Patients at Risk for Transfusion-A Six-Year Multicentre Analysis of More Than 320,000 Helicopter Emergency Medical Service Missions.

BACKGROUND: In Europe, ambulances are increasingly being equipped with blood products for prehospital use. Available evidence on the early administration of blood products comes from military medicine and the Anglo-American medical literature; the evidence cannot be easily transferred to European countries. OBJECTIVES: This study assesses the incidence of patients with massive haemorrhage after trauma and the potential need for prehospital blood transfusions. METHODS: Data reported by 37 German air rescue stations between 2015 and 2020 were retrospectively analysed to predict the need for massive transfusion. RESULTS: A total of 320,347 helicopter emergency medical service (HEMS) missions were performed and involved 2982 patients with potential need for massive transfusion after trauma (approximately 13 transfusions per helicopter per year). Men were most affected (73%). The median age of patients was 38 years. Traffic accidents accounted for 59% of the cases. Most patients sustained multiple injuries including traumatic brain injuries (62%), as well as thoracic (54%), abdominal (39%), and extremity injuries (41%). The median "rSIG" (reversed shock index multiplied with the Glasgow Coma Scale) decreased from 4.31 to 3.78. CONCLUSIONS: Although the incidence of haemorrhagic trauma patients is low, the prehospital administration of blood products might be useful as a potentially life-saving bridging treatment until hospital admission.

Education of schoolchildren in cardiopulmonary resuscitation - overview of the current literature.

PURPOSE OF REVIEW: Recognition of cardiac arrest and initiation of cardiopulmonary resuscitation (CPR) can be learned and adequately replicated by schoolchildren. Regular instruction of schoolchildren in CPR is therefore a core element to increase low bystander CPR rates. Thereby, schoolchildren CPR training evolved as own scientific field within the last decade. Aim was to describe current evidence in terms of epidemiology, teaching approaches and political aspects. RECENT FINDINGS: Schoolchildren demonstrate a high motivation to be trained in CPR. Teaching approaches that combine theoretical and practical learning sessions guarantee a sustainable learning effect. Schoolchildren can adequately perform chest compressions and mouth-to-mouth ventilation from the age of 12 years. Use of digital media is a highly promising teaching approach. CPR training conducted by teachers from the own school is effective and guarantees continuous development of CPR skills. Integration of schoolchildren CPR training into school curricula is the foundation for a sustainable increase of lay resuscitation rates in the population. Scientific and political promotion of schoolchildren CPR training is needed to sensitize the population and move bystander CPR in the social focus. SUMMARY: While bystander CPR rates are low in Europe comprehensive establishment of schoolchildren CPR training may sustainably increase survival after cardiac arrest.

[Medical emergencies during running events]. / Notfallmedizinische Aspekte bei Laufveranstaltungen.

Background: The number of short- and long-distance running events in Germany is increasing. Running as a popular sport is practiced by a large number of people of different ages, risk groups, and degrees of professionalism, which results in a wide range of medical emergencies. Objective: The present article elucidates incidence, pathophysiology and therapy of relevant emergencies during running events. Aim was the optimization of work processes of emergency personnel. Materials and methods: A literature search was conducted in PubMed. Results: Exercise-associated muscle cramps, gastrointestinal symptoms, collapse, compartment syndrome, and tendinopathy are common clinical manifestations. Cardiac arrest and sudden cardiac death are rare events. Consciousness and seizures are major complications. Disseminated intravascular coagulation, exercise-associated hyponatremia, heat stroke, rhabdomyolysis, and thromboembolism are associated with high morbidity and mortality. Substances increasing pain resilience as well as performance-enhancing substances are popular among amateur and professional runners and are associated with a high incidence of side effects. Conclusion: General symptoms including vomiting, fever, collapse, muscle-pain, nausea and weakness are the leading symptoms during running events. A careful anamnesis is important for targeted clinical therapy. Symptom control is the main task. Fluid management the most challenging task for healthcare providers in the prehospital setting.

[Diagnosis and Treatment of Severe Fournier's Gangrene: Introduction of a Surgical Approach, Evaluation of Risk Factors, Microbiological Characteristics and Review of the Literature]. / Diagnose und zielgerichtete Therapie der Fournier-Gangrän mit septischem Verlauf: Vorstellung eines Behandlungsalgorithmus, Identifikation von Risikofaktoren, Betrachtung des Mikrobioms und Abgleich mit der Literatur.

BACKGROUND: Fournier's gangrene is a necrotising fasciitis type I occurring in the perineal and genital region. The disease expands progressively and still has poor outcome, especially in critical ill patients. This study's focus was placed on the evaluation of risk factors and comorbidities, on the bacteriological spectrum, laboratory analyses, mortality and the course according to the algorithmic approach. METHOD: The medical records were reviewed of 10 patients with severe Fournier's gangrene from 2010 to 2019 who underwent intensive care therapy for at least 48 hours. Ten patients with Fournier's gangrene and sepsis and intensive therapy lasting at least 48 hours were recorded and analysed descriptively. RESULTS: The patient cohort consisted of six men and four women with a median age of 62 years (range 42 - 78 years). The median time between the onset of symptoms and hospitalisation was four days (range 3 - 5 days). The commonest aetiological event was a minor trauma. Predisposing factors included diabetes mellitus (30%) and overweight (80% BMI > 25). 90% of patients exhibited polymicrobial infection. All patients had systemic sepsis with SOFA-Score between 3 and 17 points. The mortality rate was 40%. Significant differences between surviving and deceased patients were shown by PCT, INR and aPTT (p < 0.05). CONCLUSION: Severe Fournier's gangrene continues to be a major challenge with a high mortality rate. Only rapid diagnosis, urgent extensive surgical debridement and intensive care therapy can lead to a favourable outcome in these critically ill patients. Vacuum-assisted closure can be successfully used in the management of soft-tissue defects.

Status quo of the use of DCS concepts and outcome with focus on blunt abdominal trauma : A registry-based analysis from the TraumaRegister DGU®.

INTRODUCTION: Damage control surgery (DCS) is a standardized treatment concept in severe abdominal injury. Despite its evident advantages, DCS bears the risk of substantial morbidity and mortality, due to open abdomen therapy (OAT). Thus, identifying the suitable patients for that approach is of utmost importance. Furthermore, little is known about the use of DCS and the related outcome, especially in blunt abdominal trauma. METHODS: Patients recorded in the TraumaRegister DGU® from 2008 to 2017, and with an Injury Severity Score (ISS) ≥ 9 and an abdominal injury with an Abbreviated Injury Scale (AIS) score ≥ 3 were included in that registry-based analysis. Patients with DCS and temporary abdominal closure (TAC) were compared with patients who were treated with a laparotomy and primary closure (non-DCS) and those who did receive non-operative management (NOM). Following descriptive analysis, a matched-pairs study was conducted to evaluate differences and outcomes between DCS and non-DCS group. Matching criteria were age, abdominal trauma severity, and hemodynamical instability at the scene. RESULTS: The injury mechanism was predominantly blunt (87.1%). Of the 8226 patients included, 2351 received NOM, 5011 underwent laparotomy and primary abdominal closure (non-DCS), and 864 were managed with DCS. Thus, 785 patient pairs were analysed. The rate of hepatic injuries AIS > 3 differed between the groups (DCS 50.3% vs. non-DCS 18.1%). DCS patients had a higher ISS (p = 0.023), required more significant volumes of fluids, more catecholamines, and transfusions (p < 0.001). More DCS patients were in shock at the accident scene (p = 0.022). DCS patients had a higher number of severe hepatic (AIS score ≥ 3) and gastrointestinal injuries and more vascular injuries. Most severe abdominal injuries in non-DCS patients were splenic injuries (AIS, 4 and 5) (52.1% versus 37.9%, p = 0.004). CONCLUSION: DCS is a strategy used in unstable trauma patients, severe hepatic, gastrointestinal, multiple abdominal injuries, and mass transfusions. The expected survival rates were achieved in such extreme trauma situations.

[Manikin-based comparison of the use of different supraglottic airways by laypersons]. / Vergleich der Anwendung verschiedener extraglottischer Atemwegshilfen durch Laien am Phantom.

BACKGROUND: Supraglottic airways (SGA) are an established method of airway management both in prehospital medicine and clinical settings. Endotracheal intubation is the gold standard, but SGA offer advantages in terms of faster application learnability. OBJECTIVES: In the present study it was investigated whether the time until the first sufficient ventilation in the three examined SGAs applied by bystander differed significantly. MATERIALS AND METHODS: A total of 160 visitors to a shopping mall were assigned to one of the three SGA after permutative block randomization. The primary endpoint of the present study was the required placement time until the first sufficient ventilation. RESULTS: Participants managed to place the i­gel laryngeal mask airway (i-gel, Intersurgical Beatmungsprodukte GmbH, Sankt Augustin, Germany) after a median time of 11 s, whereas the median time until the first sufficient ventilation using a classic laryngeal mask airway (LMA; 26 s) or a laryngeal tube (LT; 28 s) was significantly longer. Thus, the time savings when using the i­gel compared to the LT and LMA were each significant (p < 0.001), whereas the times between LT and LMA did not differ significantly (p 0.65). CONCLUSION: The results show that laypersons are able to successfully apply various supraglottic airways to the phantom after a short learning period. The i­gel laryngeal mask could be placed with the highest success rate and speed.

Anaesthesia protocol evaluation of the videolaryngoscopy with the McGrath MAC and direct laryngoscopy for tracheal intubation in 1000 patients undergoing rapid sequence induction: the randomised multicentre LARA trial study protocol.

INTRODUCTION: Rapid sequence induction of anaesthesia is indicated in patients with an increased risk of pulmonary aspiration. The main objective of the technique is to reduce the critical time period between loss of airway protective reflexes and rapid inflation of the cuff of the endotracheal tube to minimise the chance of aspiration of gastric contents. The COVID-19 pandemic has reinforced the importance of first-pass intubation success to ensure patient and healthcare worker safety. The aim of this study is to compare the first-pass intubation success rate (FPS) using the videolaryngoscopy compared with conventional direct laryngoscopy in surgical patients with a high risk of pulmonary aspiration. METHODS AND ANALYSIS: The LARA trial is a multicentre, patient-blinded, randomised controlled trial. Consecutive patients requiring tracheal intubation are randomly allocated to either the McGrath MAC videolaryngoscope or direct laryngoscopy using the Macintosh laryngoscope. The expected rate of FPS is 92% in the McGrath group and 82% in the Macintosh group. Each group must include a total of 500 patients to achieve 90% power for detecting a difference at the 5% significance level. Successful intubation with the FPS is the primary endpoint. The secondary endpoints are the time to intubation, the number of intubation attempts, the necessity of airway management alternatives, the visualisation of the glottis using the Cormack and Lehane Score and the Percentage Of Glottic Opening Score and definite adverse events. ETHICS AND DISSEMINATION: The project is approved by the local ethics committee of the Medical Association of the Rhineland Palatine state (registration number: 2020-15502) and medical ethics committee of the University of Freiburg (registration number: 21-1303). The results of this study will be made available in form of manuscripts for publication and presentations at national and international meetings. TRIAL REGISTRATION: NCT04794764.

Triage Decisions in the Context of COVID-19: Old Burden, New Challenge-The Structured Approach for Intensive Care Unit Triage (SAINT) Protocol.

INTRODUCTION: The medical treatment facilities (MTF) represent the equivalent of the healthcare system in the home countries, but they face the limitations of an outpost at the end of the supply chain. The capabilities are limited, and the necessary effort to extend the treatment capacity is tremendous. Algorithms based on scientific evidence or at least profound medical expertise are a tool to facilitate the decision-making process in triage under difficult circumstances. The aim of this article is to present a protocol that regards the specific entities military MTF abroad have to deal with in context of the COVID-19 pandemic. MATERIAL AND METHODS: To prepare our own health system within the Resolute Support mission, an interdisciplinary team of consultants and nurses located at the multinational role 2E, Camp Marmal, Mazar-e-Sharif, Afghanistan, individually reviewed medical databases and the current literature concerning triage on intensive care units. The identified literature was evaluated by all authors. In the next step, an adapted flow chart for triage on intensive care unit in MTF abroad was set up on the basis of existing triage tools found in the reviewed literature. RESULTS: The authors created the "Structured Approach for Intensive Care Unit Triage (SAINT)" protocol. It is an approach that fits to the specific entities (e.g., limited medical resources in the whole system, limited intensive care unit capabilities for long-term stay or organ replacement therapy, etc.) that determine the framework of the special military health system abroad. CONCLUSIONS: The presented triage protocol may be a tool for medical personnel to facilitate the difficult task of triaging. It provides guidance along patient-centered criteria like individual medical, ethical, and legal issues while taking into account the available resources. Future studies are needed to investigate the effectiveness of the SAINT protocol.

Facing COVID-19: Early Recognition and Triage Tool for Medical Treatment Facilities With Limited Resources.

INTRODUCTION: Coronavirus Disease 2019 (COVID-19) is spreading all over the world. Health systems around the globe have to deal with decreased capabilities and exhausted resources because of the surge of patients. The need to identify COVID-19 patients to achieve a timely opportunity to treat and isolate them is an ongoing challenge for health care professionals everywhere. A lack of testing capabilities forces clinicians to make the crucial initial decision on the basis of clinical findings and routine diagnostic laboratory test. This article reviews the current literature and presents a new adapted protocol for diagnosing and triaging COVID-19 patients. A special emphasis lies on the stepwise approach guiding the medical provider to a triage decision that is suitable for the individual patient and the situation of the local medical treatment facility. MATERIALS AND METHODS: On March 30, 2020, a PubMed based literature research on COVID-19 following the preferred reporting items for systematic reviews and meta-analyses guidelines was performed. A diagnostic and triage tool for COVID-19 was designed based on the major findings in the reviewed literature. RESULTS: After a selection process, focusing on the topics "epidemiology," "clinical characteristics," and "diagnostic tools," 119 out of a total amount of 1,241 publications were selected to get an overview of the growing evidence. CONCLUSIONS: The designed Early Recognition and Triage Tool enables the medical provider to use the applicable modules of the protocol for capabilities of the local setting to get the most appropriate diagnostic and triage done. The tool should give guidance for the initial approach until specific testing for the COVID-19 virus is available.

Airway management techniques in a restricted-access situation: a manikin study.

BACKGROUND: Access to patients can be restricted in emergency situations. A variety of techniques and devices are available for use in patients who require oxygenation in a restricted-access situation. OBJECTIVES: The aim of this study was to investigate whether there is one ventilation technique that is superior to others. MATERIALS AND METHODS: Fifty-four emergency medical services providers including emergency medical technicians, paramedics and physicians were asked to use a bag-valve mask (BVM), a laryngeal mask airway (LMA), and a laryngeal tube (LT) to ventilate a full-scale manikin sitting upright in the driver's seat of a motor vehicle. Access to the manikin was gained through the side window and from the backseat. RESULTS: There were significant differences in time to first successful ventilation between the two approaches for access to the airway. The fastest median time to ventilation was obtained with the BVM (7 and 8 s), followed by the LT (13 and 14 s) and the LMA (15 s for both types of access). Overall success rates were 97.2% for the BVM, 96.3% for the LMA, and 100% for the LT. Most participants needed two attempts for each device. There were no significant differences between participants depending on the level of qualification or professional experience. The BVM was rated the lowest and the LT was rated the highest for ease of use. CONCLUSION: Supraglottic airway devices appear to offer advantages in restricted-access situations.

Laryngeal tube placement on manikin by laypersons: is there a possibility for 'public access airway management'?

Mouth-to-mouth ventilation is often refused by laypersons because of hygienic reasons. Supraglottic airway devices (SADs) might reduce the adverse effects of mouth-to-mouth ventilation. We tried to verify the possibility for untrained laypersons to use SADs properly after having read written instructions only. The participants were told to ventilate a manikin using a laryngeal tube (LT). The time to ventilation and the rate of success were recorded. After a practical skill demonstration, a second placement of the LT was performed. A successful placement of the LT was achieved by 53% after the first and 98% after the second attempt. Time to ventilation was 124 s (±45 s) for the first attempt and 12 s (±2.75 s) for the second attempt. Delivering ventilation through an SAD is a reasonable way for laypersons. After a prior hands-on training, the placement can be performed in an adequate time frame with high success rates.