F. Walcher

Focused echocardiographic evaluation in resuscitation management: concept of an advanced life support-conformed algorithm.

Emergency ultrasound is suggested to be an important tool in critical care medicine. Time-dependent scenarios occur during preresuscitation care, during cardiopulmonary resuscitation, and in postresuscitation care. Suspected myocardial insufficiency due to acute global, left, or right heart failure, pericardial tamponade, and hypovolemia should be identified. These diagnoses cannot be made with standard physical examination or the electrocardiogram. Furthermore, the differential diagnosis of pulseless electrical activity is best elucidated with echocardiography. Therefore, we developed an algorithm of focused echocardiographic evaluation in resuscitation management, a structured process of an advanced life support–conformed transthoracic echocardiography protocol to be applied to point-of-care diagnosis. The new 2005 American Heart Association/European Resuscitation Council/International Liaison Committee on Resuscitation guidelines recommended high-quality cardiopulmonary resuscitation with minimal interruptions to reduce the no-flow intervals. However, they also recommended identification and treatment of reversible causes or complicating factors. Therefore, clinicians must be trained to use echocardiography within the brief interruptions of advanced life support, taking into account practical and theoretical considerations. Focused echocardiographic evaluation in resuscitation management was evaluated by emergency physicians with respect to incorporation into the cardiopulmonary resuscitation process, performance, and physicians’ ability to recognize characteristic pathology. The aim of the focused echocardiographic evaluation in resuscitation management examination is to improve the outcomes of cardiopulmonary resuscitation.

Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: A prospective trial ,

PURPOSE OF THE STUDY Focused ultrasound is increasingly used in the emergency setting, with an ALS-compliant focused echocardiography algorithm proposed as an adjunct in peri-resuscitation care (FEEL). The purpose of this study was to evaluate the feasibility of FEEL in pre-hospital resuscitation, the incidence of potentially treatable conditions detected, and the influence on patient management. PATIENTS, MATERIALS AND METHODS A prospective observational study in a pre-hospital emergency setting in patients actively undergoing cardio-pulmonary resuscitation or in a shock state. The FEEL protocol was applied by trained emergency doctors, following which a standardised report sheet was completed, including echo findings and any echo-directed change in management. These reports were then analysed independently. RESULTS A total of 230 patients were included, with 204 undergoing a FEEL examination during ongoing cardiac arrest (100) and in a shock state (104). Images of diagnostic quality were obtained in 96%. In 35% of those with an ECG diagnosis of asystole, and 58% of those with PEA, coordinated cardiac motion was detected, and associated with increased survival. Echocardiographic findings altered management in 78% of cases. CONCLUSIONS Application of ALS-compliant echocardiography in pre-hospital care is feasible, and alters diagnosis and management in a significant number of patients. Further research into its effect on patient outcomes is warranted.

Prehospital ultrasound imaging improves management of abdominal trauma

Blunt abdominal trauma with intra‐abdominal bleeding is often underdiagnosed or even overlooked at trauma scenes. The purpose of this prospective, multicentre study was to compare the accuracy of physical examination and prehospital focused abdominal sonography for trauma (PFAST) to detect abdominal bleeding.

Out-of-hospital airway management by paramedics and emergency physicians using laryngeal tubes

CONCEPT Endotracheal intubation (ETI) is considered to be the gold standard of prehospital airway management. However, ETI requires substantial technical skills and ongoing experience. Because failed prehospital ETI is common and associated with a higher mortality, reliable airway devices are needed to be used by rescuers less experienced in ETI. We prospectively evaluated the feasibility of laryngeal tubes used by paramedics and emergency physicians for out-of-hospital airway management. MATERIAL AND METHODS During a 24-month period, all cases of prehospital use of the laryngeal tube disposable (LT-D) and laryngeal tube suction disposable (LTS-D) within five operational areas of emergency medical services were recorded by a standardised questionnaire. We determined indications for laryngeal tube use, placement success, number of placement attempts, placement time and personal level of experience. RESULTS Of 157 prehospital intubation attempts with the LT-D/LTS-D, 152 (96.8%) were successfully performed by paramedics (n=70) or emergency physicians (n=87). The device was used as initial airway (n=87) or rescue device after failed ETI (n=70). The placement time was < or =45s (n=120), 46-90s (n=20) and >90s (n=7). In five cases the time needed was not specified. The number of placement attempts was one (n=123), two (n=25), three (n=2) and more than three (n=2). The majority of users (61.1%) were relative novices with no more than five previous laryngeal tube placements. CONCLUSION The LT-D/LTS-D represents a reliable tool for prehospital airway management in the hands of both paramedics and emergency physicians. It can be used as an initial tool to secure the airway until ETI is prepared, as a definitive airway by rescuers less experienced with ETI or as a rescue device when ETI has failed.

Excellence in performance and stress reduction during two different full scale simulator training courses: A pilot study☆☆☆

BACKGROUND Simulator training is well established to improve technical and non-technical skills in critical situations. Few data exist about stress experienced during simulator training. This study aims to evaluate performance and stress in intensivists before and after two different simulator-based training approaches. METHODS Thirty-two intensivists took part in one of six 1-day simulator courses. The courses were randomised to either crew resource management (CRM) training, which contains psychological teaching and simulator scenarios, or classic simulator training (MED). Before and after the course each participant took part in a 10-min test scenario. Before (T1) and after (T2) the scenario, and then again 15 min later (T3), saliva samples were taken, and amylase and cortisol were measured. Non-technical skills were evaluated using the Anaesthetists Non-Technical Skills (ANTS) assessment tool. Clinical performance of the participants in the test scenarios was rated using a checklist. RESULTS Twenty-nine participants completed the course (17-CRM, 12-MED). ANTS scores as well as clinical performances were significantly better in the post-intervention scenario, with no differences between the groups. Both cortisol concentration and amylase activity showed a significant increase during the test scenarios. In the post-intervention scenario, the increase in amylase but not cortisol was significantly smaller. There were no differences between the CRM and MED group. CONCLUSIONS High fidelity patient simulation produces significant stress. After a 1-day simulator training, stress response measured by salivary alpha-amylase was reduced. Clinical performance and non-technical skills improved after 1 day of simulator training. Neither stress nor performance differed between the groups.

Optimierung des Traumamanagements durch präklinische Sonographie

ZusammenfassungFragestellung. Die technische Entwicklung kleiner, mobiler Ultraschallgeräte erlaubt deren Einsatz auch außerhalb der Klinik. In der vorliegenden Arbeit wird untersucht, in wieweit die präklinische Sonographie eine praktikable Methode darstellt, um am Unfallort abdominelle Blutungen zu diagnostizieren und inwieweit dies Einfluss auf das Management schwerverletzter Patienten hat. Methodik. Die präklinische Sonographie wurde an 61 Patienten, bei denen eine intraabdominelle Verletzung klinisch nicht sicher ausgeschlossen werden konnte, von einem nicht an der Notfallversorgung beteiligten Untersucher angewendet. Es wurden standardisiert der Morison- und Koller-Pouch, beide Pleuraräume sowie das kleine Becken auf freie Flüssigkeit hin untersucht. Unmittelbar nach Klinikaufnahme wurde der präklinisch festgestellte Ultraschallbefund mittels erneuter Ultraschalluntersuchung bzw. Computertomographie des Abdomens im Rahmen der Schockraumdiagnostik kontrolliert. Ergebnisse. Bei einer Untersuchungsdauer von durchschnittlich 2,8±1,2 min wurde bei 16 Patienten (26,2%) freie Flüssigkeit gefunden, 7 mit massivem, 9 mit moderatem pathologischen Befund. 4 der Patienten mit massivem Befund wurden unmittelbar nach Klinikaufnahme laparotomiert und 3 aufgrund einer Milzruptur splenektomiert. Drei Patienten verstarben am Unfallort u. a. aufgrund ihrer abdominellen Verletzungen. Die Untersuchung ergab schließlich ein falsch-positives Ergebnis, jedoch kein falsch-negatives Ergebnis, welches eine Spezifität von 97,5% und eine Sensitivität von 100% ergibt. In 36% der Einsätze wurde das präklinische Management modifiziert und in 21% aufgrund der sonographischen Diagnose die Wahl der Zielklinik beeinflusst. Schlussfolgerungen. Die präklinische Sonographie hat sich in der vorliegenden Untersuchung als sichere und fehlerarme Methode zur präklinischen Diagnostik freier intraperitonealer Flüssigkeit bewährt. Die Daten sind Grundlage für die Durchführung einer Multicenterstudie in der Flugrettung, in der geklärt werden soll, ob die präklinische Sonographie generell für den Einsatz im Notarztdienst empfohlen werden kann.AbstractAim. The purpose of the study was to evaluate the practicability and the benefit of focused abdominal sonography for trauma (FAST) on scene. Methods. Prehospital ultrasound was performed on 61 patients being suspicious for abdominal trauma. Free fluid in the Kollers and Morisons pouch, pelvis and pleural space was investigated. After admission routine ultrasound and computer tomography scan was obtained to control prehospital findings. Results. The mean investigation time was 2.8±1.2 min. In 16 patients (26.2%) free fluid was detected with 7 massive and 9 moderate findings. 3 patients died on the scene due to their abdominal injuries. 4 patients underwent laparotomy immediately after admission with 3 splenectomies performed. There was one false positive but no negative FAST resulting in a specifity of 97.5% and sensitivity of 100%. In 37% of the cases the prehospital management was modified and hospital selection was influenced in 21% of the cases due to the findings of the FAST. Conclusion. In the present study the data have shown that the prehospital ultrasound is a useful and reliable tool for diagnostic procedure on the scene. The data are the basis for a multicenter study in the helicopter rescue service. This study will try to answer the question whether prehospital ultrasound may be generally recommended in trauma patients suspicious for abdominal trauma.

Microcirculatory disturbances and leucocyte adherence in transplanted livers after cold storage in Euro-Collins, UW and HTK solutions

Abstract. Integrity of the hepatic microcirculation and maintenance of endothelial cell viability are critical components in preventing primary non‐function after liver transplantation. Therefore, hepatic microcirculation and leucocyte‐endothelial interaction were studied in rat livers stored for 1 h in Euro‐Collins (EC), University of Wisconsin (UW), and histidine‐tryptophan‐ketoglutarate (HTK) solutions and subsequently transplanted. One hour after transplantation surgery, the livers were exposed under an intravital fluorescence microscope. After injection of the leucocyte marker acridine orange (1 μmol/kg), six pericentral fields were observed for 30 s and experiments were recorded continuously. The percentage of perfused sinusoids was reduced in the livers in the EC group (82.9%) in contrast to the UW (93.2%) and HTK groups (91.0%). Livers in the EC group showed a reduction in the diameters of pericentral sinusoids (7.3 ± 0.2μm; mean ± SEM) compared with the UW group (9.5 ± 0.2μm; P < 0.05) and HTK group (10.2 ± 0.8 μm; P < 0.05), indicating substantial cell swelling in livers stored in EC solution. Permanent adherence of leucocytes was most frequently observed in the EC group (33.5 ± 1%), while this phenomenon was less pronounced in the UW group (14.5 + 1.1%; P < 0.05) and HTK group (16.3 ± 0.7%; P <0.05). Conversely, temporary adherence of leucocytes was reduced in the EC group (19.7 + 1.3%) compared with the UW group (30.5 + 2.1%) and the HTK group (34.4 + 0.8%). Microcireulatory failure and cell swelling in the EC group might be due to the lack of osmotic substances or oxygen radical scavengers included in UW (allopurinol, glutathione) and HTK (mannitol) solutions. In conclusion, cold storage of livers in U W and HTK solutions results in better preservation of the microcirculation and prevention of adhesion of leucocytes after transplantation compared with the EC solution.

ANTIOXIDATIVE RESUSCITATION SOLUTION PREVENTS LEUKOCYTE ADHESION IN THE LIVER AFTER HEMORRHAGIC SHOCK

BACKGROUND The generation of iron-dependent toxic oxygen radicals during the initial resuscitation from hemorrhagic shock was shown to be a relevant factor for the initiation of the inflammatory cascade. Therefore, this experimental study was designed to evaluate the effects of a deferoxamine-conjugated hydroxyethyl-starch solution (HES-DFO) on oxygen radical induced injury and microcirculatory alterations in the rat liver compared with resuscitation with regular hydroxyethyl-starch, lactated Ringers solution (RL), or a gelatin-based solution. METHODS After hemorrhage and random assignment to 1 hour of blood-free resuscitation with the aforementioned solutions, hepatic microcirculation and leukocyte adhesion characteristics were assessed by intravital fluorescence microscopy in anesthetized rats. Oxygen radical activity was estimated by determination of glutathione levels in liver homogenate and determination of thiobarbituric acid-reactive substances in plasma as markers of lipid peroxidation. RESULTS Resuscitation by HES-DFO resulted in restoration of hemodynamic parameters compared with gelatin-based solution and HES. The hepatic microcirculation was severely altered 1 hour after resuscitation from shock in all groups indicated by sinusoidal narrowing and reduced sinusoidal blood flow. HES-DFO, however, attenuated leukocyte adhesion and improved velocity index in sinusoids as well as sinusoidal perfusion. The shock-associated generation of oxygen radicals during resuscitation was prevented by HES-DFO as indicated by restored glutathione and reduced thiobarbituric acid-reactive substances. CONCLUSION The results suggest that HES-DFO effectively reduces oxygen radical formation during the initial resuscitation period, thus, attenuating pathologically enhanced leukocyte adhesion and improving hepatic microcirculation.

Serum procalcitonin levels in patients with multiple injuries including visceral trauma.

Procalcitonin (PCT) is known to be a reliable biomarker of sepsis and infection. Elevation of serum or plasma PCT has also been observed after major surgery or trauma. The association of PCT with the severity or location of injury in multiple traumatized (polytrauma) patients has not been clearly established, to date. The aim of this study was therefore to evaluate the sensitivity of PCT as a biomarker for the diagnosis of abdominal trauma. In a prospective clinical study, PCT, interrleukin-6, and C-reactive protein were measured in blood (serum) samples obtained in the emergency room (D0) from 74 patients with multiple injuries and in serum samples obtained on the 2 days after trauma (D1, D2). PCT significantly increased during the first two posttraumatic days in patients with severe multiple injuries (n = 24, day 1: 3.37 ng/mL +/- 0.92 ng/mL; day 2: 3.27 ng/mL +/-0.97 ng/mL) as compared with patients with identical Injury Severity Score but without abdominal injury (day 1: 0.6 ng/mL +/- 0.18 ng/mL; 0.61 ng/mL +/- 0.21 ng/mL). Interrleukin-6 and C-reactive protein serum levels were not able to discriminate between patients with and without abdominal injury during the 2-day posttrauma observation period. In a specific evaluation of the abdominal injury pattern, a significant increase of serum PCT concentrations was observed on day 1 after trauma of the liver (4.04 ng/mL +/- 0.99 ng/mL) and the gut (4.63 ng/mL +/- 1.12 ng/mL) compared with other abdominal lesions (0.62 ng/mL +/- 0.2 ng/mL). Markedly elevated PCT concentrations were also evident after severe multiple injuries, including the liver/spleen in combination with thorax trauma (9.37 ng/mL +/- 2.71 ng/mL). Assessment of serum PCT seems to be significantly increased after abdominal trauma in severe multiple traumatized patients and may serve as a useful biomarker to support other diagnostic methods including ultrasound and CT scan. Although elevated levels of PCT during the first 2 days after trauma are more likely to be indicative of traumatic impact than of an ongoing status of sepsis, multiple events such as surgery, massive transfusion, and intensive care therapy might influence the PCT concentration.

High Prevalence of Anti-HCV Antibodies in Two Metropolitan Emergency Departments in Germany: A Prospective Screening Analysis of 28,809 Patients

Background and Aims The prevalence of hepatitis C virus (HCV) antibodies in Germany has been estimated to be in the range of 0.4–0.63%. Screening for HCV is recommended in patients with elevated ALT levels or significant risk factors for HCV transmission only. However, 15–30% of patients report no risk factors and ALT levels can be normal in up to 20–30% of patients with chronic HCV infection. The aim of this study was to assess the HCV seroprevalence in patients visiting two tertiary care emergency departments in Berlin and Frankfurt, respectively. Methods Between May 2008 and March 2010, a total of 28,809 consecutive patients were screened for the presence of anti-HCV antibodies. Anti-HCV positive sera were subsequently tested for HCV-RNA. Results The overall HCV seroprevalence was 2.6% (95% CI: 2.4–2.8; 2.4% in Berlin and 3.5% in Frankfurt). HCV-RNA was detectable in 68% of anti-HCV positive cases. Thus, the prevalence of chronic HCV infection in the overall study population was 1.6% (95% CI 1.5–1.8). The most commonly reported risk factor was former/current injection drug use (IDU; 31.2%) and those with IDU as the main risk factor were significantly younger than patients without IDU (p<0.001) and the male-to-female ratio was 72% (121 vs. 46 patients; p<0.001). Finally, 18.8% of contacted HCV-RNA positive patients had not been diagnosed previously. Conclusions The HCV seroprevalence was more than four times higher compared to current estimates and almost one fifth of contacted HCV-RNA positive patients had not been diagnosed previously.