Search

Background: 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 Dreyfus & Dreyfus 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'., Methods: 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., Results: 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' (p<0.001). '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' (p<0.05). 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)., Conclusions: 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., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objectives: For experienced personnel endotracheal intubation (ETI) is the gold standard to secure the airway in prehospital emergency medicine. Nevertheless, substantial procedural difficulties have been reported with a significant potential to compromise patients' outcomes. Systematic evaluation of ETI in paramedic operated emergency medical systems (EMS) and in a mixed physician/anaesthetic nurse EMS showed divergent results. In our study we systematically assessed factors associated with difficult ETI in an EMS exclusively operating with physicians., Methods: Over a 1-year period we prospectively collected data on the specific conditions of all ETIs of two physician staffed EMS vehicles. Difficult ETI was defined by more than 3 attempts or a difficult visualisation of the larynx (Cormack and Lehane grade 3, or worse). For each patient ETI conditions, biophysical characteristics and factors of the surrounding scene were assessed. Additionally, physicians were asked whether they had expected difficult ETI in advance., Results: Out of 3979 treated patients 305 (7.7%) received ETI. For 276 patients complete data sets were available. The incidence of difficult ETI was 13.0%. In 4 cases (1.4%) ETI was impossible, but no patient was unable to be ventilated sufficiently. Predicting conditions for difficult intubation were limited surrounding space on scene (p<0.01), short neck (p<0.01), obesity (p<0.01), face and neck injuries (p<0.01), mouth opening<3 cm (p<0.01) and known ankylosing spondylitis (p<0.01). ETI on the floor or with C-spine immobilisation in situ were of no significant influence. The incidence of unexpected difficult ETI was 5.0%., Conclusions: In a physician staffed EMS difficult prehospital ETI occurred in 13% of cases. Predisposing factors were limited surrounding space on scene and certain biophysical conditions of the patient (short neck, obesity, face and neck injuries, and anatomical restrictions). Unexpected difficult ETI occurred in 5% of the cases., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

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.

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

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: Time to cardiopulmonary resuscitation (CPR) is a main determinant of survival after out-of-hospital cardiac arrest. Only widespread implementation of training courses for laypersons can decrease response time., Methods and Results: In this prospective randomized trial, we evaluated how laypersons retained CPR skills and skills in using the automated external defibrillator (AED). A total of 1095 volunteers were randomly assigned to receive CPR/AED-training courses of 2h (375 persons), 4h (378 persons) or 7h (342 persons) duration. Courses were held in accordance with the guidelines for CPR. All trainees were tested immediately after the initial class in a standardized test scenario using an AED and a manikin. Either at 6 or at 12 months, retests were given to 164 and 206 volunteers, respectively. In 479 volunteers, retesting was completed at both 6- and 12-month intervals. At the immediate tests, the 7-h training group showed a slightly higher rate of correct responses (7h: 96%, 4h: 94%, 2h: 92%) (p<0.001). Skill retention decreased significantly in the three groups and was lowest after 12 months if no 6-month retests were done. In trainees who did undergo retesting at 6 months, skills did not deteriorate at 12 months. There were no significant differences between the three groups (overall correct responses: 2h: 72%, 4h: 73%, 7h: 74%) (ns)., Conclusions: A 2-h class is sufficient to acquire and retain CPR and AED skills for an extended time period provided that a brief re-evaluation is performed after 6 months.

Up to 90% of cardiac arrests are due to acute myocardial infarction or severe myocardial ischaemia. Thrombolysis is an effective treatment for ST-elevation myocardial infarction (STEMI), but there is no evidence or guideline to put forward a thrombolysis strategy during cardiopulmonary resuscitation (CPR). In two physician-manned emergency medical service (EMS) units in Berlin, Germany, using thrombolysis is based on an individual judgment of the EMS physician managing the CPR attempt. In this retrospective analysis over 3 years (total 22.164 scene calls), thrombolysis was started at the scene in 50 patients during brief intermittent phases of spontaneous circulation, and in 3 patients during ongoing CPR. On-scene diagnosis of myocardial infarction was established in 45 patients (85%) by a 12-lead ECG, 5 (9%) patients had a left bundle branch block. Sixteen patients (30%) died at the scene, 37 patients (70%) were admitted to a hospital. In-hospital mortality was 35% (13 of 37 patients), with cause of death being cardiogenic shock in nine patients, hypoxic cerebral coma in two and acute haemorrhage in two other patients. All 24 of 53 (45%) survivors were discharged with an excellent neurological recovery. CPR was started by an EMS physician in 18 of the 24 survivals (75%) and emergency medical technicians who arrived first in six (25%). Duration of CPR until return of spontaneous circulation was <10 min in 13 of 24 (54%) of the survivors. Thrombolysis was initiated during intermittent phases of spontaneous circulation in 50 (94%) of all patients and in 23 (96%) of the 24 survivors. In conclusion, this retrospective analysis shows excellent survival rates and neurological outcome in selected patients with a high likelihood of myocardial infarction, who develop cardiac arrest and are treated with thrombolysis.

Objectives: 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., Design: 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., Main Outcome Measures: Clinically significant BLS skills, and overall BLS skills, each assessed by structured clinical examination (SCE). Theoretical knowledge assessed by written (open question) test., Results: 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" (p<0.001). 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., Conclusion: 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.

Early defibrillation by emergency medical technicians or even less qualified personnel has been shown to improve survival rates for out-of-hospital cardiac arrest caused by ventricular fibrillation. It has been questioned whether these favourable results can be applied within the context of physician-attended emergency medical systems. Taking into consideration the results of a pilot study and after a careful analysis of the logistic and epidemiological background, the first German EMT-D program was introduced in the former West Berlin in December 1988. The first 2 years of experience with 499 technician-initiated resuscitation attempts in which the mobile intensive care unit of Klinikum Steglitz was involved, confirmed the results of the pilot study with an improved long-term survival rate (18%) for patients with ventricular fibrillation. We conclude that EMT defibrillation should be introduced in emergency physician-attended two-tiered emergency medical systems, whenever a thorough analysis of the existing rescue systems exhibits a 'relevant frequency' of resuscitation and response interval of 15 min or less.