Time delays to reach dispatch centres in different regions in Europe. Are we losing the window of opportunity? - The EUROCALL study.

AIM: In out of hospital cardiac arrest (OHCA) the start of Cardiopulmonary Resuscitation (CPR) by a single rescuer may be delayed considerably if the total time (TT) to connect the telephone call to the Emergency Medical Communication Centre (EMCC) is prolonged. EUROCALL investigated the TT-EMCC and its components using different calling procedures. METHODS: This prospective, multicentre, randomised study was performed in April 2013. Telephone calls were randomly allocated to time of call, and to those connecting directly to the EMCC (1-step procedure) and those diverted before connecting to the EMCC (2-step procedure). RESULTS: Twenty-one EMCCs from 11 countries participated in the study. Time to first ringtone was similar between 1-step 3.7s (IQR 1.0-5.2) and 2-step calls 4.0s (IQR 2.4-5.2). For the 1878 1-step calls, the median TT-EMCC was 11.7s (IQR 8.7-18.5). For the 1550 2-step calls, the median time from first ringtone to first call-taker was 7s (IQR 4.6-11.9) and from first call-taker to EMCC was 18.7s (IQR 13.4-29.9). Median TT-EMCC was 33.2 s (IQR 24.7-46.1) and was significantly longer than the TT-EMCC observed with the 1-step procedure (P<0.0001). Significant differences existed among participating regions between and within different countries both for 1-step and 2-step procedures. CONCLUSION: TT-EMCC was significantly shorter in a 1-step procedure compared to a 2-step procedure. Regional differences existed between countries but also within countries. This may be relevant in cases of OHCA and other situations where patient outcome is critically time-dependent.

[EUROPEAN RESUSCITATION COUNCIL GUIDELINES FOR RESUSCITATION 2015].

Adult basic life support and automated external defibrillation ­ Interactions between the emergency medical dispatcher, the bystander who provides CPR and the timely deployment of an AED is critical. All CPR providers should perform chest compressions, those who are trained and able should combine chest compressions and rescue breaths in the ratio 30:2. Defibrillation within 3­5 min of collapse can produce survival rates as high as 50­70%. Adult advanced life support ­ Continued emphasis on minimally interrupted high-quality chest compressions, paused briefly only to enable specific interventions, including interruptions for less than 5 s to attempt defibrillation. Use of self-adhesive pads for defibrillation. Waveform capnography to confirm and continually monitor tracheal tube placement, quality of CPR and to provide an early indication of return of spontaneous circulation. Cardiac arrest in special circumstances ­ Special causes: hypoxia; hypo-/hyperkalemia, and other electrolyte disorders; hypo-/hyperthermia; hypovolemia; tension pneumothorax; tamponade; thrombosis; toxins. Special environments are specialised healthcare facilities, commercial airplanes or air ambulances, field of play, outside environment or the scene of a mass casualty incident. Special patients are those with severe comorbidities and with specific physiological conditions. Post resuscitation care is new to the ERC Guidelines. Targeted temperature management remains, now aiming at 36°C instead of the previously recommended 32 ­ 34°C. Pediatric life support ­ For chest compressions, the lower sternum should be depressed by at least one third the anterior-posterior diameter of the chest (4 cm for the infant and 5 cm for the child). For cardioversion of a supraventricular tachycardia (SVT), the initial dose has been revised to 1 J kg­1. Resuscitation and support of transition of babies at birth ­ For uncompromised babies, a delay in cord clamping of at least one minute from the complete delivery of the infant, is now recommended for term and preterm babies. Tracheal intubation should not be routine in the presence of meconium and should only be performed for suspected tracheal obstruction. Ventilatory support of term infants should start with air. Acute coronary syndrome (ACS) ­ Pre-hospital recording of a 12-lead electrocardiogram (ECG) is recommended in patients with suspected ST segment elevation acute myocardial infarction (STEMI). Patients with acute chest pain with presumed ACS do not need supplemental oxygen unless they present with signs of hypoxia, dyspnea, or heart failure. In geographic regions where PCI facilities exist and are available, direct triage and transport for PCI is preferred to pre-hospital fibrinolysis for STEMI. First aid is included for the first time in the 2015 ERC Guidelines. Principles of education in resuscitation ­ Directive CPR feedback devices are useful for improving compression rate, depth, release, and hand position. Whilst optimal intervals for retraining are not known, frequent 'low dose' retraining may be beneficial. Training in non-technical skills is an essential adjunct to technical skills. The ethics of resuscitation and end-of-life decisions ­ Ethical principles in the context of patient-centered health care: autonomy, beneficence, non-maleficence; justice and equal access. The need for harmonisation in legislation, jurisdiction, terminology and practice still remains within Europe.

[European Resuscitation Council guidelines for resuscitation 2010]. / Smjernice za reanimaciju europskog vijeca za reanimatologiju 2010. godine.

BASIC LIFE SUPPORT: All rescuers trained or not, should provide chest compressions to victims of cardiac arrest. The aim should be to push to a depth of at least 5 cm at a rate of at least 100 compressions per minute, to allow full chest recoil, and to minimise interruptions in chest compressions. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. ELECTRICAL THERAPIES: Much greater emphasis on minimising the duration of the pre-shock and post-shock pauses; the continuation of compressions during charging of the defibrillator is recommended. Further development of AED programmes is encouraged. ADULT ADVANCED LIFE SUPPORT: Increased emphasis on high-quality chest compressions throughout any ALS intervention paused briefly only to enable specific interventions. Removal of the recommendation for a pre-specified period of cardiopulmonary resuscitation before out-of-hospital defibrillation following cardiac arrest unwitnessed by the EMS. The role of precordial thump is de-emphasized. Delivery of drugs via a tracheal tube is no longer recommended, drugs should be given by the intraosseous (IO) route. Atropine is no longer recommended for routine use in asystole or pulseless electrical activity. Reduced emphasis on early tracheal intubation unless achieved by highly skilled individuals with minimal interruptions in chest compressions. Increased emphasis on the use of capnography. Recognition of potential harm caused by hyperoxaemia. Revision of the recommendation of glucose control. Use of therapeutic hypothermia to include comatose survivors of cardiac arrest associated initially with shockable rhythms, as well as non-shockable rhythms, with a lower level of evidence acknowledged for the latter. INITIAL MANAGEMENT OF ACUTE CORONARY SYNDROMES: The term non-ST-elevation myocardial infarction-acute coronary syndrome (non-STEMI-ACS) has been introduced for both NSTEMI and unstable angina pectoris. Primary PCI (PPCI) is the preferred reperfusion strategy provided it is performed in a timely manner by an experienced team. Non-steroidal anti-inflammatory drugs should be avoided, as well as routine use of intravenous beta-blockers; oxygen is to be given only to those patients with hypoxaemia, breathlessness or pulmonary congestion. PAEDIATRIC LIFE SUPPORT: The decision to begin resuscitation must be taken in less than 10 seconds. Lay rescuers should be taught to use a ratio of 30 compressions to 2 ventilations, rescuers with a duty to respond should learn and use a 15:2 ratio; however, they can use the 30:2 compression-ventilation ratio if they are alone. Ventilation remains a very important component of resuscitation in asphyxial arrest. The emphasis is on achieving quality compressions with the rate of at least 100 but not greater than 120 per minute, with minimal interruptions. AEDs are safe and successful when used in children older than 1 year. A single shock strategy using a non-escalating dose of 4 J/kg is recommended for defibrillation in children. Cuffed tubes can be used safely in infants and young children. Monitoring exhaled carbon dioxide (CO2), ideally by capnography, is recommended during resuscitation. RESUSCITATION OF BABIES AT BIRTH: For uncompromised babies, a delay in cord clamping of at least one minute from the complete delivery is now recommended. For term infants, air should be used fro resuscitation at birth. For preterm babies less than 32 weeks gestation blended oxygen and air should be given judiciously and its use guided by pulse oximetry. Preterm babies of less than 28 weeks gestation should be completely covered in a plastic wrap up to their necks, without drying, immediately after birth. The recommended compression: ventilation ratio remains at 3:1 for newborn resuscitation. Attempts to aspirate meconium from the nose and mouth of the unborn baby, while the head is still on the perineum, are not recommended. If adrenaline is given the n the intravenous route is recommended using a dose of 10-30 microg/kg. Newly born infants born at term or near-term with moderate to severe hypoxic-ischaemic encephalopathy should be treated with therapeutic hypothermia. PRINCIPLES OF EDUCATION IN RESUSCITATION: The aim is to ensure that learners acquire and retain skill and knowledge that will enable them to act correctly in actual cardiac arrest and improve patient outcome. Short video/computer self-instruction courses, with minimal or no instructor coaching, combined with hands-on practice can be considered as an effective alternative to instructor-led basic life support (BLS and AED) courses. Ideally all citizens should be trained in standard CPR that includes compressions and ventilations. Basic and advanced life support knowledge and skills deteriorate in as little as three to six months. CPR prompt or feedback devices improve CPR skill acquisition and retention.

Emergency medicine training for Croatia: a Croatia-Australia partnership.

As part of a health system improvement project, the Republic of Croatia has been conducting a pilot project aimed at rationalizing care delivery across the primary care, hospital and secondary care systems. One component was the development of an emergency department at Dr T Bardek Hospital in Koprivnica and training of its staff. This paper describes how a training programme was conducted, using an established emergency department in Australia as the training host, and the outcome of the project. This type of training programme could form a model for specialist Emergency Medicine training in the future.

[European Resuscitation Council guidelines for cardiopulmonary resuscitation in 2005]. / Smjernice iz kardiopulmonalne reanimacije Europskog vijeca za reanimatologiju 2005.

ADULT BASIC LIFE SUPPORT: The ratio of compressions to ventilations is 30:2 for all adult victims of cardiac arrest. AUTOMATED EXTERNAL DEFIBRILLATION: A single defibrillatory shock is delivered, immediately followed by two minutes of uninterrupted CPR. ADULT ADVANCED LIFE SUPPORT: In out-of-hospital cardiac arrest attended, but unwitnessed, by healthcare professionals equipped with manual defibrillators, give CPR for 2 minutes before defibrillation. The recommended initial energy for biphasic defibrillators is 150-200 J, for second and subsequent shocks is 150-360 J. The recommended energy when using a monophasic defibrillator is 360 J for both the initial and subsequent shocks. Rhythm checks must be brief, and pulse cheks undertaken only if an organised rhythm is observed. Adrenaline is given 1 mg i.v. as soon as intravenous access is obtained, and repeated every 3-5 min thereafter until return of spontaneous circulation is achieved. Consider thrombolytic therapy when cardiac arrest is thought to be due to proven or suspected pulmonary embolus. Unconscious adult patinets, with spontaneous circulation, after out-of-hospital VF cardiac arrest should be cooled to 32-34 degrees C for 12-24 hours. PAEDIATRIC BASIC LIFE SUPPORT: Lay rescuers or lone rescuers witnessing paediatric cardiac arrest will start with 5 rescue breaths and continue with the 30:2 ratio as thaught in adult BLS. Two or more rescuers with a duty to respond will use the 15:2 ration in a child up to the onset of puberty. PAEDIATRIC ADVANCED LIFE SUPPORT: When using a manual defibrillator, a dose of 4 J/kg (biphasic or monophasic waveform) should be used for the first and subsequent shocks. Adrenaline iv. or i.o. should be given at the dose of 10 microg/kg (0.01 mg/kg) and repeated every 3-5 minutes. NEONATAL LIFE SUPPORT: Protect the newborn from heat loss. Standard resuscitation in delivery room should be made with 100% oxygen. Suctioning meconium from the baby's nose and mouth before delivery of the baby's chest (intrapartum suctioning) is not useful and no longer recommended.

EMS system in Croatia.

This article describes the features of Croatia's emergency medical services. Pre-hospital emergency medical services (EMS) access, regional differences and the main features of the service are described. EMS personnel education and skill levels are also discussed. The author offers a critical analysis of the current status and proposals for the future development of emergency medicine in Croatia based on changes in organisation and education.