Mesenchymal stem cells in peripheral blood of severely injured patients.

PURPOSE: Mesenchymal stem cells (MSCs) are primarily stromal cells present in bone marrow and other tissues that are crucial for tissue regeneration and can be mobilized into peripheral blood after different types of organ damage. However, little is known about MSC appearance in blood in the setting of polytrauma. METHODS: We conducted a monocentered and longitudinal observational clinical study in 11 polytraumatized patients with an injury severity score (ISS) ≥ 24 to determine the numbers of MSCs in peripheral blood. Blood was collected from healthy volunteers and patients after polytrauma in the emergency room and 4, 12, 24, 48 h, 5 and 10 day later, and cells carrying MSC-surface markers (negative for CD45, positive for CD29, CD73, CD90, CD105, and CD166 in different combinations also employing the more stringent markers STRO1 and MSCA1) were detected and characterized using flow cytometry. Relative numbers of MSC-like cells were correlated with clinical parameters to evaluate if specific injury patterns had an influence on their presence in the blood cell pool. RESULTS: We were able to detect MSC marker-positive cells in both cohorts; however, the percentage of those cells present in the blood of patients during the first 10 day after injury was mostly similar to healthy volunteers, and significantly lowers starting at 4 h post trauma for one marker combination when compared to controls. Furthermore, the presence of a pelvis fracture was partly correlated with reduced relative numbers of MSC-like cells detectable in blood. CONCLUSIONS: Polytrauma in humans was associated with partly reduced relative numbers of MSC-like cells detected in peripheral blood in the time course after injury. Further studies need to define if this reduction was due to lower mobilization from the bone marrow or to active migration to the sites of injury.

[Patients with Acute, Non-Traumatic Abdominal Pain in German Emergency Departments: A Prospective Monocentric Observation Study]. / Patienten mit akutem, nicht traumatischem Abdominalschmerz in der zentralen Notaufnahme ­ eine prospektive, monozentrische Beobachtungsstudie.

Background: Up to 11 % of patients in an Emergency Department (ED) present with non-traumatic acute abdominal pain. Based on this presenting symptom, this study aimed to analyse how residents (surgery, internal medicine, anaesthesiology and other fields) working in an ED during their second and third year of education treat these patients. Material and Methods: We performed a prospective, monocentric observation study in an ED in accordance with the STROBE recommendations, following the recommendations from the Ethics Committee of the University of Ulm (application no. 335/12) and the Declaration of Helsinki. The hospital's data protection officer approved the study. During a 12-month period (Dec. 2012 to Dec. 2013), a random sample of patients with non-traumatic abdominal pain was obtained in the ED of a major German acute care hospital by an independent observer, who was not part of the ED team. In addition to demographic data, the study focused on analysing processes and patient care (including medical history taking and physical examinations). In addition, subgroups were defined (clinical background of the treating physician, severity pursuant to the Manchester Triage Score [MTS]). Results: 143 patients met the inclusion criteria. The clinical background of the physician had no influence on the reviewed processes such as medical history taking, initial examinations, the request of consultative examinations or diagnostic procedures. Patients triaged as "urgent" were treated significantly earlier than patients triaged as "non-urgent" (time to first physician contact 26 ± 24 vs. 46 ± 34 min, p < 0.001). However, the overall time spent in the ED was equal (210 ± 79 vs. 220 ± 114 min, p = 0.555). Yet the initially estimated urgency was correlated with the need for hospitalisation (share: 57 %). Conclusion: The overall compliance with standards of care was high. The clinical background (surgery, internal medicine, anaesthesiology, other fields) of the physician in charge of initial treatment had no influence on the reviewed processes.

Initial assessment and treatment of refugees in the Mediterranean Sea (a secondary data analysis concerning the initial assessment and treatment of 2656 refugees rescued from distress at sea in support of the EUNAVFOR MED relief mission of the EU).

BACKGROUND: As a part of the European Union Naval Force - Mediterranean Operation Sophia (EUNAVFOR Med), the Federal Republic of Germany is contributing to avoid further loss of lives at sea by supplying two naval vessels. In the study presented here we analyse the medical requirements of such rescue missions, as well as the potential benefits of various additional monitoring devices in identifying sick/injured refugees within the primary onboard medical assessment process. METHODS: Retrospective analysis of the data collected between May - September 2015 from a German Naval Force frigate. Initial data collection focused on the primary medical assessment and treatment process of refugees rescued from distress at sea. Descriptive statistics, uni- and multivariate analysis were performed. The study has received a positive vote from the Ethics Commission of the University of Ulm, Germany (request no. 284/15) and has been registered in the German Register of Clinical Studies (no. DRKS00009535). RESULTS: A total of 2656 refugees had been rescued. 16.9 % of them were classified as "medical treatment required" within the initial onboard medical assessment process. In addition to the clinical assessment by an emergency physician, pulse rate (PR), core body temperature (CBT) and oxygen saturation (SpO2) were evaluated. Sick/injured refugees displayed a statistically significant higher PR (114/min vs. 107/min; p < .001) and CBT (37.1 °C vs. 36.7 °C; p < .001). There was no statistically significant difference in SpO2-values. The same results were found for the subgroup of patients classified as "treatment at emergency hospital required". However, a much larger difference of the mean PR and CBT (35/min resp. 1.8 °C) was found when examining the subgroups of the corresponding refugee boats. A cut-off value of clinical importance could not be found. Predominant diagnoses have been dermatological diseases (55.4), followed by internal diseases (27.7) and trauma (12.1 %). None of the refugees classified as "healthy" within the primary medical assessment process changed to "medical treatment required" during further observation. CONCLUSIONS: The initial medical assessment by an emergency physician has proved successful. PR, CBT and SpO2 didn't have any clinical impact to improve the identification of sick/injured refugees within the primary onboard assessment process.

[Civilian blast injuries: an underestimated problem? : Results of a retrospective analysis of the TraumaRegister DGU®]. / Zivile Explosionstraumata - ein unterschätztes Problem? : Ergebnisse einer retrospektiven Analyse aus dem TraumaRegister DGU®.

BACKGROUND: Blast injuries are a rare cause of potentially life-threatening injuries in Germany. During the past 30 years such injuries were seldom the cause of mass casualties, therefore, knowledge and skills in dealing with this type of injury are not very extensive. MATERIAL AND METHODS: A retrospective identification of all patients in the TraumaRegister DGU® of the German Trauma Society (TR-DGU) who sustained blast injuries between January 1993 and November 2012 was carried out. The study involved a descriptive characterization of the collective as well as three additional collectives. The arithmetic mean, standard deviation and 95 % confidence interval of the arithmetic mean for different demographic parameters and figures for prehospital and in-hospital settings were calculated. A computation of prognostic scores, such as the Revised Injury Severity Classification (RISC) and the updated version RISC II (TR-DGU-Project-ID 2012-035) was performed. RESULTS: A total of 137 patients with blast injuries could be identified in the dataset of the TR-DGU. Of the patients 90 % were male and 43 % were transported by the helicopter emergency service (HEMS) to the various trauma centres. The severely injured collective with a mean injury severity scale (ISS) of 18.0 (ISS ≥ 16 = 52 %) had stable vital signs. In none of the cases was it necessary to perform on-site emergency surgery but a very high proportion of patients (59 %) had to be surgically treated before admittance to the intensive care unit (ICU). Of the patients 27 % had severe soft tissue injuries with an Abbreviated Injury Scale (AIS) ≥ 3 and 90 % of these injuries were burns. The 24 h in-hospital fatality was very low (3 %) but the stay in the ICU tended to be longer than for other types of injury (mean 5.5 ventilation days and 10.7 days in the intensive care unit). Organ failure occurred in 36 % of the cases, multiorgan failure in 29 % and septic events in 14 %. Of the patients 16 % were transferred to another hospital during the first 48 h. The RISC and the updated RISC II tended to underestimate the severity of injuries and mortality (10.2 % vs. 6.8 % and 10.7 % vs. 7.5 %, respectively) and the trauma associated severe hemorrhage (TASH) score underestimated the probability for transfusion of more than 10 units of packed red blood cells (5.0 % vs. 12.5 %). CONCLUSION: This article generates several hypotheses, which should be confirmed with additional investigations. Until then it has to be concluded that patients who suffer from accidental blast injuries in the civilian setting (excluding military operations and terrorist attacks) show a combination of classical severe trauma with blunt and penetrating injuries and additionally a high proportion of severe burns (combined thermomechanical injury). They stay longer in the ICU than other trauma patients and suffer more complications, such as sepsis and multiorgan failure. Established scores, such as RISC, RISC II and TASH tend to underestimate the severity of the underlying trauma.

[Out-of-hospital airway management in trauma patients : Experiences with the C-MAC® video laryngoscope]. / Präklinische Atemwegssicherung bei Traumapatienten : Erfahrungen mit dem C-MAC®-Videolaryngoskop.

BACKGROUND: Securing the airway is the top priority in trauma resuscitation. The most important factor for successful endotracheal intubation (ETI) is good visualization of the vocal cords. The aim of this study was to summarize the practical experiences with the C-MAC® video laryngoscope as initial device in out-of-hospital airway management of trauma patients. METHODS: The C-MAC® video laryngoscope uses standard Macintosh shaped laryngoscope blades. At the Helicopter Emergency Medical Service (HEMS) Christoph 22 it is used as the initial device for every out-of-hospital ETI. All prehospital data on ETI involving trauma patients were documented for a period of 17 months. RESULTS: A total of 116 out-of-hospital ETIs were enrolled in this study (overall success rate 100 %). In 88.8 % the first attempt was successful, whereas in 10.3 % a second and in 0.9 % a third ETI attempt was necessary. No patient required alternative airway devices or surgical airway interventions. The results of a subgroup with an immobilized cervical spine (n = 17) did not show any increased difficulties. CONCLUSION: The use of the C-MAC® video laryngoscope by experienced anesthesiologists in an out-of-hospital setting seems to be a safe method even in patients with an immobilized cervical spine. Adverse laryngoscopy results (C/L III and IV) were reduced compared to other studies.

[Differential Treatment Strategy of Pleural Empyema in a Post-Pneumonectomy Cavity]. / Differenzierte Behandlungsstrategie des Pleuraempyems in der Postpneumonektomiehöhle.

INTRODUCTION: Pleural empyema in a post-pneumonectomy cavity (PEC) occurs with a frequency of 2% -15% and a mortality of more than 10%. It can occur with or without bronchopleural fistula (BPF). The treatment of empyema in the PEC requires a strict algorithm: drainage, bronchoscopy, closure of the fistula, thorough cleaning of the PEC, filling the cavity, thoracoplasty. METHODS: 39 cases with an empyema in the PEC were analysed retrospectively (men: n = 38; women: n = 1; mean age: 60.3 ±â€Š7.6 years). In 32 (82.1%) of the patients, a BPF was detected (right: n = 26, left: n = 6). The average length of stay in hospital was 125 days (22 - 293 days). Cleaning of the PEC was achieved in all surviving patients (n = 23, 65.1%). All patients (n = 39) underwent bronchoscopy with placement of a chest tube for drainage. The BPF was closed in three cases (7.7%) with a stent while in 12 cases (30.8%) a vascularized flap was used. In 14 patients (35.9%) the bronchial stump was either reclosed with sutures or resected. In three cases (7.7%) a re-anastomosis was performed. RESULTS: The PEC became sterile by regular flushing with antibiotic solution in three patients (7.7%). In 35.9% of the patients (n = 14), aggressive surgical debridement (Weder procedure) was necessary. A thoracic window was applied in 22 patients (56.4%), followed by negative pressure wound therapy (NPWT) and change of dressing every three to four days or a tamponade of the thoracic cavity with simple dressings. In 19 patients (48.7%) the thoracic cavity was sealed with an antibiotic solution. In 5 cases an Alexander thoracoplasty took place. CONCLUSIONS: Pleural empyema after pneumonectomy still poses a serious postoperative complication. A bronchopleural fistula is often detected. Thus, two problems arise at the same time ­ fistula and infection in the pleural cavity. Through a strict algorithm, both problems can be dealt with in stages. After sealing the fistula, the thoracic cavity is thoroughly cleaned and finally the thorax is closed. Only in a small number of patients (1.3%) in whom these measures remain ineffective (persistent MRSA, aspergillus colonization) should the cavity be obliterated by thoracoplasty.

[Prevention and treatment of intraoperative complications of thoracic surgery]. / Vorbeugung und Behandlung intraoperativer Komplikationen bei thoraxchirurgischen Eingriffen.

In order to achieve a minimal complication rate there is a need for a comprehensive strategy. This means in the first line preventive steps which include patient positioning, suitable approaches and access, an appropriately qualified surgical team as well as a carefully planned dissection and preparation. Furthermore, a supply of additional instrumentation, such as thrombectomy catheters, special vascular clamps and even extracorporeal membrane oxygenation (ECMO) and a heart-lung machine (HLM) in cases of centrally located lesions should be on stand-by. Control instruments, such as a bronchoscope and esophagoscope should not be forgotten. In selected cases a preoperative embolization (vascular malformation) or cream swallow (thoracic duct injury) can be helpful. Special interventions to overcome complications arising are described for the chest wall, lung parenchyma, pulmonary vessels, great vessels, bronchial arteries, trachea and bronchi, esophagus, thoracic duct, heart, vertebral column and sternum corresponding to the topography.

[Treatment Strategies for Septic Arthritis of the Sternoclavicular Joint]. / Behandlungsstrategie der septischen Arthritiden des Sternoklavikulargelenks.

Septic arthritis of the sternoclavicular joint (SCJ) is a relatively rare disease. Due to serious complications including mediastinitis and generalised sepsis early diagnosis and rapid onset of treatment are mandatory. The disease often affects immunocompromised patients, diabetics, or patients with other infectious diseases. The therapeutic options range from administration of antibiotics to extended surgery including reconstructive procedures. Apart from rare situations where conservative treatment with antibiotics is sufficient, joint resection followed by plastic surgical procedures are required. We present a retrospective analysis with data from two hospitals. From January 2008 to December 2012 23 patients with radiographically confirmed septic arthritis of various aetiology were included. Fourteen (60.8 %) male, nine (39.2 %) female patients with an average age of 60.3 ± 14.2 years (range: 23-88 years) with septic arthritis of the SCJ were treated. Seven (30.4 %) patients suffered from Diabetes mellitus, nine (39.1 %) had underlying diseases with a compromised immune system. In 14 (60.8 %) out of 23 patients a bacterial focus was detected. Only six (26 %) patients suffered from confined septic arthritis of the SCG, in 17 (73,9 %) patients osteomyelitis of the adjacent sternum, and the clavicle was present. In addition, 15 (65.2 %) patients already suffered from mediastinitis at the time of diagnosis, eight (35 %) patients even from septicaemia. In conclusion, septic arthritis requires an active surgical treatment. Limited incision of the joint and debridement alone is only successful at early stages of the disease. The treatment concept has to include the local joint and bone resection as well as complications like mediastinitis. After successful treatment of the infection, the defect of the chest wall requires secondary reconstructive surgery using a pedicled pectoralis muscle flap.

[Primary treatment of penetrating injuries. Part 1: blast trauma]. / Primärversorgung penetrierender Verletzungen. Teil 1: Explosionstrauma.

Blast injuries may result from a variety of causes but the biomechanical impact and pathophysiological consequences do not differ between domestic or industrial accidents or even terrorist attacks. However, this differentiation relevantly affects the tactical procedures of the rescue teams. Focusing on further detonations, top priority is given to the personal safety of all rescue workers. The rareness of blast injuries in a civilian setting results in a lack of experience on the one hand but on the other hand the complexity of blast injuries to the human body places high demands on the knowledge and skills of the entire rescue team for competent treatment. The purpose of this article is to explain the physicochemical principles of explosions and to convey tactical and medical knowledge to emergency medical services.

[Reliability of emergency medical field triage : Exemplified by traffic accident victims]. / Zuverlässigkeit notärztlicher Verdachtsdiagnosen : Beispiel Verkehrsunfallopfer.

BACKGROUND: Trauma is the leading cause of death in the patient group under 40 years of age. Within the prehospital management of seriously injured trauma victims the accuracy of the field triage by emergency physicians is of utmost importance. OBJECTIVE: The aim of this study was to determine the accuracy of prehospital emergency physician field triage in road traffic accident victims. MATERIAL AND METHODS: The study involved a retrospective analysis and comparison of prehospital and inhospital trauma records of road traffic accident victims treated by a Helicopter Emergency Medical Service (HEMS) team and transferred to a level I trauma centre. A comparison of prehospital and inhospital diagnostic findings was carried out according to an anatomical score (AIS). RESULTS: Included in the analysis were 479 patients with a mean age of 37.0 ± 18.2 years, males 65.8 %, mean injury severity score (ISS) 15.5 ± 13.5, ISS > 16 in 41,1 % and mortality 7.3 %. The leading causes of injury were motor vehicle accidents (56.2 %), followed by motorcycle (24.0 %) and bicycle accidents (11.6 %) as well as truck accidents (4.0 %) and pedestrian accidents (4.2 %). The most common body regions injured (AIS ≥ 3) were the chest (37 %), head (25.1 %) and lower extremities (16.7 %). A correct prehospital field triage by emergency physicians was found for injuries with an AIS ≥ 3 of the head 77 %, chest 69 %, abdomen 51 %, pelvis 49 %, extremities 70 %, neck/cervical spine 67 % and thoracic/lumbar spine 70 %. Overlooked injuries in the prehospital setting (AIS ≥ 3) comprised predominantly injuries of the trunk (chest 12.6 %, abdomen 16.9 % and pelvis 15 %). Overlooked injuries were found significantly less for the head in patients with a Glasgow Coma Score ≤ 8 on arrival at the scene (5.4 % versus 19 %, p = 0.015), for the chest in patients with a S(p)O(2) ≤ 96 % on arrival at the scene (18.1 % versus 35.5 %, p = 0.004) and for the abdomen in patients with a systolic blood pressure < 90 mmHg on arrival at the scene (28.6 % versus 52.5 %, p = 0.025). CONCLUSION: Accurate field triage in seriously injured road accident victims, even by trained physicians, is difficult. This pertains especially to injuries to the abdomen and the pelvis. For the field triage a combination of anatomical and physiological criteria as well as the mechanism of injury should be used to increase accuracy.

[Intraosseous infusion in the German Air Rescue Service : Guideline recommendations versus mission reality]. / Intraossäre Punktion im deutschen Luftrettungsdienst : Leitlinienempfehlungen vs. Einsatzrealität.

BACKGROUND: In emergency medicine intraosseous access (IOA) has been established as an alternative to conventional intravenous access. Originally the use of IOA was strictly limited to children up to 6 years of age and to adults for cardiopulmonary resuscitation. These limitations have been relaxed and the indications for IOA have been expanded. MATERIAL AND METHODS: A retrospective nationwide analysis of rescue missions by all helicopter emergency medical services of the German Automobile Club (ADAC) Air Rescue Service as well as the German Air Rescue (DRF) over a 7-year period was carried out. RESULTS: A total of 466,813 patients were treated during the study period and an IOA was established in 1,498 (0.32 %) patients. There was a significant increase in using an IOA from 0.1-0.5 % (p < 0.05) from 2005 to 2011. Furthermore, there was an increase in using an IOA in elderly patients and in patients with lower degrees of severity according to the National Advisory Committee for Aeronautics (NACA) scales (2005-2011): decreased use of IOA in patients up to 6 years of age from 92.4 % to 19.7 % (p < 0.05) and in patients with NACA grades VII/VI from 74.4 % to 46.6 % (p < 0.05) and temporarily limited increase of non-indicated IOA use in patients with NACA grade III between 2008 and 2010. Furthermore, there was an increase in the number of the different drug groups used for intraosseous infusion over the study period. CONCLUSION: The current guidelines and recommendations for the use of IOA in the prehospital setting are reflected more and more in mission reality for helicopter emergency medical services.

[The TraumaRegister DGU® as the basis of medical quality management. Ten years experience of a national trauma centre exemplified by emergency room treatment]. / Das TraumaRegister DGU® als Basis eines medizinischen Qualitätsmanagements. 10 Jahre Erfahrung eines überregionalen Traumazentrums am Beispiel der Schockraumversorgung.

BACKGROUND: The trauma register of the German Society of Trauma Surgery (TraumaRegister DGU®/TR-DGU) has been proven to be a valuable tool for external assessment of quality in the treatment of patients with major trauma. This publication shows for the first time how the quality of trauma treatment in a level I trauma centre could be improved over a period of almost ten years with the help of continuous quality management, i.e. recognizing a problem, developing a solution and evaluating its effect. MATERIALS AND METHODS: Tracer parameters and indicators of quality are presented in four periods over a total study period from 1st January 1989 to 31st March 2007. The division into four periods is due to major changes in the trauma treatment algorithms or structural changes in the trauma room. The results are displayed for all patients treated in the trauma room and for those patients with an injury severity score (ISS)≥16. RESULTS: Over all four periods a total number of n=2,239 patients were admitted to the trauma room. Based on the results of the trauma register a number of changes were made, not only structural changes, such as the introduction of point-of-care diagnostics, initially conventional X-ray, then digital X-ray and finally multislice computed tomography (CT) scanning in the trauma room but also changes in the way personnel participating in the trauma treatment are trained. Advanced trauma life support (ATLS®) has become the standard training for doctors and prehospital trauma life support (PHTLS®) for nurses. Time efficient treatment algorithms were introduced. All measures led to changes in several parameters which are chosen as indicators for good treatment quality. It was for instance possible to reduce the average total trauma treatment time for patients with an ISS≥16 from initially 90.9±48.6 min to 37.4±18.  min in the final study period. CONCLUSIONS: The external quality management performed by the TR-DGU has proved to be a constant source of inspiration. The effects of the changes made can be scientifically proven. It is to be discussed to what extent a sole external quality management can be useful.

[The concept of small volume resuscitation for preclinical trauma management. Experiences in the Air Rescue Service]. / Das Konzept der "small volume resuscitation" im Rahmen des präklinischen Traumamanagements. Erfahrungen im Luftrettungsdienst

BACKGROUND: Prompt hemorrhage control and adequate fluid resuscitation are the key components of early trauma care. However, the optimal resuscitation strategy remains controversial. In this context the small volume resuscitation (SVR) concept with hypertonic-hyperoncotic solutions is a new strategy. PATIENTS AND METHODS: This was a retrospective study in the Helicopter Emergency Medical Service over a 5-year period. Included were all major trauma victims if they were candidates for SVR (initially 4 ml HyperHaes/kg body weight, followed by conventional fluid resuscitation with crystalloids and colloids). Demographic data, type and cause of injury and injury severity score (ISS) were recorded and the amount of fluid volume and the hemodynamic profile were analyzed. Negative side-effects as well as sodium chloride serum levels on hospital admission were recorded. RESULTS: A total of 342 trauma victims (male 70.2%, mean age 39.0 ± 18.8 years, ISS 31.6 ± 16.9, ISS>16, 81.6%) underwent prehospital SVR. A blunt trauma mechanism was predominant (96.8%) and the leading cause of injury was motor vehicle accidents (61.5%) and motorcycle accidents (22.3%). Multiple trauma and polytrauma were noted in 87.4% of the cases. Predominant was traumatic brain injury (73.1%) as well as chest injury (73.1%) followed by limb injury (69.9%) and abdominal/pelvic trauma (45.0%). Within the whole study group in addition to 250 ml HyperHaes, mean volumes of 1214 ± 679 ml lactated Ringers and 1288 ± 954 ml hydroxethylstarch were infused during the prehospital treatment phase. There were no statistically significant differences in the amount of crystalloids and colloids infused regarding the subgroups multisystem trauma (ISS>16), severe traumatic brain injury (GCS<9) and entrapment trauma compared to the total study group. In patients with an initial systolic blood pressure (SBP) >80 mmHg significantly less colloids (1035 ± 659 ml vs. 1288 ± 954 ml, p<0.006) were infused, whereas in patients with an initial SBP ≤ 80 mmHg significantly more colloids were infused (1609 ± 1159 ml vs. 1288 ± 954 ml, p<0.002). There was a statistically significant increase in systolic as well as diastolic blood pressure at all times of blood pressure measurement during prehospital treatment after bolus infusion of HyperHaes within the whole study group. The same applies to the subgroups multisystem trauma, severe traumatic brain injury and entrapment trauma. Minor negative side-effects were observed in 4 cases (1.2%). The mean serum sodium chloride profile on hospital admission was 146.9 ± 5.0 mmol/l, the base excess (BE) was -5.7 ± 5.3 mmol/l) and the pH was 7.3 ± 0.1. CONCLUSION: The concept of small volume resuscitation provides early and effective hemodynamic control. Clinical side-effects associated with bolus infusion of hypertonic-hyperoncotic solutions are rare.

Incidence of transient hypoxia during pre-hospital rapid sequence intubation by anaesthesiologists.

BACKGROUND: Pre-hospital tracheal intubation (TI) is an important but difficult procedure with the potential to produce hypoxaemia. The aim of this study was to determine the incidence of desaturation episodes during out-of-hospital rapid sequence induction (RSI) and TI by the medical team of a German Helicopter Emergency Medical Service (HEMS). METHODS: We performed a prospective study at HEMS 'CHRISTOPH 22'. TI was performed as RSI according to a standard protocol. Desaturation was defined as a reduction in SpO(2) below 90% or a reduction of more than 10% from baseline SpO(2) when initial values were less than 90%. RESULTS: The RSI/TI manoeuvre was attempted in 150 patients [107 male (71.3%); median age 40 years (IQR 21-61); overall success rate 100%]. The incidence of desaturation episodes was 13.3% with a median duration of 50 sec. (IQR 30-92) and a median SpO(2) decrease of 24 ± 10%. Upon hospital admission, all patients had SpO(2) values ≥ 96%. In the desaturation group the duration of successful TI was significantly longer [median 85 sec. (IQR 60-119) vs. median 63 sec. (IQR 48-70); P < 0.01], and the number of patients with a baseline SpO(2) ≥ 90% was significantly lower (65.0% vs. 88.5%; P < 0.01). Among patients with difficult to manage airway, those with desaturation were significantly younger, and technical problems were significantly more frequent. CONCLUSION: The incidence of episodes of desaturation during pre-hospital RSI/TI at HEMS Ulm is relatively low, and the duration of such episodes is short.

Prognostic aspects, survival rate, and predisposing risk factors in patients with Fournier's gangrene and necrotizing soft tissue infections: evaluation of clinical outcome of 55 patients.

OBJECTIVE: To determine predisposing or prognostic factors and mortality rates of patients with Fournier's gangrene compared to other necrotizing soft tissue infections (NSTI). MATERIAL AND METHODS: Data of 55 intensive care patients (1981-2010) with NSTI were evaluated. Data were collected prospectively. RESULTS: 43.4% of the patients were in septic condition and 27.3% were hemodynamically unstable. Half of the patients showed predisposing factors (52.7%). The lower extremity (63.2%), abdomen (30.9%), and perineum (14.5%) were most affected. Polymicrobial infections were frequent (65.5%, mean 2.8, range: 1-4). The mortality rate was 16.4% (n = 9). An increase was shown for diabetes mellitus (20%), cardiac insufficiency (22.3%), septic condition at presentation (33.3%), abdominal affection (47.1%), and hemodynamic instability (46.7%). Comparing survivors and nonsurvivors, statistical significance was seen with age (p < 0.001), septic condition at admission (p < 0.001), hemodynamic instability (p < 0.001), low blood pressure (p < 0.001), and abdominal affection (p < 0.001). In laboratory findings, an increase of creatine kinase (p < 0.001) and lactate (p < 0.001) and a decrease of antithrombin III (p < 0.007) and the Quick value (p < 0.01) proved to be significant. CONCLUSION: Patients with Fournier's gangrene do not differ in all aspects from those with other NSTI. Successful treatment consists of immediate surgical debridement, broad-spectrum antibiotic treatment, and critical care management. Supportive hyperbaric oxygen therapy should be considered.

[Extended medical quality management exemplified by the tracer diagnosis multiple trauma. Pilot study in the air rescue service]. / Erweitertes medizinisches Qualitätsmanagement am Beispiel der "Tracer"-Diagnose "Polytrauma". Pilotstudie aus dem Bereich des Luftrettungsdienstes.

BACKGROUND: Adequate prehospital and inhospital primary care is a decisive factor in the successful treatment of multiple trauma patients. For optimization of treatment algorithms the implementation of a medical quality management is of utmost importance. The aim of this study was to extend quality management by including data on process quality. METHODS: A retrospective study of primary rescue missions of the Helicopter Emergency Medical Service (HEMS) Christoph 22 in Ulm over a period of 2.5 years was performed. In a detailed analysis of filter criteria, in which relevant deviations from the recommendations (not fulfilled in > 10% of the cases) occurred, process data was included (vital data, measurements and events). RESULTS: In the study population (n = 298, males 71.8%, mean age 39.8 ± 21.8 years) 2 filter criteria were identified in which relevant deviations where observed: time management where prehospital treatment time ≤ 60 min in 36% of the cases was not fulfilled and circulatory management where the systolic blood pressure, detected with Riva-Rocci method (RR(sys)) ≥ 120 mmHg on hospital admission in patients with severe head trauma was not fulfilled in 45% of the cases. In patients with deviations in time management, prehospital treatment time was prolonged (75.6 ± 18.3 min versus 50.5 ± 6.7 min; p < 0.01) caused by a prolonged on scene attendance time (34.1 ± 22.1 min versus 20.6 ± 9.2 min; p < 0.01) and transport time (17.3 ± 9.4 min versus 13.3 ± 4.8 min; p < 0.01). In entrapment trauma prehospital treatment time was expanded (44% versus 10%; p < 0.01). Patients in whom circulatory management deviations were observed were more often in shock on arrival at the scene (RR(sys) ≤ 90 mmHg: 60% versus 30%; p < 0.01), more often hypoxemic [pulse oximeter oxygen saturation (S(p)O(2)) ≤ 90%: 36% versus 19%; p < 0.05] and more often sustained a trauma to the chest as well as to chest and abdomen/pelvis (69% versus 52% and 42% versus 28%, respectively; p < 0.05). Furthermore, the infusion volume of colloids was higher (1241 ± 810 ml versus 753 ± 359 ml; p < 0.05) and the combined usage of small volume resuscitation and catecholamines was more often necessary (42% versus 25%; p < 0.05). CONCLUSIONS: Including process data of prehospital mission data recording facilitates an extended medical quality management.

[Use of intraosseus infusion in the German air rescue service : nationwide analysis in the time period 2005 to 2009]. / Einsatz der intraossären Infusion im deutschen Luftrettungsdienst : Bundesweite Analyse im Zeitraum von 2005 bis 2009.

BACKGROUND: Intraosseous infusion has become established as a fast and safe alternative to conventional vascular access in emergency situations. Originally the use of intraosseous access was limited to children up to 6 years of age and to adults for cardiopulmonary resuscitation but this limitation has now been removed. The aim of this study was to obtain data on mission reality regarding the use of intraosseous access in the prehospital setting against the background of the expanded recommendations on the use of the intraosseous infusion. METHODS: An analysis of rescue missions by all rescue helicopters of the ADAC (German Automobile Club) Air Rescue as well as the German Air Rescue Service (58 helicopter emergency medical service bases) over a 4 year period from January 2005 to December 2008 was carried out. RESULTS: A total of 247,454 rescue missions were carried out during the study period and in 525 patients (0.2% of the total study collective) an intraosseous access was established. There was a significant increase in the intraosseous infusion rate from 0.1% to 0.4% (p<0.05). Furthermore, there was a significant increase in its use in elderly patients and in patients with lower National Advisory Committee for Aeronautics (NACA) scores (2005 vs. 2008): 92.4% vs. 42.9% of all intraosseous infusions in patients ≤ 6 years of age (p<0.05) and 74.4% vs. 42.9% of all intraosseous infusions in patients with NACA score VI/VII (p<0.05). The proportion of trauma patients in the total study collective was 33% and there was no significant change in the frequency of trauma cases over the study period but there was a remarkable increase of intraosseous infusions in trauma patients in the last year of the study period compared to the previous years (38% in 2008 vs. 27-30% in 2005-2007). Furthermore, there was an increase in the number of different drug groups used for intraosseous infusion over the study period. CONCLUSIONS: The expanded indication recommendations for the use of intraosseous infusion in the prehospital setting enter more and more mission reality in air rescue services in Germany.

[Special aspects of the emergency medical care of head and neck injuries]. / Besonderheiten der notärztlichen Versorgung von Kopf-/Halsverletzten.

The overall incidence of severe head, face and neck injuries as seen from the German Trauma Registry of the National Association of German Trauma Surgeons is 81.3%. The leading causes of death among these patients are hemorrhage and severe traumatic brain injury. The aim of prehospital emergency medical care is to stabilize vital functions in order to ensure primary survival and to reduce morbidity with appropriate prehospital treatment of the individual injuries within the overall injury pattern. In this review, special aspects as well as pitfalls of the prehospital management of patients with head, face and neck injuries are demonstrated. Prehospital airway management concepts as well as concepts for stopping bleeding in the head, face and neck region are discussed in detail.

[Pediatric emergency patients in the air rescue service. Mission reality with special consideration to "invasive" measures]. / Pädiatrischer Notfallpatient im Luftrettungsdienst. Einsatzrealität unter besonderer Berücksichtigung "invasiver" Maßnahmen.

BACKGROUND: In Germany only 2-9% of rescue missions performed by emergency physicians are pediatric emergencies. Therefore, an emergency physician has to deal with a pediatric emergency on average every 1.1-1.3 months. There are only a few studies in the literature evaluating the frequency of "invasive" techniques and procedures (e.g. vascular access, endotracheal intubation, alternative airway techniques and insertion of chest tube) in pediatric patients in the prehospital setting performed by German emergency physicians. The purpose of this study was to evaluate the frequency of these kinds of procedures in pediatric emergencies in the field of the Helicopter Emergency Medical Service (HEMS). METHODS: Evaluation of pediatric emergencies (defined as <18 years of age) over a 4 year period at the Helicopter Emergency Medical Service (HEMS) was carried out retrospectively. RESULTS: During the study period 5,826 rescue missions (4,778 primary rescue missions, 571 inter-hospital transfers and 461 others) were completed. A total of 643 (11%) pediatric emergency patients were treated by the HEMS team. Out of this pediatric study group 16.3% had an initial Glasgow Coma Score (GCS) <9 and 59.3% were rated IV-VII on the National Advisory Committee of Aeronautics (NACA) scale. Within the pediatric study group children 1-5 years of age and children 14-17 years of age were predominant (29.2% and 25.8%, respectively). Regarding the whole pediatric study group trauma was predominant (57.9%). In children <1 year of age and children 1-4 years of age, non-traumatic emergencies were predominant (84.2% and 56.9%, respectively), whereas in children 6-9 years of age, 10-13 years of age and 14-17 years of age, traumatic injuries were predominant (64.2%, 74.8% and 72.3%, respectively). Non-invasive standard monitoring by ECG (electrocardiogram), blood pressure (RR) and pulse oximetry (S(p)O(2)) was established in more than 75% of the pediatric patients (ECG: 77.0%, RR: 81.5%, S(p)O(2): 96.7%) and the older the children the more monitoring was established (children <1 year of age: ECG: 47.4%, RR: 36.8%, S(p)O(2): 93.0% vs. children 14-17 years of age: ECG: 89.8%, RR: 98.2%, S(p)O(2): 100.0%). Regarding the whole pediatric study group, vascular access was established in 81.5% of the cases and in 2.5% of the cases as intraosseous infusion. Out of a total of 16 intraosseous infusions performed within the study period 14 (87.4%) were performed in children <6 years of age. In 20.7% of the cases an endotracheal intubation was performed and in 92.5% of these cases induction of anaesthesia was necessary. The insertion of a chest tube within the study period was only necessary in 1.2% of the cases. CONCLUSIONS: Compared to the results of other studies the number of pediatric emergency patients with a NACA score IV-VII in this study is very high. Furthermore, the percentages of non-invasive monitoring procedures applied to the patients as well as invasive therapeutic procedures performed by the HEMS team were also high. Therefore, a special pediatric training course for emergency physicians seems to be necessary.

[Primary documentation quality for paper-assisted digital mission data documentation. Initial results from the air rescue service]. / Primäre Dokumentationsqualität bei papiergestützter digitaler Einsatzdokumentation. Erste Ergebnisse aus dem Luftrettungsdienst.

BACKGROUND: With the assistance of digital pen and paper technology in the field of prehospital data reporting, it seems to be possible to fulfill the requirements of "documentation" as well as the requirements of "quality management". The aim of this study was to determine the "primary documentation quality" (PDQ) of a data reporting system based on digital pen and paper technology (so-called DINO) within a helicopter emergency medical service (HEMS) over a 6-month period. RESULTS: The PDQ is defined as the proportion of prehospital documented data, which is primarily recorded correctly by the data reporting system. For the national uniform core dataset (so-called MIND2) the PDQ was 96.7%, for "checkbox" and "numeric data fields" the PDQ was 99.8% and 93.6%, respectively and for "vital data" the PDQ was 96.7% [heart rate (HF), measurement of blood pressure] and 84.1% [peripheral oxygen saturation (S(p)O2), end tidal carbon dioxide concentration (etCO2), oxygen administration (O2)]. For "measurements" the PDQ was 96.9% (time stamps) and 86.9% (time frames), for "drugs" the PDQ was 43.6% (drug name) and 69.8% (drug dosage) and for"placement of infusion" 42% (infusion name) and 85.3% (infusion time), respectively. The average time for the "verification process" after mission completion was 1.5+/-0.4 min/mission. CONCLUSIONS: The "primary documentation quality" of prehospital mission data reporting with the assistance of a digital pen and paper based documentation system (DINO) has been shown to completely fulfill the requirements of rapid and safe data documentation in actual missions, even at this early stage of development.