[Which patients benefit from transport with ongoing cardiopulmonary resuscitation? : Retrospective analysis of 70 patients with refractory preclinical cardiac arrest]. / Welcher Patient profitiert von einem Transport unter laufender kardiopulmonaler Reanimation? : Retrospektive Analyse von 70 Patienten mit refraktärem präklinischem Herzstillstand.

BACKGROUND: Mortality in patients with out-of-hospital cardiac arrest (OHCA) remains very high despite advances in resuscitation algorithms. Most of these patients die at the scene and do not reach hospital. It is currently the subject of discussion whether transport to hospital with ongoing cardiopulmonary resuscitation (CPR) improves survival and neurological outcome in patients with OHCA. OBJECTIVE: The aim of this study was to identify predictors of survival and good neurological outcome in patients after OHCA who were transported to hospital with ongoing CPR. PATIENTS AND METHODS: A total of 70 consecutive patients with refractory OHCA (mean age 54.7 ± 15 years) transported to hospital with ongoing CPR were retrospectively analyzed. Neurological outcome was assessed after 30 days based on the Glasgow-Pittsburgh cerebral performance category (CPC). RESULTS: After 30 days 82.9% of the patients enrolled in the trial died (CPC score of 5), 8 patients (11.4%) showed a good neurological recovery with CPC scores of 1-2 and 4 patients (5.7%) had a poor neurological outcome with CPC scores of 3-4. Predictors of good neurological outcome were witnessed arrest, initial defibrillatable rhythm and serum lactate levels on admission. In all patients with good outcome, the index event for OHCA was from cardiac causes. CONCLUSION: Selected patient collectives can benefit from transport to hospital with ongoing cardiopulmonary resuscitation (CPR).

[Nationwide implementation of a hospital resource register for daily trauma care, mass casualties and disasters : Position paper of the German Trauma Society and the Federation of German Medical Directors of Emergency Medical Services]. / Bundesweite Einführung eines Krankenhauskatasters in den Klinikalltag und bei Großschadens- und Bedrohungslagen : Positionspapier der DGU und des BV-ÄLRD e. V.

The introduction of requirements for a minimum intake capacity of trauma patients by the German Trauma Society (DGU) into the so-called white book of treatment of seriously injured patients, is helpful for a sufficient preparation for threats and for dealing with mass casualties for trauma centers as well as for the emergency medical services (EMS). In the hospital information database provided by the Federation of German Medical Directors of Emergency Medical Services, more than 1300 hospitals are currently listed. This information supports the allocation of trauma patients from the field to the appropriate trauma center. Currently, without any coordination requirements, the current 626 trauma centers in Germany are able to immediately handle 6260 patients. This number could be doubled by activating the local hospital action plan, where a priority plan is set up. Additionally, the implementation of a nationwide flexible standardized communication structure between the dispatch center of the ambulance service and the hospitals, would improve daily care as well as the management of threats and mass casualties. It is the obligation of the local medical director of the EMS, to maintain and update the hospital database. Providing the information in the database with the hospital resources and the flexible standard communication structure, is appropriate to improve the daily collaboration and the preparation for mass casualties.

Effect of H1-antagonism on cardiovascular, pulmonary, and immunological dysfunction in porcine endotoxic shock.

The definite role of histamine in early hyperdynamic septic shock is not yet clear. Therefore a randomized, controlled, blind trial was performed to investigate the effect of the H1-antagonist dimethindene in hyperdynamic porcine shock. Lipopolysaccharide (LPS) infusion (5 micrograms/kg/h) in anesthetized pigs (n = 6) in the control-group induced a hyperdynamic shock state with a decrease in mean arterial blood pressure, and systemic vascular resistance (SVR), and an increase in mean arterial pulmonary pressure and pulmonary vascular resistance (PVR). In the verum group (n = 6) dimethindene (2 mg/kg) administered 15 min before LPS application prevented the decrease in SVR significantly (p < .05) and ameliorated the increase in MPAP and PVR. The impairment in pulmonary function, as measured by the oxygenation ratio (PaO2/FiO2) in LPS-treated animals, was reduced by the H1-antagonist (p = .01). Tissue oxygenation was ameliorated by the H1-antagonist treatment, as demonstrated by plasma lactate levels and base excess values (p < .05, control group versus dimethindene group). The increase in tumor necrosis factor alpha by LPS infusion was not influenced by H1-antagonist pretreatment. The early decrease in SVR did not correlate with an enhanced nitric oxide formation, as measured by nitrate/nitrite plasma levels.

H1-antagonism improves intestinal mucosal pH and heart function in porcine hypodynamic endotoxic shock.

Porcine hypodynamic shock was induced by continuous infusion of 5 micrograms lipopolysaccharide/kg per hour. This resulted in a decrease of cardiac output from baseline values of 3.5 +/- .9 L/min to 1.5 +/- .8 L/min and a reduced left ventricular stroke work index in the endotoxin-group (n = 6 animals). Pretreatment with the H1-antagonist dimethindene (2 mg/kg) in a second group (n = 6) significantly prevented these effects. Furthermore animals pretreated with the H1-antagonist showed a stable mean arterial blood pressure, whereas the control endotoxin-treated group revealed a drastic reduction in mean arterial blood pressure (99 +/- 4.7 mmHg versus 65.8 +/- 10 mmHg after 240 min, respectively). Pulmonary function and systemic vascular resistance were not ameliorated by the H1-antagonist in hypodynamic shock. Gastrointestinal mucosal pH (pHi), which indicates oxygenation of the mucosa, was decreased by endotoxin-infusion (7.45 +/- .32 baseline value to 6.92 +/- .24 after 120 min). This parameter as well as base excess values and lactate levels were significantly improved by dimethindene-pretreatment (p < .05). These results may indicate a beneficial effect of H1-antagonist-pretreatment on endotoxin-induced deterioration of the microcirculation. Furthermore our results clearly demonstrated that only pretreatment before endotoxemia with H1-antagonism is effective, since infusion of H1-antagonist in hypodynamic shock 45 min after addition of endotoxin (n = 6 animals) did not improve the cardiovascular system or the microcirculation.

Beneficial effect of H2-agonism and H1-antagonism in rat endotoxic shock.

Although histamine release is generally considered harmful in endotoxic shock, several data exist to doubt this view. Own previous studies in rats let us assume a possible beneficial effect only with H1-antagonists, however a detrimental effect on survival with H2-antagonists. Consequently H1- and H2-agonists and antagonists were studied to prove the hypothesis of a beneficial H2-agonistic and H1-antagonistic effect. Two randomized studies were performed in a standardized rat endotoxic shock model (45 mg of Escherichia coli endotoxin/kg body weight (b.w.)). In both, methylprednisolone (50 mg/kg b.w.) and saline were used as positive and negative controls, respectively. Study I compared the effects of H1- and H2-agonists (betahistine, .1 mg/kg/h, and impromidine, 100 micrograms/kg/h) with H1- and H2-antagonists (astemizole and famotidine both 1 mg/kg b.w.; 20 rats/dose). Study II was performed to estimate the dose-response relationship of a new, highly potent H2-agonist with additional H1-antagonistic features (BU-E 75: .01, .1, 1.0, 10, and 100 micrograms/kg/h; 20 rats/dose). Animals receiving impromidine or BU-E 75 all received omeprazole (1 mumol/kg b.w.) to suppress gastric acid secretion. In study I impromidine significantly increased the survival-time and -course compared to famotidine treated animals (p = .01 and p < .05). Study II showed a positive dose-response relationship of BU-E 75 with an increase in survival rates from 30% (.01 microgram/kg/h) to 70% (100 micrograms/kg/h). These data strongly support the hypothesis of a beneficial effect of H2-agonism and H1-antagonism on survival parameters in rat endotoxic shock.

Prehospital care of burns: an analysis of 3 years use of the emergency physician system (EPS) Cologne.

Little information is available about the vital parameters of burns victims shortly after the accident. Therefore cases of burns, electrical and caustic injuries presenting to the Cologne Emergency Physician System over 3 years (n = 262) were prospectively studied and analysed. The average incidence in Cologne, Germany (population 1 million), of burns victims attended by the Emergency Medical System and emergency physicians at the scene was 74 adults and 14 children per year. Children are mainly injured by scalds (41.4 per cent); adults by fire accidents (43 per cent). A classification of the victims at the site of the accident according to their vital signs (Trauma Score (TS) after Champion H. R., Sacco W. J. and Carnazzo A. J. et al. (1981) Trauma Score. Crit. Care Med. 9, 672) showed, that in spite of a major burn injury, the vital signs were usually not or only slightly impaired. Subsequent measurements instituted by the emergency physician at the scene increased with decreasing initial TS. With TS = 14, 50 per cent of the patients were intubated; below 14 points nearly 100 per cent. The fluid administered also increased with a decreasing TS.

Helicopters as part of a regional EMS system--a cost-effectiveness analysis for three EMS regions in Germany.

With increasing health care costs the use of rescue helicopters is being questioned on the grounds of expense. No data exist on the cost-effectiveness of the use of rescue helicopters as part of a regional EMS. The end-point of this study was to analyse the cost-effectiveness of a 15 min response time (state regulation) of advanced life support (ALS) equipment provided by helicopter (1,575,000 DM annual costs) versus a ground-based ambulance (1,004,000 DM annual costs) in three EMS systems (50 km radius) with differing demographic and geographic features in Germany. The effect of varying the ratio of helicopters to ground-based vehicles (ALSC) has also been considered using two additional models. In model 1 each region was allocated one additional helicopter and had six ALS cars removed (daytime only). This improved the response times and saved nearly 1,500,000 DM per year. In model 2 each region had its existing helicopter withdrawn and replaced with six ALS cars. This made response times longer and increased expenditure. In conclusion, the additional use of rescue helicopters in EMS regions (50 km radius) remains cost-effective up to an ALSC:helicopter cost ratio of 1:6.

Prehospital detection of uncontrolled haemorrhage in blunt trauma.

The field strategy for trauma victims is still controversial. The first randomized study in penetrating truncal trauma by Martin et al. (1992) supported experimental findings (Gross et al., 1988, 1989; Kowalenko et al., 1992; Krausz et al., 1992b) that fluid therapy in uncontrolled haemorrhage increases mortality. No controlled data in blunt trauma are available. In this retrospective analysis of blunt trauma victims (n = 353), the parameters systolic blood pressure, capillary refilling time and Traumascore (Champion et al., 1981) were evaluated in the prehospital detection of uncontrolled bleeding. With the CART methodology (Breiman et al., 1984) systolic blood pressure (BP) was the most sensitive parameter. Uncontrolled haemorrhage was found in nearly 50% of patients whose BP was below 90 mmHg and in 66% of those whose BP was below 50 mmHg. An accompanying traumatic brain injury (TBI) impaired the ability of BP to detect uncontrolled bleeding. Future studies evaluating prehospital fluid therapy in severe blunt trauma with a mixture of injuries, should take into account that BP in our study population classified less than 50% patients with uncontrolled haemorrhage.

Evolution of rescue systems: a comparison between Cologne and Cleveland.

INTRODUCTION: Comparisons of different emergency medical services (EMS) systems often are reduced to simple comparisons between distinct facilities or strategies (e.g., prehospital physician versus paramedic, "scoop and run" versus "stay and play"). METHODS: The EMS systems of similar cities (Cologne and Cleveland) in two different countries (Germany and the United States) are compared. The comparison is seen from the perspective of an evolutionary standpoint that reflects the development of the EMS system in connection with the special environments. Data on rescue times, facilities, and (trauma) outcomes are compared. RESULTS: No statistically significant differences in outcome between the systems were detected. CONCLUSION: Both systems are developed in special environments and are optimized over decades, which explains the similarities in outcome.

[Reducing medical error and improving patient safety]. / Reduzierung medizinischer Fehler und Verbesserung der Patientensicherheit.

Within the last years in the public discussion medical error became a new issue. Several studies have addressed problems in the delivery of medical services, which create a breakdown of trust in doctors and the health care system. One of the reasons may be a broader and faster (global) information network system together with media which search extensively for mistakes and problems, despite the fact that diagnostic and therapeutic methods, skills and accuracy could be improved. Nevertheless, the medical system has to address these challenges in order to definitively reduce medical errors and improve patient safety. In contrast to the discussion about quality assurance and management systems in health care, medical errors and patient safety do not have the smell of expensive or not really necessary products, but they are urgent and very important. So the topics "medical error" and "patient safety" have in fact the potential to enhance quality management systems (QMS), which are an accepted technology to solve these problems.

[Recommendations for the conversion of scientific information into practice-relevant guidelines for emergency care in the city of Cologne. Conception of an 8-step program]. / Empfehlungen zur Umsetzung wissenschaftlicher Informationen in handlungsrelevante Leitlinien für den Rettungsdienst der Stadt Köln. Konzeption in einem 8-Schritte Programm.

Guidelines for prehospital emergency care within the chain of rescue are recommended. At the scene, information about the patient and therapeutical tools are limited. Accidents and emergencies happen outside of hospitals and doctor's offices, while environmental factors and logistic problems strongly determine the rescue process. The sequence of interventions or the choice of the right hospital with specific triage criterias are only examples for these problems. There is only limited scientific evidence for therapies performed prehospitally. However, scientific material for the preparation of guidelines should be evaluated by using standardized criteria. The rules of evidence based medicine according to Cook are a practical way to evaluate and classify scientific material and to establish practical guidelines. In this paper, an 8-step-program is introduced to develop practical guidelines for the Emergency Medical Services Cologne.

[Stroke always with an emergency physician? - Pro]. / "Schlaganfall immer mit Notarzt?" - "Pro".

Good management of acute stroke is dependent on time and expertise. In Germany emergency medical care by ambulance services sometimes occurs without an emergency physician being sent to the scene. By reviewing current literature the question of patient care in the ambulance with or without an emergency physician is discussed. Presence of an emergency physician at the scene results in high diagnostic accuracy, allows for invasive procedures to be carried out, and enables referral to a specialist centre with a stroke-unit. The "rendezvous" system of separate deployment of patient ambulance and emergency physician allow flexible assignment of the physician resulting in short response times. Current research does not support a turn away from the deployment of an emergency physician in cases of acute stroke.

Duration of antibiotic treatment in surgical infections of the abdomen. Minimal antibiotic therapy: technology assessment instead of clinical trials.

In modern medicine which already uses maximal resources, additional improvements involve huge extra efforts. With increasing complexity of diseases, specific treatments have only a limited influence on the "whole process". In complex clinical situations (including sepsis and SIRS) the available methodology to identify groups of patients who may benefit from a specific treatment are weak. This is why prospective randomised "megatrials" may be needed to detect small differences in outcome. We suggest that careful prospective assessment of cohorts of well stratified patients, subjected to a specific and standardised treatment, may replace prospective controlled trials.

Atresia of the right atrial ostium of the coronary sinus.

A case of asymptomatic congenital occlusion of the ostium of the coronary sinus is described. The myocardial venous drainage was maintained via a persistent left superior vena cava as well via ectatic, widened atrial veins of the dorsal wall of the left atrium. The study shows that complete ostial occlusion of the coronary sinus does not reduce cardiac venous drainage. The view of the literature allows a comparison with the comprehensive classification of coronary sinus anomalies.

Lungs of Polypterus and Erpetoichthys.

The wall of the asymmetrical saclike lungs of the fishes Polypterus and Erpetoichthys consists of several functionally different tissue layers. Their lumen is lined by a surface epithelium composed of (1) highly attenuated cells, termed pneumocytes I; (2) pneumocytes II with lamellar bodies, presumably indicating surfactant production; (3) mucous cells; and (4) ciliated cells. Underlying the pneumocytes I is a dense capillary net. The thin continuous endothelium of this net, together with the pneumocytes I, constitute the very thin blood-air barrier. The basement membrane of epithelium and endothelium fuse in the area of the blood-air barrier (thickness 210 m̈m). Secretory and ciliary cells form longitudinal rows in the epithelium. Below the zone with a gas-exchanging tissue, a layer of connective tissue containing collagen and special elastic fibers occurs. The blood vessels that give rise to or drain the superficial capillary plexus are located in this connective tissue. The outermost layer of the lung consists of muscle cells, a narrow inner zone with smooth muscle cells, and an outer, broader zone with cross-striated muscle cells. The lung is innervated by myelinated and nonmyelinated nerve fibers. The morphology of the gas-exchange tissue in the lungs of these primitive bony fish is fundamentally very similar to that of the lungs of tetrapod vertebrates. The morphologic observations are in close agreement with physiologic data, disclosing well-developed respiratory capacities. Structural simplicity can be regarded as a model from which the lungs of the higher vertebrates derived. In addition to respiratory function, the lungs seem also to have hydrostatic tasks.

Nonsuture microsurgical vessel anastomosis using an absorbable cuff.

The nonabsorbable cuff used for nonsuture anastomosis can cause residual vessel stenosis as well as regional wall rigidity. Resulting disturbances in laminar flow promote the development of irregularities in the intimal endothelial vessel lining distal to the anastomosis. Using absorbable cuffs, the degree of stenosis can be appreciably reduced, thereby diminishing thrombogenic flow turbulence. The absorbable cuff can thus facilitate clinical application of nonsuture microsurgical vessel anastomosis.

[Assessment of critical care costs of an intensive care unit with TISS (Therapeutic Intervention Scoring System)--an economic analysis of intensive care]. / Erfassung des Pflegeaufwandes einer Intensivstation mit TISS--eine ökonomische Analyse der Intensivtherapie.

The parallel documentation of Apache II and TISS scores on a surgical intensive care unit allows detailed cost-effectiveness analyses. 929 patient were observed over 18 months with an average Apache score of 12.8 and 32.3 TISS points per patient-day. A value of 44.46 DM per TISS point resulted from a detailed cost analysis.

[Multiple trauma: preclinical needs, transportation, time sequences]. / Polytrauma--präklinische Erfordernisse, Rettungsmittel, Rettungszeiten.

Compared to the magnitude of the trauma problem few precise data exist on prehospital care of trauma patients. The aim of the study was the collection and careful evaluation of prehospital data on trauma patients concerning time sequences, patients' status and prehospital interventions. From 1. 1. 1987 to 31. 12. 1990 all 49,045 prehospital emergencies in Cologne were prospectively registered. 8792 trauma patients were treated by an emergency physician in the field. 9.5% were severely injured, defined by a trauma score less than or equal to 12. 9.9% of the trauma patients were intubated, 54.9% received an i.v. line, and 20.6% were triaged to a trauma center. Our data form a valid base for analysis of the effectiveness of prehospital trauma care.