[Emergency medicine yesterday]. / Notfallmedizin gestern.

It was only during the early sixties that emergency medicine started developing both world wide and especially in Germany. Although it had been realised already in the 19 th century that absence of treatment for a period after infliction of a wound had a crucial effect on recovery, and in spite of the fact that in 1938 Kirschner had stressed the need for preclinical medical care, results of research on the pathophysiology of sudden death were not available until 1960. At the same time it became possible to develop measures and methods enabling to preserve the vital functions essential for survival already at the site of an accident and during transportation or to restore them after circulatory arrest. Basing on these realisations, an emergency sequence of survival measures was worked out and within a period of 20 years the prerequisites were translated into reality that ensured a chain of emergency measures including the necessary organisational, structural and personal requirements for immediate and effective action, including the requisite means of transportation and the essential diagnostic and therapeutic equipment. The following article describes both the positive developments and the deficits that still existed in 1990. German anaesthesiology has made highly decisive contributions to the present and internationally recognised efficiency of emergency medicine and emergency intensive-care services.

[Quality management in emergency medicine]. / Qualitätsmanagement in der Notfallmedizin.

Although the need for the implementation of a quality management concept for the German emergency medical system (EMS) has been discussed for more than 10 years, such a concept has not been realised on a broad scale. Standardised national data sheets were developed many years ago. They are used by many local agencies, but a data-gathering system on a state or national basis is still lacking. In times of reduced funds for health care expenditures, quality management could be a reliable way to ensure that the EMS provides safe services to the patient based on the current state of medical science in an efficient manner. Based on clear definitions, structure, process, and outcome quality can be analysed, and the results provide the basis for continuous quality-improvement strategies. As not all aspects of the system can be analysed continuously, one has to select areas of special importance. External and internal quality control are equally important. Quality control works on the basis that all EMS team members are motivated to perform on a professional level to ensure that each patient is treated adequately. It evaluates the system to create circumstances that enhance the achievement of this goal. Quality management is not only concerned with mishaps, because areas with documented good performance also provide important information.

[Research and ethics in emergency medicine. Findings of a workshop]. / Forschung und Ethik in der Notfallmedizin. Empfehlungen eines Workshops.

Prerequisites for experimental study designs are extremely difficult to realise under prehospital emergency conditions. Results obtained in animal experiments always need validation with prehospital or in hospital patient studies. Investigations related to emergency medicine are, however, an ethical obligation on behalf of the patient. A retrospective analysis of the available literature should be considered a prerequisite for prospective randomised and controlled studies. Frequently, a pilot study or feasibility trial needs to precede the actual study. Informed consent must be obtained for all patient studies. However, under emergency conditions informed consent cannot always be obtained due to unconsciousness, etc. Nevertheless, the following principles should be observed: (a) randomised studies are essential, even in emergency medicine; (b) they are ethically acceptable if the treatment provided for the study group is at least equivalent to the therapy for the control group; (c) only these preconditions guarantee that the patient always receives treatment in accordance with the standard of treatment. If the patient is unconscious or otherwise unable to give informed consent, the principle of deferred consent is acceptable. The deferred consent principle should be carefully documented. A prospective randomized study represents the gold standard for an investigation, even under emergency conditions. There are different principles of randomization: telephone or telefax randomisation, etc. Emergency medicine investigations need to be completed within a reasonable time frame which should, as a rule, not exceed 2 years. Otherwise, too many items might change without being noted. Curative treatment and the intention to treat are terms employed by ethics committees. If an investigation does not bear in itself additional risk factors, it does not necessarily have to be brought before the ethics committee. If, however, for example, the effect of obtaining blood samples is investigated separately for research purposes, the patient needs to be informed and sign the respective agreement. In Germany the ethics committees have agreed to accept their respective decisions. For multicentre and multinational studies, however, the ethics committees also need to accept decisions made by non-German ethics committees. Not all therapeutic principles can serve as the basis of prospective randomized studies because they need to be considered the present standard of care (e.g., endotracheal intubation, etc.). Nevertheless, the feasibility of a study should be assessed according to the 1-3 rating proposed by the American Heart Association. In principle, the overall emergency physician protocol does not fulfill scientific requirements. For all studies, particularly in the prehospital setting, an independent observer should be involved for documentation purposes. Scores can be of importance for investigating different treatment regimens. Biases in emergency medicine studies focus on the variability of EMS, personnel qualifications, etc. This is in part why it is extremely difficult to prove efficacy and efficiency in emergency medicine. The results of emergency medicine investigations should be published in suitable journals, i.e., journals with a reasonable rating.

Emergency medical training for dental students.

Twenty-four of the thirty-two German universities that have dental schools replied to a questionnaire survey that showed that all the schools responding held lectures on the topic "Medical Emergencies" although this is not mandatory for registration. All of the universities in the former East Germany also offered practical training sessions as part of the curriculum. The proportion of West German universities offering such courses is only 60%. The basic essentials of the theory and practice of emergency medicine should only be taught in courses with mandatory participation.

Glucose and urea production and leucine, ketoisocaproate and alanine fluxes at supraphysiological plasma adrenaline concentrations in volunteers.

OBJECTIVE: To determine the magnitude and time course of adrenergic effects on metabolism in volunteers and possible implications for the use of sympathomimetics in the critically ill. DESIGN: Descriptive laboratory investigation. SUBJECTS: 7 volunteers. INTERVENTION: Primed continuous infusions of stable isotope tracers ([15N2]-urea, [6,6-D2]-glucose, [methyl-D3]-L-leucine, [15N]-L-alanine) were used. After isotopic steady state had been reached an infusion of adrenaline (0.1 microgram/kg/min) was administered (4 h). Isotopic enrichment was measured using gas chromatography-mass spectrometry and the corresponding rates of appearance were calculated. MEASUREMENTS AND MAIN RESULTS: Glucose production increased from 14.1 +/- 1.2 to 21.5 +/- 2.0 mumol/kg/min (p < 0.05) after 80 min of adrenergic stimulation and then decreased again to 17.9 +/- 1.2 mumol/kg/min after 240 min. Leucine and ketoisocaproate (KIC) fluxes were 2.3 +/- 0.2 and 2.6 +/- 0.2 mumol/kg/min, respectively, at baseline and gradually decreased to 1.8 +/- 0.2 and 2.2 +/- 0.1 mumol/kg/min, respectively, after 240 min of adrenaline infusion (both p < 0.05). Alanine flux increased from 3.7 +/- 0.5 to 6.9 +/- 0.9 mumol/kg/min (p < 0.05) after 80 min of adrenergic stimulation. Urea production slightly decreased from 4.8 +/- 0.9 to 4.3 +/- 0.8 mumol/kg/min during adrenaline (p < 0.05). CONCLUSIONS: Adrenaline induced an increase in glucose production lasting for longer than 240 min. The decrease in leucine and KIC flux suggests a reduction in proteolysis, which was supported by the decrease in urea production. The increase in alanine flux is therefore most likely due to an increase in de-novo synthesis. The ammonia donor for alanine synthesis in peripheral tissues and the target for ammonia after alanine deamination in the liver remain to be investigated. These results indicate that adrenaline infusion most probably will not promote already enhanced proteolysis in critically ill patients. Gluconeogenesis is an energy consuming process and an increase may deteriorate hepatic oxygen balance in patients.

[Preoperative risk factors and intraoperative and postoperative risk management in 11,890 anesthesias. Initial results of a prospective study]. / Präoperative Risikofaktoren und intra- und postoperative Risikoverwirklichung bei 11890 Anästhesien. Erste Ergebnisse einer prospektiven Studie.

OBJECTIVE: The relation of the frequency and severity of pitfalls, events and complications (PECs) was analysed in respect of preoperative risk factors. The epidemiological data were gathered as a contribution to a current project of the German Society for Anaesthesiology and Intensive Care. METHOD: Preoperative data (age, sex, preexisting diseases, pathological findings, grade of urgency and ASA-class) were integrated in a paper record, as well as the perioperative interventions and directly postoperative events, type of anaesthesia, and kind of operation. The automatically readable paper records were routinely in use for every patient. After control and correction the data were stored in a modern data base. MAIN RESULTS: From October 1, 91 to May 20, 92 11,890 anaesthesias were recorded. 2,959 of them with a total of 4,184 PECs. 2,397 PECs were cardiovascular, 875 respiratory. PECs of grade I (no impact on treatment in the recovery room [RR]) occurred in 14% of patients, grade II (impact on treatment in RR, but no impact on discharge to ward) 7.2%, grade III (prolonged stay in RR or special monitoring in the ward) 2.88%; grade IV (PEC leads to transfer to the ICU) 0.63%, and grade V (PEC leads to disabling damage or death) 0.13%. 13 of 15 patients suffering from PECs grade V were of ASA class 4 or 5. PECs had a certain relation to the ASA-classification of anaesthetic risk. But this relation is quite different in several surgical disciplines. CONCLUSIONS: Preoperatively known risk factors of the patient and the measures taken by specialists of various disciplines contribute to the incidence of PECs. Available data could be processed multicentrally and in standard form for producing prognostic data for risk prediction. Since PECs of grade II or higher are cost- relevant, requiring an interdisciplinary approach, it appears meaningful to base costing on such an interdisciplinary approach in accordance with the requirements of diagnosis and treatment.

Effects of norepinephrine, epinephrine, and dopamine infusions on oxygen consumption in volunteers.

OBJECTIVE: To determine the relationships between plasma concentrations of norepinephrine, epinephrine, and dopamine and oxygen consumption (VO2) during infusion of these catecholamines. DESIGN: Prospective, randomized variable dose, pharmacologic study in which a noncumulative infusion-rate design was used. SETTING: Laboratory of the Department of Anesthesiology at a University Hospital. PATIENTS: Twenty-one normal volunteers. INTERVENTIONS: After a control period of 20 mins, norepinephrine (three infusion rates; 0.06 to 0.2 microgram/kg/min; n = 7), epinephrine (four infusion rates; 0.02 to 0.2 microgram/kg/min; n = 7), or dopamine (three infusion rates; 3 to 12 micrograms/kg/min; n = 7) was administered to normal volunteers (n = 21) for the purpose of constructing plasma concentration/VO2 response curves. MEASUREMENTS AND MAIN RESULTS: Systolic and diastolic blood pressure, heart rate, plasma concentrations of norepinephrine, epinephrine, and dopamine, and VO2 were measured at the end of the control period and at the end of each catecholamine infusion. VO2 was measured using a ventilated canopy system and a differential oxygen sensor. Typical hemodynamic responses to vasopressors were seen during adrenergic receptor agonist infusions. VO2 increased from 132 +/- 7 to 153 +/- 10 mL/min/m2 during the highest infusion rate of norepinephrine, from 133 +/- 7 to 182 +/- 11 mL/min/m2 during the highest infusion rate of epinephrine, and from 132 +/- 13 to 163 +/- 8 mL/min/m2 during the highest infusion rate of dopamine (p < .05; paired t-test). Increases in VO2 were correlated with the logarithms of the corresponding plasma catecholamine concentrations. Effects on VO2 and hemodynamic responses occurred at similar plasma concentrations for each of the three catecholamines. CONCLUSIONS: Administration of norepinephrine, epinephrine, or dopamine results in marked increases in VO2 in volunteers. In patients, the administration of catecholamines or sympathomimetics to attain optimal values of cardiac index, oxygen delivery (DO2), and VO2 may increase the oxygen demand and thus obscure the DO2-VO2 relationship.

Effects of active compression-decompression resuscitation on myocardial and cerebral blood flow in pigs.

BACKGROUND: This study was designed to assess the effects of a modified cardiopulmonary resuscitation (CPR) technique that consists of both active compression and active decompression of the chest (ACD CPR) versus standard CPR (STD CPR) on myocardial and cerebral blood flow during ventricular fibrillation both before and after epinephrine administration. METHODS AND RESULTS: During a 30-second period of ventricular fibrillation cardiac arrest, 14 pigs were randomized to receive either STD CPR (n = 7) or ACD CPR (n = 7). Both STD and ACD CPR were performed using an automated pneumatic piston device applied midsternum, designed to provide either active chest compression (1.5 to 2.0 in.) and decompression or only active compression of the chest at 80 compressions per minute and 50% duty cycle. Using radiolabeled microspheres, median total myocardial blood flow after 5 minutes of ventricular fibrillation was 14 (7 to 30, minimum to maximum) STD CPR versus 30 (9 to 46) mL.min-1 x 100 g-1 with ACD CPR (P < .05). Median cerebral blood flow was 15 (10 to 26) mL.min-1 x 100 g-1 with STD CPR and 30 (21 to 39) with ACD CPR (P < .01). When comparing STD with ACD CPR, aortic systolic (62 mm Hg [48 to 70] vs 80 [59 to 86]) and diastolic (22 [18 to 28] vs 28 [21 to 36]) pressures, calculated coronary systolic (30 [22 to 36] vs 49 [37 to 56]) and diastolic (18 [16 to 23] vs 26 [21 to 31]) perfusion pressures, end-tidal CO2 (1.4% [0.8 to 1.8] vs 2.1 (1.8 to 2.4]), cerebral O2 delivery (3.1 mL.min-1 x 100 g-1 [1.5 to 4.5] vs 5.3 [3.8 to 7.5]), and cerebral perfusion pressure (14 mm Hg [4 to 22] vs 26 [6 to 34]) were all significantly higher with ACD CPR: To compare these parameters before and after vasopressor therapy, a bolus of high-dose epinephrine (0.2 mg/kg) was given to all animals after 5 minutes of ventricular fibrillation. Organ blood flow and calculated perfusion pressures increased significantly in both the STD and ACD groups after epinephrine. The differences observed between STD and ACD CPR before epinephrine were diminished 90 seconds after epinephrine but were again statistically significant when assessed 5 minutes later, once the acute effects of epinephrine had decreased. No difference in short-term resuscitation success was found between the two groups. CONCLUSIONS: We conclude that ACD CPR significantly increases myocardial and cerebral blood flow during cardiac arrest in the absence of vasopressor therapy compared with STD CPR:

Devices for expired air resuscitation.

OBJECTIVES: Expired air resuscitation is an essential part of first-aid and cannot be replaced by other measures. Because of the risk of transmitting infectious diseases, the use of devices is recommended. Three types are available--masks, tubes, and foils. PARTICIPANTS: Six masks (Air-Vita Bi-Protect, Laerdal Pocketmask, Dräger Hivita Mask E, Rescue-Med Device, Resuscitator, SealEasy Resuscitation Kit), five tube instruments (Dr. Brook Airway, Dual-Aid, Goettinger Tubus, Lifeway, Sussex Valve Airway), and two foils (Ambu Life-Key, Laerdal ResusciFace Shield) were studied. MEASUREMENTS: Inspiratory and expiratory resistance, valve leakage, ability to protect against infection transmission, and practicability (e.g., possibility of training on standard mannequins, seal) were measured and tested in the laboratory. RESULTS: Only a few of the mask and tube devices had low inspiratory and expiratory resistances. Some of the one-way valves failed. There were definite risks of provoking complications (vomiting, lacerations) when using tube instruments. CONCLUSIONS: Devices consisting of a foil have definite advantages, and seem to be more appropriate for the use by first-aiders [first responders].

Metabolic and haemodynamic effects of dopamine plus domperidone in volunteers.

There are no studies of the relationship between infusion rate of dopamine and the arterial and venous dopamine plasma concentration and the resulting haemodynamic and metabolic effects. Dopamine was administered to seven volunteers using five infusion rates (1, 3, 6, 9, 13 micrograms/kg per minute) in an escalating sequence lasting for 30 min for each step. Since dopamine can cause nausea and vomiting, this relationship was investigated after administration of domperidone for infusion rates above 3 micrograms/kg per minute. Haemodynamic effects were assessed using 2-dimensional echocardiography. During the highest infusion rate the arterial plasma dopamine concentration reached 1,379 +/- 181 nmol/l. There was a linear correlation between the dopamine infusion rate and both the arterial and the venous plasma concentration. There was no significant change in heart rate or diastolic blood pressure. Systolic blood pressure, ejection fraction and cardiac index increased in a dose-dependent manner. Systemic vascular resistance decreased during the two low doses of dopamine and was not different from baseline values during the three high infusion rates. The plasma concentrations of glucose and non-esterified fatty acids increased from 5.3 +/- 0.4 to 0.68 +/- 0.9 nmol/l, and from 360 +/- 119 to 971 +/- 307 mumol/l, respectively, during the 13 micrograms/kg per minute infusion rate. As the plasma noradrenaline concentration increased up to 7.84 +/- 2.46 nmol/l in correlation to the dopamine plasma concentration, an indirect sympathomimetic effect may contribute to the actions of dopamine plasma concentration.