[Emergency physician and AutoPulse--a good duo in preclinical emergency services?: case example and report on experience]. / Notarzt und AutoPulse--ein gutes Duo im präklinischen Rettungsdienst?: Fallbeispiel und Erfahrungsbericht.

Survival rates after cardiac arrest remain poor despite substantial efforts to advance the cardiopulmonary resuscitation algorithm in the last decades. Recent changes in the resuscitation guidelines in 2005 focused on minimizing interruptions during chest compressions. The aim to provide optimal chest compressions led to the development of automated mechanical chest compression devices, one of which is the AutoPulse resuscitation system. A case of successful use of the AutoPulse system in a 66-year-old patient with sudden cardiac arrest is presented and a review is given of more than 3 years experience in the routine use of this mechanical device for CPR in the emergency medical system in Bonn. Based on this experience, the AutoPulse system is considered to be a safe and effective technical advancement that under certain CPR conditions can be a helpful tool and provide an increased quality of chest compressions.

Eicosanoids in rat brain during ischemia and reperfusion--correlation to DC depolarization.

The effects of complete ischemia on cerebral arachidonic acid (AA) metabolism were investigated in the isolated perfused rat brain. During 12.5 min of ischemia, AA, 5-hydroxy-6,8,11,14-eicosatetraenoic acid, and 15-hydroxy-5,8,11,13-eicosatetraenoic acid increased 129-, 4-, and 10-fold, respectively, while subsequent reperfusion for 30 min resulted in normalized levels independently of the duration of preceding ischemia. Prostaglandin (PG) F2 alpha, PGE2, PGD2, 6-keto-PGF1 alpha, and thromboxane (Tx) B2 remained at preischemic levels during 12.5 min of complete ischemia. However, at the end of subsequent reperfusion for 30 min, the levels of the prostanoids PGF2 alpha, PGE2, PGD2, 6-keto-PGF1 alpha, and TxB2 increased according to the preceding ischemic time. The levels reached a maximum after 7.5 min of ischemia and were elevated by 7-, 14-, 48-, 3-, and 30-fold, respectively. A prolongation of ischemia of up to 12.5 min was not associated with further increases of prostanoids at the end of reperfusion. The mechanisms underlying the metabolism of eicosanoids are discussed in relation to the changes of cortical direct current potential.

[Accidental urban hypothermia. Severe hypothermia of 20.7 degrees C]. / Akzidentelle urbane Unterkühlung. Schwere Hypothermie von 20.7 degrees C.

In emergency medicine accidental hypothermia (<35 degrees C) is a common epiphenomenon of many medical conditions. In contrast, severe hypothermia (<28 degrees C) occurs very seldom and presents a difficult medical situation. Here we present a female patient with severe urban hypothermia (core temperature of 20.7 degrees C) and circulatory arrest. An overview of the emergency treatment, rewarming strategy with extracorporeal circulation and the clinical course will be given. The survival of the patient and the favorable neurological outcome will be discussed considering the current literature. Due to the paucity of treatment guidelines or clear prognostic criteria of withholding or withdrawing treatment in severe hypothermia, the decision of prolonged resuscitation and rewarming strategy is solely dependent on the individual judgement and medical experience of the physician. The positive clinical outcome which can be gleaned from case reports or single retrospective studies should encourage the emergency physician to selectively rewarm a severe hypothermic patient with extracorporeal circulation under prolonged CPR.

[Comparison of the emergency medical services systems of Birmingham and Bonn: process efficacy and cost effectiveness]. / Effektivitäts- und Effizienzvergleich der Rettungsdienstsysteme in Birmingham (UK) und Bonn (D).

OBJECTIVE: Due to rising health care costs there is a need to verify that the treatment by Emergency Medical Services (EMS) systems is efficient and cost effective. The integration of emergency physicians is inherent part of out-of-hospital emergency care and regulated by law in Germany but not in England and the United States of America. Aim of this study therefore was to conduct a cost performance analysis by evaluating the underlying structure, the costs incurred and the achieved performance in two EMS systems with paramedics or emergency physicians on scene. METHODS: The study was carried out in West-Birmingham, a part of the West-Midlands-Ambulance-Service (WMAS), and the EMS of Bonn. Pre defined questionnaires, EMS protocols, calculations of purchasing power parity and recent publications concerning out-of-hospital resuscitation (CPR) were used to evaluate the operating costs, to describe the structure and to measure the quality of performance. Significance was assumed at p < 0.01 for CHI(2)- or t-test, respectively. RESULTS: Birmingham used state of the art technology for dispatch and logistics whereas Bonn trusted in high qualified personnel. In the 1st quarter 1997 the Mainz-Emergency-Evaluation Score could be achieved before (MEES A) and after preclinical treatment (MEES B) in 3502 and 3422 patients in Birmingham and Bonn, respectively. In Birmingham 7.5 % and in Bonn 17 % of all patients could be improved by the EMS treatment, respectively (p < 0.01). Looking at severely ill patients (MEES A < 22) the EMS in West-Birmingham achieved an improvement in 27.9 % of these patients with an averaged change in MEES of 0.9 +/- 1.7 points in all of them. In contrast the Bonn EMS improved the status in 47.8 % of these patients and MEES A could be improved considerably by 2.3 +/- 3.4 points (p < 0.01). Pharmacological treatment was less frequently used in Birmingham than in Bonn (12.9 % vs. 32.4 %, respectively; p < 0.01). At equal incidences of CPR attempts discharge rate after CPR was only 4 % in WMAS compared to 14.7 % in Bonn-North (p < 0.01). Per inhabitant and year total costs amounted to 10.43 euro for the EMS system in Birmingham, which is 42 % less than in Bonn. Unit hour utilisation reached 0.6 in Birmingham and only 0.33 in Bonn. In severely ill patients the improvement of MEES A by 0.1 points cost per inhabitant and year 1.16 euro in Birmingham and only 0.65 euro in Bonn. The survival of one patient after CPR was calculated to 0.7 euro in Birmingham and 0.17 euro in Bonn. CONCLUSIONS: The provider of the EMS in West-Birmingham--WMAS--organised a reliable system with high efficiency concerning unit hour utilisation and response time reliability. In the EMS of Bonn, in contrast, the complex therapy by the emergency physicians improved MEES considerably and increased probability of survival after CPR at a higher level of efficiency. Further investigations however are necessary to evaluate the presented parameter of efficiency.