GFAP point-of-care measurement for prehospital diagnosis of intracranial hemorrhage in acute coma.

BACKGROUND: Prehospital triage and treatment of patients with acute coma is challenging for rescue services, as the underlying pathological conditions are highly heterogenous. Recently, glial fibrillary acidic protein (GFAP) has been identified as a biomarker of intracranial hemorrhage. The aim of this prospective study was to test whether prehospital GFAP measurements on a point-of-care device have the potential to rapidly differentiate intracranial hemorrhage from other causes of acute coma. METHODS: This study was conducted at the RKH Klinikum Ludwigsburg, a tertiary care hospital in the northern vicinity of Stuttgart, Germany. Patients who were admitted to the emergency department with the prehospital diagnosis of acute coma (Glasgow Coma Scale scores between 3 and 8) were enrolled prospectively. Blood samples were collected in the prehospital phase. Plasma GFAP measurements were performed on the i-STAT Alinity® (Abbott) device (duration of analysis 15 min) shortly after hospital admission. RESULTS: 143 patients were enrolled (mean age 65 ± 20 years, 42.7% female). GFAP plasma concentrations were strongly elevated in patients with intracranial hemorrhage (n = 51) compared to all other coma etiologies (3352 pg/mL [IQR 613-10001] vs. 43 pg/mL [IQR 29-91.25], p < 0.001). When using an optimal cut-off value of 101 pg/mL, sensitivity for identifying intracranial hemorrhage was 94.1% (specificity 78.9%, positive predictive value 71.6%, negative predictive value 95.9%). In-hospital mortality risk was associated with prehospital GFAP values. CONCLUSION: Increased GFAP plasma concentrations in patients with acute coma identify intracranial hemorrhage with high diagnostic accuracy. Prehospital GFAP measurements on a point-of-care platform allow rapid stratification according to the underlying cause of coma by rescue services. This could have major impact on triage and management of these critically ill patients.

Blood Product Supply for a Helicopter Emergency Medical Service.

BACKGROUND: Long patient transport times to trauma centers are a well-known problem in sparsely populated regions with a low hospital density. Transfusion of red blood cell concentrates (RBC) and plasma improves outcome of trauma patients with severe bleeding. Helicopter emergency services (HEMS) are frequently employed to provide early advanced medical care and to reduce time to hospital admission. Supplying HEMS with blood products allows prehospital transfusion and may help to prevent exsanguination or prolonged hemorrhagic shock. We have investigated the maintenance of blood product quality under air transport conditions and the logistical steps to introduce a HEMS blood depot into routine practice. METHODS: A risk analysis was performed and a validation plan developed. A special, commercially available transport container for blood products was identified. Maintenance of temperature conditions between 2 and 6°C in the box were monitored at ambient temperatures up to 35°C over 48 h. Quality of blood products before and after helicopter air transport were evaluated including (1) for RBCs: hemoglobin, hematocrit, hemolysis rate; (2) for thawed plasma: aPTT, INR, single clotting factor activities. The logistics for blood supply of the regional HEMS were developed by the transfusion service of the Greifswald University Hospital in collaboration with the in-hospital transport team, the HEMS team, and the HEMS operator. RESULTS: The transport container maintained a temperature below 6°C up to 36 h at 35°C ambient temperature. Vibration during helicopter operation did not impair quality of RBC and thawed plasma. To provide blood products for HEMS at least two transport containers and an additional set of cooling tiles is needed as the cooling tiles need a special temperature priming over 20 h. The two boxes were used at alternate days. To reduce wastage, RBCs and thawed plasmas were exchanged every fourth day and reintegrated into the blood bank inventory for further in-hospital use. CONCLUSIONS: Supplying HEMS with RBCs and plasma is feasible. Helicopter transport has no negative impact on blood product quality. The logistic challenges require close collaboration between the HEMS team and the blood transfusion service.

[Transfer of critically ill patients between hospitals - fundamentals and requirements]. / Intensivtransport - Grundlagen und Voraussetzungen.

Due to the increasingly changed clinical landscape, which leads to a reduction of clinical facilities in rural regions. This also leads to a centralized clinical care, in addition to limited care options in the periphery. Therefore the interhospital transfer is becoming increasingly important. Specialized centers have become more and more important through this centralization of clinical care. Not only the number of transports, but also the transport distances have steadily increased in recent years. It is necessary to differentiate centripetal transports into the centers of the maximum and centrifugal transports back to peripheral clinics, weaning devices or rehabilitation facilities. Especially in the case of the latter, the number of patients still to be transported under intensive medical conditions has clearly increased.

[Effect of a 1-day "REBOA course" on the theoretical and practical skills for the prehospital REBOA setting : Experiences from the RIBCAP-HEMS project]. / Effekt eines eintägigen "REBOA-Kurses" auf die theoretischen und praktischen Fähigkeiten zur prähospitalen REBOA-Anlage : Erfahrungen aus dem RIBCAP-HEMS-Projekt.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) represents an endovascular procedure for aortic occlusion. The procedure can be used for temporary hemorrhage control as a bridge until surgical treatment for noncompressible abdominal or pelvic bleeding and to improve coronary and cerebral perfusion pressure during cardiopulmonary resuscitation. The prehospital administration is challenging and currently hardly possible in Germany. In the REBOA in bleeding and cardiac arrest in the prehospital care by helicopter emergency medical service (RIBCAP-HEMS) project, the prehospital use of REBOA will be tested in a feasibility study. This article describes the training course on the procedure in preparation for prehospital use, which was conducted before the start of the aforementioned feasibility study for the emergency physicians and paramedics (HEMS-TC) of the DRF Air Rescue Base in Halle (Saale). The course provided the necessary theoretical and practical skills to apply REBOA in the prehospital setting to patients in extremis in a safe, indications-conform and time-critical manner. The fact that all emergency physicians of the two air ambulances Christoph 84 and Christoph 85 in Halle are specialists in anesthesiology with corresponding experience in the placement of invasive arterial catheters proved to be advantageous. The training course was able to significantly improve the theoretical and practical abilities of the participants. The results of the currently ongoing study must show whether the procedure can be usefully integrated into the prehospital care of patients in extremis.

Synthetic polyion-counterion transport systems in polymersomes and gels.

Transport across the membranes of polymersomes remains difficult in part due to the great thickness of the polymer bilayers. Here, we report that dynamic polyion-counterion transport systems are active in fluorogenic polymersomes composed of poly(dimethylsiloxane)-b-poly(2-methyloxazoline) (PDMS-PMOXA). These results suggest that counterion-activated calf-thymus DNA can act as cation carrier that moves not only across lipid bilayer and bulk chloroform membranes but also across the "plastic" membranes of polymersomes. Compared to egg yolk phosophatidylcholine (EYPC) lipsosomes, activities and activator scope in PDMS-PMOXA polymersomes are clearly reduced. Embedded in agar gel matrices, fluorogenic PDMS-PMOXA polymersomes respond reliably to polyion-counterion transporters, with high contrast, high stability and preserved selectivity. Compared to standard EYPC liposomes, it cannot be said that PDMS-PMOXA polymersomes are better. However, they are different, and this difference could be interesting for the development of sensing devices.

Survival of bacteria on metallic copper surfaces in a hospital trial.

Basic chemistry of copper is responsible for its Janus-faced feature: on one hand, copper is an essential trace element required to interact efficiently with molecular oxygen. On the other hand, interaction with reactive oxygen species in undesired Fenton-like reactions leads to the production of hydroxyl radicals, which rapidly damage cellular macromolecules. Moreover, copper cations strongly bind to thiol compounds disturbing redox-homeostasis and may also remove cations of other transition metals from their native binding sites in enzymes. Nature has learned during evolution to deal with the dangerous yet important copper cations. Bacterial cells use different efflux systems to detoxify the metal from the cytoplasm or periplasm. Despite this ability, bacteria are rapidly killed on dry metallic copper surfaces. The mode of killing likely involves copper cations being released from the metallic copper and reactive oxygen species. With all this knowledge about the interaction of copper and its cations with cellular macromolecules in mind, experiments were moved to the next level, and the antimicrobial properties of copper-containing alloys in an "everyday" hospital setting were investigated. The alloys tested decreased the number of colony-forming units on metallic copper-containing surfaces by one third compared to control aluminum or plastic surfaces. Moreover, after disinfection, repopulation of the surfaces was delayed on copper alloys. This study bridges a gap between basic research concerning cellular copper homeostasis and application of this knowledge. It demonstrates that the use of copper-containing alloys may limit the spread of multiple drug-resistant bacteria in hospitals.

Accuracy of prehospital focused abdominal sonography for trauma after a 1-day hands-on training course.

OBJECTIVES: To establish a training course for Prehospital Focused Abdominal Sonography for Trauma (P-FAST) and to evaluate the accuracy of the participants after the course and at the trauma scene. METHODS: A training programme was developed to provide medical staff with the skills needed to perform P-FAST. In order to evaluate the accuracy of P-FAST performed by the students, nine participants (five emergency doctors and four paramedics) were followed during their course and in practice after the course. An assessment was made of 200 ultrasound procedures performed during the course in healthy volunteers and in patients with peritoneal dialysis or ascites. Regular P-FAST performed on-scene by the participants commenced immediately following the course. The results for the nine participants (C-group, course group) were compared with those members of medical staff with more than 3 years of experience in FAST (P-group, professional group). A group of physicians untrained in P-FAST served as a control (I-group, indifferent group). P-FAST findings were further verified by subsequent FAST and CT scans in the emergency department. RESULTS: After the training programme the C-group performed 39 P-FAST procedures without any false negative or false positive findings (100% accuracy). In the P-group, 112 procedures were performed with one false positive case. In the I-group there were 2 false negative cases among the 46 procedures performed. CONCLUSION: Following completion of a 1-day P-FAST course, participants were able to perform ultrasound procedures at the scene of an accident with a high level of accuracy.

Pre-hospital care & interfacility transport of 385 COVID-19 emergency patients: an air ambulance perspective.

BACKGROUND: COVID-19, the pandemic caused by the severe acute respiratory syndrome coronavirus-2, is challenging healthcare systems worldwide. Little is known about problems faced by emergency medical services-particularly helicopter services-caring for suspected or confirmed COVID-19 patients. We aimed to describe the issues faced by air ambulance services in Europe as they transport potential COVID-19 patients. METHODS: Nine different HEMS providers in seven different countries across Europe were invited to share their experiences and to report their data regarding the care, transport, and safety measures in suspected or confirmed COVID-19 missions. Six air ambulance providers in six countries agreed and reported their data regarding development of special procedures and safety instructions in preparation for the COVID-19 pandemic. Four providers agreed to provide mission related data. Three hundred eighty-five COVID-19-related missions were analysed, including 119 primary transport missions and 266 interfacility transport missions. RESULTS: All providers had developed special procedures and safety instructions in preparation for COVID-19. Ground transport was the preferred mode of transport in primary missions, whereas air transport was preferred for interfacility transport. In some countries the transport of COVID-19 patients by regular air ambulance services was avoided. Patients in interfacility transport missions had a significantly higher median (range) NACA Score 4 (2-5) compared with 3 (1-7), needed significantly more medical interventions, were significantly younger (59.6 ± 16 vs 65 ± 21 years), and were significantly more often male (73% vs 60.5%). CONCLUSIONS: All participating air ambulance providers were prepared for COVID-19. Safe care and transport of suspected or confirmed COVID-19 patients is achievable. Most patients on primary missions were transported by ground. These patients were less sick than interfacility transport patients, for whom air transport was the preferred method.

[Physician health: What makes us ill? What keeps us healthy?] / Arztgesundheit: Was macht uns krank ­ Was hält uns gesund?

The medical profession is a particular health risk. Internal reasons for this are the common practice of self-diagnosis and self-therapy, presenteeism (work despite illness), and increased risks of addiction and suicide. External reasons include infectious diseases, violence against health professionals, the increasingly difficult working conditions - due to economisation, among other things - and the posttraumatic stress syndrome. Therefore, it is increasingly important to proactively take care of one`s own health. Science has shown that the underlying mechanisms leading to this problem are the high self-demand and lack of self-care observed in medical professionals. These starting points and available programs (cognitive-emotional reflection, stress management, relaxation techniques, conflict resolution techniques, mindfulness, priming, framing, meditation, embodiment, etc.) to strengthen resilience offer instruments to optimise the salutogenesis of health professionals. This review article presents interdependencies and concepts aiming to strengthen the resilience of health professionals.

[Introduction Course HEMS-Physician - from idea to course concept]. / Einführungskurs "Arzte in der Luftrettung" - Von der Idee zum Kurskonzept.

Physicians who take a role as flight physicians in a Helicopter Emergency Medical System (HEMS) will encounter more frequently certain emergencies - such as multiple trauma, mass casualties etc. - compared to physicians in a ground based Emergency Medical System (EMS). Furthermore EMS teams already present on scene have a variance of expectations towards HEMS-Physicians. Therefore HEMS-Physicians not only must have the capabilities to treat patients properly, especially under difficult circumstances. Particularly with regard to leadership and Crew Resource Management (CRM) they will be demanded. Not least HEMS-Physicians need to have knowledge of safety and technical aspects of rescue helicopters and of operation tactics as well. Since there has been no uniform or standardised training for physicians, who will take a role in a HEMS, a course concept has been developed to improve and standardise the preparation for this challenging task.

Solvent structures of mixed water/acetonitrile mixtures at chromatographic interfaces from computer simulations.

Atomistic simulations are used to characterize the molecular dynamics (MD) of alkyl chains with different functionalizations in different water/acetonitrile mixtures (80/20 and 50/50). Starting from fully equilibrated solvent systems (flat density profile for both components), microheterogeneous structuring of the solvent in the chromatographic system is found for both mixtures. Depending on the functionalization of the alkyl chain (nitrile, amide, nitro, phenyl), differences in the density profiles of the two solvents (water/acetonitrile), the effective width of the stationary phase and the solvent gradients in the overlap region are observed. The solvent mixture (mobile phase) in RPLC is a liquid which is directly involved in the physical process and must be included explicitly. Far from the surface, the solvent displays bulk properties; closer to it the mixed solvent partitions due to the presence of the stationary phase. This creates a gradient in solvent strength perpendicular to the surface which influences the motions of the analyte. The surface is found to define the amount of water that can bind to it and defines its hydrophilic character. Proposals from the literature, such as the existence of persistent water filaments extending from the functionalized silica layer towards the bulk solvent, are discussed. Simulations of acridine orange near a -NH(2)- and -phenol-functionalized surface highlight the different dynamical behaviour (insertion vs. adsorption) of an analyte depending on the functionalization of the surface.

Automated evaluation of functional residual capacity by oxygen washout.

OBJECTIVE: Measurement of functional residual capacity (FRC) is of considerable interest for monitoring ventilated patients in ICUs. However, the lack of instruments that can be used in the clinical setting has so far impeded the routine application of this measurement. It was the aim of our study to evaluate the accuracy and the reproducibility of a simplified oxygen washout technique (FRC[O2]). MATERIALS AND METHODS: For the evaluation of FRC[O2J, gas flow, CO2 and O2 concentrations were determined by the flow probe of an ICU ventilator, a mainstream capnometer and O2 analyser. In 30 volunteers FRC[O2] as measured during spontaneous breathing was compared to: 1. Helium dilution technique (FRC[He], n = 21), 2. Body plethysmography (FRC[bp], n = 9). In n = 7 male patients FRC[O2] was repeatedly evaluated during mechanical ventilation and compared to the preoperative FRC[bp]. RESULTS: FRC[O2J corresponded well with FRC[He] (range: 1.9 to 6.0 l, bias of FRC[O2]: 0.53 l (95% CI 0.24 l to 0.82 l)) and FRC[bp] (range: 2.1 to 4.3 l, bias of FRC[O2] 0.03 l (95% CI -0.30 l to 0.37 l)). The mean of the repeated FRC[O2]-measurements (basic range: 1.3 to 3.6 l) during mechanical ventilation with unchanged ventilator settings stayed unchanged. The within subject-between error ranged from 0.1 to 0.4 l (mean = 0.23 1). Mean FRC[O2] during mechanical ventilation decreased to 66.6 percent of the preoperative mean FRC[bp]. CONCLUSIONS: The automated oxygen washout technique is a simple method to measure FRC in the ICU patient.