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Die transthorakale Defibrillation

Physiologische und pathophysiologische Grundlagen und deren Bedeutung für den Reanimationserfolg

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Zusammenfassung

Die frühzeitige transthorakale Defibrillation ist ein wichtiges Glied in der Kette der lebenserhaltenden Erstmaßnahmen zur Beendigung eines bestehenden Kammerflimmerns/-flatterns (KF). Entscheidend für den Defibrillationserfolg ist der Stromfluss durch eine kritische Herzmuskelmasse. Bei zu geringem Strom erfolgt keine Rhythmuskonversion; ein zu hoher Strom kann jedoch Myokardschäden induzieren. Durch unterschiedlich hohe transthorakale Widerstände wird die am Herz wirkende Stromstärke erheblich beeinflusst. Ein optimierter Strom muss deshalb, vergleichbar zu anderen Therapieverfahren, auch für die transthorakale Defibrillation patientenabhängig individuell ermittelt werden, um Unter- oder Überschreitungen zu verhindern. Der Einsatz biphasischer gegenüber monophasischen Impulsformen ermöglicht bei geringerem Strom eine Rhythmuskonversion mit gleich hoher (bzw. höherer) Effizienz. Hierdurch können mögliche strominduzierte Myokardschäden deutlich reduziert werden. Auch bei individuell unterschiedlicher Thoraximpedanz kann durch biphasische Impulsform in Verbindung mit einer geräteseitigen Impedanzkompensation eine effiziente Rhythmuskonversion erfolgen. Der optimale Zeitpunkt einer Defibrillation im Rahmen einer Reanimation muss neu definiert werden. Entsprechend der unterschiedlichen Entstehungsmechanismen des KF (elektrisch induziert oder spontan auf dem Boden einer Herzerkrankung entstanden) ist die Wahrscheinlichkeit einer erfolgreichen Rhythmuskonversion durch einen Defibrillationsimpuls ebenfalls unterschiedlich. Zur besseren Vergleichbarkeit zukünftiger Studien sollte eine einheitliche Definition des Defibrillationserfolges in Abhängigkeit vom nachfolgenden hämodynamisch wirksamen Herzrhythmus festgelegt werden. Der zur biphasischen Konversion benötigte geringere Strom erlaubt eine weitere Miniaturisierung der Defibrillatoren. Dies ermöglicht in Verbindung mit einer hoch sensitiven automatischen Rhythmusanalyse eine weitere Verbreitung (halb)automatischer Defibrillatoren in der Öffentlichkeit. Hierdurch kann ein wichtiges Glied in der Kette der lebenserhaltenden Erstmaßnahmen gestärkt werden.

Abstract

As one major link in the chain of survival, early transthoracic (external) cardiac defibrillation is aimed at the termination of ventricular flutter and ventricular fibrillation. Most important to the success of defibrillation is the passage of a defined amount of current through a critical mass of heart muscle. Different transthoracic resistances reduce the effective density of the current within the heart. As for other therapeutic intervention procedures, recommendations for the optimal strength of current to be applied to the fibrillating heart need to be evaluated and defined for therapeutical defibrillation too. Unnecessarily high current density causes damage to the heart and should be prevented. By using biphasic waveforms in contrast to monophasic impulses, the amount of current can be reduced but the same or even higher efficacy is attained. Therefore possible myocardial damage might be clearly reduced. Even with individually altered thoracic impedance effective conversion of cardiac rhythm can be achieved by device-controlled compensation and biphasic waveforms. According to their different mechanisms or origin (electrically induced or spontaneously caused by organic heart desease) the probability of successful conversion of the cardiac rhythm by one single electrical impulse varies. The optimum point in time for defibrillation during resuscitation needs to be redefined. In order to improve comparability, further studies should use standardized definitions for successful defibrillation relating to the resulting cardiac rhythm.

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Authors and Affiliations

  1. Anästhesie-Abteilung und operative Intensivmedizin, Hochtaunus-Kliniken gGmbH, Bad Homburg v.d.H.

    V. Lischke

  2. Abteilung für Anästhesie und Intensivmedizin, Orthopädische Universitätskliniken, Frankfurt am Main

    P. Kessler

  3. Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Klinikum der J. W. Goethe-Universität, Frankfurt am Main

    C. Byhahn

  4. Abteilung für Anästhesie und Intensivmedizin, Katharina-Kasper-Kliniken, Frankfurt am Main

    K. Westphal

  5. Universitätsklinik für Anästhesie und Allgemeine Intensivmedizin, Leopold-Franzens-Universität, Innsbruck, Österreich

    A. Amann

  6. Anästhesie-Abteilung und operative Intensivmedizin, Hochtaunus-Kliniken gGmbH, Urselerstr. 33, 61348, Bad Homburg

    V. Lischke

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Lischke, V., Kessler, P., Byhahn, C. et al. Die transthorakale Defibrillation. Anaesthesist 53, 125–136 (2004). https://doi.org/10.1007/s00101-003-0635-3

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