Burkhard Dirks

Randomised comparison of epinephrine and vasopressin in patients with out-of-hospital ventricular fibrillation

BACKGROUNDnStudies in animals have suggested that intravenous vasopressin is associated with better vital-organ perfusion and resuscitation rates than is epinephrine in the treatment of cardiac arrest. We did a randomised comparison of vasopressin with epinephrine in patients with ventricular fibrillation in out-of-hospital cardiac arrest.nnnMETHODSn40 patients in ventricular fibrillation resistant to electrical defibrillation were prospectively and randomly assigned epinephrine (1 mg intravenously; n = 20) or vasopressin (40 U intravenously; n = 20) as primary drug therapy for cardiac arrest. The endpoints of this double blind study were successful resuscitation (hospital admission), survival for 24 h, survival to hospital discharge and neurological outcome (Glasgow coma scale). Analyses were by intention to treat.nnnFINDINGSnSeven (35%) patients in the epinephrine group and 14 (70%) in the vasopressin group survived to hospital admission (p = 0.06). At 24 h, four (20%) epinephrine-treated patients and 12 (60%) vasopressin-treated patients were alive (p = 0.02). Three (15%) patients in the epinephrine group and eight (40%) in the vasopressin group survived to hospital discharge (p = 0.16). Neurological outcomes were similar (mean Glasgow coma score at hospital discharge 10.7 [SE 3.8] vs 11.7 [1.6], p = 0.78).nnnINTERPRETATIONnIn this preliminary study, a significantly larger proportion of patients created with vasopressin than of those treated with epinephrine were resuscitated successfully from out-of-hospital ventricular fibrillation and survived for 24 h. Based upon these findings, larger multicentre studies of vasopressin in the treatment of cardiac arrest are needed.

Externe Qualitätssicherung im Rettungsdienst

ZusammenfassungIn Baden-Württemberg werden an 138xa0Standorten pro Jahr 150.000 bodengebundene Notarzteinsätze abgewickelt und seit 2001 einheitlich dokumentiert. Zweimal jährlich erfolgt eine zentrale Datenauswertung mit dem Ziel, konsekutive Einsätze und dokumentierte medizinische Sachverhalte unter dem Aspekt externer Qualitätssicherung zu analysieren. Die Grundlage dafür stellt der minimale Notarztdatensatz MIND dar. Mit der landesweit ausgelegten Analyse präklinischer Versorgungsprozesse gelang es 2003 erstmals, in einem Bundesland der Bundesrepublik Deutschland Daten über Struktur-, Prozess- und Ergebnisqualität von Notarztdiensten flächendeckend darzustellen. Notfallmedizinisch relevante Indikatoren kennzeichnen den Zielerreichungsgrad und dienen dem Vergleich und Benchmarking. Mit einer Teilnahme von 62% der Notarztstandorte liefert das mittlerweile etablierte Verfahren repräsentative Daten aus Baden-Württemberg für das Qualitätsmanagement.AbstractIn Baden-Württemberg 105,000 ground missions performed annually by emergency physicians are processed at 138xa0EMS stations and have been documented following a standard protocol since 2001. Two times a year the data are evaluated at a control center with the goal of analyzing consecutive missions and the documented medical facts of the cases with respect to quality assurance. The emergency physician minimum dataset MIND provides a basis for this analysis. The statewide analysis of preclinical medical care processes made it possible in 2003 to collect data for the first time on the quality of the structure, process, and results of emergency physician services covering an entire federal state in Germany. Indicators relevant to emergency medicine characterize the goal achievement level and serve for comparison purposes and benchmarking. The procedure has now become well established with the participation of 62% of the EMS stations and supplies representative data from Baden-Württemberg for quality management.

DIVI-Notarzteinsatzprotokoll-Version 4.0

1991 hat Herr Prof. Dr. H.-N. Herden im Auftrag der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI) das bundeseinheitliche Notfalleinsatzprotokoll vorgestellt [3]. 1994 folgte das bundeseinheitliche Rettungsdienstprotokoll der DIVI [4]. Beide Protokolle haben sich in den vergangenen Jahren in zahllosen Rettungsdienstbezirken erfolgreich durchgesetzt. Inzwischen existieren sogar Übersetzungen in andere Sprachen.1997 hat die DIVI den Auftrag erteilt, die Erfahrungen aus der Anwendung des DIVI-Notarzteinsatzprotokolls in einer neuen Version (Version 4.0) einfließen zu lassen (Abb. 1). Die Überarbeitung des Protokolls war davon geleitet, die Grundstruktur unverändert zu lassen und lediglich Details zu optimieren. Um den minimalen Notarztdatensatz (MIND) [1] bilden zu können, wurde insbesondere der Mainz Emergency-Evaluation-Score (MEES) [2] integriert.

Active compression-decompression cardiopulmonary resuscitation - Instructor and student manual for teaching and training Part I: The Workshop*

In an attempt to standardize the teaching and training of active compression-decompression cardiopulmonary resuscitation (ACD-CPR), a group of leading emergency physicians, cardiologists, anesthesiologists, paramedics and nurses with practical, theoretical, educational, and scientific experience in the subject met in June 1995. The group was called The International Working Group of Teaching and Training Active Compression-Decompression CPR. The group was born as a result of the first International Conference of Active Compression-Decompression CPR held in Copenhagen in March 1995. The following paper describes the background, development and text of and ACD-CPR course manual for both students and instructors.

Die „Interdisziplinäre Notaufnahme“ im Zentrum zukünftiger Notfallmedizin

ZusammenfassungBereits zum 10.xa0Male boten die Leinsweiler Gespräche die Möglichkeit, zukünftige Strategien und Konzepte der Notfallmedizin in einer repräsentativen Runde zu diskutieren. Vertreter der Politik, der Länderministerien und der Hilfsorganisationen, Notärzte und Vertreter des Klinikmanagements stellten sich diesmal der Frage, wie die Rolle der „Interdisziplinären Notaufnahme“ in der zukünftigen Notfallmedizin aussehen wird. Als Schnittstelle zwischen der präklinischen und der klinischen Versorgung bietet die interdisziplinäre Notaufnahme die Möglichkeit, die präklinische Diagnostik zeitnah zu vervollständigen und ebenso rasch die optimale klinische Therapie einzuleiten. Die notfallmedizinisch notwendigen Ansprüche an eine interdisziplinäre Notaufnahme müssen noch genauer definiert werden. Dabei können die Erfahrungen national und international schon bestehender Einrichtungen genutzt werden. Auch die rettungsdienstlichen Partner — Ministerien, Kommunen, Rettungszweckverbände und Hilfsorganisationen — müssen bei der Realisierung von interdisziplinären Notaufnahmen einbezogen werden. Nur ein schlüssiges Gesamtkonzept der Akutversorgung wird in Zukunft die rasche Versorgung des Notfallpatienten deutlich verbessern.AbstractFor the tenth time, the Leinsweiler talks provided the opportunity to discuss future strategies and concepts in emergency medical services (EMS) among a representative group of participants. Politicians, representatives from state ministries and relief organizations, physicians, and representatives of clinic management approached the question of how the role of an “interdisciplinary emergency room” could be structured in future EMS. As the interface between preclinical and clinical care, the interdisciplinary emergency room offers the possibility for promptly completing the preclinical diagnostic work-up and just as quickly initiating optimal clinical treatment. The emergency medicine requirements in an interdisciplinary emergency unit have to be more precisely defined. The experience gathered by national and international units already in existence can be used for this purpose. Organizations affiliated with EMS — ministries, local authorities, rescue associations, and relief agencies — all have to be involved in creating interdisciplinary emergency rooms. Only a coherent overall concept for acute management will noticeably improve the rapid care of emergency patients in the future.

Bispectral index (BIS) and suppression ratio (SR) as an early predictor of unfavourable neurological outcome after cardiac arrest

INTRODUCTIONnPredicting the neurological outcome after cardiopulmonary resuscitation (CPR) is extremely difficult. We tested the hypothesis whether monitoring of bispectral index (BIS) and suppression ratio (SR) could serve as an early prognostic indicator of neurological outcomes after CPR.nnnMETHODSnCerebral monitoring (BIS, SR) was started as soon as possible after initiation of CPR and was continued for up to 72h. The functional neurological outcome was measured on day 3, day 7 and again one month after CPR via a clinical examination and assessment according to the cerebral performance category score (CPC).nnnRESULTSnIn total 79 patients were included. Of these, 26 patients (32.9%) survived the observation period of one month; 7 of them (8.9%) showed an unfavourable neurological outcome. These 7 patients had significantly lower median BIS values (25 [21;37] vs. 61 [51;70]) and higher SR (56 [44;64] vs. 7 [1;22]) during the first 4h after the initiation of CPR. Using BIS<40 as threshold criteria, unfavourable neurological outcome was predicted with a specificity of 89.5% and a sensitivity of 85.7%. The odds ratio for predicting an unfavourable neurological outcome was 0.921 (95% CI 0.853-0.985). The likelihood to remain in a poor neurological condition decreased by 7.9% for each additional point of BIS, on average.nnnCONCLUSIONnOur results suggest that BIS and SR are helpful tools in the evaluation of the neurological outcomes of resuscitated patients. Nevertheless, therapeutic decisions have to be confirmed through further examinations due to the far-ranging consequences of false positive results.

The quality of emergency medical care in baden-württemberg (Germany): four years in focus.

BACKGROUNDnIn 2004, the German federal state of Baden-Württemberg implemented a quality management system for pre-hospital emergency care. Since then, there has been a semi-annual assessment of the frequency of different types of emergency medical interventions and the quality of care.nnnMETHODSnThe frequencies of different types of intervention were determined and reported both in absolute numbers and as incidence figures, i.e., interventions per 1000 inhabitants per year. The quality of care was rated with the Mainz Emergency Evaluation Score (MEES), and analyses of resuscitation outcomes and guideline implementation were performed.nnnRESULTSnFrom 2004 to 2008, there were a total of 524,833 pre-hospital emergency medical interventions in Baden-Württemberg. The annual incidence of emergency interventions rose by 22% over this period (from 16.2 to 19.9 interventions per 1000 inhabitants per year), and the percentage of patients who were severely ill or severely injured rose as well, from 47.3% to 51.1%. The percentage of patients over age 75 rose from 29.1% to 31.3%. 11,858 patients with myocardial infarction (MI) were treated in 2008; the incidence of treatment for MI rose by 60% from 2004 to 2008, from 0.907 to 1.448 interventions per 1000 inhabitants per year. A major improvement in the diagnostic evaluation of MI came about through the purchase of more 12-channel ECG machines. In 2008, the emergency medical teams succeeded in improving the patients condition in 69.07% of all cases (77.9% for MI, 63.2% for stroke, 74.4% for multiple trauma). 21 patients per 100,000 inhabitants per year arrived in the hospital alive after out-of-hospital cardiac arrest and pre-hospital resuscitation.nnnCONCLUSIONSnEven in the face of increasing utilization, the quality of emergency medical care in Baden-Württemberg has remained high. Since a quality management system was introduced in 2004, the physicians in charge of emergency medical teams have had access to the data that they need in order to evaluate and further develop the services that they provide.

Die Zentrale Notaufnahme als Mittelpunkt zukünftiger Notfallmedizin

ZusammenfassungEnde 2008 endet für alle Krankenhäuser die Bezahlung der stationären Leistungen nach zuvor ausgehandelten Budgets. Mit Ende der Konvergenzphase tritt 2009 die neue Vergütung nach Fallpauschalen in Kraft (GDRG), die erhebliche Auswirkungen auf die Krankenhauslandschaft haben wird. Marktwirtschaftliche Gesichtspunkte werden einen dominierenden Einfluss auf die Neuausrichtung der Krankenhäuser ausüben, fachübergreifende Abläufe und Strukturen werden allein schon aus wirtschaftlichen Gründen die bisherigen Abteilungsgrenzen verwischen. Für die Erstversorgung von Notfallpatienten entstehen zurzeit an vielen Kliniken zentrale interdisziplinäre Notaufnahmen, die verhindern sollen, dass Notfallpatienten nach der Erstbehandlung erst über Umwege in die richtige Fachabteilung übernommen werden. Für die Notfallmedizin ergibt sich mit der Einrichtung dieser Zentralen Notaufnahmen die Chance, die außer- und innerklinische Notfallversorgung organisatorisch, personell und fachlich zu verbinden und sich damit als klinisches Fach zu etablieren. Notarzt und Rettungssanitäter werden dabei Mitarbeiter der Zentralen Notaufnahme, der ärztliche Leiter gleichzeitig Leiter des Notarztstandorts. Therapiekonzepte und Behandlungsstrategien der innerklinischen Akutversorgung würden nahtlos in die außerklinische Erstversorgung übernommen, die Schnittstellenproblematik würde weitgehend entfallen und der Rettungsdienst hätte nur eine Anlaufstelle für Notfälle. Ob dabei die Notfallmedizin weiter als interdisziplinäres Konzept organisiert und geführt wird oder sich zu einem eigenen Fachgebiet entwickelt, bleibt der zukünftigen Entwicklung vorbehalten.AbstractAt the end of 2008 the previously negotiated budget for payment of inpatient services will expire. With completion of the convergence phase, the new system of remuneration based on diagnosis-related groups (G-DRG) will take effect in 2009 and will have considerable impact on the hospital environment. Aspects of a market economy will exert a dominant influence on the reorientation of hospitals. Interdisciplinary activities and structures will blur the boundaries between existing departments. Many clinics are currently establishing centralized interdisciplinary emergency departments for initial management of emergency patients and after providing primary care should prevent these patients from traveling a circuitous route before reaching the appropriate department. The creation of these centralized emergency departments gives the field of emergency medicine the chance to combine out-of-hospital and inhospital services in terms of organization, personnel, and specialty and thus the opportunity to fortify its position as a clinical discipline. The emergency physicians and medical technicians will become members of the centralized emergency department staff and the medical director will simultaneously become the chief of the emergency physicians’ base station. There would be a smooth transition of inhospital therapy concepts and treatment strategies for acute care into the workings of initial out-of-hospital management, the problems involved in an interface would to a large extent be resolved, and there would be only one command center for EMS. Whether emergency medicine will continue to be organized following an interdisciplinary concept or whether it will evolve into an independent specialty is subject to future developments.

Fate of Patients With Prehospital Resuscitation for ST-Elevation Myocardial Infarction and a High Rate of Early Reperfusion Therapy (Results from the PREMIR [Prehospital Myocardial Infarction Registry])

Patients with acute ST-segment elevation myocardial infarction (STEMI) needing prehospital cardiopulmonary resuscitation (CPR) have a very high adverse-event rate. However, little is known about the fate of these patients and predictors of mortality in the era of early reperfusion therapy. From March 2003 through December 2004, 2,317 patients with prehospital diagnosed STEMI were enrolled in the Prehospital Myocardial Infarction Registry. One hundred ninety patients (8.2%) underwent prehospital CPR and were included in our analysis. Overall 90% of patients were treated with early reperfusion therapy, 56.3% received prehospital thrombolysis and 1/2 of these patients received early percutaneous coronary intervention after thrombolysis, 28.4% of patients were treated with primary percutaneous coronary intervention, and 5.3% received in-hospital thrombolysis. Total mortality was 40.0%. The highest mortality was seen in patients with asystole (63%) or pulseless electric activity (64%). Independent predictors of mortality were need for endotracheal intubation and older age, whereas ventricular fibrillation as initial heart rhythm was associated with survival. In conclusion, in this large registry with prehospital diagnosed STEMI, incidence of prehospital CPR was about 8%. Even with a very high rate of early reperfusion therapy, in-hospital mortality was high. Especially in elderly patients with asystole as initial heart rhythm and with need for endotracheal intubation, prognosis is poor despite aggressive reperfusion therapy.

Leitstelle – Perspektiven für die zentrale Schaltstelle des Rettungsdienstes

ZusammenfassungDie 11.xa0berufspolitische Tagung der Arbeitsgemeinschaft Südwestdeutscher Notärzte (agswn e.xa0V.) befasste sich mit den Perspektiven für die Leitstelle unter den Aspekten Personalqualifikation, Leitstellentechnologie, Organisationsstruktur und Qualitätsmangement.Die Qualifikation als Leitstellendisponent setzt die Ausbildung zum Rettungsassistenten oder Feuerwehrbeamten voraus. Entsprechend dem Aufgabenspektrum der Leitstelle muss eine umfangreiche Zusatzausbildung im jeweils anderen Dispositionsbereich sowie eine leitstellenspezifische Ausbildung erfolgen.Technische Entwicklungsmöglichkeiten im Bereich der Leitstelle bestehen in der Nutzung der Dienste öffentlicher Mobilfunk- und Festnetze (SMS, UMTS), die GPS-gesteuerte Fahrzeugdisposition, der Online-Datenaustausch mit Nachbarleitstellen, Arztpraxen, Kliniken und Rettungswachen sowie die Übermittlung von Positionsdaten beim Notruf 112. Notrufabfrageprotokolle können die Einsatzdisposition durch Einführung standardisierter und überprüfbarer Abläufe optimieren.Die Einführung der europaweit gültigen Notrufnummer 112 für alle nichtpolizeilichen Notrufe bedingt den Aufbau Integrierter Leitstellen als optimale Organisationsstruktur. Die Umsetzung eines entsprechenden Konzeptes bedarf einer klaren gesetzlichen Vorgabe sowie einer detaillierten Projektplanung bezüglich Organisationsstruktur (Betreiberkonzept), Personalplanung, eingesetzter Leitstellentechnologie und Kostenmanagements.Qualitätsmanagement in der Leitstelle umfasst die Bereiche Strukturqualität (personelle Ausstattung und Organisationsstruktur), Prozessqualität (Entwicklung strukturierter Abfragesysteme, von Indikationskatalogen für die einzelnen Rettungsmittel sowie die Festlegung von Zielkliniken für vitalbedrohte Patientengruppen) und Ergebnisqualität (Überprüfung des Zeitmanagements in der Leitstelle und Kontrolle der Dispositionsqualität).AbstractThe 11th professional political meeting of the working group Southwest German Emergency Physicians considered the perspectives for a control center under the aspects of personal qualifications, management technology, organisatzional structure, and quality management.The qualification of the center’s director requires training as a rescue assistant or fire services official. Corresponding to the spectrum of work at the center, wide ranging additional training in the different disposition areas as well as center specific training are required.Possibilities for technical development within the control center involve the use of cell phones and fixed networks (SMS, UMTS), GPS navigated vehicle disposition, online data exchange with neighboring control centers, medical practices, hospitals and emergency services, as well as the transmission of location data using the emergency number 112. Emergency call question protocols can optimize the assignment disposition by the introduction of standardized and verifiable courses of action.The introduction of the Europe wide emergency number 112 for all non-police emergency calls presupposes the introduction of integrated control centers as an optimal organizational structure. The realization of such a concept requires clear legal guidelines as well as a detailed project planning in terms of organizational structure (operational concept), personnel planning, the use of control center technology and cost management.Quality management in the control center includes the areas of structural quality (personnel, organizational structure), process quality (development of structured questioning schemes, indication of catalogues for individual rescue agents, as well as setting target hospitals for life threatened patient groups), and the quality of results (checking time management in the control center and control of the quality of the dispositions).