Hemostatics in patients with inhibited coagulation-A viscoelastic in-vitro analysis.

BACKGROUND: The military has used topical hemostatic agents to successfully treat life-threatening external bleeding for years. In contrast to the military environment, the general population are increasingly prescribed anticoagulants. There are only few comparative evaluations of topical hemostatic agents with anticoagulated human blood. It is important to understand the impact of these agents on those who take anticoagulants. STUDY DESIGN AND METHODS: Citrated blood of patients treated with enoxaparin, heparin, and acetylsalicylic acid, apixaban or phenprocoumon was incubated with different hemostatic agents (QuikClot Gauze, Celox Granules, Celox Gauze, Chito SAM 100, WoundClot Trauma Gauze, QuikClot Gauze Moulage Trainer and Kerlix) and rotational thromboelastometry was performed with non-activated thromboelastometry (NATEM reagent). RESULTS: All tested agents improved the onset of coagulation in all anticoagulants, mostly to a significant degree. Most significant improvements were produced by QuikClot Gauze and QuikClot Gauze Moulage Trainer, followed by the tested chitosans (Celox Granules, Celox Gauze, Chito SAM 100). Of the anticoagulant groups, the most significant improvements were seen in enoxaparin. This was followed in order by apixaban, heparin, and acetylsalicylic acid, and phenprocoumon. DISCUSSION: All the hemostatic agents tested were able to activate the clotting cascade earlier and initiate faster clot formation in anticoagulated blood. A definitive head-to-head comparison is not feasible, because of the limitations of an in-vitro analysis. However, the sometimes-presented hypothesis that kaolin-based hemostatic agents are ineffective in anticoagulated blood is inaccurate according to our data. Hemostasis with hemostatic agents appears most challenging with phenprocoumon.

First pass success of tracheal intubation using the C-MAC PM videolaryngoscope as first-line device in prehospital cardiac arrest compared with other emergencies: An observational study.

BACKGROUND: Successful airway management is a priority in the resuscitation of critically ill or traumatised patients. Several studies have demonstrated the importance of achieving maximum first pass success, particularly in prehospital advanced airway management. OBJECTIVE: To compare success rates of emergency intubations between patients requiring cardiopulmonary resuscitation (CPR) for cardiac arrest (CPR group) and other emergencies (non-CPR group) using the C-MAC PM videolaryngoscope. DESIGN: Ongoing analysis of prospective collected prehospital advanced airway management core variables. SETTING: Single helicopter emergency medical service (HEMS) 'Christoph 22', Ulm Military Hospital, Germany, May 2009 to July 2018. PATIENTS: We included all 1006 HEMS patients on whom prehospital advanced airway management was performed by board-certified anaesthesiologists on call at HEMS 'Christoph 22'. INTERVENTIONS: The C-MAC PM was used as the first-line device. The initial direct laryngoscopy was carried out using the C-MAC PM without the monitor in sight. After scoring the direct laryngoscopic view according to the Cormack and Lehane grade, the monitor was folded within the sight of the physician and tracheal intubation was performed using the videolaryngoscopic view without removing the blade. MAIN OUTCOME MEASURES: The primary outcome was successful airway management. Secondary outcomes were the patient's position during airway management, necessity for suction, direct and videolaryngoscopic view according to Cormack and Lehane grading, as well as number of attempts needed for successful intubation. RESULTS: A patent airway was achieved in all patients including rescue techniques. There was a lower first pass success rate in the CPR group compared with the non-CPR group (84.4 vs. 91.4%, P = 0.01). In the CPR group, direct laryngoscopy resulted more often in a clinically unfavourable (Cormack and Lehane grade 3 or 4) glottic view (CPR vs. non-CPR-group 37.2 vs. 26.7%, P = 0.0071). Using videolaryngoscopy reduced the clinically unfavourable grading to Cormack and Lehane 1 or 2 (P < 0.0001). The odds of achieving first pass success were approximately 12-fold higher with a favourable glottic view than with an unfavourable glottic view (OR 12.6, CI, 6.70 to 23.65). CONCLUSION: Airway management in an anaesthesiologist-staffed HEMS is associated with a high first pass success rate but even with skilled providers using the C-MAC PM videolaryngoscope routinely, patients who require CPR offer more difficulties for successful prehospital advanced airway management at the first attempt. TRIAL REGISTRATION: German Clinical trials register (drks.de) DRKS00020484.

Oligoanalgesia in Patients With an Initial Glasgow Coma Scale Score ≥8 in a Physician-Staffed Helicopter Emergency Medical Service: A Multicentric Secondary Data Analysis of >100,000 Out-of-Hospital Emergency Missions.

BACKGROUND: Oligoanalgesia, as well as adverse events related to the initiated pain therapy, is prevalent in out-of-hospital emergency medicine, even when a physician is present. We sought to identify factors involved in insufficient pain therapy of patients presenting with an initial Glasgow Coma Scale (GCS) score of ≥8 in the out-of-hospital phase, when therapy is provided by a physician-staffed helicopter emergency medical service (p-HEMS). METHODS: This was a multicenter, secondary data analysis of conscious patients treated in primary p-HEMS missions between January 1, 2005, and December 31, 2017. Patients with a numeric rating scale (NRS) pain score ≥4, GCS score ≥8 on the scene, without cardiopulmonary resuscitation (CPR), and a National Advisory Committee for Aeronautics (NACA) score

[Prehospital Strategies to Stop the Bleeding]. / Prähospitale Strategien zur Minimierung des Blutverlustes.

Seriously injured patients represent only a small group of patients in the emergency medical service with 0.5% (ground based) to 5% (HEMS), but they are associated with a high mortality rate. Among people younger than 45, trauma is the most common cause of death, mostly as a result of severe traumatic brain injury (TBI) and/or extreme hemorrhage. As the outcome of severe TBI prehospitally can only be influenced to a very limited extent, a majority of preventable deaths in prehospital setting are caused by "critical" bleeding. The "critical" bleeding is defined by its life-threatening dimension. Anticoagulation medication can have a reinforcing effect. Adequate prehospital therapy strategies exist for external bleeding. In contrast, internal bleeding regularly evades a causal prehospital care, so that in such cases, transport prioritization and rapid definitive surgical intervention remain the only option. In the civilian environment the tested and evaluated "ABCDE" scheme must be preceded by the (for "critical bleeding") in order to react time-critically to compressible external bleeding, possibly even prior to airway management. These findings have found their way into the current version of the S3 guideline on treatment of multi system trauma by the German Society for Trauma Surgery (DGU). According to this "severely bleeding injuries that can impair vital functions should be treated with priority". Thus, this publication focuses on prehospital bleeding control.

Necessity to depict difficult neck anatomy for training of cricothyroidotomy: A pilot study evaluating two surgical devices on a new hybrid training model.

BACKGROUND: Everyone dealing with airway emergencies must be able to accomplish cricothyroidotomy, which cannot be trained in real patients. Training models are necessary. OBJECTIVE: To evaluate the suitability of a hybrid training model combining synthetic and porcine parts to depict variable neck anatomy. DESIGN: Model-based comparative trial. SETTING: Armed Forces Hospital Ulm, Germany, August 2018. INTERVENTION: On four anatomical neck variations (long slim/long obese/short slim/short obese) we performed two surgical approaches to cricothyroidotomy (SurgiCric II vs. ControlCric). PARTICIPANTS: Forty-eight volunteers divided into two groups based on their personal skill level: beginners group and proficient performers group. MAIN OUTCOME MEASURES: Time to completion was recorded for each procedure. Once the operator had indicated completion, the correct anatomical tube placement was confirmed by dissection and structures were inspected for complications. Primary outcomes were successful tracheal placement of an airway tube and time needed to achieve a patent airway. Secondary outcome was assessment of complications. RESULTS: Overall, 384 procedures were performed. Median time to completion was 74 s. In total, 284 procedures (74%) resulted in successful ventilation. Time to completion was longer in short obese than in long slim and the risk of unsuccessful procedures was increased in short obese compared with long slim. Even if ControlCric resulted in faster completion of the procedure, its use was less successful and had an increased risk of complications compared with SurgiCric II. Proficient performers group performed faster but had an increased risk of injuring the tracheal wall compared with beginners group. CONCLUSION: Participants had difficulties in performing cricothyroidotomy in obese models, but various and difficult anatomical situations must be expected in airway management and therefore must be taught. A new hybrid model combining porcine and synthetic materials offers the necessary conditions for the next step in training of surgical airway procedures. TRIAL REGISTRATION: The study was performed without human tissue or living animals, and was therefore exempted from ethical review by the University of Ulm Ethical Committee, Germany (Chairperson Prof Dr C. Lenk) on 9 August 2018. Hence a protocol number was not attributed.

[Mass casualty incident - special features of "threatening situations"]. / Massenanfall von Verletzten ­ Besonderheiten von "bedrohlichen Lagen".

Terrorist attacks or amok runs may cause "threatening situations" for emergency medical services (EMS), fire fighters and physicians. Cooperation with the police is of paramount importance. In order to minimize the risk to rescue personnel and affected persons, emergency medical care has to follow tactical principles. So, the strategy in such "threatening situations" is "Stop the bleeding and clear the scene". The police define three areas of danger: unsafe, partly safe and secure. Medical care in these areas follows the concept of Tactical Combat Casualty Care. While only police should act in the unsafe area, the EMS can operate in the partly safe area after appropriate arrangements. Safety may only be achieved in emergency departments, which have to be made to secure areas by certain measures.The task force "Tactical Medicine" of the Scientific Working Group Emergency Medicine of the German Association for Anesthesiology and Intensive Care describes in this article essential criteria for a coordinated approach in "threatening situations".

[Prehospitale analgesia in adults]. / Prähospitale Analgesie beim Erwachsenen - Schmerzerfassung und Therapieoptionen.

After securing vital function, treatment of pain is an important aspect in emergency medical care. Irrespective of the underlying disease or injury, pain is an important warning symptom of the body and the most common reason for an emergency alert notification. A patient assesses quality of care and success of prehospital care using the criteria of the extent of pain relief he experiences. Since mild pain does not usually lead to an emergency alert, the criteria apply mainly to treatment of severe and very severe pain. Pain perception varies from individual to individual. Accordingly, assessment of pain intensity is the very first step in pain therapy. The Numeric Rating Scale (NRS) ranging from 0 (no pain) to 10 (worst pain imaginable) is suitable for pain assessment in adult emergency patients. Above a grade of 4, therapeutic intervention should be initiated with the goal of reducing pain to reach a value of <4, or at least to achieve a reduction by 3 points. The choice of analgesics that can be meaningfully used in pre-hospital emergency medicine is limited. The emergency physician should be aware of available drugs and administration routes.

Improvement in glottic visualisation by using the C-MAC PM video laryngoscope as a first-line device for out-of-hospital emergency tracheal intubation: An observational study.

BACKGROUND: Out-of-hospital tracheal intubation is associated with life-threatening complications. To date, no study has compared direct and video laryngoscopic views simultaneously in the same patients in an out-of-hospital setting. OBJECTIVES: The aim of this study was to determine the effect of C-MAC PM video laryngoscope on laryngeal view, compared with direct laryngoscopy, and to estimate possible consequences for patient safety. DESIGN: An observational, single-centre study. SETTING: Helicopter Emergency Medical Service (HEMS) 'CHRISTOPH 22', Ulm, Germany. PATIENTS: Two-hundrend and twenty-eight emergency patients undergoing airway management out of hospital. INTERVENTIONS: Laryngoscopy and tracheal intubation using C-MAC PM video laryngoscope. For all intubations, the HEMS physician used CMAC PM as the first-line device and performed an initial direct laryngoscopy followed by a video laryngoscopy, without changing the laryngoscope blade. MAIN OUTCOME MEASURES: The difference in laryngeal view was recorded as well as the number of intubation attempts along with the success rate and difficulties in airway management. Improvement in glottic visualisation from Cormack and Lehane grade III/IV to I/II was rated as being clinically relevant. RESULTS: During a 20-month study period, a total of 228 out-of-hospital emergency patients requiring tracheal intubation were included. The overall success rate in securing the airway was 100%. For 226 patients (99.1%), tracheal intubation was successful with two or fewer attempts. For comparison of direct and indirect laryngoscopic views, five patients were excluded because of the use of an indirect laryngoscope blade. Of 223 patients, 120 had a glottic view rated as Cormack and Lehane grade II to IV with direct laryngoscopy; in these patients, visualisation of the glottis was significantly improved with the C-MAC PM video laryngoscope (P < 0.001). In 56 patients (25.1%), improvement of glottic visualisation was clinically relevant (P < 0.001). CONCLUSION: Use of the C-MAC PM video laryngoscope is associated with improved visualisation of the glottis according to the Cormack and Lehane grading system and an excellent success rate for out-of-hospital tracheal intubation. These results suggest that the use of C-MAC PM as a first-line device for tracheal intubation by out-of-hospital emergency medical services is a safe procedure.

Transport with ongoing resuscitation: a comparison between manual and mechanical compression.

AIM: In special circumstances it may be necessary to transport out-of-hospital cardiac arrest patients with ongoing resuscitation to the hospital. External mechanical chest compression devices could be an alternative for these resuscitations. The study compares manual chest compression with external mechanical devices and a semiautomatic device in transport conditions using a resuscitation manikin. METHODS: Manual chest compressions were compared with LUCAS 2, AutoPulse and animax mono devices using the Ambu Man Wireless MegaCode manikin (10 series each). The measurements were performed in a standard ambulance vehicle during transport on a predefined track of 5.0 km. RESULTS: Mean compression frequencies in the manual group (117 ± 18 min(-1)) and in the animax mono group (115 ± 10 min(-1)) were significantly higher than in the LUCAS 2 group (100 min(-1), p=0.02) and the AutoPulse group (80 min(-1), p<0.01). Both mechanical devices worked absolutely constantly. Only the animax mono group reached with 51.2 mm the recommended compression depth. The quality of manual compressions decreased considerably during braking or change manoeuvres while the mechanical devices continued to work constantly. CONCLUSIONS: During a patient transport with ongoing resuscitation, external mechanical compression devices may be a good alternative to manual compression because they increase the safety of the rescuer and patient. Yet, in this study only animax mono reached the guideline specifications regarding chest compressions' frequency and depth. Concerning constancy, the mechanical devices work reliably and more independently from motion influences. Further studies are necessary to evaluate the effectiveness of these devices in patient transport.

Emergency cricothyroidotomy performed by inexperienced clinicians--surgical technique versus indicator-guided puncture technique.

BACKGROUND: To improve the ease and safety of cricothyroidotomy especially in the hand of the inexperienced, new instruments have been developed. In this study, we compared a new indicator-guided puncture technique (PCK) with standard surgical technique (ST) regarding success rate, performance time and complications. METHODS: Cricothyroidotomy in 30 human cadavers performed by 30 first year anaesthesia residents. The set chosen for use was randomised: PCK-technique (n=15) and ST (n=15). Success rates, insertion times and complications were compared. Traumatic lesions were anatomically confirmed after dissection. RESULTS: The ST-group had a higher success rate (100% vs 67%; p=0.04). There was no difference in time taken to complete the procedure (PCK 82 s. vs ST 95 s.; p=0.89). There was a higher complication rate in the PCK-group (67% vs 13%; p=0.04). Most frequent complication in the PCK-group was injury to the posterior tracheal wall (n=8), penetration to the oesophageal lumen (n=4) and injury to the thyroid and/or cricoid cartilage (n=5). In the ST-group in only 2 cases minor complications were observed (small vessel injury). CONCLUSIONS: In this human cadaver study the PCK technique produced more major complications and more failures than the ST. In the hand of the inexperienced operator the standard surgical approach seems to be a safe procedure, which can successfully be performed within an adequate time. The PCK technique cannot be recommended for inexperienced operators.

[Explosion injuries - prehospital care and management]. / Explosionsverletzungen - Präklinische Versorgung und Management.

Explosion injuries are not restricted to war-like military conflicts or terrorist attacks. The emergency physician may also encounter such injuries in the private or industrial fields, injuries caused by fireworks or gas explosions. In such cases the injury patterns are especially complex and may consist of blunt and penetrating injuries as well as thermal damage. Emergency medical personnel must be prepared to cope with explosion trauma not only in individual cases but also in major casualty incidents (MCI). This necessitates a sound knowledge about the mechanisms and processes of an explosion as well as the particular pathophysiological relationships of explosion injuries in order to be able to initiate the best possible, guideline-conform trauma therapy.

Prehospital predictors of the need for transfusion in patients with major trauma.

PURPOSE: Severe haemorrhage is a leading cause of early mortality following major trauma. By early identification of patients at risk, blood transfusion could already be initiated in the prehospital period. Aim of the study was to evaluate the extent to which prehospital lactate and base excess, which are known to be associated with trauma-induced coagulopathy, and additional clinical parameters are associated with the need for early transfusion. METHODS: In this prospective, single-centre observational study, trauma patients treated by a helicopter emergency medical service were included, regardless of the injury severity. Patients with coagulation-influencing drugs in long-term therapy were excluded. Blood samples obtained at the beginning of the prehospital treatment were analysed. Primary outcome was the association of lactate and base excess with the need for early transfusion (resuscitation room or immediate surgery). Receiver operating characteristic curves were created, and the area under the curve (AUROC) was calculated. RESULTS: Between 2015 and 2018, 21 out of 130 adult trauma patients received blood products during the early in-hospital treatment. Both prehospital lactate and base excess were associated with the transfusion (AUROC 0.731 and 0.798, respectively). The optimal calculated cut-off values were 4 mmol/l (lactate) and - 2.5 mmol/l (base excess). When circulatory instability and suspected relevant bleeding were included, the association further improved (AUROC 0.871 and 0.866, respectively). CONCLUSION: Prehospital lactate and base excess could be used in combination with other clinical parameters as indicators of the need for early transfusion. This relationship has yet to be confirmed in the current validation study. TRIAL REGISTRATION: German Clinical Trials Register, www.drks.de (No. DRKS 00009559).

Prehospital endotracheal intubation and chest tubing does not prolong the overall resuscitation time of severely injured patients: a retrospective, multicentre study of the Trauma Registry of the German Society of Trauma Surgery.

BACKGROUND: The aim of this study was to determine whether prehospital endotracheal intubation (ETI) and chest tube placement is unnecessarily time consuming in severely injured patients. PATIENTS AND METHODS: A retrospective, multicentre study including all adult patients (ISS ≥9; 2002-7) of the Trauma Registry of the German Society of Trauma Surgery who were not secondarily transferred to a trauma centre and received a definitive airway and a chest tube. Creating four groups: AA (n=963) receiving ETI and chest tube on scene, AB (n=1547) ETI performed in the prehospital setting but chest tubing later in the emergency department (ED) and BB (n=640) receiving both procedures in the ED. The BA collective (ETI performed in the ED, but chest tubing on scene) was excluded from the study because of the small sample size (n=41). The trauma resuscitation time (TRT), demographic data, injuries, treatment and outcome of the remaining three collectives were compared. RESULTS: The prehospital TRT of the AA collective was longer than the AB and BB subgroups (80±37 min vs 77±44 min 65±46 min; p<0.01). Although the AA and AB subgroups were more severely injured (ISS 35±15 vs 38±15 vs 31±12; p<0.01) and showed poorer vital parameters on scene, the overall TRT (accident until end of ED treatment) were equal for all three groups (152±59 min vs 151±62 min vs 148±68 min; p=0.07). The TRISS adjusted mortality was also equal in all three groups. CONCLUSIONS: In a physician-based emergency medical service, prehospital ETI and chest tube placement do not prolong the total TRT of severely injured patients.

The C-MAC videolaryngoscope for prehospital emergency intubation: a prospective, multicentre, observational study.

BACKGROUND: In this preliminary prospective observational study at four physician-led air rescue centres, the efficacy of the C-MAC (Karl Storz, Tuttlingen, Germany), a new portable videolaryngoscope, was evaluated during prehospital emergency endotracheal intubations. METHODS: 80 consecutive patients requiring prehospital emergency intubation, treated by a physician introduced in the use of the C-MAC were enrolled in this study. RESULTS: Indication for prehospital intubation was trauma in 45 cases (including maxillo-facial trauma in 10 cases), cardiopulmonary resuscitation in 14 cases, and unconsciousness of neurological aetiology and cardiogenic dyspnoea in 21 cases. Forty-nine patients were intubated with a C-MAC blade size 3, and 31 with a C-MAC blade size 4. Median time to successful intubation was 20 (min-max: 5-300) seconds; 63 patients were intubated on the first attempt, 13 on the second and four after more than two attempts. A Cormack-Lehane class 1 view of the glottis was seen in 46 patients, class 2a view in 21, class 2b in eight, class 3 in three and class 4 in two. Six patients could not be intubated with the videolaryngoscopic view, but were successfully intubated at the same attempt using the C-MAC with the direct laryngoscopic view. CONCLUSION: The C-MAC videolaryngoscope was suitable for prehospital emergency endotracheal intubations with complicated airway conditions, such as maxillo-facial trauma. The option to perform direct laryngoscopy and videolaryngoscopy with the same device appears to be exceptionally important in the prehospital setting.

Prehospital evaluation and detection of induced coagulopathy in trauma: The PREDICT study.

BACKGROUND: Hemorrhage with trauma-induced coagulopathy (TIC) and hyperfibrinolysis (HF) increases the mortality risk after severe trauma. While TIC at hospital admission is well studied, little is known about coagulopathy at the incident site. The aim of the study was to investigate coagulation disorders already present on scene. METHODS: In a prospective single-center observational study, blood samples of trauma patients obtained before and at hospital admission were analyzed. Data on rotational thromboelastometry, blood gas analysis, prehospital treatment, injury severity, in-hospital blood transfusions, and mortality were investigated according to the presence of coagulation disorders at the incident site. The patients were divided into three groups according to the presence of coagulation disorders (no coagulopathy, TIC, TIC with HF). In a subgroup analysis, patients with a Trauma-Induced Coagulopathy Clinical Score (TICCS) of ≥10 were investigated. RESULTS: Between August 2015 and February 2018, 148 patients were enrolled in the study. The mean Injury Severity Score was 22.1, and overall mortality was 7.4%. Trauma-induced coagulopathy and HF were already detectable at the incident site in 18.2% and 6.1%, respectively. Patients with HF had significantly altered circulation parameters with significant changes in pH, hemoglobin, lactate, and base excess at the incident site. In patients with TICCS of ≥10 (14.2%), TIC was detected in 47.6% of the cases and HF in 28.6%. Furthermore, in these patients, blood gas parameters significantly changed and the need for blood transfusion and mortality. CONCLUSION: Trauma-induced coagulopathy and HF can be detected in severely injured patients even before medical treatment is started. Furthermore, in patients with HF and TICCS of ≥10, blood gas parameters were significantly changed at the incident site. LEVEL OF EVIDENCE: Prognostic study, level III.

Survival Following Lay Resuscitation.

BACKGROUND: Resuscitation by laypersons is important in bridging the time between the occurrence of an out-of-hospital cardiac arrest (OHCA) and the arrival of emergency rescue service personnel. Depending on the reason for the cardiac arrest, however, the effectiveness of chest compressions is uncertain. The aim of this study was to explore the impact of lay resuscitation on survival following OHCA of different causes. METHODS: The data set for analysis comprised all cases of cardiac arrest before the arrival of emergency rescue service personnel that were fully documented in the German Resuscitation Registry in the period 2007-2019. The following endpoints related to resuscitation by bystanders were evaluated-separately for each cause-descriptively and by means of multivariate logistic regression analysis: return of spontaneous circulation (ROSC), 30 days' survival/discharged alive from the hospital, and good neurological function at discharge. RESULTS: Altogether, 40 604 cases of cardiac arrest were included. Resuscitation by laypersons was carried out in 35.1% of these cases. The rate of ROSC was statistically significantly higher after lay resuscitation for OHCA caused by cardiac events, drowning, intoxication, or central nervous system disorders (overall 48.1% versus 41.0%). For all causes-with the exception of trauma/bleeding to death and sepsis- the endpoint 30 days' survival/discharged alive was better with lay resuscitation (overall 17.0% versus 9.5%). In multivariate regression analysis, lay resuscitation was associated with improvement of the endpoint 30 days' survival/discharged alive only for OHCA caused by cardiac events (odds ratio [OR] 1.16) or intoxication (OR 1.81). For all other causes-except hypoxia-lay resuscitation tended to yield better results. Neurological function at discharge was also significantly better (overall 11.5% versus 6.1%) after lay resuscitation for OHCA of all causes except trauma/ bleeding to death, hypoxia, and sepsis. CONCLUSION: Resuscitation by laypersons is associated with an improved result regarding the endpoint 30 days' survival/discharged alive in cases of OHCA caused by cardiac events and intoxication. These two groups account for 81% of the resuscitation patients in the study. Because there was also a tendency towards higher survival rates following OHCA of other causes (except hypoxia), laypersons should continue to be encouraged to attempt resuscitation in all cases of OHCA, whatever the cause.

Emergency response to terrorist attacks: results of the federal-conducted evaluation process in Germany.

PURPOSE: Rescue missions during terrorist attacks are extremely challenging for all rescue forces (police as well as non-police forces) involved. To improve the quality and safety of the rescue missions during an active killing event, it is obligatory to adapt common rescue mission goals and strategies. METHODS: After the recent attacks in Europe, the Federal Office of Civil Protection and Disaster Assistance started an evaluation process on behalf of the Federal Ministry of the Interior and the Federal Ministry of Health. This was done to identify weaknesses, lessons learned and to formulate new adapted guidelines. RESULTS: The presented bullet point recommendations summarise the basic and most important results of the ongoing evaluation process for the Federal Republic of Germany. The safety of all the rescue forces and survival of the greatest possible number of casualties are the priority goals. Furthermore, the preservation and re-establishment of the socio-political integrity are the overarching goals of the management of active killing events. Strategic incident priorities are to stop the killing and to save as much lives as possible. The early identification and prioritised transportation of casualties with life-threatening non-controllable bleeding are major tasks and the shortest possible on-scene time is an important requirement with respect to safety issues. CONCLUSION: With respect to hazard prevention tactics within Germany, we attributed the highest priority impact to the bullet points. The focus of the process has now shifted to intense work about possible solutions for the identified deficits and implementation strategies of such solutions during mass killing incidents.

[German recommendations on lung and thoracic ultrasonography in patients with COVID-19]. / Empfehlungen zur Lungen- und Thoraxsonographie bei Patienten mit COVID-19-Erkrankung.

Lung and chest ultrasound are further examination modalities in addition to computed tomography and laboratory diagnostics in patients with COVID-19. It extends the clinical-physical examination because it can examine lung surface sensitively. Lung surface pattern changes have been found in sonograms of patients with COVID-19 pneumonia and during the course of the disease. German specialist societies of clinical acute, emergency and intensive care medicine as well as imaging, which are concerned with the care of patients with SARS-CoV­2 infection and COVID-19, have coordinated recommendations for lung and thorax sonography. This document has been created within a transparent process, led by the German Society of Interdisciplinary Emergency and Acute Medicine e. V. (DGINA), and worked out by an expert panel and delegates from the societies. Sources of the first 200 cases were summarized. Typical thorax sonographic findings are presented. International sources or standards that were available in PubMed until May 24, 2020 were included. Using case studies and multimedia content, the document is intended to not only support users but also demonstrate quality features and the potential of chest and lung sonography. The German Society for Ultrasound in Medicine (DEGUM) is carrying out a multicenter study (study coordination at the TU Munich).