Diagnostik und Therapie nach präklinischem Kreislaufstillstand

Trotz optimaler Rettungswege und hochtechnisierter klinischer Versorgung liegt die Mortalität bei Patienten mit präklinischem Herz-Kreislauf-Stillstand oft bei über 90 %. Eine optimale Akutversorgung durch standardisierte Diagnostik und Therapie kann die Überlebenschancen auf 40 % anheben. Laufende klinische Studien dienen der Schaffung von Evidenz der aktuell empfohlenen Maßnahmen, um so die Behandlungsalgorithmen der Leitlinien in der Zukunft weiter verbessern können.

Abstract

Out-of-hospital circulatory arrest represents a challenging situation in emergency medicine even until today. Despite optimal emergency care and clinical treatment pathways, we are faced with a mortality rate above 90 %. It is possible to improve the survival rate to more than 40 % under ideal clinical and preclinical conditions. Thus, more people’s life could be saved by standardized SOPs and networks in emergency medicine. About 14.000 preclinical resuscitation cases are reported in Germany per year. The prognosis out-of-hospital circulatory arrest patients is determined by best preclinical treatment including early resuscitation by bystanders. However, ethical considerations for not performing cardiopulmonary resuscitation include comorbidities, advanced age, and prognostic markers of intensive care medicine like lactate level or neuron-specific enolase. Since myocardial infarction is the underlying disease in about 3 quarters of acute circulatory arrest cases, early angiography and coronary revascularization is of upmost importance. In addition, it is essential to provide hemodynamic stabilization for prevention of multiorgan dysfunction syndrome. Neuroprotection by therapeutic hypothermia may further help to improve survival and quality of life. Mechanical circulatory support devices may be considered adjunct to pharmacological measures for hemodynamic stabilization. Due to lack of evidence, these devices are currently under evaluation and prospectively randomized trials. We expect new treatment algorithms for optimal care of these high-risk patients in the near future.

Schlüsselwörter

Herz-Kreislauf-Stillstand - Wiederbelebung - kardiogener Schock - extrakorporale kardiopulmonale Reanimation

Key words

cardiac arrest - resuscitation - cardiogenic shock - extracorporeal cardiopulmonary resuscitation

• Literatur

• 1 Atwood C, Eisenberg MS, Herlitz J. et al Incidence of EMS-treated out-of-hospital cardiac arrest in Europe. Resuscitation 2005; 67: 75-80 . doi:10.1016/j.resuscitation.2005.03.021
• 2 Hochman JS, Sleeper LA, Webb JG. et al Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock. N Engl J Med 1999; 341: 625-634 . doi:10.1056/nejm199908263410901
• 3 van Diepen S, Katz JN, Albert NM. et al Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation 2017; 136: e232-e268 . doi:10.1161/cir.0000000000000525
• 4 Deutsche Gesellschaft für Kardiologie – Herz- und Kreislaufforschung e. V. (DGK). Deutsch-österreichische S3-Leitlinie „Infarktbedingter kardiogener Schock – Diagnose, Monitoring und Therapie“. 2019 www.awmforg/leitlinien/detail/ll/019-013html
• 5 Baran DA, Grines CL, Bailey S. et al SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019. Catheter Cardiovasc Interv 2019; 94: 29-37 . doi:10.1002/ccd.28329
• 6 Sulzgruber P, Sterz F, Poppe M. et al Age-specific prognostication after out-of-hospital cardiac arrest – The ethical dilemma between ‘life-sustaining treatment’ and ‘the right to die’ in the elderly. Eur Heart J Acute Cardiovasc Care 2017; 6: 112-120 . doi:10.1177/2048872616672076
• 7 Janssens U, Jung C, Hennersdorf M. et al Empfehlungen zum hämodynamischen Monitoring in der internistischen Intensivmedizin. Kardiologe 2016; 10: 149-169 . doi:10.1007/s12181-016-0060-x
• 8 Zhang Z. Echocardiography for patients undergoing extracorporeal cardiopulmonary resuscitation: a primer for intensive care physicians. J Intensive Care 2017; 5: 15 . doi:10.1186/s40560-017-0211-6
• 9 Wnorowski AM, Halpern EJ. Diagnostic Yield of Triple-Rule-Out CT in an Emergency Setting. Am J Roentgenol 2016; 207: 295-301 . doi:10.2214/ajr.15.15717
• 10 Thiele H, Akin I, Sandri M. et al PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock. N Engl J Med 2017; 377: 2419-2432 . doi:10.1056/NEJMoa1710261
• 11 Fernando SM, Tran A, Cheng W. et al Pre-arrest and intra-arrest prognostic factors associated with survival after in-hospital cardiac arrest: systematic review and meta-analysis. BMJ (Clinical research ed) 2019; 367: l6373 . doi:10.1136/bmj.l6373.
• 12 Attana P, Lazzeri C, Chiostri M. et al Lactate clearance in cardiogenic shock following ST elevation myocardial infarction: a pilot study. Acute Card Care 2012; 14: 20-26 . doi:10.3109/17482941.2011.655293
• 13 Luescher T, Mueller J, Isenschmid C. et al Neuron-specific enolase (NSE) improves clinical risk scores for prediction of neurological outcome and death in cardiac arrest patients: Results from a prospective trial. Resuscitation 2019; 142: 50-60 . doi:10.1016/j.resuscitation.2019.07.003
• 14 Pfeifer R, Ferrari M, Borner A. et al Serum concentration of NSE and S-100b during LVAD in non-resuscitated patients. Resuscitation 2008; 79: 46-53 . doi:10.1016/j.resuscitation.2008.04.016
• 15 Riddersholm S, Kragholm K, Mortensen RN. et al Organ support therapy in the intensive care unit and return to work in out-of-hospital cardiac arrest survivors-A nationwide cohort study. Resuscitation 2018; 125: 126-134 . doi:10.1016/j.resuscitation.2018.01.001
• 16 Deutsche Gesellschaft für Neurologie e. V. (DGN). S1-Leitlinie Hypoxisch-ischämische Enzephalopathie (HIE) im Erwachsenenalter. 2017 www.awmforg/leitlinien/detail/ll/030-119html
• 17 Khoshnood A, Carlsson M, Akbarzadeh M. et al Effect of oxygen therapy on myocardial salvage in ST elevation myocardial infarction: the randomized SOCCER trial. Eur J Emerg Med 2018; 25: 78-84 . doi:10.1097/mej.0000000000000431
• 18 Barbateskovic M, Schjorring OL, Russo Krauss S. et al Higher versus lower fraction of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit. Cochrane Database Syst Rev 2019; 27 (11)
• 19 Janssens U, Riessen R. Inotrope Substanzen beim infarktbedingten kardiogenen Schock. Dtsch med Wochenschr 2017; 142: 811-815 . doi:10.1055/s-0043-105224
• 20 Russ MA, Prondzinsky R, Carter JM. et al Right ventricular function in myocardial infarction complicated by cardiogenic shock: Improvement with levosimendan. Crit Care Med 2009; 37: 3017-3023 . doi:10.1097/CCM.0b013e3181b0314a
• 21 Thiele H, Zeymer U, Neumann FJ. et al Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012; 367: 1287-1296 . doi:10.1056/NEJMoa1208410
• 22 Ferrari M, Kruzliak P, Spiliopoulos K. An insight into short- and long-term mechanical circulatory support systems. Clin Res Cardiol 2015; 104: 95-111 . doi:10.1007/s00392-014-0771-6
• 23 Michels G, Wengenmayer T, Hagl C. et al Empfehlungen zur extrakorporalen kardiopulmonalen Reanimation (eCPR). Der Kardiologe 2018; 12: 332-341 . doi:10.1007/s12181-018-0268-z
• 24 Dankiewicz J, Cronberg T, Lilja G. et al Targeted hypothermia versus targeted Normothermia after out-of-hospital cardiac arrest (TTM2): A randomized clinical trial-Rationale and design. Am Heart J 2019; 217: 23-31 . doi:10.1016/j.ahj.2019.06.012
• 25 Bol ME, Suverein MM, Lorusso R. et al Early initiation of extracorporeal life support in refractory out-of-hospital cardiac arrest: Design and rationale of the INCEPTION trial. Am Heart J 2019; 210: 58-68 . doi:10.1016/j.ahj.2018.12.008
• 26 Udesen NJ, Moller JE, Lindholm MG. et al Rationale and design of DanGer shock: Danish-German cardiogenic shock trial. Am Heart J 2019; 214: 60-68 . doi:10.1016/j.ahj.2019.04.019