Emergency critical care: closing the gap between onset of critical illness and intensive care unit admission.

Critical illness is an exquisitely time-sensitive condition and follows a disease continuum, which always starts before admission to the intensive care unit (ICU), in the majority of cases even before hospital admission. Reflecting the common practice in many healthcare systems that critical care is mainly provided in the confined areas of an ICU, any delay in ICU admission of critically ill patients is associated with increased morbidity and mortality. However, if appropriate critical care interventions are provided before ICU admission, this association is not observed. Emergency critical care refers to critical care provided outside of the ICU. It encompasses the delivery of critical care interventions to and monitoring of patients at the place and time closest to the onset of critical illness as well as during transfer to the ICU. Thus, emergency critical care covers the most time-sensitive phase of critical illness and constitutes one missing link in the chain of survival of the critically ill patient. Emergency critical care is delivered whenever and wherever critical illness occurs such as in the pre-hospital setting, before and during inter-hospital transfers of critically ill patients, in the emergency department, in the operating theatres, and on hospital wards. By closing the management gap between onset of critical illness and ICU admission, emergency critical care improves patient safety and can avoid early deaths, reverse mild-to-moderate critical illness, avoid ICU admission, attenuate the severity of organ dysfunction, shorten ICU length of stay, and reduce short- and long-term mortality of critically ill patients. Future research is needed to identify effective models to implement emergency critical care systems in different healthcare systems.

Early discharge and home treatment of patients with acute pulmonary embolism in the tertiary care setting.

Acute pulmonary embolism (PE) is a potentially life-threatening disease. Current guidelines suggest risk-adapted management. Hospitalization is required for intermediate- and high-risk patients. Early discharge and home treatment are considered safe in the majority of low-risk patients. In this study, we describe characteristics, discharge, and outcome of outpatients diagnosed with acute PE at a tertiary care center. All outpatients undergoing computed tomography pulmonary angiography or ventilation/perfusion lung scan between 01.01.2016 and 31.12.2019 at the University Hospital Vienna, Austria, were screened for a PE diagnosis. Electronic patient charts were used to extract characteristics, clinical course, and outcomes. Within the 4-year period, 709 outpatients (median age: 62 years, 50% women) were diagnosed with PE. Thirty-three (5%) patients were classified as high-risk, 159 (22%) as intermediate-high, 332 (47%) as intermediate-low, and 185 (26%) as low-risk PE according to the European Society of Cardiology risk stratification. In total, 156 (22%) patients (47% with low-risk and 20% with intermediate-low-risk PE) were discharged as outpatients and received home treatment. Rates for home treatment increased 2.4-fold during the study period. Thirty-day mortality in the entire population was 4.9%. All low-risk patients and all but one patient with home treatment survived the first 30 days. Home treatment significantly increased over time and seems to be safe in routine clinical practice. Notably, one in five intermediate-low-risk patients was discharged immediately, suggesting that a subpopulation of intermediate-low-risk patients may also be eligible for home treatment.

[Hypothermic temperature control after successful resuscitation of out-of-hospital cardiac arrest in adults : Statement from the resuscitation and postresuscitation treatment working groups of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN) and the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), the German Society for Interdisciplinary Emergency and Acute Medicine (DGINA) and the Austrian Association of Emergency Medicine (AAEM)]. / Hypotherme Temperaturkontrolle nach erfolgreicher Wiederbelebung eines außerklinischen Herz-Kreislauf-Stillstands beim Erwachsenen : Statement der Arbeitsgruppen Reanimation und Post-Reanimationsbehandlung in der Deutschen Gesellschaft für Internistische Intensiv- und Notfallmedizin (DGIIN) und Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI), der Deutschen Gesellschaft Interdisziplinäre Notfall- und Akutmedizin (DGINA) und der Österreichischen Gesellschaft für Notfallmedizin (AAEM).

In Germany per year approximately 60,000 and in Austria 5,000 adult patients suffer from out-of-hospital cardiac arrest. Only 10-15% of these patients survive without neurological damage. For decades hypothermic temperature control has been a central component of post-resuscitation treatment, but is controversial due to recently published studies.

Postresuscitation management.

PURPOSE OF REVIEW: To describe the most recent scientific evidence on ventilation/oxygenation, circulation, temperature control, general intensive care, and prognostication after successful resuscitation from adult cardiac arrest. RECENT FINDINGS: Targeting a lower oxygen target (90-94%) is associated with adverse outcome. Targeting mild hypercapnia is not associated with improved functional outcomes or survival. There is no compelling evidence supporting improved outcomes associated with a higher mean arterial pressure target compared to a target of >65 mmHg. Noradrenalin seems to be the preferred vasopressor. A low cardiac index is common over the first 24 h but aggressive fluid loading and the use of inotropes are not associated with improved outcome. Several meta-analyses of randomized clinical trials show conflicting results whether hypothermia in the 32-34°C range as compared to normothermia or no temperature control improves functional outcome. The role of sedation is currently under evaluation. Observational studies suggest that the use of neuromuscular blockade may be associated with improved survival and functional outcome. Prophylactic antibiotic does not impact on outcome. No single predictor is entirely accurate to determine neurological prognosis. The presence of at least two predictors of severe neurological injury indicates that an unfavorable neurological outcome is very likely. SUMMARY: Postresuscitation care aims for normoxemia, normocapnia, and normotension. The optimal target core temperature remains a matter of debate, whether to implement temperature management within the 32-34°C range or focus on fever prevention, as recommended in the latest European Resuscitation Council/European Society of Intensive Care Medicine guidelines Prognostication of neurological outcome demands a multimodal approach.

[Tendency to fall and injuries related to the Covid-19 pandemic at a department of emergency medicine]. / Sturzneigung und Verletzungen im Zusammenhang mit der COVID-19-Pandemie in einer Klinik für Notfallmedizin.

INTRODUCTION: This study investigates whether restrictions associated with the Covid-19 pandemic, in particular the temporary restrictions on social contacts in 2020, affected the number of inpatients admitted by the Department of Emergency Medicine of Jena University Hospital with a documented susceptibility to falls, injury or a susceptibility to falls resulting in at least one injury. METHODS: Using the ICD-10-GM code for susceptibility to falls (R29.6) and the codes for injuries (S00 to T14) from medicare claims data, the incidence rates of inpatient admissions between the years 2019 and 2020 were compared. In addition to all inpatient admissions recorded by the Department of Emergency Medicine, the cases of inpatients aged 65 years or older were considered separately, as they have an increased risk of having a fall. RESULTS: In 2020, the number of inpatient admissions in all age groups with one or more codes for injuries (S00 to T14) was significantly lower than in 2019 (2019: 19.2%, 2020: 17.3%, p<0.001). Regarding the codes for a documented susceptibility to falls (R29.6) or a documented susceptibility to falls (R29.6) with at least one injury (S00-T14), no differences were observed between the two years. In the group of inpatients 65 years or older, there were also no differences between 2019 and 2020 for any of the diagnoses considered. CONCLUSION: In this monocentric study of Jena University Hospital, it could be demonstrated for the first time that the Covid-19 pandemic had little impact on the number of inpatients admitted to the Department of Emergency Medicine with a documented diagnosis of susceptibility to falls (R29.6) and of susceptibility to falls in combination with at least one documented injury (S00-T14). As observed in previous publications, the number of inpatient admissions with documented injury diagnoses (S00 to T14) decreased.

Temporal Trends in the Use of Computed Tomographic Pulmonary Angiography for Suspected Pulmonary Embolism in the Emergency Department : A Retrospective Analysis.

BACKGROUND: Recently, validated clinical decision rules have been developed that avoid unnecessary use of computed tomographic pulmonary angiography (CTPA) in patients with suspected pulmonary embolism (PE) in the emergency department (ED). OBJECTIVE: To measure any resulting change in CTPA use for suspected PE. DESIGN: Retrospective analysis. SETTING: 26 European EDs in 6 countries. PATIENTS: Patients with CTPA performed for suspected PE in the ED during the first 7 days of each odd month between January 2015 and December 2019. MEASUREMENTS: The primary end points were the CTPAs done for suspected PE in the ED and the number of PEs diagnosed in the ED each year adjusted to an annual census of 100 000 ED visits. Temporal trends were estimated using generalized linear mixed regression models. RESULTS: 8970 CTPAs were included (median age, 63 years; 56% female). Statistically significant temporal trends for more frequent use of CTPA (836 per 100 000 ED visits in 2015 vs. 1112 in 2019; P < 0.001), more diagnosed PEs (138 per 100 000 in 2015 vs. 164 in 2019; P = 0.028), a higher proportion of low-risk PEs (annual percent change [APC], 13.8% [95% CI, 2.6% to 30.1%]) with more ambulatory management (APC, 19.3% [CI, 4.1% to 45.1%]), and a lower proportion of intensive care unit admissions (APC, -8.9% [CI, -17.1% to -0.3%]) were observed. LIMITATION: Data were limited to 7 days every 2 months. CONCLUSION: Despite the recent validation of clinical decision rules to limit the use of CTPA, an increase in the CTPA rate along with more diagnosed PEs and especially low-risk PEs were instead observed. PRIMARY FUNDING SOURCE: None specific for this study.

Quality indicators for post-resuscitation care after out-of-hospital cardiac arrest: a joint statement from the Association for Acute Cardiovascular Care of the European Society of Cardiology, the European Resuscitation Council, the European Society of Intensive Care Medicine, and the European Society for Emergency Medicine.

AIMS: Quality of care (QoC) is a fundamental tenet of modern healthcare and has become an important assessment tool for healthcare authorities, stakeholders and the public. However, QoC is difficult to measure and quantify because it is a multifactorial and multidimensional concept. Comparison of clinical institutions can be challenging when QoC is estimated solely based on clinical outcomes. Thus, measuring quality through quality indicators (QIs) can provide a foundation for quality assessment and has become widely used in this context. QIs for the evaluation of QoC in acute myocardial infarction are now well-established, but no such indicators exist for the process from resuscitation of cardiac arrest and post-resuscitation care in Europe. METHODS AND RESULTS: The Association of Acute Cardiovascular Care of the European Society Cardiology, the European Resuscitation Council, European Society of Intensive Care Medicine and the European Society for Emergency Medicine, have reflected on the measurement of QoC in cardiac arrest. A set of QIs have been proposed, with the scope to unify and evolve QoC for the management of cardiac arrest across Europe. CONCLUSION: We present here the list of QIs (6 primary QIs and 12 secondary Qis), with descriptions of the methodology used, scientific justification and motives for the choice for each measure with the aim that this set of QIs will enable assessment of the quality of postout-of-hospital cardiac arrest management across Europe.

Non-patient-related SARS-CoV-2 exposure from colleagues and household members poses the highest infection risk for hospital employees in a German university hospital: follow-up of the prospective Co-HCW seroprevalence study.

PURPOSE: The Co-HCW study is a prospective, longitudinal, single-center observational study that aims to assess the SARS-CoV-2 seroprevalence and infection status in staff members of Jena University Hospital (JUH) in Jena, Germany. METHODS: This follow-up study covers the observation period from 19th May 2020 to 22nd June 2021. At each of the three voluntary study visits, participants filled out a questionnaire regarding their SARS-CoV-2 exposure and provided serum samples to detect specific SARS-CoV-2 antibodies. Participants who were tested positive for antibodies against nucleocapsid and/or spike protein without previous vaccination and/or reported a positive SARS-CoV-2 PCR test were regarded to have been infected with SARS-CoV-2. Multivariable logistic regression modeling was applied to identify potential risk factors for infected compared to non-infected participants. RESULTS: Out of 660 participants that were included during the first study visit, 406 participants (61.5%) were eligible for the final analysis as their COVID-19 risk area (high-risk n = 76; intermediate-risk n = 198; low-risk n = 132) did not change during the study. Forty-four participants [10.8%, 95% confidence interval (95%CI) 8.0-14.3%] had evidence of a current or past SARS-CoV-2 infection detected by serology (n = 40) and/or PCR (n = 28). No association between SARS-CoV-2 infection and the COVID-19 risk group according to working place was detected. However, exposure to a SARS-CoV-2 positive household member [adjusted OR (AOR) 4.46, 95% CI 2.06-9.65] or colleague (AOR 2.30, 95%CI 1.10-4.79) was found to significantly increase the risk of a SARS-CoV-2 infection. CONCLUSION: Our results demonstrate that non-patient-related SARS-CoV-2 exposure posed the highest infection risk for hospital staff members of JUH.

Management of comatose survivors of out-of-hospital cardiac arrest in Europe: current treatment practice and adherence to guidelines. A joint survey by the Association for Acute CardioVascular Care (ACVC) of the ESC, the European Resuscitation Council (ERC), the European Society for Emergency Medicine (EUSEM), and the European Society of Intensive Care Medicine (ESICM).

AIMS: International guidelines give recommendations for the management of comatose out-of-hospital cardiac arrest (OHCA) survivors. We aimed to investigate adherence to guidelines and disparities in the treatment of OHCA in hospitals in Europe. METHODS AND RESULTS: A web-based, multi-institutional, multinational survey in Europe was conducted using an electronic platform with a predefined questionnaire developed by experts in post-resuscitation care. The survey was disseminated to all members of the societies via email, social media, websites, and newsletters in June 2021. Of 252 answers received, 237 responses from different units were included and 166 (70%) were from cardiac arrest centres. First-line vasopressor used was noradrenaline in 195 (83%) and the first-line inotrope was dobutamine in 148 (64%) of the responses. Echocardiography is available 24/7 in 204 (87%) institutions. Targeted temperature management was used in 160 (75%) institutions for adult comatose survivors of OHCA with an initial shockable rhythm. Invasive or external cooling methods with feedback were used in 72 cardiac arrest centres (44%) and 17 (24%) non-cardiac arrest centres (P < 0.0003). A target temperature between 32 and 34°C was preferred by 46 centres (21%); a target between 34 and 36°C by 103 centres (52%); and <37.5°C by 35 (16%). Multimodal neuroprognostication was poorly implemented and a follow-up at 3 months after discharge was done in 71 (30%) institutions. CONCLUSION: Post-resuscitation care is not well established and varies among centres in European hospitals. Cardiac arrest centres have a higher coherence with guidelines compared with respondents from non-cardiac arrest centres. The overall inconsistency in approaches and deviation from recommendations could be a focus for improvement.

Deep vein thrombosis and pulmonary embolism: a prospective, observational study to evaluate diagnostic performance of the Tina-quant D-Dimer Gen.2 assay.

Background: D-Dimer testing is a diagnostic tool for exclusion of deep vein thrombosis (DVT) and pulmonary embolism (PE). This study evaluated the diagnostic performance of the Tina-quant® D-Dimer Gen.2 assay (Roche Diagnostics International Ltd, Rotkreuz, Switzerland) in patients with low/intermediate pre-test probability of DVT/PE using standard, age-, and clinical probability-adjusted cut-offs. Methods: In this prospective, observational, multicenter study (July 2017-August 2019), plasma samples were collected from hospital emergency departments and specialist referral centers. DVT/PE was diagnosed under hospital standard procedures and imaging protocols. A standard D-dimer cut-off of 0.5 µg fibrinogen equivalent units (FEU)/ml was combined with the three-level Wells score; cut-offs adjusted for age (age × 0.01 µg FEU/ml for patients >50 years) and clinical probability (1 µg FEU/ml for low probability) were also evaluated. An assay comparison was conducted in a subset of samples using the Tina-quant D-Dimer Gen.2 assay and the previously established routine laboratory assay, STA-Liatest D-Di Plus assay (Stago Deutschland GmbH, Düsseldorf, Germany). Results: 2,897 patients were enrolled; 2,516 completed the study (DVT cohort: 1,741 PE cohort: 775). Clinical assessment plus D-dimer testing using the standard cut-off resulted in 317 (DVT) and 230 (PE) false positives, and zero (DVT) and one (PE) false negatives. Negative predictive value (NPV) was 100.0% (95% confidence interval [CI]: 99.7%-100.0%) and 99.8% (95% CI: 98.8%-100.0%) for DVT and PE, respectively. After age-adjustment, NPV was 99.9% (95% CI: 99.6%-100.0%) and 99.1% (95% CI: 97.8-99.7) for DVT and PE, respectively. False positive rates decreased (>50%) in clinical probability-adjusted analyses vs. primary analysis. In the assay comparison, the performances of the two assays were comparable. Conclusion: The Tina-quant D-Dimer Gen.2 assay and standard D-dimer cut-off level combined with the three-level Wells score accurately identified patients with a very low probability of DVT/PE.

Integration of ultrasonography training into undergraduate medical education: catch up with professional needs.

OBJECTIVE: Ultrasonography (US) has become the first-line imaging modality even for physicians who are not imaging specialists. The progress has not yet been sufficiently considered in medical education. The aim was to develop a curriculum that integrates US as a compulsory part into medical education directly from the start, to build up professional competencies toward residency. METHODS: Development was based on Kern's six-step approach to identify problems, specify needs, define goals, outline strategies, and propose methods. RESULTS: The proposed curriculum follows a spiral course within which students should pass through four levels of training with increasing complexity. Students will be asked to independently prepare for courses by using learning videos. On the first training level, US should be closely linked to anatomy and physiology courses. Competency-centered courses should be held in small groups. On the second level, in the third year of education, students will apply point-of-care ultrasonography concerning multiple medical disciplines. On the third level, they will select a compulsory course in a specialty of their choice, held at five consecutive dates. From then on, US will be conducted in patients. Finally, during the final year, students are expected to use US under pro-active supervision with a large degree of independence and confidence. Throughout the curriculum, the discipline of radiology combines vertically with foundational sciences and horizontally with other medical specialties. CONCLUSION: The conceptual proposal for a longitudinal US curriculum presented here has been developed by radiologists to equip students with competencies needed for contemporary patient care.

Association between prehospital FPS and ROSC in adults with OHCA : A retrospective multicenter study using the German Resuscitation Registry and Intubation Registry (FiPS-CPR).

BACKGROUND: Advanced airway management (AAM) is part of the standard treatment during advanced cardiac life support (ACLS). Current studies underline the importance of a first-pass intubation success (FPS) during in-hospital ACLS. It was shown that a failed initial intubation attempt in out-of-hospital cardiac arrest (OHCA) patients in the emergency department is an independent risk factor for the decreased effectiveness of ACLS measured by the return of spontaneous circulation (ROSC). OBJECTIVE: This study first examines the association between prehospital FPS and ROSC in adults with OHCA and second identifies factors associated with FPS and ROSC. The initial hypothesis was that FPS would increase the probability of ROSC as well as decrease the time to ROSC. MATERIAL AND METHODS: A retrospective multicenter analysis of 180 adult non-traumatic OHCA patients on whom advanced airway management (AAM) was performed between July 2017 and December 2018 in five different German physician-staffed ambulance stations. For information on FPS the Intubation Registry, and for information on ROSC the German Resuscitation Registry were used. In addition to yes/no questions, multiple answers and free text answers are possible in those questionnaires. The main outcome variables were 'FPS', 'ROSC' and 'time to ROSC'. Mann-Whitney tests, χ2-tests, Fisher's exact tests and multivariate binary logistic regressions were used for the statistical evaluation. Demographic factors, characteristics of the performer, selected equipment, laryngoscopy type, intubation method, medications, verification of tube position, respiratory evaluation, complications and time to ROSC were examined with respect to the influence on FPS. Concerning ROSC, the following factors were examined: demographic factors, initial heart rhythm, initial breathing, medications, defibrillation and AAM. RESULTS: An FPS was recorded in 150 patients (83.3%), and ROSC was achieved in 82 patients (45.5%) after an average time of 22.16 min. There was a positive association between FPS and ROSC (p = 0.027). In patients with FPS, a trend for shorter time to ROSC was observed (p = 0.059; FPS 18 min; no FPS 28 min). The use of capnography (odds ratio, OR = 7.384, 95% confidence interval, CI 1.886-28.917) and complications during AAM (OR = 0.033, 95% CI: 0.007-0.153) were independently associated with FPS. The independent factor associated with ROSC was FPS (OR = 5.281, 95% CI: 1.800-15.494). CONCLUSION: In prehospitally resuscitated adult OHCA patients with AAM, FPS is associated with a higher chance of ROSC.

Medical and cardio-vascular emergency department visits during the COVID-19 pandemic in 2020: is there a collateral damage? A retrospective routine data analysis.

BACKGROUND: In this retrospective routine data analysis, we investigate the number of emergency department (ED) consultations during the COVID-19 pandemic of 2020 in Germany compared to the previous year with a special focus on numbers of myocardial infarction and acute heart failure. METHODS: Aggregated case numbers for the two consecutive years 2019 and 2020 were obtained from 24 university hospitals and 9 non-university hospitals in Germany and assessed by age, gender, triage scores, disposition, care level and by ICD-10 codes including the tracer diagnoses myocardial infarction (I21) and heart failure (I50). RESULTS: A total of 2,216,627 ED consultations were analyzed, of which 1,178,470 occurred in 2019 and 1,038,157 in 2020. The median deviation in case numbers between 2019 and 2020 was - 14% [CI (- 11)-(- 16)]. After a marked drop in all cases in the first COVID-19 wave in spring 2020, case numbers normalized during the summer. Thereafter starting in calendar week 39 case numbers constantly declined until the end of the year 2020. The decline in case numbers predominantly concerned younger [- 16%; CI (- 13)-(- 19)], less urgent [- 18%; CI (- 12)-(- 22)] and non-admitted cases [- 17%; CI (- 13)-(- 20)] in particular during the second wave. During the entire observation period admissions for chest pain [- 13%; CI (- 21)-2], myocardial infarction [- 2%; CI (- 9)-11] and heart failure [- 2%; CI (- 10)-6] were less affected and remained comparable to the previous year. CONCLUSIONS: ED visits were noticeably reduced during both SARS-CoV-2 pandemic waves in Germany but cardiovascular diagnoses were less affected and no refractory increase was noted. However, long-term effects cannot be ruled out and need to be analysed in future studies.

Predictors for Prehospital First-Pass Intubation Success in Germany.

(1) Background: Endotracheal intubation in the prehospital setting is an important skill for emergency physicians, paramedics, and other members of the EMS providing airway management. Its success determines complications and patient mortality. The aim of this study was to find predictors for first-pass intubation success in the prehospital emergency setting. (2) The study was based on a retrospective analysis of a population-based registry of prehospital advanced airway management in Germany. Cases of endotracheal intubation by the emergency medical services in the cities of Tübingen and Jena between 2016 and 2019 were included. The outcome of interest was first-pass intubation success. Univariate and multivariable regression analysis were used to analyse the influence of predefined predictors, including the characteristics of patients, the intubating staff, and the clinical situation. (3) Results: A total of 308 patients were analysed. After adjustment for multiple confounders, the direct vocal cord view, a less favourable Cormack-Lehane classification, the general practitioner as medical specialty, and location and type of EMS were independent predictors for first-pass intubation success. (4) Conclusions: In physician-led emergency medical services, the laryngoscopic view, medical specialty, type of EMS, and career level are associated with FPS. The latter points towards the importance of experience and regular training in endotracheal intubation.