[The position of the emergency physician in the emergency medical service]. / Stellung des Notarztes im Rettungsdienst.

The participation of emergency physicians guarantees the quality of a modern emergency medical service (EMS). Within the scope of cost savings in health-care system, it is questioned whether emergency medical services in the future can be managed without emergency physicians. Deficits of structure and qualitaty of the emergency physician service are raised objections. Recent studies have shown that preclinical care carried out by an emergency physician assure better results. An ongoing improvement in the quality of care should be achieved by the introduction of the new professional training for physicians "emergency medicine". In a direct comparison of two emergency medical services, one with emergency physicians, one only with paramedics it could be demonstrated that the integration of emergency physicians will increase the rate of patients, whose vital status could be improved by more than 20 %. The rate of patients discharged from hospital after cardiopulmonal resuscitation is 3 fold higher than in a rescue service without emergency physicians. However this improvement of quality of care by physicians is linked to higher financial charges. Another aspect supporting the obligatory employment of emergency physicians in Germany is the jurisdiction guaranteeing the right of the patient to receive advanced medical treatment only by (emergency) physicians.

[The Würzburg polytrauma algorithm. Concept and first results of a sliding-gantry-based computer tomography diagnostic system]. / Der Würzburger Schockraumalgorithmus. Gesamtkonzept und erste Ergebnisse einer "sliding-gantry-basierten" Computertomographiediagnostik.

BACKGROUND: The purpose of this study was to show the practicability of a new algorithm in the management of polytraumatized patients based on Advanced Trauma Live Support (ATLS) and using mobile whole body multislice CT (MMDCT) as the primary imaging system. PATIENTS AND METHODS: A series of 120 trauma patients referred to the Würzburg University Hospital Trauma Emergency Room were categorized into suspected polytrauma and suspected non-polytrauma groups. The polytraumatized patients were investigated using the Würzburg polytrauma-algorithm including whole body multislice CT with a 16-row-scanner. The algorithm is described. The time for the diagnostic procedure was measured and compared with data from the Trauma Registry of the German Society of Trauma Surgery. RESULTS: From 120 patients 78 (66%) underwent whole body CT. The diagnostic procedure was quick with significant advantages especially for cranial and trunk diagnostics. CONCLUSION: The Würzburg polytrauma algorithm worked well. There was excellent cooperation within the interdisciplinary leading team consisting of anaesthesiologists, surgeons, and radiologists. The principles of ATLS could be respected. Mobile whole body multislice CT was an effective tool in the diagnostic evaluation of polytrauma patients.

[Injuries to car passengers protected by air bags]. / Verletzungen airbaggeschützter PKW-Insassen.

OBJECTIVE: The air bag, like the seatbelt, is a further development of the inside protection of motorcar passengers. However, the airbag has also been made responsible for severe internal injuries. METHODS: In a retrospective case control study, 394 accidents in which the air bag was released were analysed. At least medium severe injuries (Maximum Abbreviated Injury Scale: MAIS > or = 2) occurred in 69 cases. Three different patterns of injury were distinguished depending on the level of difficulty of diagnosis by the emergency physician. Damage to the vehicles was scored in five intensities or damage grades. RESULTS: Thoracic injury was most frequently diagnosed in the patients (in 61.5 % of cases), followed by injuries to the lower (50.8 %) and upper extremities (47.7 %). Single injuries with a grade of severity of 2 (MAIS) predominated (59.7 %). In most of the cases the injury was easy to diagnose (64.6 %) because of external signs, in 24.6 % internal injuries were assumed and in only 10.8 % were there no sings of damage to body cavities. Most frequent were occult injuries in the thoracic region (100 %) and in the abdomen (74.4 %). However, occult injuries did not always conform to the grade of deformation to the vehicle, since in 66.7 % the grade of damage was 3. This was not true for the remaining types of injury because external injuries increased with the grade of damage to the vehicle. CONCLUSION: After the release of the air bag, occult injuries of the body cavities have to be expected, even if there are no signs of external injury. Women under 35 years of age are particularly endangered. There exists no minimum velocity for the occurrence of injuries to the body cavities because harm can simply be a result of the release of the air bag.

[The "Würzburg T". A concept for optimization of early multiple trauma care in the emergency department]. / Das "Würzburger T". Ein Konzept zur Optimierung der frühen Polytraumaversorgung in der Notfallaufnahme.

INTRODUCTION: Anaesthesia management, radiological diagnostic and the concept of damage control surgery should be combined in the resuscitation room. Defined clinical targets and their realisation are a CT-scan and complete damage control surgery in the shock room. Furthermore minimised patient transfer and positioning with continuous access to the head, upper parts of the body and anaesthesia machine should be realised during diagnostic procedures. METHODS: Based on a carbon-slide fixed on a turntable and innovative alignment of diagnostic devices, a three phase treatment algorithm has been established. RESULTS: Phase A includes primary survey, anaesthetic management and ultrasound examination. Following a turn of the table conventional x-ray diagnostic is assessed in phase B. Tracks for the slide enable immediate transfer to a spiral CT-scan without additional patient positioning (phase C). Following complete CT-scan rearrangement of the table to phase A facilitates immediate damage control surgery. To accelerate device operation and treatment the integrated anaesthesia workstation is ceiling-mounted and manoeuvres close to the patient. CONCLUSIONS: This concept realizes complete diagnostic procedures and damage control surgery without time consuming patient transfer or rearrangement.

Skills and self-assessment in cardio-pulmonary resuscitation of the hospital nursing staff.

UNLABELLED: Differences in the success rates of the pre-hospital or in-hospital resuscitation attempts seem to be attributable to the skill of the various rescuers. Whereas the definite success rate for pre-hospital resuscitation is 7%, the corresponding rate for in-hospital settings is 15%. In this context, the resuscitation skills and the self-assessment of CPR methods of hospital staff were investigated. METHODS: during 53 CPR refresher courses offered to nursing staff members, the individual skills and competence in CPR procedures of 425 nurses were examined according to the standards and guidelines of the German Medical Association. During the first part of the study the participants were asked to subjectively rate their proficiencies in CPR followed by a practical assessment of their manual CPR skills by an independent observer. Scores were calculated for artificial ventilation and chest compression. Quality criteria were defined, grouped and analysed statistically by the chi-squared test. RESULTS: 16.2% of the participants felt sufficiently trained to perform CPR independently and 77.2% did not. Thirty-six percent estimated their CPR skills to be sufficient or good. Only four participants (0.9%) were able to perform all standard CPR procedures as recommended by the guidelines and 71.8% failed to perform effective CPR manoeuvres. The CPR skills did not differ with regard to the nurses' educational degree, professional experience, previous CPRs performed or work area within the hospital. Of the nursing staff, 6.6% were found to have good skills in artificial ventilation. The attempts at artificial ventilation made by 58.6% were completely inadequate. Correct chest compression was performed by 14.1%. The majority of the test group (44.7%) failed to carry out effective cardiac message. CONCLUSIONS: CPR skills of hospital staff are inadequate, mainly because of lack of manual dexterity. Obviously the special skills learned in CPR courses are lost in spite of a positive self-assessment after a relatively short time. The results, however, do not suggest completely inadequate handling of CPR procedures in a hospital setting. Indeed, an increasing rate of successful resuscitations inside the hospital (up to 27%) has been reported in the literature. As a consequence of our findings, refresher courses in specific CPR techniques must be demanded, which should be made compulsory for nursing staff every 2 years.

[Cesarean section with subsequent craniotomy in the area of the posterior cranial fossa]. / Sectio Caesarea mit anschliessender Kraniotomie im Bereich der hinteren Schädelgrube.

We report on a 31-year old pregnant patient with von-Hippel-Lindau syndrome who presented to the emergency room with symptoms of increased intracranial pressure. She was found in premature labour with a normal foetus of 29 weeks' gestational age in breech presentation. We discuss an anaesthetic and neurosurgical management during emergent craniotomy and Caesarean section. Caesarean section and posterior fossa craniotomy with resection of an angioblastoma are performed in one setting. Following rapid sequence induction with thiopentone and succinylcholine, anaesthesia is maintained with fentanyl, flunitrazepam and pancuronium; nitrous oxide and volatile anaesthetics are avoided. The advantages of this technique include haemodynamic stability and maintenance of intracranial pressure. Neonatal depression is likely with this technique and requires resuscitative measures. The indications for rapid sequence induction in pregnant patients with raised intracranial pressure at risk for aspiration are discussed. Different options for monitoring during this procedure are described.

[Effect of external cervical spine immobilization on intracranial pressure]. / Auswirkung der externen Halswirbelsäulenimmobilisation auf den intrakraniellen Druck.

We measured the intracranial pressure (ICP) in 18 patients with severe head injury in the neurosurgical intensive-care unit before and after placement of a rigid collar for cervical spine immobilisation. The purpose of the study was to determine whether the rigid collars, commonly used to, prevent cervical spine movement during transport to the treatment facility could lead to an increase in ICP. Patients who had an epidural transducer in place were studied and their ICP recorded during placement of either the Spieth cervical collar (n = 12) or the Philadelphia cervical collar (n = 6). The baseline ICP was 17.0 +/- 6.1 mmHg versus 17.7 +/- 6.4 mmHg 10 min after placement of the cervical collar 5 min after removal the ICP was 17.2 +/- 5.9 mmHg. No significant changes in ICP could be demonstrated during this study. Placement of the cervical collar is a simple and practical measure to immobilize the cervical spine during rescue and transport of intubated and ventilated patients. Its risk of increasing the ICT appears to be low even in the patient with severe head injury.

Studies of tissue PO2 in normal and pathological human brain cortex.

Brain cortex PO2 was measured after craniotomy and opening of the dura mater in 26 patients. We determined the brain tissue PO2 under standard narcotic conditions and after changing arterial PO2 and PCO2. Patients were divided into two groups (normal and pathological), depending on the aspect of their cortex on Ct/MRI and intraoperative appearance of the cortex. No statistical significantly difference was seen between tissue PO2 of the normal and the pathological group. A significant difference was seen only between the normal group and a subgroup with brain swelling (p = 0.0344). In the normal group no correlation was seen between tissue PO2 and arterial PO2 (r = 0.1541, p = 0.3076), whereas in the pathological group and especially in the oedema subgroup there was a highly significant correlation between tissue PO2 and PaO2 (r = 0.754, p = 0.0015 and r = 0.888, p = 0.0007). Breathing 100% oxygen changed tissue PO2 to 137.8 or 352 mmHg in the normal or the pathological group, respectively. Again, there was no correlation between tissue PO2 and PaO2 in the normal group (r = 0.1071, p = 0.392), whereas this correlation was significant in the pathological and the oedema subgroup (r = 0.6291, p = 0.0473 and r = 0.8385, p = 0.0185). This is evidence for regulatory mechanisms of tissue PO2. During hyperventilation no significant difference in tissue PO2 between the normal and the pathological group was seen. Low tissue PO2 values, however, indicate a risk for inducing ischemia.