrillation occurring for the first time on the ICU. MAIN OUTCOME MEASURES: Primary endpoint: occurrence of cardiac-arrest in the ICU. Secondary endpoints: diagnostic and therapeutic measures; risk factors and marginal probabilities of no-return of spontaneous circulation; rates of return of spontaneous circulation, hospital discharge, 1-year-survival and 1-year-neurological outcome. RESULTS: A total of 114 cardiac arrests were observed out of 14 264 ICU admissions; incidence 0.8%; 95% confidence interval (CI) 0.7 to 1.0; 45.6% received at least one additional diagnostic test, such as blood gas analysis (36%), echocardiography (19.3%) or chest x-ray (9.9%) with a resulting change in therapy in 52%, (more frequently in those with a return of spontaneous circulation vs none, P  = 0.023). Risk factors for no-return of spontaneous circulation were cardiac comorbidities (OR 5.4; 95% CI, 1.4 to 20.7) and continuous renal replacement therapy (OR 5.9; 95% CI, 1.7 to 20.8). Bicarbonate levels greater than 21 mmol 1 were associated with a higher mortality risk in combination either with cardiac comorbid-ities (bicarbonate <21 mmol I-1: 13%; 21 to 26 mmolI-1 45%; >26mmolI-1:42%)orwithaSOFA at least 2 (bicarbonate <21 mmolI-1 8%; 21 to 26 mmolI-1: 40%; >26mmolI-1: 37%). "In-hospital mortality was 78.1% (n = 89); 1-year-survival-rate was 10.5% (95% CI, 5.5 to 17.7) and survival with a good neurological outcome was 6.1% (95% CI, 2.5 to 12.2). CONCLUSION: Cardiac arrest in ICU is a rare complication with a high mortality and low rate of good neurological outcome. The development of a structured approach to resuscitation should include all available resources of an ICU and adequately consider the complete diagnostic and therapeutic spectra as our results indicate that these are still underused. The development of prediction models of death should take into account cardiac and hepatic comorbidities, continuous renal replacement therapy, SOFA at least 2 before cardiac arrest and bicarbonate level. Further research should concentrate on identifying early predictors and on the prevention of cardiac arrest in ICU.

First responder systems can stay operational under pandemic conditions: results of a European survey during the COVID-19 pandemic.

BACKGROUND: Dispatching first responders (FR) to out-of-hospital cardiac arrest in addition to the emergency medical service has shown to increase survival. The promising development of FR systems over the past years has been challenged by the outbreak of COVID-19. Whilst increased numbers and worse outcomes of cardiac arrests during the pandemic suggest a need for expansion of FR schemes, appropriate risk management is required to protect first responders and patients from contracting COVID-19. This study investigated how European FR schemes were affected by the pandemic and what measures were taken to protect patients and responders from COVID-19. METHODS: To identify FR schemes in Europe we conducted a literature search and a web search. The schemes were contacted and invited to answer an online questionnaire during the second wave of the pandemic (December 2020/ January 2021) in Europe. RESULTS: We have identified 135 FR schemes in 28 countries and included responses from 47 FR schemes in 16 countries. 25 schemes reported deactivation due to COVID-19 at some point, whilst 22 schemes continued to operate throughout the pandemic. 39 schemes communicated a pandemic-specific algorithm to their first responders. Before the COVID-19 outbreak 20 FR systems did not provide any personal protective equipment (PPE). After the outbreak 19 schemes still did not provide any PPE. The majority of schemes experienced falling numbers of accepted call outs and decreasing registrations of new volunteers. Six schemes reported of FR having contracted COVID-19 on a mission. CONCLUSIONS: European FR schemes were considerably affected by the pandemic and exhibited a range of responses to protect patients and responders. Overall, FR schemes saw a decrease in activity, which was in stark contrast to the high demand caused by the increased incidence and mortality of OHCA during the pandemic. Given the important role FR play in the chain of survival, a balanced approach upholding the safety of patients and responders should be sought to keep FR schemes operational.

Drones delivering automated external defibrillators-Integrating unmanned aerial systems into the chain of survival: A simulation study in rural Germany.

BACKGROUND: Community first responders (CFR) improve survival in out-of-hospital cardiac arrest (OHCA) but are often hampered by limited availability of public access defibrillation. Unmanned aerial systems (UAS) delivering automated external defibrillators (AED) directly to an OHCA site could help overcome this. We evaluated the feasibility of integrating UAS into the chain of survival in rural Northeast Germany. METHODS: This simulation study explored UAS-AED delivery combined with a smartphone-based CFR dispatch. Five OHCA locations (A-E) were randomly selected. We routed a flight corridor to each of these sites from a corresponding UAS base; 50 OHCA scenarios with 10 flights per corridor were scheduled. All steps were accurately simulated, from a bystander finding the patient, making an emergency call, conducting dispatcher-assisted cardiopulmonary resuscitation, and simultaneous CFR plus UAS deployment, to the bystander and CFR interacting with UAS and AED. This process was time-tracked and video-recorded until defibrillation. RESULTS: We performed 46 OHCA simulations. Missions were flown autonomously but needed pilot assistance during landing. Distances (km) and average time intervals from alert to defibrillation (td in min:sec ± SD) were 0.4 (6:02 ± 0:56), 2.29 (6:53 ± 0:19), 4.0 (8:54 ± 0:25), 7.43 (14:51 ± 1:055), and 9.79 (15:51 ± 1:16) for routes A to E, respectively. All participants were able to retrieve the AED within seconds after UAS landing and interacted safely with the UAS and AED. CONCLUSIONS: Integrating airborne AED delivery into the chain of survival appeared feasible and safe but remains an experimental technology. Linking this with CFR potentially improves the availability of early public-access defibrillation, particularly in rural regions.

[Technology-enhanced learning in anesthesiology and emergency medicine : A new approach to medical school teaching in the wake of the pandemic]. / "Technology-enhanced learning" in Anästhesiologie und Notfallmedizin : Ein neuer Weg in der studentischen Lehre im Schatten der Pandemie.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has brought about unprecedented challenges to medical schools. Physical distancing as the most effective means of infection prevention renders traditional classroom teaching nearly impossible and new teaching methods are required to contain the infection risk whilst ensuring high-level education. OBJECTIVE: In order to minimize the need for classroom teaching we have created an interactive multimedia eLearning environment using the open-source learning management system "Moodle". This article describes the development of the eLearning environment and aims to establish the acceptance of technology-enhanced learning (TEL) among medical students and the evaluation of TEL as an alternative to classroom teaching. MATERIAL AND METHODS: We have built a multimedia eLearning environment for fourth year medical students covering the medical school curriculum "anesthesiology and emergency medicine", which is based on the recommendations of the German Society for Anesthesiology and Intensive Care Medicine (DGAI). We have chosen the open-source learning management system "Moodle" as a platform. "Moodle" is widely used by Anglo-American educational institutions to support and conduct academic and nonacademic teaching. In order to assess the students' experience, we have carried out an anonymized post-course survey consisting of multiple-choice and free-answer questions. RESULTS: Of the 157 participants 85.4% rated the course as "very good", 12.1% as "good" and 1.9% as "OK". Lower ratings were not given, 54.8% rated the course content as "very relevant", 43.3% as "relevant" and 1.9% as "neutral", 94.3% felt that more comparable online courses should be offered. The free-text answers revealed that accessibility and multimedia self-controlled learning were highly valued; however, it was felt that hands-on training cannot be replaced by eLearning. CONCLUSION: Technology Enhanced Learning was highly valued by our students and helped to reduce the need for classroom teaching; however, for teaching practical skills classroom teaching remains indispensable.