Zusammenfassung
Bei der Durchsicht der notfallmedizinischen Publikationen der vergangenen Monate in
internationalen medizinischen Zeitschriften konnten zahlreiche neue, klinisch wichtige
Ergebnisse identifiziert werden. So ist bei Schädel-Hirn-Trauma die Anwendung hypertoner
Lösungen möglich, ohne dass jedoch das Langzeitergebnis wesentlich verbessert wird.
Wichtig erscheint die prähospitale Kapnometrie, da ansonsten bis zu 40 % aller beatmeten
Patienten hypoventiliert werden. Eine Studie an 200 Patienten mit prähospitalem Kreislaufstillstand
zeigt, dass in einer Subgruppe ein besseres Überleben (14 % vs. 2 %) erreicht wurde,
wenn bei einer Anfahrtszeit der Ambulanz von > 5 min vor der ersten Defibrillation
zunächst für 3 min konventionell reanimiert wurde, um das Herz zu reperfundieren.
Bei einer Kombination von ACD („active compression decompression”)-CPR mit einem speziellen
Beatmungsventil („inspiratory impedance threshold device”, ITD), das keine passive
Inspiration zulässt, kann ein signifikant besseres Überleben bis 24 h erreicht werden.
Ein solches Ventil führt zu einem verstärkten Blutrückstrom zum Herzen. Hochdosiertes
Adrenalin führte bei intrahospitaler CPR bei Kindern nicht zu einer Verbesserung,
sondern eher zu einer Verschlechterung der Überlebensrate. Im Vergleich zwischen einem
englischen Rettungssystem ohne Notarzt und dem deutschen Rettungssystem ist u. a.
die Überlebensrate nach prähospitalem Kreislaufstillstand mit Notarzt deutlich besser.
Die europäische multizentrische Studie zum Vasopressin vs. Adrenalin als initialem
Vasopressor bei der CPR an 1219 Patienten zeigte insgesamt identische Ergebnisse mit
beiden Vasopressoren. Bei den Subgruppen mit Asystolie bzw. längerer CPR war Vasopressin
überlegen. In weiteren Subgruppenanalysen waren die Gabe von Amiodaron und die Thrombolyse
während der CPR mit einer besseren Überlebensrate assoziiert. Die Lyse während der
Reanimation scheint die Rate der hämodynamischen Stabilisierung zu erhöhen, ohne mit
einer erhöhten Blutungsrate assoziiert zu sein. In einem klaren Statement des „International
Liaison Committee on Resuscitation” (ILCOR) wird die milde Hypothermie (Kühlung auf
32 - 34°C Körperkerntemperatur für 12 - 24 h nach Kreislaufstillstand kardialer Genese)
nicht nur für bewusstlose Patienten mit Kammerflimmern als initialem prähospitalem
Herzrhythmus, sondern auch für alle anderen erwachsenen Patienten (andere Herzrhythmen,
intrahospitale CPR) nach Kreislaufstillstand definitiv empfohlen. In randomisierten
klinischen Studien konnte so sehr eindrucksvoll das Überleben verbessert werden. Eine
solche therapeutische Kühlung kann theoretisch nahezu überall auch mit einfachen Mitteln
- wie der Infusion eiskalter Lösungen - durchgeführt werden.
Abstract
According to scientific publications focusing on emergency medicine and published
in international journals in the past few months, new and clinically important results
can be identified. In patients with severe head trauma (SHT), application of hypertonic
solutions is possible; long term outcome, however, is not improved by this measure.
Prehospital capnometry is important, because otherwise up to 40 % of all mechanically
ventilated patients are hypoventilated. In a study in 200 patients with prehospital
cardiac arrest and ventricular fibrillation as initial cardiac rhythm, subgroup analysis
(alarm-response time > 5 min) showed an increase in survival rate (14 % vs. 2 %),
if defibrillation was proceeded by 3 min of conventional cardiopulmonary resuscitation
(CPR) for reperfusion. If ACD („active compression decompression”)-CPR is combined
with a specific ventilatory valve („inspiratory impedance threshold device”, ITD)
which does not allow passive inspiration, survival rate after cardiac arrest is increased
for up to 24 h. Such a device facilitates an increase in venous return to the heart
during decompression of the thorax. High-dose adrenalin for intrahospital CPR in children
is not associated with better survival but with worse outcome. Comparison of an emergency
medical service (EMS) system from U.K. with paramedics and a physician-staffed German
EMS system demonstrated that survival rate following prehospital cardiac arrest is
markedly increased with doctors on board. The European multicentre trial comparing
vasopressin vs. adrenalin as first vasopressor during CPR in 1219 patients did not
reveal any differences between both groups. In subgroup analyses of patients with
asystoly and prolonged CPR, vasopressin was superior without being associated with
a benefit on neurological outcome. Further subgroup analyses revealed beneficial effects
of amiodarone and thrombolysis during CPR. Thrombolysis during CPR apears to be associated
with an increased rate of haemodynamic stabilisation without increased risk of bleeding
complications. In a very clear advisory statement, the ”International Liaison Committee
on Resuscitation” (ILCOR) has recommended mild therapeutic hypothermia (i. e., cooling
of cardiac arrest victims to 32 - 34°C central body temperature for 12 - 24 h following
cardiac arrest of cardiac etiology) not only for unconciuous patients with ventricular
fibrillation as initial prehospital rhythm, but also for all other adult patients
(other rhythms, intrahospital CPR) following cardiac arrest. In randomised controlled
clinical trials, this therapy has markedly improved survival rate and neurological
outcome. Such therapeutic cooling can be initiated nearly everywhere and with simple
methods - like the infusion of ice-cold cristalloid solutions.
Schlüsselwörter
Notfallmedizin - Schädel-Hirn-Trauma - Polytrauma - Kreislaufstillstand - kardiopulmonale
Reanimation
Key words
Emergency medicine - severe head trauma - polytrauma - cardiac arrest - cardiopulmonary
resuscitation
Literatur
- 1 http://www.uni-duesseldorf.de/WWW/AWMF/II/neur-047.htm.
- 2
Ruchholtz S, Nast-Kolb D.
Schädelhirntrauma.
Chirurg.
2002;
73
194-207
- 3
Polytrauma - Leitlinie für die unfallchirurgische Diagnostik und Therapie .
Unfallchirurg.
2001;
104
902-912
- 4
Liener U C, Rapp U, Lampl L, Helm M, Richter G, Gaus M, Wildner M, Kinzl L, Gebhard F.
Inzidenz schwerer Verletzungen. Ergebnisse einer populationsbezogenen Untersuchung.
Unfallchirurg.
2004;
107
483-490
- 5
Böttiger B W, Grabner C, Bauer H, Bode C, Weber T, Motsch J, Martin E.
Long term outcome after out-of-hospital cardiac arrest with physician staffed emergency
medical services: the Utstein style applied to a midsized urban/suburban area.
Heart.
1999;
82
674-679
- 6
Vassar M J, Perry C A, Gannaway W L, Holcroft J W.
7.5 % sodium chloride/dextran for resuscitation of trauma patients undergoing helicopter
transport.
Arch Surg.
1991;
126
1065-1072
- 7
Cooper D J, Myles P S, McDermott F T, Murray L J, Laidlaw J, Cooper G, Tremayne A B,
Bernard S S, Ponsford J,. HTS Study Investigators .
Prehospital hypertonic saline resuscitation of patients with hypotension and severe
traumatic brain injury: a randomized controlled trial.
JAMA.
2004;
291
1350-1357
- 8
Lewis R J.
Prehospital care of the multiply injured patient: the challenge of figuring out what
works.
JAMA.
2004;
291
1382-1384
- 9
Helm M, Schuster R, Hauke J, Lampl L.
Tight control of prehospital ventilation by capnography in major trauma victims.
Br J Anaesth.
2003;
90
327-332
- 10
Cera S M, Mostafa G, Sing R F, Sarafin J L, Matthews B D, Heniford B T.
Physiologic predictors of survival in post-traumatic arrest.
Am Surg.
2003;
69
140-144
- 11
Bunch T J, White R D, Gersh B J, Meverden R A, Hodge D O, Ballman K V, Hammill S C,
Shen W K, Packer D L.
Long-term outcomes of out-of-hospital cardiac arrest after successful early defibrillation.
N Engl J Med.
2003;
348
2626-2633
- 12
Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care
International consensus on science .
Circulation.
2000;
102 (suppl)
I-1-I-384
- 13
Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care.
International consensus on science .
Resuscitation.
2000;
46
1-447
- 14
Wik L, Hansen T B, Fylling F, Steen T, Vaagenes P, Auestad B H, Steen P A.
Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with
out-of-hospital ventricular fibrillation: a randomized trial.
JAMA.
2003;
289
1389-1395
- 15
Eftestol T, Wik L, Sunde K, Steen P A.
Effects of cardiopulmonary resuscitation on predictors of ventricular fibrillation
defibrillation success during out-of-hospital cardiac arrest.
Circulation.
2004;
110
10-15
- 16
Fischer M, Krep H, Wierich D, Heister U, Hoeft A, Edwards S, Castrillo-Riesgo L G,
Kraft T.
Effektivitäts- und Effizienzvergleich der Rettungsdienstsysteme in Birmingham (UK)
und Bonn (D).
Anästhesiol Intensivmed Notfallmed Schmerzther.
2003;
38
630-643
- 17
Frascone R J, Bitz D, Lurie K.
Combination of active compression decompression cardiopulmonary resuscitation and
the inspiratory impedance threshold device: state of the art.
Curr Opin Crit Care.
2004;
10
193-201
- 18
Mauer D, Schneider T, Dick W, Withelm A, Elich D, Mauer M.
Active compression-decompression resuscitation: a prospective, randomized study in
a two-tiered EMS system with physicians in the field.
Resuscitation.
1996;
33
125-134
- 19
Nolan J, Smith G, Evans R, McCusker K, Lubas P, Parr M, Baskett P.
The United Kingdom pre-hospital study of active compression-decompression resuscitation.
Resuscitation.
1998;
37
119-125
- 20
Plaisance P, Lurie K G, Payen D.
Inspiratory impedance during active compression-decompression cardiopulmonary resuscitation:
a randomized evaluation in patients in cardiac arrest.
Circulation.
2000;
101
989-994
- 21
Wolcke B B, Mauer D K, Schoefmann M F, Teichmann H, Provo T A, Lindner K H, Dick W F,
Aeppli D, Lurie K G.
Comparison of standard cardiopulmonary resuscitation vs. the combination of active
compression-decompression cardiopulmonary resuscitation and an inspiratory impedance
threshold device for out-of-hospital cardiac arrest.
Circulation.
2003;
108
2201-2205
- 22
Plaisance P, Lurie K G, Vicaut E, Martin D, Gueugniaud P Y, Petit J L, Payen D.
Evaluation of an impedance threshold device in patients receiving active compression-decompression
cardiopulmonary resuscitation for out of hospital cardiac arrest.
Resuscitation.
2004;
61
265-271
- 23
Stiell I G, Hebert P C, Weitzman B N, Wells G A, Raman S, Stark R M, Higginson L A,
Ahuja J, Dickinson G E.
High-dose epinephrine in adult cardiac arrest.
N Engl J Med.
1992;
327
1045-1050
- 24
Zaritsky A.
Pediatric resuscitation pharmacology. Members of the Medications in Pediatric Resuscitation
Panel.
Ann Emerg Med.
1993;
22
445-455
- 25
Perondi M B, Reis A G, Paiva E F, Nadkarni V M, Berg R A.
A comparison of high-dose and standard-dose epinephrine in children with cardiac arrest.
N Engl J Med.
2004;
350
1722-1730
- 26
Wenzel V, Krismer A C, Arntz H R, Sitter H, Stadlbauer K H, Lindner K H, European
Resuscitation Council Vasopressor during Cardiopulmonary Resuscitation Study Group.
A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation.
N Engl J Med.
2004;
350
105-113
- 27
Lindner K H, Dirks B, Strohmenger H U, Prengel A W, Lindner I M, Lurie K G.
Randomised comparison of epinephrine and vasopressin in patients with out-of-hospital
ventricular fibrillation.
Lancet.
1997;
349
535-537
- 28
Padosch S A, Martin E, Böttiger B W.
Vasopressin and epinephrine for cardiac arrest.
Lancet.
2001;
358
2080-2082
- 29
Wenzel V, Padosch S A, Böttiger B W, Lindner K H.
Klinische Erfahrungen mit Vasopressin bei der kardiopulmonalen Reanimation: Bestätigung
der CPR-Richtlinien oder Zündstoff für neue Diskussion?.
Notfall Rettungsmed.
2001;
4
524-527
- 30
Stiell I G, Hebert P C, Wells G A, Vandemheen K L, Tang A S, Higginson L A, Dreyer J F,
Clement C, Battram E, Watpool I, Mason S, Klassen T, Weitzman B N.
Vasopressin vs. epinephrine for inhospital cardiac arrest: a randomised controlled
trial.
Lancet.
2001;
358
105-109
- 31
McIntyre K M.
Vasopressin in asystolic cardiac arrest.
N Engl J Med.
2004;
350
179-181
- 32
Alvarez G F, Bihari D.
Vasopressin vs. epinephrine for cardiopulmonary resuscitation.
N Engl J Med.
2004;
350
2206-2209
- 33
Nolan J P, Nadkarni V, Montgomery W H.
Vasopressin vs. epinephrine for cardiopulmonary resuscitation.
N Engl J Med.
2004;
350
2206-2209
- 34
Dorian P, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A.
Amiodarone as compared with lidocaine for shock-resistant ventricular fibrillation.
N Engl J Med.
2002;
346
884-890
- 35
Kudenchuk P J, Cobb L A, Copass M K, Cummins R O, Doherty A M, Fahrenbruch C E, Hallstrom A P,
Murray W A, Olsufka M, Walsh T.
Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular
fibrillation.
N Engl J Med.
1999;
341
871-878
- 36
Böttiger B W, Bode C, Kern S, Gries A, Gust R, Glätzer R, Bauer H, Motsch J, Martin E.
Efficacy and safety of thrombolytic therapy after initially unsuccessful cardiopulmonary
resuscitation: a prospective clinical trial.
Lancet.
2001;
357
1583-1585
- 37
Lederer W, Lichtenberger C, Pechlaner C, Kroesen G, Baubin M.
Recombinant tissue plasminogen activator during cardiopulmonary resuscitation in 108
patients with out-of hospital cardiac arrest.
Resuscitation.
2001;
50
71-76
- 38
Böttiger B W, Groeben H, Heine J.
Notfallmedizin - Verbessertes Überleben bei Herz-Kreislaufstillstand durch neue Konzepte
und Therapieverfahren.
Anasthesiol Intensivmed Notfallmed Schmerzther.
2003;
38
63-67
- 39
Spöhr F, Böttiger B W.
Safety of thrombolysis during cardiopulmonary resuscitation.
Drug Saf.
2003;
26
367-379
- 40
Spöhr F, Böttiger B W.
Thrombolytic therapy during or after cardiopulmonary resuscitation - Efficacy and
safety of a new therapeutic approach.
Minerva Anesthesiol.
2003;
69
357-364
- 41
Lederer W, Lichtenberger C, Pechlaner C, Kinzl J, Kroesen G, Baubin M.
Long-term survival and neurological outcome of patients who received recombinant tissue
plasminogen activator during out-of-hospital cardiac arrest.
Resuscitation.
2004;
61
123-129
- 42
Böttiger B W, Padosch S A, Wenzel V.
Tissue plasminogen activator in cardiac arrest with pulseless electrical activity.
N Engl J Med.
2002;
347
1281-1282
- 43
Abu-Laban R B, Christenson J M, Innes G D, van Beek C A, Wanger K P, McKnight R D,
MacPhail I A, Puskaric J, Sadowski R P, Singer J, Schechter M T, Wood V M.
Tissue plasminogen activator in cardiac arrest with pulseless electrical activity.
N Engl J Med.
2002;
346
1522-1528
- 44
Fatovich D M, Dobb G J, Clugston R A.
A pilot randomised trial of thrombolysis in cardiac arrest (The TICA trial).
Resuscitation.
2004;
61
309-313
- 45
Keeling P, Hughes D, Price L, Shaw S, Barton A.
Safety and feasibility of prehospital thrombolysis carried out by paramedics.
BMJ.
2003;
327
27-28
- 46
Lederer W, Mair D, Rabl W, Baubin M.
Frequency of rib and sternum fractures associated with out-of-hospital cardiopulmonary
resuscitation is underestimated by conventional chest X-ray.
Resuscitation.
2004;
60
157-162
- 47 http://www.erc.edu/index.php/newsitem/en/nid=146.
- 48
Bernard S A, Gray T W, Buist M D, Jones B M, Silvester W, Gutteridge G, Smith K.
Treatment of comatose survivors of out-of hospital cardiac arrest with induced hypothermia.
N Engl J Med.
2002;
346
557-563
- 49
The Hypothermia After Cardiac Arrest Study Group.
Mild therapeutic hypothermia to improve outcome after cardiac arrest.
N Engl J Med.
2002;
346
549-556
- 50
Padosch S A, Kern K B, Böttiger B W.
Therapeutic hypothermia after cardiac arrest.
N Engl J Med.
2002;
347
63-65
- 51
Nolan J P, Morley P T, Hoek T L, Hickey R W.
Advancement Life support Task Force of the International Liaison Committee on Resuscitation.
Therapeutic hypothermia after cardiac arrest. An advisory statement by the Advancement
Life support Task Force of the International Liaison Committee on Resuscitation.
Resuscitation.
2003;
57
231-235
- 52
Nolan J P, Morley P T, Vanden Hoek T L, Hickey R W, Kloeck W G, Billi J, Boettiger B W,
Morley P T, Nolan J P, Okada K, Reyes C, Shuster M, Steen P A, Weil M H, Wenzel V,
Hickey R W, Carli P, Vanden Hoek T L, Atkins D. International Liaison committee on
Resuscitation .
Therapeutic hypothermia after cardiac arrest: an advisory statement by the advanced
life support task force of the International Liaison Committee on Resuscitation.
Circulation.
2003;
108
118-121
- 53
Bernard S, Buist M, Monteiro O, Smith K.
Induced hypothermia using large volume, ice-cold intravenous fluid in comatose survivors
of out-of-hospital cardiac arrest: a preliminary report.
Resuscitation.
2003;
56
9-13
Prof. Dr. med. Bernd W. Böttiger
Klinik für Anästhesiologie, Universitätsklinikum Heidelberg ·
Im Neuenheimer Feld 110 · 69120 Heidelberg
eMail: bernd.boettiger@med.uni-heidelberg.de
