Effektivit�t pr�klinischer Notfallversorgung Fiktion oder Fakt?

Abstract

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...

Zukunft der pr�klinischen Notfallmedizin in Deutschland

“…Die im Verlauf der Entwicklung "des besten und höchstqualifizierten" Rettungssytem der Welt dabei geschaffenen materiellen und personellen Strukturen werden als beispielhaft beschrieben [10].…”

Small Volume Resuscitation - Solution for the Routine or Ultima Ratio?

“…Die angesprochenen Limitierungen hinsichtlich der Datenlage spiegeln aber auch die methodologischen Probleme klinischer Forschung im Bereich der Notfallmedizin wider: Nichterreichen der zur statistischen Absicherung der Studienhypothese notwendigen Fallzahl [11,18], auch aufgrund des Rückgangs schwerer Verkehrsunfälle und kurzen Eintreffzeiten des Rettungsdienstes, und -besonders im Vergleich der einzelnen Studien -die Inkongruenz hinsichtlich Ursache und Ausmaß des Traumas, der Begleiterkrankungen, sowie der Art der Begleittherapie. Auch fällt der Nachweis der Effizienz einer Einzelmaßnahme bei der Behandlung einer komplexen Notfallsituation, wie sie das Polytrauma darstellt [20], um so schwerer, je umfassender und wirksamer das bisherige Gesamtversorgungskonzept beschaffen ist.…”

Neue mechanische Methoden der kardiopulmonalen Reanimation (CPR)

“…CPR Studien befindet sich in Vorbereitung und wird möglicherweise verläßli-chere Aussagen über diese CPR-Technik zulassen [11]. Trotz guter Ergebnisse aus dem Tierversuch und Teilerfolgen der ACD CPR in der Klinik und im Rettungsdienst ist die Physiologie bei dieser Reanimationsmethode nicht hinreichend bekannt und muß weiter untersucht werden.…”