Bernd W. Böttiger

Fremdblut sparende Maßnahmen

Die Gabe von Fremdblut im operativen und intensivmedizinischen Bereich gehört zum Aufgabenbereich des Anästhesisten. Sie wird häufig als unumgänglich betrachtet, um die Gewebsoxygenierung eines Patienten zu gewährleisten. Wegen der mit der Fremdbluttransfusion verbundenen Risiken bedarf die Indikationsstellung zur Fremdblutgabe jedoch der kritischen Abwägung von Nutzen und Risiken im Einzelfall. Die unterschiedliche Bewertung dieser Frage hat in der Vergangenheit zu sehr unterschiedlichen Transfusionspraktiken bei der Behandlung der gleichen Kategorie von Patienten geführt.Fremdblut sparende Maßnahmen versprechen den Nutzen einer ausreichenden Anzahl von Sauerstoffträgern ohne die typischen Nachteile der allogener Bluttransfusion. Dennoch erlaubt nur die genaue Kenntnis dieser Verfahren einen für den Patienten effektiven und risikoarmen Einsatz.Im Folgenden werden Nutzen und Risiken des Einsatzes von Fremdblut, sowie Maßnahmen zur Verringerung allogener Transfusionen kritisch beleuchtet. Diese Maßnahmen können einerseits im restriktiven Einsatz von Fremdblut, andererseits in spezifischen Fremdblut sparenden Maßnahmen liegen. Darüber hinaus ist eine blutarme Operationstechnik entscheidend für das Einsparen von Fremdbluttransfusionen; dies soll jedoch hier nicht näher erläutert werden.

[Comparison of ready-to-use devices for emergency cricothyrotomy : randomized and controlled feasibility study on a mannequin].

ZusammenfassungHintergrundDie Koniotomie stellt die „Ultima-Ratio“-Maßnahme zur Sicherung des nichtbeherrschbaren Atemwegs dar. Im Notarztdienst muss diese in vivo nichttrainierbare Maßnahme durch Kollegen verschiedenster Fachdisziplinen gemeistert werden. Zur Erleichterung des Vorgehens existieren daher Fertigkoniotomiesets, die sich in Einzelheiten unterscheiden. Ziel dieser randomisierten und kontrollierten Anwendungsstudie war es daher, diese Sets im praktischen Einsatz zu testen und zur konventionell-chirurgischen Technik zu vergleichen.MethodenNach positivem Ethikvotum führten ausgebildete Notärzte in randomisierter Reihenfolge eine Koniotomie mit Skalpell, peripherer Venenverweilkanüle sowie den Sets TracheoQuick, Airfree, Portex-Crico-Kit, Quicktrachxa0I und Quicktrachxa0II an einem Halsphantom unter standardisierten Bedingungen durch. Handhabung und Zeitdauer der Maßnahmen wurden analysiert. Hierbei kam der Wilcoxon-Vorzeichen-Rang-Test zur Anwendung; ein pu2009<u20090,05 galt als statistisch signifikant.ErgebnisseInsgesamt nahmen 20xa0Kollegen teil. Das Durchschnittsalter lag bei 34xa0Jahren. Die mittlere Koniotomiedauer mit Skalpell betrug 35,4xa0s (Median). Signifikant schneller wurde mit TracheoQuick (20,2xa0s), Airfree (22,8xa0s), Quicktrachxa0I (21,1xa0s) und der peripheren Venenverweilkanüle (19,2xa0s) koniotomiert. Fehlpunktionen wurden nicht beobachtet.SchlussfolgerungIn dieser randomisierten, kontrollierten Untersuchung am standardisierten Halsphantom konnte von ausgebildeten Notärzten mit allen untersuchten Systemen erfolgreich koniotomiert werden. Kein System wies einen signifikant längeren Zeitbedarf als die Skalpelltechnik auf. Die Koniotomie mit gecufften Hilfsmitteln dauerte länger als mit ungecufften. In der Realität spielt dieser Unterschied jedoch nur eine untergeordnete Rolle, da das Ziel der effektiven Ventilation lediglich durch die Eigenschaften „Blockbarkeit“ und „Innendurchmesser mindestens 4xa0mm“ erreicht werden kann.AbstractBackgroundAccording to various algorithms of airway management, emergency cricothyrotomy (coniotomy) represents the ultimate step for managing the difficult airway. As most physicians have limited experience with this technique several ready-to-use devices have emerged on the market with the aim of simplifying the procedure. However, they differ in details, such as configuration or the order of particular steps. Therefore, the intention of this randomized and controlled feasibility study was to test various sets and compare them to the classical surgical approach.MethodsAfter obtaining informed consent German anesthesiologists who were also board-certified emergency physicians were asked to perform the cricothyrotomy procedure in a cervical mannequin (Frova Crico-Trainer, VBM Medizintechnik) in a randomized order using a scalpel, peripheral intravenous cannula and the commercial devices TracheoQuick, Airfree, Portex-Crico-Kit, Quicktrachxa0I and Quicktrachxa0II. Handling and duration of the procedures were analyzed utilizing the Wilcoxon signed-rank test. A p-value u2009<u20090.05 was considered significant.ResultsA total of 20 anesthesiologists (11 residents and 9 specialists) with a mean age of 34 years were included in this study and all had the additional qualification of emergency physician, which enabled them to work in prehospital emergency medicine in Germany. Participants had been working in this field for an average of 29.9 months (range 6–84 months) performing a mean of 1.9 24xa0h shifts per month (range 1–6 shifts/month). Of the participants only 2 (10%) had performed a coniotomy in reality before. In this study surgical coniotomy required a median time of 35.4xa0s (range 30.0–61.8xa0s). No significant differences were seen when the cuffed devices Quicktrachxa0II (median: 29.9xa0s, range 25.0–50.5xa0s) and Portex-Crico-Kit (median: 46.7xa0s, range 37.0–67.3xa0s) were used. A significantly faster airway was established using the non-cuffed devices TracheoQuick (median: 20.2xa0s, range 11.4–44.7xa0s), Airfree (median: 22.8xa0s, range 14.3–33.2xa0s), Quicktrachxa0I (median: 21.1xa0s, range 14.5–32.4xa0s) and the peripheral intravenous cannula (median: 19.2xa0s, range 10.8–27.8xa0s). Incorrect tube placements were not observed.ConclusionThis study allowed the comparison of surgical coniotomy to several ready-to-use devices in a standardized setting utilizing a reusable plastic mannequin. The interpretation for real emergency conditions is limited as individual anatomy, traumatic alterations of the neck or complications, such as bleeding or damage of important structures were not part of the study objectives. However, all participating emergency physicians successfully used the coniotomy sets provided at the first attempt. No device required significantly more time than the surgical approach. The procedures using cuffed devices lasted longer in comparison to procedures using uncuffed ones; however, this difference would only play a minor role in reality as effective ventilation with minute volumes greater than 7xa0l/min will only be achieved by a cuffed cannula with a minimum internal diameter of 4xa0mm. Devices with no cuff or with tube diameters smaller than 4xa0mm will only allow oxygenation of the patient, which in turn requires an inspiratory oxygen concentration of 100% and a relatively high ventilation frequency.BACKGROUNDnAccording to various algorithms of airway management, emergency cricothyrotomy (coniotomy) represents the ultimate step for managing the difficult airway. As most physicians have limited experience with this technique several ready-to-use devices have emerged on the market with the aim of simplifying the procedure. However, they differ in details, such as configuration or the order of particular steps. Therefore, the intention of this randomized and controlled feasibility study was to test various sets and compare them to the classical surgical approach.nnnMETHODSnAfter obtaining informed consent German anesthesiologists who were also board-certified emergency physicians were asked to perform the cricothyrotomy procedure in a cervical mannequin (Frova Crico-Trainer, VBM Medizintechnik) in a randomized order using a scalpel, peripheral intravenous cannula and the commercial devices TracheoQuick, Airfree, Portex-Crico-Kit, Quicktrachxa0I and Quicktrachxa0II. Handling and duration of the procedures were analyzed utilizing the Wilcoxon signed-rank test. A p-value u2009<u20090.05 was considered significant.nnnRESULTSnA total of 20 anesthesiologists (11 residents and 9 specialists) with a mean age of 34 years were included in this study and all had the additional qualification of emergency physician, which enabled them to work in prehospital emergency medicine in Germany. Participants had been working in this field for an average of 29.9 months (range 6-84 months) performing a mean of 1.9 24xa0h shifts per month (range 1-6 shifts/month). Of the participants only 2 (10%) had performed a coniotomy in reality before. In this study surgical coniotomy required a median time of 35.4xa0s (range 30.0-61.8xa0s). No significant differences were seen when the cuffed devices Quicktrachxa0II (median: 29.9xa0s, range 25.0-50.5xa0s) and Portex-Crico-Kit (median: 46.7xa0s, range 37.0-67.3xa0s) were used. A significantly faster airway was established using the non-cuffed devices TracheoQuick (median: 20.2xa0s, range 11.4-44.7xa0s), Airfree (median: 22.8xa0s, range 14.3-33.2xa0s), Quicktrachxa0I (median: 21.1xa0s, range 14.5-32.4xa0s) and the peripheral intravenous cannula (median: 19.2xa0s, range 10.8-27.8xa0s). Incorrect tube placements were not observed.nnnCONCLUSIONnThis study allowed the comparison of surgical coniotomy to several ready-to-use devices in a standardized setting utilizing a reusable plastic mannequin. The interpretation for real emergency conditions is limited as individual anatomy, traumatic alterations of the neck or complications, such as bleeding or damage of important structures were not part of the study objectives. However, all participating emergency physicians successfully used the coniotomy sets provided at the first attempt. No device required significantly more time than the surgical approach. The procedures using cuffed devices lasted longer in comparison to procedures using uncuffed ones; however, this difference would only play a minor role in reality as effective ventilation with minute volumes greater than 7xa0l/min will only be achieved by a cuffed cannula with a minimum internal diameter of 4xa0mm. Devices with no cuff or with tube diameters smaller than 4xa0mm will only allow oxygenation of the patient, which in turn requires an inspiratory oxygen concentration of 100% and a relatively high ventilation frequency.

„Kids Save Lives“ – Wiederbelebungstrainings für Schulkinder

BACKGROUNDnEven in western developed countries, the probability of survival after out-of-hospital cardiac arrest (OHCA) is only 6-10%. In order to improve survival after OHCA, early initiation of cardiopulmonary resuscitation (CPR) by laypersons is essential. Introduction of CPR training in schoolchildren seems to be effective to increase lay-CPR rates.nnnOBJECTIVEnThe objective of the present investigation was to elucidate educational aspects of teaching schoolchildren in CPR and to summarize campaigns related to axa0comprehensive establishment of lay-CPR worldwide.nnnMATERIALS AND METHODSnAxa0literature research in PubMed was performed, the cutoff date was 27xa0Februaryxa02017. Overall, 192 abstracts were analyzed; 51xa0articles were considered relevant and included in the manuscript. An additional keyword research in Google revealed >230,000 entries, and 20xa0of those were included in the present manuscript.nnnRESULTSnA minimum age of 12-13xa0years is required to achieve axa0comparable quality of CPR to adult basic life support (BLS). Key issues are (i)xa0the correct detection of axa0cardiac arrest, (ii)xa0axa0correctly performed call for help, (iii)xa0thoracic compressions and (iv)xa0if applicable, the initiation of adequate mouth-to-mouth ventilation. Practical training showed axa0significantly higher CPR quality compared to theoretical training only or to the use of instruction or online videos only. Worldwide implementation of axa02-h BLS training per year in children from the age of 12xa0or younger is recommended by the Kids Save Lives- statement since 2015. In Germany, implementation at the level of the federal states has progressed to different degrees.ZusammenfassungHintergrundSelbst in den westlichen Industriestaaten beträgt die Überlebenswahrscheinlichkeit nach einem außerklinischen Herz-Kreislauf-Stillstand lediglich 6–10u2009%. Ein frühzeitiger Beginn der Wiederbelebungsmaßnahmen durch Laien ist entscheidend zur Steigerung der Überlebensrate. Die systematische Durchführung von Wiederbelebungstrainings bei Schulkindern erscheint effektiv zur Erhöhung der Laienreanimationsrate.FragestellungZiele der vorliegenden Arbeit sind die Analyse und die Darstellung derzeitiger wissenschaftlicher Erkenntnisse zur effektiven Unterrichtung von Schulkindern in Wiederbelebung sowie die Erörterung von nationalen und internationalen Konzepten zur flächendeckenden Etablierung der Laienreanimation.Material und MethodenFür die vorliegende Analyse wurde eine Literaturrecherche in PubMed durchgeführt; Stichtag war der 27.xa0Februar 2017. Insgesamt wurden 192 Abstracts analysiert; 51xa0Artikel wurden als relevant beurteilt und in das Manuskript eingearbeitet. Eine zusätzliche Stichpunktsuche in Google ergab >230.000 Ergebnisse, von denen 20xa0in das vorliegende Manuskript einflossen.ErgebnisseEin Alter von 12 bis 13xa0Jahren wird allgemein vorausgesetzt, um eine mit dem Erwachsenenalter vergleichbare Qualität der Wiederbelebung zu erzielen. Im Mittelpunkt stehen i)xa0die korrekte Erkennung eines Herz-Kreislauf-Stillstands, ii)xa0das suffiziente Absetzen eines Notrufs, iii)xa0die bezüglich Kompressionstiefe und -frequenz korrekt durchgeführte Herzdruckmassage, iv)xa0ggf. die in Beatmungsfrequenz und -volumen korrekt durchgeführte Mund-zu-Mund-Beatmung. Eine praktische Lerneinheit zeigt eine höhere Qualität der Wiederbelebung im Vergleich zur alleinigen Durchführung einer theoretischen Lerneinheit bzw. der alleinigen Verwendung von Instruktions- oder Onlinevideos als Lerninstrument. Das „Kids-Save-Lives“-Statement empfiehlt seit 2015 jährliche Wiederbelebungstrainings für alle Schulkinder ab dem 12.xa0Lebensjahr oder jünger im Umfang von zwei Stunden. In Deutschland ist die Umsetzung auf Ebene der Bundesländer bisher unterschiedlich weit fortgeschritten.AbstractBackgroundEven in western developed countries, the probability of survival after out-of-hospital cardiac arrest (OHCA) is only 6–10%. In order to improve survival after OHCA, early initiation of cardiopulmonary resuscitation (CPR) by laypersons is essential. Introduction of CPR training in schoolchildren seems to be effective to increase lay-CPR rates.ObjectiveThe objective of the present investigation was to elucidate educational aspects of teaching schoolchildren in CPR and to summarize campaigns related to axa0comprehensive establishment of lay-CPR worldwide.Materials and methodsAxa0literature research in PubMed was performed, the cutoff date was 27xa0Februaryxa02017. Overall, 192 abstracts were analyzed; 51xa0articles were considered relevant and included in the manuscript. An additional keyword research in Google revealed >230,000 entries, and 20xa0of those were included in the present manuscript.ResultsA minimum age of 12–13xa0years is required to achieve axa0comparable quality of CPR to adult basic life support (BLS). Key issues are (i)xa0the correct detection of axa0cardiac arrest, (ii)xa0axa0correctly performed call for help, (iii)xa0thoracic compressions and (iv)xa0if applicable, the initiation of adequate mouth-to-mouth ventilation. Practical training showed axa0significantly higher CPR quality compared to theoretical training only or to the use of instruction or online videos only. Worldwide implementation of axa02-h BLS training per year in children from the age of 12xa0or younger is recommended by the “Kids Save Lives”- statement since 2015. In Germany, implementation at the level of the federal states has progressed to different degrees.

Vergleich von Fertigsets zur Koniotomie

ZusammenfassungHintergrundDie Koniotomie stellt die „Ultima-Ratio“-Maßnahme zur Sicherung des nichtbeherrschbaren Atemwegs dar. Im Notarztdienst muss diese in vivo nichttrainierbare Maßnahme durch Kollegen verschiedenster Fachdisziplinen gemeistert werden. Zur Erleichterung des Vorgehens existieren daher Fertigkoniotomiesets, die sich in Einzelheiten unterscheiden. Ziel dieser randomisierten und kontrollierten Anwendungsstudie war es daher, diese Sets im praktischen Einsatz zu testen und zur konventionell-chirurgischen Technik zu vergleichen.MethodenNach positivem Ethikvotum führten ausgebildete Notärzte in randomisierter Reihenfolge eine Koniotomie mit Skalpell, peripherer Venenverweilkanüle sowie den Sets TracheoQuick, Airfree, Portex-Crico-Kit, Quicktrachxa0I und Quicktrachxa0II an einem Halsphantom unter standardisierten Bedingungen durch. Handhabung und Zeitdauer der Maßnahmen wurden analysiert. Hierbei kam der Wilcoxon-Vorzeichen-Rang-Test zur Anwendung; ein pu2009<u20090,05 galt als statistisch signifikant.ErgebnisseInsgesamt nahmen 20xa0Kollegen teil. Das Durchschnittsalter lag bei 34xa0Jahren. Die mittlere Koniotomiedauer mit Skalpell betrug 35,4xa0s (Median). Signifikant schneller wurde mit TracheoQuick (20,2xa0s), Airfree (22,8xa0s), Quicktrachxa0I (21,1xa0s) und der peripheren Venenverweilkanüle (19,2xa0s) koniotomiert. Fehlpunktionen wurden nicht beobachtet.SchlussfolgerungIn dieser randomisierten, kontrollierten Untersuchung am standardisierten Halsphantom konnte von ausgebildeten Notärzten mit allen untersuchten Systemen erfolgreich koniotomiert werden. Kein System wies einen signifikant längeren Zeitbedarf als die Skalpelltechnik auf. Die Koniotomie mit gecufften Hilfsmitteln dauerte länger als mit ungecufften. In der Realität spielt dieser Unterschied jedoch nur eine untergeordnete Rolle, da das Ziel der effektiven Ventilation lediglich durch die Eigenschaften „Blockbarkeit“ und „Innendurchmesser mindestens 4xa0mm“ erreicht werden kann.AbstractBackgroundAccording to various algorithms of airway management, emergency cricothyrotomy (coniotomy) represents the ultimate step for managing the difficult airway. As most physicians have limited experience with this technique several ready-to-use devices have emerged on the market with the aim of simplifying the procedure. However, they differ in details, such as configuration or the order of particular steps. Therefore, the intention of this randomized and controlled feasibility study was to test various sets and compare them to the classical surgical approach.MethodsAfter obtaining informed consent German anesthesiologists who were also board-certified emergency physicians were asked to perform the cricothyrotomy procedure in a cervical mannequin (Frova Crico-Trainer, VBM Medizintechnik) in a randomized order using a scalpel, peripheral intravenous cannula and the commercial devices TracheoQuick, Airfree, Portex-Crico-Kit, Quicktrachxa0I and Quicktrachxa0II. Handling and duration of the procedures were analyzed utilizing the Wilcoxon signed-rank test. A p-value u2009<u20090.05 was considered significant.ResultsA total of 20 anesthesiologists (11 residents and 9 specialists) with a mean age of 34 years were included in this study and all had the additional qualification of emergency physician, which enabled them to work in prehospital emergency medicine in Germany. Participants had been working in this field for an average of 29.9 months (range 6–84 months) performing a mean of 1.9 24xa0h shifts per month (range 1–6 shifts/month). Of the participants only 2 (10%) had performed a coniotomy in reality before. In this study surgical coniotomy required a median time of 35.4xa0s (range 30.0–61.8xa0s). No significant differences were seen when the cuffed devices Quicktrachxa0II (median: 29.9xa0s, range 25.0–50.5xa0s) and Portex-Crico-Kit (median: 46.7xa0s, range 37.0–67.3xa0s) were used. A significantly faster airway was established using the non-cuffed devices TracheoQuick (median: 20.2xa0s, range 11.4–44.7xa0s), Airfree (median: 22.8xa0s, range 14.3–33.2xa0s), Quicktrachxa0I (median: 21.1xa0s, range 14.5–32.4xa0s) and the peripheral intravenous cannula (median: 19.2xa0s, range 10.8–27.8xa0s). Incorrect tube placements were not observed.ConclusionThis study allowed the comparison of surgical coniotomy to several ready-to-use devices in a standardized setting utilizing a reusable plastic mannequin. The interpretation for real emergency conditions is limited as individual anatomy, traumatic alterations of the neck or complications, such as bleeding or damage of important structures were not part of the study objectives. However, all participating emergency physicians successfully used the coniotomy sets provided at the first attempt. No device required significantly more time than the surgical approach. The procedures using cuffed devices lasted longer in comparison to procedures using uncuffed ones; however, this difference would only play a minor role in reality as effective ventilation with minute volumes greater than 7xa0l/min will only be achieved by a cuffed cannula with a minimum internal diameter of 4xa0mm. Devices with no cuff or with tube diameters smaller than 4xa0mm will only allow oxygenation of the patient, which in turn requires an inspiratory oxygen concentration of 100% and a relatively high ventilation frequency.BACKGROUNDnAccording to various algorithms of airway management, emergency cricothyrotomy (coniotomy) represents the ultimate step for managing the difficult airway. As most physicians have limited experience with this technique several ready-to-use devices have emerged on the market with the aim of simplifying the procedure. However, they differ in details, such as configuration or the order of particular steps. Therefore, the intention of this randomized and controlled feasibility study was to test various sets and compare them to the classical surgical approach.nnnMETHODSnAfter obtaining informed consent German anesthesiologists who were also board-certified emergency physicians were asked to perform the cricothyrotomy procedure in a cervical mannequin (Frova Crico-Trainer, VBM Medizintechnik) in a randomized order using a scalpel, peripheral intravenous cannula and the commercial devices TracheoQuick, Airfree, Portex-Crico-Kit, Quicktrachxa0I and Quicktrachxa0II. Handling and duration of the procedures were analyzed utilizing the Wilcoxon signed-rank test. A p-value u2009<u20090.05 was considered significant.nnnRESULTSnA total of 20 anesthesiologists (11 residents and 9 specialists) with a mean age of 34 years were included in this study and all had the additional qualification of emergency physician, which enabled them to work in prehospital emergency medicine in Germany. Participants had been working in this field for an average of 29.9 months (range 6-84 months) performing a mean of 1.9 24xa0h shifts per month (range 1-6 shifts/month). Of the participants only 2 (10%) had performed a coniotomy in reality before. In this study surgical coniotomy required a median time of 35.4xa0s (range 30.0-61.8xa0s). No significant differences were seen when the cuffed devices Quicktrachxa0II (median: 29.9xa0s, range 25.0-50.5xa0s) and Portex-Crico-Kit (median: 46.7xa0s, range 37.0-67.3xa0s) were used. A significantly faster airway was established using the non-cuffed devices TracheoQuick (median: 20.2xa0s, range 11.4-44.7xa0s), Airfree (median: 22.8xa0s, range 14.3-33.2xa0s), Quicktrachxa0I (median: 21.1xa0s, range 14.5-32.4xa0s) and the peripheral intravenous cannula (median: 19.2xa0s, range 10.8-27.8xa0s). Incorrect tube placements were not observed.nnnCONCLUSIONnThis study allowed the comparison of surgical coniotomy to several ready-to-use devices in a standardized setting utilizing a reusable plastic mannequin. The interpretation for real emergency conditions is limited as individual anatomy, traumatic alterations of the neck or complications, such as bleeding or damage of important structures were not part of the study objectives. However, all participating emergency physicians successfully used the coniotomy sets provided at the first attempt. No device required significantly more time than the surgical approach. The procedures using cuffed devices lasted longer in comparison to procedures using uncuffed ones; however, this difference would only play a minor role in reality as effective ventilation with minute volumes greater than 7xa0l/min will only be achieved by a cuffed cannula with a minimum internal diameter of 4xa0mm. Devices with no cuff or with tube diameters smaller than 4xa0mm will only allow oxygenation of the patient, which in turn requires an inspiratory oxygen concentration of 100% and a relatively high ventilation frequency.

Gender aspects in cardiopulmonary resuscitation by schoolchildren: A systematic review

AIMnBystander CPR-rates are embarrassingly low in some European countries. To increase bystander CPR-rates, many different approaches are used; one of them is training of schoolchildren in CPR. Multiple authors investigated practical and theoretical CPR performance and demonstrated gender differences related to schoolchildren CPR. The objective was to elaborate gender aspects in practical and theoretical CPR-performance from the current literature to better address female and male students.nnnMETHODSnA systematic search in PubMed-database with different search terms was performed for controlled and uncontrolled prospective investigations. Altogether, nu202f=u202f2360 articles were identified and checked for aptitude. From nu202f=u202f97 appropriated articles, nu202f=u202f24 met the inclusion criteria and were finally included for full review and incorporated in the manuscript.nnnRESULTSnFemale students demonstrated higher motivation to attend CPR-training (pu202f<u202f0.001), to respond to cardiac arrest (CA) (pu202f<u202f0.01), scored higher in a CPR-questionnaire (pu202f<u202f0.025), revealed better remembrance of the national emergency phone-number (pu202f<u202f0.05) and showed a higher multiplier effect (pu202f<u202f0.0001). Male students showed higher confidence in CPR-proficiency (pu202f<u202f0.05), revealed deeper chest compressions (CC) (pu202f<u202f0.001; pu202f<u202f0.0015; pu202f<u202f0.01), a higher CC-fraction (pu202f<u202f0.01) and a higher arbitrary cardiac output simulated equivalent index (pu202f<u202f0.05). Male gender could not be detected to be a predictor for higher tidal volume (pu202f=u202f0.70; pu202f=u202f0.0212).nnnCONCLUSIONnIn context of schoolchildren CPR, gender aspects are underestimated. Female students seem to be more motivated to attend CPR-training, reach more people in the role of a multiplier and need to be individually addressed in intensified practical training. Male students achieve a more sufficient chest compression depth and -fraction and could benefit from individual motivation.

Spezielle Probleme beim Intensivpatienten

Die Thrombozytopenie betrifft 15–60 % aller Intensivpatienten. Chirurgische ICU-Patienten zeigen eine hohere Frequenz als medizinische ICU-Patienten.

Vergleich von Fertigsets zur Koniotomie@@@Comparison of ready-to-use devices for emergency cricothyrotomy: Randomisierte und kontrollierte Anwendungsstudie am Halsphantom@@@Randomized and controlled feasibility study on a mannequin

ZusammenfassungHintergrundDie Koniotomie stellt die „Ultima-Ratio“-Maßnahme zur Sicherung des nichtbeherrschbaren Atemwegs dar. Im Notarztdienst muss diese in vivo nichttrainierbare Maßnahme durch Kollegen verschiedenster Fachdisziplinen gemeistert werden. Zur Erleichterung des Vorgehens existieren daher Fertigkoniotomiesets, die sich in Einzelheiten unterscheiden. Ziel dieser randomisierten und kontrollierten Anwendungsstudie war es daher, diese Sets im praktischen Einsatz zu testen und zur konventionell-chirurgischen Technik zu vergleichen.MethodenNach positivem Ethikvotum führten ausgebildete Notärzte in randomisierter Reihenfolge eine Koniotomie mit Skalpell, peripherer Venenverweilkanüle sowie den Sets TracheoQuick, Airfree, Portex-Crico-Kit, Quicktrachxa0I und Quicktrachxa0II an einem Halsphantom unter standardisierten Bedingungen durch. Handhabung und Zeitdauer der Maßnahmen wurden analysiert. Hierbei kam der Wilcoxon-Vorzeichen-Rang-Test zur Anwendung; ein pu2009<u20090,05 galt als statistisch signifikant.ErgebnisseInsgesamt nahmen 20xa0Kollegen teil. Das Durchschnittsalter lag bei 34xa0Jahren. Die mittlere Koniotomiedauer mit Skalpell betrug 35,4xa0s (Median). Signifikant schneller wurde mit TracheoQuick (20,2xa0s), Airfree (22,8xa0s), Quicktrachxa0I (21,1xa0s) und der peripheren Venenverweilkanüle (19,2xa0s) koniotomiert. Fehlpunktionen wurden nicht beobachtet.SchlussfolgerungIn dieser randomisierten, kontrollierten Untersuchung am standardisierten Halsphantom konnte von ausgebildeten Notärzten mit allen untersuchten Systemen erfolgreich koniotomiert werden. Kein System wies einen signifikant längeren Zeitbedarf als die Skalpelltechnik auf. Die Koniotomie mit gecufften Hilfsmitteln dauerte länger als mit ungecufften. In der Realität spielt dieser Unterschied jedoch nur eine untergeordnete Rolle, da das Ziel der effektiven Ventilation lediglich durch die Eigenschaften „Blockbarkeit“ und „Innendurchmesser mindestens 4xa0mm“ erreicht werden kann.AbstractBackgroundAccording to various algorithms of airway management, emergency cricothyrotomy (coniotomy) represents the ultimate step for managing the difficult airway. As most physicians have limited experience with this technique several ready-to-use devices have emerged on the market with the aim of simplifying the procedure. However, they differ in details, such as configuration or the order of particular steps. Therefore, the intention of this randomized and controlled feasibility study was to test various sets and compare them to the classical surgical approach.MethodsAfter obtaining informed consent German anesthesiologists who were also board-certified emergency physicians were asked to perform the cricothyrotomy procedure in a cervical mannequin (Frova Crico-Trainer, VBM Medizintechnik) in a randomized order using a scalpel, peripheral intravenous cannula and the commercial devices TracheoQuick, Airfree, Portex-Crico-Kit, Quicktrachxa0I and Quicktrachxa0II. Handling and duration of the procedures were analyzed utilizing the Wilcoxon signed-rank test. A p-value u2009<u20090.05 was considered significant.ResultsA total of 20 anesthesiologists (11 residents and 9 specialists) with a mean age of 34 years were included in this study and all had the additional qualification of emergency physician, which enabled them to work in prehospital emergency medicine in Germany. Participants had been working in this field for an average of 29.9 months (range 6–84 months) performing a mean of 1.9 24xa0h shifts per month (range 1–6 shifts/month). Of the participants only 2 (10%) had performed a coniotomy in reality before. In this study surgical coniotomy required a median time of 35.4xa0s (range 30.0–61.8xa0s). No significant differences were seen when the cuffed devices Quicktrachxa0II (median: 29.9xa0s, range 25.0–50.5xa0s) and Portex-Crico-Kit (median: 46.7xa0s, range 37.0–67.3xa0s) were used. A significantly faster airway was established using the non-cuffed devices TracheoQuick (median: 20.2xa0s, range 11.4–44.7xa0s), Airfree (median: 22.8xa0s, range 14.3–33.2xa0s), Quicktrachxa0I (median: 21.1xa0s, range 14.5–32.4xa0s) and the peripheral intravenous cannula (median: 19.2xa0s, range 10.8–27.8xa0s). Incorrect tube placements were not observed.ConclusionThis study allowed the comparison of surgical coniotomy to several ready-to-use devices in a standardized setting utilizing a reusable plastic mannequin. The interpretation for real emergency conditions is limited as individual anatomy, traumatic alterations of the neck or complications, such as bleeding or damage of important structures were not part of the study objectives. However, all participating emergency physicians successfully used the coniotomy sets provided at the first attempt. No device required significantly more time than the surgical approach. The procedures using cuffed devices lasted longer in comparison to procedures using uncuffed ones; however, this difference would only play a minor role in reality as effective ventilation with minute volumes greater than 7xa0l/min will only be achieved by a cuffed cannula with a minimum internal diameter of 4xa0mm. Devices with no cuff or with tube diameters smaller than 4xa0mm will only allow oxygenation of the patient, which in turn requires an inspiratory oxygen concentration of 100% and a relatively high ventilation frequency.BACKGROUNDnAccording to various algorithms of airway management, emergency cricothyrotomy (coniotomy) represents the ultimate step for managing the difficult airway. As most physicians have limited experience with this technique several ready-to-use devices have emerged on the market with the aim of simplifying the procedure. However, they differ in details, such as configuration or the order of particular steps. Therefore, the intention of this randomized and controlled feasibility study was to test various sets and compare them to the classical surgical approach.nnnMETHODSnAfter obtaining informed consent German anesthesiologists who were also board-certified emergency physicians were asked to perform the cricothyrotomy procedure in a cervical mannequin (Frova Crico-Trainer, VBM Medizintechnik) in a randomized order using a scalpel, peripheral intravenous cannula and the commercial devices TracheoQuick, Airfree, Portex-Crico-Kit, Quicktrachxa0I and Quicktrachxa0II. Handling and duration of the procedures were analyzed utilizing the Wilcoxon signed-rank test. A p-value u2009<u20090.05 was considered significant.nnnRESULTSnA total of 20 anesthesiologists (11 residents and 9 specialists) with a mean age of 34 years were included in this study and all had the additional qualification of emergency physician, which enabled them to work in prehospital emergency medicine in Germany. Participants had been working in this field for an average of 29.9 months (range 6-84 months) performing a mean of 1.9 24xa0h shifts per month (range 1-6 shifts/month). Of the participants only 2 (10%) had performed a coniotomy in reality before. In this study surgical coniotomy required a median time of 35.4xa0s (range 30.0-61.8xa0s). No significant differences were seen when the cuffed devices Quicktrachxa0II (median: 29.9xa0s, range 25.0-50.5xa0s) and Portex-Crico-Kit (median: 46.7xa0s, range 37.0-67.3xa0s) were used. A significantly faster airway was established using the non-cuffed devices TracheoQuick (median: 20.2xa0s, range 11.4-44.7xa0s), Airfree (median: 22.8xa0s, range 14.3-33.2xa0s), Quicktrachxa0I (median: 21.1xa0s, range 14.5-32.4xa0s) and the peripheral intravenous cannula (median: 19.2xa0s, range 10.8-27.8xa0s). Incorrect tube placements were not observed.nnnCONCLUSIONnThis study allowed the comparison of surgical coniotomy to several ready-to-use devices in a standardized setting utilizing a reusable plastic mannequin. The interpretation for real emergency conditions is limited as individual anatomy, traumatic alterations of the neck or complications, such as bleeding or damage of important structures were not part of the study objectives. However, all participating emergency physicians successfully used the coniotomy sets provided at the first attempt. No device required significantly more time than the surgical approach. The procedures using cuffed devices lasted longer in comparison to procedures using uncuffed ones; however, this difference would only play a minor role in reality as effective ventilation with minute volumes greater than 7xa0l/min will only be achieved by a cuffed cannula with a minimum internal diameter of 4xa0mm. Devices with no cuff or with tube diameters smaller than 4xa0mm will only allow oxygenation of the patient, which in turn requires an inspiratory oxygen concentration of 100% and a relatively high ventilation frequency.

Management of the Patient With Fulminant Pulmonary Embolism Undergoing Cardiopulmonary Resuscitation

Patients with cardiac arrest after fulminant pulmonary embolism (PE) have a very poor prognosis. Conventional cardiopulmonary resuscitation (CPR) is frequently unsuccessful because it does not treat the underlying condition. Although thrombolysis is an effective therapeutic option for patients with acute PE, this treatment has traditionally been withheld during CPR because of the anticipated risk of severe hemorrhagic complications associated with chest compressions. This chapter focuses on the mechanisms of action of thrombolytic therapy during CPR after acute PE on the basis of experimental and clinical data. In fact, most data suggest a significant improvement of overall and neurological outcome in patients receiving thrombolysis during CPR after massive PE. Although the use of thrombolytics is indeed associated with an increased incidence of hemorrhagic complications in this setting, critical bleeding complications are rare and do not seem to outweigh the potential benefits of this therapeutic option. Therefore, thrombolytic therapy should not be withheld in patients suffering cardiac arrest after massive PE, particularly if conventional CPR has failed to show immediate success and other treatment options (e.g., surgical embolectomy) are not available.