[Special emergency situations and hazard control in German hospitals-A survey on the current state]. / Sonderlagen und Gefahrenabwehr in deutschen Krankenhäusern ­ eine Umfrage zum Ist-Zustand.

BACKGROUND AND RESEARCH QUESTION: In case of events such as a cyber attack or a mass casualty incident, ad hoc measures have to be taken in hospitals. As part of the critical infrastructure, hospitals are required by law to prepare, update and exercise alarm and emergency plans for various special situations. The processes and instruments involved for emergency response are defined in the hospital alert and emergency planning. The present study aims to explain with which resources and for which special situations hospitals are prepared. METHODS: A prospective, exploratory, anonymous survey of hospitals in Germany was conducted. Hospitals with both internal medicine and surgery departments were included. Out of 2497 hospitals listed in the German Hospital Directory ( www.deutsches-krankenhaus-verzeichnis.de ), 1049 met the inclusion criteria. After correcting for hospital groups with shared administrations, 850 employees were identified and contacted by e­mail. Quality and risk management managers were asked about resources, risks, and content of their own hospital alert and emergency planning using a standardized questionnaire. The survey was conducted using the online platform EFS Survey (Tivian XI GmbH, Cologne) via www.unipark.de . Access to the survey was via a nonpersonalized hyperlink. Apart from the size and type of hospital surveyed, no data were collected that would allow identification of an individual person. RESULTS: Of the participating hospitals 45% (n = 43) were primary care hospitals, 24% (n = 23) were specialty care hospitals, 10% (n = 9) were nonuniversity maximum care hospitals, and 21% (n = 20) were university maximum care hospitals. In total 95 hospitals participated in the survey, of which 98% (n = 93) reported having a hospital alert and emergency plan. Preparation for individual scenarios varied widely. Of the participating hospitals 45% (n = 43) reported having been the target of cyber attacks with an emphasis on maximum care hospitals (55%, n = 11 of 20). Technical redundancy for computer systems is available in 67% (n = 63) of participating hospitals, while independent means of communication exist in 50% (n = 47) of hospitals. A physician-staffed crisis and disaster management unit existed in 60% (n = 56) of the surveyed hospitals. At least a part time position for planning issues was installed in 12 hospitals. CONCLUSION: Most participating hospitals are aware of the need for a hospital alert and emergency plan and have various scenario-specific plans in place. Especially mass casualty events, fire and hospital evacuation scenarios are uniformly covered among participating hospitals; however, gaps appear to exist not only for chemical, biological or radionuclear situations but also especially in the area of extreme weather events and infrastructure failures. Only about two thirds of all participating hospitals have contingency plans for water supply and/or heating failures. An important limitation of the study is the comparatively low response rate of 12.9% (n = 95 of 850). While primary care hospitals were underrepresented in the study, 32% of Germany's larger hospitals (> 800 beds) participated. In the future, there is a particular need to engage enough medical staff in the area of hospital alert and emergency planning and refunding of these measures by hospitals.

[Resuscitative endovascular balloon occlusion of the aorta (REBOA) : Current aspects of material, indications and limits: an overview]. / "Resuscitative endovascular balloon occlusion of the aorta" (REBOA) : Aktuelles zu Material, Indikationen und Grenzen: ein Überblick.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) describes an endovascular procedure in which a blocking balloon is introduced into the aorta to reduce bleeding situated distal to the balloon and simultaneously to improve cardiac and cerebral oxygenation. OBJECTIVE: Presentation of the REBOA technique, the possible indications, the required material and possible complications of the procedure. MATERIAL AND METHODS: Non-systematic review of the currently available literature. RESULTS: The REBOA procedure is an adjunct to achieve hemodynamic stabilization in patients with traumatic hemorrhage and ruptured aortic aneurysms. The complication rate of the procedure is approximately 5%, whereby access complications are the most common; however, fatal complications are also possible. CONCLUSION: A balloon block of the aorta is well established in the treatment of ruptured aortic aneurysms. There is growing evidence that REBOA is a minimally invasive alternative to open surgical cross-clamping of the aorta by thoracotomy for the treatment of patients with polytrauma and hemorrhagic shock due to abdominal or visceral bleeding. Due to the development of new balloon catheters, which can be placed without stiff guidewires and require smaller sheath diameters, REBOA is also discussed for treatment of postoperative abdominal or gynecological bleeding or as a possible adjunct to cardiopulmonary resuscitation for nontraumatic cardiac arrest.

[Conventional intubation and laryngeal tube in cervical spine instability : Changes in the width of the dural sac in unfixed human body donors]. / Konventionelle Intubation und Larynxtubus bei Halswirbelsäuleninstabilität : Änderungen der Duralsackweite am unfixierten humanen Körperspender.

BACKGROUND: Airway management in patients with an unstable cervical spine requires a cautious approach if secondary damage is to be prevented but the question regarding the optimum method remains unresolved. The primary aim of the study was to investigate whether there were differences between intubation by conventional Macintosh laryngoscopy and placement of a laryngeal tube (LTS-D) with respect to dural sac compression on an unfixed human cadaver model with unstable injuries of the upper cervical spine. Secondary parameters that could be relevant in patients with unstable spinal injuries were also investigated. MATERIAL AND METHODS: Orotracheal intubation by conventional direct laryngoscopy using a Macintosh blade and placement of a laryngeal tube (LTS-D) were performed in six fresh human cadavers. The dural sac was filled with contrast dye to allow continuous myelography by lateral fluoroscopy. Changes in the width of the dural sac at the cervical segments (C) C0/C1 and the C1/C2 levels as well as secondary parameters (angulation, distraction, intervention time) were assessed in the intact spine as well as in the presence of combined atlanto-occipital dislocation and atlanto-axial instability. The intubation methods were considered independent and examined using the Mann-Whitney U­test. RESULTS: At the C0/C1 level in the intact spine, conventional laryngoscopy caused less reduction of the width of the dural sac than placement of the LTS-D (0.33 mm vs. 0.46 mm, p = 0.035); however, in the presence of combined atlanto-occipital dislocation and atlanto-axial instability, placement of the LTS-D caused less reduction in the width of the dural sac than conventional intubation (1.18 mm vs. 0.68 mm, p = 0.005). At the C1/C2 level no differences were found with respect to changes in the width of the dural sac, neither in the intact spine nor in combined atlanto-occipital dislocation and atlanto-axial instability. Conventional intubation caused more angulation than placement of the LTS-D at both levels measured. Both methods did not cause distraction. The intervention times for placement of the laryngeal tube were shorter. CONCLUSION: In an unfixed human cadaver model with combined atlanto-occipital dislocation and atlanto-axial instability, placement of the LTS-D caused less reduction in the width of the dural sac than conventional intubation at the level of the craniocervical junction. The LTS-D also caused less angulation and could be placed faster. It could therefore also be advantageous over conventional intubation in living patients with an unstable cervical spine.

Effects of combined helium pre/post-conditioning on the brain and heart in a rat resuscitation model.

BACKGROUND: The noble gas helium induces cardio- and neuroprotection by pre- and post-conditioning. We investigated the effects of helium pre- and post-conditioning on the brain and heart in a rat resuscitation model. METHODS: After approval by the Animal Care Committee, 96 Wistar rats underwent cardiac arrest for 6 min induced by ventricular fibrillation. Animals received 70% helium and 30% oxygen for 5 min before cardiac arrest and for 30 min after restoration of spontaneous circulation (ROSC). Control animals received 70% nitrogen and 30% oxygen. Hearts and brains were excised after 2, 4 h or 7 days. Neurological degeneration was evaluated using TUNEL and Nissl staining in the hippocampal CA-1 sector. Cognitive function after 7 days was detected with the tape removal test. Molecular targets were measured by infrared western blot. Data are shown as median [Interquartile range]. RESULTS: Helium treatment resulted in significantly less apoptosis (TUNEL positive cells/100 pixel 73.5 [60.3-78.6] vs.78.2 [70.4-92.9] P = 0.023). Changes in Caveolin-3 expression in the membrane fraction and Hexokinase-II in the mitochondrial fraction were observed in the heart. Caveolin-1 expression of treated animals significantly differed from control animals in the membrane fraction of the heart and brain after ROSC. CONCLUSION: Treatment with helium reduced apoptosis in our resuscitation model. Differential expression levels of Caveolin-1, Caveolin-3 and Hexokinase II in the heart were found after helium pre- and post-conditioning. No beneficial effects were seen on neurofunctional outcome.

[Air rescue: current significance and practical issues]. / Luftrettung: Aktueller Stellenwert und praktische Aspekte.

Germany has a nationwide and powerful helicopter emergency medical services system (HEMS), which executes primary rescue missions and interhospital transfer of intensive care patients. In recent years the range of HEMS missions has become modified due to demographic changes and structural changes in the healthcare system. Furthermore, the number of HEMS missions is steadily increasing. If reasonably used air rescue contributes to desired reductions in overall preclinical time. Moreover, it facilitates prompt transport of patients to a hospital suitable for definitive medical care and treatment can be initiated earlier which is a particular advantage for severely injured and critically ill patients. Because of complex challenges during air rescue missions the qualifications of the HEMS personnel have to be considerably higher in comparison with ground based emergency medical services.

[In-hospital emergencies at a surgical university hospital]. / Innerklinische Notfälle in einer chirurgischen Universitätsklinik.

BACKGROUND: Emergency treatment and resuscitation within hospitals are managed by so-called medical emergency teams (MET). The present study examined the circumstances, number, initial treatment and further hospital course of in-hospital emergency cases at a level 1 university hospital. METHODS: A retrospective study of in-hospital emergencies on the surgical wards of a university hospital including all non-intensive care areas from January 2007 to June 2010 was carried out. A self-developed documentation protocol which was introduced in 2006 was used by the MET to document general patient characteristics and details of the emergency treatment. These data included the place where the emergency situation arose, the patient's assignment to a surgical discipline, a detailed description of the emergency situation, the effectiveness of basic life support measures as well as the further hospital course of the patient. RESULTS: A total of 235 emergency cases were documented within the study period of 3.5 years. The frequency of in-hospital emergencies was 4/1,000 admitted patients per year. Cardiac arrest was encountered in 31,5%. Out of all patients 54,5% were admitted to an intensive care unit. CONCLUSION: The tasks of a MET at a surgical university hospital go beyond mere cardiopulmonary resuscitation. Emergency cases within the full spectrum of perioperative complications are encountered. Further multicenter studies with standardized protocols are required to analyze the management of German in-hospital emergencies.

[Update: studies in intensive care medicine. Results of the last 12 months]. / Update: intensivmedizinische Studien. Ergebnisse der vergangenen 12 Monate.

Intensive care medicine plays an important role in the medical care of patients as well as the economic success of hospitals. Knowledge and implementation of recent relevant scientific evidence are prerequisites for high quality care in intensive care medicine. The aim of this review is to present an overview of the most important publications in intensive care medicine published in 2010 and the first half of the year 2011 and to comment on their attributable clinical relevance for intensive care practitioners. In 2010 and up to June 2011 many studies with high patient numbers have been published. The main topics were the treatment of respiratory failure, sepsis and investigations to improve analgosedation.

[Therapeutic hypothermia]. / Therapeutische Hypothermie.

The use of therapeutic hypothermia has been shown to improve survival and neurological outcome following cardiac arrest. Patients with traumatic brain injury or ischemic stroke also responded positively to therapeutic hypothermia, which may be induced by various procedures including surface cooling, endovascular cooling catheter and cold infusion. Possible side effects include infection and hemorrhage, as well as changes in water and electrolyte levels. It is the aim of this article to provide an overview of studies to date, as well as practical guidance for the application of therapeutic hypothermia.

[Regulated hypothermia after cardiac arrest. A glimpse into the future]. / Regulierte Hypothermie nach Herz-Kreislauf-Stillstand. Ein Blick in die Zukunft.

The introduction of therapeutic mild hypothermia after cardiac arrest allows the neuronal damage caused by global cerebral ischemia to be advantageously influenced for the first time. Currently, hypothermia is induced by external or internal cooling of the patient (forced hypothermia). However, this results in activation of counter-regulation mechanisms which could be possible risk factors for the patient. The aim of this article is to give a review of possible, but at present only experimental, methods which could allow the body temperature set point to be decreased pharmacologically (regulated hypothermia). Various classes of substances will be discussed based on their effect on thermoregulation and their performance in animal experiments on cerebral ischemia.

[Morphological study of placenta and liver of pregnant rats in experimental endotoxicosis and after ceolite protection].

In 45 rats and 120 fetuses the protective effect of food, containing the additives of natural ceolites, on the outcome of pregnancy complicated by an acute experimental endotoxicosis, caused by hyperthermic challenge of the animals, was studied. Using gravimetric, histological, histochemical, electron microscopical methods and monitoring the markers of endogenous intoxication, it was demonstrated that the consumption of ceolite additives contributed to the increase of resistance of the organism to the extremal challenge. Ceolite enteroprotection of acute endotoxicosis, caused by hyperthermic challenge of the pregnant rats, resulted in the increased survival of animals, lower embryonic losses, adaptive changes in placenta and maternal liver.

[Therapeutic hypothermia after cardiac arrest]. / Therapeutische milde Hypothermie nach Herz-Kreislauf-Stillstand.

The use of therapeutic hypothermia following different hypoxic-ischaemic insults has played an important role in various concepts of non-specific protection of cells for a long time. Although the use of deep therapeutic hypothermia after cardiac arrest in the last century did not lead to an improved outcome, recent data have demonstrated very positive effects of mild therapeutic hypothermia. The data from the European multicenter trial as well as those from Australia have clearly demonstrated a decrease in mortality and a better neurological outcome for patients being cooled to 32-34 degrees C for 12 or 24 h. In 2003, this led to the implementation of mild therapeutic hypothermia (32-34 degrees C) into the International Liaison Committee on Resuscitation (ILCOR) recommendations and guidelines for the treatment of unconscious patients after prehospital cardiac arrest. This article gives an overview on existing concepts and future perspectives of therapeutic mild hypothermia.

Altered protein expression levels of Fas/CD95 and Fas ligand in differentially vulnerable brain areas in rats after global cerebral ischemia.

To assess the role of the apoptosis-inducing death receptor Fas/CD95 and Fas Ligand (FasL) after global cerebral ischemia, expression of these proteins was investigated in differentially, i.e. selectively vulnerable brain areas. Following experimentally induced cardiac arrest of 6 min duration, rats were resuscitated. After 3, 6, and 24 h of reperfusion, the thalamus and hippocampus of one hemisphere were analyzed for Fas/CD95 and FasL by immunoblotting and semiquantitative densitometry. Corresponding hemispheres were examined by immunohistochemistry. No significant changes in hippocampal Fas/CD95 expression were revealed in comparison to sham operated animals. In the thalamus, a significant reduction in Fas/CD95 expression was observed after 24 h of reperfusion. FasL expression in the hippocampus had declined after 3 and 6 h, as compared with control animals. In contrast, in the thalamus a significant induction of FasL expression was observed after 3 h. Immunohistochemistry revealed a predominantly neuronal expression of the two proteins. In light of the observed increased expression of FasL in the thalamus, such an induction may lead to significant activation of the Fas/CD95 signaling cascade. Our results suggest for the first time a possible role of the Fas/CD95-FasL system after global cerebral ischemia.

[Implantation of UV-absorbing posterior chamber lenses]. / Zur Implantation UV-absorbierender Hinterkammerlinsen.

The authors report on their experience with UV-absorbent posterior chamber IOLs (ORC) implanted between April 1, 1984 and April 1, 1985 (n = 125). Short-term complications and in particular post-operative sterile uveitis, corresponded to those in a group (n = 135) who had had regular PMMA lenses implanted. While no significant lowering of glare perception could be proved after implantation of the UV-block-lenses, color perception seemed to be more correct with these lenses. Because of the short observation time no significant statements can be made regarding the frequency of cystoid macular edema.

[Results of penalisation treatment (author's transl)]. / Resultate der Penalisation

The results of penalisation treatment are given in the cases of 233 children with squint and 9 with amblyopia without a squint angle. With regard to amblyopia treatment penalisation is indeed not so effective as direct total occlusion, but it can be used, for example when the parents or children fight against the occlusion or when a plaster allergy is present. Even in school children the near-penalisation in cases of amblyopia diagnosed too late can bring very satisfactory visual improvements (in over 50%), provide care and stamina are present. For prophylaxis against amblyopia, the penalisation is especially suitable. In only 1/3 of cases the squint angle becomes obviously smaller, and signs of incomitance are not affected. Less than one third incomitance are not affected. Less than one third of the children attain with penalisation alone binocular vision--and even this usually on the basis of anomalous development.