Anatolij Truhlář

European Resuscitation Council Guidelines for Resuscitation 2015: Section 1. Executive summary.

This executive summary provides the essential treatment algorithms for the resuscitation of children and adults and highlights the main guideline changes since 2010. Detailed guidance is provided in each of the ten sections, which are published as individual papers within this issue of Resuscitation. The sections of the ERC Guidelines 2015 are:

Pre-hospital cooling of patients following cardiac arrest is effective using even low volumes of cold saline

IntroductionPre-hospital induction of therapeutic mild hypothermia (TH) may reduce post-cardiac arrest brain injury in patients resuscitated from out-of-hospital cardiac arrest. Most often, it is induced by a rapid intravenous administration of as much as 30 ml/kg of cold crystalloids. We decided to assess the pre-hospital cooling effectivity of this approach by using a target dose of 15-20 ml/kg of 4°C cold normal saline in the setting of the physician-staffed Emergency Medical Service. The safety and impact on the clinical outcome have also been analyzed.MethodsWe performed a prospective observational study with a retrospective control group. A total of 40 patients were cooled by an intravenous administration of 15-20 ml/kg of 4°C cold normal saline during transport to the hospital (TH group). The pre-hospital decrease of tympanic temperature (TT) was analyzed as the primary endpoint. Patients in the control group did not undergo any pre-hospital cooling.ResultsIn the TH group, administration of 12.6 ± 6.4 ml/kg of 4°C cold normal saline was followed by a pre-hospital decrease of TT of 1.4 ± 0.8°C in 42.8 ± 19.6 min (p < 0.001). The most effective cooling was associated with a transport time duration of 38-60 min and with an infusion of 17 ml/kg of cold saline. In the TH group, a trend toward a reduced need for catecholamines during transport was detected (35.0 vs. 52.5%, p = 0.115). There were no differences in demographic variables, comorbidities, parameters of the cardiopulmonary resuscitation and in other post-resuscitation characteristics. The coupling of pre-hospital cooling with subsequent in-hospital TH predicted a favorable neurological outcome at hospital discharge (OR 4.1, CI95% 1.1-18.2, p = 0.046).ConclusionsPre-hospital induction of TH by the rapid intravenous administration of cold normal saline has been shown to be efficient even with a lower dose of coolant than reported in previous studies. This dose can be associated with a favorable impact on circulatory stability early after the return of spontaneous circulation and, when coupled with in-hospital continuation of cooling, can potentially improve the prognosis of patients.Trial RegistrationClinicalTrials (NCT): NCT00915421

Prehospital cooling by cold infusion: searching for the optimal infusion regimen

Background The cooling efficacy of intravenous administration of cold crystalloids can be enhanced by optimisation of the procedure. This study assessed the temperature stability of different application regimens of cold normal saline (NS) in simulated prehospital conditions. Methods Twelve different application regimens of 4°C cold NS (volumes of 250, 500 and 1000 ml applied at infusion rates of 1000, 2000, 4000 and 6000 ml/h) were investigated for infusion temperature changes during administration to an artificial detention reservoir in simulated prehospital conditions. Results An increase in infusion temperature was observed in all regimens, with an average of 8.1±3.3°C (p<0.001). This was most intense during application of the residual 20% of the initial volume. The lowest rewarming was exhibited in regimens with 250 and 500 ml bags applied at an infusion rate of 6000 ml/h and 250 ml applied at 4000 ml/h. More intense, but clinically acceptable, rewarming presented in regimens with 500 and 1000 ml bags administered at 4000 ml/h, 1000 ml at 6000 ml/h and 250 ml applied at 2000 ml/h. Other regimens were burdened by excessive rewarming. Conclusion Rewarming of cold NS during application in prehospital conditions is a typical occurrence. Considering that the use of 250 ml bags means the infusion must be exchanged too frequently during cooling, the use of 500 or 1000 ml NS bags applied at an infusion rate of ≥4000 ml/h and termination of the infusion when 80% of the infusion volume has been administered is regarded as optimal.

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.

Intra-arrest formation of right-heart thrombi – a case illustrated by real-time ultrasonography

The presence of free‐floating right‐heart thrombus has been reported in a cardiac arrest patient in the periarrest period. Free‐floating right atrial thrombus is a rare phenomenon seen in patients developing severe pulmonary embolism, and is associated with increased mortality. However, there have been no previously reported cases of right‐heart thrombus formation during a resuscitated cardiac arrest. We present the pre‐hospital case of a woman in the clinical setting of cardiogenic shock due to acute myocardial infarction who developed asystolic cardiac arrest on the scene. Recent implementation of ultrasonography into the regional pre‐hospital care protocol enabled sonographic investigation before and during cardiac arrest. This allowed detection of right atrial septal thrombus formation in the course of advanced life support and its migration through the tricuspid valve. The pathophysiological consequences, clinical significance and potential therapeutic options are discussed.

Implementation of pre-hospital therapeutic hypothermia in post-cardiac arrest patients in the Czech Republic

In the Czech Republic, post-cardiac arrest therapeutic hypotheria is now commonly used in hospitals.1 Indeed, the physiciantaffed emergency medical service system, and a network of ercutaneous coronary intervention centres offer a high-level ost-cardiac arrest care. This also now includes the pre-hospital nitiation of therapeutic hypothermia. After a feasibility study and ocal implementation of pre-hospital cooling, we undertook a surey about pre-hospital therapeutic hypothermia use in the Czech epublic.2 In October 2010, all physician members of the Czech ociety for Emergency and Disaster Medicine were sent a webased questionnaire. Fifty-five percent (126 out of 227) of the physicians responded. f these, 52 (41.3%) had used pre-hospital therapeutic hypothermia Fig. 1). Physicians who used pre-hospital therapeutic hypothermia sed it in about half of cases (45.4 ± 25.9%). A strong predicor of pre-hospital therapeutic hypothermia use was attendance y a physician with five or less years of pre-hospital emergency edicine experience (OR 5.6, 95%CI 1.8–19.7, p = 0.004). Taking part n, or knowledge of a local clinical study (PRE-COOL) was a strong redictor (n = 22, 42.3%), as well as familiarity with current Euroean and, or Czech resuscitation guidelines (n = 21, 40.4%).2–4 A ritten pre-hospital cooling protocol was used by 86.5% (n = 45) f the responders using pre-hospital therapeutic hypothermia. hirty-two (61.5%) of the pre-hospital therapeutic hypothermia sers accepted a broad indication for cooling irrespective of the iniial rhythm, the presence of witnesses and whether the supposed rigin was a cardiac or not. The need for vasopressors was given s a reason for not using pre-hospital therapeutic hypothermia by 7 (32.7%), suspected pulmonary embolism by 31 (59.6%), age less han 18 years by 25 (48.1%), and pregnancy by 43 (82.7%) of preospital therapeutic hypothermia users. The most frequently used ooling method was infusion of cold crystalloids (n = 44, 84.6%). Surace cooling with ice-packs was used less frequently (n = 14, 26.9%) nd other techniques (intranasal cooling, EMCOOLS) were rarely sed (n = 2, 3.8%). Only half of the respondents sedated patients outinely and 36.5% (n = 19) of the respondents never or rarely sed neuromuscular blocking agents during pre-hospital therapeuic hypothermia. Tympanic temperature was measured by 78.8% n = 41) of responders. A third of responders used pre-hospital herapeutic hypothermia without temperature measurement at aseline and on hospital arrival. Of non-users, 33.8% planned to mplement the use of pre-hospital therapeutic hypothermia as soon s possible. Common reasons for non-use were lack of equipment 59.1%), no in-hospital cooling in the local hospital (27.3%), lack f supporting evidence for pre-hospital therapeutic hypothermia 21.2%), and short transport times (15.1%).

Erratum zu: Kreislaufstillstand in besonderen Situationen. Kapitel 4 der Leitlinien zur Reanimation 2015 des European Resuscitation Council

Notfall Rettungsmed 2017 · 20:540–542 DOI 10.1007/s10049-017-0337-z Online publiziert: 11. Juli 2017

Erratum zu: Kurzdarstellung. Kapitel 1 der Leitlinien zur Reanimation 2015 des European Resuscitation Council@@@Erratum to: Executive Summary. Section 1 of the European Resuscitation Council Guidelines for Resuscitation 2015

Notfall Rettungsmed 2017 · 20:538–539 DOI 10.1007/s10049-017-0338-y Online publiziert: 11. Juli 2017

Erratum zu: Kurzdarstellung. Kapitel 1 der Leitlinien zur Reanimation 2015 des European Resuscitation Council

Diese Kurzdarstellung zeigt die wesentlichen Behandlungsalgorithmen für die Wiederbelebung von Kindern und Erwachsenen und hebt die wichtigsten Leitlinienänderungen seit 2010 hervor. In jedem der 10 Kapitel, die als Einzelartikel in diesem Heft von Notfall + Rettungsmedizin publiziert werden, wird eine detaillierte Anleitung gegeben. Die Kapitel der ERC-Leitlinien 2015 sind: 1. Kurzdarstellung 2. Basismaßnahmen zur Wiederbelebung Erwachsener und Verwendung automatisierter externer Defibrillatoren [1] 3. Erweiterte Reanimationsmaßnahmen für Erwachsene [2] 4. Kreislaufstillstand unter besonderen Umständen [3] 5. Postreanimationsbehandlung [4] 6. Lebensrettende Maßnahmen bei Kindern [5] 7. Die Versorgung und Reanimation des Neugeborenen [6] 8. Das initiale Management des akuten Koronarsyndroms [7] 9. Erste Hilfe [8] 10. Ausbildung und Implementierung der Reanimation [9] 11. Ethik der Reanimation und Entscheidungen am Lebensende [10]