[Aspects of intensive care medicine in emergency medicine]. / Intensivmedizinische Aspekte in der Notfallmedizin.

Emergency medicine and intensive care medicine have many similarities. In this review, we will first discuss the terminology of emergency medicine in a hospital in terms of a uniform designation as a department for emergency medicine or emergency department. Emergency medicine and intensive care medicine are a location-independent concept of patient care in the sense of the recognition, treatment and diagnosis of acute health disorders. Emergency medicine covers the entire range of disease severity, while intensive care medicine focuses on organ replacement and organ preservation, uses highly specialized technology for this purpose and treats only the seriously ill. The treatment of seriously ill patients in the emergency departments requires special intensive care medical knowledge both by the physicians and nursing staff. In the medical field, the curriculum for the European emergency medicine specialist takes into account all aspects necessary for the diagnosis and treatment of critically ill patients. For the nursing sector, Germany has had its own recognized specialty training program in emergency medicine for several years. However, the treatment of critically ill patients in emergency departments also requires that the emergency departments be adequately equipped. In this regard, there is an urgent need for statutory quality criteria that are concrete and structured. We know from the literature that intensive care competence in emergency departments reduces the admission rate to intensive care units and the mortality of all emergency patients. The concept of intensive care units in the emergency department is gaining popularity in the USA and should also be evaluated for implementation in the German-speaking countries.

Safety and efficacy of pharmacological cardioversion of recent-onset atrial fibrillation: a single-center experience.

BACKGROUND AND AIM: The management of patients with recent-onset atrial fibrillation (AF) presenting at emergency departments (EDs) varies widely. Our aim was to describe the management of patients with recent-onset (<48 hours) AF, to determine safety and efficacy of pharmacological cardioversion at the ED, and to evaluate the incidence of thromboembolism or death at 30 days. METHODS: In a prospective, observational, single-center study, 236 subjects with recent-onset AF were consecutively enrolled from January 2011 until January 2013. Follow-up information was obtained by reviewing all available clinical records. RESULTS: As first-line therapy, 45.3% (n = 107) received ibutilide, 28.8% (n = 68) vernakalant, 25% (n = 59) flecainide, and 0.8% (n = 2) amiodarone, respectively. Successful cardioversion was achieved in 72.5% (n = 171) of patients after first-line therapy. There was no significant difference between treatment groups. In univariable logistic regression analysis, age (odds ratio [OR] = 1.027; 95% confidence interval [CI], 1.003-1.052; P= .03), duration of symptoms (OR = 0.968; 95% CI, 0.938-0.999; P= .045), as well as the CHA2DS2-VASc score (1 point for Congestive heart failure, Hypertension, Age between 65 and 74 years, Diabetes, Vascular disease, Sex category if female and 2 points for previous TIA/Stroke and Age ≥ 75 years) (OR = 1.237; 95% CI, 1.01-1.515; P= .04) were associated with success of pharmacological cardioversion. Within 30 days, 1 patient suffered from fatal ischemic stroke. CONCLUSION: Pharmacological cardioversion followed by discharge after a short observation period is safe. There was no significant difference between the agents used in terms of short-term safety and efficacy. Importantly, the coherence of the ED to recent guidelines regarding first-line therapy is high.

Transport with ongoing cardiopulmonary resuscitation may not be futile.

BACKGROUND: Despite it being generally regarded as futile, patients are regularly brought to the emergency department with ongoing cardiopulmonary resuscitation (CPR). METHODS: Long-term outcome and its predictors in patients who were transported during ongoing CPR were evaluated in an observational study. Adult patients with non-traumatic cardiac arrest admitted to the Department of Emergency Medicine of a tertiary-care facility after transport with ongoing chest compression were retrospectively analysed. Multivariate analysis of epidemiological variables, treatment, blood gas values on admission, cause of arrest, and location of arrest was performed to find factors that were predictive for favourable long-term outcome (6-month survival, best cerebral performance category 1 or 2). RESULTS: Over 15 yr (1991-2006), a total of 2643 patients were treated after cardiac arrest. Of these, 327 patients received chest compressions during transport and were analysed (out-of-hospital cardiac arrest: n=244, in-hospital: n=83; the remaining 2316 patients were either stabilized before transport or suffered their arrest in our department). Return of spontaneous circulation was achieved in 31% of patients (n=102). Of these, 19 (19%) had favourable long-term outcome (6% of total). Independent predictors of good outcome were age, witnessed arrest, amount of epinephrine, and initial shockable rhythm. Among the patients with cardiac origin of arrest, 11 out of 197 patients (6%) survived; pulmonary origin, 4 out of 46 patients (9%); hypothermic arrest, 1 of 10 patients (10%); and intoxications, one out of nine patients (11%). CONCLUSIONS: Post-resuscitation care in patients who receive CPR during transport is not futile. Once restoration of spontaneous circulation is established, one out of five patients will have good long-term outcome.

Cardiac arrest patients in an alpine area during a six year period.

OBJECTIVE: The components of the 'chain of survival' remain the strongest pathway to save more people from out-of-hospital cardiac arrest. The 'Utstein Style' terminology has been applied to this study to evaluate survival in patients cared for by Emergency Medical Technicians--Defibrillation (EMT-D) and physicians in a rural alpine area. METHODS: Over a 6-year period in a descriptive observational study with prospective data collection special efforts were made to identify weaknesses in the 'links' of our emergency cardiac care system considering the special geographical and legal aspects. Data from all emergency calls dispatched by the ambulance centre for patients with cardiac arrest were collected and are presented as a median and interquartile range. RESULTS: We recorded 368 cardiac arrests and in 338 patients resuscitation was attempted. Ventricular fibrillation (VF) was observed in 118 patients (35%), of whom 13 (4%) were defibrillated by EMT-Ds and 105 (31%) by physicians. Response times were 1 (0,2) min to call, 8 (6-11) min to arrival of first tier and 16 (10-26) min to defibrillation. Restoration of spontaneous circulation was achieved in 54 (46%) VF-patients. In EMT-D vs. physician treated VF-patients 1 year survival was 1 (8%) versus 20 (19%). CONCLUSION: With the exception of publications on avalanche victims and mountaineers, there are no reports of patients with out-of-hospital cardiac arrest in alpine areas. Response intervals and survival rate are not as poor as might be expected and are similar to metropolitan areas.

Effects of bystander first aid, defibrillation and advanced life support on neurologic outcome and hospital costs in patients after ventricular fibrillation cardiac arrest.

OBJECTIVE: To evaluate the effects of basic life support, time to first defibrillation and emergency medical service arrival time on neurologic outcome and expenses for hospital care in patients after cardiac arrest. SETTING: Large urban emergency medical services system and emergency department in a 2000-bed university hospital. DESIGN: Outcome and cost benefit analysis of patients admitted to the hospital after witnessed, out-of-hospital, ventricular fibrillation cardiac arrest from October 1, 1991, until December 31, 1997. PATIENTS: Out of 1054 patients with out-of-hospital cardiac arrest, 276 were eligible. MEASUREMENTS AND RESULTS: The effects of basic and advanced life support measures on neurologic outcome and hospital expenses were evaluated. In contrast to intubation (odds ratio 1.08; 95% CI: 0.51-2.31; p=0.84), basic life support (odds ratio 0.44; 95% CI: 0.24-0.77; p=0.004) and time to first defibrillation (odds ratio 1.08; 95% CI: 1.03-1.13; p=0.001) were significantly correlated with good neurologic outcome. Among the patients who did not receive basic life support, the average cost per patient with good neurologic outcome significantly increased with the delay of the first defibrillation (p<0.001). CONCLUSIONS: In contrast to intubation, bystander basic life support and time to first defibrillation were significantly associated with good neurologic outcome and resulted in fewer expenses spent on in-hospital efforts.

Hyperthermia after cardiac arrest is associated with an unfavorable neurologic outcome.

BACKGROUND: Moderate elevation of brain temperature, when present during or after ischemia, may markedly worsen the resulting injury. OBJECTIVE: To evaluate the impact of body temperature on neurologic outcome after successful cardiopulmonary resuscitation. METHODS: In patients who experienced a witnessed cardiac arrest of presumed cardiac cause, the temperature was recorded on admission to the emergency department and after 2, 4, 6, 12, 18, 24, 36, and 48 hours. The lowest temperature within 4 hours and the highest temperature during the first 48 hours after restoration of spontaneous circulation were recorded and correlated to the best-achieved cerebral performance categories' score within 6 months. RESULTS: Over 43 months, of 698 patients, 151 were included. The median age was 60 years (interquartile range, 53-69 years); the estimated median no-flow duration was 5 minutes (interquartile range, 0-10 minutes), and the estimated median low-flow duration was 14.5 minutes (interquartile range, 3-25 minutes). Forty-two patients (28%) underwent bystander-administered basic life support. Within 6 months, 74 patients (49%) had a favorable functional neurologic recovery, and a total of 86 patients (57%) survived until 6 months after the event. The temperature on admission showed no statistically significant difference (P =.39). Patients with a favorable neurologic recovery showed a higher lowest temperature within 4 hours (35.8 degrees C [35.0 degrees C-36.1 degrees C] vs 35.2 degrees C [34.5 degrees C-35.7 degrees C]; P =.002) and a lower highest temperature during the first 48 hours after restoration of spontaneous circulation (37.7 degrees C [36.9 degrees C-38.6 degrees C] vs 38.3 degrees C [37.8 degrees C-38.9 degrees C]; P<.001) (data are given as the median [interquartile range]). For each degree Celsius higher than 37 degrees C, the risk of an unfavorable neurologic recovery increases, with an odds ratio of 2.26 (95% confidence interval, 1.24-4.12). CONCLUSION: Hyperthermia is a potential factor for an unfavorable functional neurologic recovery after successful cardiopulmonary resuscitation.

Therapeutic hypothermia after cardiac arrest.

This review discusses the mechanisms of neurologic damage during and after global cerebral ischemia caused by cardiac arrest. The different pathways of membrane destruction by radicals, free fatty acids, excitatory amino acids (neurotransmitters), calcium, glucose metabolism, and oxygen availability and demand in relation to metabolic rate are briefly discussed. The main focus of this review paper, however, lies in therapeutic (resuscitative) hypothermia after cardiac arrest. Two pioneering studies of the 1950s and four recent publications (in part preliminary results of ongoing studies) in humans are discussed in detail. The conclusions are as follows: (1) hypothermia holds promise as the only specific brain therapy after cardiac arrest so far; (2) hyperthermia is not tolerable after successful resuscitation; and (3) if the ongoing European multicenter trial of hypothermia after cardiac arrest finds a significant benefit to mild hypothermia, withholding hypothermia may be ethically hard to defend.

Cardiopulmonary resuscitation performed by bystanders does not increase adverse effects as assessed by chest radiography.

UNLABELLED: Important adverse effects of bystander cardiopulmonary resuscitation (CPR) are well known. We describe the number of nonmedical professional CPR-related complications in patients surviving cardiac arrest, as assessed by chest radiograph. Within 2 yr, all consecutive patients admitted to the department of emergency medicine at a university hospital who had a witnessed, nontraumatic, normothermic cardiac arrest were studied. Radiologically evaluated adverse effects were compared with Mann-Whitney U-tests between patients who received bystander basic life support (Bystander group) and patients who did not receive bystander basic life support before advanced life support was started (ALS group). For assessment of bystander CPR-associated complications, chest radiographs were used. Of 224 patients, 173 were eligible. The median age was 58 yr (interquartile range, 51-71 yr), and 126 patients (73%) were men. The incidence of adverse effects associated with assisted-ventilation maneuvers and external chest compressions did not differ significantly between groups (severe gastric insufflation, 17% vs 18% between the Bystander group [n = 59] and the ALS group [n = 96], respectively; suspicion of aspiration, 22% vs 17%, respectively; soft tissue emphysema, 2% vs 1%, respectively; and serial rib fractures, 8% vs 8%, respectively). CPR administered by nonmedical personnel did not increase the number of life support-related adverse effects in patients surviving cardiac arrest as assessed by means of chest radiograph on admission. IMPLICATIONS: Complications related to cardiopulmonary bypass (CPR) are not increased when CPR is administered by nonmedical personnel, as assessed by chest radiograph. These data may be valuable in motivating lay people to perform basic life support.

The attitudes of cardiac arrest survivors and their family members towards CPR courses.

OBJECTIVES: to evaluate self-assessment of first aid knowledge, readiness to make use of it in case of a medical emergency and judgement of a 1-day CPR course by cardiac arrest survivors, their family members and friends as compared to the general public. BACKGROUND: the recurrence rate of a cardiac arrest after successful resuscitation is high and most of out-of-hospital cardiac arrests occur at the patient's home. METHODS: medical students trained in basic and advanced life support provided 101 members of the target group and 94 of a sex and age matched control group with a 1-day course in CPR. RESULTS: after the course, half of the participants in both groups considered their knowledge of first aid to be very good or good. The readiness to perform first aid in a medical emergency increased significantly. Of the target group 96% of the participants as compared with the control group where 91% felt confident to recognise a cardiac arrest; 79 versus 68% considered themselves capable to perform CPR if needed. The course was judged as very good in 71 versus 69% and as good in 25 versus 27% with no differences between groups. CONCLUSION: one-day CPR courses are well accepted by cardiac arrest survivors, their family members and friends and help to reduce fears of reacting in medical emergencies. They seem to be more motivated to gain and use first aid knowledge than others.

Comparison of conventional surgical versus Seldinger technique emergency cricothyrotomy performed by inexperienced clinicians.

BACKGROUND: Cricothyrotomy is the ultimate option for a patient with a life-threatening airway problem. METHODS: The authors compared the first-time performance of surgical (group 1) versus Seldinger technique (group 2) cricothyrotomy in cadavers. Intensive care unit physicians (n = 20) performed each procedure on two adult human cadavers. Methods were compared with regard to ease of use and anatomy of the neck of the cadaver. Times to location of the cricothyroid membrane, to tracheal puncture, and to the first ventilation were recorded. Each participant was allowed only one attempt per procedure. A pathologist dissected the neck of each patient and assessed correctness of position of the tube and any injury inflicted. Subjective assessment of technique and cadaver on a visual analog scale from 1 (easiest) to 5 (worst) was conducted by the performer. RESULTS: Age, height, and weight of the cadavers were not different. Subjective assessment of both methods (2.2 in group 1 vs. 2.4 in group 2) and anatomy of the cadavers (2.2 in group 1 vs. 2.4 in group 2) showed no statistically significant difference between both groups. Tracheal placement of the tube was achieved in 70% (n = 14) in group 1 versus 60% (n = 12) in group 2 (P value not significant). Five attempts in group 2 had to be aborted because of kinking of the guide wire. Time intervals (mean +/- SD) were from start to location of the cricothyroid membrane 7 +/- 9 s (group 1) versus 8 +/- 7s (group 2), to tracheal puncture 46 +/- 37s (group 1) versus 30 +/- 28s (group 2), and to first ventilation 102 +/- 42s (group 1) versus 100 +/- 46s (group 2) (P value not significant). CONCLUSIONS: The two methods showed equally poor performance.

Acute renal failure and rhabdomyolysis after inadvertent intra-arterial infusion of excessive doses of epinephrine during cardiopulmonary resuscitation.

Severe renal dysfunction or even acute renal failure necessitating renal replacement therapy are rather infrequent observations in patients following cardiopulmonary resuscitation. A low flow situation alone does not seem to be sufficient for renal breakdown and in addition other factors, such as preexisting renal disease, severe infections or congestive heart failure must be present. We report a patient, in whom during cardiopulmonary resuscitation a central venous catheter was placed which inadvertently was located in the aortic arch. Through this malpositioned line increasing and finally excessive amounts of epinephrine (in total 150 mg) were injected because of inadequate therapeutic response. After finally successful resuscitation the patient developed rhabdomyolysis and acute renal failure, which required hemodialyis therapy. Intraarterial infusion of the vasoconstrictor catecholamine obviously caused a critical reduction in renal and skeletal muscle perfusion. Nevertheless, the patient was discharged from hospital in good neurologic condition and with normal renal function.

Life supporting first aid training of the public--review and recommendations.

Since the introduction around 1960 of external cardiopulmonary resuscitation (CPR) basic life support (BLS) without equipment, i.e. steps A (airway control)-B (mouth-to-mouth breathing)-C (chest (cardiac) compressions), training courses by instructors have been provided, first to medical personnel and later to some but not all lay persons. At present, fewer than 30% of out-of-hospital resuscitation attempts are initiated by lay bystanders. The numbers of lives saved have remained suboptimal, in part because of a weak or absent first link in the life support chain. This review concerns education research aimed at helping more lay persons to acquire high life supporting first aid (LSFA) skill levels and to use these skills. In the 1960s, Safar and Laerdal studied and promoted self-training in LSFA, which includes: call for the ambulance (without abandoning the patient) (now also call for an automatic external defibrillator); CPR-BLS steps A-B-C; external hemorrhage control; and positioning for shock and unconsciousness (coma). LSFA steps are psychomotor skills. Organizations like the American Red Cross and the American Heart Association have produced instructor-courses of many more first aid skills, or for cardiac arrest only-not of LSFA skills needed by all suddenly comatose victims. Self-training methods might help all people acquire LSFA skills. Implementation is still lacking. Variable proportions of lay trainees evaluated, ranging from school children to elderly persons, were found capable of performing LSFA skills on manikins. Audio-tape or video-tape coached self-practice on manikins was more effective than instructor-courses. Mere viewing of demonstrations (e.g. televised films) without practice has enabled more persons to perform some skills effectively compared to untrained control groups. The quality of LSFA performance in the field and its impact on outcome of patients remain to be evaluated. Psychological factors have been associated with skill acquisition and retention, and motivational factors with application. Manikin practice proved necessary for best skill acquisition of steps B and C. Simplicity and repetition proved important. Repetitive television spots and brief internet movies for motivating and demonstrating would reach all people. LSFA should be part of basic health education. LSFA self-learning laboratories should be set up and maintained in schools and drivers' license stations. The trauma-focused steps of LSFA are important for 'buddy help' in military combat casualty care, and natural mass disasters.

Long-term cardiac arrest survivors of the Vienna emergency medical service.

The purpose of this study was to describe the life of survivors after successful resuscitation and to see if there was an association with the type of emergency cardiac care. The 'Utstein-style' data of patients surviving non-traumatic cardiac arrest 24 (14-32) months were prospectively collected. The everyday activities and psychological concerns of patients with a cerebral performance category (CPC) of 1 and 2 using a questionnaire were analyzed. The chi2-square test was used for statistical analysis. The questionnaires of 92 patients (median age 59, IQR 51-68; females 36) were evaluated. Patients enjoy life (84%; n=73), have depression (36%; n=31), consider their survival a 'second chance' (84%; n=73) and fear that they may suffer cardiac arrest again (56%; n = 45). The average quality of life is 7 on a scale from 0 (worst) to 10 (perfect). The majority of cardiac arrest survivors have a satisfactory life. No significant correlation between the type of emergency cardiac care and post cardiac arrest life was found. The fact that there was no association with the type of emergency cardiac care may be due to the narrow selection of patients (CPC 1 and 2), the small number of patients or factors contributing to post cardiac arrest life other than emergency treatment.

Gene therapy in surgery: Part II: Application to septic shock and to organ transplantation.

BACKGROUND: With the increasing body of knowledge in molecular biology, gene transfer respectively gene therapy becomes more and more a valid therapeutic option. METHODS: This is a critical review of gene therapy protocols for treatment of different types of cancer. Furthermore, the pathophysiological mechanism, therapeutically strategies as well as experimental approaches toward gene transfer in septic shock and organ transplantation are critically elucidated. RESULTS: Gene transfer as a therapeutic option was first successfully applied in children with severe combined immunodeficiency (SCID) in 1990. The majority of gene marking or gene therapy protocols approved for human clinical trials to date are related to the treatment of cancer. Besides viral vectors for brain tumors, non-viral vectors, liposomes particularly, with almost no side effects are increasingly used. CONCLUSIONS: Different approaches of gene transfer in cancer patients are under investigation. Experimental data of septic shock treatment and rejection therapy of the allograft in organ recipients with gene transfer are encouraging for future applications in clinical trials.