European Resuscitation Council Guidelines for Resuscitation 2005

The use of mice and rats as animal models for cardiopulmonary resuscitation research

Cardiopulmonary resuscitation (CPR) after the induction of cardiac arrest (CA) has been studied in mice and rats. The anatomical and physiological parameters of the cardiopulmonary system of these two species have been defined during experimental studies and are comparable with those of humans. Moreover, these animal models are more ethical to establish and are easier to manipulate, when compared with larger experimental animals. Accordingly, the effects of successful CPR on the function of vital organs, such as the brain, have been investigated because damage to these vital organs is of concern in CA survivors. Furthermore, the efficacy of several drugs, such as adrenaline (epinephrine), vasopressin and nitroglycerin, has been evaluated for use in CA in these small animal models. The purpose of these studies is not only to increase the rate of survival of CA victims, but also to improve their quality of life by reducing damage to their vital organs after CA and during CPR.

Postpartum Severe Sinus Bradycardia following Methylergonovine Administration

The case is reported of a 30-year-old multigravida, with insignificant history and stable vital signs, admitted to the labour room for normal vaginal delivery of twins. She received combined spinal epidural analgesia (bupivacaine plus fentanyl) for 3 h. Following uneventful delivery she received 0.2 mg methylergonovine maleate, intramuscularly. Nausea and vomiting occurred 70 min after placenta delivery, heart rate decreased, arterial blood pressure increased and there was chest pain. After excluding cardiac ischaemia, 0.5 mg atropine sulphate was administered intravenously. Chest pain improved but heart rate and blood pressure increased more than expected. The patient had mild headache and nausea, and antiemetic 4 mg ondansetron was given intravenously. Continuous monitoring for 4 h showed spontaneous chest pain relief and blood pressure improvement. In conclusion, serious delayed side-effects arising from methylergonovine maleate can occur in young, normal patients and close monitoring is required. Intravenous atropine sulphate following methylergonovine maleate administration may lead to severe hypertension and tachycardia.

[Teaching emergency medicine at the University Medical Center Freiburg: establishment of an integrative concept]

Efforts to improve the quality of undergraduate medical education are commonly hampered by limited human and financial resources. This deficiency may be offset by the development of well structured and innovative teaching concepts, which optimize available assets. The newly conceived modular course "Emergency Medicine" at the University Medical Center Freiburg was conducted for the first time in the winter semester 2006/2007. The core of the course is a 3-day practical training period. It provides the possibility to teach a maximum number of medical students with only four lecturers using patient simulators, interactive case scenarios (simulation software MicroSim), and case scenarios with standardized patients. Evaluation of the course revealed standardized patients to be the best of all teaching methods with an overall average grade of 1.1 (patient simulators 1.2, computer simulation 1.4). Of the students, 88% stated that the practical training encouraged their interest in the speciality emergency medicine. The excellent student evaluation results show that the new course "Emergency Medicine" for medical students constitutes a successful balance between the constraint of resource limitation and the goal of excellent medical education.

The early minutes of in-hospital cardiac arrest: shock or CPR? A population based prospective study

Objectives

In the early minutes of cardiac arrest, timing of defibrillation and cardiopulmonary resuscitation during the basic life support phase (BLS CPR) is debated. Aims of this study were to provide in-hospital incidence and outcome data, and to investigate the relation between outcome and time from collapse to defibrillation, time to BLS CPR, and CPR quality.

Methods

Resuscitation attempts during a 3-year period at St. Olav's University Hospital (960 beds) were prospectively registered. The times between collapse and initiation of BLS CPR, and defibrillation were determined. CPR quality was assessed by the resuscitation team. The relation between these variables and outcome (short term survival and discharge) was explored using non-parametric correlation and logistic regression.

Results

CPR was started in a total of 223 arrests, an incidence of 77 episodes per 1000 beds per year. Return of spontaneous circulation occurred in 40%, and 29 patients (13%) survived to discharge. Median time from collapse to BLS CPR was 1 minute; CPR was judged to be of good quality in half of the episodes. CPR during the first 3 minutes in ventricular fibrillation (VF/VT) was negatively associated with survival, but later proved beneficial. For patients with non-shockable rhythms, we found no association between outcome and time to BLS or CPR quality.

Conclusion

Our findings indicate that defibrillation should have priority during the first 3 minutes of VF/VT. Later, patients benefit from CPR in conjunction with defibrillation. Patients presenting with non-shockable rhythms have a grave prognosis, and the outcome was not associated with time to BLS or CPR quality.

Prognostication after out-of-hospital cardiac arrest, a clinical survey

Background

Numerous parameters and tests have been proposed for outcome prediction in comatose out-of-hospital cardiac arrest survivors. We conducted a survey of clinical practice of prognostication after therapeutic hypothermia (TH) became common practice in Norway.

Methods

By telephone, we interviewed the consultants who were in charge of the 25 ICUs admitting cardiac patients using 6 structured questions regarding timing, tests used and medical specialties involved in prognostication, as well as the clinical importance of the different parameters used and the application of TH in these patients.

Results

Prognostication was conducted within 24–48 hours in the majority (72%) of the participating ICUs.

The most commonly applied parameters and tests were a clinical neurological examination (100%), prehospital data (76%), CCT (56%) and EEG (52%). The parameters and tests considered to be of greatest importance for accurate prognostication were prehospital data (56%), neurological examination (52%), and EEG (20%).

In 76% of the ICUs, a multidisciplinary approach to prognostication was applied, but only one ICU used a standardised protocol. Therapeutic hypothermia was in routine use in 80% of the surveyed ICUs.

Conclusion

Despite the routine use of TH, outcome prediction was performed early and was mainly based on prehospital information, neurological examination and CCT and EEG evaluation. Somatosensory evoked potentials appear to be underused and underrated, while the importance of prehospital data, CCT and EEG to appear to be overrated as methods for making accurate predictions.

More evidence-based protocols for prognostication in cardiac arrest survivors, as well as additional studies on the effect of TH on known prognostic parameters are needed.

Out-of-hospital airway management with the LMA CTrach--a prospective evaluation

AIM OF THE STUDY

Airway management in an out-of-hospital setting is a critical and demanding skill. Previous studies evaluated the intubating laryngeal mask airway (ILMA) as a valuable tool in this area. The LMA CTrach Laryngeal Mask Airway (CTrach) may increase intubation success. Therefore, we evaluated the CTrach as the primary tool for airway management in the out-of-hospital setting in adult patients.

METHODS

From October 2006 until September 2007 EAN and SGR included all patients who needed advanced airway management during out-of-hospital emergency medicine service. Ventilation and intubation has been performed via the CTrach as the primary choice. Before intubation, visualization of the vocal cords was optimized under continuous ventilation via the CTrach. The time needed, manoeuvres to optimize vision, grades of vision and success rates have been documented.

RESULTS

16 patients have been included. Ventilation and intubation via the CTrach was possible in all patients. Ventilation was mostly established in less than 15s and was established in 15 of 16 (94%) patients at the first attempt. Intubation was successful in 15 of 16 (94%) patients on the first attempt. Visualization of the laryngeal structures was achieved in 69% of patients, while intubation without sight was performed in 31%, respectively.

CONCLUSION

In this study, ventilation and intubation via the CTrach was successful and could be rapidly established in all patients. Our data suggest that the use of the CTrach may be suitable for the out-of-hospital setting as it provides ventilation and facilitates intubation with a very high success rate.

Pre-hospital airway management: guidelines from a task force from the Scandinavian Society for Anaesthesiology and Intensive Care Medicine

This article is intended as a generic guide to evidence-based airway management for all categories of pre-hospital personnel. It is based on a review of relevant literature but the majority of the studies have not been performed under realistic, pre-hospital conditions and the recommendations are therefore based on a low level of evidence (D). The advice given depends on the qualifications of the personnel available in a given emergency medical service (EMS). Anaesthetic training and routine in anaesthesia and neuromuscular blockade is necessary for the use of most techniques in the treatment of patients with airway reflexes. For anaesthesiologists, the Task Force commissioned by the Scandinavian Society of Anaesthesia and Intensive Care Medicine recommends endotracheal intubation (ETI) following rapid sequence induction when securing the pre-hospital airway, although repeated unsuccessful intubation attempts should be avoided independent of formal qualifications. Other physicians, as well as paramedics and other EMS personnel, are recommended the lateral trauma recovery position as a basic intervention combined with assisted mask-ventilation in trauma patients. When performing advanced cardiopulmonary resuscitation, we recommend that non-anaesthesiologists primarily use a supraglottic airway device. A supraglottic device such as the laryngeal tube or the intubation laryngeal mask should also be available as a backup device for anaesthesiologists in failed ETI.

Pre-hospital advanced airway management by anaesthesiologists: is there still room for improvement?

Background

Endotracheal intubation is an important part of pre-hospital advanced life support that requires training and experience, and should only be performed by specially trained personnel. In Norway, anaesthesiologists serve as Helicopter Emergency Medical Service HEMS physicians. However, little is known about how they themselves evaluate the quality and safety of pre-hospital advanced airway management.

Method

Using a semi-structured questionnaire, we interviewed anaesthesiologists working in the three HEMS programs covering Western Norway. We compared answers from specialists and non-specialists as well as full- and part-time HEMS physicians.

Results

Of the 17 available respondents, most (88%) felt that their continuous exposure to intubations was not sufficient. Additional training was mainly acquired through other clinical practice and mannequin- or cadaver-based skills training. Of the respondents, 77% and 35% reported having experienced difficult and failed intubations, respectively. Further, 59% reported knowledge of airway management-related deaths in their HEMS program. Significantly more full- than part-time HEMS physicians had experienced these problems. All respondents had airway back-up equipment in their service, but 29% were not familiar with all the equipment.

Conclusion

The majority of anaesthesiologists working as HEMS physicians view pre-hospital advanced airway management as a high-risk procedure. Relevant airway management competencies for HEMS physicians in Norway seem to be insufficiently trained and maintained. A better-defined level of competence with better training methods and systems seems warranted.

A manikin-based observational study on cardiopulmonary resuscitation skills at the Osaka Senri medical rally

AIM

To examine the current status and problems of resuscitation management in Japan as demonstrated at the 2006 and 2007 Osaka Senri medical rallies.

METHODS

Using manikins, the quality of resuscitation was evaluated in 33 teams that participated in the medical rallies. The challenge was to deliver defibrillation shocks for ventricular fibrillation; data were recorded using the Laerdal PC Skill Reporting System (Norway). The teams were first subjectively (visually) evaluated by a panel of judges and these evaluations were later reaffirmed using video records.

RESULTS

An approximately 30s delay was observed between the time of contact and initiation of chest compression in the teams that adopted the American Heart Association (AHA) method compared with those that adopted the European Resuscitation Council (ERC) method. Although the overall quality of chest compressions was very good, in several instances, the hand positions were inappropriate and complete chest recoil was not achieved. The left paddle was incorrectly positioned by all teams. Only 15.8% of the teams were able to deliver shocks with less than 10s of interruption between the chest compressions. Regarding interruption of chest compressions at confirmation of correct tracheal tube placement, among the eight teams that adopted the AHA method, pauses of more than 10s were confirmed in five (62.5%).

CONCLUSIONS

Significant differences in performance between the AHA and ERC methods were observed. The ERC guidelines were more rational and suitable in terms of actual application than the AHA guidelines.

Induced hypothermia and fever control for prevention and treatment of neurological injuries

Increasing evidence suggests that induction of mild hypothermia (32-35 degrees C) in the first hours after an ischaemic event can prevent or mitigate permanent injuries. This effect has been shown most clearly for postanoxic brain injury, but could also apply to other organs such as the heart and kidneys. Hypothermia has also been used as a treatment for traumatic brain injury, stroke, hepatic encephalopathy, myocardial infarction, and other indications. Hypothermia is a highly promising treatment in neurocritical care; thus, physicians caring for patients with neurological injuries, both in and outside the intensive care unit, are likely to be confronted with questions about temperature management more frequently. This Review discusses the available evidence for use of controlled hypothermia, and also deals with fever control. Besides discussing the evidence, the aim is to provide information to help guide treatments more effectively with regard to timing, depth, duration, and effective management of side-effects. In particular, the rate of rewarming seems to be an important factor in establishing successful use of hypothermia in the treatment of neurological injuries.

Paramedic versus emergency physician emergency medical service: role of the anaesthesiologist and the European versus the Anglo-American concept

PURPOSE OF REVIEW

Much controversy exists about who can provide the best medical care for critically ill patients in the prehospital setting. The Anglo-American concept is on the whole to provide well trained paramedics to fulfil this task, whereas in some European countries emergency medical service physicians, particularly anaesthesiologists, are responsible for the safety of these patients.

RECENT FINDINGS

Currently there are no convincing level I studies showing that an emergency physician-based emergency medical service leads to a decrease in overall mortality or morbidity of prehospital treated patients, but many methodical, legal and ethical issues make such studies difficult. Looking at specific aspects of prehospital care, differences in short-term survival and outcome have been reported when patients require cardiopulmonary resuscitation, advanced airway management or other invasive procedures, well directed fluid management and pharmacotherapy as well as fast diagnostic-based decisions.

SUMMARY

Evidence suggests that some critically ill patients benefit from the care provided by an emergency physician-based emergency medical service, but further studies are needed to identify the characteristics and early recognition of these patients.

Reversal of central nervous system and cardiac toxicity after local anesthetic intoxication by lipid emulsion injection

A 91-yr-old man (57 kg, 156 cm, ASA III) received an infraclavicular brachial plexus block for surgery of bursitis of the olecranon. Twenty minutes after infraclavicular injection of 30 mL of mepivacaine 1% (Scandicain) and 5 min after supplementation of 10 mL of prilocaine 1% (Xylonest) using an axillary approach, the patient complained of agitation and dizziness and became unresponsive to verbal commands. In addition, supraventricular extrasystole with bigeminy occurred. Local anesthetic toxicity was suspected and a dose of 200 mL of a 20% lipid emulsion was infused. Symptoms of central nervous system and cardiac toxicity disappeared within 5 and 15 min after the first lipid injection, respectively. Plasma concentrations of local anesthetics were determined before, 20, and 40 min after lipid infusion and were 4.08, 2.30, and 1.73 microg/mL for mepivacaine and 0.92, 0.35, and 0.24 microg/mL for prilocaine. These concentrations are below previously reported thresholds of toxicity above 5 microg/mL for both local anesthetics. Signs of toxicity resolved and the patient underwent the scheduled surgical procedure uneventfully under brachial plexus blockade.

Care of the intubated patient in the PACU: the 'ABCDE' approach

This paper discusses airway management in the post anaesthetic care unit (PACU). Many patients will be extubated on arrival to the PACU, however a small number will need further support with tracheal intubation. Patient assessment is a key role for the PACU staff and using the ABCDE approach will provide a systematic method for assessing the patient and determining suitability for extubation. Care of the patient following extubation is also described.

Emergency intubation for acutely ill and injured patients

BACKGROUND

Emergency intubation has been widely advocated as a life saving procedure in severe acute illness and injury associated with real or potential compromises to the patient's airway and ventilation. However, some initial data have suggested a lack of observed benefit.

OBJECTIVES

To determine in acutely ill and injured patients who have real or anticipated problems in maintaining an adequate airway whether emergency endotracheal intubation, as opposed to other airway management techniques, improves the outcome in terms of survival, degree of disability at discharge or length of stay and complications occurring in hospital.

SEARCH STRATEGY

We searched the Cochrane Injuries Group Specialised Register (December 2006), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4), MEDLINE (1950 to November 2006), EMBASE (1980 to week 50, December 2006), National Research Register (Issue 4, 2006), CINAHL (1980 to December 2006), BIDS (to December 2006) and ICNARC (to December 2006). We also examined reference lists of articles for relevant material and contacted experts in the field. Non-English language publications were searched for and examined.

SELECTION CRITERIA

All randomised (RCTs) or controlled clinical trials involving the emergency use of endotracheal intubation in the injured or acutely ill patient were examined.

DATA COLLECTION AND ANALYSIS

The full texts of 452 studies were reviewed independently by two authors using a standard form. Where the review authors felt a study may be relevant for inclusion in the final review or disagreed, the authors examined the study and a collective decision was made regarding its inclusion or exclusion from the review. The results were not combined in a meta-analysis due to the heterogeneity of patients, practitioners and alternatives to intubation that were used.

MAIN RESULTS

We identified three eligible RCTs carried out in urban environments. Two trials involved adults with non-traumatic out-of-hospital cardiac arrest. One of these trials found a non-significant survival disadvantage in patients randomised to receive a physician-operated intubation versus a combi-tube (RR 0.44, 95% CI 0.09 to 1.99). The second trial detected a non-significant survival disadvantage in patients randomised to paramedic intubation versus an oesophageal gastric airway (RR 0.86, 95% CI 0.39 to 1.90). The third included study was a trial of children requiring airway intervention in the prehospital environment. The results indicated no difference in survival (OR 0.82, 95% CI 0.61 to 1.11) or neurologic outcome (OR 0.87, 95% CI 0.62 to 1.22) between paramedic intubation versus bag-valve-mask ventilation and later hospital intubation by emergency physicians; however, only 42% of the children randomised to paramedic endotracheal intubation actually received it.

AUTHORS' CONCLUSIONS

The efficacy of emergency intubation as currently practised has not been rigorously studied. The skill level of the operator may be key in determining efficacy. In non-traumatic cardiac arrest, it is unlikely that intubation carries the same life saving benefit as early defibrillation and bystander cardiopulmonary resuscitation (CPR). In trauma and paediatric patients, the current evidence base provides no imperative to extend the practice of prehospital intubation in urban systems. It would be ethical and pertinent to initiate a large, high quality randomised trial comparing the efficacy of competently practised emergency intubation with basic bag-valve-mask manoeuvres (BVM) in urban adult out-of-hospital non-traumatic cardiac arrest.