Cardiac arrest results in immediate interruption of blood flow. The primary goal of cardiopulmonary resuscitation (CPR) is to re-establish blood flow and hence oxygen delivery to the vital organs. This thesis describes different pharmacological interventions aimed at increasing cerebral blood flow during CPR and after restoration of spontaneous circulation (ROSC). In a porcine model of cardiac arrest, continuous infusion of adrenaline generated higher cortical cerebral blood flow during CPR as compared to bolus administration of adrenaline. While bolus doses resulted in temporary peaks in cerebral blood flow, continuous infusion led to a sustained increase in this flow. Administration of vasopressin resulted in higher cortical cerebral blood flow and a lower cerebral oxygen extraction ratio as compared to continuous infusion of adrenaline during CPR. In addition, vasopressin generated higher coronary perfusion pressure during CPR and increased the likelihood of achieving ROSC. Parameters of coagulation and inflammation were measured after successful resuscitation from cardiac arrest. Immediately after ROSC, thrombin-antithrombin complex, a marker of thrombin generation, was elevated and eicosanoid levels were increased, indicating activation of coagulation and inflammation after ROSC. The thrombin generation was accompanied by a reduction in antithrombin. In addition, there was substantial haemoconcentration in the initial period after ROSC. By administration of antithrombin during CPR, supraphysiological levels of antithrombin were achieved. However, antithrombin administration did not increase cerebral circulation or reduce reperfusion injury, as measured by cortical cerebral blood flow, cerebral oxygen extraction and levels of eicosanoids, after ROSC. In a clinical study, the adrenaline dose interval was found to be longer than recommended in the majority of cases of cardiac arrest. Thus, the adherence to recommended guidelines regarding the adrenaline dose interval seems to be poor.

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In der vorliegenden Arbeit wurde systematisch der Einfluß verschiedener Volumensubstitutionstherapeutika (Ringer-Lactat, hypertone NaCl 7,5%-Lösung und hyperton -hyperonkotische Kombinationslösung) auf wiederholt gleiche Zustände künstlich herbeigeführter Hypovolämie (Entnahme von 20-25% des Blutvolumens) beim Menschen untersucht. Bei dem 7 köpfigen Probandenkollektiv wurden so an unterschiedlichen Tagen und individuell gleicher Blutmengenentnahme unterschiedlich substituiert und anschließend über einen mehrstündigen Zeitraum kardio-zirkulatorische Parameter, intravasale Volumeneffekte sowie metabolische Größen und Elektrolyte entweder direkt gemessen oder indirekt bestimmt. Abschließend erfogte die Rückgabe des entnommenen Blutes und eine mindestens 10 tägige Pause bis zum nächsten Versuchstag. Neben der exakten Quantifizierung aufgrund der standartisierten Bedingungen bei dieser homogenen Untersuchungsgruppe wurde ein Modell über die Funktionsweise der einzelnen Therapeutika entwickelt und eine Präferenz für die Gabe hypertoner Lösungen, besonders aber das hyperton-hyperonkotische Therapeutikum herausgearbeitet. Die Ergebnisse werden anhand zahlreicher Graphiken dargestellt und vergleichbar, statistisch ausgewertet und teilweise durch zusätzliche Tabellen und Abbildungen erläutert.

Bakgrund: Tidigare har närstående inte tillåtits att närvara vid hjärt-lungräddning (HLR) men diskussionen har ökat i omfattning. European Resuscitation Council och American Heart Association förespråkar närståendes närvaro men trots detta tillåter många länder inte detta. Sveriges sjukhus inrapporterade 2586 hjärtstopp år 2014. Närstående upplever lidande när en nära blir sjuk, vilket kopplas till familjefokuserad omvårdnad där de närstående och patienten ska ses som en helhet. Här läggs det vikt vid socialt stöd som har betydelse för en individs hälsa, en sjuksköterska kan vara lämplig som stödjande person. Syfte: Syftet med denna litteraturöversikt var att beskriva sjuksköterskans uppfattningar av att ha närstående närvarande vid HLR. Metod: En litteraturöversikt har gjorts innehållande 12 vetenskapliga artiklar med både kvantitativ och kvalitativ ansats. Resultat: Sjuksköterskor känner oro för hur närstående påverkas av att bevittna HLR, att de ska ingripa i återupplivningsarbetet. Sjuksköterskor uppfattar stöd till närstående som väsentligt för att möjliggöra närvaro vid HLR. Närstående uppfattas påverka den sociala och fysiska miljön. Riktlinjer för sjuksköterskor behövs. Konklusioner: Sjuksköterskor uppfattar att det saknas förutsättningar för närstående att närvara vid HLR. Med en stödperson för de närstående och tydliga riktlinjer kan detta främjas. Däremot finns det hinder så som arbetsmiljö som försvårar möjligheten för närståendes närvaro. / Background: Earlier, relatives’ weren ́t allowed to be present at cardiopulmonary resuscitation (CPR) but nowdays the topic is highly relevant. European Resuscitation Council and American Heart Association recommends this practice. However, many countries don ́t allow this. In 2014, 2586 cardiac arrests were reported in Swedish hospitals. Relatives are suffering when loved ones becomes ill, which is linked to family-centered care where relatives and patient should be seen as a whole. This places emphasis on social support which ́s important to peoples health. A nurse may be suitable as a support person. Purpose: The purpose of this literature review was to describe nurses' perceptions of having relatives present during cardiopulmonary resuscitation. Method: A literature review was made containing 12 scientific articles with both quantitative and qualitative approach. Results: Nurses are concerned about how relatives are affected by witnessing CPR, that they may interfere in the resuscitation efforts. Nurses perceive that support for the relatives are essential. Relatives are perceived to have impact on the social and physical environment. Guidelines for nurses are needed. Conclusions: Nurses perceive that with staff who can support the family and with the availability of guidelines and a well-functioning work environment it ́s possible to have relatives present during CPR.

Background: Every two seconds a person dies by the result of a trauma. The trauma teams' initial assessment is a structured and systematic concept, where the treaters in the acute care setting are involved in excluding life-threatening conditions and to do an accurate medical examination of the patient. The trauma resuscitation is a fast encounter between the patient and the trauma team. Patients is often affected by the acute event when they lose control over their own situation. Aim: The aim of this study was to describe the patient experience of the trauma resuscitation at the emergency department. Method: A literature review has been made of 5 qualitative and 5 quantitative articles. Articles were analyzed by searching for similarities and differences. The analyzed articles were published between 2004-2015. Results: The result showed that patients had unique needs such as; be treated like individuals and be cared for by competent personnel. The results also showed the importance of sufficient information on examination and treatment. The patient could feel either insecure or cared for in the trauma resuscitation depending on nurses’ communication. Conclusion: The trauma resuscitation is a complex concept and involves many aspects that a nurse should keep track of. The nurse and the traumateam need to face the high requirements of the resuscitation to provide good and safe care for the patient under the whole intervention.

Syfte: var att undersöka vilken pedagogisk metod, instruktörsledd eller filmbaserad med facilitator som ger bäst kunskap såväl kortsiktigt som långsiktigt vid hjärt-lungräddningsutbildning (HLR) i årskurs sju. Syftet var även att undersöka elevers motivation till att ingripa i en akut hjärtstoppssituation. Teori Då lärande enligt läroplanen ska ske i social miljö, genom samspel har jag i studien valt att utgå från det sociokulturella perspektivet där kontexten är viktig i ett sammanhang, i kombination med praktikorienterad teori för att beskriva lärandet. Metod Datainsamling har skett genom en kombination av kvantitativ och kvalitativ metod. Åttio elever utförde treminuters praktiskt test direkt efter utbildningstillfället i HLR samt efter tre månader. Bedömning av medvetandekontroll och andningskontroll utfördes genom direktobservation. Kvalitet på utförd HLR registrerades via en övningsdocka kopplad till ett datorbaserat program, Leaerdal PC skill reporter. Insamlad data registrerades i en modifierad version av mätinstrumentet Cardiff Test. I testet bedömdes 13 variabler med total poängsumma 12-48 poäng. Primärt effektmått var den totala poängen med enskilda variabler som sekundär endpoints. En hypotes är att det inte är någon skillnad mellan utbildningsmetoderna gällande elevernas totalpoäng, vilket medför att den filmbaserade metoden är effektivare då den utförts i helklass. Semistrukturerade intervjuer genomfördes direkt efter utbildningstillfället för att undersöka elevers motivation till att göra en livräddande insats. Resultat: Ingen signifikant skillnad ses mellan utbildningsgrupperna beträffande kvalitetstestets totalpoäng, vare sig vid mätning direkt efter utbildningstillfället; instruktörsledd 33 poäng, DVD-baserad 34 poäng, eller vid tre månaders uppföljning; instruktörsledd 31 poäng, DVD-baserad 30 poäng. Vid tremånaders test utförde majoriteten av eleverna bröstkompressioner med handplacering för långt ned mot bröstbensspetsen, DVD-baserad 20 %, instruktörsledd 48 %. I den instruktörsledda gruppen sågs vid tre månaders uppföljning en signifikant ökning av andelen elever som utförde kompressioner med korrekt kompressionsdjup (5-6 cm), 7,5 % vs 32,5 %, DVD-baserad 10 % vs 25 %. Flertalet elever ansåg spontant att de hade tillräckliga kunskaper för att göra en livräddande insats. Vid följdfrågor framkom dock att flertalet av de intervjuade kände oro och rädsla för bristande kunskaper, dels för att skada den drabbade, dels för att göra fel vid en livräddande insats i verkligheten. Några elever beskrev att bekräftelse och återkoppling bidrog till att stärka elevens självkänsla till att våga ingripa i en verklig situation, vilket kan vara svårt att hinna med vid utbildning i stora grupper. En möjlig slutsats är att den filmbaserade metoden är effektivare sätt till antal utbildade deltagare, men med stöd av sociokulturell teori bör det i framtida utbildningar avsättas mer tid för gemensamt lärande, tillvaratagande av frågeställningar samt avsättning av tid för individuell och gemensam reflektion. / Aim: To compare students’ practical CPR skills and attitude to perform bystander CPR after instructor-led versus DVD-based training. Method:  Data was collected through a combination of quantitative and qualitative methods. CPR skills were assessed of 80 seventh grade students during a three minutes practical test, directly after training and at three months follow up by using a PC Skill Reporting System. For CPR skills a total score, 12-48 points, was calculated.  A hypothesis is that there is no difference between training methods regarding students' total score, which means that the DVD-based method is more efficient when performed with the whole class. Nine semi-structured interviews were conducted immediately after the training to investigate students' motivation to make a life-saving effort. Result: There were no significant differences between the instructor-led or the DVD-based group regarding CPR skills, a total score of 33 points versus 34 points directly after training and 31 points versus 30 points at three months, respectively.Most students felt spontaneously that they had enough knowledge to make a life-saving effort, but the follow-up questions showed that the majority of the responders, felt worry and fear of lack of sufficient knowledge, to harm the victim or to make mistakes in a life-saving situation. Some students described that feedback after the practical test, helped to strengthen the student's self-esteem, which can be difficult to find time for when training in large groups.One possible conclusion is that the DVD-based method is more efficient in number of participants trained, but with support of the socio-cultural theory, it should in future trainings aside more time for joint learning, valorization of issues and deposition of time for individual and collective reflection.

Ventricular fibrillation (VF) is a lethal heart rhythm that leads to cardiac arrest. It has been shown that amplitude spectral area (AMSA) in prolonged VF correlates with success of resuscitation. This study will compare traditional resuscitation with a novel resuscitation algorithm using AMSA and end-tidal carbon dioxide (ETCO2) to time defibrillations.VF will be induced in 60 swine. Resuscitation will commence after 10 minutes of untreated VF. Cases will receive defibrillation if AMSA is >19.8 mVHz and ETCO2 >20 mm of Hg, otherwise chest compressions will continue for another 90 seconds. Controls will have standard resuscitation. Sub group analysis will include effect of induced myocardial infarction (MI).End points will include survival, neurologic scores, duration of resuscitation efforts, and number of defibrillations.This experiment will establish whether using AMSA and ETCO2 to time defibrillations results in superior resuscitation compared with standard techniques.

Emergency response team (ERT) member characteristics that contribute to High Reliability performance during patient care resuscitation events or other Critical Incident Management Situations are poorly understood. Findings from this study describe individual characteristics that experienced interprofessional ERT members perceive as contributing to High Reliability performance within the critical incident management context. This study supports the need for interprofessional research about emergency response teams’ High Reliability in hospital-based settings. ERT High Reliability, or “better than expected” team performance has been linked to overall patient care and safety. The purpose of this study was to identify and describe individual team member characteristics that contribute to High Reliability performance of ERT members and the overall emergency response team in a naturalistic setting during Critical Incident Management Situations. Using a qualitative descriptive design, data collection included participant observations, field notes, and interviews. Narrative data were audio-taped, transcribed and coded using Ethnograph v6©. Data content were analyzed thematically using inductive interpretive methods. Two major domains derived from the data were Self-Regulation and Whole-Team Regulation. The overarching theme, Orchestrating High Reliability at the Edge of Chaos, encompassed characteristics contributing to High Reliability performance of the ERT during Critical Incident Management Situations.

Acute Respiratory Distress Syndrome (ARDS) following hemorrhagic shock/resuscitation (S/R) is an important contributor to late morbidity and mortality in trauma patients. S/R promotes ARDS by inducing oxidative stress that primes cells of the innate immune system for excessive responsiveness to small inflammatory stimuli, termed the “twohit” hypothesis. Activated alveolar macrophages (AM) play a central role and when recovered from S/R animals exhibit an exaggerated responsiveness to lipopolysaccharide (LPS) with increased activation of the proinflammatory transcription factor NF-κB, and augmented expression of cytokines. LPS triggers AM signalling through Toll like receptor 4 (TLR4), which resides in plasma membrane lipid rafts. The objective of this work is to define cellular mechanisms of macrophage priming by oxidative stress following shock resuscitation. The main hypothesis investigated is that altered cellular distribution of TLR4 can lead to macrophage priming and antioxidant resuscitation strategies can diminish these effects. AM of rodents, exposed in vivo to oxidant stress following S/R, increase their surface levels of TLR4, which in turn results in augmented NF-κB translocation in response to small doses of LPS. Furthermore, in vitro H2O2 treatment of RAW 264.7 macrophages results in similar TLR4 surface translocation. Depletion of intracellular calcium, disruption of the cytoskeleton or inhibition of the Src kinases prevents the H2O2-induced TLR4 translocation, suggesting the involvement of receptor exocytosis. Further, fluorescent resonance energy iii transfer between TLR4 and lipid rafts as well as biochemical raft analysis demonstrated that oxidative stress redistributes TLR4 to surface lipid rafts. Preventing the oxidant-induced movement of TLR4 to lipid rafts using methyl-ß-cyclodextrin precluded the increased responsiveness of cells to LPS after H2O2 treatment. Further, AM priming by oxidative stress can be diminished by early exposure to resuscitation regimens with direct or indirect systemic antioxidant effects, such as 25% albumin, N-acetylcysteine and hypertonic saline. Hyperosmolarity was found to modulate AM TLR4 gene and protein expression. Collectively, these studies suggest a novel mechanism whereby oxidative stress might prime the responsiveness of cells of the innate immune system. Targeting the TLR4 signalling pathway early during shock resuscitation may represent an anti-inflammatory strategy able to ameliorate late morbidity and mortality following S/R.

Bakgrund: Hos sjuksköterskor på akutmottagning råder delade meningar om närståendes närvaro vid hjärt-lungräddning. Detta kan bero på om sjuksköterskan har positiva eller negativa upplevelser av situationen. Sedan flera år finns internationella riktlinjer skrivna som förespråkar närståendes närvaro, dessa används generellt inte i någon större utsträckning. Syfte: Att belysa sjuksköterskans upplevelse av närståendes närvaro vid hjärt-lungräddning på akutmottagning. Metod: En litteraturstudie har genomförts med 12 kvalitativa och kvantitativa vetenskapliga artiklar. Resultat: Under senare år har majoriteten av sjuksköterskorna gått från negativ inställning till positiv för närståendes närvaro vid HLR. Att närstående varit närvarande i de fall där HLR inte varit lyckad trodde sjuksköterskorna kunde underlätta det kommande sorgarbetet. Sjuksköterskorna trodde att närstående lättare kunde acceptera det plötsliga dödsfallet om de fick beröra, ta farväl och vara ett stöd den sista stunden i livet för sin familjemedlem. Slutsats: För att sjuksköterskan ska kunna behålla sin positiva upplevelse till närståendes närvaro vid HLR på akutmottagning krävs utvecklings–och förbättringsarbete. I detta arbete krävs både teoretisk och praktisk utbildning inom området. Samt etablering av de internationella riktlinjerna till lokala riktlinjer. / Background: Among nurses in emergency department is a difference of opinion regarding the issue of relatives being present during cardiopulmonary resuscitation. This can depend on the nurse have positive or negative experience of the situation. Since several years international guidelines are written to recommend relatives being present but in general they are not used. The aim: Of this study was to explain nurse’s experiences of relative’s presence during cardiopulmonary resuscitation in emergency department. Method: A literature review in which 12 qualitative and quantitative scientific papers have been reviewed. Results: During the last years most parts of the nurses changed their opinion from negative to positive regarding to relatives being present at CPR. If relatives been present when CPR wasn´t successful the nurses believed could help the coming grieving process. Nurses believed that relatives easier could accept the sudden death if they were able to touch, to say goodbye and share the last moments in life with their family member. Conclusion: To maintain the nurse positive experience of relative presence during CPR in emergency department needs development- and improvement work. This work needs both theoretical and practical education. And also there are needs to establish the international guidelines to local guidelines.