Wolfgang Dick

Comparison of Standard Cardiopulmonary Resuscitation Versus the Combination of Active Compression-Decompression Cardiopulmonary Resuscitation and an Inspiratory Impedance Threshold Device for Out-of-Hospital Cardiac Arrest

Background—Active compression-decompression (ACD) CPR combined with an inspiratory impedance threshold device (ITD) improves vital organ blood flow during cardiac arrest. This study compared survival rates with ACD+ITD CPR versus standard manual CPR (S-CPR). Methods and Results—A prospective, controlled trial was performed in Mainz, Germany, in which a 2-tiered emergency response included early defibrillation. Patients with out-of-hospital arrest of presumed cardiac pathogenesis were sequentially randomized to ACD+ITD CPR or S-CPR by the advanced life support team after intubation. Rescuers learned which method of CPR to use at the start of each work shift. The primary end point was 1-hour survival after a witnessed arrest. With ACD+ITD CPR (n=103), return of spontaneous circulation and 1- and 24-hour survival rates were 55%, 51%, and 37% versus 37%, 32%, and 22% with S-CPR (n=107) (P =0.016, 0.006, and 0.033, respectively). One- and 24-hour survival rates in witnessed arrests were 55% and 41% with ACD+ITD CPR versus 33% and 23% in control subjects (P =0.011 and 0.019), respectively. One- and 24-hour survival rates in patients with a witnessed arrest in ventricular fibrillation were 68% and 58% after ACD+ITD CPR versus 27% and 23% after S-CPR (P =0.002 and 0.009), respectively. Patients randomized ≥10 minutes after the call for help to the ACD+ITD CPR had a 3 times higher 1-hour survival rate than control subjects (P =0.002). Hospital discharge rates were 18% after ACD+ITD CPR versus 13% in control subjects (P =0.41). In witnessed arrests, overall neurological function trended higher with ACD+ITD CPR versus control subjects (P =0.07). Conclusions—Compared with S-CPR, ACD+ITD CPR significantly improved short-term survival rates for patients with out-of-hospital cardiac arrest. Additional studies are needed to evaluate potential long-term benefits of ACD+ITD CPR.

Guidelines for the basic management of the airway and ventilation during resuscitation

Writing Subcommittee: P.J.F. Baskett ** (UK), L. Bossaert (Belgium), P. Carli (France), D. Chamberlain (UK), W. Dick (Germany), J.P. Nolan (UK), M.J.A. Parr (UK), D. Scheidegger (Switzerland), D. Zideman (UK) With contributions from: W. Blancke (Belgium), H. Delooz (Belgium), A. Handley (UK), D. Kettler (Germany), W. Kloeck (South Africa), E. Kramer (South Africa), L. Quan (USA), W. Studer (Switzerland), A. Van Drenth (The Netherlands)

Utstein-style guidelines for uniform reporting of laboratory CPR research

Both laboratory and clinical investigators contribute to the multidisciplinary knowledge base of resuscitation science. While diversity can be a strength, it can also be a hindrance because of the lack of a common language and poor communication among investigators. Modern cardiopulmonary resuscitation (CPR) research depends on the use of animal models that are designed to simulate cardiac arrest in humans [1,2]. Such models are used to explore important new treatments and to refine protocols used in standard interventions, including doses of drugs, chest compression techniques, defibrillation energies, and cerebral resuscitation, before they are applied to humans [3]. When favorable results are reported in animal models, the new or refined techniques are often implemented soon afterward in human victims of cardiac arrest. Unfortunately, the results obtained in one laboratory may not be reproducible in another laboratory or in human trials. For example, highdose epinephrine therapy significantly improves survival in most animal models of cardiac arrest but does not improve survival in humans [4–7]. In addition, some animal studies have documented the efficacy of administering bicarbonate during cardiac arrest, while others have shown it to be ineffective or deleterious [8]. Some of these differences are to be expected because an animal simulation is not a perfect model of cardiac arrest in humans. However, it is likely that some of these conflicting results are due to differences in experimental methods and laboratory model design. Variations in study design, such as the quality of chest compressions and ventilation, definitions of variables, or time intervals between an event and the beginning of therapy, are probably responsible for many of the inconsistencies and contradictions reported. The lack of standardization and the use of nonuniform terminology in reports of studies of cardiac arrest in humans have been described as a ‘Tower of Babel’ [9]. To address these problems, par‘Utstein-Style Guidelines for Uniform Reporting of Laboratory CPR Research’ was approved by the American Heart Association Science Advisory and Coordinating Committee on June 20, 1996. This statement is also being published in Circulation and Annals of Emergency Medicine. Single requests for reprints are free: should be sent to the American Heart Association, Public Information, 7272 Greenville Avenue, Dallas, TX 75231-4596. Fax to Public Information, 214 369 3685.© 1996 American Heart Association, Inc.

Controversies in resuscitation: to infuse or not to infuse (1)

In an influential article on immediate (on site) versus delayed (in hospital) fluid resuscitation for hypotensive patients with penetrating torso injury, Bickell and his colleagues [1] from Houston suggested that the latter strategy was usually optimal and that ‘aggressive’ infusion should be delayed until the time of definitive operative intervention. This view was based on the results of observations that were prospective and randomised. Although at variance with recent conventional wisdom [2] they were not open to the principal criticisms of Jones and Brenneis [3] who, in 1991, reviewed critically the nine relevant studies available at that time. A plea was made for prospective randomised trials involving standard&d or widely accepted levels of service for victims with well documented blunt, penetrating, and thermal injuries of at least moderate severity. Many observations based on retrospective studies with variable case mix comprising patients with penetrating injury, blunt injury, and even brain trauma, had drawn conclusions of limited validity. General guidance can be drawn only from an analysis of studies that are better focused. The study of Bickell et al. warrants careful consideration. Bickell and colleagues [1] hypothesise that a major disadvantage of on-site aggressive fluid replacement is accentuated bleeding and haemodilution. But in the pre-hospital phase this is very difficult to measure. Another objection to immediate infusion relates to the time wasted in line placement, especially by paramedics [4,5]. This criticism has substance, although the delays quoted in published data have been very variable. Cwinn and others [6] reported that the time for insertion of one or two venous lines was approximately 14 min, but with an overall success rate of 94%. Donovan et al. [7] found the time for line placement was approximately 20 min, increasing onscene time by 6 or 7 min. There was no evidence of any benefit to the patients from this intervention. On the other hand, Spaite and colleagues [8] reported that the average times for positioning onscene intravenous lines were 1.3 min for successful attempts and 2.1 min for unsuccessful ones. Even during transport, only 2 min were required, and overall the success rate was 98%. Another paper from the same centre [9] concluded that, in an urban Emergency Medical System with strong medical control, short on-scene times can be achieved without adversely affecting subsequent advanced life support. Jones et al. [IO] reported that intravenous line placement could be achieved by over 90% of paramedics in approximately 2.5 min. Similarly, Gervin [ 1 I] investigated the use of large bore intravenous cannulae in trauma patients and found that 83% were successfully introduced by paramedics in a mean time of 50 s. As a result of infusions averaging 4.2 litres of crystalloid over an 18&n transport time, mean blood pressure increased from 70 to 96 mmHg. The clinical need for pre-hospital infusion, as well as its logistics, has also been contentious. Scalea [ 121 conducted a study using retrospective

Johann Friedrich August von Esmarch--a pioneer in the field of emergency and disaster medicine.

Esmarch was born on 9 January 1823 in northern Germany, into a family of physicians, judges and lawyers with a long academic tradition. His father was a highly respected surgeon, who encouraged his gifted son to follow in his footsteps. von Esmarch began his medical studies at the University of Kiel in 1843, to graduate only 3 years later from the University of Gottingen. His career advanced at a rapid pace and he received an appointment as professor and chairman of the department of surgery at the University of Kiel. In 1867 von Esmarch married, an aunt of Emperor Wilhelm II, who raised him to the rank of a peer in 1887 in recognition of his outstanding achievements in the field of medicine. von Esmarch founded the German Society of Surgeons and was named president in 1894. On 23 October 1908 he died from the effects of an influenza infection. In the early 19th century the focus of surgical interventions was primarily on the body surface and the extremities. From the beginning of his medical career von Esmarch showed a passionate interest in trauma care, placing the emphasis on reconstructive surgery instead of the conventional practice of limb amputation in battle victims. The political climate of the time favoured decisions made on the battlefield over diplomatic solutions and his work as a surgeon in the campaigns against Denmark, led by Bismarck in 1848 and 1864, provided him with ample experience in the treatment of war injuries. In contrast to the rapid progress in war technologies with all their horrible consequences, improvements in the military medical service sadly lagged behind and the soldiers received inadequate treatment under unacceptable conditions which had remained unchanged over the preceding centuries. Common consequences of surgical interventions were wound infections, frequently leading to the death of a patient due to massive septic shock. In the 1850s the causes of wound infections were still largely unknown by the practising physicians. von Esmarch’s observation that the cooling of wounds resulted in a reduction in local inflammation and pus-formation and thus to an improvement in the patient’s outcome led him to introduce cryotherapy into clinical practice. In 1862 he published his findings, introducing his new therapeutic

European comprehensive training course on prehospital advanced trauma life support in adults.

Training in prehospital advanced trauma life support is carried out by various specialties and various organizations. The classical course was outlined many years ago by the American College of Surgeons. This course has been distributed and sold by the College throughout Europe and in other parts of the world. It should, however, be mentioned that this course has never concentrated on prehospital trauma life support and is, at least in part, outdated (e.g. airway management, cut downs, etc.) Some feel that a 1-day course is sufficient and that emergency physicians should teach trainee physicians rather than trauma surgeons. With respect to basic and advanced prehospital trauma life support, a separate course based on paramedic care only has been developed jointly with the American College of Surgeons. However, in various countries, particularly European ones, prehospital trauma life support is carried out by specialized physicians, including anaesthesiologists, trauma surgeons, etc., together with paramedics, emergency medical technicians or nurses.

Einfache lebensrettende Sofortmaßnahmen beim Erwachsenen

ZusammenfassungIm folgenden wird der Aktionsplan dargestellt, der den Richtlinien des European Resuscitation Council für „Einfache lebensrettende Sofortmaßnahmen beim Erwachsenen” zugrunde liegt (Algorithmus 1: „Einfache lebensrettende Sofortmaßnahmen beim Erwachsenen”). Der Aktionsplan ist primär für die „Einmann-Reanimation” beim Erwachsenen gedacht. Im Text wird die männliche Form auch für die weibliche verwendet.We present the plan of action on which the Guidelines of the European Resuscitation Council for ”Adult Basic Life Support” is based (algorithm: ”Basic Life-Support Measures for Adults). The plan of action is primarily intended for ”one-person reanimation” procedures in adults.

Erweiterte lebensrettende Sofortmaßnahmen beim Erwachsenen

Die Publikation der Leitlinien für erweiterte lebensrettende Sofortmaßnahmen durch das European Resuscitation Council (ERC) 1992 war ein Meilenstein internationaler Kooperation und Koordination [1]. Davor hatten zwar einzelne Länder oder Gruppen Leitlinien produziert [2, 3], zum ersten Mal aber erreichte eine internationale Expertengruppe einen Konsensus auf der Basis der besten seinerzeit verfügbaren wissenschaftlichen Informationen. Seit 1992 hat sich eine noch bessere internationale Zusammenarbeit und gegenseitige Unterstützung entwickelt. Insbesondere die Etablierung des International Liaison Committee on Resuscitaton (ILCOR) hat die weltweite Kooperation und Diskussion zwischen Repräsentanten aus Nordamerika, Europa, dem südlichen Afrika, Australien und neuerdings Südamerika erleichtert.Im Jahre 1992 ließen die Leitlinien schon erkennen, daß in regelmäßigen Abständen eine Überarbeitung nötig sein würde. Dabei werden Veränderungen nicht um ihrer selbst Willen befürwortet und auch nicht ohne überzeugende wissenschaftliche und edukatorische Notwendigkeit. Ausbildung und Ausbildungsorganisation sind Prozesse mit langer Latenz; es kann für Lehrende und Lernende verwirrend sein, wenn der Lehrinhalt inkonsistent ist.Aus: Resuscitation 37 (1998): 81-90