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In the past decades, zoos have increasingly developed into conservation and education centers and today make an important contribution to environmental education. In this context, this study invest...

BackgroundOver the past years, several emergency medical service providers have introduced mechanical chest compression devices (MCDs) in their protocols for cardiopulmonary resuscitation (CPR). Especially in helicopter emergency medical systems (HEMS), which have limitations regarding loading weight and space and typically operate in rural and remote areas, whether MCDs have benefits for patients is still unknown. The aim of this study was to evaluate the use of MCDs in a large Swiss HEMS system.Materials and methodsWe conducted a retrospective observational study of all HEMS missions of Swiss Air rescue Rega between January 2014 and June 2016 with the use of an MCD (Autopulse®). Details of MCD use and patient outcome are reported from the medical operation journals and the hospitals’ discharge letters.ResultsMCDs were used in 626 HEMS missions, and 590 patients (94%) could be included. 478 (81%) were primary missions and 112 (19%) were interhospital transfers. Forty-nine of the patients in primary missions were loaded under ongoing CPR with MCDs. Of the patients loaded after return of spontaneous circulation (ROSC), 20 (7%) experienced a second CA during the flight. In interhospital transfers, 102 (91%) only needed standby use of the MCD. Five (5%) patients were loaded into the helicopter with ongoing CPR. Five (5%) patients went into CA during flight and the MCD had to be activated. A shockable cardiac arrhythmia was the only factor significantly associated with better survival in resuscitation missions using MCD (OR 0.176, 95% confidence interval 0.084 to 0.372,p ConclusionWe conclude that equipping HEMS with MCDs may be beneficial, with non-trauma patients potentially benefitting more than trauma patients.

Background: Airway management is a key skill in any helicopter emergency medical service (HEMS). Successful intubation is less often than in the hospital, and alternative forms of airway management are needed more often. Methods: Retrospective observational cohort study in an anaesthesiologist-staffed HEMS in Switzerland. Patients charts from all scene calls (n=9035) that took place between June 2016 and May 2017 (12 months) were analysed. The primary outcome parameter was intubation success rate. Secondary parameters included number of patients intubated by ground-based emergency medical services, alternative devices used, and comparison of patients with and without difficulties in airway management. Results: A total of 676 patients with invasive ventilatory support were identified. Difficulties in airway management were rare, occurring in 44 (6.5%) patients, and trauma was significantly more common (59.1% vs. 38.6%, pConclusion: Despite overall high success rates for endotracheal intubation in the physician-staffed service, each physician gets little real-life experience with advanced airway management in the field, highlighting the importance of a solid basic competence such as anaesthesiology and additional training. Direct laryngoscopy is still a valuable skill and an important Plan B in difficult airway situations in which factors such as fogging, blood, bright radiation on the video laryngoscopes screen, impaired the success of video laryngoscopes intubation.

Objective We aimed to investigate the medical characteristics of helicopter hoist operations (HHO) in HEMS missions. Methods We designed a retrospective study evaluating all HHO and other human external cargo (HEC) missions performed by Swiss Air-Rescue (Rega) between January 1, 2010, and December 31, 2019. Results During the study period, 9,963 (88.7 %) HEMS missions with HHO and HEC were conducted during the day, and 1,265 (11.3 %) at night. Of the victims with time-critical injuries (NACA ≥ 4), 21.1 % (n = 400) reached the hospital within 60 min during the day, and 9.1 % (n = 18) at night. Nighttime missions, a trauma diagnosis, intubation on-site, and NACA Score ≥ 4 were independently and highly significantly associated with longer mission times (p n = 3,731, 37.5 %) while practicing recreational activities (n = 5,492, 55.1 %). In daytime HHO missions, the most common medical interventions performed were insertion of a peripheral intravenous access (n = 3,857, 38.7 %) and administration of analgesia (n = 3,121, 31.3 %). Conclusions Nearly 20 % of patients who needed to be evacuated by a hoist were severely injured, and complex and lifesaving medical interventions were necessary before the HHO procedure. Therefore, only adequately trained and experienced medical crew members should accompany HHO missions.

ObjectiveWe aimed to investigate the medical characteristics of helicopter hoist operations (HHO) in HEMS missions.MethodsWe designed a retrospective study evaluating all HHO and other human external cargo (HEC) missions performed by Swiss Air-Rescue (Rega) from 1 January 2010 to 31 December 2019.ResultsDuring the study period, 9,963 (88.7%) HEMS missions with HHO and HEC were conducted during the day, and 1,265 (11.3%) at night. Of the victims with time-critical injuries (NACA ≥4), 21.1% (n=400) reached the hospital within 60 min during the day, and 9.1% (n=18) at night. Nighttime missions, a trauma diagnosis, intubation on-site, and NACA Score ≥4were independently and highly significantly associated with longer mission times (p

Background: Simultaneous ventilation of two patients, e.g., due to a shortage of ventilators in a pandemic, may result in hypoventilation in one patient and hyperinflation in the other patient. Methods: In a simulation of double patient ventilation using artificial lungs with equal compliances (70mL∙mbar-1), we tried to voluntarily direct gas flow to one patient by using 3D-printed y-adapters and stenosis adapters during volume-, and pressure-controlled ventilation. Subsequently, we modified the model using a special one-way valve on the limited flow side and measured in pressure-controlled ventilation with the flow sensor adjusted on either side in a second and third setup. In the last setup, we also measured with different lung compliances.Results: Volume- or pressure-controlled ventilation using standard connection tubes with the same compliance in each lung resulted in comparable minute volumes in both lungs, even if one side was obstructed to 3mm (6.6±0.2vs.6.5±0.1L for volume-controlled ventilation, p=.25 continuous severe alarm and 7.4±0.1vs.6.1±0.1L for pressure-controlled ventilation, p=.02 no alarm). In the second setup, pressure-controlled ventilation resulted at a 3mm flow limitation in minute ventilation of 9.4±0.3vs3.5±0.1L∙min-1, p=.001. In a third setup using the special one-way valve and the flow sensor on the unobstructed side, pressure-controlled ventilation resulted at a 3mm flow limitation in minute ventilation of 7.4±0.2vs3±0L∙min-1, at the compliance of 70mL∙mbar-1 for both lungs, 7.2±0vs4.1±0L∙ min-1, at the compliances of 50 vs. 70mL∙mbar-1, and 7.2±0.2vs5.7±0L∙ min-1, at the compliance of 30 vs. 70mL∙mbar-1 (all p=.001).Conclusions: Overriding a modern intensive care ventilator's safety features are possible, thereby ventilating two lungs with one ventilator simultaneously in a laboratory simulation using 3D-printed y-adapters. Directing tidal volumes in different pulmonary conditions towards one lung using 3D-printed flow limiters with diameters

Background Pain is one of the major symptoms complained about by patients in the prehospital setting, especially in the case of trauma. When there is mountainous topography, as in Switzerland, there may be a time delay between injury and arrival of professional rescuers, in particular on ski slopes. Administration of a safe opioid by first responders may improve overall treatment. We therefore assessed administration of nasal nalbuphine as an analgesic treatment for trauma patients in Switzerland. Methods This observational cohort study examined 267 patients who were treated with nasal nalbuphine by first responders in six ski resorts in Switzerland. All first responders were instructed to begin treatment by assessing the feasibility of using nalbuphine to treat pain in the patient. A treatment algorithm was developed and distributed to assure that nalbuphine was only administered following a strict protocol. Data regarding pain scores and pain reduction after administration of nalbuphine were collected on-site. Refills were handed out to the first responders with the return of each completed questionnaire. Results Nalbuphine provided effective pain relief, with the median level of pain on the numeric rating scale for pain reduced by 3 units on average, from 8 points (p p = 0.006). No major side effects were observed. Conclusion Nasal administration of nalbuphine by first responders is a presumably safe and effective noninvasive pain management strategy for acutely injured patients in the prehospital setting. This may be an alternative, especially in the case of severe pain and prolonged time between arrival of the first responders and arrival of EMS/HEMS personnel on scene.

BACKGROUND: Deranged glucose metabolism after moderate to severe trauma with either high or low concentrations of blood glucose is associated with poorer outcome. Data on prehospital blood glucose concentrations and trauma are scarce.OBJECTIVES: The primary aim was to describe the relationship between traumatic shock and prehospital blood glucose concentrations. The secondary aim was to determine the additional predictive value of prehospital blood glucose concentration for traumatic shock when compared with vital parameters alone.DESIGN: Retrospective analysis of the predefined, observational database of a nationwide Helicopter Emergency Medical Service (34 bases).SETTINGEmergency trauma patients treated by Helicopter Emergency Medical Service between 2005 and 2013 were investigated.PATIENTS: All adult trauma patients (18 years) with recorded blood glucose concentrations were enrolled.OUTCOMES: Primary outcome: upper and lower thresholds of blood glucose concentration more commonly associated with traumatic shock. Secondary outcome: additional predictive value of prehospital blood glucose concentrations when compared with vital parameters alone.RESULTS: Of 51 936 trauma patients, 20 177 were included. In total, 220 (1.1%) patients died on scene. Hypoglycaemia (blood glucose concentration 2.8 mmol l1 or less) was observed in 132 (0.7%) patients, hyperglycaemia (blood glucose concentration exceeding 15 mmol l1 ) was observed in 265 patients (1.3%). Blood glucose concentrations more than 10 mmol l1 (n ¼ 1308 (6.5%)) and 2.8 mmol l1 or less were more common in patients with traumatic shock (P < 0.0001). The Youden index for traumatic shock ((sensitivity R specificity) 1) was highest when blood glucose concentration was 3.35 mmol l1 (P < 0.001) for patients with low blood glucose concentrations and 7.75 mmol l1 (P < 0.001) for those with high blood glucose concentrations. In logistic regression analysis of patients with spontaneous circulation on scene, prehospital blood glucose concentrations (together with common vital parameters: Glasgow Coma Scale, heart rate, blood pressure, breathing frequency) significantly improved the prediction of traumatic shock in comparison with prediction by common vital parameters alone (P < 0.0001). CONCLUSION: In adult trauma patients, low and high blood glucose concentrations were more common in patients with traumatic shock. Prehospital blood glucose concentration measurements in addition to common vital parameters may help identify patients at risk of traumatic shock.

Summary The aim of this study was to analyse publication trends from the anaesthetic literature of the G-20 countries. We performed a literature search in Medline to identify articles related to anaesthetic departments published between 2001 and 2015, by specific G-20 countries according to the affiliation field of the authors, and to three time periods 2001–2005, 2006–2010 and 2011–2015. The number of articles, number of original articles (vs. reviews, editorials or correspondence), articles per million inhabitants, and citations per article were analysed. In total, 96,920 articles were published between 2001 and 2015 in 74 anaesthetic and in 4117 non-anaesthetic journals, with an increase of +104% absolute (i.e. from 23,028 in 2001–05 to 46,887 articles in 2010–15) and +85% as articles per million inhabitants. Similarly, the number of original articles increased by 21%, but the anaesthetic specialty's share of original articles (as a proportion of total articles in biomedicine) decreased from 31% in 2001–2005 to 19% in 2011–2015 (−38%). The USA published most articles (2011–15 16,016; 31% of total), second came the EU as a whole and third Japan (from 2001 to 2005) or Germany (2006–2010) until 2011–2015 when China took over the third rank. In 2011–2015, Canada published most articles per million inhabitants (68.7 articles/million inhabitants). China and India exhibited the most publication growth 11- and 9-fold, respectively, and are now among the top five countries for the number of published articles.

Background Radiation therapy (RT) of the head and neck region is often accompanied by serious side effects. Research in this area is needed to improve treatment outcomes and ameliorate therapy tolerance. Laboratory rodents are barely matching today's clinical standards in RT research. Yet domestic swine (Sus scrofa domestica) have previously proved suitable for various advanced tests in clinical research and training. We therefore investigated whether S. scrofa domestica is also appropriate for irradiation of the mandible. Study Design A common scheme for irradiation treatment of S. scrofa domestica mandibles in a split-mouth design was acquired by applying computed tomography (CT) scanning under sedation. Basing on close anatomic resemblance, a standard treatment plan comprising 2 opposed irradiation fields could be accomplished. Results RT was carried out in a clinical environment with 2 × 9 Gy. The resulting operating procedure facilitated complication-free sedation, transport, positioning, CT scanning, and effective irradiation. Conclusion Based on common standards applied for RT in humans, domestic pigs can be employed to progress RT clinical research. Due to their human-like anatomy, physiology, size, and weight, the swine model is expedient for advancing experimental RT of the head and neck area.

In den deutschsprachigen Landern stellen Anasthesisten die zweitgroste Berufsgruppe unter allen Arzten im Krankenhaus dar, aber diese Relation spiegelt sich an den meisten Universitatskliniken nicht im Ausmas der Aufgaben in der studentischen Lehre wieder. Damit ist die Wahrscheinlichkeit, dass Medizinstudierende das Fach Anasthesiologie im Studium als berufliche Perspektive fur sich erkennen konnen, niedriger als in anderen grosen Fachern. Nachwuchssorgen sind die logische Folge, obwohl viele gute und wichtige Grunde fur die Anasthesie als berufliche Perspektive sprechen. Traditionelle Ansatze bei der Ausbildung von Medizinstudierenden bestehen in der Anasthesie haufig allein aus dem Erlernen verschiedener Strategien im Airwaymanagement oder der kardiopulmonalen Reanimation an Ubungsphantomen. Die Anasthesie ist eine komplexe Interaktion aus Anatomie, Physiologie, Pharmakologie, klinischer Beurteilung, Erfahrung, Wissen und manuellem Geschick. Wenn Medizinstudierende sich fur eine Famulatur oder das Praktische Jahr in der Anasthesie entscheiden, besteht die Chance dem beruflichen Nachwuchs die umfangreiche Welt der Anasthesie zu zeigen. Junge Talente mussen entdeckt, gefordert und gefordert werden. Wir haben eine Kurzanleitung zur praktischen Anasthesie bei Erwachsenen mit webbasierter Videoillustrierung fur Medizinstudierende in einer Famulatur oder dem Praktischem Jahr erstellt. Es werden die Grundzuge der Pramedikation, der Narkoseeinleitung und Narkosefuhrung sowie der Regionalanasthesie erklart. Auserdem werden die wichtigsten, fur die Anasthesie relevanten Medikamente diskutiert und praktische Fahigkeiten wie das Anlegen einer Venenverweilkanule, der Maskenbeatmung und die endotracheale Intubation anhand von Kurzfilmen erklart. Diese Informationen sind mittels Quick-Response(QR)-Code auf einem Smartphone abrufbar. Es wurde nicht auf lokale Eigenheiten und besondere Patientengruppen (z. B. Kinder, Patienten mit speziellen Vorerkrankungen), lokale Leitlinien oder „standard operating procedures“ (SOP) eingegangen. Medizinstudierende konnen fur die Anasthesie begeistert werden, wenn man ihnen nicht nur die fachlichen Regeln und Strategien erklart, sondern auch klinische Erfolgserlebnisse durch erlerntes und angewandtes Wissen ermoglicht. Eine ubersichtliche Darstellung der Anasthesie ermoglicht bereits im Vorfeld einer Famulatur oder des praktischen Jahres eine schnelle und erfolgreiche Orientierung; ob dies anschliesend auch eine Rekrutierungswahrscheinlichkeit fur die Anasthesie erhoht, ist derzeit nicht bekannt.

Injuries to blood vessels near the heart can quickly become life-threatening and include arterial injuries during central venous puncture, which can lead to hemorrhagic shock. We report 6 patients in whom injury to the subclavian artery and vein led to life-threatening complications. Central venous catheters are associated with a multitude of risks, such as venous thrombosis, air embolism, systemic or local infections, paresthesia, hemothorax, pneumothorax, and cervical hematoma, which are not always immediately discernible. The subclavian catheter is at a somewhat lower risk of catheter-associated sepsis and symptomatic venous thrombosis than approaches via the internal jugular and femoral veins. Indeed, access via the subclavian vein carries a substantial risk of pneumo- and hemothorax. Damage to the subclavian vein or artery can also occur during deliberate and inadvertent punctures and result in life-threatening complications. Therefore, careful consideration of the access route is required in relation to the patient and the clinical situation, to keep the incidence of complications as low as possible. For catheterization of the subclavian vein, puncture of the axillary vein in the infraclavicular fossa is a good alternative, because ultrasound imaging of the target vessel is easier than in the subclavian vein and the puncture can be performed much further from the lung.

Department of Anaesthesiology and Pain Medicine, University Hospital Bern and University of Bern, Bern, Switzerland Emergency Department, Calderdale Royal Hospital, Halifax, Salterhebble HX3 0PW, UK School of Nursing, Midwifery & Social Work, The University of Manchester, Manchester, UK Danish Institute for Medical Simulation, Center for HR, Capital Region of Denmark, Copenhagen, Denmark Knowledge Centre, ACM Training Centre, Elburg, The Netherlands Emergency Medicine, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium

This executive summary provides the essential treatment algorithms for the resuscitation of children and adults and highlights the main guideline changes since 2010. Detailed guidance is provided in each of the ten sections, which are published as individual papers within this issue of Resuscitation. The sections of the ERC Guidelines 2015 are

Achieving system-level dependability is a demanding task. The manifold requirements and dependability threats can no longer be statically addressed at individual abstraction layers. Instead, all components of future multi-processor systems-on-chip (MPSoCs) have to contribute to this common goal in an adaptive manner. In this paper we target a generic heterogeneous MPSoC that combines general purpose processors along with dedicated application-specific hard-wired accelerators, fine-grained reconfigurable processors, and coarse-grained reconfigurable architectures. We present different reactive and proactive measures at the layers of the runtime system (online resource management), system architecture (global communication), micro architecture (individual tiles), and gate netlist (tile-internal circuits) to address dependability threats.

Background— Utstein-style guidelines use an established consensus process, endorsed by the international resuscitation community, to facilitate and structure resuscitation research and publication. The first “Guidelines for Uniform Reporting of Data From Drowning” were published over a decade ago. During the intervening years, resuscitation science has advanced considerably, thus making revision of the guidelines timely. In particular, measurement of cardiopulmonary resuscitation elements and neurological outcomes reporting have advanced substantially. The purpose of this report is to provide updated guidelines for reporting data from studies of resuscitation from drowning. Methods— An international group with scientific expertise in the fields of drowning research, resuscitation research, emergency medical services, public health, and development of guidelines met in Potsdam, Germany, to determine the data that should be reported in scientific articles on the subject of resuscitation from drowning. At the Utstein-style meeting, participants discussed data elements in detail, defined the data, determined data priority, and decided how data should be reported, including scoring methods and category details. Results— The template for reporting data from drowning research was revised extensively, with new emphasis on measurement of quality of resuscitation, neurological outcomes, and deletion of data that have proved to be less relevant or difficult to capture. Conclusions— The report describes the consensus process, rationale for selecting data elements to be reported, definitions and priority of data, and scoring methods. These guidelines are intended to improve the clarity of scientific communication and the comparability of scientific investigations.

Schlafmangel und Schlafstorungen bei Arzten im Schichtdienst konnen sowohl direkte gesundheitliche Folgen als auch indirekte, durch Leistungsminderung negative Auswirkungen auf die Patientensicherheit haben. Selbst bei optimaler auserer Anpassung an Schichtarbeit und Schlafausgleich tagsuber ist Schlafmangel bei Arzten haufig. Ziel dieser Arbeit ist es, Ursachen und Konsequenzen von Schlafstorungen bei Arzten zu diskutieren sowie Verbesserungsmasnahmen zur Adaptation bei Schichtarbeit aufzuzeigen. Risikofaktoren fur die Entwicklung von Schlafstorungen bei Arzten reichen von genetischen Faktoren bei ca. 15 % der Bevolkerung, Alter uber 50 Jahre, komorbid vorhandenen, jedoch oft nichtdiagnostizierten schlafmedizinischen Erkrankungen, Alkoholmissbrauch bzw. Schlafmangel durch Mehrfachbelastungen in Klinik (mit Schichtarbeit), Forschung, Lehre und Familie. Mehrere Studien weisen auf eine erhohte Fehlerrate von ubermudeten Arzten hin. Schichtarbeiter haben ein erhohtes Risiko fur psychiatrische, kardiovaskulare und moglicherweise auch fur Krebserkrankungen. Es bestehen Zusammenhange zwischen kurzer Schlafdauer und gestorter Nahrungsaufnahme, Diabetes mellitus, Adipositas, Bluthochdruck oder koronarer Herzerkrankung. Nikotin- und Alkoholkonsum sind bei Schichtarbeitern haufiger. Soziookonomisch zeigen sich erhohte Krankenstande und Unfallraten bei Arzten auf dem Nachhauseweg, insbesondere nach Nachtschichten. Um die Leistungsfahigkeit zu verbessern und Ermudungserscheinungen zu vermindern, sind Kurzschlafepisoden („naps“) wahrend der Schicht, evtl. in Kombination mit Koffein, wirksame Coping-Strategien. Wenn die Naps zu einem Zeitpunkt mit niedrigem zirkadianen Schlafdruck stattfinden, sind sie weniger effektiv, da die Betroffenen nicht immer einschlafen konnen. Helle Beleuchtung und blaues Licht unterstutzen die Wachheit wahrend der Schicht. Bereits auf dem Nachhauseweg von der Schicht sollte direkte Sonnenlichtexposition auf die Retina vermieden werden, z. B. durch Tragen dicht abschliesender, sehr dunkler Sonnenbrillen oder von Brillen mit orangenen Glasern. Nach Schichtende sollte in sehr dunkler Umgebung geschlafen werden, um die endogene Melatoninsekretion nicht zu behindern, was als Nachtsignal gilt und die Schlafkontinuitat fordern soll. Schlafstorungen konnen mit richtigem Umgang mit Licht, Verhaltensstrategien und Umgebungsstrategien therapiert werden, um Schlafdefizite moglichst gut zu kompensieren. Erschopfung durch Schlafmangel kann nur durch Schlafen konsequent therapiert werden.

Die Publikationsleistungen der Universitatskliniken fur Anasthesiologie in Deutschland, Osterreich und der Schweiz wurden verglichen. Hierzu wurden die Zahl der Originalarbeiten, der Gesamtpublikationen, „Impact“-Punkte und Zitierungen analysiert. Berucksichtigt wurden alle Fachzeitschriften, die im „Journal Citation Report 2013“ von Thomson Reuters‘ ISI Web of Knowledge in den Bereichen Anasthesie/Schmerztherapie, Intensivmedizin, Notfallmedizin angefuhrt und in PubMed gelistet waren. Analysiert wurden die Funfjahreszeitraume 2001–2005 und 2006–2010. Um eine moglichst vollstandige Erfassung der Veroffentlichungen der Universitatskliniken fur Anasthesiologie in Deutschland, Osterreich und der Schweiz durchzufuhren, wurden auch PubMed-Publikationen aus nichtanasthesiologischen Fachzeitschriften berucksichtigt, bei denen im Feld des korrespondierenden Autors („affiliation“) die Wortwurzel Anasthesiologie (d. h. anes*, anaes*, anast*, anast*) erscheint. Die Zuordnung einer Publikation zu einer Universitatsklinik fur Anasthesiologie in Deutschland, Osterreich und der Schweiz erfolgte ebenfalls uber das Feld „affiliation“. Insgesamt gingen 45 Universitatskliniken fur Anasthesiologie aus Deutschland, Osterreich und der Schweiz in die Analyse ein, und es wurden 125.979 Publikationen aus 2863 Zeitschriften (65 anasthesiologische Fachzeitschriften, 2798 nichtanasthesiologische Fachzeitschriften) berucksichtigt. Es waren 23 % der Publikationen keiner Universitatsklinik zuordenbar. Im untersuchten Zeitraum veroffentlichte die Universitatsklinik Wien am meisten Originalarbeiten (n = 156), die Universitatsklinik Berlin hingegen die hochste Anzahl an Gesamtpublikationen (Original- und Nichtoriginalarbeiten; n = 479) und erzielte die meisten Impact-Punkte (1384 Punkte). Bei den Publikationen/1 Mio. Einwohner fuhrt 2006–2010 Osterreich (n = 50:106) vor der Schweiz (n = 49:106) und Deutschland (n = 35:106). Die Zahl der Publikationen nahm im Beobachtungszeitraum ab (Deutschland ~ 0,5 %, Osterreich ~ 7 %, Schweiz ~ 8 %). Die Publikationsleistungen der Universitatskliniken fur Anasthesiologie in Deutschland, Osterreich und der Schweiz variieren stark. Grose Universitatskliniken wie z. B. Berlin und Wien fuhren die Rangliste an. Die Publikationsleistung der Universitatskliniken fur Anasthesiologie in Deutschland, Osterreich und der Schweiz ist rucklaufig. Die Datenaufbereitung auf PubMed sollte verbessert werden.

Tragische Unfalle z. B. von prominenten Patienten oder schwerwiegende Zwischenfalle im Krankenhaus ereignen sich plotzlich, erzeugen haufig starkes Medieninteresse und konnen das Fuhrungspersonal in Krankenhausern sowie Rettungsdiensten schnell uberfordern. Wahrend Arzte, Krankenhauser und Rettungsdienste eine moglichst objektive Berichterstattung wunschen, steht fur viele Medien die emotionalisierte und dramatisierte Berichterstattung im Mittelpunkt, um maximale Aufmerksamkeit und maximale Auflage zu erzielen. Bei einer Informationsweitergabe an die Medien ist allerdings der Grat zwischen einer professionellen, reflektierten Auskunft und einer unglucklichen und oftmals auch unbewussten Desinformation sehr schmal. Dies kann durch daran anknupfende Beitrage sensationsgieriger Medien vor dem Hintergrund einer kompetitiven Krankenhauslandschaft und von klagefreudigen Juristen schnell Imageprobleme und rechtliche Konsequenzen auslosen. In diesem Beitrag werden entscheidende Aspekte diskutiert, um moglichst erfolgreiche Medienarbeit leisten zu konnen.

Emergency anaesthesia is an important therapeutic measure in out-of-hospital emergency medicine. The associated risks are considerably higher than those of in-hospital anaesthesia. The primary objectives of emergency anaesthesia are hypnosis, analgesia, oxygenation and ventilation through airway management. The secondary objectives of emergency anaesthesia are amnesia, anxiolysis, the reduction of oxygen consumption and respiratory work, the protection of vital organs and the avoidance of secondary myocardial and cerebral damage. A critical evaluation of the indications for outof- hospital emergency anaesthesia must take into consideration patient, case and provider-related factors. Rapid sequence induction of emergency anaesthesia includes standard monitoring, preoxygenation, standardised preparation of emergency anaesthesia, drug administration, manual in-line stabilisation during intubation (if necessary), airway management and checking of correct tube placement. Spontaneously breathing casualties should receive preoxygenation for at least 3 to 4 min with a tight-fitting facemask with reservoir using 12 to 15 l min_1 of oxygen or with a demand valve providing 100% oxygen. As an alternative, preoxygenation may be performed as noninvasive ventilation with 100% oxygen. Standardised anaesthesia preparation comprises filling drugs into syringes and labelling them, checking ventilation equipment, preparing endotracheal tube and syringe for inflating the cuff and the introducer, stethoscope and fixation material, preparing alternative instruments for airway management as well as checking suction, ventilation and standard monitoring devices, including capnography. Standard monitoring for out-of-hospital emergency anaesthesia comprises ECG, blood pressure measurement and pulse oximetry. Continuous capnography is always and exclusively performed to check the placement of airway devices, as well as to indirectly monitor haemodynamics.

Lediglich auf Basis randomisierter, prospektiver klinischer Studien kann die Therapie von Patienten mit lebensgefahrlichen Verletzungen oder Erkrankungen verbessert werden. Beobachtungen aus England und Nordamerika zeigten allerdings einen deutlichen Ruckgang solcher Studien. Untersucht wurde der Beitrag deutschsprachiger Lander an Publikationen von klinischen randomisierten, prospektiven Studien in der Notfallmedizin der letzten 22 Jahre. Fur den Zeitraum 01.01.1990 bis 31.12.2012 wurde eine Internetrecherche in der Onlinedatenbank Medline mit den (Tracer-)Diagnosen „Herz-Kreislauf-Stillstand“, „kardiopulmonale Reanimation“, „Polytrauma“, „hamorrhagischer Schock“, „Schadel-Hirn-Trauma“, „Schlaganfall“ oder „Herzinfarkt“ durchgefuhrt. Nur prospektive, randomisierte und kontrollierte Arbeiten aus Deutschland, Osterreich und der Schweiz wurden aufgenommen. Von 474 Studien aus deutschsprachigen Landern erfullten 25 (5,3 %) die Einschlusskriterien. Von 1990 bis Ende 2012 wurde gleichbleibend ca. eine prospektive, randomisierte, kontrollierte Studie pro Jahr aus Deutschland, Osterreich und der Schweiz zu den genannten Diagnosen publiziert. Die Patientenzahl betrug im Median bei 159 (Minimum 16, Maximum 1219). Die meisten Studien (80 %) hatten ihren Ursprung in Deutschland und wurden uberwiegend im Fachbereich der Anasthesiologie (68 %) durchgefuhrt. In 68 % der Studien war der „Herz-Kreislauf-Stillstand“ das untersuchte Thema. Etwa die Halfte der Studien bekam finanzielle Unterstutzung von der Industrie. In dieser retrospektiven Studie konnte keine eindeutige Zu- oder Abnahme an prospektiven, randomisierten, kontrollierten Studien in der deutschsprachigen Notfallmedizin der letzten 22 Jahre festgestellt werden, obwohl insgesamt die Zahl an notfallmedizinischen Studien zugenommen hat. Pro Jahr kommt durchschnittlich nur eine prospektive, randomisierte, klinische Studie mit notfallmedizinischen (Tracer-)Kerndiagnosen aus Deutschland, Osterreich oder der Schweiz.

Background and aim The majority of avalanche victims who sustain complete burial die within 35 min due to asphyxia and injuries. After 35 min, survival is possible only in the presence of a patent airway, and an accompanying air pocket around the face may improve survival. At this stage hypothermia is assumed to be an important factor for survival because rapid cooling decreases oxygen consumption; if deep hypothermia develops before cardiac arrest, hypothermia may be protective and prolong the time that cardiac arrest can be survived. The aim of the study was to investigate the combined effects of hypoxia, hypercapnia and hypothermia in a porcine model of avalanche burial. Methods Eight piglets were anaesthetised, intubated and buried under snow, randomly assigned to an air pocket ( n = 5) or ambient air ( n = 3) group. Results Mean cooling rates in the first 10 min of burial were −19.7 ± 4.7 °C h −1 in the air pocket group and −13.0 ± 4.4 °C h −1 in the ambient air group ( P = 0.095); overall cooling rates between baseline and asystole were −4.7 ± 1.4 °C h −1 and −4.6 ± 0.2 °C h −1 ( P = 0.855), respectively. In the air pocket group cardiac output ( P = 0.002), arterial oxygen partial pressure ( P = 0.001), arterial pH ( P = 0.002) and time to asystole ( P = 0.025) were lower, while arterial carbon dioxide partial pressure ( P = 0.007) and serum potassium ( P = 0.042) were higher compared to the ambient air group. Conclusion Our results demonstrate that hypothermia may develop in the early phase of avalanche burial and severe asphyxia may occur even in the presence of an air pocket.

The aim of the study was to assess the effects of positioning the head on a support on "head position angles" to optimally open the upper airway during bag-valve mask ventilation.We ventilated the lungs of anesthetized adults with a bag-valve mask and the head positioned with (n = 30) or without a support (n = 30). In both groups, head position angles and ventilation parameters were measured with the head positioned in (1) neutral position, (2) in a position deemed optimal for ventilation by the investigator, and (3) in maximal extension.Between groups ("head with/without a support") and between head positions within each group, head position angles and ventilation parameters differed (P.0001, respectively). However, head position angles and ventilation parameters between head positions differed less "with a support" (P.001), and ventilation parameters improved with a support compared with the head-without-a-support group (P.001).In the head-with-a-support group, when compared with the head-without-a-support group, head position angles differed less, indicating a decreased potential for failure during bag-valve mask ventilation with the head on a support. Moreover, in the head-with-a-support group, ventilation parameters differed less between head positions, and ventilation improved. These findings suggest a potential benefit of positioning the head on a support during bag-valve mask ventilation.

BACKGROUND Ventilation of an unprotected airway may result in stomach inflation. The purpose of this study was to evaluate the effect of clinically realistic stomach inflation on cardiopulmonary function during hemorrhagic shock in a porcine model. METHODS Pigs were randomized to a sham control group (n = 9), hemorrhagic shock (35 mL kg over 15 min [n = 9]), and hemorrhagic shock combined with stomach inflation (35 mL kg over 15 min and 5 L stomach inflation [n = 10]). RESULTS When compared with the control group, hemorrhagic shock (n = 9) increased heart rate (103 ± 11 vs. 146 ± 37 beats min; P = 0.002) and lactate (1.4 ± 0.5 vs. 4.0 ± 1.9 mmol L; P

Background. Emergency airway management (AM) is a priority when resuscitating critically ill or severely injured patients. The goal of this study was to determine the success rates of LT insertion during AM.Methods. Studies that included LT first-pass insertion (FPI) and overall-pass insertion (OPI) success by emergency medical services and in-hospital providers performing AM for emergency situations as well as for scheduled surgery published until July 2014 were searched systematically in Medline.Results. Data of 36 studies (n= 1,897) reported a LT FPI success by physicians of 82.5% with an OPI success of 93.6% (p<0.001). A cumulative analysis of all 53 studies (n= 3,600) led to FPI and OPI success of 80.1% and 92.6% (p<0.001), respectively. The results of 26 studies (n= 2,159) comparing the LT with the laryngeal mask airway (LMA) demonstrated a FPI success of 77.0 versus 78.7% (p=0.36) and an OPI success of 92.2 versus 97.7% (p<0.001).Conclusion. LT insertion failed in the first attempt in one out of five patients, with an overall failure rate in one out of 14 patients. When compared with the LT, the LMA had a cumulative 5.5% better OPI success rate.

Basic life support (BLS) performed by lay rescuers is poor. We developed software for mobile phones augmented with a metronome to improve BLS.To assess BLS in lay rescuers with or without software assistance.Medically untrained volunteers were randomized to run through a cardiac arrest scenario with ("assisted BLS") or without ("non-assisted BLS") the aid of a BLS software program installed on a mobile phone.Sixty-four lay rescuers were enrolled in the "assisted BLS" and 77 in the "non-assisted BLS" group. The "assisted BLS" when compared to the "non-assisted BLS" group, achieved a higher overall score (19.2 ± 7.5 vs. 12.9 ± 5.7 credits; p0.001). Moreover, the "assisted BLS" when compared to the "non-assisted" group checked (64% vs. 27%) and protected themselves more often from environmental risks (70% vs. 39%); this group also called more often for help (56% vs. 27%), opened the upper airway (78% vs. 16%), and had more correct chest compressions rates (44% ± 38% vs. 14% ± 28%; all p0.001). However, the "assisted BLS" when compared to the "non-assisted BLS" group, was slower in calling the dispatch center (113.6 ± 86.4 vs. 54.1 ± 45.1 s; p0.001) and starting chest compressions (165.3 ± 93.3 vs. 87.1 ± 53.2 s; p0.001)."Assisted BLS" augmented by a metronome resulted in a higher overall score and a better chest compression rate when compared to "non-assisted BLS." However, in the "assisted BLS" group, time to call the dispatch center and to start chest compressions was longer. In both groups, lay persons did not ventilate satisfactorily during this cardiac arrest scenario.

The best chance of survival with a good neurological outcome after cardiac arrest is afforded by early recognition and high-quality cardiopulmonary resuscitation (CPR), early defibrillation of ventricular fibrillation (VF), and subsequent care in a specialist center. Compression-only CPR should be used by responders who are unable or unwilling to perform mouth-to-mouth ventilations. After the first defibrillator shock, further rhythm checks and defibrillation attempts should be performed after 2 min of CPR. The underlying cause of cardiac arrest can be identified and treated during CPR. Drugs have a limited effect on long-term outcomes after cardiac arrest, although epinephrine improves the success of resuscitation, and amiodarone increases the success of defibrillation for refractory VF. Supraglottic airway devices are an alternative to tracheal intubation, which should be attempted only by skilled rescuers. Care after cardiac arrest includes controlled reoxygenation, therapeutic hypothermia for comatose survivors, percutaneous coronary intervention, circulatory support, and control of blood-glucose levels and seizures. Prognostication in comatose survivors of cardiac arrest needs a careful, multimodal approach using clinical and electrophysiological assessments after at least 72 h.

The aim of this survey was to investigate clinicians' current approach to the haemodynamic management and resuscitation endpoints in septic shock.This cross-sectional, self-reported questionnaire-based survey was sent to the clinical director of selected ICUs in 16 European countries. The questionnaire consisted of two parts and 25 questions. The first part retrieved general information on the hospital and ICU, and the second part of the questionnaire collected detailed information on the approach to haemodynamic management of septic shock.Of 481 clinicians invited to participate, 237 (49.3%) responded. Ninety-two questionnaires were excluded because of more than 20% missing responses, rendering 145 (30.1%) for statistical analysis. Administration of albumin (P = 0.007), gelatine preparations (P = 0.002), Ringer's solution (P = 0.02) and isotonic saline (P = 0.001) for fluid resuscitation varied between respondents from different countries. Further differences between respondents from different countries were observed for the choice of the first-line inotropic drug (P0.001), use of supplementary vasopressin (P = 0.02), supplementary fludrocortisone (P = 0.05) and measurement of cardiac output with the transpulmonary thermodilution (P = 0.001), lithium dilution (P = 0.004) and oesophageal Doppler (P = 0.005) technique. Mean arterial blood pressure (87%), central venous oxygen saturation (65%), central venous pressure (59%), systolic arterial blood pressure (48%), mixed venous oxygen saturation (42%) and cardiac index (42%) were the six haemodynamic variables most commonly claimed to be used as resuscitation endpoints.The current approach to the haemodynamic management of septic shock patients in a selected cohort of European ICU clinicians is in agreement with the Surviving Sepsis Campaign guidelines with the exception of the haemodynamic goals.

Erwachsene Thoraxkompressionen (mindestens 100/min, mindestens 5-cm-Drucktiefe): Beatmung (Atemzugvolumen 500–600 ml, Inspirationszeit 1s, FIO2 moglichst 1,0) im Verhaltnis 30: 2 durchfuhren. Jegliche Unterbrechungen der Thoraxkompressionen vermeiden. Nach jeder Defibrillation (initial biphasisch 120–200 J, monophasisch 360 J; dann mit der jeweils hochsten Energie) unverzuglich unabhangig vom resultierenden EKG-Rhythmus fur 2 min CPR durchfuhren. Die Intubation gilt als optimale Methode der Atemwegssicherung wahrend einer CPR, ist jedoch ausschlieslich dem in der Intubation erfahrenen Helfer vorbehalten. Laryngoskopie wahrend laufender Thoraxkompressionen durchfuhren, fur die Platzierung des Tubus Thoraxkompressionen maximal 10 s unterbrechen. Supraglottische Atemwegshilfen sind Alternativen zur endotrachealen Intubation. Zugangswege fur Notfallmedikamente bei Erwachsenen und Kindern: Erste Wahl i.v., zweite Wahl intraossar (i.o.). Vasopressoren: Alle 3–5 min 1 mg Adrenalin i.v. Nach der dritten erfolglosen Defibrillation Amiodaron i.v. (300 mg), Repetition (150 mg) moglich. Natriumbikarbonat (50 ml, 8,4%ig) nur bei exzessiver Hyperkalamie, vorbestehender metabolischer Acidose oder Intoxikation mit trizyklischen Antidepressiva, Theophyllin (5 mg/kgKG) erwagen. Thrombolyse bei Spontankreislauf nur bei Myokardinfarkt und fulminanter Lungenembolie, wahrend laufender kardiopulmonaler Reanimation („cardiopulmonary resuscitation“, CPR) nur bei Hinweisen auf fulminante Lungenembolie. „Active-compression-decompression“- (ACD-), maschinelle und „Inspiratory-threshold-valve“- (ITV-)CPR sind guter Standard-CPR nicht uberlegen.

Die Basismasnahmen zur Wiederbelebung („basic life support“, BLS) beziehen sich auf das Freihalten der Atemwege sowie das Aufrechterhalten von Atmung und Kreislauf ohne Verwendung von Hilfsmitteln, abgesehen von einfachen Mitteln zum Eigenschutz [1]. Diese Sektion enthalt die Leitlinien zu den Basismasnahmen zur Wiederbelebung Erwachsener und zur Verwendung eines automatisierten externen Defibrillators (AED). Sie beinhaltet auch das Erkennen des plotzlichen Herztodes, die stabile Seitenlage und das Handeln bei Ersticken (Verlegung der Atemwege durch Fremdkorper). Leitlinien fur den Einsatz von manuellen Defibrillatoren und zur Einleitung von Wiederbelebungsmasnahmen im Krankenhaus finden sich in den Sektionen 3 und 4 [2, 3].

Arginin-Vasopressin (Vasopressin) wird heute als integraler Bestandteil der neuroendokrinen Stressantwort bei einem Herz-Kreislauf-Stillstand angesehen. Die enge Beziehung zwischen endogener Vasopressin-Sekretion und dem Uberleben eines Herz-Kreislauf-Stillstands hat zu einer Anzahl von experimentellen Studien gefuhrt, bei denen ein Uberlebensvorteil mit Vasopressin im Vergleich zu Adrenalin gezeigt werden konnte. Aktuelle Ergebnisse experimenteller Studien schreiben Vasopressin und Adrenalin eine ahnliche Potenz in der Wiederherstellung eines Spontankreislaufs beim bei Herz-Kreislauf-Stillstand zu. Bisher liesen sich in der klinischen Anwendung in Bezug auf die Langzeituberlebensraten keine signifikanten Unterschiede beweisen bzw. konnten die Vorteile, die im Rahmen von experimentellen Studien aufgezeigt wurden, nicht reproduziert werden. Die neuesten internationalen Reanimationsrichtlinien schlagen Vasopressin daher lediglich als einen alternativen Vasopressor zum Standardmedikament Adrenalin vor. Im vorliegenden Artikel wird die aktuelle Literatur bezuglich Vasopressin diskutiert. Dabei wird vermutet, dass durch das Design der bisher durchgefuhrten Studien potenzielle Vorteile von Vasopressin maskiert wurden. Ein Schlusselproblem scheinen die Ein- und Ausschlusskriterien fur praklinische Reanimationsstudien darzustellen, da die Randomisierung von asystolen Patienten zu unbefriedigenden Ergebnissen gefuhrt hat. Diese Vermutung muss allerdings im Sinne der evidenzbasierten Medizin durch weitere multizentrisch angelegte Studien mit adaptierten Ein- und Ausschlusskriterien verifiziert werden.

Objective Lay rescuers have difficulties acquiring ventilation skills during training. Non-feedback manikins are still widely employed, although skill acquisition is suboptimal. We analysed if a longer training time and verbal feedback, given by an instructor, improved ventilation skill acquisition with non-feedback manikins. Methods Forty-three high school students without prior medical training participated in this prospective randomised trial. Under one-to-one instructor guidance, 25 volunteers were trained on a manikin with a mouth-to-mask device for 10 min, and 18 volunteers for 20 min. After training, volunteers were assessed and verbal feedback was given: ventilate more if the mean tidal volume 0.7 L or ventilate the same for 0.5–0.7 L. The volunteers were then reassessed. Results At the assessment, tidal volume, minute volume, peak airway pressure, ventilation rate and stomach inflation rate were comparable between the 10 and 20 min groups. After verbal feedback, at reassessment both groups increased tidal volume (assessment 0.75±0.24 vs reassessment 0.80±0.16 l/min; p=0.007), minute volume (9.1±3.0 vs 10.0±2.4 l/min; p=0.001), peak airway pressure (17.0±5.2 vs 18.3±3.4 cmH 2 O; p=0.003) and stomach inflation rate (67 vs 88%; p=0.02), while ventilation rate (12.3±2.1 vs 12.6±2.3 ventilations/min; p=NS) remained comparable. Conclusions Both 10 and 20 min ventilation training times resulted in comparable skills. Volunteers hyperventilated the manikin and produced excessive stomach inflation in this model. This increased even further after verbal feedback.

Neben Fehldiagnosen ist das Lazarus-Phanomen (spontane Wiedererlangung eines Kreislaufs nach Kreislaufstillstand) eine Ursache fur falsch-positive Todesfeststellungen. Aufgrund potenzieller juristischer Konsequenzen und daher eines negativen Publikations-Bias in der Fachliteratur ist die Haufigkeit falsch-positiver Todesfeststellungen derzeit unklar. Da solche Falle zumindest bei einer Strafverfolgung mediale Aufmerksamkeit nach sich ziehen, wurden zahlreiche Medienarchive in Deutschland, Osterreich und der Schweiz auf entsprechende Berichte untersucht. In diesen 3 Landern konnten 9 Falle falsch-positiver arztlicher Todesfeststellungen seit Anfang der 1990er Jahre identifiziert werden; davon fielen 8 in den Rettungsdienstbereich. Mogliche Ursache konnten neben mangelnder arztlicher Sorgfalt bei der Todesfeststellung auch echte Lazarus-Phanomene sein. Da sichere Todeszeichen zum Zeitpunkt des Patientenkontakts durch den Notarzt haufig noch nicht vorliegen, erscheint es aus Autorensicht nicht moglich, dass Notarzte unter Zeitdruck mit Sicherheit den eingetretenen Tod feststellen und bescheinigen konnen. Somit besteht organisationsbedingt bei einer praklinischen Todesfeststellung das Restrisiko einer strafbaren Fehlbescheinigung, da in dieser Phase noch ein Lazarus-Phanomen auftreten konnte. Eine Ubertragung der Todesfeststellungen von den Notarzten auf nachfolgende entsprechend qualifizierte Arzte konnte sowohl die Rechtssicherheit fur Notarzte im Einsatz als auch die Patientensicherheit erhohen.

Aims To review anaesthesia in prehospital emergencies and in the emergency room, and to discuss guidelines for anaesthesia indication; pre-oxygenation; anaesthesia induction and drugs; airway management; anaesthesia maintenance and monitoring; side effects and training. Methods A literature search in the PubMed database was performed and 87 articles were included in this non-systematic review. Conclusions For pre-oxygenation, high-flow oxygen should be delivered with a tight-fitting face-mask provided with a reservoir. In haemodynamically unstable patients, ketamine may be the induction agent of choice. The rocuronium antagonist sugammadex may have the potential to make rocuronium a first-line neuromuscular blocking agent in emergency induction. An experienced health-care provider may consider prehospital anaesthesia induction. A moderately experienced health-care provider should optimise oxygenation, fasten hospital transfer and only try to intubate a patient in extremis. If intubation fails twice, ventilation should be resumed with an alternative supra-glottic airway or a bag-valve-mask device. A lesser experienced health-care provider should completely refrain from intubation, optimise oxygenation, fasten hospital transfer and only in extremis ventilate with an alternative supra-glottic airway or a bag-valve-mask device. With an expected difficult airway, the patient should be intubated awake. With an unexpected difficult airway, bag-valve-mask ventilation should be resumed and an alternative supra-glottic airway device inserted. Senior help should be called early. In a “can-not-ventilate, can-not-intubate” situation an alternative airway should be tried and if unsuccessful because of severe upper airway pathology, a surgical airway should be performed. Ventilation should be monitored continuously with capnography. Clinical training is important to increase airway management skills.

Hintergrund Im Rahmen dieser Post-hoc-Analyse wurde der Effekt der intravenosen Gabe von Amiodaron bei der praklinischen kardiopulmonalen Reanimation (CPR) untersucht.

Despite being a standard procedure during induction of anaesthesia, facemask ventilation can be a major challenge especially for inexperienced anaesthetists. We manufactured a Jaw-Thrust-Device designed to keep the patient's jaws in an optimised position, and thus to maintain the airway in a permanently patent state. Using a cross over design, we compared the influence of using the Esmarch manoeuvre (bimanual jaw-thrust), a nasopharyngeal airway, an oropharyngeal airway, or the Jaw-Thrust-Device on airway physiology in 50 healthy adults with body mass index < 35 kg.m(-2), undergoing standard facemask ventilation for routine induction of anaesthesia. The main study endpoints were expiratory tidal volumes, airway resistances, and gas flow rates. The Jaw-Thrust-Device was more effective in increasing expiratory tidal volumes and peak inspiratory flow than a standard Esmarch manoeuvre, and was more effective than both nasopharyngeal and oropharyngeal airways in decreasing airway resistance.