Outcome of out-of-hospital cardiac arrest after fibrinolysis with reteplase in comparison to the return of spontaneous circulation after cardiac arrest score in a geographic region without emergency coronary intervention.

Coronary occlusion and pulmonary embolism are responsible for the majority of cases of out-of-hospital cardiac arrest (OHCA). Despite previous favourable results of pre-hospital fibrinolysis in cases of OHCA, the benefit could not be confirmed in a large controlled study using the fibrinolytic tenecteplase. For reteplase (r-PA), there are hardly any data regarding pre-hospital fibrinolysis during ongoing resuscitation. The present study reported results using r-PA therapy in a German physician-supported Emergency Medical Services system. The data of OHCA patients who received pre-hospital fibrinolytic treatment with r-PA after an individual risk/benefit assessment were retrospectively analysed. To assess the effectiveness of this approach, the rate of patients with a return of spontaneous circulation (ROSC) was compared with the corresponding figure that was calculated with the help of the RACA (ROSC after cardiac arrest) score. The RACA algorithm predicts the probability of ROSC based on data from the German Resuscitation Registry. Further outcome data comprised hospital discharge rate and neurologic status at discharge. From 2001 to 2009, 43 patients (mean age, 58.5 years; 65.1% male; 58.1% ventricular fibrillation) received r-PA. Of these, 20 patients (46.5%) achieved ROSC, compared to a probability of 49.8% according to the RACA score (P=0.58). A total of 8 patients (18.6%) were discharged alive, including 5 (11.2%) with a good neurological outcome. For the analysed small patient collective, pre-hospital r-PA did not offer any benefits with regard to the ROSC rate. Further analyses of larger patient numbers on a nationwide registry basis are recommended.

Prehospital CPAP Therapy by Emergency Physicians in Patients with Acute Respiratory Failure due to Acute Cardiogenic Pulmonary Edema or Acutely Exacerbated COPD.

BACKGROUND: Acute respiratory failure is a frequent cause of emergency medical missions. Continuous positive airway pressure (CPAP) therapy could be particularly beneficial, avoiding risks associated with intubation and invasive ventilation. Hardly any data exist from Germany on this matter. PATIENTS AND METHODS: CPAP therapy with the Boussignac system as additional measure was introduced in cases of acute cardiogenic pulmonary edema (ACPE) or decompensated chronic obstructive pulmonary disease (COPD) in a physician-supported emergency medical services system (EMS). RESULTS: A total of 57 patients, 35 with ACPE and 22 with COPD, received CPAP. Oxygen saturation improved from 81.6% to 94.8%, and respiration rate from 26.9/min to 18.9/min (p<0.001). Seven patients (12.2%) needed secondary intubation [COPD: one patient; ACPE: six patients, including three with acute coronary syndrome (ACS)]. CONCLUSION: In physician-supported EMS, CPAP using the Boussignac system is an effective additional measure for ACPE or COPD. For causal ACS, the risk of therapy failure increases.

Psychiatric emergencies in prehospital emergency medical systems: a prospective comparison of two urban settings.

BACKGROUND: Psychiatric emergency situations (PES) are of high importance to the German prehospital physician-based emergency medical system. So far, however, no prospective studies regarding the incidence of PES have been performed, neither have effects of training programs on diagnostic and therapeutic accuracy been studied. METHOD: The protocols of two emergency medical services (EMS) were collected and analyzed prospectively. Emergency physicians (EPs) in Kaiserslautern (KL) attended a standardized educational program and underwent daily supervision. EPs in Homburg (HOM) had not been informed about the study. In KL, sociodemographic variables were collected. An investigator who was not involved in the individual EMS mission assessed the correct classification of PES. RESULTS: Among all calls for an EP, 11.8% were classified as PES. There was no difference between the two centers. Correct classification of PES in KL was significantly higher than that in HOM (94.3% vs. 80.6%). Documentation of suicidal behavior was deficient in both centers. EPs in KL gave verbal crisis intervention significantly more often, administered less medication overall, and dispensed more specific drugs in psychotic disorders and significantly less drugs in substance abuse disorders. Patients were more often treated at the scene and were less often transported to a hospital. Some sociodemographic variables were associated with psychiatric morbidity of treatment. CONCLUSION: Accounting for 12% of all missions, psychiatric emergencies are a frequent reason for calls for EPs, equaling trauma-related and neurological emergencies. The most frequent reasons for calls were alcohol intoxication, states of agitation and suicidal behavior. The diagnostic and therapeutic accuracy of EPs may be improved with a concise standardized teaching program.