Demographics and functional outcome of shallow water diving spinal injuries in northern Germany - A retrospective analysis of 160 consecutive cases.

AIM: To describe demographic findings, typical injuries and functional neurological outcomes in patients with cervical trauma and tetraplegia sustained after diving into shallow water. PATIENTS AND METHODS: A retrospective study was performed including all patients treated in BG Klinikum Hamburg suffering from tetraplegia after jumping into shallow water between 1st June 1980 and 31st July 2018. RESULTS: One hundred and sixty patients with cervical spinal injuries and tetraplegia following a dive into shallow water were evaluated. Of these, 156 patients (97.5%) were male. The mean age was 24.3 years ± 8.1 and the accidents occurred most often in inland waters (56.2%) and mostly between May and August (90.6%). In all cases there was one vertebra fractured, whereas in 48.1% of cases, two vertebrae were severed. In the majority of cases (n = 146), a surgical procedure was performed. Overall, the mean hospital stay was 202 days (±72, range: 31-403) and one patient died. On admission, 106 patients (66.2%) showed a complete lesion according to AIS A, with incomplete lesions in the remaining 54 patients (AIS B: n = 25 [15.6%], AIS C: n = 26 [16.3%], AIS D: n = 3 [1.9%]). In two thirds of the patients, the level of paralysis on admission was at the level of segments C4 (31.9%) or C5 (33.7%). Seventeen patients (10.6%) needed prehospital resuscitation. In 55 patients (34.4%), the neurological findings improved during the course of inpatient treatment and rehabilitation. Sixty-eight patients (42.5%) developed pneumonia, of which 52 patients (76.5%) were ventilated. In addition, 56.5% of patients with paralysis levels C0-C3 required ventilation, whereas only 6.3% of patients with paralysis levels C6-C7 were affected. Three patients (1.9%) were discharged from hospital with continuous ventilation. Overall, 27.4% of all AIS A patients, 56% of all AIS B patients and 46.2% of all AIS C patients improved neurologically, with 17% of all patients being able to walk. CONCLUSIONS: The consequences of a cervical spine injury after diving into shallow water are severe and lifelong. Functionally, patients may benefit from care in a specialised centre, both in the acute phase and during rehabilitation. The more incomplete the primary paralysis, the greater the possibility of neurological recovery.

Relationship between ambient temperature and severe acute poisoning by alcohol and drugs.

AIM: To test the hypothesis that severe acute poisoning by alcohol and drugs is more frequent at higher rather than at lower ambient temperatures. METHOD: This was a prospective observational study performed in a prehospital setting under marine west coast climate conditions. Data from the Emergency Medical Service in Hamburg (Germany) and data from the local weather station were evaluated over a 5-year period. Temperature data were obtained and matched with the associated rescue mission data, which were divided into the following groups: 1) alcohol poisoning, 2) opioid poisoning, 3) poisoning by sedatives/hypnotics, multiple drugs, volatile solvents, and other psychoactive substances. Lowess-Regression analysis was performed to assess the relationship between ambient temperature and frequency of severe acute poisoning. Additionally, three temperature ranges were defined in order to compare them with each other with regard to frequency of severe poisoning (<10 °C vs. 10-20 °C vs. >20 °C). The severity of emergencies was assessed using the National Advisory Committee for Aeronautics (NACA) scoring system. RESULTS: In 1535 patients, severe acute alcohol or drug poisoning associated with loss of consciousness, hypotension, and impaired respiratory function was treated (alcohol: n = 604; opioids: n = 295; sedatives/hypnotics/multiple drugs: n = 636). Compared to mild temperatures (10-20 °C), the frequency of poisoning increased in all three groups at higher temperatures and decreased at lower temperatures (p < 0.01). No significant correlation was found between severity of emergencies and temperature. CONCLUSIONS: Our results suggest a continuously increasing probability of occurrence of severe acute poisoning by alcohol and drugs with rising temperature.

Association between the experience of violence and burnout among paramedics.

PURPOSE: Similar to many occupational groups in the rescue service, paramedics show increased mental health problems. Both situational and work-organizational factors play a role in the development of mental illnesses. The aim of the study is to investigate the connection of experienced violence and the development of burnout in the paramedical profession. METHODS: To analyze this association, 358 paramedics working for a German metropolitan fire brigade were examined using the Hamburg burnout inventory and a questionnaire on the history of violence, using one-factorial variance analyses, t tests and regression analyses. RESULTS: The examined sample did not show elevated burnout rates, but 97.5% reported that they had already been insulted or spit on while in service. The experience of feeling threatened proved to be a significant predictor for emotional exhaustion and an aggressive response to emotional stress. Also, the experience of being jailed or insulted and the number of years of service are associated with the burnout score. All other experiences showed no significant association with the burnout burden. CONCLUSION: It can be concluded that specific experiences with violence in the service of paramedics can particularly be associated with burnout symptoms. In general, however, violence seems to play a minor role.

Association between Weather-Related Factors and Cardiac Arrest of Presumed Cardiac Etiology: A Prospective Observational Study Based on Out-of-Hospital Care Data.

OBJECTIVE: The objective of this study was to determine the association between weather-related factors and out-of-hospital cardiac arrest (OHCA) of presumed cardiac etiology. METHODS: This was a prospective observational study performed in a prehospital setting. Data from the Emergency Medical Service in Hamburg (Germany) and data from the local weather station were evaluated over a 5-year period. Weather data (temperature, humidity, air pressure, wind speed) were obtained every minute and matched with the associated rescue mission data. Lowess-Regression analysis was performed to assess the relationship between the above-mentioned weather-related factors and OHCA of presumed cardiac etiology. Additionally, varying measuring-ranges were defined for each weather-related factor in order to compare them with each other with regard to the probability of occurrence of OHCA. RESULTS: During the observation period 1,558 OHCA with presumed cardiac etiology were registered (age: 67 ± 19 yrs; 62% male; hospital admission: 37%; survival to hospital discharge: 6.7%). Compared to moderate temperatures (5 - 25°C), probability of OHCA-occurrence increased significantly at temperatures above 25°C (p = 0.028) and below 5°C p = 0.011). Regarding air humidity, probability of OHCA-occurrence increased below a threshold-value of 75% compared to values above this cut-off (p = 0.006). Decreased probability was seen at moderate atmospheric pressure (1000 hPa - 1020 hPa), whereas increased probability was seen above 1020 hPa (p = 0.023) and below 1000 hPa (p = 0.035). Probability of OHCA-occurrence increased continuously with increasing wind speed (p < 0.001). CONCLUSIONS: There are associations between several weather-related factors such as temperature, humidity, air pressure, and wind speed, and occurrence of OHCA of presumed cardiac etiology. Particularly dangerous seem to be cold weather, dry air and strong wind.

Molecular autopsy of sudden unexplained deaths reveals genetic predispositions for cardiac diseases among young forensic cases.

AIMS: Coronary artery disease accounts for the majority of sudden cardiac deaths (SCD) in the older population whereas cardiomyopathies and arrhythmogenic abnormalities predominate in younger SCD victims (<35 years) with a significant genetic component. The elucidation of the pathogenetic cause of death might be relevant for the prevention of further deaths within affected families. Aim of this study was to determine the portion of underlying genetic heart diseases among unexplained putative SCD cases from a large German forensic department. METHODS AND RESULTS: We included 10 forensic cases of sudden unexplained death (SUD) victims aged 19-40 years, who died by SCD due to forensic autopsy. DNA was analysed by next generation panel sequencing of 174 candidate genes for channelopathies and cardiomyopathies. Cardiological examinations, genetic counselling, and subsequent genetic testing were offered to all affected families. We identified within 1 year 10 cases of SUD among 172 forensic cases. Evidence for a genetic disposition was found in 8 of 10 (80%) cases, with pathogenic mutations in 3 and variants of uncertain significance in 5 of SCD cases. Subsequent selective screening of family members revealed two additional mutation carriers. CONCLUSION: The study provides strong evidence that molecular genetics improves the post mortem diagnosis of fatal genetic heart diseases among SUD victims. Molecular genetics should be integrated in forensic and pathological routine practice.

Reduced frequency of severe hypoglycemia at mild ambient temperatures between 10 and 20 °C: A population-based study under marine west coast climate conditions.

AIMS: To determine the association between ambient temperature and severe hypoglycemia. METHODS: This was a prospective observational study performed in a prehospital setting. Data from the Emergency Medical Service in Hamburg (Germany) and data from the local weather station were evaluated over a 5-year period. Lowess-regression analysis was conducted to assess the relationship between ambient temperature and frequency of severe hypoglycemia. Additionally, three temperature-ranges were defined in order to compare them with each other with regard to frequency of severe hypoglycemia (<10°C vs. 10-20°C vs. >20°C). RESULTS: In 2592 patients severe hypoglycemia was diagnosed and treated by emergency physicians (T1DM: n=829/32%; T2DM: n=1763/68%). The median age of patients was 64 (57-72 [20-85]) years. Compared to mild temperatures (10-20°C) the frequency of severe hypoglycemia increased significantly at temperatures above 20°C (+18% (95%-CI: [7%; 22%], p=0.007) and below 10°C (+15% (95%-CI: [6%; 24%], p<0.001). CONCLUSIONS: The results suggest the existence of a "thermal comfort zone" covering a temperature range from 10 to 20°C in which the frequency of severe hypoglycemia was significantly lower than below 10°C and above 20°C.

Relationship between ambient temperature and frequency and severity of cardiovascular emergencies: A prospective observational study based on out-of-hospital care data.

OBJECTIVE: To test the hypothesis that more cardiovascular emergencies occur at low rather than at high temperatures under moderate climatic conditions. METHODS: This was a prospective observational study performed in a prehospital setting. Data from the Emergency Medical Service in Hamburg (Germany) and from the local weather station were evaluated over a 5-year period. Temperature data were matched with the associated rescue mission data. Lowess-Regression analysis was performed to assess the relationship between the temperature and the frequency of individual cardiovascular emergencies. In addition, three threshold-temperatures (0°C, 10°C, 20°C) were defined in order to determine the frequency of cardiovascular emergencies above and below each cut-off value. The severity of emergencies was assessed using the National Advisory Committee for Aeronautics (NACA) scoring system. RESULTS: A total of 35,390 cardiovascular emergencies were treated by Emergency Physicians. Transient Loss of Consciousness increased at high temperatures (above 20°C): +43% (95%-CI: [27%; 59%]). In contrast, Coronary Artery Disease +26% (95%-CI: [17%; 34%]), Cardiac Pulmonary Edema +21% (95%-CI: [14%; 27%]), Hypertensive Urgency +18% (95%-CI: [10%; 25%]) and Cerebrovascular Accident +17% (95%-CI: [8%; 24%]) increased at low temperatures, particularly below 10°C (significance level for all: p<0.001). No temperature-related effect was seen in Cardiac Arrhythmia and Pulmonary Embolism and no significant correlation was found between the severity of emergencies and temperature. CONCLUSIONS: Our findings suggest that some cardiovascular emergencies such as Coronary Artery Disease, Cardiac Pulmonary Edema, Hypertensive Urgency and Cerebrovascular Accident are more frequent in low temperatures even under mild climatic conditions.

Air Medical Evacuations From the German North Sea Wind Farm Bard Offshore 1: Traumatic Injuries, Acute Diseases, and Rescue Process Times (2011-2013).

OBJECTIVE: Our purpose was 2-fold: 1) to show emergency-related traumatic injury and acute disease patterns and 2) to evaluate air rescue process times in a remotely located German offshore wind farm. Optimally, this will support methodologies to reduce offshore help time (time from the incoming emergency call until offshore arrival of the helicopter). METHODS: The type and severity of traumatic injuries and acute diseases were retrospectively analyzed for 39 air medevacs from August 2011 to December 2013, and the process times of air rescue missions were evaluated in detail. RESULTS: Forty-nine percent of the medevacs were related to traumatic injuries, whereas 41% were associated with acute diseases and 10% remained unclear. Cardiovascular and gastrointestinal disorders accounted for 90% of internal medical cases. About 69% of the trauma was related to contusions, lacerations, and cuts. The main body regions injured were limbs (∼59%) and head (∼32%). The total rescue time until arrival at the destination facility averaged 175.3 minutes (standard deviation = 54.4 minutes). The mean helicopter offshore arrival time was 106.9 minutes (standard deviation = 57.4 minutes) after the incoming emergency call. In 64% of the medevacs, the helicopter arrived on scene within a help time of 90 minutes. CONCLUSION: A reduction of help time (≤ 60 minutes) for time-critical severe trauma and acute diseases may be anticipated through rapid and focused medical and logistic decision-making processes by the onshore dispatch center combined with professional, qualified, and well-trained flight and rescue personnel.

[Pre-hospital care management of acute spinal cord injury]. / Die akute traumatische Querschnittslähmung - Wie ist präklinisch vorzugehen?

Acute injury to the spine and spinal cord can occur both in isolation as also in the context of multiple injuries. Whereas a few decades ago, the cause of paraplegia was almost exclusively traumatic, the ratio of traumatic to non-traumatic causes in Germany is currently almost equivalent. In acute treatment of spinal cord injury, restoration and maintenance of vital functions, selective control of circulation parameters, and avoidance of positioning or transport-related additional damage are in the foreground. This article provides information on the guideline for emergency treatment of patients with acute injury of the spine and spinal cord in the preclinical phase.

[Cooperation between emergency and forensic medicine - retrospective evaluation of pre-hospital emergency measures]. / Netzwerk Rechts- und Notfallmedizin - Retrospektive Evaluation präklinischer Notfallmaßnahmen.

Emergency medical research is subject to special conditions. Emergency patients e.g. are generally considered to be non-capable of giving consent. This results in sparse emergency medical data when compared to clinical observation studies under controlled conditions. After emergency medical treatment, deceased patients are not rarely subject to forensic investigation. The cooperation between emergency and forensic medicine has not only emergency medical training potential in individual cases, but also scientific innovation potential especially with respect to the retrospective evaluation of pre-hospital emergency measures. Such partnerships (like in Berlin at the Charité - Universitätsmedizin Berlin between the Institute of Legal Medicine and the Center for Musculoskeletal Surgery or in Hamburg between the Institute for Legal Medicine at the University Hospital and the Municipal Fire Brigade with the Emergency Medical Service) are yet exceptional in Germany.

[Invasive emergency techniques - intraosseous devices]. / Invasive Notfalltechniken - Der intraossäre Zugang.

On-site invasive emergency procedures, such as cricothyroidotomy, chest drainages, intraosseous puncture or the even rarer on-site amputations, are often unavoidable when indicated, and present a major challenge for the emergency physician. Personal, temporal or local conditions are often unsuitable. Even with regular participation in the emergency medical services, "last resort" measures occur very infrequently, particularly in paediatric emergencies. As well as theoretical training, practice-oriented course concepts are essential in order to achieve high quality in these procedures. In this article we describe the use of intraosseous devices on adults and children, with reference to the indication, implementation, problems and risks. It is the third part of a series of four articles on the subject of invasive emergency techniques.

[Spinal cord injury (SCI) - Aspects of intensive medical care]. / Die Querschnittlähmung - Intensivmedizinische Aspekte.

With 2000 new cases/year in Germany spinal cord injury (SCI) is quantitatively less important for intensive care medicine than, e.g., sepsis. But, due to the consequences for the patient, the intricacy of treatment and the enormous costs, it is a significant clinical picture. Outside of specialized centers, routine experience with SCI is largely lacking, particularly in cases of tetraplegia. Dependent on the level of the paralysis, complications in the acute situation, the hospitalization and the rehabilitation are common and need intensive medical care. Lifelong mechanical ventilation is needed in some cases of cervical SCI, for which experience has since grown. New therapeutic options have become implemented (e.g., electrophrenic/diaphragm pacing), have a need to be examined, and extend lifespan in cases of SCI. As a result more patients have a chance for rehabilitation today than in previous decades."

[Injuries caused by acids and bases - emergency treatment]. / Verletzungen durch Säuren und Laugen - Versorgung im Rettungsdienst.

Emergency medical care for injuries caused by acids and bases is challenging for rescue services. They have to deal with operational safety, detection of the toxic agent, emergency medical care of the patient and handling of the rescue mission. Because of the rareness of such situations experience and routine are largely missing. This article highlights some basic points for the therapy and provides support for such rescue missions.

[Invasive emergency techniques--cricothyroidotomy]. / Invasive Notfalltechniken--Die Koniotomie.

On-scene invasive emergency procedures, such as cricothyroidotomy, chest drain, intraosseous puncture or even on-field-amputation, are often unavoidable, when indicated, and present a major challenge for the emergency physician. Personal, temporal or local conditions are often unsuitable. Even with regular intervention by the emergency medical service, "last resort" measures occur very infrequently, particularly in relation to paediatric emergencies. As well as theoretical training, practice-oriented course concepts are essential in order to achieve high quality in these procedures. This article presents the use of cricothyroidotomy on adults and children, with reference to indication, implementation, problems and risks. It is part of a series of four articles on the subject of invasive emergency techniques.

[Invasive emergency techniques--decompression of the pleura]. / Invasive Notfalltechniken--Entlastung des Pleuraraumes.

On-scene invasive emergency procedures, such as cricothyroidotomy, chest drain, intraosseous puncture or even on-field-amputation, are often unavoidable, when indicated, and present a major challenge for the emergency physician. Personal, temporal or local conditions are often unsuitable. Even with regular intervention by the emergency medical service, "last resort" measures occur very infrequently, particularly in relation to paediatric emergencies. Beside a theoretical education, practice-oriented course concepts are necessary to achieve a high quality of these measures. This article presents the use of decompression of the pleura on adults and children, with reference to indication, implementation, problems and risks. It is the second part of a series of four articles on the subject of invasive emergency techniques.

[Mass casualty incidents - current concepts and developments]. / Massenanfall von Verletzten†/†Erkrankten - Aktuelle Aspekte zur medizinischen Versorgung.

Medical concepts and strategies are permanently changing. Due to the emergency response in a mass casualty incident everyone who is involved has to work together with different organisations and public authorities, which are not part of the regular emergency medical service. Within the last 25 years throughout the whole country of Germany the role of a "chief emergency physician" has been implemented and in preparation for the FIFA World Cup 2006 mobile treatment units were set up. In 2007, special units of the "Medical Task Force" - funded by the german state - were introduced and have been established by now. They will be a permanent part of regional plannings for mass casualty incidents. This article highlights current concepts and developments in different parts of Germany.

[Sepsis in emergency medicine--pre-hospital and early in-hospital emergency treatment]. / Die Sepsis in der Notfallmedizin--Präklinische und frühe innerklinische Notfalltherapie.

Sepsis is a complex life threatening disease whose outcome decisively depends on a fast diagnosis and treatment. Emergency Medicine is confronted with the task to identify theses septic patients reliably and initiate early goal directed therapy and treatment with antibiotics as soon as possible to avoid a dangerous delay and reduce sepsis-related mortality. This article presents a review focused on the early steps of sepsis therapy in pre-hospital and early in-hospital emergency medicine.

[Intoxications in the prehospital setting]. / Vergiftungen im Rettungsdienst--Diagnose und Therapie.

Poisoning is an uncommon indication for the activation of the emergency medical service. Personal safety of the rescue team especially in situations with unknown toxins has highest priority. The goal of prehospital treatment includes symptom driven standard procedures as well as a specific treatment by antidotes. Hospital admission is strongly influenced by the further treatment options.

[Bicycle accident on the way to school--an interactive case report]. / Kasuistik interaktiv--Fahrradunfall auf dem Schulweg.

We report on the case of a multiply injured 14-year-old girl with severe open brain trauma, prehospital cardiopulmonary rescuscitation and immediate decompressive craniectomy. Despite the extremely poor prognosis, a very good outcome has been achieved. We discuss the influence of the time management on the outcome.