Reanimation im Krankenhaus – Erst mal Intubieren? Eher nicht!

Es kommt zur Reanimation im Krankenhaus. Der Patient hat noch keine Atemwegssicherung. CPR beginnt, soll ich direkt den Atemweg durch Intubation sichern? Nein sagen die Autoren der American Heart Asscociation! Sie untersuchten anhand der Daten ihres „Get With The Guidelines – Resuscitation“ Registers den Zusammenhang zwischen Intubation und Überleben.

Die ersten Minuten einer Reanimation sind auch für gut gedrillte Teams eine Herausforderung. Je nach Situation ist in möglichst kurzer Zeit ein Arbeitsfeld zu schaffen, ein Kammerflimmern zu defibrillieren, eine Asystolie über den geschaffenen Zugang mit Adrenalin zu behandeln, eine Anamnese zu erfahren, eine Versorgungs– und Transportlogistik zu schaffen, weitere Kolleginnen und Kollegen, Behandler und Vorgesetzte zu informieren, ggf. anwesende Angehörige oder Bystander zu betreuen. Dies alles unter unbedingt kontinuierlicher und möglichst nicht unterbrochener, hochwertiger CPR. Ach ja, dazu gehört auch eine Zufuhr von Sauerstoff in die Lungen und die Verhinderung einer Aspiration. Also doch direkt erstmal intubieren?

Aus dem Register, ähnlich dem deutschen Reanimationsregister, wurden retrospektiv Reanimationen an 108.079 erwachsenen Patienten aus 668 verschiednen Krankenhäusern untersucht. Insgesamt überlebten 24.256 Patienten (22.4%) bis zur Krankenhausentlassung.

Von den 71.163 Patienten, die in den ersten 15 Minuten intubiert wurden (66,3%), wurden 43.314 Patienten mit einem Patienten „gematched“, der nicht in der gleichen Minute intubiert wurde.

Ergebnis: Die intubierten Patienten überlebten seltener!

Gruppe Überleben
Intubiert 7052 von 43.314 (16.3%)
Nicht-Intubiert 8407 von 43.314 (19.4%)
RiskRatio [RR] = 0.84; 95% CI: 0.81-0.87; P < .001

Aggressiv ausgedrückt: Die Sterblichkeit hätte sich um 16% senken lassen, wenn andere Dinge als die Intubation im Vordergrund gestanden hätten.

Dies ließ sich über alle untersuchten Subgruppen reproduzieren.

 

 

Wohlgemerkt: Hierbei handelt es sich um retrospektive Registerdaten. Sie hinterfragen nicht, warum ein Patient intubiert wurde oder warum grade nicht. Wurde er intubiert, weil genügend Team-Mitglieder mit benötigten Skills vor Ort waren? Wurde er aus Verzweiflung oder als Übersprungshandlung intubiert? Oder grade nicht, weil die Situation dem Kliniker grade aussichtslos erschien, oder nur ein inhaltlich oder zahlenmäßig unzureichendes Team bereit stand?

 

Fazit:

Die vorliegende Studie schließt den Nutzen einer Intubation während der ersten 15 Minuten einer Reanimation nicht sicher in jedem Fall aus, ein grundsätzlicher Vorteil wohnt ihr aber offensichtlich nicht inne.

Cerebrospinal fluid (CSF) interpretation

This guide provides a structured approach to cerebrospinal fluid (CSF) interpretation, including typical CSF results for specific disease processes. Reference ranges vary between labs, so always consult your local medical school or hospital guidelines.

Normal CSF ranges (adults)

Appearance: Clear and colourless

White blood cells (WBC): 0 – 5 cells/µL

  • No neutrophils present, primarily lymphocytes
  • Normal cell counts do not rule out meningitis or any other pathology

Red blood cells (RBC): 0 – 10/mm³

Protein: 0.15 – 0.45 g/L (or <1% of the serum protein concentration)

Glucose: 2.8 – 4.2 mmol/L (or ≥ 60% plasma glucose concentration)

Opening pressure: 10 – 20 cm H2O

CSF findings in specific diseases

Bacterial meningitis

Appearance: Cloudy and turbid

Opening pressure: Elevated (>25 cm HO)

WBC: Elevated >100 cell/µL (primarily polymorphonuclear leukocytes (>90%))

Glucose level: Low (<40% of serum glucose)

Protein level: Elevated (>50 mg/dL)

 

Causes:

  • Newborns: Listeria monocytogenes, E. Coli, Group B Streptococci
  • Older children: Neisseria meningitidis, Haemophilus influenzae Type B, Streptococcus pneumoniae
  • Adults: Neisseria meningitidis, Streptococcus pneumoniae, Listeria monocytogenes

 

Symptoms:

  • Headache
  • Fever
  • Neck stiffness
  • Photophobia
  • Meningococcal meningitis presents with a characteristic petechial rash

 

Further investigations:

  • CSF gram stain and cultures
  • CSF bacterial antigens
  • CSF PCR
  • Blood cultures
  • Imaging to rule out other intracranial pathology – CT / MRI head

 

Viral (aseptic) meningitis

Appearance: Clear

Opening pressure: Normal or elevated

WBC: Elevated (50 – 1000 cells/µL, primarily lymphocytes, can be PMN early on)

Glucose level: Normal (>60% serum glucose however may be low in HSV infection)

Protein level: Elevated (>50 mg/dL)

 

Causes:

  • Herpes simplex virus (HSV 2 is more common than HSV 1)
  • Enteroviruses
  • Varicella zoster virus (VZV)
  • Mumps
  • HIV
  • Adenovirus

 

Symptoms:

  • Headache
  • Fever
  • Neck stiffness
  • Photophobia

 

Further investigations:

  • CSF PCR for viruses (e.g. Herpes simplex virus (HSV) / Varicella-zoster virus (VZV))
  • Blood cultures
  • Imaging to rule out other intracranial pathology – CT / MRI head

 

Fungal meningitis

Appearance: Clear or cloudy

Opening pressure: Elevated

WBC: Elevated (10 – 500 cells/µL)

Glucose level: Low

Protein level: Elevated

 

Causes:

  • Cryptococcus neoformans
  • Candida

 

Symptoms:

  • Patients are often immunocompromised
  • Headache
  • Confusion
  • Nausea
  • Vomiting
  • Fever and neck stiffness are less common

 

Further investigations:

  • CSF cultures
  • CSF PCR
  • CSF staining
  • HIV test (with consent)
  • Blood cultures
  • Imaging to rule out other intracranial pathology – CT / MRI head

 

Tuberculosis meningitis

Appearance: Opaque, if left to settle it forms a fibrin web

Opening pressure: Elevated

WBC: Elevated (10 – 1000 cells/µL, Early PMNs then mononuclears)

Glucose level: Low

Protein level: Elevated (1-5 g/L)

 

 

Symptoms:

  • Headache
  • Fever
  • Neck stiffness
  • Photophobia
  • Delirium
  • Cranial nerve palsies

 

Further investigations:

  • CSF cultures
  • CSF bacterial antigens
  • CSF PCR
  • HIV test (with consent)
  • Blood cultures
  • Imaging to rule out other intracranial pathology – CT / MRI head
  • Chest X-ray

 

Subarachnoid haemorrhage

Appearance: Blood stained initially, then xanthochromia (yellowish) >12 hours later

Opening pressure: Elevated

WBC: Elevated (WBC to RBC ratio of approx 1:1000)

RBC: Elevated

Glucose level: Normal

Protein level: Elevated

 

Causes:

  • Trauma
  • Vascular malformations (e.g. aneurysms, arteriovenous malformations)

 

Symptoms:

  • Sudden onset “thunderclap” headache (patients may describe it as the “worst headache ever”)
  • Stiff neck
  • Vomiting
  • Seizures
  • Confusion
  • Neurological deficits (e.g. weakness / sensory disturbance)

 

Further investigations:

  • Cerebral angiogram
  • CT angiography

 

Guillain Barre syndrome

Appearance: Clear or xanthochromia

Opening pressure: Normal or elevated

WBC: Normal

Glucose level: Normal

Protein level: Elevated (>5.5 g/L)

 

Causes:

  • Campylobacter jejuni
  • CMV
  • EBV
  • Mycoplasma pneumonia
  • VZV

 

Symptoms:

  • Often occurs after a recent bacterial / viral illness
  • Symmetrical ascending muscle weakness primarily affecting proximal musculature (trunk/respiratory muscles)

 

Further investigations:

  • Serologic studies
  • Nerve conduction studies
  • EMG
  • Imaging to rule out other intracranial pathology – CT / MRI head

 

Multiple sclerosis

Appearance: Clear

Opening pressure: Normal

WBC: 0 – 20 cells/µL (primarily lymphocytes)

Glucose level: Normal

Protein level: Mildly elevated (0.45 – 0.75 g/L)

 

Symptoms:

  • Optic neuritis
  • Limb weakness
  • Sensory disturbances
  • Diplopia
  • Ataxia

 

Further investigations:

  • MRI head
  • Oligoclonal bands of IgG on electrophoresis (CSF and Serum)
  • Evoked potential tests (visual/somatosensory)

Worked examples

Case 1

A 55-year-old woman has been getting more confused over the last 2 months. Over the last 3 days, she has been vomiting and suffering from lack of energy. She has no neck stiffness and a CD4 count of 100/mm³

CSF results

Appearance: Cloudy

Opening pressure: 25 cm HO

WBC: 400 cells/µL

Glucose level: < 40% of serum glucose concentration

Protein level: 1g/L

Reveal answer

This is fungal meningitis, in this particular case this lady is found to have cryptococcal meningitis on CSF culture. The patient is also found to have HIV, likely the cause of her impaired immune function (CD4 count 100/mm³), leaving her vulnerable to cryptococcal infection.

 

Case 2

A 28 year old male presents with a 12 hour history of high fever, severe headache, confusion, photophobia and neck stiffness. He has no significant past medical history and takes no regular medication.

 

CSF results

Appearance: Cloudy

Opening pressure: 30 cm HO

WBC: 936 cells/µL (>95% PMN cells)

Glucose level: < 40% of serum glucose

Protein level: 3 g/L

Reveal answer

This is bacterial meningitis. This young gentleman has presented with meningeal symptoms, fever, confusion which have progressed rapidly over the last 12 hours. The CSF is cloudy on inspection, the white cell count is significantly raised and glucose levels are low. The history and CSF results are strongly suggestive of bacterial meningitis and therefore he should be treated empirically whilst culture results are awaited.

Case 3

A 38 year old female presents with 24 hours of headache, photophobia, mild neck stiffness, in addition to coryzal symptoms. She is fully orientated and her observations are stable.

 

CSF results

Appearance: Clear

Opening pressure: 23 cm HO

WBC: 150 cells /µL (primarily lymphocytes)

Glucose level: Normal

Protein level: 90 mg/dL

 

Reveal answer

This is viral meningitis.  This lady has presented with a history of meningitic symptoms alongside coryzal symptoms which suggests the presence of a viral type illness. The CSF findings are more suggestive of viral meningitis given the clear appearance of the CSF, the mildly raised WCC (consisting mainly of lymphocytes), raised protein level and normal glucose. Further investigations including CSF PCR can be useful in identifying the specific virus.

 

Case 4

A 52 year old male presents to A&E with history of a sudden onset severe headache which occurred whilst he was at his desk yesterday. Since the headache he has been feeling nauseated, but he is otherwise well and fully orientated. Examination is largely unremarkable, but he does appear to have some mild neck stiffness.

 

CSF results

Appearance: Yellowish

Opening pressure: 23 cm HO

WBC: Normal

Red cell count: Raised

Glucose level: Normal

Protein level: 80 mg/dL

Xanthochromia: positive

Reveal answer

This is subarachnoid haemorrhage (SAH). The typical history of a sudden severe headache (often described as thunderclap) and meningitic symptoms (neck stiffness) is strongly suggestive of SAH. CT head is often the first line investigation, but it has a sensitivity of 98% in the first 12 hours and becomes less sensitive after that. As a result lumbar puncture is used to rule out SAH. The CSF typically shows a persistently raised red cell count (due to blood present in the CSF from the initial bleed). Within several hours, the red blood cells in the cerebrospinal fluid are destroyed, releasing their oxygen-carrying molecule heme, which is metabolized by enzymes to bilirubin, a yellow pigment. This yellow pigment can be detected and it’s presence is referred to as xanthochromia

The post Cerebrospinal fluid (CSF) interpretation appeared first on Geeky Medics.

Paediatric Gastroenteritis

What? A 4-year-old male presents to the Emergency Department (ED) with a 3-day history of diarrhoea. The illness began with 24-hours of vomiting, subsiding as the diarrhoea became apparent. He had been running a low-grade fever (temperature  37.8C) accompanied by episodes of lethargy.  His parents are concerned that his fluid intake is decreasing and although

Trauma In Pregnancy 4: Imaging

Everyone worries about imaging pregnant patients. As with most medical tests, it always boils down to risks vs benefits. What are the chances of causing mutations or cancers or a spontaneous abortion, and what is the risk of missing a critical injury? In general, reasonable studies involving a fetus at just about any point in gestation won’t cause major problems. At least as far as we know. What is not clear are the longer term, hard to measure effects. So the general philosophy should be to order just what you absolutely need, and shield the fetus during any studies other than of the abdomen/pelvis.

Now, to put these numbers into perspective, have a look at this list of delivered doses from common studies. The table above is listed in milliGrays, and this one is in milliSieverts. These are roughly comparable, except that the former is a measure of radiation dose absorbed, and the latter measures radiation delivered.

Bottom line: Think hard about the imaging you really need. If you generally do this for all patients, you probably won’t change your practice in pregnant women. Don’t worry about chest and pelvic x-rays. Shield the fetus for anything not involving the abdomen/pelvis. For major torso trauma, you probably will need CT of the chest/abdomen/pelvis. If so, do it right. Order with contrast so you don’t get substandard images that need to be repeated.

Source: http://thetraumapro.com/2017/02/16/trauma-in-pregnancy-4-imaging/

The 52 in 52 Review: Hyperbaric Oxygen for Acute Carbon Monoxide Poisoning

Weaver LK, Hopkins RO, Chan KJ, et al. Hyperbaric oxygen for acute carbon monoxide poisoning. N Engl J Med. 2002 Oct 3;347(14):1057-67.

 

What we already know about the topic: Carbon monoxide poisoning is responsible for about 40,000 visits to emergency departments every year in the U.S. Patients who survive the initial insult are vulnerable to cognitive sequelae, which generally occur within 20 days of exposure. Hyperbaric oxygen therapy is one potential treatment modality for CO poisoning.

 

Why this study is important: In this study, the authors investigate whether simply giving a patient hyperbaric oxygen therapy decreases the rate of cognitive sequelae after CO poisoning. It is one of the first articles to support the use of hyperbaric oxygen as a treatment modality.

 

Brief overview of the study: In this study, 156 patients with CO poisoning (elevated carboxyhemoglobin level, elevated ambient CO concentration, or obvious CO exposure plus other symptoms) were randomized to receive either hyperbaric O2 or normobaric O2 (76 patients in each arm). Every patient had three chamber sessions over 24 hours, either with hyperbaric or normobaric O2. Patients completed a battery of neuropsychological tests before therapy, after the first and third chamber sessions, and again at 2 weeks, 6 weeks, 6 months, and 12 months. The primary outcome was the incidence of cognitive sequelae 6 weeks after therapy. Cognitive sequelae were significantly less frequent at 6 weeks, 6 months, and 12 months in the hyperbaric group.

 

Limitations: The normobaric group had a higher rate of cerebellar dysfunction before intervention. Also, the study was not designed to determine how much hyperbaric therapy (i.e. the number of sessions) is necessary to experience a benefit.

 

Take home points: This article suggests that in patients suffering from acute carbon monoxide poisoning, undergoing three sessions of hyperbaric oxygen therapy appears to decrease the risk of experiencing cognitive sequelae. While side effects such as barotrauma and hyperoxic seizures are possible risks of hyperbaric therapy, only one patient in this study had TM rupture (although seven experienced anxiety that caused premature cessation of treatment). The most recent ACEP clinical policy on CO poisoning, released in January 2017 (https://www.acep.org/Physician-Resources/Policies/Clinical-policies/Clinical-Policy-COPoisoning/), suggests that ED physicians should use hyperbaric therapy or high-flow normobaric therapy for acute CO patients. This is a level B recommendation.