[Add-on-LUCAS2™ resuscitation at NEF Innsbruck]. / Add-on-LUCAS2™-Reanimation am NEF Innsbruck.

STUDY GOAL: The study goals were to analyze the course and compare it with patients who were only resuscitated manually as well as to record the influencing factors in patients in whom the mechanical chest compression aid LUCAS2™ was used as an add-on treatment at the NEF Innsbruck. MATERIAL AND METHODOLOGY: Retrospective history data analysis of patients in the study period from 01.01.2014 to 31.12.2019 of the NEF Innsbruck from the German Resuscitation Register (GRR), in which LUCAS2™ was used as an add-on treatment according to an emergency doctor's order. RESULT: A total of 123 add-on LUCAS2™ applications (18.8%) were performed in 653 resuscitations. Of all patients 16.2% survived the first 30 days. By using add-on-LUCAS2TM application 7.3% (9/123) of all add-on LUCAS2TM resuscitations and 1.4% (n = 9) of all CPR survived. Cardiac arrest was observed in 8/9 add-on LUCAS2™ 30-day survivors and bystander CPR was performed and 8/9 showed ventricular fibrillation as the primary rhythm. Compared to manual CPR alone, add-on LUCAS2™ resuscitation was used highly significantly (p < 0.001) more frequently in younger, male patients, in public, in shockable initial rhythms and during transport, and significantly more frequently in observed cardiac arrest (p < 0.05). The 30-day mortality with additive lysis treatment was 100%. DISCUSSION: By using add-on LUCAS2™ CPR a percentage increase in survival rate can be achieved and thus appears advantageous (1.4% in our study). This means that high-quality CPR can be carried out on patients with favorable prognostic factors, even with technically complex rescue operations (turntable ladder, staircase, transport in an ambulance) and thus transport can be made possible; however, there is a higher admission rate under CPR and thus the treatment target decision is shifted to the shock room.

[Evaluation of cancelled emergency physician missions and patient handovers in the area of Innsbruck : Retrospective assessment of physician-staffed emergency medical service cancellations and handovers from the emergency physician to the emergency medical service in 2017 and 2018]. / Evaluierung der NEF-Fehl- und Übergabeeinsätze im Raum Innsbruck : Retrospektive Auswertung der NEF-Stornierungen und Übergabeeinsätze vom Notarzt an den Rettungsdienst in den Jahren 2017 und 2018.

BACKGROUND: Human and vehicle resource management indicates a good emergency medical system (EMS). Frequently, an emergency medical technician (EMT) is the first responder to the emergency, which negates the necessity for an emergency physician (EP) and is just as sensible as handing over a stable patient to the EMT for transport to the hospital. The Austrian EMS is utilized by EMTs, in cases of potential life-threatening emergencies the dispatch center dispatches an additional team with an on-board EP. During the years 2017-2018 nearly every fifth EP mission in Innsbruck (including surrounding areas) ended in a cancellation. The numbers of patient handovers from EP to EMT are slightly lower with mission cancellations resulting in every fourth patient. Therefore, due to the high number of cancellations and handovers evaluated in this study, the findings suggest that there is a potential need to re-evaluate procedures. The re-evaluation of these procedures could determine whether these cancellations/handovers were justified or if an over hasty decision making was at fault. All cases considered in this study were from the Innsbruck and Telfs EP bases between 1 January 2017 and 13 December 2018. METHODS: Out of a total of 96,908 emergency dispatches, there were 2470 cancellation/handover occurrences. These occurrences consisted of 1190 cancellations and 1280 patient handovers from the EP to the EMT. Patients who were transferred to the University Hospital Innsbruck were included in these figures. The protocols of the emergency dispatches have been filtered from the so-called CarPC. They have subsequently been grouped into cancellation and handover categories. The clinical diagnoses of the patients with inpatient treatment were evaluated from the hospital information system (KIS) of the University Hospital Innsbruck. This was done with the help of the so-called emergency physician indications catalogue of the German Medical Council. The diagnosis was documented in the hospital information system. The emergency protocols from the EMTs were also evaluated retrospectively. The Innsbruck based EP patients are hospitalized in the Innsbruck Hospital due their geographical position. When there is no need for a specific intervention the patients of the EPs based in Telfs are transferred to a local hospital. When a specific intervention is necessary, patient care must be provided by the University Hospital Innsbruck. Due to the privacy practices of the Innsbruck Medical University "vote of ethics" only the data of patients transferred to the Innsbruck Clinic can be evaluated. The information provided from the EPs based in Innsbruck was exclusively from the University Hospital Innsbruck's anesthesiologists. The physicians from the Telfs EP base are of mixed medical specialities. All of them, however, have an emergency medical physician diploma, in addition to the ius practicandi. Lastly, there are no EPs in Innsbruck or Telfs, who have any special obligations during their duty. RESULTS: The results show that in 210 cases (8.5%) the indications for the EP, based on the emergency physician indications catalogue of the German Medical Council were given. Also, 8.7% of all cancellations and 8.4% of patient handovers were not justified. Patients with emergency indications had a longer hospitalization. The EP base EMS Innsbruck had more cancellations than the EP base EMS Telfs. The EMS Innsbruck also had more cancellations than patient handovers. Conversely, the EMS Telfs had more patient handovers than cancellations. On the weekends between 6:00 pm and 6:00 am there were less cancellations and handovers from both EP bases. The documentation from the EMT protocols was incomplete in 284 cancellations (23.9% of the cancellations) and 339 handovers (26.5% of the handovers), 35 patients after cancellations (2.9%), 35 patients after handovers (2.7%) needed intensive care treatment, 20 patients after cancellations (1.7% of all cancellations), and 24 patients after handovers (1.9% of all handovers) who needed intensive care treatment had a critical diagnosis. In 40 cases of patient handovers, the EP was alerted to another emergency follow-up within 10 min. CONCLUSION: In Austria, the introduction of a standardized emergency indication checklist might help dispatch centers to provide a more accurate dispatch as well as all EMS team members. Furthermore, a better traceability system (according to EP cancellations and patient handovers from the EP to the EMT) could be achieved. The documentation requirements should be more precise by all members of the EMT staff, not only for the legal aspects but also for improving the overall management quality. Intense education and training as well as diagnosis feedbacks could help to reduce the number of risky cancellations/patient handovers.

[Reform of emergency physician training in Austria : Finally up to date?] / Reform der Notarztausbildung in Österreich : Endlich zeitgemäß?

During the last 20 years Austrian prehospital emergency medical services (EMS) have significantly improved. The structure and organization of Austrian EMS comply with European standards but training requirements for prehospital EMS physicians are insufficient when compared with other countries. Although some EMS systems follow the German or Swiss postgraduate training concepts, the legal requirements in Austria defining the scope of mandatory training for physicians in the prehospital setting are only minimal. Thus, besides board certification as a general practitioner or specialist of any discipline, the only formal requirement is a 1-week theoretical course comprising some manikin simulations. Experience in anesthesia or intensive care medicine is still not mandatory. The Austrian Society of Anesthesiology, Resuscitation and Intensive Care Medicine (ÖGARI) drafted a reform paper in 2009, which was adapted by the Austrian Chamber of Physicians, section of emergency medicine, and subsequently presented to the Austrian Ministry of Health. Due to the slowness of the legislation process, the relevant § 40 of the Austrian Physician 's Act is still unchanged. In the meantime, Austrian specialist training regulations were restructured in 2015 with significant consequences. Due to changes in the residency programs, board certification and subsequent full working permit becomes more difficult to obtain, thus further aggravating the shortage of emergency physicians in Austria. In order to counteract the threatening shortage of prehospital EMS physicians, the ÖGARI section of emergency medicine was requested by the Ministry of Health to develop a reasonable model for how physicians could be qualified and subsequently employed in EMS prior to full board certification. Presently, the Austrian Ministry of Health, the Chamber of Physicians and medical societies are in discussion on whether this approach might fit into the legal framework. This manuscript details the development and present status as well as key points of an ongoing discussion on how high-quality EMS care in Austria can be safeguarded in the future or could even make it impossible.

Telephone-assisted CPR: A literature review.

INTRODUCTION: Despite numerous efforts, out-of-hospital cardiac arrest (OHCA) survival has not significantly increased in recent decades. The first telephone-assisted cardiopulmonary resuscitation (T-CPR) studies were published in the 1980s, but only in the last decade has T­CPR been implemented in dispatch centers. T­CPR is still not available in all dispatch centers and no national or international T­CPR recommendations are available. METHODS: Studies from PubMed were identified and evaluated. Preliminary information from the European Dispatch Center Survey (EDiCeS) is also included. RESULTS: In all, 42 studies were included. T­CPR is implemented in 87.6 % of those dispatch centers which have joined the not-yet published EDiCeS. According to German Resuscitation Registry data, about 10 % of OHCA patients received T­CPR in 2014. Agonal breathing is the leading cause for nonrecognition of OHCA by the dispatcher. Sensitivity of OHCA recognition by the dispatcher is about 75 %, whereby 8-45 % of these patients were not in cardiac arrest. The time interval from call to first compression is 140-328 s. Instructing rescue breathing by telephone is time consuming, leads to extensive hands-off times, and often to ineffective ventilation; therefore, rescue breathing is not indicated in adults with primary cardiac arrest. Studies showed improved survival with standardized T­CPR implementation. CONCLUSION: T-CPR is established in many dispatch centers. However, emergency call interrogation and T­CPR vary between dispatch centers and are often performed without evaluation. International recommendations with standardized quality control are necessary and may lead to improved survival.

Expectations of patients, nurses and physicians in geriatric nursing home emergencies.

OBJECTIVES: To determine contentment with the performance of primary mission emergency care providers. METHODS: A prospective cohort study was conducted using key informant interviews to assess quality of life and self-rated degree of contentment with care in geriatric emergencies. RESULTS: Interviews concerning a total of 152 geriatric emergency cases in nursing homes were conducted with patients in 13 (8.6%) cases, geriatric nurses in 132 (86.8%) cases and emergency physicians in 116 (76.3%) cases within a 3-month period. All responding patients as well as the majority of nurses (96.2%) and physicians (79.4%) were content with the quality of emergency care, but showed less contentment with communication (57.6% of nurses; 22.4% of physicians) and with cooperation on-site (57.6% of nurses; 20.7% of physicians). CONCLUSIONS: Participants perceived a deficit in communication and cooperation on-site. There is a need for intensified education in managing geriatric emergency patients, especially with regard to communication and psychosocial issues.

[Comments on the 2010 guidelines on cardiopulmonary resuscitation of the European Resuscitation Council]. / Kommentar zu den Leitlinien 2010 zur kardiopulmonalen Reanimation des European Resuscitation Council.

ADULTS: Administer chest compressions (minimum 100/min, minimum 5 cm depth) at a ratio of 30:2 with ventilation (tidal volume 500-600 ml, inspiration time 1 s, F(I)O2 if possible 1.0). Avoid any interruptions in chest compressions. After every single defibrillation attempt (initially biphasic 120-200 J, monophasic 360 J, subsequently with the respective highest energy), chest compressions are initiated again immediately for 2 min independent of the ECG rhythm. Tracheal intubation is the optimal method for securing the airway during resuscitation but should be performed only by experienced airway management providers. Laryngoscopy is performed during ongoing chest compressions; interruption of chest compressions for a maximum of 10 s to pass the tube through the vocal cords. Supraglottic airway devices are alternatives to tracheal intubation. Drug administration routes for adults and children: first choice i.v., second choice intraosseous (i.o.). Vasopressors: 1 mg epinephrine every 3-5 min i.v. After the third unsuccessful defibrillation amiodarone (300 mg i.v.), repetition (150 mg) possible. Sodium bicarbonate (50 ml 8.4%) only for excessive hyperkaliemia, metabolic acidosis, or intoxication with tricyclic antidepressants. Consider aminophylline (5 mg/kgBW). Thrombolysis during spontaneous circulation only for myocardial infarction or massive pulmonary embolism; during on-going cardiopulmonary resuscitation (CPR) only when indications of massive pulmonary embolism. Active compression-decompression (ACD-CPR) and inspiratory threshold valve (ITV-CPR) are not superior to good standard CPR. CHILDREN: Most effective improvement of outcome by prevention of full cardiorespiratory arrest. Basic life support: initially five rescue breaths, followed by chest compressions (100-120/min depth about one third of chest diameter), compression-ventilation ratio 15:2. Foreign body airway obstruction with insufficient cough: alternate back blows and chest compressions (infants), or abdominal compressions (children >1 year). Treatment of potentially reversible causes: ("4 Hs and 4 Ts") hypoxia and hypovolaemia, hypokalaemia and hyperkalaemia, hypothermia, and tension pneumothorax, tamponade, toxic/therapeutic disturbances, thrombosis (coronary/pulmonary). Advanced life support: adrenaline (epinephrine) 10 µg/kgBW i.v. or i.o. every 3-5 min. Defibrillation (4 J/kgBW; monophasic or biphasic) followed by 2 min CPR, then ECG and pulse check. NEWBORNS: Initially inflate the lungs with bag-valve mask ventilation (p(AW) 20-40 cmH2O). If heart rate remains <60/min, start chest compressions (120 chest compressions/min) and ventilation with a ratio 3:1. Maintain normothermia in preterm babies by covering them with foodgrade plastic wrap or similar. POSTRESUSCITATION PHASE: Early protocol-based intensive care stabilization; initiate mild hypothermia early regardless of initial cardiac rhythm [32-34°C for 12-24 h (adults) or 24 h (children); slow rewarming (<0.5°C/h)]. Consider percutaneous coronary intervention (PCI) in patients with presumed cardiac ischemia. Prediction of CPR outcome is not possible at the scene, determine neurological outcome <72 h after cardiac arrest with somatosensory evoked potentials, biochemical tests and neurological examination. ACUTE CORONARY SYNDROME: Even if only a weak suspicion of an acute coronary syndrome is present, record a prehospital 12-lead ECG. In parallel to pain therapy, administer aspirin (160-325 mg p.o. or i.v.) and clopidogrel (75-600 mg depending on strategy); in ST-elevation myocardial infarction (STEMI) and planned PCI also prasugrel (60 mg p.o.). Antithrombins, such as heparin (60 IU/kgBW, max. 4000 IU), enoxaparin, bivalirudin or fondaparinux depending on the diagnosis (STEMI or non-STEMI-ACS) and the planned therapeutic strategy. In STEMI define reperfusion strategy depending on duration of symptoms until PCI, age and location of infarction. TRAUMA: In severe hemorrhagic shock, definitive control of bleeding is the most important goal. For successful CPR of trauma patients a minimal intravascular volume status and management of hypoxia are essential. Aggressive fluid resuscitation, hyperventilation and excessive ventilation pressure may impair outcome in patients with severe hemorrhagic shock. TRAINING: Any CPR training is better than nothing; simplification of contents and processes is the main aim.

Assessment of reperfusion following thrombolysis with mean fibrillation and amplitude spectrum area in patients with sustained ventricular fibrillation.

BACKGROUND: Improved microcirculatory reperfusion in patients with ventricular fibrillation (VF) enhances the electrical activity of the fibrillation process and increases the likelihood of successful defibrillation. METHODS: Changes in amplitude spectrum area (AMSA) and mean fibrillation (MF) in patients with sustained VF were analysed after administration of rt-PA variant tenecteplase in out-of-hospital cardiac arrest (OHCA) during cardiopulmonary resuscitation (CPR). RESULTS: A total of 69 ECG sequences from nine patients were evaluated. Patients who received tenecteplase showed significantly longer duration of VF (p = 0.016). While AMSA declined significantly during CPR (p = 0.001), MF did not differ between groups. There were two survivors in the treatment group and one in the control group. CONCLUSION: When tenecteplase was administered during CPR, VF lasted significantly longer than in controls. Changes in MF and AMSA did not indicate improved myocardial perfusion in patients who received tenecteplase during CPR.

[The new 2005 resuscitation guidelines of the European Resuscitation Council: comments and supplements]. / Die neuen Reanimationsleitlinien 2005 des European Resuscitation Council: Kommentar und Ergänzungen.

The new CPR guidelines are based on a scientific consensus which was reached by 281 international experts. Chest compressions (100/min, 4-5 cm deep) should be performed in a ratio of 30:2 with ventilation (tidal volume 500 ml, Ti 1 s, FIO2 if possible 1.0). After a single defibrillation attempt (initially biphasic 150-200 J, monophasic 360 J, subsequently with the respective highest energy), chest compressions are initiated again immediately for 2 min. Endotracheal intubation is the gold standard; other airway devices may be employed as well depending on individual skills. Drug administration routes for adults and children: first choice IV, second choice intraosseous, third choice endobronchial [epinephrine dose 2-3x (adults) or 10x (pediatric patients) higher than IV]. Vasopressors: 1 mg epinephrine every 3-5 min IV. After the third unsuccessful defibrillation attempt amiodarone IV (300 mg); repetition (150 mg) possible. Sodium bicarbonate (1 ml/kg 8.4%) only in excessive hyperkalemia, metabolic acidosis, or intoxication with tricyclic antidepressants. Consider atropine (3 mg) and aminophylline (5 mg/kg). Thrombolysis during spontaneous circulation only in myocardial infarction or massive pulmonary embolism; during CPR only during massive pulmonary embolism. Cardiopulmonary bypass only after cardiac surgery, hypothermia or intoxication. Pediatrics: best improvement in outcome by preventing cardiocirculatory collapse. Alternate chest thumps and chest compression (infants), or abdominal compressions (>1-year-old) in foreign body airway obstruction. Initially five breaths, followed by chest compressions (100/min; approximately 1/3 of chest diameter): ventilation ratio 15:2. Treatment of potentially reversible causes (4 "Hs", "HITS": hypoxia, hypovolemia, hypo- and hyperkaliemia, hypothermia, cardiac tamponade, intoxication, thrombo-embolism, tension pneumothorax). Epinephrine 10 microg/kg IV or intraosseously, or 100 microg (endobronchially) every 3-5 min. Defibrillation (4 J/kg; monophasic oder biphasic) followed by 2 min CPR, then ECG and pulse check. Newborns: inflate the lungs with bag-valve mask ventilation. If heart rate<60/min chest compressions:ventilation ratio 3:1 (120 chest compressions/min). Postresuscitation phase: initiate mild hypothermia [32-34 degrees C for 12-24 h; slow rewarming (<0.5 degrees C/h)]. Prediction of CPR outcome is not possible at the scene; determining neurological outcome within 72 h after cardiac arrest with evoked potentials, biochemical tests and physical examination. Even during low suspicion for an acute coronary syndrome, record a prehospital 12-lead ECG. In parallel to pain therapy, aspirin (160-325 mg PO or IV) and in addition clopidogrel (300 mg PO). As antithrombin, heparin (60 IU/kg, max. 4000 IU) or enoxaparine. In ST-segment elevation myocardial infarction, define reperfusion strategy depending on duration of symptoms until PCI (prevent delay>90 min until PCI). Stroke is an emergency and needs to be treated in a stroke unit. A CT scan is the most important evaluation, MRT may replace a CT scan. After hemorrhage exclusion, thrombolysis within 3 h of symptom onset (0.9 mg/kg rt-PA IV; max 90 mg within 60 min, 10% of the entire dosage as initial bolus, no aspirin, no heparin within the first 24 h). In severe hemorrhagic shock, definite control of bleeding is the most important goal. For successful CPR of trauma patients, a minimal intravascular volume status and management of hypoxia are essential. Aggressive fluid resuscitation, hyperventilation, and excessive ventilation pressure may impair outcome in severe hemorrhagic shock. Despite bad prognosis, CPR in trauma patients may be successful in select cases. Any CPR training is better than nothing; simplification of contents and processes remains important.

Waveform analysis of biphasic external defibrillators.

BACKGROUND AND OBJECTIVE: All internal defibrillators and some external defibrillators use biphasic waveforms. The study analysed the discharged waveform pulses of two manual and two semi-automated biphasic external defibrillators. METHODS AND RESULTS: The defibrillators were discharged into resistive loads of 25, 50 and 100 Omega simulating the patient's transthoracic impedance. The tested biphasic defibrillators differed in initial current as well as initial voltage, varying from 10.9 to 73.3 A and from 482.8 to 2140.0 V, respectively. The energies of the manual defibrillators set at 100, 150 and 200 J deviated by up to +19.1 or -28.9% from the selected energy. Impedance-normalised delivered energy varied from 1.0 to 12.5 J/Omega. Delivered energy, shock duration and charge flow were examined with respect to the total pulse, its splitting into positive and negative phases and their impedance dependence. For three defibrillators pulse duration increased with the resistive load, whereas one defibrillator always required 9.9 ms. All tested defibrillators showed a higher charge flow in the positive phase. Defibrillator capacitance varied between approximately 200 and 100 mu F and internal resistance varied from 2.0 to 7.6 Omega. Defibrillator waveform tilt ranged from -13.1 to 61.4%. CONCLUSIONS: The tested defibrillators showed remarkable differences in their waveform design and their varying dependence on transthoracic impedance.

Recombinant tissue plasminogen activator during cardiopulmonary resuscitation in 108 patients with out-of-hospital cardiac arrest.

BACKGROUND: Thrombolytic therapy during cardiopulmonary resuscitation (CPR) is a controversial issue in emergency medicine practice. This study was conducted to determine whether administration of recombinant tissue plasminogen activator (rt-PA) in out-of-hospital cardiac arrest of non-traumatic aetiology improves CPR outcome. METHODS AND RESULTS: A retrospective chart review of 401 patients with out-of-hospital cardiac arrest who were resuscitated by the emergency medical services (EMS) during a 6 year period was performed. A total of 108 patients received rt-PA during CPR and were compared to 216 controls, closely matched according to baseline characteristics, arrival status and ECG findings. Administration of rt-PA was optional. Return of spontaneous circulation (ROSC) occurred in 76 patients under rt-PA treatment (70.4 vs. 51.0% in controls; P=0.001). Fifty-two patients from the lysis group survived the first 24 h (48.1 vs. 32.9% in controls; P=0.003), while 27 (25.9%) survived to discharge. Autopsy reports revealed major bleeding complications in six patients receiving rt-PA treatment. Fulminant intracranial haemorrhage was observed in one patient who received rt-PA and in two cases from the control group. CONCLUSIONS: Thrombolytic therapy may improve frequency of return of spontaneous circulation substantially and increase primary survival in patients with non-traumatic cardiac arrest. Serious bleeding complications are not frequently observed under rt-PA treatment.

The beneficial effect of basic life support on ventricular fibrillation mean frequency and coronary perfusion pressure.

BACKGROUND AND OBJECTIVE: Chest compressions before initial defibrillation attempts have been shown to increase successful defibrillation. This animal study was designed to assess whether ventricular fibrillation mean frequency after 90 s of basic life support cardiopulmonary resuscitation (CPR) may be used as an indicator of coronary perfusion and mean arterial pressure during CPR. METHODS AND RESULTS: After 4 min of ventricular fibrillation cardiac arrest in a porcine model, CPR was performed manually for 3 min. Mean ventricular fibrillation frequency and amplitude, together with coronary perfusion and mean arterial pressure were measured before initiation of chest compressions, and after 90 s and 3 min of basic life support CPR. Increases in fibrillation mean frequency correlated with increases in coronary perfusion and mean arterial pressure after both 90 s (R=0.77, P<0.0001, n=30; R=0.75, P<0.0001, n=30, respectively) and 3 min (R=0.61, P<0.001, n=30; R=0.78, P<0.0001, n=30, respectively) of basic life support CPR. Increases in fibrillation mean amplitude correlated with increases in mean arterial pressure after both 90 s (R=0.46, P<0.01; n=30) and 3 min (R=0.42, P<0.05, n=30) of CPR. Correlation between fibrillation mean amplitude and coronary perfusion pressure was not significant both at 90 s and 3 min of CPR. CONCLUSIONS: In this porcine laboratory model, 90 s and 3 min of CPR improved ventricular fibrillation mean frequency, which correlated positively with coronary perfusion pressure, and mean arterial pressure.

[The new international guidelines for cardipulmonary resuscitation: an analysis and comments on the most important changes]. / Die neuen internationalen Richtlinien zur kardiopulmonalen Reanimation. Eine Analyse und Kommentierung der wichtigsten Anderungen.

In August 2000, the American Heart Association and the European Resuscitation Council published the conclusions of the International Guidelines 2000 Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care which contains both the new recommendations and an in-depth review. The discussions and drafting began at a conference in March 1999, followed by a second conference in September 1999, both attended by approx. 250 participants and another conference in February 2000 which was attended by approx. 500 participants. Review of the current state of science, discussion and final consensus continued subsequently via email, conference calls, fax, and personal conversation. During the entire process, scientists and resuscitation councils from all over the world participated, with participants from the United States comprising approx. 60%, and scientists from outside of the United States comprising approx. 40%. In order to ensure that the CPR recomendations are not dominated by any given nation or resuscitation council, most topics were reviewed and interpretated by two scientists from the United States and two scientists from outside of the United States. Accordingly, changes in these new CPR recommendations are the result of an evidence-based review by worldwide experts. The most important changes in the recommendations according to the authors are discontinuation of the pulse-check for lay people, 500 ml instead of 800-1200 ml tidal volume during bag-valve-mask ventilation (FiO2 > 0.4) of a patient with an unprotected airway, verifying correct endotracheal intubation with capnography and an esophageal detector, employing mechanical devices such as interposed abdominal compression CPR, vest CPR, active-compression-decompression CPR, and the inspiratory threshold valve (ITV) CPR as alternatives or adjuncts to standard manual chest compressions, defibrillation with < 200 Joule biphasic instead of with 200-360 Joule monophasic impulses, vasopressin (40 units) and epinephrine (1 mg) as comparable drugs to treat patients with ventricular fibrillation, amiodarone (300 mg) for shock-refractory ventricular fibrillation and intravenous lysis for patients who have suffered a stroke.

Vasopressin decreases endogenous catecholamine plasma concentrations during cardiopulmonary resuscitation in pigs.

OBJECTIVE: The purpose of this study was to evaluate the effect of vasopressin vs. saline placebo on catecholamine plasma concentrations during cardiopulmonary resuscitation (CPR). DESIGN: Prospective, randomized laboratory investigation by using an established porcine CPR model with instrumentation for measurement of hemodynamic variables, vital organ blood flow, and return of spontaneous circulation. SETTING: University hospital laboratory. SUBJECTS: Sixteen domestic pigs. INTERVENTIONS: After 15 mins of untreated cardiac arrest and 3 mins of CPR, 16 pigs were randomized to be treated with either 0.8 U/kg vasopressin (n = 8) or placebo (normal saline; n = 8). Arterial epinephrine and norepinephrine plasma concentrations were sampled at prearrest, after 1.5 mins of chest compressions, and at 1.5 mins and 5 mins after drug administration during CPR. MEASUREMENTS AND MAIN RESULTS: In comparison with placebo pigs at 1.5 and 5 mins after drug administration, animals resuscitated with vasopressin had significantly (p < .01) higher mean +/- SEM left ventricular myocardial (131+/-27 vs. 10+/-1 mL x mins(-1) x 100 g(-1) and 62+/-13 vs. 9+/-2 mL x mins(-1) x 100 g(-1)); total cerebral (90+/-8 vs. 14+/-3 mL x mins(-1) x 100 g(-1) and 51+/-4 vs. 12+/-2 mL x mins(-1) x 100 g(-1)); and adrenal gland perfusion (299+/-36 vs. 38+/-7 mL x mins(-1) x 100 g(-1) and 194+/-23 vs. 29+/-5 mL x mins(-1) x 100 g(-1)). Significantly lower mean +/- SEM epinephrine concentrations in the vasopressin pigs compared with the placebo group were measured 1.5 mins and 5 mins after drug administration, (24167+/-7919 vs. 80223+/-19391 pg/mL [p < .01] and 8346+/-1454 vs. 71345+/-10758 pg/mL [p < .01]). Mean +/- SEM norepinephrine plasma concentrations in the vasopressin animals in comparison with placebo were at 1.5 and 5 mins after drug administration significantly lower (41729+/-13918 vs. 82756+/-9904 pg/mL [p = .01] and 10642+/-3193 vs. 62170+/-8797 pg/mL [p < .01]). CONCLUSIONS: Administration of vasopressin during CPR resulted in significantly superior vital organ blood flow, but significantly decreased endogenous catecholamine plasma concentrations when compared with placebo.