The current increase in the cost of health care must be considered as a severe threat to the prehospital emergency services system. Two examples have been selected--the patient with polytrauma and the patient in cardiac arrest--to demonstrate the dilemma between a need for objective data and the requirements of emergency patients. Study results obtained in trauma patients indicating that total prehospital time, including scene time, is correlated to patient outcome have led to the conclusion that at the scene treatment by emergency physicians may be dispensable. It has, however also been demonstrated that the time required for medical treatment at the scene is equivalent to 20% of the total scene time, thus representing only a fraction of the total prehospital time. Correlating the total prehospital time or scene time to outcome therefore appears absurd. The treatment principle of aggressive shock treatment in polytrauma needs critical reevaluation on the basis of results obtained by recent preclinical studies in patients with penetrating torso injuries. Small volume resuscitation could not be demonstrated to improve outcome in polytrauma patients, although a slight improvement in patients with brain injury may be assumed. Endotracheal intubation and early artificial ventilation are proven therapeutic principles in polytraumatized patients. Unfortunately, for ethical reasons randomised carefully controlled comparative studies can not be performed in polytrauma patients unless the patient is fully conscious. The importance of endotracheal intubation and artificial ventilation in unconscious trauma patients becomes apparent under conditions of anaesthesia where the application of the endotracheal tube averts regurgitation, aspiration and concomitant morbidity and mortality. The common causes of cardiovascular collapse and their pathomechanisms, as well as the mechanisms of cardiopulmonary resuscitation, have been widely investigated. Nevertheless, various aspects of their application are still controversial. The most recent study results have recommended initial ventilation prior to thoracic compression. New methods of assisting mechanical cardiopulmonary resuscitation, such as ACD CPR or vest CPR, have shown promising results in animal experiments. However, the importance of results obtained by preclinical randomised controlled investigations in humans need to be confirmed by further studies as to outcome. The efficacy of defibrillation in cases of ventricular fibrillation has been clearly demonstrated, particularly with a view to the interval between ventricular fibrillation and defibrillation. It has further been demonstrated that basic cardiopulmonary resuscitation preserves ventricular fibrillation and thus improves the chance of survival. The present generation of defibrillators has been further improved, particularly by the introduction of biphasic defibrillator wave forms, which may reduce the required energy, as well as possible complications, while offering an increase in the efficacy of defibrillation an...
Evidence Based (Emergency) Medicine (EB(E)M is a term referring to the application into daily clinical practice of only those methods, procedures, medications etc. which are based on scientific evidence. Where diagnostic and therapeutic principles have not been validated on a prospective, controlled randomised basis, this should be tried out at a later time, if at all possible. This concept may allow to bridge the gap between research and clinical practice, and represents the major goal of EB(E)M. Protagonists of EBEM are at times confronted with criticism that EBEM does not constitute the only but one out of several possible approaches to quality controlled medical care. The fact that more than 50% of all emergency procedures are not evidence based give rise to the question as to whether the performance of randomised controlled studies is ethically justifiable, if control groups are included whose treatment leaves out generally recommended and recognised (though not evidence based) therapeutic and/or diagnostic principles. The following examples may enumerate some of the procedures, methods or medications, respectively, without proven scientific evidence: Medication for resuscitation of cardiac arrest victims. Medication for acute asthmatic attacks Initial treatment of uncontrolled haemorrhagic shock. Endotracheal intubation in VF/VT. The principle need for initial ventilation and the volumes of ventilation in cardiac arrest patients. Effectiveness of ACD- and VEST-CPR. A few typical examples are presented to illustrate the requirements of current study designs which have to be met before results of an evaluation are accepted by the EBEM scientists to obtain approval for application of a procedure, method or medication in clinical practice (large patient numbers, power calculations, ethical issues) as well as their benefits and drawbacks.
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