https://genoplivning.dk/wp-content/uploads/2013/07/european-resuscitation-council-guidelines-for-resuscitation-2010-section-4-adult-advanced-life-support.pdf

European Resuscitation Council Guidelines for Resuscitation 2010 Section 4 Adult advanced life support

European Resuscitation Council Guidelines for Resuscitation.

In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest. Asphyxia begins with a variable period of systemic hypoxemia, hypercapnea, and acidosis, progresses to bradycardia and hypotension, and culminates with cardiac arrest.1

Another mechanism of cardiac arrest, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), is the initial cardiac rhythm in approximately 5% to 15% of pediatric in-hospital and out-of-hospital cardiac arrests;2,–,9 it is reported in up to 27% of pediatric in-hospital arrests at some point during the resuscitation.6 The incidence of VF/pulseless VT cardiac arrest rises with age.2,4 Increasing evidence suggests that sudden unexpected death in young people can be associated with genetic abnormalities in myocyte ion channels resulting in abnormalities in ion flow (see “Sudden Unexplained Deaths,” below).

Since 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR),10 it seems appropriate to review the progressive improvement in outcome of pediatric resuscitation from cardiac arrest. Survival from in-hospital cardiac arrest in infants and children in the 1980s was around 9%.11,12 Approximately 20 years later, that figure had increased to 17%,13,14 and by 2006, to 27%.15,–,17 In contrast to those favorable results from in-hospital cardiac arrest, overall survival to discharge from out-of-hospital cardiac arrest in infants and children has not changed substantially in 20 years and remains at about 6% (3% for infants and 9% for children and adolescents).7,9

It is unclear why the improvement in outcome from in-hospital cardiac arrest has occurred, although earlier recognition and management of at-risk patients on general inpatient units …

https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.110.971101

Part 14: Pediatric Advanced Life Support 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Early goal-directed therapy in the treatment of severe sepsis and septic shock

There is increasing concern that most current published research findings are false. The probability that a research claim is true may depend on study power and bias, the number of other studies on the same question, and, importantly, the ratio of true to no relationships among the relationships probed in each scientific field. In this framework, a research finding is less likely to be true when the studies conducted in a field are smaller; when effect sizes are smaller; when there is a greater number and lesser preselection of tested relationships; where there is greater flexibility in designs, definitions, outcomes, and analytical modes; when there is greater financial and other interest and prejudice; and when more teams are involved in a scientific field in chase of statistical significance. Simulations show that for most study designs and settings, it is more likely for a research claim to be false than true. Moreover, for many current scientific fields, claimed research findings may often be simply accurate measures of the prevailing bias. In this essay, I discuss the implications of these problems for the conduct and interpretation of research.

Why most published research findings are false

Ende August 2000 haben die American Heart Association und das European Resuscitation Council gemeinsam die internationalen Richtlinien zur kardiopulmonalen Reanimation (CPR) veroffentlicht; das Ergebnis sind CPR-Richtlinien, die gleichzeitig ein umfassendes Nachschlagewerk darstellen. Die Diskussion und erste Entwurfe begann in einer Konferenz in Dallas, Texas/USA im Marz 1999 sowie danach in einer zweiten Konferenz im September 1999 (jeweils ∼:250 Teilnehmer), und schlieslich einer dritten Konferenz im Februar 2000 (∼500 Teilnehmer). Eine genaue Durchsicht der aktuellen Literatur, Diskussionen, und Ubereinstimmung erfolgten danach per e-mail, Konferenzschaltungen, Facsimile, und personliche Treffen. Wahrend dem gesamten Prozess waren Wissenschaftler und Wiederbelebungsgesellschaften aus aller Welt beteiligt; wobei Teilnehmer aus den USA etwa 60%, und Teilnehmer von auserhalb der USA etwa 40% ausmachten. Um ein Ubergewicht eines Landes oder einer Wiederbelebungsgesellschaft zu vermeiden, wurden alle Themen von jeweils zwei Wissenschaftlern aus den USA und von auserhalb der USA untersucht und bewertet. Auf diese Weise kann man sagen, dass Anderungen in den neuen CPR Richtlinien anhand dieses “evidence-based” Konzepts durch Experten aus aller Welt getragen werden. Die wichtigsten Anderungen der Empfehlungen nach Einschatzung der Autoren sind die Abschaffung des Pulschecks fur Laien, 500 ml statt 800–1.200 ml Beatmungszugvolumina bei der Maskenbeatmung (FiO2 >0,4) eines Patienten mit ungesichertem Luftweg, Verifizierung einer endotrachealen Intubation durch Kapnometrie und einen Osophagusdetektor, Einsatz mechanischer Hilfsmittel wie interponierter abdominaler Kompressions-CPR, Westen CPR, aktiver-Kompressions-Dekompresions CPR, und der “inspiratory threshold valve” (ITV) CPR als Alternativen bzw. Erganzung zur manuellen Thoraxkompression, die Defibrillation mit <200 Joule biphasischen statt mit 200–360 Joule monophasischen Impulsen, Injektion von Vasopressin (40 Einheiten) und Adrenalin (1 mg) als vergleichbar wirksame Medikamente bei Herzkammerflimmern, Amiodaron (300 mg) bei refraktarem Kammerflimmern und pulsloser Kammertachykardie, sowie intravenose Lyse beim Schlaganfall.

Die neuen internationalen Richtlinien zur kardiopulmonalen Reanimation

Die Infusion von Volumenersatzmitteln stellt eine Basistherapie zur Korrektur von Flussigkeitsdefiziten dar. Zum Ausgleich eines primar intravasalen Volumendefizits wie z. B. im Rahmen eines Volumenmangelschocks stehen sowohl kristalloide als auch kolloidale Losungen zur Verfugung. Alternativ werden hypertone (HS) oder hyperton-hyperonkotische Losungen (HHL) zur raschen Auffullung des Intravasalraumes eingesetzt. Trotz der mittlerweile jahrzehntelangen Erfahrung mit Volumentherapeutika ist bis heute nicht vollstandig geklart, welches Volumenersatzmittel in welcher Menge, zu welchem Zeitpunkt und mit welcher Infusionsgeschwindigkeit verabreicht werden sollte. Das Konzept der „aggressiven“ Volumentherapie, wie es noch vor einigen Jahren zur Kreislaufstutzung bei schweren Traumen empfohlen wurde, wird heute jedenfalls zunehmend kritisch betrachtet. Die Leitsymptome Hypotension und Tachykardie bleiben jedoch in Ermangelung von Alternativen auch weiterhin die einzigen Zielgrosen einer Volumenersatztherapie.

Die Evidenz der Volumentherapie

Pain relief in the prehospital setting is often insufficient, as the administration of potent intravenous analgesic drugs is mostly reserved to physicians. In Australia, inhaled methoxyflurane has been in routine use by paramedics for decades, but experience in Central European countries is lacking. Thus, we aimed to assess whether user friendliness and effectiveness of inhaled methoxyflurane as sole analgesic match the specific capabilities of local ground and air-based EMS systems in Austria.Observational study in adult trauma patients (e.g. dislocations, fracture or low back pain following minor trauma) with moderate to severe pain (numeric rating scale [NRS] ≥4). Included patients received a Penthrop® inhaler containing 3 mL of methoxyflurane (maximum use 30 min). When pain relief was considered insufficient (NRS reduction < 3 after 10 min), intravenous analgesics were administered by an emergency physician. The primary endpoint was effectiveness of methoxyflurane as sole analgesic for transport of patients. Secondary endpoints were user friendliness (EMS personell), time to pain relief, vital parameters, side effects, and satisfaction of patients.Median numeric pain rating was 8.0 (7.0-8.0) in 109 patients. Sufficient analgesia (reduction of NRS ≥3) was achieved by inhaled methoxyflurane alone in 67 patients (61%). The analgesic effect was progressively better with increasing age. Side effects were frequent (n = 58, 53%) but mild. User satisfaction was scored as very good when pain relief was sufficient, but fair in patients without benefit. Technical problems were observed in 16 cases (14.7%), mainly related to filling of the inhaler. In every fifth use, the fruity smell of methoxyflurane was experienced as unpleasant. No negative effects on vital signs were observed.In prehospital use, inhaled methoxyflurane as sole analgesic is effective for transport of trauma patients (62%) with moderate to severe pain. Older patients benefit especially from inhaled methoxyflurane. Side effects are mild and vital parameters unaffected. Thus, inhaled methoxyflurane could be a valuable device for non-physician EMS personnel rescue services also in the central Europe region. 

https://bmcemergmed.biomedcentral.com/counter/pdf/10.1186/s12873-021-00565-6

Usability and effectiveness of inhaled methoxyflurane for prehospital analgesia - a prospective, observational study

Air medical transport of patients suffering of highly infectious diseases is typically performed employing portable isolation chambers. Although the likelihood of decompression flight emergencies is low, sustainability of the devices used is crucial. When a standard isolation unit was subjected to an explosive cabin decompression of 493 hPa, simulating a 32808 ft flight level accident, leak tightness of the unit was lost due to rupture of the bag caused by over expansion. When the pressure chamber experiment was repeated with a modified unit, distension was minimized by an additional compensation air bag, thus ensuring leak tightness.

/pdf/airplane-transport-isolators-may-loose-leak-tightness-after-pfun2enznb.pdf

Airplane transport isolators may loose leak tightness after rapid cabin decompression.

Hintergrund
Die perkutane transhepatische Cholangiodrainage (PTCD) und die Gallengangsstenteinlage sind sehr schmerzhafte Eingriffe in der interventionellen Radiologie und erfordern eine adaquate Analgesie. Der Einsatz von Remifentanil konnte bei spontan atmenden Patienten eine mogliche Strategie sein.

Wolfgang G. Voelckel

Papers

Die neuen internationalen Richtlinien zur kardiopulmonalen Reanimation

Die Evidenz der Volumentherapie

Usability and effectiveness of inhaled methoxyflurane for prehospital analgesia - a prospective, observational study

Airplane transport isolators may loose leak tightness after rapid cabin decompression.

Analgosedierung mit Remifentanil bei spontan atmenden Patienten für Eingriffe in der interventionellen Radiologie