Preclinical Emergency Medicine Research Articles

Acute Coronary Syndrome (ACS) in Preclinical Emergency Medicine

Acute coronary syndrome (ACS) is a common diagnosis in preclinical emergency medicine. The term summarizes the acute manifestations of coronary artery disease. It ranges from unstable angina pectoris via cardiogenic shock to sudden cardiac death. The leading key symptom is chest pain. With this trigger symptom, a clinical diagnostic algorithm is initiated, acting quickly on the suspected diagnosis of acute myocardial infarction. Due to the potentially life-threatening course, rapid diagnosis and initiation of therapeutic measures is crucial. Pre-clinical antithrombotic medication and therapy for accompanying symptoms are paramount. As part of the initial assessment, important differential diagnoses should be considered and, within the first 10 minutes after medical contact, an ECG diagnosis should differentiate between ACS with and without ST segment elevations. If ACS is diagnosed, acetylsalicylic acid should be given to inhibit platelet aggregation. The benefits outweigh the very low risk of unnecessary administration. Patients with ACS should be taken to hospital immediately for coronary interventions (PCI). In the case of an ACS with ST segment elevations, reperfusion therapy should be carried out within 120 minutes. In the case of an ACS without ST segment elevations, the time limit (2 - 72 h) until reperfusion is based on the risk stratification. In the majority of cases, the coronary stenosis causing the infarction can be treated with PCI. However, invasive diagnostics show no significant stenosis in a significant proportion of patients with myocardial infarction (prevalence 1 - 14%). This is known as "myocardial infarction with non-obstructive coronary arteries" (MINOCA) and further differential diagnosis should be initiated in these patients.

Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure (AWMF-S3-guideline): relevance for preclinical and clinical emergency medicine

Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure (AWMF-S3-guideline): relevance for preclinical and clinical emergency medicine

Accreditation Council for Graduate Medical Education Milestones for Emergency Medicine Residency Training Incorporated into First- and Second-Year Medical Student Elective.

Introduction: As part of its Next Accreditation System, the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine describe 6 competencies containing 23 sub-competencies graded by milestones ranging from level 1 (expected of an incoming intern) to level 5 (demonstrates abilities of an attending) that are used to track resident training progression. To the best of our knowledge, there have been no studies introducing a milestones-based curriculum to medical students prior to their introduction to the wards, so we sought to determine the effects that a pre-clinical Emergency Medicine Interest Group (EMIG) Milestones Elective would have on preparing the students interested in Emergency Medicine (EM) as a specialty to meet the level 1 milestones prior to their intern year.Methods: The elective hosted 15 events throughout the academic year, and pre- and post-curriculum surveys were administered. Thirteen first- and second-year medical students at our institution who completed the elective self-reported their perception of preparedness for each level 1 milestone in the 19 sub-competencies. A repeated measures design was used through identical pre- and post-curriculum surveys to determine any changes in self-reported preparedness for meeting level 1 milestones after completing the elective using Wilcoxon Signed Ranks Test.Results: There was a significant increase in the median scoring from 1 to 2 (p=0.027) in overall self-reported preparedness for meeting the level 1 milestones included in the elective, as well as significant increases in subcategories across competencies 1-4 outlined by the ACGME. There was no significant increase in preparedness for professionalism or interpersonal communication competencies. There was no significant increase in interest in EM as a result of the elective.Conclusion: Implementing a milestones-based curriculum during the pre-clinical years shows improved self-reported preparedness of students interested in pursuing EM for meeting level 1 milestones prior to residency. Additionally, a specialty-based elective such as this one offered through EMIG may further increase interest in the field during pre-clinical years.

Effects of realistic e-learning cases on students' learning motivation during COVID-19.

Keeping up motivation to learn when socially isolated during a pandemic can be challenging. In medical schools, the COVID-19 pandemic required a complete switch to e-learning without any direct patient contact despite early reports showing that medical students preferred face-to-face teaching in clinical setting. We designed close to real-life patient e-learning modules to transmit competency-based learning contents to medical students and evaluated their responses about their experience. Weekly e-learning cases covering a 10-week leading symptom-based curriculum were designed by a team of medical students and physicians. The internal medicine curriculum (HeiCuMed) at the Heidelberg University Medical School is a mandatory part of clinical medical education in the 6th or 7th semester. Case-design was based on routine patient encounters and covered different clinical settings: preclinical emergency medicine, in-patient and out-patient care and follow-up. Individual cases were evaluated online immediately after finishing the respective case. The whole module was assessed at the end of the semester. Free-text answers were analyzed with MaxQDa following Mayring`s principles of qualitative content analyses. N = 198 students (57.6% female, 42.4% male) participated and 1252 individual case evaluations (between 49.5% and 82.5% per case) and 51 end-of-term evaluations (25.8% of students) were collected. Students highly appreciated the offer to apply their clinical knowledge in presented patient cases. Aspects of clinical context, interactivity, game-like interface and embedded learning opportunities of the cases motivated students to engage with the asynchronously presented learning materials and work through the cases. Solving and interpreting e-learning cases close to real-life settings promoted students' motivation during the COVID-19 pandemic and may partially have compensated for missing bedside teaching opportunities.

Development, implementation and evaluation of an ECG algorithm for ambulance service

In order to facilitate and accelerate the interpretation of ECG images in preclinical emergency medicine, an algorithm was developed to test this. In an online test, 357 staff of emergency medical service tested the functionality of the analysis procedure. Defibrillation-worthy ECG images are not included in this work because they belong to the resuscitation, has already been extensively published. The development of the algorithm involved three levels: The first was to define the properties of preclinical ECG images based on questions that needed to be answered dichotomically, such as "Are P-waves present?" "Yes" or "No". The answers were summarized in a table, from which the graphic processing of the information in the form of a search tree took place as a second level of development. The algorithmic query always started with the question "Did the patient have a pulse?" And ended with a defined ECG target image. This created a complex primary algorithm. As a third stepp, the primary algorithm was compressed to make it practical. The 11 questions are tested in this study. The study population was guided online through a web-based test. Each study was randomly assigned to the group with or without algorithm. In the case of using the secondary algorithm, it appeared of the screen throughout the duration of the interpretation. The test persons had to interpret 15 ECG images in succession, each with 5 predefined answers. The results of the query were collected in a database and formed the basis of the statistical calculations. From 15.05.2013 to 10.07.2013, a total of 387 people took part in the online survey. n = 357 subjects (92.25%) completed the complete ECG study with input questions and the interpretation of 15 images. All of the following results refer exclusively to the participants with closed interpretation: group without algorithm (μ0) n = 175: correct answers x ̅ = 11,70; σ = 2.024 and total time in sec. x ̅ = 392.35; σ = 294,687. Group with algorithm (μ) n = 182: correct answers x ̅ = 12,17; σ = 2.877 and total time in sec. x ̅ = 316.83; σ = 149.56. The statistical mass consisted of 154 (43.1%) paramedics, 77 (21.6%) paramedics, 63 (17.6%) paramedics and 35 (9.8%) specialists. The remaining participants had a qualification as first responder or fireman. 62.7% of the study participants worked full-time in the rescue service. The average age was 31.6 years. 62.7% interpreted an ECG 1 to 10 times a month, 15.7% 11 to 20 a month. 82.3% of the subjects rated their ECG interpretability as medium good. The hypothesis that the number of correct answers in the interpretation of preclinical ECG images increases with the aid of the algorithm was again rejected in favor of the null hypothesis - for lack of significance α = 0.072. By contrast, the analysis time for ECG interpretation decreases as expected by using the developed algorithm. H1 was retained, with α = 0.003, validated by t-test in independent samples. Neither age nor gender influenced the number of correct answers or interpretation time. Rs = 0.387 with α = 0.05 between the medical qualification and the number of correct answers. Furthermore, with rs = -0.261 and α = 0.05, a correlation between the medical qualification and the analysis time was to be recorded. rp = 0.362; Significance 2-sided α = 0.05 was found in the self-assessment of the subjects. This means that they have generally assessed their ECG interpretation skills correctly. For emergency responders there was a higher number of correct responses with α = 0.05, but no faster interpretation time. The frequency of the ECG interpretation in each case exercised had an influence on the number of correct answers when using the algorithm. rs = 0.362; Significance 2-sided α = 0.05. The time span since the acquisition of the last and highest medical qualification has a highly significant influence of α = 0.005 on the number of correct answers when using the algorithm. That is, the shorter the distance to the end of the training, the more correct answers. In addition, it could be shown that subjects with a low medical qualification using the algorithm were able to increase the number of correct interpretations most strongly (α = 0.05). In summary, the interpretation of preclinically relevant ECG images using the newly developed algorithm is recommended on this data basis. All occupational groups involved in the study benefited from it.

Notärztliches Atemwegsmanagement in Abhängigkeit von Fachrichtung und Weiterbildung

Difficult airway management is akey skill in preclinical emergency medicine. Alower rate of subjective difficult airways and an increased success rate of endotracheal intubation have been reported for highly trained emergency physicians. The aim of this study was therefore to analyze the effect for different specialists and the individual state of training in the German emergency medical system. In aretrospective register analysis of 6024 preclinical anesthesia procedures, the frequencies of airway devices, neuromuscular blocking agents, capnography and difficult airways were analyzed with respect to specialization and status of training. Additionally, low, medium and highly experienced emergency physicians in airway management were summarized by specialization and status of training according to the Dreyfus model of skill acquisition and compared. The incidence of subjective difficult airway situations was 10% for anesthesiological emergency physicians compared to 15-20% for other disciplines. The latter used supraglottic airway devices more often (7-9% vs. 4%) and video laryngoscopes less often (3% vs. 5%) compared to anesthesiological emergency physicians. The discipline-related state of training was inhomogeneous and revealed areduced rate of supraglottic airway devices for internal specialists with further training (10% vs. 2%). Anesthetists specialized in intensive care medicine used capnography less frequently compared to other anesthetists (79% vs. 72%). With higher levels of experience in airway management, the frequency of endotracheal intubation (86% vs. 94%), neuromuscular blocking agents (59% vs. 73%) and video laryngoscopy (3% vs. 6%) increased and the incidence of subjective difficult airway situations (16% vs. 10%) decreased. The level of training in airway management especially for non-anesthetists is inhomogeneous. The recently published German S1 guidelines for prehospital airway management recommend education and training as well as the primary use of the video laryngoscope with Macintosh blade. The implementation could lower the incidence of subjective difficult airways.

Development of ground-based physician-staffed emergency missions in the city of Leipzig from 2003 to 2013

The annual number of physician-based emergency missions reported is continuously increasing. Data from large cities concerning this development over long periods is sparse. In this retrospective study the charts of all ground-based physician-staffed emergency missions in the city of Leipzig for the first quarters of 2003 and 2013 were analyzed. Patient characteristics, injury and illness severities, mission location, hospital admission rate, as well as emergency interventions were collated. The emergency mission rate was calculated as rescue missions per 1000 inhabitants per year. The number of physician-staffed emergency missions increased by approximately 24% between 2003 and 2013 (6030 vs. 7470, respectively). The emergency mission rate was 48 vs. 58 in the 2 study periods. The median patient age increased from 66 to 70years. The number of geriatric patients (age≥ 85years: n= 650 (11%) vs. n= 1161 (16%), p< 0.01) also increased. The corresponding number of emergency missions in nursing homes showed a fourfold (n= 175, 3% vs. n= 750, 10%, p< 0.01). The percentage of hospital admissions also increased (n= 3049, 51% vs. n= 4738, 66%, p< 0.01). Achange in patient distribution to levelI hospitals was noticed (n= 1742, 29% vs. n= 3436, 46%, p< 0.01). The findings suggest that the necessity for the high number of physician-staffed emergency missions should be verified, especially in the context of strained emergency healthcare resources. The basis of an optimized use of resources could be abetter inclusion of alternative, especially ambulant, healthcare structures and the implementation of astructured emergency call questionnaire accompanied by amore efficient disposition of the operating resources, not least in view of the economic aspects. Taking the concentrated patient allocation to level1 hospitals into consideration, there is a need for optimized patient distribution strategies to minimize the overload of individual institutions and thereby improve the general quality of care at the interface between preclinical and clinical emergency medicine.

Psychiatric Emergencies in the Preclinical Emergency Medicine Service in Ulm, Germany in 2000 and 2010, andPractical Consequences

Background Psychiatric emergencies (PE) in preclinical emergency medical services are about 5 - 10 % of all emergencies and represent often a source of difficulties in handling for the non-psychiatric professional helpers that deal with them. Studies informing about quantitative and qualitative changes of PEs in preclinical emergency medicine in Germany are scarce. Methods Therefore, we conducted a retrospective cross-sectional study of PE in a preclinical emergency medical service based on the protocols of the emergency ambulance of the Section for Emergency Medicine at the University Hospital Ulm comparing the years 2000 and 2010. Results We observed a significant increase of PEs from 8.8 % in the year 2000 (n = 285, from a total of n = 3227) to 10.3 % in 2010 (n = 454, from a total of n = 4425). In both years intoxications were the most common PE [2000: n = 116 (44.4 %); 2010: n = 171 (37.7 %)], followed by suicide-related behavior [2000: n = 59 (22.6 %); 2010: n = 78 (17.2 %)] and acute anxiety disorders [2000: n = 37 (13 %); 2010: n = 105 (23.1 %)]. The mentioned three conditions accounted for about 80 % of all PE. Most frequently PE occurred at the weekend and with the highest density in the evening and at night (18 - 24 h) in both years. Patients with PE were predominantly men, but the rate of women causing PE increased between 2000 and 2010. Discussion/Conclusion This study provides preliminary data on current trends in PEs in preclinical emergency medicine in Germany and has implications for improving the medical care provided.

The situation of emergency psychiatry in Germany

The impact of psychiatric emergencies for the care of patients in preclinical emergency medicine, in emergency departments and in psychiatric hospitals has been underestimated for a long time. There is still insufficient knowledge and a need for further research. There are, however, sufficient reasons to assume that annually approximately 500,000 patients with a psychiatric emergency receive treatment from a preclinical emergency physician and another 1.5 million in emergency departments in Germany. Further, approximately 500,000 patients are admitted to psychiatric hospitals as an emergency. The most frequent reasons are intoxication, agitation, aggressiveness and suicidal ideation, posing a threat of self-harm to the patient or to other persons and evoking other life-threatening conditions. Emergency psychiatry also plays a role in collective injuries, such as mass disasters, catastrophes and rampage situations. There is some evidence that the number of psychiatric emergencies is increasing. Reasons are, among others, changes in the services provided for inpatient and outpatient treatment, a reduction in stabilizing psychosocial factors and a general increase in the utilization of emergency healthcare services.

Antiemetic therapy in preclinical emergency medicine - a literature review

Nausea and vomiting are frequent symptoms in emergency medicine and require a targeted drug intervention. Despite known disadvantages in terms of efficacy and side effects, metoclopramide is still often used in the emergency medical service to treat nausea and vomiting. Recent studies show that, especially in the therapy of opioid-triggered vomiting, metoclopramide is not significantly effective when compared to placebo. Dimenhydrinate seems to be an effective drug for various forms of nausea, but can often be relatively or absolutely contraindicated in emergency medicine due to its sedative effect. Based on a literature review, 5-HT3-antagonists appear to be a good alternative for the treatment of emesis in the emergency service. However, as for all antiemetics, the maximum dosage and potential side effects need to be paid attention to. In addition, neither of the 5-HT3-antagonists are approved for therapy of non-chemotherapy-induced vomiting or PONV. In conclusion, it may be considered to include 5-HT3-antagonists in addition to dimenhydrinate in the ambulance medical equipment. The routine use of a specific antiemetic is not recommended.

Simulation in preclinical emergency medicine.

Emergency medicine has been a stronghold of simulation-based training ever since high-fidelity simulators became available. The preclinical setting differs remarkably from any in-hospital environment in both available technology and resources, and thus stress levels of the health-care professionals involved in patient care – ideal factors for the simulation-based teaching approach. This review reports on the current status of the method for teaching preclinical scenarios from an educational and practical perspective. Particular attention is given to contents, formats, and evaluation of success.

What's new in emergencies, trauma and shock? studying traffic related injuries in India.

In urban India, cycle rickshaws are a significant mode of transport. Exact numbers are hard to obtain, but it is estimated that there are 2 million or more rickshaws on the road. Taken together, cycle rickshaws account for 6-8 billion passenger kilometer/year. Recent research analyzed the workload of cycle rickshaw pullers. The investigators concluded that pulling the cycle rickshaw is heavy to very heavy, which also corresponds to the subjective assessment of the participants. As known from other countries, pedestrians, cyclists, and other (motorized) two wheeled vehicle users are the most endangered road users to sustain accidents and corresponding serious injuries and death. Said this, rickshaw pullers as well as rickshaw users have to be categorized into this high-risk group. So far, little is known about injury pattern and characteristics of cycle rickshaw pullers or users. The study at hand presents new data of 84 patients, which were involved in a road traffic accident related to cycle rickshaws. A predominance of young men was evident with a peak between 20 years and 30 years of age. Crash characteristics were differentiated between single and multiple vehicle crashes. Interestingly, overturned vehicles were predominant in this group. The authors found an overload of the rickshaw in 28.5% which most likely contributes to that type of accidents with cycle rickshaws. In case of multiple vehicle crashes, the majority involved crashes with big vehicles like trucks. During hospital stay, three patients died from traumatic brain injury. Another study dealing with injuries from cycle rickshaw accidents was performed by Jaiswal et al. In their study, the majority of the participants were children or young adults. The majority of the injuries were soft-tissue injuries mostly due to the chain and the rear sprocket, but a number of fractures were also described. In summary, the authors described injuries related to rickshaws comparable to those of bicycles. The majority of patients travelled on rickshaws in a dangerous way, which also included overloaded rickshaws. The authors concluded that most of the rickshaw related injuries are preventable by restricting the number of persons travelling on cycle rickshaws and application of chain covers on new rickshaws. Another form of transport, which is popular in Asia including India, is the motorized rickshaw. Although, these vehicles reach higher traffic speeds, motorized rickshaws may serve to compare injury patterns and characteristics to those of cycle rickshaws. A study of Schmucker et al. analyzed these items in a prospective trial. In total, 60% of the reported accidents led to injuries of the rickshaw occupant. Of these the investigators were able to recruit a total of 139 patients including 82 injured motorized rickshaw occupants. Of these patients, 50% had multiple injuries and there was an alarming mortality of 12.2% in that group. This data demonstrates the need of further research to improve traffic safety in these road traffic users. To compare data of the mentioned studies to other countries, further studies are required, which also include the preclinical management. Particularly, the organization preclinical emergency medicine has to be described and should be analyzed. Based on these data including multivariate analyses, an international comparison to bicycle or motorcycle accidents might be supposable. Possibly, some implemented safety features out of the research performed in accident research units world-wide are transferable to cycle rickshaws in order to improve the safety of this mode of transport. Language: en

Attitudes towards homeless people among emergency department teachers and learners: a cross-sectional study of medical students and emergency physicians

BackgroundMedical students’ attitudes and beliefs about homeless people may be shaped by the attitudes of their teachers and one of the most common sites for learning about homeless patients is the emergency department. The objective of this study was to determine if medical students in the preclinical and clinical years and emergency medicine faculty and residents have different attitudes and beliefs about homeless people.MethodsThe Health Professional Attitudes Toward the Homeless Inventory (HPATHI), was administered to all medical students, and emergency medicine physicians and residents at a large academic health sciences center in Canada. The HPATHI examines attitudes, interest and confidence on a 5-point Likert scale. Differences among groups were examined using the Kruskal Wallis test and Pearson’s chi-square test.ResultsThe HPATHI was completed by 371 individuals, for an overall response rate of 55%. Analysis of dichotomized median and percentage results revealed 5/18 statements were significant by both methods. On the attitudes subscales physicians and residents as a group were more negative for 2/9 statements and on the confidence subscale more positive for 1/4 statements. The interest subscale achieved overall statistical significance with decreased positive responses among physicians and residents compared to medical students in 2/5 statements.ConclusionThis study revealed divergences in attitudes, interests and beliefs among medical students and emergency medicine physicians and residents. We offer strategies for training interventions and systemic support of emergency faculty. Emergency medicine physicians can examine their role in the development of medical students through both formal and informal teaching in the emergency department.

Simulation in Medical Student Education: Survey of Clerkship Directors in Emergency Medicine

IntroductionThe objective of this study is to identify (1) the current role of simulation in medical student emergency medicine (EM) education; (2) the challenges to initiating and sustaining simulation-based programs; and (3) educational advances to meet these challenges.MethodsWe solicited members of the Clerkship Directors in Emergency Medicine (CDEM) e-mail list to complete a Web-based survey addressing the use of simulation in both EM clerkships and preclinical EM curricula. Survey elements addressed the nature of the undergraduate EM clerkship and utilization of simulation, types of technology, and barriers to increased use in each setting.ResultsCDEM members representing 60 EM programs on the list (80%) responded. Sixty-seven percent of EM clerkships are in the fourth year of medical school only and 45% are required. Fewer than 25% of clerkship core curriculum hours incorporate simulation. The simulation modalities used most frequently were high-fidelity models (79%), task trainers (55%), and low-fidelity models (30%). Respondents identified limited faculty time (88.7%) and clerkship hours (47.2%) as the main barriers to implementing simulation training in EM clerkships. Financial resources, faculty time, and the volume of students were the main barriers to additional simulation in preclinical years.ConclusionA focused, stepwise application of simulation to medical student EM curricula can help optimize the ratio of student benefit to faculty time. Limited time in the curriculum can be addressed by replacing existing material with simulation-based modules for those subjects better suited to simulation. Faculty can use hybrid approaches in the preclinical years to combine simulation with classroom settings for either small or large groups to more actively engage learners while minimizing identified barriers.

Transparency was created

The authors mention the error reporting system CIRSmedical Germany, the patient safety optimization system (PaSOS) used in anesthesiology, and two further error reporting systems used in preclinical emergency medicine and geriatric care. No mention was made of the assessors' Medical Error Reporting System (MERS), which was developed by Germany's arbitration and review boards. These institutions check whether a patient was subjected to treatment errors and whether a causal relation exists with the reported health problem. Decisions made by arbitration boards will be shared with the patient, the doctor's or hospital's professional indemnity insurers, and the reviewer consulted by the arbitration board. MERS has shown that in 2008, in 2090 out of 7133 cases of arbitration, errors were noted—including deficiencies in how risk was communicated. The results are presented to the public every year by the German Medical Association in collaboration with the arbitration boards. The results are in the public domain (www.bundesaerztekammer.de, www.schlichtungsstelle.de). Publication of the results creates transparency about error related health problems in Germany. Medical problem areas are identified on a statistically sound basis. The arbitration boards publish the results regularly in their medical journals. Doctors and lawyers in the arbitration boards give presentations about the results gained by using MERS. The boards thus make a valuable contribution to error prevention and increasing patient safety. The work of the arbitration boards and MERS should not be omitted from an article on patient safety and error management.

Standard operating procedures as a tool to improve medical documentation in preclinical emergency medicine

AimTo evaluate the effect of standard operating procedures (SOPs) to improve the completion of patient care documentation items on patient care reports (PCRs) in a physician-staffed, 4500-calls-per-year preclinical ground emergency...

Interdisziplinäre Notaufnahme - Das Göttinger Modell - mehr Effizienz, weniger Kosten

Configuration of the interdisciplinary emergency unit within the university clinic of Göttingen was successfully reorganized during the past two years. All emergencies except traumatologic, gynecologic and pediatric emergencies are treated within this functional unit which is guided by the center of internal medicine. It is organized in a three shift operation manner over a period of 24 hours. Due to a close interdisciplinary collaboration between different departments patients receive optimal diagnostic and therapeutic treatment within a short period of time. To improve processes within the emergency department a series of measures were taken including the -establishment of an intermediate care unit for unstable patients, setting up of special diagnostic and therapeutic units for the acute coronary syndrome as well as stroke, implementation of standardized clinical pathways, establishment of an electronic data processing network in close communication with all diagnostic entities, introduction of a quality assurance system and reduction of medical costs. Reorganization measures lead to a substantial optimization and acceleration of emergency proceedings and thus, provides optimal patient care around the clock. In addition, medical costs could clearly be reduced at the interface between preclinical and clinical emergency medicine.

Pediatric cases in preclinical emergency medicine

Pediatric cases in preclinical emergency medicine

Nicht-invasive Bestimmung des Herzzeitvolumens durch einen transkutanen CW Doppler in der Luftrettung

Determination of cardiac output (CO) enables to assess the hemodynamic situation as well as to administer optimal catecholamine therapy especially in critically compromised patients with hemodynamic instability. Invasive determination of CO is possible via a Swan-Ganz-catheter with its associated risk of implantation in the hospital. Using the Doppler technique, we evaluated the feasibility of the USCOM-system for non-invasive CO determination in preclinical emergency medicine in air rescue service. In 32 patients (17 months to 92-years-old) cardiac output was determined non-invasively (USCOM) at the scene and during the helicopter transport at Christoph 4, based at Hannover Medical School. Simultaneously, blood pressure, ECG and oxygen saturation were determined. Non-invasive CO was assessed by a suprasternal access aiming at the aorta ascendens. 19 patients were unconscious due to cardial and non-cardial reasons, and 13 were conscious (sepsis, status epilepticus, anaphylactic reaction). 7 patients were hemodynamically unstable. In three patients the monitor was used during interhospital transfer by helicopter. Non-invasively determined CO via the USCOM system was 4.8 +/- 0.7 l/min with a cardiac index of 2.4 +/- 0.3 l/m (2). Highest CO values were determined in a patient with sepsis and during a grand-mal-status in epilepsy (CO 8.2 l/min). All examinations were done by the same emergency physician of the emergency helicopter Christoph 4 immediately after arrival at the scene. The examination took on average 25 seconds. During the helicopter transport, several consecutive CO measurements were performed to assess volume and catecholamine therapy with increase of stroke volume after volume load with colloidal fluids. Using the USCOM system it is possible to determine the beat-to-beat cardiac output in air rescue service non-invasively. The emergency physician gains additional crucial hemodynamic information to diagnose and treat adequately by administration of volume load and catecholamines at the scene and during flight conditions. Further preclinical prospective trials are mandatory to elucidate the value of this novel device in emergency medicine.

Stabile Tachykardie mit breitem QRS-Komplex in der prähospitalen Notfallmedizin

Sustained, stable wide QRS-complex tachycardia (WCT) remains a diagnostic challenge, because the treatment of supra-ventricular tachycardia (SVT) with aberrant conduction differs considerably from that of a ventricular tachycardia (VT). A usual recommendation for treating a case of a stable WCT is to manage it as if it were VT, in accordance with the consideration of "first do no harm". The aim of this study was to determine whether Board-certified emergency-physicians are able to differentiate VT from SVT with aberrant conduction in a high percentage of cases (> 90%), thus to assure more precise prehospital treatment." Eight electrocardiograms with WCT (four with electrophysiologically proven VT or SVT, respectively) were evaluated in a blinded fashion by 64 Board-certified emergency-physicians (23 female, 41 male, mean age: 37,8 + 5,1 years). Initially, the diagnosis had to be made without any further information. Afterwards the same electrocardiograms were presented again, providing important additional information. 55% of the study population were able to establish the correct diagnosis merely by evaluating the electrocardiogram. Providing the above mentioned additional information, the number of correct diagnoses increased to 61%. These results were roughly similar in all subgroups, only the subgroup of cardiologists showed a trend to better results with correct diagnoses in 68% without and 73 % with additional information. None of the subgroups reached the pre-specified cut-off of > or = 90% correct diagnoses. Specialist status as well as experience in emergency medicine had no significant influence on the results, only the subgroup of emergency physicians with an experience of more than five years showed a trend towards a higher rate of correct diagnosis, compared with the subgroup with less than one year experience in emergency medicine. In cases of stable WCT the evaluation of the electrocardiogram without further information in prehospital emergency-medicine leads to unsatisfactory results. The correct diagnosis in WCT can be improved by using additional data but the diagnostic accuracy is still low. Therefore, the differential diagnosis of stable WCT in preclinical emergency-medicine cannot be recommended. Until proven otherwise, any stable WCT should be managed as if it were VT.