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BACKGROUND: The city of Freiburg has been among the most affected regions by the COVID-19 pandemic in Germany. In out of hospital cardiac arrest (OHCA) care, all parts of the rescue system were exposed to profound infrastructural changes. We aimed to provide a comprehensive overview of these changes in the resuscitation landscape in the Freiburg region. METHODS: Utstein-style quantitative data on OHCA with CPR initiated, occurring in the first pandemic wave between February 27th, 2020 and April 30th, 2020 were compared to the same time periods between 2016 and 2019. Additionally, qualitative changes in the entire rescue system were analyzed and described. RESULTS: Incidence of OHCA with attempted CPR did not significantly increase during the pandemic period (11.1/100.000 inhabitants/63 days vs 10.4/100.000 inhabitants/63 days, p = 1.000). In witnessed cases, bystander-CPR decreased significantly from 57.7% (30/52) to 25% (4/16) (p = 0.043). A severe pre-existing condition (PEC) was documented more often, 66.7% (16/24) vs 38.2% (39/102) there were longer emergency medical services (EMS) response times, more resuscitation attempts terminated on scene, 62.5% (15/24) vs. 34.3% (35/102) and less patients transported to hospital (p = 0.019). Public basic life support courses, an app-based first-responder alarm system, Kids Save Lives activities and a prehospital extracorporeal CPR (eCPR) service were paused during the peak of the pandemic. CONCLUSION: In our region, bystander CPR in witnessed OHCA cases as well as the number of patients transported to hospital significantly decreased during the first pandemic wave. Several important parts of the resuscitation landscape were paused. The COVID-19 pandemic impedes OHCA care, which leads to additional casualties. Countermeasures should be taken.
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COVID-19 , Reanimação Cardiopulmonar , Serviços Médicos de Emergência , Parada Cardíaca Extra-Hospitalar , COVID-19/epidemiologia , Alemanha/epidemiologia , Humanos , Estudos Observacionais como Assunto , Parada Cardíaca Extra-Hospitalar/epidemiologia , Parada Cardíaca Extra-Hospitalar/terapia , Pandemias , Sistema de RegistrosRESUMO
Emergency personnel assess their patients as an essential part of their daily work in emergency settings. The clinical assessment can help differentiate between immediately life-threatening conditions and milder diseases in patients. This assessment is the basis for an adequate preclinical treatment and for a rational referral to the hospital providing further care. Carried out in a thoughtful manner it allows reasonable allocation of resources for inpatient care.Well-founded training, clinical experience, scores, and tools in the form of acronyms for assessing the patient lead to successful assessments according to quality standards.The preclinical initial assessment is crucial for ensuring appropriate care for patients on site with life-threatening conditions as well as those with minor problems. Prioritization of a treatment depends on the severity of the condition or injury.
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Hospitalização , Triagem , Alemanha , Hospitais , Humanos , Encaminhamento e ConsultaRESUMO
BACKGROUND: Severe courses of coronavirus disease 2019 (COVID-19) are associated with elevated levels of interleukin 6 (IL-6). However, there is a growing body of evidence pointing to a broad and more complex disorder of proinflammatory and antiviral responses with disturbed interferon signaling in COVID-19. METHODS: In this prospective, single-center registry, we included severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive patients and patients with similar symptoms and severity of disease but negative for SARS-CoV-2 admitted to the emergency department and compared their serum protein expression profiles. RESULTS: IL-6 abundance was similar in SARS-CoV-2-positive patients (n = 24) compared with SARS-CoV-2-negative controls (n = 61). In contrast, we observed a specific upregulation of the immunomodulatory protein progranulin (GRN). High GRN abundance was associated with adverse outcomes and increased expression of IL-6 in COVID-19. CONCLUSIONS: The data from this registry reveal that GRN is specifically upregulated in SARS-CoV-2-positive patients while IL-6 may serve as marker for disease severity. The potential of GRN as a biomarker and a possible impact of increased GRN expression on interferon signaling, virus elimination, and virus-induced lung tissue damage in COVID-19 should be further explored.
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COVID-19/metabolismo , Progranulinas/metabolismo , SARS-CoV-2 , Regulação para Cima , Idoso , COVID-19/sangue , COVID-19/imunologia , Estudos de Casos e Controles , Feminino , Humanos , Interleucina-6/sangue , Interleucina-6/metabolismo , Masculino , Pessoa de Meia-Idade , Progranulinas/sangue , Estudos Prospectivos , Sistema de Registros , Índice de Gravidade de DoençaRESUMO
Subpleural consolidations have been found in lung ultrasound in patients with COVID-19, possibly deriving from pulmonary embolism (PE). The diagnostic utility of impact of lung ultrasound in critical-ill patients with COVID-19 for PE diagnostics however is unclear. We retrospectively evaluated all SARS-CoV2-associated ARDS patients admitted to our ICU between March 8th and May 31th 2020. They were enrolled in this study, when a lung ultrasound and a computed tomography pulmonary angiography (CTPA) were documented. In addition, wells score was calculated to estimate the probability of PE. The CTPA was used as the gold standard for the detection of PE. Twenty out of 25 patients met the inclusion criteria. In 12/20 patients (60%) (sub-) segmental PE were detected by CT-angiography. Lung ultrasound found subpleural consolidations in 90% of patients. PE-typical large supleural consolidations with a size ≥ 1 cm were detectable in 65% of patients and were significant more frequent in patients with PE compared to those without (p = 0.035). Large consolidations predicted PE with a sensitivity of 77% and a specificity of 71%. The Wells score was significantly higher in patients with PE compared to those without (2.7 ± 0.8 and 1.7 ± 0.5, respectively, p = 0.042) and predicted PE with an AUC of 0.81. When combining the two modalities, comparing patients with considered/probable PE using LUS plus a Wells score ≥ 2 to patients with possible/unlikely PE in LUS plus a Wells score < 2, PE could be predicted with a sensitivity of 100% and a specificity of 80%. Large consolidations detected in lung ultrasound were found frequently in COVID-19 ARDS patients with pulmonary embolism. In combination with a Wells score > 2, this might indicate a high-risk for PE in COVID-19.
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COVID-19/complicações , Regras de Decisão Clínica , Angiografia por Tomografia Computadorizada , Pulmão/diagnóstico por imagem , Artéria Pulmonar/diagnóstico por imagem , Embolia Pulmonar/diagnóstico por imagem , Ultrassonografia , Idoso , COVID-19/diagnóstico , Estado Terminal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Imagem Multimodal , Valor Preditivo dos Testes , Embolia Pulmonar/etiologia , Sistema de Registros , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de RiscoRESUMO
BACKGROUND: Hypercoagulability in Coronavirus Disease 2019 (COVID-19) causes deep vein thrombosis and pulmonary embolism necessitating systemic anticoagulation. Case reports of intracerebral hemorrhages in ventilated COVID-19 patients warrant precaution. It is unclear, however, if COVID-19 patients with acute respiratory distress syndrome (ARDS) with or without veno-venous extracorporeal membrane oxygenation therapy (VV-ECMO) have more intracerebral hemorrhages (ICH) compared to other ARDS patients. METHODS: We conducted a retrospective observational single-center study enrolling all patients with ARDS from 01/2018 to 05/2020. PCR-positive SARS-CoV-2 patients with ARDS were allocated to the COVID-19 group. Propensity score matching was performed for age, VV-ECMO, and bleeding risk. RESULTS: A total of 163 patients with moderate or severe ARDS were identified, 47 (28.8%) in the COVID-19 group, and 116 (71.2%) in the non-COVID-19 group. In 63/163 cases (38.7%), VV-ECMO therapy was required. The ICU survival was 52.8%. COVID-19 patients were older, more often male, and exhibited a lower SOFA score, but the groups showed similar rates of VV-ECMO therapy. Treatments with antiplatelet agents (p = 0.043) and therapeutic anticoagulation (p = 0.028) were significantly more frequent in the COVID-19 patients. ICH was detected in 22 patients (13.5%) with no statistical difference between the groups (11.2 vs. 19.1% without and with SARS-CoV-2, respectively, p = 0.21). Propensity score matching confirmed similar rates of ICH in both groups (12.8 vs. 19.1% without and with SARS-CoV-2, respectively, p = 0.57), thus leveling out possible confounders. CONCLUSIONS: Intracerebral hemorrhage was detected in every tenth patient with ARDS. Despite statistically higher rates of antiplatelet therapy and therapeutic anticoagulation in COVID-19 patients, we found a similar rate of ICH in patients with ARDS due to COVID-19 compared to other causes of ARDS.
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COVID-19/complicações , Hemorragia Cerebral/epidemiologia , Hemorragia Cerebral/virologia , Síndrome do Desconforto Respiratório/virologia , Adulto , Idoso , Idoso de 80 Anos ou mais , COVID-19/mortalidade , COVID-19/terapia , Hemorragia Cerebral/terapia , Cuidados Críticos , Oxigenação por Membrana Extracorpórea , Feminino , Alemanha , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Sistema de Registros , Respiração Artificial , Síndrome do Desconforto Respiratório/mortalidade , Síndrome do Desconforto Respiratório/terapia , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Adulto JovemRESUMO
COVID-19 is associated with a variety of clinical complications including coagulopathy, which frequently results in venous thromboembolism (VTE). Retrospective analyses reported a markedly increased rate of VTEs in COVID-19. However, most recent studies on coagulopathy in COVID-19 were only focused on critically ill patients, and without suitable control groups. We aimed to evaluate the rate of VTEs in an all-comers cohort with suspected COVID-19 during a 30-days follow-up period. We also studied the level of D-dimers and their association with the course of disease. In our prospective single-center study (DRKS00021206, 03/30/2020), we analyzed 190 patients with suspected COVID-19 admitted to the emergency department between March and April 2020. Forty-nine patients were SARS-CoV-2 positive (25.8%). The 141 SARS-CoV-2-negative patients served as control group. After completion of a 30-days follow-up, VTE was diagnosed in 3 patients of the SARS-CoV-2-positive group (6.1%, amongst these 2 ICU cases) versus 5 patients in the SARS-CoV-2-negative group (3.5%), however the difference was not statistically significant (p = 0.427). 30-days mortality was similar in both groups (6.1% vs. 5%, p = 0.720). Disease severity correlated with the maximum level of D-dimers during follow-up in COVID-19. The rate of VTE was numerically higher in SARS-CoV-2 positive all-comers presenting with suspected COVID-19 as compared to well-matched controls suffering from similar symptoms. VTEs in the COVID-19 group predominantly occurred in ICU courses. The maximum level of D-dimers during follow-up was associated with disease severity in COVID-19, whereas the level of D-dimers at admission was not.
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Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Embolia Pulmonar/epidemiologia , Tromboembolia Venosa/epidemiologia , Trombose Venosa/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Betacoronavirus/patogenicidade , Biomarcadores/sangue , COVID-19 , Estudos de Casos e Controles , Infecções por Coronavirus/sangue , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/virologia , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Alemanha/epidemiologia , Interações Hospedeiro-Patógeno , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/sangue , Pneumonia Viral/diagnóstico , Pneumonia Viral/virologia , Estudos Prospectivos , Embolia Pulmonar/sangue , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/virologia , Sistema de Registros , Medição de Risco , Fatores de Risco , SARS-CoV-2 , Índice de Gravidade de Doença , Fatores de Tempo , Tromboembolia Venosa/sangue , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/virologia , Trombose Venosa/sangue , Trombose Venosa/diagnóstico , Trombose Venosa/virologiaRESUMO
BACKGROUND: Typical lung ultrasound (LUS) findings in patients with a COVID-19 infection were reported early on. During the global SARS-CoV-2 pandemic, LUS was propagated as a useful instrument in triage and monitoring. We evaluated LUS as a rapid diagnostic triage tool for the management of patients with suspected COVID-19 in the emergency department (ED). METHODS: The study retrospectively enrolled patients with suspected COVID-19, who were admitted from 1st April to 25th of April 2020 to the ED of a tertiary care center in Germany. During clinical work-up, patients underwent LUS and polymerase chain reaction (PCR) testing for SARS-CoV-2. The recorded ultrasound findings were analyzed and judged regarding typical signs of viral pneumonia, blinded for clinical information of the patients. The results were compared with PCR test and chest computed tomography (CT). RESULTS: 2236 patients were treated in the ED during the study period. 203 were tested for SARS-CoV-2 using PCR, 135 (66.5%) underwent LUS and 39 (28.9%) of the patients were examined by chest CT scan. 39 (28.9%) of the 135 patients were tested positive for SARS-CoV-2 with PCR. In 52 (38.5%) COVID-19 was suspected from the finding of the LUS, resulting in a sensitivity of 76.9% and a specificity of 77.1% compared with PCR results. The negative predictive value reached 89.2%. The findings of the LUS had - compared to a positive chest CT scan for COVID-19 - a sensitivity of 70.6% and a specificity of 72.7%. CONCLUSIONS: LUS is a rapid and useful triage tool in the work-up of patients with suspected COVID-19 infection during a pandemic scenario. Still, the results of the LUS depend on the physician's experience and skills.
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Teste para COVID-19/métodos , COVID-19/diagnóstico , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Índice de Gravidade de Doença , Adulto , COVID-19/diagnóstico por imagem , Serviço Hospitalar de Emergência , Feminino , Humanos , Pulmão/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/diagnóstico por imagem , Estudos Retrospectivos , SARS-CoV-2/isolamento & purificação , Tomografia Computadorizada por Raios XRESUMO
Hemodynamic monitoring plays a crucial role in the supportive treatment of critically ill patients. In this setting, the use of the pulmonary artery catheter (PAC) is a standard procedure. In this study we prospectively compare the accuracy and precision of pulmonary thermodilution (PTD) by PAC and transcardiopulmonary thermodilution (TC-PTD) in patients with cardiogenic shock following an acute cardiac event. In this prospective study 77 hemodynamic measurements were taken in 11 patients presenting cardiogenic shock (CS) treated at the medical intensive care unit of our university hospital. Hemodynamic parameters were measured simultaneously by PTD and by TC-PTD. Both techniques assessed showed a strong correlation in the obtained hemodynamic parameters. The mean bias of cardiac index between measured by PTD (CIpa) and by TC-PTD (CIpi) was 0.04 ± 0.35 L/min/m2. During intra-aortic balloon pump (IABP) counterpulsation and therapeutic hypothermia (TH) in post-resuscitation care, mean bias between CIpa and CIpi was 0.04 ± 0.36 and 0.04 ± 0.34 L/min/m2, respectively. Similarly, patients presenting mitral or tricuspid regurgitation showed interchangeable parameters. Preload parameters obtained by TC-PTD showed significant differences in patients with left ventricular ejection fraction (LVEF) <35 %, compared to patients with LVEF ≥35 %. In contrast, pulmonary arterial occlusion pressure showed no significant difference. Hemodynamic measurements by PTD and TC-PTD are interchangeable during therapy of CS, including patients IABP, TH, mitral or tricuspid regurgitation. Preload parameters measured by TC-PTD seem to be more accurate in these patients than pressure parameters of PTD to gather the acute hemodynamic situation.
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Choque Cardiogênico/terapia , Termodiluição/métodos , Idoso , Idoso de 80 Anos ou mais , Débito Cardíaco , Cateterismo , Feminino , Hemodinâmica , Humanos , Hipotermia Induzida , Unidades de Terapia Intensiva , Balão Intra-Aórtico , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral , Monitorização Fisiológica/métodos , Estudos Prospectivos , Artéria Pulmonar/patologia , Reprodutibilidade dos Testes , Insuficiência da Valva Tricúspide , Função Ventricular EsquerdaRESUMO
INTRODUCTION: Microparticles are elevated in patients after successful cardiopulmonary resuscitation (CPR) and may play a role in the development of endothelial dysfunction seen in post-cardiac arrest syndrome (PCAS), a life threatening disease with high mortality. To identify mechanisms of endothelial activation and to develop novel approaches in the therapy of PCAS, the impact of selenium, a trace element with antioxidative properties, was characterized in endothelial dysfunction induced by microparticles of resuscitated patients. Additionally, course of plasma selenium levels was characterized in the first 72 hours post-CPR. METHODS: Endothelial cells were exposed to microparticles isolated of the peripheral blood of resuscitated patients, and leukocyte-endothelial interaction was measured by dynamic adhesion assay. Expression of adhesion molecules was assessed by immunoblotting and flow chamber. Blood samples were drawn 24, 48 and 72 hours after CPR for determination of plasma selenium levels in 77 resuscitated patients; these were compared to 50 healthy subjects and 50 patients with stable cardiac disease and correlated with severity of illness and outcome. RESULTS: Microparticles of resuscitated patients enhance monocyte-endothelial interaction by up-regulation of ICAM-1 and VCAM-1. Selenium administration diminished ICAM-1 and VCAM-1-mediated monocyte adhesion induced by microparticles of resuscitated patients, suggesting that selenium has anti-inflammatory effects after CPR. Lowered selenium plasma levels were observed in resuscitated patients compared to controls and selenium levels immediately and 24 hours after CPR, inversely correlated with clinical course and outcome after resuscitation. CONCLUSIONS: Endothelial dysfunction is a pivotal feature of PCAS and is partly driven by microparticles of resuscitated patients. Administration of selenium exerted anti-inflammatory effects and prevented microparticle-mediated endothelial dysfunction. Decline of selenium was observed in plasma of patients after CPR and is a novel predictive marker of ICU mortality, suggesting selenium consumption promotes inflammation in PCAS.
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Antioxidantes/uso terapêutico , Reanimação Cardiopulmonar , Micropartículas Derivadas de Células/metabolismo , Inflamação/prevenção & controle , Selênio/uso terapêutico , Estudos de Casos e Controles , Adesão Celular/efeitos dos fármacos , Células Cultivadas , Células Endoteliais/fisiologia , Humanos , Inflamação/metabolismo , Molécula 1 de Adesão Intercelular/metabolismo , Monócitos/fisiologia , Selênio/sangue , Regulação para Cima , Molécula 1 de Adesão de Célula Vascular/metabolismoRESUMO
Acute angioedema is mostly found in the head and neck region. Therefore, it can be life threatening by potentially endangering air way patency. Pathophysiologically angioedemas can be divided into mast cell-mediated or bradykinin-mediated forms. Differentiation is essential due to the different therapeutic strategies. In cases of doubt, initial therapy with adrenalin, antihistamines, and glucocorticoids should be initiated. This initial emergency treatment is comparable to the treatment of allergic reactions. For diagnosed or suspected hereditary angioedema, specific treatments are available. For drug-associated forms, immediate and life-long cessation of the medication is crucial. In the emergency situation, diagnosis can only be based on medical history and clinical symptoms. Recognition of impending airway obstruction and securing the airway is of highest priority; final diagnosis must be confirmed later.
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Angioedema , Humanos , Angioedema/terapia , Angioedema/tratamento farmacológico , Bradicinina/uso terapêutico , Serviço Hospitalar de Emergência , Epinefrina/uso terapêuticoRESUMO
Background: Conflicting results have been reported on platelet activity ex vivo and responsiveness in vitro among patients with COVID-19 with or without thromboembolic complications. Objectives: To assess platelet reactivity in patients with moderate disease at early stages of COVID-19. Methods: We performed a prospective, descriptive analysis of 100 consecutive patients presenting with suspected SARS-CoV-2 infection at University Medical Center Freiburg during the first or second wave of the pandemic. Following polymerase chain reaction testing and compliance with study inclusion criteria, 20 SARS-CoV-2-positive and 55 SARS-CoV-2-negative patients (serving as patient controls) were enrolled. In addition, 15 healthy subjects were included. Platelet reactivity was assessed using whole-blood impedance aggregometry and flow cytometry in response to various agonists. Results: Platelet aggregation was significantly impaired in the patients with COVID-19 compared with that in the patient controls or healthy subjects. The reduced platelet responsiveness in the patients with COVID-19 was associated with impaired activation of GPIIb/IIIa (αIIbß3). In contrast, low expression of P-selectin at baseline and intact secretion upon stimulation in vitro suggest that no preactivation in vivo, leading to "exhausted" platelets, had occurred. The proportion of circulating platelet-neutrophil complexes was significantly higher in the patients with COVID-19 (mean ± SD, 41% ± 13%) than in the patient controls (18% ± 7%; 95% CI, 11.1-34.1; P = .0002) or healthy subjects (17% ± 4%; 95% CI, 13.8-33.8; P < .0001). An analysis of neutrophil adhesion receptors revealed upregulation of CD11b (α-subunit of αMß2) and CD66b (CEACAM8) but not of CD162 (PSGL-1) in the patients with COVID-19. Conclusion: Despite reduced platelet responsiveness, platelet-neutrophil complexes are increased at early stages of moderate disease. Thus, this cellular interaction may occur during COVID-19 without preceding platelet activation.
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Acute gastrointestinal bleeding often leads to admission to the emergency room. Especially in elderly patients and in those with significant comorbidities it is associated with increased morbidity and mortality. Approximately 2â% of the patients with gastrointestinal bleeding present with hemorrhagic shock. This review focusses on the structured preclinical and clinical management of gastrointestinal bleeding in the emergency department.
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Serviço Hospitalar de Emergência , Hemorragia Gastrointestinal , Doença Aguda , Fatores Etários , Idoso , Comorbidade , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/terapia , HumanosRESUMO
The emergency department (ED) is one of the crucial parts of the hospital infrastructure during all phases of the pandemic. The ED plays an important part in detecting an increasing number of new contagious diseases, which could potentially lead to an epidemic or pandemic.During a pandemic, the ED's main task is to detect infected individuals. These patients then need to be isolated and an adequate treatment is required. The ED must be prepared in order to perform well in such a situation. One major part for readiness is communication in an open manner to all partners within the department, as well as with emergency medical services and other departments of the hospital.The ED must be restructured to withstand the rising number of infected patients. These patients must be separated from other critically ill patients. Strategies for a diagnostic workup depending on the kind of infection have to be put in place. Pathways for the outpatient and inpatient management must be defined to avoid overcrowding in the ED. Depending on the number of patients, escalation and de-escalation strategies have to be set up within the hospital.Over the whole course of the pandemic, all staff members are the key resources for the ED and the entire hospital. The ED can only cope with a pandemic situation if staff are working together as a whole. This implies several important steps to get the staff prepared: Recurring, open conversations about fears, problems, and successes are critical for staff morale. Training must be continually provided, and protection strategies implemented. In the chronic phase of the pandemic the focus should shift more towards strategies on how to create possibilities for recuperation, domestic support measures, and mental health care for staff.
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Serviços Médicos de Emergência , Serviço Hospitalar de Emergência , Pandemias , HumanosRESUMO
Evidence has arisen in recent years suggesting that a tissue renin-angiotensin system (tRAS) is involved in the progression of various human diseases. This system contains two regulatory pathways: a pathological pro-inflammatory pathway containing the Angiotensin Converting Enzyme (ACE)/Angiotensin II (AngII)/Angiotensin II receptor type 1 (AGTR1) axis and a protective anti-inflammatory pathway involving the Angiotensin II receptor type 2 (AGTR2)/ACE2/Ang1-7/MasReceptor axis. Numerous studies reported the positive effects of pathologic tRAS pathway inhibition and protective tRAS pathway stimulation on the treatment of cardiovascular, inflammatory, and autoimmune disease and the progression of neuropathic pain. Cell senescence and aging are known to be related to RAS pathways. Further, this system directly interacts with SARS-CoV 2 and seems to be an important target of interest in the COVID-19 pandemic. This review focuses on the involvement of tRAS in the progression of the mentioned diseases from an interdisciplinary clinical perspective and highlights therapeutic strategies that might be of major clinical importance in the future.
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Antagonistas de Receptores de Angiotensina/farmacologia , Inibidores da Enzima Conversora de Angiotensina/farmacologia , COVID-19/metabolismo , Peptidil Dipeptidase A/metabolismo , Receptores de Angiotensina/metabolismo , Sistema Renina-Angiotensina/efeitos dos fármacos , Envelhecimento/metabolismo , Envelhecimento/patologia , Animais , Autoimunidade/efeitos dos fármacos , Autoimunidade/genética , COVID-19/genética , Doenças Cardiovasculares/genética , Doenças Cardiovasculares/metabolismo , Humanos , Inflamação/tratamento farmacológico , Inflamação/genética , Inflamação/metabolismo , Receptores de Angiotensina/genética , Regeneração/efeitos dos fármacos , Regeneração/genética , Regeneração/fisiologia , Sistema Renina-Angiotensina/genética , Sistema Renina-Angiotensina/fisiologia , Vulvodinia/imunologia , Vulvodinia/fisiopatologia , Tratamento Farmacológico da COVID-19RESUMO
BACKGROUND: Germany reported sufficient intensive care unit (ICU) resources throughout the first wave of coronavirus disease 2019 (COVID-19). The treatment of critically ill COVID-19 patients without rationing may improve the outcome. We therefore analyzed ICU resources allocated to COVID-19 patients with respiratory failure and their outcomes. METHODS: Retrospectively, we enrolled severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR)-positive patients with respiratory failure from 03/08/2020 to 04/08/2020 and followed until 05/28/2020 in the university hospital of Freiburg, Germany. RESULTS: In the defined interval, 34 COVID-19 patients were admitted to the ICU with median age of 67±13 (31-86) years. Six of 34 (17.6%) were female. All patients suffered from moderate or severe acute respiratory distress syndrome (ARDS), 91.2% of the patients were intubated and 23.5% required extracorporeal membrane oxygenation (ECMO). Proning was performed in 67.6%, renal replacement therapy (RRT) was required in 35.3%. Ninety-six percent required more than 20 nursing hours per day. Mean ICU stay was 21±19 (1-81) days. Sixty-day survival of critically ill COVID-19 patients was 50.0% (17/34). Causes of death were multi-organ failure (52.9%), refractory ARDS (17.6%) and intracerebral hemorrhage (17.6%). CONCLUSIONS: Treatment of critically ill COVID-19 patients is protracted and resource-intense. In a context without resources shortage, 50% of COVID-19 with respiratory failure survived up to 60 days.
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BACKGROUND: A central element in the management of cardiogenic shock (CS) comprises mechanical circulatory support (MCS) systems to maintain cardiac output (CO). This study aims to quantify incidence, outcome and influence of MCS in CS over the last decade. METHODS: All patients hospitalized with CS in a tertiary university hospital in Germany between 2007 and 2017 were identified utilizing the international coding system ICD-10 with code R57.0. Application of MCS was identified via German procedure classification codes (OPS). RESULTS: 383,983 cases of cardiogenic shock were reported from 2007 to 2017. Patients had a mean age of 71 years and 38.5% were female. The incidence of CS rose by 65.6% from 26,828 cases in 2007 (33.1 per 100,000 person-years, hospital survival 39.2%) to 44,425 cases in 2017 (53.7 per 100,000 person-years, survival 41.2%). In 2007, 16.0% of patients with CS received MCS (4.6 per 100,000 person-years, survival 46.6%), dropping to 13.9% in 2017 (6.6 per 100,000 person-years, survival 38.6%). Type of MCS changed over the years, with decreasing use of the intra-aortic balloon pump (IABP), an increase in extracorporeal membrane oxygenation (VA-ECMO) and percutaneous ventricular assist device (pVAD) usage. Significant differences regarding in-hospital survival were observed between the devices (survival: overall: 40.2%; medical treatment = 39.5%; IABP = 49.5%; pVAD = 36.2%; VA-ECMO = 30.5%; p < 0.001). CONCLUSIONS: The incidence of CS is increasing, but hospital survival remains low. MCS was used in a minority of patients, and the percentage of MCS usage in CS has decreased. The use rates of the competing devices change over time.
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Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Coração Auxiliar/estatística & dados numéricos , Balão Intra-Aórtico/estatística & dados numéricos , Choque Cardiogênico/terapia , Idoso , Oxigenação por Membrana Extracorpórea/tendências , Feminino , Alemanha , Coração Auxiliar/tendências , Mortalidade Hospitalar , Hospitais Universitários , Humanos , Incidência , Balão Intra-Aórtico/tendências , Masculino , Sistema de Registros , Choque Cardiogênico/epidemiologia , Choque Cardiogênico/mortalidade , Taxa de Sobrevida , Fatores de TempoRESUMO
BACKGROUND: The role of the renin-angiotensin-aldosterone system (RAAS) in coronavirus disease 2019 (COVID-19) is controversially discussed. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) enters host cells by binding to angiotensin-converting enzyme 2 (ACE2) and activity of the RAAS may affect susceptibility to SARS-CoV-2 infection and outcome of patients with COVID-19. METHODS: In this prospective single-center study, we determined the serum levels of ACE2, angiotensin II, and aldosterone in patients with COVID-19 compared with control patients presenting with similar symptoms in the emergency unit. RESULTS: We analyzed serum samples from 24 SARS-CoV-2 positive and 61 SARS-CoV-2 negative patients. SARS-CoV-2 positive and control patients did not differ in baseline patients characteristics, symptoms, and clinical presentation. Mean serum concentrations of ACE2, angiotensin II, and aldosterone did not differ between the SARS-CoV-2 positive and the control group. In line with this, serum potassium as surrogate parameter for RAAS activity and blood pressure were similar in both groups. CONCLUSIONS: In summary, we did not find evidence for altered RAAS activity including angiotensin II, aldosterone, or potassium levels, and blood pressure in patients with COVID-19. CLINICAL TRIALS REGISTRATION: Trial Number DRKS00021206.
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Aldosterona/sangue , Angiotensina II/sangue , Enzima de Conversão de Angiotensina 2/sangue , COVID-19 , Hipertensão , Potássio/sangue , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Determinação da Pressão Arterial/estatística & dados numéricos , COVID-19/sangue , COVID-19/diagnóstico , COVID-19/epidemiologia , COVID-19/fisiopatologia , Feminino , Alemanha/epidemiologia , Humanos , Hipertensão/sangue , Hipertensão/tratamento farmacológico , Hipertensão/epidemiologia , Hipertensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Sistema Renina-Angiotensina/fisiologia , SARS-CoV-2/isolamento & purificaçãoRESUMO
Pulmonary sonography can be a valuable aid in the differential diagnosis of a variety of cardiopulmonary diseases, including patients with COVID-19. Pulmonary sonography is an examination method that is also quickly available at the bedside without additional risks for the patient. When COVID-19 is suspected, lung sonography is a valuable component of initial diagnosis when used systematically, performed hygienically and correctly. However, the findings of pulmonary sonography must be placed in the clinical context; sonography does not replace the gold standard of PCR diagnosis. The article shows how this sonography is performed and which findings in COVID-19 are relevant.
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Infecções por Coronavirus/diagnóstico por imagem , Pulmão/diagnóstico por imagem , Pneumonia Viral/diagnóstico por imagem , Ultrassonografia/métodos , Betacoronavirus , COVID-19 , Diagnóstico Diferencial , Humanos , Pandemias , SARS-CoV-2RESUMO
Acute bleeding is a common and challenging condition in the emergency room. The need for staff and medical resources in these patients depends on the clinical status and extent of the bleeding. The causes of acute bleeding are heterogeneous. Patients may appear in an emergency department with gastrointestinal, traumatic, intracerebral, gynecological or urological bleeding. Bleeding may be triggered or aggravated by underlying diseases or the use of anticoagulants or antiplatelet therapy. The treatment can range from general measures to complex intensive care with antidotes, blood coagulation and transfusion management. Nevertheless, the initial management in such cases is often the same.The purpose of this article is to give an overview of the different types of acute bleeding in an emergency room and how to overcome these specific challenges. Important is the initial management with appropriate general measures to stabilize the patient to avoid serious complications. It is helpful to set up structured processes for these cases.