Gerhard Prause

Cardiac Movement Identified on Prehospital Echocardiography Predicts Outcome in Cardiac Arrest Patients

Abstract Introduction. The prognostic value of emergency echocardiography (EE) in the management of cardiac arrest patients has previously been studied in an in-hospital setting. These studies mainly included patients who underwent cardiopulmonary resuscitation (CPR) by emergency medicine technicians at the scene and who arrived at the emergency department (ED) still in a state of cardiac arrest. In most European countries, cardiac arrest patients are normally treated by physician-staffed emergency medical services (EMS) teams on scene. Transportation to the ED while undergoing CPR is uncommon. Objective. To evaluate the ability of EE to predict outcome in cardiac arrest patients when it is performed by ultrasound-inexperienced emergency physicians on scene. Methods. We performed a prospective, observational study of nonconsecutive, nontrauma, adult cardiac arrest patients who were treated by physician-staffed urban EMS teams on scene. Participating emergency physicians (EPs) received a two-hour course in EE during CPR. After initial procedures were accomplished, EE was performed during a rhythm and pulse check. A single subxiphoid, four-chamber view was required for study enrollment. We defined sonographic evidence of cardiac kinetic activity as any detected motion of the myocardium, ranging from visible ventricular fibrillation to coordinated ventricular contractions. The CPR had to be continued for at least 15 minutes after the initial echocardiography. No clinical decisions were made based on the results of EE. Results. Forty-two patients were enrolled in the study. The heart could be visualized successfully in all patients. Five (11.9%) patients survived to hospital admission. Of the 32 patients who had cardiac standstill on initial EE, only one (3.1%) survived to hospital admission, whereas four out of 10 (40%) patients with cardiac movement on initial EE survived to hospital admission (p = 0.008). Neither asystole on initial electrocardiogram nor peak capnography value, age, bystander CPR, or downtime was a significant predictor of survival. Only cardiac movement was associated with survival, and cardiac standstill at any time during CPR resulted in a positive predictive value of 97.1% for death at the scene. Conclusion. Our results support the idea of focused echocardiography as an additional criterion in the evaluation of outcome in CPR patients and demonstrate its feasibility in the prehospital setting.

Increasing arterial oxygen partial pressure during cardiopulmonary resuscitation is associated with improved rates of hospital admission

AIM As recent clinical data suggest a harmful effect of arterial hyperoxia on patients after resuscitation from cardiac arrest (CA), we aimed to investigate this association during cardiopulmonary resuscitation (CPR), the earliest and one of the most crucial phases of recirculation. METHODS We analysed 1015 patients who from 2003 to 2010 underwent out-of-hospital CPR administered by emergency medical services serving 300,000 inhabitants. Inclusion criteria for further analysis were nontraumatic background of CA and patients >18 years of age. One hundred and forty-five arterial blood gas analyses including oxygen partial pressure (paO2) measurement were obtained during CPR. RESULTS We observed a highly significant increase in hospital admission rates associated with increases in paO2 in steps of 100 mmHg (13.3 kPa). Subsequently, data were clustered according to previously described cutoffs (≤ 60 mmHg [8 kPa]], 61-300 mmHg [8.1-40 kPa], >300 mmHg [>40 kPa]). Baseline variables (age, sex, initial rhythm, rate of bystander CPR and collapse-to-CPR time) of the three compared groups did not differ significantly. Rates of hospital admission after CA were 18.8%, 50.6% and 83.3%, respectively. In a multivariate analysis, logistic regression revealed significant prognostic value for paO2 and the duration of CPR. CONCLUSION This study presents novel human data on the arterial paO2 during CPR in conjunction with the rate of hospital admission. We describe a significantly increased rate of hospital admission associated with increasing paO2. We found that the previously described potentially harmful effects of hyperoxia after return of spontaneous circulation were not reproduced for paO2 measured during CPR. CLINICAL TRIAL REGISTRATION n/a.

Prehospital lung ultrasound in the distinction between pulmonary edema and exacerbation of chronic obstructive pulmonary disease.

We present 2 cases of dyspneic patients, where prehospital lung ultrasound helped to distinguish between pulmonary edema and acute exacerbation of chronic obstructive pulmonary disease.

Arterial blood gases during and their dynamic changes after cardiopulmonary resuscitation: A prospective clinical study

PURPOSE An arterial blood gas analysis (ABG) yields important diagnostic information in the management of cardiac arrest. This study evaluated ABG samples obtained during out-of-hospital cardiopulmonary resuscitation (OHCPR) in the setting of a prospective multicenter trial. We aimed to clarify prospectively the ABG characteristics during OHCPR, potential prognostic parameters and the ABG dynamics after return of spontaneous circulation (ROSC). METHODS ABG samples were collected and instantly processed either under ongoing OHCPR performed according to current advanced life support guidelines or immediately after ROSC and data ware entered into a case report form along with standard CPR parameters. RESULTS During a 22-month observation period, 115 patients had an ABG analysis during OHCPR. In samples obtained under ongoing CPR, an acidosis was present in 98% of all cases, but was mostly of mixed hypercapnic and metabolic origin. Hypocapnia was present in only 6% of cases. There was a trend towards higher paO2 values in patients who reached sustained ROSC, and a multivariate regression analysis revealed age, initial rhythm, time from collapse to CPR initiation and the arterio-alveolar CO2 difference (AaDCO2) to be associated with sustained ROSC. ABG samples drawn immediately after ROSC demonstrated higher paO2 and unaltered pH and base excess levels compared with samples collected during ongoing CPR. CONCLUSIONS Our findings suggest that adequate ventilation and oxygenation deserve more research and clinical attention in the management of cardiac arrest and that oxygen uptake improves within minutes after ROSC. Hyperventilation resulting in arterial hypocapnia is not a major problem during OHCPR.

Arterial line in prehospital emergency settings – A feasibility study in four physician-staffed emergency medical systems ☆

BACKGROUND AND AIM OF THE STUDY Arterial lines are widely used in operating rooms, critical care and emergency departments. Although invasive arterial blood pressure monitoring and arterial blood gas analysis are prehospitally available, the use of arterial lines in the field remains an exception. This study evaluates the feasibility, indications and therapeutic consequences of prehospital arterial line insertion. METHODS Prospective observational study in four physician-staffed emergency medical systems (EMS), documenting patient status, indications, location of puncture, number of tries and time for puncture and therapeutic consequences. RESULTS During the one-year observation period, arterial line placement succeeded in 115 (83.9%) of 137 patients. The median time for successful arterial cannulation was 2 min (IQR 1, 3 min; range: 30-600s), for preparing the invasive blood pressure monitoring 3 min (IQR 2, 4 min, range: 30-600s). Main indications were cardiopulmonary resuscitation (36.5%), post-resuscitation care (16.8%), respiratory insufficiency (24.1%) and unconsciousness (22.6%). Therapeutic consequences depended on whether the EMS was equipped with a blood gas analyzer or not and were, overall, reported in 51.3% of patients: fluids, vasoactive or antihypertensive therapy, correction of ventilation or acidosis. No complications occurred during the prehospital phase. CONCLUSION The insertion of arterial lines is feasible under prehospital conditions, without delaying or complicating patient care. Indications originating from intrahospital use are also valid in the field. In particular when combined with arterial blood gas measurement, the use of arterial lines often leads to important therapeutic consequences.

Tight control of effectiveness of cardiac massage with invasive blood pressure monitoring during cardiopulmonary resuscitation.

The continuity of chest compression is the main challenge in prehospital cardiopulmonary resuscitation in the field as well as during transport. Invasive blood pressure monitoring with visible pulse waves by means of an arterial line set prehospitally allows for tight control of the effectiveness of chest compressions as well as of the impact of the administered epinephrine and also captures beginning fatigue of the rescuers. In this case, maintaining uninterrupted circulation through manual as well as mechanical chest compressions continued until the successful percutaneous coronary intervention saved the patients life without neurologic damage.

Successful prolonged resuscitation involving the use of tenecteplase without neurological sequelae

Prehospital cardiac arrest is associated with a very poor prognosis. We report a case of complete neurological recovery after prolonged resuscitation involving the use of tenecteplase in a patient with undifferentiated cardiac arrest with a return of spontaneous circulation after 1 hour of resuscitation, where basic life support was commenced immediately by a bystanding family member. Factors associated with an increased chance of survival from out-of-hospital cardiac arrest are discussed as well as the role of thrombolytics in cardiopulmonary resuscitation.

Differential lung ventilation and emergency hyperbaric oxygenation for repair of a tracheal tear.

Purpose: To report the anaesthetic management of a case of tracheal rupture, using different types of ventilation and additional hyperbaric oxygenation (HBO).Clinical features: An 8 cm postintubation tracheal tear was repaired in a 66-yr-old woman with acute myocardial reinfarction, mediastinal and subcutaneous emphysema, cardiac failure and unrecognized lymphoma. Intraoperative monitoring included dual oximetry: arterial (SaO2) and mixed venous saturations (SvO2). Maintenance of free surgical access and a series of life-threatening events like dislocation of the jet catheter required many ventilation modes. An episode of supraventricular tachycardia was interrupted by cardioversion. Differential lung ventilation with a combination of conventional and high-frequency jet ventilation (HFJV) modes preserved oxygenation (PO2 139.2 mmHg, PCO2 42.4 mmHg, FiO2 1.0) until acute tube obstruction and decrease of saturation values (SaO2 58%, SvO2 45%) required emergency HBO: immediate cardiac and respiratory stabilization was provided by double-lung HFJV and apneic oxygenation under hyperbaric conditions at 2.5 atmospheres absolute for 35 min (SaO2 100%).The patient recovered from surgery but died of non-Hodgkin lymphoma.Conclusion: The combination of different ventilation modes including HFJV and the additional use of HBO resulted in sufficient oxygenation during tracheal repair.RésuméObjectif: Présenter un cas de rupture trachéale où on a utilisé, pendant l’anesthésie, différents types de ventilation et de l’oxygénation hyperbare (OHB) additionnelle.Éléments cliniques: Une lacération trachéale postintubation de 8 cm a été réparée chez une femme de 66 ans qui présentait une récidive d’infarctus myocardique aigu, un emphysème médiastinal et sous-cutané, une insuffisance cardiaque et un lymphome méconnu. La surveillance peropératoire comprenait une double oxymétrie: du sang artériel (SaO2) et du sang veineux mêlé (SvO2). Le maintien d’un libre accès chirurgical et une série d’événements graves comme le déplacement du cathéter de ventilation en jet ont nécessité l’utilisation de nombreux modes de ventilation. Un épisode de tachycardie supraventriculaire a été interrompu par une cardioversion. Une ventilation pulmonaire différentielle combinée à une ventilation classique et en jet à haute fréquence (VJHF) ont préservé l’oxygénation (PO2 139,2 mmHg, PCO2 42,4 mmHg, FiO2 1,0) jusqu’à ce qu’une obstruction du tube et une baisse de la saturation soudaines (SaO258 %, SvO2 45 %) exigent une OHB d’urgence: une stabilisation cardiaque et respiratoire immédiate ont suivi grâce à la VJHF bilatérale et à l’oxygénation apnéique en conditions hyperbares à 2,5 atmosphères absolues pendant 35 min (SaO2 100 %). La patiente s’est bien remise de l’opération mais est décédée d’un lymphome non hodgkinien.Conclusion: La combinaison de différents modes ventilatoires incluant la VJHF et l’emploi complémentaire d’OHB ont fourni une oxygénation suffisante pendant la réparation trachéale.

The Medizinercorps Graz: A 120-Year-Old Institution of Emergency Medicine

Abstract One year after the establishment of the rescue service of Graz, Austria, in 1889, twelve young medical students were recruited because of the lack of accredited physicians for emergency care, leading to the foundation of the Medizinercorps Graz. This concept of involving medical students in prehospital emergency care has been retained for more than 120 years, and today the Medizinercorps is integrated into the local Red Cross branch, staffing two emergency ambulance vehicles. The responsible medical officer is called Rettungsmediziner and is an advanced medical student with a specialized emergency medical training of more than 3,000 hours, comprising theoretical lectures; in-hospital clerkships in anesthesia, internal medicine, and surgery; manikin training; and hands-on peer-to-peer teaching during assignments. The local emergency medical system provides at least 10 regular basic ambulance vehicles, the two emergency ambulance vehicles, and two emergency physicians on a 24-hours-a-day/seven-days-a-week basis for about 300,000 people. The emergency ambulance vehicles staffed with a Rettungsmediziner respond to all kinds of possibly life-threatening situations and also provide interhospital transfer of intensive care patients. This entirely volunteer-based system enables extremely high-level prehospital emergency care, saves resources and reduces costs, and employs modern training concepts for the continuing advancement of prehospital emergency care.

Subacute Progressive Ascending Myelopathy from L2 to C4 after A Burst Fracture of the Second Lumbar Vertebra

Subacute progressive ascending myelopathy is a rare, poorly understood neurological complication of spinal cord injury, unrelated to mechanical compression, instability, or syrinx formation at the level of injury or above. To date, there is no known treatment for this dramatic spinal cord injury complication. We present a case of subacute progressive myelopathy after lumbar spine trauma. The therapy consisted of plasmapheresis, hyperbaric oxygen, high-dose cortisol, antibiotic, and antiviral drugs. At 1 year post injury, the patient had recovered most of his lost upper-extremity function and MRI demonstrated only discrete signal intensity alterations extending to T3/4.