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Notfalleinsatze sind schwierig, wenn aus scheinbar volliger Gesundheit ohne klar erkennbare oder nachvollziehbare Ursache, wie z. B. einem Unfall, eine lebensgefahrliche Situation plotzlich und unerwartet eintritt. Der vorliegende Fall zeigt eindrucklich, wie ein Einsatz auch uber den Dienstschluss, ja sogar viele Jahre danach hinaus beschaftigen kann.

Kopfverletzungen konnen, wie es dieser Fall zeigt, sehr schnell sehr dramatisch ausfallen, vor allem, wenn „schwere Maschinen“ zum Einsatz kommen. Der vorliegende Fall zeigt zudem, dass man im Notarztdienst nicht davor gefeit ist, auch schreckliche Situationen, denen man eine Einmaligkeit unterstellt, ein weiteres Mal zu durchleben.

Dieses Fallbeispiel zeigt auf, wie wichtig eine konsequente CPR sein kann, und wie uberraschend ein Notfall seinen Lauf nehmen kann – auch noch uber Jahre nach dem Ereignis.

ObjectivesOutcome from out-of-hospital cardiac arrest (OHCA) highly depends on bystander cardiopulmonary resuscitation (CPR) with high-quality chest compressions (CCs). Precondition is a supine position of the victim on a firm surface. Until now, no study has systematically analysed whether bystanders of OHCA apply appropriate positions to victims and whether the position is associated with a particular outcome.DesignProspective observational cohort study.SettingMetropolitan emergency medical services (EMS) serving a population of 400 000; dispatcher-assisted CPR was implemented. We obtained information from the first EMS vehicle arriving on scene and matched this with data from semi-structured interviews with witnesses of the arrest.ParticipantsBystanders of all OHCAs occurring during a 12-month period (July 2006–July 2007). From 201 eligible missions, 200 missions were fully reported by EMS. Data from 138 bystander interviews were included.Primary and secondary outcome measuresProportion of positions suitable for effective CCs; related survival with favourable neurological outcome at 3 months.ResultsPositioning of victims at EMS arrival was ‘supine on firm surface’ in 64 cases (32.0%), ‘recovery position (RP)’ in 37 cases (18.5%) and other positions unsuitable for CCs in 99 cases (49.5%). Survival with favourable outcome at 3 months was 17.2% when ‘supine position’ had been applied, 13.5% with ‘RP’ and 6.1% with ‘other positions unsuitable for CCs’; a statistically significant association could not be shown (p=0.740, Fisher’s exact test). However, after ‘effective CCs’ favourable outcome at 3 months was 32.0% compared with 5.3% if no actions were taken. The OR was 5.87 (p=0.02).ConclusionIn OHCA, two-thirds of all victims were found in positions not suitable for effective CCs. This was associated with inferior outcomes. A substantial proportion of the victims was placed in RP. More attention should be paid to the correct positioning of victims in OHCA. This applies to CPR training for laypersons and dispatcher-assisted CPR.

Immediate coronary angiography and intervention in suitable stenoses in patients resuscitated from cardiac arrest of presumed coronary origin and return of spontaneous circulation is widely established in interventional centers. The procedure is based on the analogy of positive results achieved with coronary intervention in many forms of acute coronary syndromes on the one hand and otherwise from registries showing promising data from coronary intervention of resuscitated patients. Results from randomized controlled studies, however, are not yet available. With respect to ST-elevation myocardial infarction, the diagnostic reliability of an ECG registered shortly after cardiopulmonary resuscitation is sufficient. The results of the registries are specifically promising for patients with ST-elevation myocardial infarction but less favorable for other forms of acute coronary syndromes. Moreover, insight into the results of the registries reveals that patients with the best prognostic conditions were preferentially selected for coronary intervention (e.g., younger patients, those with an initially shockable arrhythmia, bystander resuscitation), whereas those, for example, with cardiac or renal failure were excluded. For better definition of the actual benefit of coronary intervention after resuscitation from cardiac arrest and the optimal target groups, randomized controlled studies on patients with ST-elevation myocardial infarction are desirable, while for other forms of acute coronary syndromes these studies are essential.

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

This study compared the timing of onset of antiplatelet action after treatment with clopidogrel and prasugrel at first medical contact in patients with ST-segment elevation myocardial infarction (STEMI) scheduled for primary percutaneous coronary intervention (PPCI).Little is known about the timing of onset of antiplatelet action after a pre-percutaneous coronary intervention (PCI) loading dose of clopidogrel or prasugrel in patients with STEMI.This double-blind, prospective study randomized 62 patients with STEMI scheduled for PPCI in the ambulance or the emergency department to 60 mg prasugrel (n = 31) or 600 mg clopidogrel (n = 31). The primary endpoint was the platelet reactivity index (PRI) measured with the vasodilator-stimulated phosphoprotein assay 2 h after intake of the study medication. Secondary endpoints were PRI after 4 h, TIMI (Thrombolysis In Myocardial Infarction) patency of the infarct-related artery before and after PCI, and clinical events until day 30.The PRI after 2 h (50.4 ± 32.7% vs. 66.3 ± 22.2%; p = 0.035) and after 4 h (39.1 ± 27.5% vs. 54.5 ± 49.3%; p = 0.038) were significantly lower with prasugrel compared with clopidogrel. In addition, the rate of patients with a PRI50% tended to be higher with prasugrel compared with clopidogrel after 2 h (46.7% vs. 28.6%; p = 0.15) and after 4 h (63.0% vs. 38.9%; p = 0.06). There were no significant differences in TIMI 2/3 patency before PCI (39.2% vs. 31.0%; p = 0.43) and TIMI 3 patency after PCI (88.5% vs. 89.3%; p = 0.92).The pre-PCI administration of prasugrel in patients with STEMI undergoing PPCI was associated with a significant faster platelet inhibition compared with clopidogrel. Therefore, prasugrel should be preferred to clopidogrel in this setting. (ETAMI-Study: Early Thienopyridine Treatment to Improve Primary PCI in Patients With Acute Myocardial Infarction; NCT01327534).

Hintergrund Aufgrund der Entwicklung der Bevolkerungspyramide steigt der Anteil alterer Patienten stetig. Weit verbreitet ist die Meinung, dass die Behandlung akut lebensbedrohlicher Erkrankungen im Rettungsdienst durch eine uberproportional hohe Rate an unnotigen Alarmen fur alte Menschen in Altenheimen gefahrdet sei. Ziel der vorliegenden Studie war es, diese Beurteilung durch Zahlen und Fakten zu bestatigen oder zu widerlegen.

It is not known whether prehospital fibrinolysis, coupled with timely coronary angiography, provides a clinical outcome similar to that with primary percutaneous coronary intervention (PCI) early after acute ST-segment elevation myocardial infarction (STEMI).Among 1892 patients with STEMI who presented within 3 hours after symptom onset and who were unable to undergo primary PCI within 1 hour, patients were randomly assigned to undergo either primary PCI or fibrinolytic therapy with bolus tenecteplase (amended to half dose in patients ≥75 years of age), clopidogrel, and enoxaparin before transport to a PCI-capable hospital. Emergency coronary angiography was performed if fibrinolysis failed; otherwise, angiography was performed 6 to 24 hours after randomization. The primary end point was a composite of death, shock, congestive heart failure, or reinfarction up to 30 days.The primary end point occurred in 116 of 939 patients (12.4%) in the fibrinolysis group and in 135 of 943 patients (14.3%) in the primary PCI group (relative risk in the fibrinolysis group, 0.86; 95% confidence interval, 0.68 to 1.09; P=0.21). Emergency angiography was required in 36.3% of patients in the fibrinolysis group, whereas the remainder of patients underwent angiography at a median of 17 hours after randomization. More intracranial hemorrhages occurred in the fibrinolysis group than in the primary PCI group (1.0% vs. 0.2%, P=0.04; after protocol amendment, 0.5% vs. 0.3%, P=0.45). The rates of nonintracranial bleeding were similar in the two groups.Prehospital fibrinolysis with timely coronary angiography resulted in effective reperfusion in patients with early STEMI who could not undergo primary PCI within 1 hour after the first medical contact. However, fibrinolysis was associated with a slightly increased risk of intracranial bleeding. (Funded by Boehringer Ingelheim; ClinicalTrials.gov number, NCT00623623.).

Die ERC-Leitlinien empfehlen im Rahmen der Nachbehandlung nach Wiederbelebung eine routinemasige Koronarographie und eventuelle perkutane Koronarintervention (PCI) bei Patienten mit vermuteter koronarer Ursache des Kreislaufstillstands. Neben dem Analogschluss zum unkomplizierten Infarkt ist die Grundlage hierfur eine angebliche diagnostische Unsicherheit bezuglich Koronarverschlussen, die eine Abklarung notwendig machen wurde. Daneben werden zahlreiche Berichte und Fallserien zur Uberlebensrate mit gutem neurologischem Outcome fur die Empfehlungen herangezogen. Die ungewohnlich guten Ergebnisse sind moglicherweise Folge einer im Einzelfall nicht sicher nachvollziehbaren Patientenselektion und eines Publikationsbias. Hierfur spricht v. a., dass der Einfluss der PCI bei ST-Streckenhebungsinfarkt (STEMI) bzw. Non-STEMI-ACS mit Kreislaufstillstand auf das Outcome hoher zu sein scheint als bei routinemasiger Anwendung im Rahmen eines unkomplizierten STEMI oder eines Non-STEM-ACS. Aus den offenen Fragen ergeben sich die Forderung und Notwendigkeit, kunftige Leitlinien auf den Boden einer ausreichend grosen kontrollierten randomisierten Studie zu stellen, aus der der tatsachliche Nutzen eines interventionellen Vorgehens nach erfolgreicher CPR hervorgeht. Die Tatsache, dass das Risiko einer Intervention zumindest bei erfolgreicher PCI relativ begrenzt zu sein scheint und einige Publikationen aus nichtrandomisierten Studien reichen als Begrundung der Empfehlungen fur diese kritisch kranken Patienten nicht aus.

Training requirements to perform safe prehospital endotracheal intubation (ETI) are not clearly known. This study aimed to determine differences in ETI performance between 'proficient performers' and 'experts' according to the DreyfusDreyfus framework of expertise. As a model for 'proficient performers' EMS physicians with a clinical background in internal medicine were compared to EMS physicians with a background in anaesthesiology as a model for 'experts'.Over a one-year period all ETIs performed by the EMS physicians of our institution were prospectively evaluated. 'Proficient performers' and 'experts' were compared regarding incidence of difficult ETI, ability to predict difficult ETI, and decision for ETI.Mean years of professional experience were similar between the physician groups, but the median ETI experience differed significantly with 18/year for 'proficients' and 304/year for 'experts' (p0.001). 'Proficient performers' intubated 130 of their 2170 treated patients (6.0%), while 'experts' did so in 146 of 1809 cases (8.1%, p=0.01 for difference). The incidence of difficult ETI was 17.7% for 'proficient performers', and 8.9% for 'experts' (p0.05). In 4 cases ETI was impossible, all managed by 'proficient performers', but all patients could be ventilated sufficiently. Unexpected difficult ETI occurred in 6.1% for 'proficient performers', and 2.0% for 'experts' (p=0.08).In a prehospital setting 'expert' status was associated with a significantly lower incidence of 'difficult ETI' and a higher proportion of ETI decisions. In addition, ability to predict difficult ETI was higher, although non-significant. There was no difference in the incidence of impossible ventilation.

Der fortgeschriebene Minimale Notfalldatensatz MIND3 ist ein Kerndatensatz, der eine definierte und von der DIVI autorisierte Menge an Merkmalen und Merkmalsbeschreibungen enthalt, die zur Dokumentation der prahospitalen Notfallrettung durch Rettungs- und Notarztdienst erforderlich sind. Der modulare Aufbau ermoglicht eine situations- und einsatzgerechte Dokumentation auf einem Basismodul-DIVI-Notfalleinsatzprotokoll und entsprechenden Zusatzmodulen. Mit einer IT-gestutzten Datenerfassung werden die Grundlagen fur ein medizinisches Qualitatsmanagement gelegt.

In ST-elevation myocardial infarction (STEMI) the pre-hospital phase is the most critical, as the administration of the most appropriate treatment in a timely manner is instrumental for mortality reduction. STEMI systems of care based on networks of medical institutions connected by an efficient emergency medical service are pivotal. The first steps are devoted to minimize the patient's delay in seeking care, rapidly dispatch a properly staffed and equipped ambulance to make the diagnosis on scene, deliver initial drug therapy and transport the patient to the most appropriate (not necessarily the closest) cardiac facility. Primary PCI is the treatment of choice, but thrombolysis followed by coronary angiography and possibly PCI is a valid alternative, according to patient's baseline risk, time from symptoms onset and primary PCI-related delay. Paramedics and nurses have an important role in pre-hospital STEMI care and their empowerment is essential to increase the effectiveness of the system. Strong cooperation between cardiologists and emergency medicine doctors is mandatory for optimal pre-hospital STEMI care. Scientific societies have an important role in guideline implementation as well as in developing quality indicators and performance measures; health care professionals must overcome existing barriers to optimal care together with political and administrative decision makers

Im Vergleich zu den Anderungen der Leitlinien zur Wiederbelebung zwischen 2000 und 2005 sind die Neuerungen in den Leitlinien 2010 weniger pragnant. Die Vorgaben sind jedoch praziser geworden. Dies betrifft v. a. die fur das Uberleben entscheidende Qualitat der Basismasnahmen und der Herzdruckmassage. Wahrend Fragen zur optimalen Energie und Entladungscharakteristik bei der Defibrillation weiter auf Antwort warten, scheint die Integration von „ Feed-Back-Systemen“ in Defibrillatoren einen Beitrag zur Optimierung der Basisreanimation zu liefern. Unklar bleibt weiter die Rolle der Vasopressoren und Antiarrhythmika. In der Nachbehandlung wird die Bedeutung der therapeutischen Hypothermie unterstrichen, daneben die Rolle der Reperfusionstherapie bei koronarer Herzstillstandsursache herausgestellt. Bezuglich des akuten Koronarsyndroms werden sowohl die neuen Antithrombine und Plattchenhemmer als auch die Strategien zur Reperfusion bei ST-Hebungsinfarkt in ein Konzept der Initialbehandlung eingeordnet. Der vorliegende Artikel fasst in Kurzform die wesentlichen Anderungen in den neuen Leitlinien zusammen.

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.

Eng verbunden mit einer zunehmenden Zahl an Zentralen Notaufnahmen (ZNA) in Deutschland ist die Frage der zukunftigen Qualifikation des arztlichen Personals. Im Gegensatz zu einigen anderen Staaten der Europaischen Union kennt Deutschland eine Weiterbildung zum Facharzt fur Notfallmedizin nicht, Fachgesellschaften und Interessenverbande formulieren teilweise auserst kontroverse Standpunkte. Im Wissenschaftszentrum Reisensburg bei Ulm diskutierten nun Vertreter der verschiedenen Fachgesellschaften, Organisationen und Institutionen, inwieweit die Qualifikation des zukunftig in ZNA tatigen arztlichen Personals zu regeln und zu optimieren ist. Deutlich wurde dabei, dass die Entwicklung in Europa nicht negiert werden darf und den deutschen notfallmedizinisch interessierten Arztinnen und Arzten eine verlassliche Perspektive im eigenen Land gegeben werden muss. Drei Modelle erscheinen dabei moglich: 1) zusatzliche auf die Tatigkeit und die Funktion in der Notaufnahme zugeschnittene Kursformate vergleichbar mit den fur den praklinischen Bereich eingefuhrten Fachkundenachweisen bzw. Zusatzbezeichnungen, 2) Integration und Erganzung bestehender Weiterbildungen durch Inhalte des Europaischen Curriculums und fakultative Weiterbildung bzw. Zusatzbezeichnung nach Erwerb des originaren Facharzttitels sowie 3) fakultative Weiterbildung als Basis fur eine vor dem Hintergrund europaischer Initiativen auch in Deutschland in Zukunft nicht auszuschliesende Weiterbildung zum Facharzt fur Notfallmedizin. Inwieweit die ZNA sich dabei zukunftig zum Kompetenzzentrum der pra- und innerklinischen Notfallmedizin mit hoher Attraktivitat fur das eingebundene Personal entwickeln kann, bleibt abzuwarten.

Several studies have found that among patients with ST-elevation myocardial infarction (STEMI) treated by thrombolysis, female sex is associated with a worse outcome. The aim of this study was to investigate sex-related differences in clinical and angiographic findings in patients with STEMI treated with primary angioplasty and Gp IIb-IIIa inhibitors. Our population is represented by 1662 patients undergoing primary angioplasty included in the EGYPT database. Myocardial perfusion was evaluated by myocardial blush grade and ST-segment resolution. Follow-up data were collected between 30 days and 1 year after primary angioplasty. Among 1662 patients, 379 were women (22.8%). Female sex was associated with more advanced age, higher prevalence of diabetes, hypertension, more advanced Killip class, longer ischemia time, less often smokers, with higher prevalence of preprocedural recenalization. No difference was observed in terms of postprocedural TIMI flow, myocardial perfusion and distal embolization. Similar findings were observed in terms of enzymatic infarct size and preprocedural ejection fraction. Female gender was associated with higher mortality (6.4% vs. 3.6%, HR = 1.83 [1.12-3.0], P = 0.015). However, the difference disappeared after correction for baseline confounding factors (HR = 1.01 [0.56-1.83], P = 0.98). This study shows that in patients with STEMI treated by primary angioplasty, female gender is associated with higher mortality rate in comparison with men, and this is mainly due to their higher clinical and angiographic risk profiles. In fact, female sex did not emerge as an independent predictor of mortality.

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

Background An important predictor of outcomes from out-of-hospital cardiac arrest (OOHCA) is bystander resuscitation, but in industrialised nations this is undertaken only in 15–50%. To explore reasons for this low response rate we analysed bystander perceptions during the victim's collapse, and methods used to assess cardiac arrest. Methods Over a 12-month period we prospectively investigated all dispatches for witnessed cardiac arrest of two physician-staffed emergency medical service (EMS) units within a western European metropolitan area (Berlin, Germany). On scene the bystander was identified by the EMS physician and approached to have a semi-structured interview in the following days. Results Out of 201 eligible responses, 138 bystanders could be interviewed (68.7%). 63 (45.3%) of these bystanders did not detect cardiac arrest. 36 bystanders (25.9%) spontaneously reported a “bluish colour” of the patient's head or body which occurred “unexpectedly”. 39 persons (28.1%) reported abnormal breathing. Assessment of breathing was not undertaken in 27.0%, nor of circulation in 29.0%. If circulation was assessed pulse check was performed in 93.4%. Conclusion In this sample of interviewed bystanders of OOHCA, almost half of the arrests were not detected. This might be a reason for the low rate of bystander resuscitation. Common bystander perceptions of arrest presence included “bluish skin colour” and abnormal breathing of the victim. These findings indicate that improvement of perception capabilities should be incorporated as a major learning objective into lay basic life support training. In addition, information regarding skin colour may be of value in dispatch protocols.

Objective: Percutaneous coronary intervention (PCI) appears to be superior to in-hospital fibrinolysis for most patients with ST-elevation myocardial infarction (STEMI). However, few hospitals have PCI capability. The optimal prehospital strategy for facilitating rapid coronary reperfusion in STEMI patients is unclear. We sought to determine whether direct transport of adult STEMI patients by emergency medical services to primary PCI centres improves 30-day all-cause mortality when compared with a strategy of transportation to the closest hospital. Methods: We systematically searched MEDLINE, EMBASE, Cochrane “CENTRAL” database (1980-July 2007) and several other electronic databases. Two authors independently assessed citations for relevance. Two authors independently abstracted data from included studies. We included studies that, 1) transported patients directly to a PCI-capable centre for primary PCI, 2) had a control group that was transported to the closest hospital and 3) reported outcomes of treatment time intervals, all-cause mortality, reinfarction rate, stroke rate or the frequency of cardiogenic shock. We used a random effects model to provide pooled estimates of relative risk (RR) when data allowed. Results: We identified 2264 citations with the search. Five studies, including 980 STEMI patients, met inclusion criteria, and were clinically heterogeneous and of variable quality. Most studies were European (3/5) and involved physician out-of-hospital care providers. There was a trend toward increased survival with direct transport to primary PCI but this was not statistically significant (RR 0.51, 95% confidence interval [CI] 0.24–1.10). One study reported nonsignificant reductions in reinfarction (RR 0.43, 95% CI 0.11–1.60) and stroke (RR 0.33, 95% CI 0.01–8.06) with direct transport for primary PCI. Conclusion: There is insufficient evidence to support the effectiveness of direct transport of patients with STEMI for primary PCI when compared with transportation to the closest hospital.

Severe myocardial ischemia is the leading cause of arrhythmic sudden cardiac death. It is unclear, however, in which percentage of patients sudden cardiac death is triggered by ST-elevation myocardial infarction (STEMI) and whether the diagnosis of STEMI can be reliably established immediately after resuscitation from out-of-hospital sudden cardiac death.A 12-lead ECG was registered after return of spontaneous circulation after cardiac arrest. After hospital admission, further ECG, creatine kinase MB, and troponin measures; results of coronary angiograms; and autopsies were evaluated to confirm the definitive diagnosis of STEMI.Seventy-seven patients were included in our study (67% men, age 64 [14 to 93] years). STEMI was diagnosed in 44 patients. The diagnosis of myocardial infarction was confirmed in 84% of the 77 patients who survived to hospital admission. The sensitivity of the out-of-hospital ECG was 88% (95% confidence interval [CI] 74% to 96%), the specificity 69% (95% CI 51% to 83%), the positive predictive value 77% (95% CI 62% to 87%), and the negative predictive value 83% (95% CI 64% to 87%). The accuracy of the out-of-hospital ECG and that registered on admission was the same.The diagnosis of STEMI can be established in the field immediately after return of spontaneous circulation in most patients. This may enable an early decision about reperfusion therapy, ie, immediate out-of-hospital thrombolysis or targeted transfer for percutaneous coronary intervention.

Die neueste Handlungsempfehlung der „American Heart Association“ (AHA) vom 31. Marz 2008 beinhaltet die Forderung, dass Notfallzeugen eines auserklinischen Herzstillstands vermutlich kardialer Genese bei Erwachsenen, die nicht oder nicht mehr ausreichend in der kardiopulmonalen Reanimation (CPR) geubt sind, eine alleinige Herzdruckmassage ohne Beatmung durchfuhren sollen (sog. „compression-only CPR“). Sowohl der „German Resuscitation Council“ (GRC) wie auch der „European Resuscitation Council“ (ERC) sehen diesbezuglich keinen Bedarf, die aktuellen Reanimationsleitlinien des ERC fur lebensrettende Basismasnahmen bei Erwachsenen zu andern oder zu erganzen: Laienhelfer, die nicht gewillt oder unfahig sind, eine Mund-zu-Mund-Beatmung durchzufuhren, sollen eine CPR ausschlieslich mittels Thoraxkompressionen durchfuhren. Diese Aussage ist bereits in den offiziellen Reanimationsleitlinien, die vom ERC im November 2005 veroffentlicht wurden, beinhaltet. Ersthelfer, die uber eine geeignete Ausbildung und Erfahrung verfugen, sollten dagegen bis zum Eintreffen des Rettungsdienstes eine kombinierte Herz-Lungen-Wiederbelebung durchfuhren. Die Ausbildung von jugendlichen Laienhelfern und die Etablierung von Schulungsprogrammen durch Hilfsorganisationen und in Schulen muss starker gefordert werden.

Modern cardiopulmonary resuscitation is based on a concept of Safar et al (1961) suggesting a combination of chest compression and ventilation. The ratio of chest compression to ventilation has been changed from 4 : 1 (1961) to 30 : 2 at the present time, because experimental and clinical studies have demonstrated that chest compression (circulation) is more important in resuscitation of cardiac arrest (ventricular fibrillation, asystole, pulsless electrical activity) than ventilation. Mouth-to-mouth breathing is associated with problems questioning its role at the beginning of resuscitation by lay rescuer. The idea of mouth-to-mouth breathing may prevent resuscitative measures at all, may be the only measure (in about 10 % of lay resuscitations), may result in gastric inflation with vomiting, takes off important time from chest compression and may decrease cardiac output and thus diminish the chance of effective defibrillation in case of ventricular fibrillation. Recently a nurse of our hospital resuscitated a bicycle driver with ventricular fibrillation by chest compression without ventilation for at least 8 - 9 minutes. After defibrillation the patient fully recovered within some hours supporting the results of animal experiments that demonstrate that ventilation may be omitted in cardiac arrest during the first 10 minutes of resuscitation. Large prospective clinical studies are required to ultimately assess the value of ventilation in resuscitation of the adult.

The latest guidelines on the emergency care of acute ST-elevation myocardial infarction were published by the European Resuscitation Council at the end of 2005. Since then, numerous studies have been presented, which have led to important conclusions. Among pharmacological interventions, the opinion on adjuncts to anticoagulant treatment in the area of thrombolysis as well as in primary coronary intervention seems to be moving away from unfractionated heparin towards low molecular weight heparin, and possibly even factor Xa-specific pentasaccharide or the direct antithrombin bivalirudin. Clopidogrel has developed to become an accepted standard alongside aspirin in thrombolytic therapy of ST-elevation myocardial infarction, even if some questions still remain open. The promising idea of "facilitated percutaneous coronary intervention" has shown itself to at least be problematic if performed immediately and routinely after thrombolysis; "rescue" intervention in the event of ineffective thrombolysis is, on the other hand, useful and effective. Apparently, a more individualistic approach is required, which combines new therapeutic options and patients' conditions on the one side with regional resources on the other, to produce an optimal and timely strategy, remembering that one size does not fit all.

Background: Even though time-to-treatment has been shown to be a determinant of mortality in primary angioplasty, the potential benefits from early pharmacological reperfusion by glycoprotein (Gp) IIb–IIIa inhibitors are still unclear. The aim of this meta-analysis was to combine individual data from all randomised trials conducted on facilitated primary angioplasty by the use of early Gp IIb–IIIa inhibitors. Methods and results: The literature was scanned by formal searches of electronic databases (MEDLINE, EMBASE) from January 1990 to October 2007. All randomised trials on facilitation by the early administration of Gp IIb–IIIa inhibitors in ST-segment elevation myocardial infarction (STEMI) were examined. No language restrictions were enforced. Individual patient data were obtained from 11 out of 13 trials, including 1662 patients (840 patients (50.5%) randomly assigned to early and 822 patients (49.5%) to late Gp IIb–IIIa inhibitor administration). Preprocedural Thrombolysis in Myocardial Infarction Study (TIMI) grade 3 flow was more frequent with early Gp IIb–IIIa inhibitors. Postprocedural TIMI 3 flow and myocardial blush grade 3 were higher with early Gp IIb– IIIa inhibitors but did not reach statistical significance except for abciximab, whereas the rate of complete STsegment resolution was significantly higher with early Gp IIb–IIIa inhibitors. Mortality was not significantly different between groups, although early abciximab demonstrated improved survival compared with late administration, even after adjustment for clinical and angiographic confounding factors. Conclusions: This meta-analysis shows that pharmacological facilitation with the early administration of Gp IIb– IIIa inhibitors in patients undergoing primary angioplasty for STEMI is associated with significant benefits in terms of preprocedural epicardial recanalisation and ST-segment resolution, which translated into non-significant mortality benefits except for abciximab.

Die internistische Notfallmedizin bietet dem Internisten ein breites Spektrum an Moglichkeiten sowohl im prahospitalen Einsatz als auch in der Notfallambulanz und schlieslich im Rettungsteam innerhalb des Krankenhauses. Internistische Krankheitsbilder sind Schwerpunkt prahospitaler notarztlicher Tatigkeit, sie sind Schlusselprobleme bei der Entscheidung zur stationaren Therapie bzw. ambulanter Behandlung in der Notfallambulanz des Krankenhauses und auch Schwerpunkt innerklinischer Notfalleinsatze nicht nur in internistischen Abteilungen. Die Strukturierung von Krankenhausambulanzen als eigenstandige Abteilung erganzen als wichtiges und interessantes Gebiet die moglichen Aufgabenfelder des Internisten. Der wachsende Anteil der Bevolkerung mit chronischen, z.T. sehr komplexen Erkrankungen sowie die demographische Entwicklung mit zunehmend mehr multimorbiden alteren Menschen sind auf dem Hintergrund des gesellschaftlichen Wandels aber auch auf dem Hintergrund der knappen Ressourcen eine Herausforderung an die internistische Notfallmedizin. Dem verbreiterten Aufgabenspektrum steht die fortschreitende Spezialisierung des Internisten gegenuber, fur die die Notfallmedizin eher Belastung als Chance zu sein scheint. Die durch Spezialisierung hervorgerufene Anderung der Interessen, der Forschungsschwerpunkte und Karrieremoglichkeiten konnte bei fehlender Gegensteuerung zu einem weitgehenden Verlust der wichtigen Rolle des Internisten in der Notfallmedizin fuhren.

Efficacy of reperfusion therapy in acute myocardial infarction (AMI) is strictly time-dependent. Most benefit is achieved with initiation of therapy within the first 60–90 min after onset of symptoms. The majority of patients with AMIs are seen within this time window by emergency medical services. Moreover, average time gain of about 60 min is possible by prehospital thrombolysis. Randomized studies yielded a better outcome when a time gain of 90 min and more was achieved. Prehospital diagnosis of AMI is reliable. Moreover, out-of-hospital thrombolysis has no additional specific risks nor is it an obstacle for later percutaneous intervention. Consequently, patients seen within the first 60–90 min after onset of symptoms or for whom a time gain of 90 min or more can be expected should receive immediate prehospital thrombolysis. D 2001 Elsevier Science Ltd. All rights reserved.

Der Erfolg der Behandlung der Patienten im Krankenhaus ist ganz wesentlich abhangig von der Primarversorgung, die im Bereich der kardiopulmonalen Reanimation zu einem Grosteil auserhalb der Klinik (praklinisch) verlauft. Hierbei ist das Ineinandergreifen von Therapiemasnahmen im Sinne der Rettungskette von ebensolcher Bedeutung wie die Erarbeitung von „Clinical Pathways“ und „Standard Operating Procedures“ und deren Implementierung in den Klinikalltag. Im Hinblick auf Struktur-, Behandlungs- und Ergebnisqualitat der Patientenversorgung ist speziell nach kardiopulmonaler Reanimation ein Umsetzungsbedarf fur die Anwendung der milden therapeutischen Hypothermie sowie fur die fruhzeitige Defibrillation bei innerklinischem Kreislaufstillstand infolge Kammerflimmern bzw. bei pulsloser Kammertachykardie vorhanden. Grosere Bedeutung sollte dem fruhzeitigen Erkennen von Patienten mit drohenden Storungen der Vitalfunktionen beigemessen werden. Die Etablierung dazu erforderlicher Strukturen (Herzalarmteam, Medizinisches Notfallteam) ist innerklinisch mit Personal-, Material- und Organisationsaufwand verbunden. Deren Kosten mussen im Hinblick auf die Vermeidung von Zwischenfallen und schlussendlich auf das Outcome der Patienten und damit saldierte Kosten je Behandlungsfall seitens der Kostentrager kalkuliert werden.

Bereits bei der Formulierung des ILCOR Consensus on Science 2005 zur kardiopulmonalen Reanimation lagen neue Erkenntnisse vor, die nicht mehr Eingang in diesen Konsensus und damit in die daraus resultierenden praktischen Leitlinien finden konnten. Daruber hinaus zeigten sich bei der Diskussion um diese Konsens noch zahlreiche offene Fragen. Nicht jeder Teilaspekt der betroffenen Gebiete konnte abschliesend behandelt werden. So bestehen beispielsweise noch verschiedenste Wissenslucken zur Defibrillation, zur Nachbehandlung, zu Ausbildung und Training, zu den eingesetzten Medikamenten usw. Inzwischen sind rund 360 Fragestellungen formuliert, die in der Vorbereitung zum nachsten ILCOR Consensus on Science im Jahr 2010 bearbeitet werden sollen. Mehrere Treffen der Arbeitsgruppen sind bereits geplant, in denen die Worksheets zu den einzelnen Themen ausgearbeitet werden sollen. So ist zu erwarten, dass die Leitlinien 2010 wiederum wesentliche Veranderungen mit sich bringen werden.

Resuscitation in cardiac arrest rarely results in survival with a good neurologic outcome. It is therefore a common problem to decide when resuscitation should not be initiated or an ongoing attempt has to be terminated. Resuscitation attempts should be withheld or terminated if there is a do not resuscitate order (DNR), if resuscitation is not in accordance with the presumptive will of the patient or does not have a chance to allow the patient to continue an independent living. As long as ventricular fibrillation or pulseless ventricular tachycardia are present, however, resuscitation should be continued. Also in pulmonary embolism prolonged resuscitation measures may be necessary. In out-of-hospital cardiac arrest resuscitation may be stopped when the three criteria are met: not witnessed arrest, no ventricular fibrillation or pulseless tachycardia, and no return of spontaneous circulation before arrival at the hospital. According to current guidelines in-hospital resuscitation can be terminated if the patient is in asystole for at least 20 minutes. In any case termination of a resuscitation attempt is an individual decision where all possible information on circumstances and on the patient should be taken into account.

Hintergrund Die prahospitale Versorgung des akuten Koronarsyndroms (ACS) durch Anasthesisten und Kardiologen wird verglichen.

Basic life support (BLS) by doctors has been shown to be of poor quality. To improve medical education training should be simplified, and simultaneously the learner should be involved more actively. To combine both ideas we trained medical students to give BLS courses and sent them to teach school children. This was a requirement for their emergency medicine course. Our model was compared to conventional teaching.Medical students were assigned at random to one of three groups. Group 1 ("university") attended a conventional university BLS/ALS course. Group 2 ("EMS") accompanied a BLS vehicle of the emergency medical service (EMS) after suitable preparation. Group 3 ("school") was instructed to teach BLS and then sent to teach at schools.Clinically significant BLS skills, and overall BLS skills, each assessed by structured clinical examination (SCE). Theoretical knowledge assessed by written (open question) test.Clinically relevant mistakes were seen in 37.5% in group 1 ("university"), compared to 28.8% in group 2 ("EMS"), and 11.3% in group 3 ("school"). Highly significant differences were shown between "school" and "EMS" (p=0.011), and between "school" and "university" (p0.001). In practical testing for overall performance the "university" group reached a median of 78.8% (25th-75th percentile 69.2-84.6%), group "EMS" reached 76.9% (69.2-88.5%), and group "school" 84.6% (76.9-90.0). Group "school" showed significant advantages over "university" (p=0.015) and "EMS" (p=0.010). Written test results did not differ statistically.Medical students teaching BLS to school children as a compulsory element of their own medical training showed superior practical skills as compared to conventional teaching. Theoretical knowledge was equivalent to the control groups, although their course contained less theoretical information.

Ist schon die Indikationsstellung zum Beginn einer Reanimation haufig ein Problem, ist der Abbruch der Wiederbelebung, die erst einmal eingeleitet worden ist, eine noch grosere Herausforderung. Wahrend altere Untersuchungen auf die Moglichkeiten mehr oder weniger aufwandiger Untersuchungen der endexspiratorischen CO2-Konzentration bzw. des koronaren Perfusionsdrucks hinweisen, zeigen neuere Studien relativ einfache Algorithmen auf. Diese beruhen im Wesentlichen auf dem Fehlen eines defibrillationsfahigen Rhythmus und dem Fehlen der Wiederherstellung des Kreislaufs bei Kreislaufstillstand ohne Augenzeugen. Diese Algorithmen ermoglichen auch nichtarztlichen Rettungskraften, mit guter Verlasslichkeit eine Entscheidung zum Abbruch der Reanimation zu stellen, und konnen auch fur den Notarzt hilfreich sein.

Die kurzlich publizierten neuen Leitlinien zur kardiopulmonalen Reanimation, die aus einem internationalen "Consensus of Science" abgeleitet wurden, stellen viele der bisher fest gefugt erscheinenden Vorgehensweisen in Frage. Dies erklart den auserordentlichen Umfang der Anderung im Vergleich zu fruheren Leitlinien. Im Zentrum des neuen Vorgehens stehen Anderungen im Bereich der Basisreanimation. Primares Ziel ist eine Vereinfachung der Masnahmen. Daneben wird bei der Reanimation des Erwachsenen die Bedeutung der Herzdruckmassage besonders herausgestellt. Die Erkenntnis, dass moglichst fruhzeitiges Einleiten effektiver Basisreanimation der Schlussel zum Reanimationserfolg ist, war Antrieb fur diese Modifikationen. In den erweiterten Masnahmen jenseits der Fortfuhrung der neuen Regeln zur Basisreanimation finden sich nur relativ wenig Anderungen. Dagegen wird in den neuen Leitlinien die grose Bedeutung der milden therapeutischen Therapie nach primar erfolgreicher Reanimation unterstrichen.

Immediate coronary angiography and intervention in suitable stenoses in patients resuscitated from cardiac arrest of presumed coronary origin and return of spontaneous circulation is widely established in interventional centers. The procedure is based on the analogy of positive results achieved with coronary intervention in many forms of acute coronary syndromes on the one hand and otherwise from registries showing promising data from coronary intervention of resuscitated patients. Results from randomized controlled studies, however, are not yet available. With respect to ST-elevation myocardial infarction, the diagnostic reliability of an ECG registered shortly after cardiopulmonary resuscitation is sufficient. The results of the registries are specifically promising for patients with ST-elevation myocardial infarction but less favorable for other forms of acute coronary syndromes. Moreover, insight into the results of the registries reveals that patients with the best prognostic conditions were preferentially selected for coronary intervention (e.g., younger patients, those with an initially shockable arrhythmia, bystander resuscitation), whereas those, for example, with cardiac or renal failure were excluded. For better definition of the actual benefit of coronary intervention after resuscitation from cardiac arrest and the optimal target groups, randomized controlled studies on patients with ST-elevation myocardial infarction are desirable, while for other forms of acute coronary syndromes these studies are essential.

Clopidogrel, in combination with acetylsalicylic acid, has become a mainstay of the pharmacological therapy for patients with acute coronary syndromes, especially in those undergoing percutaneous coronary interventions (PCI). While a series of studies has shown that pre-treatment with a loading dose of clopidogrel 300 or 600 mg prior to PCI is effective in reducing cardiovascular complications, the optimal dose and timing in various patient groups is still unclear. The primary objective of the present randomized, open-label Clopidogrel to Improve Primary percutaneous coronary Intervention in Acute Myocardial Infarction (CIPAMI) study is to evaluate the efficacy and the safety of a 600 mg loading dose of clopidogrel in addition to standard acetylsalicylic acid/heparin treatment in the pre-hospital setting in 654 patients with acute ST elevation myocardial infarction scheduled for primary PCI. The primary efficacy endpoint is the TIMI 2/3 patency of the infarct-related artery immediately prior to PCI. The rationale, design and methods of this study are described.

Bei dem Patienten trat nach korperlicher Anstrengung ein Elektrodenbruch des implantierten Schrittmachersystems auf. Die Elektrode war mit dem frei flottierenden Ende in die Pulmonalarterie embolisiert. Mithilfe eines Lasso-Katheters konnte die Elektrode mobilisiert und extrahiert werden. Dadurch konnte eine offene Revision unter Thorakotomie vermieden werden.

Background— Out-of-hospital sudden cardiac death (SCD) is a frequent cause of death. Survival rates remain low despite increasing efforts in medical care. Better understanding of the circumstances of SCD could be helpful in developing preventive measures and facilitating proper reactions to such a pending event. Methods and Results— Information on cases of out-of-hospital SCD was collected in the Berlin, Germany, emergency medical system via a questionnaire. Bystander interviews were performed by the emergency physician on scene immediately after declaration of death or return of circulation. Of 5831 rescue missions, 406 involved patients with presumed cardiac arrest. Sixty-six percent had a known cardiac disease. In 72%, the arrest occurred at home, and in 67%, it occurred in the presence of an eyewitness. Information on symptoms immediately preceding the arrest was available in 80% (n=323) of all 406 patients and in 274 of those with witnessed arrest. Symptoms were identical in the 2 groups. Typical angina was present for a median of 120 minutes in 25% of the 274 patients with witnessed arrest and in 33% with a symptom duration of less than 1 hour. Conclusions— SCD occurs most often at home in the presence of relatives and after a longer period of typical warning symptoms. Although the much-hailed use of public access defibrillation is supported by several studies, the present results raise the question of whether educational measures and targeted educational programs tailored for patients at risk and their relatives should have a higher priority.

The new CPR guidelines are based on a scientific consensus which was reached by 281 international experts. Chest compressions (100/min, 4–5 cm deep) should be performed in a ratio of 30:2 with ventilation (tidal volume 500 ml, Ti 1 s, FIO2 if possible 1.0). After a single defibrillation attempt (initially biphasic 150–200 J, monophasic 360 J, subsequently with the respective highest energy), chest compressions are initiated again immediately for 2 min. Endotracheal intubation is the gold standard; other airway devices may be employed as well depending on individual skills. Drug administration routes for adults and children: first choice IV, second choice intraosseous, third choice endobronchial [epinephrine dose 2–3× (adults) or 10× (pediatric patients) higher than IV]. Vasopressors: 1 mg epinephrine every 3–5 min IV. After the third unsuccessful defibrillation attempt amiodarone IV (300 mg); repetition (150 mg) possible. Sodium bicarbonate (1 ml/kg 8.4%) only in excessive hyperkalemia, metabolic acidosis, or intoxication with tricyclic antidepressants. Consider atropine (3 mg) and aminophylline (5 mg/kg). Thrombolysis during spontaneous circulation only in myocardial infarction or massive pulmonary embolism; during CPR only during massive pulmonary embolism. Cardiopulmonary bypass only after cardiac surgery, hypothermia or intoxication. Pediatrics: best improvement in outcome by preventing cardiocirculatory collapse. Alternate chest thumps and chest compression (infants), or abdominal compressions (>1-year-old) in foreign body airway obstruction. Initially five breaths, followed by chest compressions (100/min; ~1/3 of chest diameter): ventilation ratio 15:2. Treatment of potentially reversible causes (4 “Hs”, “HITS”: hypoxia, hypovolemia, hypo- and hyperkaliemia, hypothermia, cardiac tamponade, intoxication, thrombo-embolism, tension pneumothorax). Epinephrine 10 µg/kg IV or intraosseously, or 100 µg (endobronchially) every 3–5 min. Defibrillation (4 J/kg; monophasic oder biphasic) followed by 2 min CPR, then ECG and pulse check. Newborns: inflate the lungs with bag-valve mask ventilation. If heart rate 90 min until PCI). Stroke is an emergency and needs to be treated in a stroke unit. A CT scan is the most important evaluation, MRT may replace a CT scan. After hemorrhage exclusion, thrombolysis within 3 h of symptom onset (0.9 mg/kg rt-PA IV; max 90 mg within 60 min, 10% of the entire dosage as initial bolus, no aspirin, no heparin within the first 24 h). In severe hemorrhagic shock, definite control of bleeding is the most important goal. For successful CPR of trauma patients, a minimal intravascular volume status and management of hypoxia are essential. Aggressive fluid resuscitation, hyperventilation, and excessive ventilation pressure may impair outcome in severe hemorrhagic shock. Despite bad prognosis, CPR in trauma patients may be successful in select cases. Any CPR training is better than nothing; simplification of contents and processes remains important.