Klaus Ellinger

Intestinal ischaemia during cardiac arrest and resuscitation: comparative analysis of extracellular metabolites by microdialysis

Intestinal ischaemia is a major complication of shock syndromes causing translocation of bacteria and endotoxins and multiple organ failure in intensive care patients. The present study was designed to use microdialysis as a tool to monitor intestinal ischaemia after cardiac arrest and resuscitation in pigs. For this purpose, microdialysis probes were implanted in pig jejunal wall, peritoneum, skeletal muscle and brain, and interstitial fluid was obtained during circulatory arrest (induced by ventricular fibrillation) and after return of spontaneous circulation (ROSC). Cardiac arrest for 4 min caused a prolonged (60 min) reduction of blood flow in jejunal wall, muscle and brain as determined by the ethanol technique. This was accompanied by cellular damage in heart muscle and brain as indicated by increased levels of troponin-I and protein S-100, respectively. Plasma levels of glucose, lactate and choline were increased at 15-60 min following cardiac arrest. In contrast, cardiac arrest induced a rapid but variable decrease of interstitial glucose levels in all monitored organs; this decrease was followed by an increase over baseline during reperfusion. In the intestine, lactate, glutamate and choline levels were increased during ischaemia and reperfusion for 60-120 min; intestinal and peritoneal samples yielded parallel changes of lactate levels. Brain and muscle samples showed similar changes as in intestinum and peritoneum except for glutamate, which was increased in brain but not in muscle. We conclude that intestinal ischaemia occurs as a consequence of cardiac arrest and resuscitation and can be monitored by in vivo microdialysis. Comparative analysis by multi-site microdialysis reveals that the intestine is equally or even more sensitive to ischaemia than brain or muscle.

Improvement in Stroke Quality Management by an Educational Programme

Time after symptom onset in ischaemic stroke has to be as short as possible to increase success of treatment. We prospectively analysed latencies from symptom onset until the start of therapy and the rate of thrombolysis in 196 patients with suspected stroke sequentially admitted to the hospital before (6 weeks prior, n = 83) and after (n = 113) initiating an educational stroke programme (EP). A total of 345 dispatchers, paramedics, and emergency staff were trained, each person for at least 2 h. The mean pre-hospital time interval from symptom onset until admission was significantly decreased by nearly 2 h (p < 0.05). Thrombolytic therapy frequencies increased from 2 to 10.5% (p < 0.01) because the overall mean time interval from admission to the start of therapy significantly decreased (p < 0.01) by 69 min after the EP, with increasing numbers of patients suitable for acute stroke therapies within a 0- to 3-hour treatment window.

Hypertonic-Hyperoncotic Solutions Reduce the Release of Cardiac Troponin I and S-100 After Successful Cardiopulmonary Resuscitation in Pigs

UNLABELLED In some patients, cardiopulmonary resuscitation (CPR) can revive spontaneous circulation (ROSC). However, neurological outcome often remains poor. Hypertonic-hyperoncotic solutions (HHS) have been shown to improve microvascular conductivity after regional and global ischemia. We investigated the effect of infusion of HHS in a porcine CPR model. Cardiac arrest was induced by ventricular fibrillation. Advanced cardiac life support was begun after 4 min of nonintervention and 1 min of basic life support. Upon ROSC, the animals randomly received 125 mL of either normal saline (placebo, n = 8) or 7.2% NaCl and 10% hydroxyethyl starch 200,000/0.5 (HHS, n = 7). Myocardial and cerebral damage were assessed by serum concentrations of cardiac troponin I and astroglial protein S-100, respectively, up to 240 min after ROSC. In all animals, the levels of cardiac troponin I and S-100 increased after ROSC (P < 0.01). This increase was significantly blunted in animals that received HHS instead of placebo. The use of HHS in the setting of CPR may provide a new option in reducing cell damage in postischemic myocardial and cerebral tissues. IMPLICATIONS Infusion of hypertonic-hyperoncotic solutions (HHS) after successful cardiopulmonary resuscitation in pigs significantly reduced the release of cardiac troponin I and cerebral protein S-100, which are sensitive and specific markers of cell damage. Treatment with HHS may provide a new option to improve the outcome of cardiopulmonary resuscitation.

Reperfusion rate and inhospital mortality of patients with ST segment elevation myocardial infarction diagnosed already in the prehospital phase: Results of the German Prehospital Myocardial Infarction Registry (PREMIR)

AIMS We sought to evaluate the in-hospital fate of patients with ST segment elevation myocardial infarction (STEMI) diagnosed already in the prehospital phase by physican equipped ambulances. METHODS A total of 2326 consecutive STEMI patients were included in PREMIR. For this analysis 218 patients with prehospital cardiopulmonary resuscitation were excluded. RESULTS The median time between symptom onset and 12-lead ECG was 85 min. The median time intervals between the diagnostic 12-lead ECG and prehospital fibrinolysis were 10 min, until inhospital fibrinolysis 52 min and until primar PCI 86min, respectively. Reperfusion therapy with prehospital fibrinolysis (24%), inhospital fibrinolysis (13%) or primary PCI (45%) was performed in 82% of the patients. Inhospital mortality was 6.0% in patients with prehospital fibrinolysis (n = 504), 5.8% in patients with inhospital fibrinolysis (n = 278), 4.5% in patients with primary percutaneous coronary intervention (n = 962) and 16.2% in patients without early reperfusion therapy (n = 377), respectively. In the multivariate propensity score analysis comparing prehospital fibrinolysis and primary PCI we observed no significant difference in the odds for in-hospital mortality (odds ratio: 1.57, 95% CI: 0.94-2.63). The final discharge diagnosis was STEMI in 90% of the patients, in patients with prehospital fibrinolysis 95%. CONCLUSIONS In patients with STEMI already diagnosed in the prehospital phase the ischemic time is short, accuracy of the diagnosis is high and reperfusion therapy is performed in over 82%. Inhospital mortality was not different between prehospital fibrinolysis and primary PCI.

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.

Empfehlung für die notfallmedizinische Absicherung bei Großveranstaltungen

ZusammenfassungGroßveranstaltungen bergen eine Reihe von Risiken, die eine Vielzahl von Verletzten bzw. Erkrankten bis hin zum Massenanfall möglich machen. Die Planung von Großveranstaltungen aus rettungs- bzw. sanitätsdienstlicher Sicht ist dennoch bisher selten geregelt. Die hier vorgestellten Empfehlungen des Landesausschusses für den Rettungsdienst Baden Württemberg bilden in erster Linie ein Konzept, wie die übliche präklinische Versorgung von Besuchern der Großveranstaltung nach den gängigen medizinischen Standards sicherzustellen ist. Aufgrund von Besucherzahlen, der Art der Veranstaltung, den Örtlichkeiten und zusätzlichen Risikofaktoren lässt sich die notwendige Vorhaltung von Rettungsmitteln kalkulieren. Darauf aufbauend kann ein Sachverständiger des Rettungsdienstes (Leitender Notarzt des Bereichsausschusses) ein Gutachten zur notfallmedizinischen Absicherung der Großveranstaltung erstellen. Dieses dient als Grundlage der von den Polizeibehörden an den Veranstalter zu übertragenden Auflagen. Die Kosten der ausreichenden Vorhaltung von Rettungsmitteln sind vom Veranstalter zu tragen. Bei sich wiederholenden Großveranstaltungen wie Fußballspielen oder Messen empfiehlt sich, neben der Kalkulation zur Routineversorgung auch ein Konzept zur Versorgung eines Massenanfalls von Verletzten im Großschadensfall zu erstellen.AbstractMass events carry a number of risks that feasibly could result in numerous injuries or illness, even on a large scale. Nevertheless, plans for large events rarely take aspects of rescue and emergency medical services (EMS) into consideration. The recommendations presented here issued by the Baden-Würtemberg State Commission for Emergency Services represent a concept for ensuring accepted preclinical measures for standard medical management of people attending mass events. The necessary contingency of rescue options can be calculated according to the number of attendees, type of event, locality, and additional risk factors. Based on these data, an adviser of the EMS (medical director) can prepare an expert opinion on how to provide for EMS at the mass event. This serves as the basis for the conditions imposed on the organizer by the police department. The costs for ensuring adequate EMS are to be borne by the organizer. For recurring events such as soccer matches or trade fairs, it is advisable to go beyond routine calculations for ensuring EMS to include a concept for management of mass injuries in disaster situations.

Erhebliche Unterschiede bei der Ausstattung von notarzt-besetzten Rettungsmitteln

ZusammenfassungIm Rettungsdienstgesetz Baden-Württemberg wird eine Ausstattung der Notarzteinsatzfahrzeuge gefordert, die dem Stand der Notfallmedizin entspricht. Anhand von einzelnen Themenkomplexen wird die Umsetzung dieser Forderung ermittelt. Dazu erhielten 127 Notarztstandorte einen Fragebogen zur Ausstattung der eingesetzten arztbesetzten Rettungsmittel sowie zur eventuell geplanten Erweiterung der Ausrüstung zum Stichtag 30.06.2001. 116 Standorte (91,3%) beteiligten sich an der Umfrage. Ein 12-Kanal-EKG halten 52,6% vor, die präklinische Fibrinolyse ist an 15 Standorten (12,9%) möglich. Alternativen zur endotrachealen Intubation werden zu 54,3% mitgeführt (Notkoniotomie: 83,6%). 31 Standorte verfügen über ein Kapnometer oder andere Hilfsmittel zur Überprüfung der korrekten Tubuslage. Ein Mobiltelefon steht an 88 Standorten (75,9%) zur Verfügung. Somit lässt sich bei der Ausstattung arztbesetzter Rettungsmittel im landesweiten Vergleich eine erhebliche Inhomogenität nachweisen.AbstractLaws regulating emergency medical systems in the federal state of Baden-Wuerttemberg call for equipment of physician-staffed ambulances that is based on current knowledge in emergency medicine. Using single issues, the grade of implementation is determined. Therefore, 127 emergency physician bases received a questionnaire regarding the equipment of the physician-staffed ambulances and helicopters, deadline June 30, 2001. 116 stations (91,3%) participated. A 12-lead ECG is available in 52,6%, out-of-hospital fibrinolysis is possible in 15 systems (12,9%). Alternatives to endotracheal intubation are carried in 53,3% (cricothyroidotomy: 83,3%). 31 bases provide capnometry or other devices for verifying correct tube placement. A mobile phone is available in 88 systems (75,9%). In conclusion, comparing equipment of physician-staffed ambulances statewide, striking differences can be found.

Verbesserung der Zusammenarbeit zwischen Notärzten und Kardiologen zur Optimierung der frühen Therapie bei akutem ST-Hebungs-Infarkt

ZusammenfassungBei ST-Hebungs-Infarkt ist das Ziel, die Zeit bis zur Reperfusion zu verringern. Neben verspäteter Alarmierung des Notarztes gibt es auch häufig Zeitverluste, weil die vom Notarzt gestellte Diagnose im Krankenhaus in Zweifel gezogen wird und daher Befunde neu erhoben werden. Vertrauensbildende Maßnahmen wie gemeinsame Workshops von Kardiologen und Notärzten können zu einer besseren Kooperation beitragen. Ein weiteres Problem ist die Finanzierung der prähospitalen Lyse. Diese früh einsetzende Therapie kann die Prognose von Patienten mit akutem ST-Hebungs-Infarkt verbessern. Doch bisher ist die Kostenübernahme dafür nicht geklärt.AbstractIn cases of ST elevation myocardial infarction (MI), the aim is to reduce the time to reperfusion. Together with delay in contacting the emergency doctor, time is also commonly lost because the emergency site diagnosis is often queried in the hospital and a new diagnosis made. Building trust between cardiologists and emergency doctors, such as at common workshops, can lead to better cooperation. Another problem is the financing of prehospital thrombolysis. This early therapy can improve the prognosis for patients with acute ST elevation MI. However, the cost carrier has not yet been clearly determined.

Hypertonic-hyperoncotic solutions decrease cardiac troponin I concentrations in peripheral blood in a porcine ischemia-reperfusion model

In this study we addressed the question of whether the measurement of cardiac Troponin I (cTnI) is able to reflect beneficial effects of hypertonic-hyperoncotic solutions after transient cardiac arrest. Ten pigs were anaesthetized and cardiac arrest was induced by electric fibrillation. After 5 minutes of global ischemia, cardiac arrest was reversed by electric defibrillation. Upon return of spontaneous circulation 5 animals received hypertonic-hyperoncotic solutions (10% Hydroxyethylstarch 200/0.5 and 7.2% NaCl). The other animals received equivalent volumes of physiological saline. We observed that cTnI serum levels of animals treated with hypertonic-hyperoncotic solutions were significantly lower than those treated with saline. We conclude that hypertonic-hyperoncotic solutions may have cardioprotective effects.

Cardiac troponin I and cardiac troponin T increases in pigs during ischemia-reperfusion damage.

In this study we addressed the question of whether the measurement of cardiac Troponin T (cTnT) and cardiac Troponin I (cTnI) is able to detect myocardial cell damage in an ischemia-reperfusion model in pigs. To answer the question 3 pigs were anaesthesized and a cardiac arrest was induced by electric fibrillation. After 5 minutes of global ischemia the cardiac arrest was reversed by electric defibrillation until normal perfusion was restored. We could clearly demonstrate an increase of cTnT and cTnI 30 minutes after reperfusion indicating myocardial injury during ischemia and subsequent reperfusion. The cTnT as well as the cTnI serum levels increased till 180 minutes after reperfusion. This ischemia-reperfusion injury is likely induced by oxygen radicals generated during hypoxia and subsequent reperfusion We conclude from our first results that troponin measurements with commercial available test kits may also reflect myocardial cell damage in pigs as it was recently demonstrated in rats. Further studies are needed for correlation of troponin serum levels and histopathological damage in this model especially if it is used to test beneficial or toxicological effects of radical neutralizing drugs.