RESUMO
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.
Assuntos
Documentação/estatística & dados numéricos , Serviços Médicos de Emergência/estatística & dados numéricos , Hospitais Universitários/estatística & dados numéricos , Assistência Perioperatória/estatística & dados numéricos , Período Perioperatório/estatística & dados numéricos , Centro Cirúrgico Hospitalar/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Reanimação Cardiopulmonar/estatística & dados numéricos , Criança , Pré-Escolar , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Alemanha , Parada Cardíaca/epidemiologia , Parada Cardíaca/terapia , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Adulto JovemRESUMO
BACKGROUND: In the German emergency medical system (EMS) obstetrical emergencies are rarely encountered, but are highly emotional situations for all concerned and form a special challenge for the emergency physician. The aim of this study was to evaluate the incidence, the course and the performance of rescue missions in a ground-based EMS system. METHODS: In a retrospective study the prehospital emergency charts concerning obstetrical emergencies over a 5-year period (10/2002-09/2007) were analysed. RESULTS: A total of 40 physician-staffed rescue missions with obstetrical emergencies were identified. On average seven rescue missions were performed per year. The majority of cases with 73% of the rescue missions was performed during the night service (16:00-07:00 h). On average the emergency patients (26th-41st week of gestation) were classified by the National Advisory Committee for Aeronautics (NACA) score as NACA III. Of the 40 obstetrical emergencies delivery occurred out of hospital in 18 cases (33rd-41st week of gestation), while the emergency physician was present in only 3 cases during childbirth. In 15 cases prehospital childbirth took place in the domestic environment of the patient, in 2 cases in an ambulance and in 1 case in the medical office of a gynecologist. In 20 cases the pregnant women were transported to hospital while labor had already begun. The emergency physicians on scene applied intravenous access, guided through labor and delivery, and administered tocolysis and in cases of prehospital delivery the emergency physicians also applied oxytocin, cut the umbilical cord and performed primary care of the newborn. CONCLUSIONS: Obstetrical emergencies are rare but recurrent in the ground-based EMS. However, prehospital management of women in labor, supervision of spontaneous prehospital delivery and the initial management of a newborn form a challenge for the emergency physician responsible. Consequently, prehospital management of obstetrical emergencies needs intensive consideration during education and training of emergency medical personnel.
Assuntos
Serviços Médicos de Emergência/organização & administração , Obstetrícia/organização & administração , Adulto , Parto Obstétrico , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Alemanha , Ginecologia , Humanos , Recém-Nascido , Trabalho de Parto , Obstetrícia/estatística & dados numéricos , Ocitócicos/uso terapêutico , Ocitocina/uso terapêutico , Parto , Médicos , Período Pós-Parto , Gravidez , Trabalho de Resgate , Estudos Retrospectivos , Terminologia como Assunto , Recursos HumanosRESUMO
BACKGROUND: The illness and injury severity of patients in emergency situations is normally rated by the National Advisory Committee for Aeronautics (NACA) score. Different issues seem to limit the validity of the NACA score, therefore, the aim of the present investigation was to analyse the association between rescue experience of pre-hospital emergency physicians and the estimated jeopardy of patients' vital functions using the NACA score. MATERIAL AND METHODS: In this retrospective study, the emergency chart protocols of patients in a ground-based emergency system from 2004 to 2005 were evaluated concerning patients demographic, diagnosis, and related NACA score. Emergency physicians were divided into two groups according to their experience as pre-hospital emergency physicians (group 1: less than 3 years and group 2: 3 or more years). RESULTS: The patients in groups 1 and 2 were comparable concerning the mean age (58+/-24 years vs. 58+/-24 years) and the percentage of males (each 54%). The reasons for the emergency call in both groups were comparable with respect to disease, trauma, and the combination of both (both 77%, 18%, and 5%, resp.). A higher percentage of emergency physicians of group 1 estimated a lower illness and injury severity score in comparison to emergency physicians of group 2 with a longer working experience (NACA I-III: 56% vs. 48%; p<0.05). Accordingly, physicians in group 1 estimated a smaller percentage of patients to be in life-threatening situations (NACA IV-V: 33% vs. 40%; p<0.05). There were no significant differences in the NACA categories VI (2%) and VII (7%) between both groups. CONCLUSION: The results demonstrate that emergency physicians with less rescue experience rated the severity of illness or injury relatively lower in comparison to colleagues who had worked in the pre-hospital setting for many years.
Assuntos
Doença/classificação , Serviços Médicos de Emergência/normas , Medicina de Emergência/normas , Padrões de Referência , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/terapia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Médicos , Qualidade da Assistência à Saúde , Trabalho de Resgate , Estudos RetrospectivosRESUMO
BACKGROUND: Time plays a crucial role in treating multiple traumatized patients and delays in management worsen the prognosis. Furthermore, current studies show that trauma patients profit from primary delivery to a trauma center. Therefore, the goal of physician-staffed ground and air rescue services in Germany is to treat these patients as quickly as possible and deliver them to a suitable trauma center. The aim of the present study was to investigate prehospital treatment times for the air rescue team in terms of disposition and efficiency when a ground rescue team was already present at the scene. METHODS: In a nationwide, multicenter analysis emergency missions carried out for traumatological emergencies in 2006 by 28 air rescue centers (ARC) of the TeamDRF and 6 ARC of the federal police were evaluated using the medical database MEDAT of the German Air Rescue Service. A distinction was made between combined missions with (MEDAT 1 group) and without (MEDAT 2 group) physician-staffed ground emergency medical services already being present at the emergency site and in particular the rescue helicopter treatment times for both groups were investigated. Furthermore, combined missions (MAN 1 group) and solo missions (MAN 2 group) for traumatological emergencies in the period 01.05.2006 to 31.01.2007 were investigated in a complementary prospective regional study at the ARC Heidelberg/Mannheim "Christoph 53". In both groups the total treatment times for all physician-staffed emergency systems involved in treatment at the scene were investigated. RESULTS: Nationwide, 26,010 primary missions could be evaluated and of these, 11,464 missions were traumatological emergencies (44.1%) with 2,229 (19.4%) carried out by the MEDAT 1 group and 9,235 (80.6%) by the MEDAT 2 group. For both groups the helicopter treatment times depended on the severity of the injuries (NACA classification) and were between 17+/-12 min (NACA I) and 34+/-19 min (NACA VII) in MEDAT group 1 versus 21+/-10 and 36+/-19 min in MEDAT group 2 (p<0.05, p<0.001), respectively. In the MEDAT 1 group, the average treatment times were between 2.8 min (NACA VII) and 8.1 min (NACA VI) shorter compared with the MEDAT 2 group. Moreover, when taking the severity of the injury into consideration, a regular and significantly higher treatment effort (e.g. intubation, repositioning and chest tube insertion) and a greater proportion of patients who were transported to the clinic via rescue helicopter were observed for the MEDAT 1 group than for the MEDAT 2 group. In the regional study 670 primary missions were evaluated including 382 traumatological emergencies (57%). From these, 90 multiple trauma patients (NACA V) were not resuscitated or died at the scene, 58 from the MAN 1 group and 32 from the MAN 2 group, and were investigated more closely. The helicopter treatment times were comparable to those observed in the nationwide study and were found to be 26+/-12 min and 35+/-20 min (p<0.05), respectively. In the MAN 1 group the treatment times for the ground rescue services up to the time when the helicopter arrived was 22+/-11 min on average; the total treatment time was 48+/-15 min and 12+/-8 min longer than the time for the MAN 2 group, which was statistically significant. In the MAN 1 group the helicopter was alerted on average 17+/-15 min after the physician-staffed ground rescue services arrived at the emergency site. Treatment by the rescue helicopter teams was significantly more extensive in the MAN 1 group. CONCLUSIONS: The treatment times for the helicopter were several minutes shorter when a physician-staffed ground rescue team had already arrived at the emergency site. However, it must be assumed that the total prehospital time is significantly longer for such missions. These results directly affect the disposition at the emergency dispatch center and indicate that when air rescue is required to transport a patient to hospital, the helicopter should be alerted at an early stage. In such settings, it is likely that initiating the operation in this way would improve the prognosis of severely injured patients and save costs.
Assuntos
Resgate Aéreo , Ambulâncias , Serviços Médicos de Emergência , Traumatismo Múltiplo/terapia , Adolescente , Adulto , Idoso , Feminino , Alemanha , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
Traumatic injury of the aorta can be a fatal complication of blunt thoracic trauma and if it is survived and diagnosed, surgery will be necessary. A prerequisite is a prompt imaging diagnosis of the injury in order to plan an optimal therapeutic procedure for the patient, depending on the severity of the injury. Digital angiography has now been replaced by non-invasive methods, such as computer tomography (CT) or transesophageal echocardiography (TEE). Using TEE it is possible to carry out a staging of the injury and this classification together with the corresponding clinical symptoms determines the therapeutic treatment regime. In many cases a staged treatment is standard procedure. In addition to the establishment of an adequate blood pressure (for prophylaxis of the open rupture), monitoring during the course of treatment may be necessary. The main advantage of TEE is that the examination of these mostly multiple traumatised patients can be carried out at the bedside. This review describes the use of TEE as a diagnostic tool in the early phase and for continuous monitoring of an initially conservative treatment regime.
Assuntos
Aorta Torácica/diagnóstico por imagem , Aorta Torácica/lesões , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/cirurgia , Adulto , Angiografia , Ecocardiografia Transesofagiana , Humanos , Masculino , Stents , Tomografia Computadorizada por Raios X , Ferimentos não Penetrantes/diagnósticoRESUMO
BACKGROUND: The acute coronary syndrome (ACS) with 16% is one of the most common indication for emergency missions. Care of ACS patients in the Heidelberg emergency service region has been carried out since the beginning of 2005 following an interdisciplinary developed concept based on the current guidelines of the German Society for Cardiology (DGK), the American College of Cardiology (ACC), the American Heart Association (AHA), the European Society of Cardiology (ESC) and the European Resuscitation Council (ERC). MATERIALS AND METHODS: Evaluation of the emergency diagnostic and therapeutic measures for the diagnosis of ACS before and after the introduction of the ACS care concept, was carried out retrospectively for the years 2004 (group 1) and 2005 (group 2) by electronic data processing of the records stored in the emergency medical services documentaion system (NADOK). RESULTS: In the years 2004 before (group 1, n=633) and 2005 after (group 2, n=628) introduction of the ACS care concept, there was a comparable basic diagnostic consisting of a 3-lead electrocardiogram (ECG; 95 versus 97%), manual blood pressure measurement (93 versus 95%) and pulse oxymetry (94 versus 91%) as well as a comparable proportion of patients who received a peripheral vene access (99 versus 100%). There were no significant differences between the two groups. However, after the introduction of the ACS concept, the 12-lead ECG was used significantly more often (49 versus 71%, p=0.0001). Furthermore, a guideline-conform medicinal treatment of ACS patients was used inceasingly more often for anticoagulation with heparin/acetylsalicylic acid (75 versus 84%,p=0.0001) and the use of beta-receptor blockers (32 versus 39%, p=0.009) after introduction of the ACS concept. CONCLUSIONS: The introduction of a regional care concept leads to an optimisation of guideline-conform prehospital treatment for ACS patients.
Assuntos
Doença das Coronárias/terapia , Programas Médicos Regionais , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Pressão Sanguínea , Doença das Coronárias/diagnóstico , Eletrocardiografia , Serviços Médicos de Emergência/normas , Feminino , Alemanha , Guias como Assunto , Humanos , Masculino , Pessoa de Meia-Idade , Oximetria , Transporte de PacientesRESUMO
Adequate antimicrobial therapy is of crucial importance for the survival of critically ill patients with severe nosocomial infections. Tigecycline is an important therapeutic option for the treatment of infections caused by multi-resistant Gram-positive and Gram-negative bacteria including vancomycin-resistant enterococci (VRE). A large randomised study (patients with APACHE-II-score >30 excluded/mean APACHE-II-score 6) demonstrated that tigecycline is not inferior to imipenem/cilastatin for treatment of complicated intra-abdominal infections. However, no case has been reported with microbiological eradication and clinical cure in a patient with septic shock due to peritonitis caused by VRE and treatment with tigecycline monotherapy. Clinical details of a patient suffering from postoperative peritonitis are presented. The patient developed severe septic shock after pancreatic surgery (multiple organ failure, APACHE-II-score 34). As the site of anastomotic leakage was very small and could not be exactly identified, irrigation-suction drains were placed followed by closed postoperative continuous lavage. The pathogen responsible was identified as a vancomycin-resistant Enterococcus faecium, therefore monotherapy with tigecycline was started which resulted in microbiological response and clinical cure. Tigecycline is a new therapeutic option for the treatment of intra-abdominal infections and from an economic point of view financially rewarding when used as monotherapy.
Assuntos
Antibacterianos/uso terapêutico , Enterococcus faecium/efeitos dos fármacos , Infecções por Bactérias Gram-Positivas/tratamento farmacológico , Minociclina/análogos & derivados , Choque Séptico/microbiologia , Choque Séptico/terapia , Resistência a Vancomicina , APACHE , Infecções por Bactérias Gram-Positivas/complicações , Infecções por Bactérias Gram-Positivas/microbiologia , Humanos , Masculino , Pessoa de Meia-Idade , Minociclina/uso terapêutico , Pancreatite/complicações , Pancreatite/cirurgia , Peritonite/etiologia , TigeciclinaRESUMO
In light of the growing proportion of illness in the general population, the complexity of modern surgery requires precise perioperative hemodynamic monitoring. Echocardiography has emerged over the past 15 years as an especially valuable diagnostic instrument for intensive medicine. No other monitoring technique provides in such a short time, with so little invasiveness, so much additional anatomic information for determining the cause of acute hemodynamic instability. There is of course the possibility of proceeding transthoracally at first, with poor imaging quality but noninvasively, or transesophageally. However, perioperative hemodynamic monitoring allows even less experienced operators to detect the various differential diagnoses of acute hemodynamic instability with an easily managed number of standard images. Starting from the first standard settings, depending on pathology the imaging should continue selectively with transthoracal echocardiography in the short parasternal axis or transesophageal echocardiography in the transgastral short midpapillary axis.
Assuntos
Doenças Cardiovasculares/diagnóstico por imagem , Fenômenos Fisiológicos Cardiovasculares , Ecocardiografia , Complicações Intraoperatórias/diagnóstico por imagem , Monitorização Intraoperatória/instrumentação , Doença Aguda , Pressão Sanguínea/fisiologia , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/fisiopatologia , Frequência Cardíaca/fisiologia , Humanos , Assistência Perioperatória , Vasoconstrição/fisiologiaRESUMO
BACKGROUND: In Germany the physician staffed emergency systems have announced an increase in rescue missions over the years. The aim of this study is to analyse the development of the spectrum of patients in an emergency system over the last 20 years in order to highlight the significant changes. METHODS: In a retrospective study we analyzed the prehospital chart views from 2004, 1992 and 1984 with respect to patients' demography, type of rescue mission, degree of internal disease or injury (NACA), state of consciousness (GCS), as well as prehospital interventions performed by prehospital emergency physician. RESULTS: In 2004 (3,825), the absolute number of missions was 2 and 4 times higher than 1992 (2,114) and 1984 (957), resp. In all of these investigated time periods non-trauma missions (74%; 2,812 vs. 66%; 1,390 vs. 51%; 485) were leading, followed by trauma missions (18%; 690 vs. 22%; 464 vs. 39%; 375), aborted missions (3%; 126 vs. 7%; 154 vs. 6%; 56), and dead on arrival (5%; 197 vs. 5%; 106 vs. 4%; 41). Although, the percentage of patients with NACA IV-VI (39% vs. 50%) or patients with GCS < or =8 (18% vs. 34%) was lower in 2004, the absolute number of patients in each category was higher than in 1984 (NACA IV-VI: 1,434 vs. 448, p<0.01; GCS: 672 vs. 303, p<0.01). CONCLUSIONS: The results of this study demonstrate, that the percentage of trauma, severely ill/injured or unconscious patients is lower than in previous years. However, the higher absolute numbers of patients demonstrate that the emergency physician now encounters more critically ill/injured, unconscious and trauma patients. It does not seem necessary to question the qualifications for an emergency physician, which have previously been considered essential for the management of acute life-threatening situations.
Assuntos
Serviços Médicos de Emergência/tendências , Transtornos da Consciência/epidemiologia , Transtornos da Consciência/terapia , Serviços Médicos de Emergência/história , Serviços Médicos de Emergência/estatística & dados numéricos , Alemanha/epidemiologia , História do Século XX , História do Século XXI , Humanos , Trabalho de Resgate/estatística & dados numéricos , Trabalho de Resgate/tendências , Estudos Retrospectivos , Fatores Socioeconômicos , Ferimentos e Lesões/terapiaRESUMO
Acute renal failure in critically ill patients in the intensive care unit is associated with high morbidity and mortality which is independent of the underlying etiology. Despite improvements in intensive care medicine and renal replacement therapy, patients with acute renal failure have much higher morbidity and mortality rates than patients without acute renal failure in the intensive care unit. In this overview, we summarize the literature on the incidence and mortality of patients with acute renal failure in the intensive care unit. Furthermore, we discuss timing of the initiation of renal replacement therapy, patient outcome with different renal replacement therapies and the adequate dialysis dose to be delivered.
Assuntos
Injúria Renal Aguda/terapia , Cuidados Críticos , Terapia de Substituição Renal/métodos , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/mortalidade , Anticoagulantes/uso terapêutico , Estado Terminal , Hemodiafiltração , Humanos , Diálise Peritoneal , Diálise Peritoneal Ambulatorial Contínua , Diálise RenalRESUMO
We report on the preclinical management of a 4-year-old child who was found in a comatose condition with respiratory failure after accidental ingestion of methadone. Emergency airway management was carried out with endotracheal intubation instead of administering the antagonist naloxone. The child could be extubated 12 h later and was released from hospital after 3 days with no neurological symptoms. The authors attempt to formulate an algorithm for the preclinical management of opioid intoxication with reference to the literature and own experience. Endotracheal intubation seems to be superior to the use of the antagonist naloxone, especially in a critical situation. This is the only way to ensure a rapid oxygenation with adequate airway protection and with the simultaneous avoidance of the side-effects of naloxone. A restrictive and critical administration of the opioid antagonist naloxone is recommended when there is suspicion of opioid ingestion but no signs of intoxication.
Assuntos
Analgésicos Opioides/intoxicação , Coma/induzido quimicamente , Metadona/intoxicação , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Analgésicos Opioides/antagonistas & inibidores , Pré-Escolar , Serviços Médicos de Emergência , Feminino , Humanos , Intubação Intratraqueal , Metadona/antagonistas & inibidores , Naloxona/efeitos adversos , Antagonistas de Entorpecentes/efeitos adversos , Oxigenoterapia , Insuficiência Respiratória/induzido quimicamenteRESUMO
In the past various attempts have been made to develop a standardized animal model of multiple organ failure (MOF). Until now there has been no large animal model, that imitates the clinical situation of multiple trauma patients up to MOF. In a manner similar to the pathophysiological sequence in multiple trauma patients, the combination of damaging mechanisms in the early phase (hemorrhagic shock, operating trauma, application of endotoxin (ET; 0.75 microgram/kg body weight) and zymosan-activated plasma (ZAP; 20 ml) every 12 h on days 1-5) leads to sequential irreversible damage to several organs in the late phase (> day 6) in sheep (n = 10). In this animal model representative organ parameters showed a similar course to that in MOF after multiple trauma in humans. The cardiac index increased significantly in the late phase (day 1: 6.47 +/- 0.41 ml/min x m2; day 10: 10.36 +/- 0.79 ml/min x m2), arterial oxygen pressure declined significantly (day 1: 103.1 +/- 1.6 mmHg; day 10: 89.8 +/- 4.2 mmHg). Liver function was impaired, bilirubin levels showed a significant increase (day 1: 2.94 +/- 0.34 mumol/l; day 10: 7.19 +/- 0.91 mumol/l). Creatinine clearance was low on day 1 (54.3 +/- 7.4 ml/min), increased up to day 5 and deteriorated again significantly in the late phase over the entire period (day 2: 104.3 +/- 26.8 ml/min; day 10: 53.1 +/- 17.6 ml/min).