[Head injuries and their wound treatment]. / Verletzungen am Kopf und ihre Wundbehandlung.

Head injuries are frequent occurrences in emergency departments worldwide and are notable for the fact that attention must be paid to the sequelae of intracranial and extracranial trauma. It is crucial to assess potential intracranial injuries and to strive for both medically sound and esthetically pleasing extracranial outcomes. The aim of this continuing education article is to provide a refresher on knowledge of head injuries and the associated nuances for wound care.

[Impact of the COVID-19 pandemic on the care of major trauma patients: analysis from the TraumaRegister DGU®]. / Auswirkung der COVID-19-Pandemie auf die Versorgung von Schwerverletzten: Analyse aus dem TraumaRegister DGU®.

BACKGROUND: The treatment of major trauma patients requires intensive care capacity, which is a critical resource particularly during the coronavirus disease 2019 (COVID-19) pandemic. Therefore, the aim of this study was to analyze the impact on major trauma care considering the intensive care treatment of COVID-19 positive patients. METHODS: Demographic, prehospital, and intensive care treatment data from the TraumaRegister DGU® of the German Trauma Society (DGU) in 2019 and 2020 were analyzed. Only major trauma patients from the state of Bavaria were included. Inpatient treatment data of COVID-19 patients in Bavaria in 2020 were obtained using IVENA eHealth. RESULTS: In total, 8307 major trauma patients were treated in the state of Bavaria in the time period investigated. The number of patients in 2020 (n = 4032) compared to 2019 (n = 4275) was not significantly decreased (p = 0.4). Regarding COVID-19 case numbers, maximum values were reached in the months of April and December with more than 800 intensive care unit (ICU) patients per day. In the critical period (> 100 patients with COVID-19 on ICU), a prolonged rescue time was evident (64.8 ± 32.5 vs. 67.4 ± 30.6 min; p = 0.003). The length of stay and ICU treatment of major trauma patients were not negatively affected by the COVID-19 pandemic. CONCLUSION: The intensive medical care of major trauma patients could be ensured during the high-incidence phases of the COVID-19 pandemic. The prolonged prehospital rescue times show possible optimization potential of the horizontal integration of prehospital and hospital.

Analysis of severe hand trauma injury frequency during "Munich's Oktoberfest" within the last 9 years in comparison to years with absence due to the COVID-19 pandemic.

INTRODUCTION: Within its 2 week period, the Oktoberfest attracts around 6 million visitors yearly to Munich, Germany. Due to alcohol intake, congested halls, and disorderly activities, numerous accidents occur. Although many hand injuries are observed, the impact of Oktoberfest on severe hand trauma injury frequency is under investigated. MATERIALS AND METHODS: Data from the regional emergency medical service (EMS) was analyzed over a 9 year period regarding the frequency of severe hand injuries during the world's largest fair and compared to the corresponding period in the years 2020 and 2021 where the event was cancelled due to the world-wide COVID-19 pandemic. Additionally, we compared the patient numbers during the same period in one Emergency Department of a level-1-trauma and hand trauma center located close to the venue. RESULTS: An exploratory description is made from data collected over a 9 year period (2013-2021) with focus on hand injuries before, during and after the "Oktoberfest". A total of 4017 hand injuries were allocated to hospitals by EMS. There was an increase in severe hand injuries by 66% during the 2-weeks-Oktoberfest-period compared to years where the Oktoberfest did not take place. Pre-pandemic statistics show an increasing severe hand trauma frequency of 57.5% in September, compared to EMS-referrals during the remanding year. CONCLUSION: The risk of injuring relevant structures of the hand during Oktoberfest is extremely high as compared to other parts of the body due to beer stein and fall-associated injuries. These injuries can lead to lifelong impairments. Our data are the first that quantifies and pinpoints the risk of severe injury to the hand during Oktoberfest and therefore, it is of great interest for visitors, hand surgeons, paramedics and emergency department healthcare workers.

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

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

Excessive hospitalization of patients with seizures in the Germany prehospital emergency system: a retrospective cohort study.

Seizures are a common reason for calling emergency medical services. A lack of guidelines on prehospital treatment in Germany leads to high transportation rates and reduced confidence in decision making by professionals. Our aim was to investigate the reasons for hospitalization and evaluate their necessity. A retrospective analysis of all emergency medical services records in Munich, Germany was performed in order to examine the reasons for hospitalization of patients with seizures and to evaluate their trajectory following admission to a university hospital. 8882 records were analyzed with 415 records reporting seizures (4.9%). Primary endpoint was transportation to hospital. In 380 cases (92%) patients were transported, of which 177 patients (47%) had known epilepsy; 35 patients (8%) were left at scene. Older patients and patients with higher amounts of administered medication at the scene were hospitalized significantly more often (p = 0.032 and p = 0.004, respectively). Median hospital length of stay was 1 night [IQR 1-2]. In patients with out-of-hospital seizures, high hospital transportation rates were evident, most of which could be considered as not indicated. One possible reason is the lack of guidelines in Germany, which leads to uncertainty among medical staff. This results in distress for the patients, their caregivers and consequently high costs.

Preparation of hospitals for mass casualty incidents in Bavaria, Germany: care capacities for penetrating injuries and explosions in TerrorMASCALs.

BACKGROUND: In a terror attack mass casualty incident (TerrorMASCAL), compared to a "normal" MASCAL, there is a dynamic course that can extend over several hours. The injury patterns are penetrating and perforating injuries. This article addresses the provision of material and personnel for the care of special injuries of severely injured persons that may occur in the context of a TerrorMASCAL. METHODS: To answer the research question about the preparation of hospitals for the care of severely injured persons in a TerrorMASCAL, a survey of trauma surgery departments in Bavaria (Germany) was conducted using a questionnaire, which was prepared in three defined steps based on an expert consensus. The survey is divided into a general, neurosurgical, thoracic, vascular and trauma surgery section. In the specialized sections, the questions relate to the implementation of and material and personnel requirements for special interventions that are required, particularly for injury patterns following gunshot and explosion injuries, such as trepanation, thoracotomy and balloon occlusion of the aorta. RESULTS: In the general section, it was noted that only a few clinics have an automated system to notify off-duty staff. When evaluating the data from the neurosurgical section, the following could be established with regard to the performance of trepanation: the regional trauma centers do not perform trepanation but nevertheless have the required material and personnel available. A similar result was recorded for local trauma centers. In the thoracic surgery section, it could be determined that almost all trauma centers that do not perform thoracotomy have the required material available. This group of trauma centers also stated that they have staff who can perform thoracotomy independently. The retrograde endovascular aortic occlusion procedure is possible in 88% of supraregional, 64% of regional and 10% of local trauma centers. Pelvic clamps and external fixators are available at all trauma centers. CONCLUSION: The results of the survey show potential for optimization both in the area of framework conditions and in the care of patients. Consistent and specific training measures, for example, could improve the nationwide performance of these special interventions. Likewise, it must be discussed whether the abovementioned special procedures should be reserved for higher-level trauma centers.

Comparison of volume-controlled, pressure-controlled, and chest compression-induced ventilation during cardiopulmonary resuscitation with an automated mechanical chest compression device: A randomized clinical pilot study.

AIM OF THE STUDY: Automated mechanical chest compression devices (AMCCDs) can help performing high-quality cardiopulmonary resuscitation (CPR). Guidelines for CPR are lacking information about the optimal ventilation mode during CPR using AMCCDs. Aim of this pilot study was to compare three common ventilation modes during CPR using AMCCD. METHODS: In this randomized controlled trial, we included patients with an out-of-hospital cardiac arrest arriving at the resuscitation room receiving chest compressions via AMCCD with an expected continuation of at least 15 min. Patients were randomly assigned to three groups: biphasic positive airway pressure with assisted spontaneous ventilation (BIPAP) with assisted spontaneous breathing, continuous positive airway pressure (CPAP) and volume-controlled ventilation (VCV). Outcomes were tidal volume, respiratory minute volume, and end-tidal CO2 during the study period. Groups were compared using generalized linear models. Data is given as median and interquartile ranges. RESULTS: Of 53 screened patients, 30 were randomized. The tidal volume was significantly (p < 0.05) lower in patients of the CPAP group (68 [64-83] ml) compared with those of the BIPAP (349 [137-500] ml), while the respiratory minute volume differed between the CPAP group (6.2 [5.3-8.1] l/min) and both the BIPAP (7.1 [6.7-10.2] l/min) and VCV group (7.2 [3.7-8.4] l/min). CONCLUSIONS: All ventilation modes achieved an adequate respiratory minute volume during CPR with an AMCCD. However, BIPAP seems to be superior due to the higher tidal volume. Therefore, we recommend starting mechanical ventilation when using AMCCD with BIPAP ventilation to avoid risks related to dead space ventilation.

Testing mechanical chest compression devices of different design for their suitability for prehospital patient transport - a simulator-based study.

BACKGROUND: Mechanical chest compression (mCPR) offers advantages during transport under cardiopulmonary resuscitation. Little is known how devices of different design perform en-route. Aim of the study was to measure performance of mCPR devices of different construction-design during ground-based pre-hospital transport. METHODS: We tested animax mono (AM), autopulse (AP), corpuls cpr (CC) and LUCAS2 (L2). The route had 6 stages (transport on soft stretcher or gurney involving a stairwell, trips with turntable ladder, rescue basket and ambulance including loading/unloading). Stationary mCPR with the respective device served as control. A four-person team carried an intubated and bag-ventilated mannequin under mCPR to assess device-stability (displacement, pressure point correctness), compliance with 2015 ERC guideline criteria for high-quality chest compressions (frequency, proportion of recommended pressure depth and compression-ventilation ratio) and user satisfaction (by standardized questionnaire). RESULTS: All devices performed comparable to stationary use. Displacement rates ranged from 83% (AM) to 11% (L2). Two incorrect pressure points occurred over 15,962 compressions (0.013%). Guideline-compliant pressure depth was > 90% in all devices. Electrically powered devices showed constant frequencies while muscle-powered AM showed more variability (median 100/min, interquartile range 9). Although physical effort of AM use was comparable (median 4.0 vs. 4.5 on visual scale up to 10), participants preferred electrical devices. CONCLUSION: All devices showed good to very good performance although device-stability, guideline compliance and user satisfaction varied by design. Our results underline the importance to check stability and connection to patient under transport.

Emergency room as primary point of access in the German healthcare system : Objective evaluation and interview of motivation for ER entrance of 235 ER patients in a German hospital.

BACKGROUND: The importance of emergency rooms (ERs) as everyday healthcare suppliers is growing. Due to increasing patient flows, hospitals are forced to raise physicians' and caregivers' headcount continuously to meet the new demand of patients seeing the ER as primary point of contact in non-emergency situations. Patients from various cultural and educational backgrounds approach the ER for different reasons. Detailed understanding of these reasons and their roots is key to be able to offer guidance for patients as well as planning and staffing of hospitals in the future. AIM: This study examines motivation for the entrance to the medical system via the ER in Germany via an anonymized patient survey. Evaluation in regard to socioeconomic and medical reasons is taken into account. MATERIALS AND METHODS: Over the course of 210 h in the ER, a total of 235 patients were interviewed in the surgical emergency room of Klinikum rechts der Isar in the year 2016. Focus was set on standard cases to allow for facilitated comparability. Heavily injured patients were excluded from the study. RESULTS: The main reasons for patients entering the ER were immediate help (45.9%) and treatment by a specialist (35.4%). Furthermore, the location/good accessibility (47.9%) and prior positive experience with the emergency room (20.7%) were decisive reasons for choosing the hospital over the outpatient sector. Analysis of demands of patients in relation to their migration background and their religious confession showed no significant difference between groups. CONCLUSION: Younger patients tend to more often access the ER instead of an outpatient clinic or doctor in private practice. As a survey suits the less urgent patients, our research describes this population in detail. The need for better information of patients regarding treatment options becomes apparent. The study's outcomes aim to teach physicians as well as operators how to influence resource management in the healthcare system by meaningful information of patients. Further research may evaluate long-term results of information measures.

Effects of weather, air pollution and Oktoberfest on ambulance-transported emergency department admissions in Munich, Germany.

BACKGROUND: Climate change and increasing risks of extreme weather events affect human health and lead to changes in the emergency department (ED) admissions and the emergency medical services (EMS) operations. For a better allocation of resources in the healthcare system, it is essential to predict ED numbers based on environmental variables. This publication aims to quantify weather, air pollution and calendar-related effects on daily ED admissions. METHODS: Analyses were based on 575,725 admissions from the web-based IVENA system recording all patients in the greater Munich area with pre-hospital emergency care in ambulance operations during 2014-2018. Linear models were used to identify statistically significant associations between daily ED admissions and calendar, meteorological and pollution factors, allowing for lag effects of one to three days. Separate analyses were performed for seasons, with additional subset analyses by sex, age and surgical versus internal department. RESULTS: ED admissions were exceptionally high during the three-week Oktoberfest, particularly for males and on the weekends, as well as during the New Year holiday. Admissions significantly increased during the years of study, decreased in spring and summer holidays, and were lower on Sundays while higher on Mondays. In the warmer seasons, admissions were significantly associated with higher temperature, adjusting for the effects of sunshine and humidity in all age groups except for the elderly. Adverse weather conditions in non-summer seasons were either linked to increasing ED admissions (from storms, gust) or decreasing them from rain. Mostly, but not exclusively, in winter, increasing ED admissions were associated with colder minimum temperatures as well as with higher NO and PM10 concentrations. CONCLUSIONS: In addition to standard calendar-related factors, incorporating seasonal weather, air pollutant and interactions with patient demographics into resource planning models can improve the daily allocation of resources and staff of EMS operations at hospital and city levels.

Code Stroke Patient Referral by Emergency Medical Services During the Public COVID-19 Pandemic Lockdown.

BACKGROUND: The COVID-19 pandemic caused public lockdowns around the world. We analyzed if the public lockdown altered the referral pattern of Code Stroke patients by Emergency Medical Services (EMS) to our Comprehensive Stroke Center. METHODS: Retrospective single-center study at a Bavarian Comprehensive Stroke Center. Patients who were directly referred to our stroke unit by EMS between the 1st of January 2020 and the 19th of April 2020 were identified and number of referrals, clinical characteristics and treatment strategies were analyzed during the public lockdown and before. The public lockdown started on 21st of March and ended on 19th April 2020. RESULTS: In total 241 patients were referred to our center during the study period, i.e. 171 before and 70 during the lockdown. The absolute daily number of Code Stroke referrals and the portion of patients with stroke mimics remained stable. The portion of female stroke patients decreased (55% to 33%; p = 0.03), and stroke severity as measured by the National Institutes of Health Stroke Scale (median 3 (IQR 0-7) versus 6 (IQR 1-15.5) points; p = 0.04) increased during the lockdown. There was no difference of daily numbers of patients receiving thrombolysis and thrombectomy. CONCLUSIONS: Referral of Code Stroke patients by EMS could be maintained sufficiently despite the COVID-19 pandemic lockdown. However, patients' health care utilization of the EMS may have changed within the public lockdown. EMS remains a useful tool for Code Stroke patient referral during lockdowns, but public education about stroke is required prior to further lockdowns.

Forced Centralized Allocation of Patients to Temporarily 'Closed' Emergency Departments.

BACKGROUND: Because insufficient data are available, the overall number of patients treated in German emergency departments can only be estimated. It is evident, however, that case numbers have been rising steadily in recent years, and that a lack of capacity is now leading with increasing freuqency to forced centralized allocation of patients by the emergency medical services (EMS) to emergency departments that are, officially, temporarily "closed". METHODS: Trends in patient allocation of this type in greater Munich, Germany, over the years 2013-2019 were analyzed for the first time on the basis of data from 904 997 cases treated by the emergency rescue services. RESULTS: From 2014 to 2019, the number of forced centralized patient allocations rose approximately by a factor of nine, from 70 to 634 per 100 000 persons per year. In the same period, the overall number of cases treated by the emergency rescue services rose by 14.5%. Peak values for forced centralized allocations were reached in the first quarter of each calendar year (2015: 1579, 2017: 2435, 2018: 3161, 2019: 3990). Of all medical specialties, internal medicine was the most heavily affected (more than 59% of the total). Especially in the years 2017-2019, the free availability of internal medicine declined in hospitals participating in the common greater Munich reporting system. CONCLUSION: The reasons for the sharp rise in forced centralized allocations are unclear. This observed trend seems likely to persist over the coming years, in view of the current staff shortage, the aging population, and diminishing hospital capacities. The relevant decision-makers must collaborate to create emergency plans that will prevent care bottlenecks so that patients will not be endangered.

The influence of foehn winds on the incidence of severe injuries in southern Bavaria - an analysis of the TraumaRegister DGU®.

BACKGROUND: Foehn describes a wind which occurs in areas with close proximity to mountains. The presence of foehn wind is associated with worsening health conditions. This study analyzes the correlation between a foehn typical circulation and the incidence for suffering a severe trauma. METHODS: This is a retrospective, multicentre observational register study. The years from 2013 to 2016 were analyzed for the presence of foehn winds. A logistic regression analysis with the number of daily admitted trauma patients as the primary target value was performed in dependence of foehn winds. Southern Bavaria is a typical foehn wind region. Individuals were treated in 37 hospitals of Southern Bavaria which participate in the TraumaRegister DGU®, an international register that includes all severe trauma patients, mainly in Germany. We analyzed patients with an Injury Severity Score (ISS) of at least nine with admission to intensive care units or prior death in the emergency room. RESULTS: 6215 patients were enrolled in this study. A foehn-typical circulation was present on 65 days (4.5%). 301 patients (5%) suffered a trauma with an ISS ≥ 9 on a foehn day. The mean ISS was 20.2 (9-75). On average, 4.3 patients (0-15 patients) were admitted on a daily basis due to a severe trauma. The multivariate regression analysis revealed a daily increase of 0.87 individuals (p = 0.004; 95% CI 0.23-1.47) on foehn days. During spring 1.07 patients (p = < 0.001; 95% CI 0.72-1.42), in summer 1.98 patients (p = < 0.001; 95% CI 1.63-2.32), in fall 0.63 (p = < 0.001; 95% CI 0.28-0.97) and on Saturdays, 0.59 patients (p = < 0.001; 95% CI 0.24-0.93) were additionally admitted due to severe trauma. CONCLUSION: Foehn winds are significantly associated with severe trauma in trauma centers of the TraumaNetzwerk DGU®.

[Delayed occurrence of compartment syndrome of the upper arm after shovelling snow by a patient under oral anticoagulation]. / Verzögert auftretendes Oberarmkompartmentsyndrom nach Schneeschaufeln unter oraler Antikoagulation.

This article reports the case of an 81-year-old male patient under treatment with oral anticoagulation who suffered delayed compartment syndrome of the upper arm from arterial capillary hemorrhage after shovelling snow. The diagnosis was made 48 h after the initial symptoms in the emergency surgical department of the Klinikum rechts der Isar (München) with the presence of clear neurological deficits. Following computed tomography angiography (CTA) imaging an emergency dermatofasciotomy was carried out as well as a vascular ligature via a medial approach. Compartment syndromes are the result of pathologically elevated tissue pressure and as a rule with a rapid clinical course. A delayed diagnosis can therefore lead to irreversible tissue and nerve damage up to the loss of the extremity. Compartment syndromes are particularly frequent in the lower extremities whereas those of the upper extremities are rare. This case report is intended to raise awareness for an insidiously occurring compartment syndrome of the upper arm due to repetitive microtrauma (in this case shovelling snow) and arterial peripheral vascular hemorrhage with simultaneous anticoagulation. The necessary diagnostic and treatment steps are also elucidated.

Continuous chest compressions with a simultaneous triggered ventilator in the Munich Emergency Medical Services: a case series.

Background: Mechanical chest compression devices are commonly used providing a constant force and frequency of chest compression during cardiopulmonary resuscitation. However, there are currently no recommendations on ventilation during cardiopulmonary resuscitation with a mechanical chest compression device using continuous mode. An effective method for ventilation in such scenarios might be a triggered oxygen-powered resuscitator. Methods: We report seven cardiopulmonary resuscitation cases from the Munich Emergency Medical Service where mechanical chest compression devices in continuous mode were used with an oxygen-powered resuscitator. In each case, the resuscitator (Oxylator®) was running in automatic mode delivering a breath during the decompression phase of the chest compressions at a frequency of 100 per minute. End-tidal carbon dioxide and pulse oximetry were measured. Additional data was collected from the resuscitation protocol of each patient. Results: End-tidal carbon dioxide was available in all cases while oxygen saturation only in four. Five patients had a return of spontaneous circulation. Based on the end-tidal carbon dioxide values of each of the cases, the resuscitator did not seem to cause hyperventilation and suggests that good-quality cardiopulmonary resuscitation was delivered. Conclusions: Continuous chest compressions using a mechanical chest compression device and simultaneous synchronized ventilation using an oxygen-powered resuscitator in an automatic triggering mode might be feasible during cardiopulmonary resuscitation.