[Changes in number of emergency medical service deployments in an urban area during the first COVID-19 pandemic-related contact restriction phase]. / Veränderungen der rettungsdienstlichen Einsatzzahlen in einer Metropolregion während der ersten COVID-19-Pandemie-bedingten Kontaktbeschränkungsphase.

Background: To contain the coronavirus disease (COVID-19) pandemic, public life was reduced through contact restriction measures (referred to as "lockdown" in the further course for reading simplicity), among other things to make health system resources available for the treatment of COVID-19 patients. In parallel, a decrease in emergency patients was observed in the public health system. Methods: For two 10-week periods before and during the lockdown, ambulance service deployment rates were analysed in 6 ambulance service areas for 6 tracer diagnoses. Random effects were minimised by comparing the results with the corresponding 2018 and 2019 time periods and a calculated expected value. Results: For emergency ambulance service calls, there was a reduction in call numbers (-16%) during the lockdown. A 20% reduction for the categories cardiac and cerebral ischaemia was found. In the urban area, the reduction in cardiac ischaemia was less pronounced at 14% than in the surrounding area at 23%. The deployment figures for intoxications decreased by 27% and for psychiatric emergencies by 16%. Conclusion: The public ambulance service was not overwhelmed by the COVID-19 pandemic; there was a decrease in depolyments during the lockdown. For the reduction in cerebral or cardiac ischaemias, the explanatory models for the influence of the lockdown are missing. Further studies on the utilisation behaviour of the ambulance service during a lockdown appear necessary in order to detect potentially fatal reductions in utilisation for the patient outcome and to be able to counteract them through education.

Elevated Serum Glial Fibrillary Acidic Protein (GFAP) is Associated with Poor Functional Outcome After Cardiopulmonary Resuscitation.

BACKGROUND: The neurological prognosis of patients after cardiopulmonary resuscitation (CPR) is difficult to assess. GFAP is an astrocytic intermediate filament protein released into bloodstream in case of cell death. We performed a prospective study aiming to compare the predictive potential of GFAP after resuscitation to the more widely used biomarker neuron-specific enolase (NSE). METHODS: One hundred patients were included at 48 h (tolerance interval ±12 h) after cardiac arrest. A serum sample was collected immediately after study inclusion. We determined serum levels of GFAP and NSE by means of immunoassays. Primary outcome was the modified Glasgow outcome scale at 4 weeks. Values below four were considered as a poor functional outcome. RESULTS: Median GFAP levels in poor outcome (n = 61) and good outcome (n = 39) patients were 0.03 µg/L (interquartile range 0.01-0.07 µg/L) and 0.02 µg/L (0.01-0.03 µg/L; p = 0.014), respectively. GFAP revealed a sensitivity of 60.7% and a specificity of 66.7% to predict a poor functional outcome. All patients having a GFAP level >0.08 µg/L had a poor functional outcome. For NSE, sensitivity was 44.3% and specificity was 100.0% for predicting a poor outcome. Multivariate regression analysis revealed GFAP, NSE, and the Karnofsky index to be independent predictors of outcome. CONCLUSIONS: The release patterns of GFAP and NSE after CPR show differences. GFAP levels above 0.08 µg/L were associated with a poor outcome in all cases, and patients with strongly elevated values (>3 µg/L) consistently had severe brain damage on brain imaging. Both biomarkers independently contribute to outcome prediction after CPR.

Helicopter Emergency Medical Service Simulation Training in the Extreme: Simulation-based Training in a Mountain Weather Chamber.

Mountain rescue operations often confront crews with extreme weather conditions. Extremely cold temperatures make standard treatment sometimes difficult or even impossible. It is well-known that most manual tasks, including those involved in mountain rescue operations, are slowed by extremely cold weather. To lessen and improve the decrement in performance of emergency medical treatment caused by cold-induced manual impairment and inadequate medical equipment and supplies, simulation training in a weather chamber, which can produce wind and temperatures up to -22°C, was developed. It provides a promising tool to train the management of complex multidisciplinary settings, thus reducing the occurrence of fatal human and technical errors and increasing the safety for both the patient and the mountain emergency medical service crew.

Simulation-Based Training in Mountain Helicopter Emergency Medical Service: A Multidisciplinary Team Training Concept.

OBJECTIVE: Mountain helicopter rescue operations often confront crews with unique challenges in which even minor errors can result in dangerous situations. Simulation training provides a promising tool to train the management of complex multidisciplinary settings, thus reducing the occurrence of fatal errors and increasing the safety for both the patient and the helicopter emergency medical service (HEMS) crew. METHODS: A simulation-based training, dedicated to mountain helicopter emergency medicine service, was developed and executed. We evaluated the impact of this training by the means of a pre- and posttraining self-assessment of 40 HEMS crewmembers. RESULTS: Multidisciplinary simulation-based educational training in HEMS is feasible. There was a significant increase in self-assessed competence in safety-related items of human factors and team resource management. The highest gain of competence was demonstrated by a trend in the domain of structured decision making. CONCLUSIONS: Interprofessional simulation-based team training could have the potential to impact patient outcomes and improve rescuer safety. Simulation trainings lead to a subjective increase of self-assuredness in the management of complex situations in a difficult working environment.

Mechanical chest compressions in an avalanche victim with cardiac arrest: an option for extreme mountain rescue operations.

Mountain rescue operations often present helicopter emergency medical service crews with unique challenges. One of the most challenging problems is the prehospital care of cardiac arrest patients during evacuation and transport. In this paper we outline a case in which we successfully performed a cardiopulmonary resuscitation of an avalanche victim. A mechanical chest-compression device proved to be a good way of minimizing hands-off time and providing high-quality chest compressions while the patient was evacuated from the site of the accident.

Benefit of mechanical chest compression devices in mountain HEMS: lessons learned from 1 year of experience and evaluation.

INTRODUCTION: Pre-hospital care of cardiac arrest patients in the mountain environment is one of the most challenging problems for helicopter medical emergency services (HEMS) teams. To provide high-quality chest compression with minimal hand s-off-time is very demanding in the alpine area. METHODS: We used and evaluated mechanical chest compression devices (Lucas and AutoPulse) and investigated if these are good and useful tools in the alpine HEMS. Over a period of 12 months we performed 7 CPRs in remote alpine terrain. CONCLUSION: On the strength of our past experience, CPR under special circumstances like deep hypothermia, in which a prolonged CPR is essential, the use of the Lucas and/or AutoPulse was an easy and sufficient tool even in difficult alpine terrain which requires special rescue missions like winch or MERS evacuation.

Incidence and challenges of helicopter emergency medical service (HEMS) rescue missions with helicopter hoist operations: analysis of 11,228 daytime and nighttime missions in Switzerland.

OBJECTIVE: We aimed to investigate the medical characteristics of helicopter hoist operations (HHO) in HEMS missions. METHODS: We designed a retrospective study evaluating all HHO and other human external cargo (HEC) missions performed by Swiss Air-Rescue (Rega) between January 1, 2010, and December 31, 2019. RESULTS: During the study period, 9,963 (88.7 %) HEMS missions with HHO and HEC were conducted during the day, and 1,265 (11.3 %) at night. Of the victims with time-critical injuries (NACA ≥ 4), 21.1 % (n = 400) reached the hospital within 60 min during the day, and 9.1 % (n = 18) at night. Nighttime missions, a trauma diagnosis, intubation on-site, and NACA Score ≥ 4 were independently and highly significantly associated with longer mission times (p < 0.001). The greatest proportion of patients who needed hoist or HEC operations in the course of the HEMS mission during the daytime sustained moderate injuries (NACA 3, n = 3,731, 37.5 %) while practicing recreational activities (n = 5,492, 55.1 %). In daytime HHO missions, the most common medical interventions performed were insertion of a peripheral intravenous access (n = 3,857, 38.7 %) and administration of analgesia (n = 3,121, 31.3 %). CONCLUSIONS: Nearly 20 % of patients who needed to be evacuated by a hoist were severely injured, and complex and lifesaving medical interventions were necessary before the HHO procedure. Therefore, only adequately trained and experienced medical crew members should accompany HHO missions.

Efficacy and efficiency of indoor nighttime human external cargo mission simulation in a high-fidelity training Centre.

BACKGROUND: The human external cargo (HEC) operations conducted by Helicopter Emergency Medical Services (HEMS) rarely take place at night, making it difficult for crew members to attain and maintain the level of expertise needed to perform winch operations in the dark. As EASA requirements for training cannot currently be met, we evaluated whether simulation training could be an option. METHODS: This paper reports on a training concept using indoor simulation for the training of nighttime HEC operations. Participants' experience and perceptions were evaluated with a survey and the procedural and economic advantages of the simulation approach were compared with those of the usual outdoor HEC training. RESULTS: Most participants had limited exposure to real-life nighttime HEC missions before undergoing the simulation-based training. The frequency of training cycles in simulation was much higher compared to conventional training (60 cycles indoors vs. 20 outdoors for HEMS-TC, 20 cycles indoors vs. 4 outdoors for MCM). Trainees perceived that their technical and non-technical skills (NTS) improved with the training. The estimated costs of standard outdoor-based nighttime HEC training (138€ per cycle) are at least 6.5 times higher than the costs of indoor simulated training (approximately 21€ per cycle). With a change to simulation, carbon dioxide emissions could potentially be reduced by more than 35 tons. CONCLUSIONS: Indoor simulation training of night HEC operations has advantages with regard to cost-effectiveness, environmental friendliness, and self-reported improvements in skills and knowledge. Its use is feasible and could improve crew and patient safety and fulfill regulatory demands for training intensity.

Challenges of helicopter mountain rescue missions by human external cargo: need for physicians onsite and comprehensive training.

BACKGROUND: Human external cargo (HEC) extrication during helicopter rescue missions is commonly used in mountain emergency medical services. Furthermore, longline or winch operations offer the opportunity to deliver professional medical care onsite. As the safety and quality of emergency medical care depends on training and experience, we aimed to investigate characteristics of mountain rescue missions with HEC. METHODS: We retrospectively reviewed all rescue missions conducted by Air Zermatt (a commercial rescue service in the high-alpine region of Switzerland) from January 2010 to September 2016. RESULTS: Out of 11,078 rescue missions 1137 (10%) required a HEC rescue. In 3% (n = 29) rapid sequence induction and endotracheal intubation, in 2% (n = 14) cardiopulmonary resuscitation, and in 0.4% (n = 3) a chest tube insertion had to be performed onsite prior to HEC extraction. The most common medical intervention onsite is analgesia or analgosedation, in 17% (n = 142) fentanyl or ketamine was used in doses of ≥ 0.2 mg or ≥ 50 mg, respectively. CONCLUSIONS: As these interventions have to be performed in challenging terrain, with reduced personnel resources, and limited monitoring, our results point out the need for physicians onsite who are clinically experienced in these procedures and specially and intensively trained for the specific characteristics and challenges of HEC rescue missions.

Advanced airway management in hoist and longline operations in mountain HEMS - considerations in austere environments: a narrative review This review is endorsed by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM).

BACKGROUND: Providing sufficient oxygenation and ventilation is of paramount importance for the survival of emergency patients. Therefore, advanced airway management is one of the core tasks for every rescue team. Endotracheal intubation is the gold standard to secure the airway in the prehospital setting. This review aims to highlight special considerations for advanced airway management preceding human external cargo (HEC) evacuations. METHODS: We systematically searched MEDLINE, EMBASE, and PubMed in August 2017 for articles on airway management and ventilation in patients before hoist or longline operation in HEMS. Relevant reference lists were hand-searched. RESULTS: Three articles with regard to advanced airway management and five articles concerning the epidemiology of advanced airway management in hoist or longline rescue missions were included. We found one case report regarding ventilation during hoist operations. The exact incidence of advanced airway management before evacuation of a patient by HEC is unknown but seems to be very low (< 5%). There are several hazards which can impede mechanical ventilation of patients during HEC extractions: loss of equipment, hyperventilation, inability to ventilate and consequent hypoxia, as well as inadequacy of monitoring. CONCLUSIONS: Advanced airway management prior to HEC operation is rarely performed. If intubation before helicopter hoist operations (HHO) and human cargo sling (HCS) extraction is considered by the rescue team, a risk/benefit analysis should be performed and a clear standard operating procedure (SOP) should be defined. Continuous and rigorous training including the whole crew is required. An international registry on airway management during HEC extraction would be desirable.

Single-dilator percutaneous tracheostomy: a comparison of PercuTwist and Ciaglia Blue Rhino techniques.

OBJECTIVE: To compare two single-dilator percutaneous tracheostomy techniques, Ciaglia Blue Rhino and the new PercuTwist technique. DESIGN AND SETTING: Randomized, observational clinical trial in patients undergoing elective percutaneous tracheostomy in the intensive care units of a university hospital. PATIENTS: Seventy consecutive, adult patients undergoing either Blue Rhino ( n=35) or PercuTwist tracheostomy ( n=35). INTERVENTIONS: Performance of percutaneous tracheostomy with a novel screwlike dilating device (PercuTwist) or conically shaped, flexible rubber dilator (Blue Rhino). RESULTS: Stoma dilation was successful with the respective device in all patients. While subsequent tracheostomy cannula insertion was uneventful in all but one patients undergoing the Blue Rhino technique, it was difficult or even impossible in eight patients who underwent PercuTwist tracheostomy. Regarding serious and intermediate procedural-related complications, two cases of posterior tracheal wall injury occurred with the PercuTwist technique. No serious or intermediate complications were noted during Blue Rhino tracheostomy. There was no statistical significance between the two techniques in terms of minor and overall complications. CONCLUSIONS: So far the new PercuTwist technique represents an alternative to the established Blue Rhino technique. Nonetheless, the two cases of posterior tracheal wall injury should not be underestimated, on the one hand, but, on the other, may be attributed to a learning curve with a new technique. The new PercuTwist technique should be performed by various teams and in a considerably larger numbers of patients before an ultimate rating can be made.

Comparison of three anesthetic techniques for off-pump coronary artery bypass grafting: general anesthesia, combined general and high thoracic epidural anesthesia, or high thoracic epidural anesthesia alone.

OBJECTIVE: This study compared general anesthesia (GA), combined GA plus thoracic epidural anesthesia (TEA), and TEA alone in patients scheduled for off-pump coronary artery bypass grafting. DESIGN: Prospective, nonrandomized clinical study SETTING: University hospital. PARTICIPANTS: Ninety consenting patients undergoing beating-heart coronary artery revascularization with comparable coronary status and left ventricular function. INTERVENTIONS: GA (n=30) was conducted with propofol, remifentanil, and cisatracurium or combined with TEA (GA+TEA, n=30) or TEA as the sole anesthetic with ropivacaine plus sufentanil (TEA, n=30). MEASUREMENTS AND MAIN RESULTS: Groups were comparable regarding the surgical approaches and the number of anastomoses. Four patients (GA, n=2; GA+TEA, n=2) who required unplanned cardiopulmonary bypass, and 4 patients in the TEA group who underwent unexpected intubation because of pneumothorax (n=2), phrenic nerve palsy, or incomplete analgesia were excluded from further analysis. Intraoperative heart rate decreased significantly with both GA+TEA and TEA. None of the patients with TEA alone was admitted to the intensive care unit, they all were monitored on average for 6 hours postoperatively in the intermediate care unit and allowed to eat and drink as desired on admission. Postoperative pain scores were lower in both groups with TEA. There were no differences among groups in patients overall satisfaction. CONCLUSION: Based on the authors data, all anesthetic techniques were equally safe from the clinicians standpoint. However, GA+TEA appeared to be most comprehensive, allowing for revascularization of any coronary artery, providing good hemodynamic stability and reliable postoperative pain relief. Nonetheless, the actual and potential risks of TEA during cardiac surgery should not be underestimated.

PercuTwist: a new single-dilator technique for percutaneous tracheostomy.

IMPLICATIONS: PercuTwist is a new technique for percutaneous tracheostomy in that stoma dilation is achieved with a unique screwlike dilating device. We describe the technique itself and our first clinical experiences with PercuTwist.

Coronary artery bypass grafting via sternotomy in conscious patients.

The application of high thoracic epidural anesthesia (TEA) as an adjunct to general anesthesia is increasingly being used for coronary artery bypass grafting (CABG) with extracorporeal circulation. Recent developments in beating heart techniques rendered the sole use of TEA in conscious patients possible, and have been reported for single-vessel beating heart CABG via lateral thoracotomy. For multi-vessel revascularization, the heart is usually approached via sternotomy; therefore, the sole use of TEA was applied in awake patients who underwent CABG via sternotomy. A total of 7 patients scheduled for awake coronary artery bypass grafting (ACAB) received TEA via an epidural catheter placed at the levels of T1-2 or T2-3, respectively. Total arterial myocardial revascularization was performed after partial lower sternotomy. Besides standard monitoring, anesthetic levels were determined using an epidural scoring scale for arm movements (ESSAM). While 6 patients were awake and spontaneously breathing during the entire procedure, one patient had to be intubated intraoperatively because of respiratory distress caused by phrenic nerve palsy. Hemodynamics were stable throughout the operation. No significant arterial hypercarbia occurred. All patients rated TEA as "good" or "excellent." We could demonstrate that the single use of TEA for CABG via sternotomy was feasible and that the patients felt well, were painfree, and remained hemodynamically stable. High patient satisfaction in our small and highly selected cohort can be reported. Because beating heart surgery in a conscious patient still carries a significant risk, further randomized controlled trials are mandatory to definitively evaluate the role of sole TEA in cardiac surgery.

High thoracic epidural anesthesia for coronary artery bypass grafting using two different surgical approaches in conscious patients.

Recent developments in coronary artery bypass graft surgery (CABG) without cardiopulmonary bypass made the sole use of high thoracic epidural anesthesia (TEA) in conscious patients feasible. Previously, TEA has been reported only for single-vessel CABG via lateral thoracotomy. We investigated the feasibility and complications of sole TEA in 20 patients undergoing beating-heart arterial revascularization via partial lower sternotomy for single-vessel disease (minimally invasive direct coronary artery bypass grafting [MIDCAB] technique; n = 10) or complete median sternotomy for multivessel disease (off-pump coronary artery bypass grafting [OPCAB] technique; n = 10). An epidural catheter was inserted at the T1-2 or T2-3 interspace. An epidural infusion of ropivacaine 0.5% and sufentanil 1.66 micro g/mL was started to establish anesthetic levels at C5-6 for OPCAB and at T1-2 for MIDCAB. Nine OPCAB and eight MIDCAB procedures were completed while patients were awake and spontaneously breathing during the entire procedure. Because of surgical pneumothorax (OPCAB), insufficient anesthesia, or phrenic nerve palsy (both MIDCAB), three patients required intraoperative conversion to general anesthesia. The heart rate decreased significantly (P < 0.05) by 10%-15% in both groups during the procedure. Compared with baseline (B), mean arterial blood pressure (mm Hg) was decreased significantly only during coronary anastomosis (CA) (B(OPCAB), 95 +/- 11; CA(OPCAB), 68 +/- 9; B(MIDCAB), 86 +/- 10; CA(MIDCAB), 73 +/- 10; P not significant between groups). PaCO(2) increased from 42 +/- 2 mm Hg to 46 +/- 7 mm Hg (P < 0.05) throughout the perioperative course during OPCAB, whereas it remained almost unaltered during MIDCAB procedures. All patients rated TEA as "good" or "excellent." In conclusion, we demonstrated that the sole use of TEA for MIDCAB and OPCAB procedures was feasible and provided a high degree of patient satisfaction in our small and highly selected cohorts. IMPLICATIONS. The sole use of high thoracic epidural anesthesia was studied in 20 patients who underwent beating-heart coronary artery bypass grafting using either median or partial lower sternotomy while awake.