[Decision support for patient admission in case of suspicion of COVID-19]. / Entscheidungshilfe zur Patientenzuweisung bei Verdacht auf COVID-19: Für die Anwendung im bayerischen Rettungsdienst.

During a pandemic situation, patients with suspected coronavirus disease (COVID-19) are also treated by emergency medical services (EMS). In order to establish an adequate procedure, a decision aid for the allocation of patients in case of suspicion of COVID-19 has been prepared for the ambulance staff as well as for the emergency physician in the Bavarian EMS. The decision-making aid includes the current guidelines and recommendations on COVID-19. A flowchart in A4 format was chosen for the presentation of the decision aid, which is structured according to the ABCDE scheme (A-Airway, B-Breathing, C-Circulation, D-Disability, E-Environment/Exposure) established in EMS. The flowchart allows patients to be categorized in three stages, based on (vital) parameters and criteria such as risk factors and specific framework conditions. The aim is to provide emergency physicians and ambulance staff with guidance for the assessment of patients and the resulting transport decision with a suitable target clinic if necessary.

Defibrillator charging before rhythm analysis causes peri-shock pauses exceeding guideline recommended maximum 5 s : A randomized simulation trial.

INTRODUCTION: Charging defibrillators prior to analyzing heart rhythms may decrease the no-flow time during rhythm check pauses while resuscitating in cardiac arrest. Although this anticipatory method is already used in some centers little is known about its safety. This study was carried out to confirm the safety and feasibility of the anticipatory method. It was hypothesized that this anticipatory method results in shorter total no-flow times, while other parameters of defibrillation efficacy including defibrillator safety and minimization of peri-shock pauses are unchanged. METHODS: This manikin study assigned 243 medical students randomly to study groups, 121 to the anticipatory method and 122 to the recommended European Resuscitation Council (ERC) algorithm. Of these 237 students ultimately underwent training (112 anticipatory method vs. 125 ERC algorithm). Participants were assessed and video recorded during a simulated cardiac arrest scenario which included three different heart rhythms (ventricular fibrillation [VF], pulseless ventricular tachycardia [pVT], asystole) in randomized order. Video and software analyses were performed. Defibrillation safety was assessed using a 17-item checklist defined beforehand. RESULTS: A total of 203 simulated cardiac arrests (75 anticipatory method and 128 ERC 2010 algorithm) were analyzed. The anticipatory method did not significantly reduce no-flow time (25.8 s, standard deviation, SD 7.4 s vs. 27.4 s SD 8.4 s, p = 0.19); however, peri-shock pauses were significantly longer in the anticipatory group compared to the ERC 2010 group (9.5 s SD 2.8 s vs. 3.3 s SD 1.9 s, p < 0.001). No significant difference concerning defibrillation safety between the groups was observed according to the 17-item checklist (14.6 SD 1.6 vs. 15.0 SD 1.4, p = 0.07). CONCLUSION: Charging defibrillators before rhythm analysis did not decrease total no-flow time in simulated cardiac arrests but resulted in significantly longer peri-shock pauses exceeding 5 s. No significant differences in defibrillation safety were observed between the groups.

[Importance of trauma and emergency surgery for German metropolitan emergency departments-an analysis of 524,716 emergency patients]. / Stellenwert der Unfallchirurgie für die Notaufnahmen einer deutschen Millionenstadt ­ Eine Auswertung von 524.716 Notfallpatienten.

BACKGROUND: The future of emergency departments in Germany is influenced by increasing numbers of patients, demographic changes, new therapeutic concepts, current legislation and expert opinions. There is a lack of reliable data concerning the quantity and the type of injuries and diseases presenting in emergency departments. MATERIAL AND METHODS: This descriptive, epidemiological study included 14 emergency departments in Munich (1.41 million inhabitants in 2014), where 524,716 patients were treated from 1 July 2013 to 30 June 2014. 393,587 were included in this prospectively planned subgroup analysis. Patients presenting in special departments, such as gynecology or ophthalmology (59,523) or cases without a documented diagnosis (71,606) were excluded. Cases were assigned to the discipline trauma surgery or orthopedics according to the ICD-10 diagnosis chapters "injuries, poisoning and certain other consequences of external causes" and "diseases of the musculoskeletal system and connective tissue". RESULTS: Of the 393,587 cases included, 169,208 were treated due to trauma or orthopedic diseases (43%). 134,507 underwent outpatient treatment (79%) and 34,701 were admitted on the same day (21%). 29,920 patients suffered from head injuries (18%), 31,143 fractures (20%) and 24,367 deep wounds (14%) were recorded. On workdays between 8am and 10am, up to 47 patients per hour were treated and between 1pm and 3pm, up to 36 patients per hour. On weekends, most patients presented between 11am and 7pm. CONCLUSION: The present study analyzed the frequency of major diagnoses corresponding to the various medical disciplines including more than 500,000 patients. Of the emergency cases included, 43% were allocated to trauma surgery or orthopedics. These patients presented in the emergency departments around the clock and necessitate the permanent attendance of a trauma and emergency surgeon. Thereby, timely surgical care and decisions regarding indications for surgery and admission are ensured. Competence in trauma and emergency surgery is therefore essential for emergency departments.

[Human factors in medicine]. / Human Factors in der Medizin.

The concept of human factors is commonly used in the context of patient safety and medical errors, all too often ambiguously. In actual fact, the term comprises a wide range of meanings from human-machine interfaces through human performance and limitations up to the point of working process design; however, human factors prevail as a substantial cause of error in complex systems. This article presents the full range of the term human factors from the (emergency) medical perspective. Based on the so-called Swiss cheese model by Reason, we explain the different types of error, what promotes their emergence and on which level of the model error prevention can be initiated.

[Human factors in medicine]. / Human Factors in der Medizin.

The concept of human factors is commonly used in the context of patient safety and medical errors, all too often ambiguously. In actual fact, the term comprises a wide range of meanings from human-machine interfaces through human performance and limitations up to the point of working process design; however, human factors prevail as a substantial cause of error in complex systems. This article presents the full range of the term human factors from the (emergency) medical perspective. Based on the so-called Swiss cheese model by Reason, we explain the different types of error, what promotes their emergence and on which level of the model error prevention can be initiated.

[Full-scale simulation in German medical schools and anesthesia residency programs : Status quo]. / Full-Scale-Simulation in der anästhesiologischen Lehre und Weiterbildung in Deutschland : Gegenwärtiger Stand.

BACKGROUND: Simulation has been increasingly used in medicine. In 2003 German university departments of anesthesiology were provided with a full-scale patient simulator, designated for use with medical students. Meanwhile simulation courses are also offered to physicians and nurses. Currently, the national model curriculum for residency programs in anesthesiology is being revised, possibly to include mandatory simulation training. OBJECTIVES: To assess the status quo of full-scale simulation training for medical school, residency and continuing medical education in German anesthesiology. METHODS: All 38 German university chairs for anesthesiology as well as five arbitrarily chosen non-university facilities were invited to complete an online questionnaire regarding their centers' infrastructure and courses held between 2010 and 2012. RESULTS: The overall return rate was 86 %. In university simulation centers seven non-student staff members, mainly physicians, were involved, adding up to a full-time equivalent of 1.2. All hours of work were paid by 61 % of the centers. The median center size was 100 m2 (range 20-500 m2), equipped with three patient simulators (1-32). Simulators of high or very high fidelity are available at 80 % of the centers. Scripted scenarios were used by 91 %, video debriefing by 69 %. Of the participating university centers, 97 % offered courses for medical students, 81 % for the department's employees, 43 % for other departments of their hospital, and 61 % for external participants. In 2012 the median center reached 46 % of eligible students (0-100), 39 % of the department's physicians (8-96) and 16 % of its nurses (0-56) once. For physicians and nurses from these departments that equals one simulation-based training every 2.6 and 6 years, respectively. 31 % made simulation training mandatory for their residents, 29 % for their nurses and 24 % for their attending physicians. The overall rates of staff ever exposed to simulation were 45 % of residents (8-90), and 30 % each of nurses (10-80) and attendings (0-100). Including external courses the average center trained 59 (4-271) professionals overall in 2012. No clear trend could be observed over the three years polled. The results for the non-university centers were comparable. CONCLUSIONS: Important first steps have been taken to implement full-scale simulation in Germany. In addition to programs for medical students courses for physicians and nurses are available today. To reach everyone clinically involved in German anesthesiology on a regular basis the current capacities need to be dramatically increased. The basis for that to happen will be new concepts for funding, possibly supported by external requirements such as the national model curriculum for residency in anesthesiology.

[Triage protocols for mass casualty incidents : An overview 30 years after START]. / Sichtungskonzepte bei Massenanfällen von Verletzten und Erkrankten : Ein Überblick 30 Jahre nach START.

BACKGROUND: Since the publication of the first mass casualty triage protocol approximately 30 years ago, numerous adaptions and alternatives have been introduced and are currently in use throughout the world. This variety may represent a challenge for the cooperation between emergency medical providers and the interoperability of emergency medical services often required during mass casualty incidents. To enhance cooperation and interoperability a standardization of triage protocols is required. OBJECTIVES: This survey was carried out in order to identify and characterize published triage protocols on national and international levels. Furthermore, evidence for validation of the identified triage algorithms was discussed and recommendations for standardization of triage protocols are given. MATERIAL AND METHODS: In a systematic literature search 59 relevant articles were identified and evaluated with respect to the given objectives. RESULTS: A total of 12 triage concepts were identified and characterized which are categorized according to the basic principle. DISCUSSION: The endpoints of the studies, the chosen observation units and the mode of data collection were discussed with respect to their impact on validation. Furthermore, the impact of the degree and dynamics of system capacity overload, which are pathognomonic for mass casualty incidents, were discussed. CONCLUSION: There is not sufficient evidence to declare one of the triage protocols superior in all aspects to the others and no triage protocol has been implemented on a comprehensive level in Germany. In order to initialize a national or regional convergence process towards an interoperability of emergency medical services, the model uniform core criteria for mass casualty triage approach has been identified as being appropriate.

[Better apprehension of errors in the early clinical treatment of the severely injured]. / Fehler in der frühklinischen Schwerverletztenversorgung besser begreifen.

BACKGROUND: Every year preventable adverse events endanger a considerable number of patients. Current guidelines of the Federal Joint Committee require clinical quality management to provide amongst others an independent clinical risk management and a critical incident reporting system (CIRS). Such guidelines increase the pressure to actively deal with errors, even in emergency medicine. Human error is considered to be the main cause of preventable adverse events in high-risk industries, such as aviation. This observation is gladly directly transferred to clinical medicine. OBJECTIVES: This study investigated where the true causes for preventable adverse events during the resuscitation of severely injured patients can be found. METHODS: A non-systematic literature search of the PubMed database was performed. RESULTS: The search identified three recent studies addressing these objectives that revealed human error as the most important cause of preventable adverse events during emergency room resuscitation (88-97%). Errors during resuscitation in the emergency room occur in approximately 10 %. It is striking that such data do not differ greatly from findings described in studies undertaken 20 years ago. One possible explanation might be that the systematic evaluation of medical errors in the emergency room is a weak spot and that too few lessons can be learnt from such incidents. Therefore, this article describes models of error development and outlines methods to collect data for root cause analysis and for clinical risk management. Thus, this review aims at a better understanding of how errors originate and to allow development of strategies to prevent errors from happening again. CONCLUSION: Human error is the most important cause of preventable adverse events during emergency room resuscitation. Presumably, errors occur unintentionally and as a result of situational misjudgment. As such errors have marked consequences on mortality and morbidity of severely injured patients, an extensive risk management is mandatory for the improvement of quality and safety. Appropriate methods to record errors in order to allow a correct root cause analysis according to well-established protocols is a basic prerequisite.

[Emergency medicine--medicine for an ageing society. A contribution to the context of emergency missions for elderly people]. / Notfallmedizin--Medizin für eine alternde Gesellschaft. Beitrag zum Kontext von Notarzteinsätzen bei alten Menschen.

Due to fundamental demographic as well as social changes, the emergency medical services (EMS) have to respond to an increasing number of geriatric emergencies. By means of some typical case histories the practical problems arising in preclinical emergency medical intervention and the central role of context factors like social isolation, reduced mental capabilities and the resulting need for help are demonstrated. It is discussed how emergency medical services (EMS) can contribute to the problems of an ageing society beyond the scope of a system which is dedicated only to the individual. One possibility is the epidemiological analysis of geriatric emergencies, the accompanying context factors and the development of an adequate infrastructure which is adapted to the needs of the elderly. The EU project EMERGE is an example of how emergency medical expertise is utilized in an interdisciplinary cooperation. An automatically working system based on ambient sensor technology is developed for early detection and prevention of emergency situations in the home environment. Supportive technology ("assisted living") should enable the elderly to live a safe and self-determined life as long as possible. Integration of this additional information into the processes of Emergency Medical Services (EMS) is the logistic prerequisite to establish a social medical assistance tailored to the needs of an ageing society.

[Permissive hypotension in severe trauma]. / Permissive Hypotension beim schweren Trauma.

Hemodynamic instability in the polytraumatized patient is a predominant feature and most commonly secondary to blood loss accompanying injury. In these patients restoration of intravascular volume attempting to achieve normal systemic pressure faces the risk of increasing blood loss and thereby potentially affecting mortality. Due to the lack of controlled clinical trials in this field, the growing evidence that "hypotensive resuscitation" results in improved long-term survival and improved neurologic outcome, mainly stems from experimental studies in animals. In patient care, several concepts exist for the reduction of blood loss in conjunction with systemic hypotension: these involve "deliberate hypotension" (synonym "controlled hypotension", used intraoperatively under conditions of normovolemia and stable hemodynamics), "delayed resuscitation" (where the hypotensive period is intentionally prolonged until operative intervention), and "permissive hypotension" (synonym "hypotensive resuscitation", where all kinds of therapy are commenced including fluid therapy, thereby increasing systemic pressure without, however, reaching normotension). In this review the concept of "permissive hypotension" is delineated on the basis of macro- and microcirculatory changes secondary to hypovolemia and low driving pressure, and potential indications as well as limitations for the care of the traumatized patient are discussed.

Is sodium acetate dextran superior to sodium chloride dextran for small volume resuscitation from traumatic hemorrhagic shock?

Small volumes (4 mL/kg body weight (bw)) of hypertonic sodium chloride dextran effectively restore cardiac output and nutritional blood flow and increase arterial pressure in severe hemorrhagic shock. It has been suggested that the chloride anion be replaced with acetate to provide a solution that avoids the risk of hyperchloremia and has the advantage of supplying a buffering base to optimize hypertonic resuscitation. This study compares the effects of hypertonic sodium chloride dextran solution (7.2% NaCl/10% dextran 60 [NaCl-Dx]; n = 7) with sodium acetate dextran (10.4% Na-Ac/10% dextran 60 [NaAc-Dx]; n = 6) on hemodynamic, oxygen transport, and metabolic variables. Both solutions had the identical osmolality (2400 mOsmol/kg). Dogs (16.9 +/- 1.9 kg) were anesthetized and mechanically ventilated. Shock was induced by exteriorization of intestine and blood withdrawal (50% of blood volume) to maintain mean arterial blood pressure (MAP) at 40 mm Hg for 75 min. Thereafter, resuscitation was performed either with NaCl-Dx (4 mL/kg over 2 min) or NaAc-Dx (4 mL/kg over 4 min). During hypertonic resuscitation, there was a short-lasting decrease in MAP, which was more pronounced in the NaAc-Dx group (delta MAP -7.3 +/- 2.5 mm Hg). Cardiac index and oxygen consumption were normalized within 5 min after resuscitation with both solutions. In NaAc-Dx-treated animals, MAP remained at lower values as compared to NaCl-Dx-treated dogs at 5 and 30 min after resuscitation (52 +/- 3 vs 74 +/- 6, and 61 +/- 7 vs 79 +/- 12 mm Hg; P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)