Mechanical trauma in children and adolescents in Berlin.

Management of severe pediatric trauma remains challenging. Injury patterns vary according to patient age and trauma mechanism. This study analyzes trauma mechanisms in deceased pediatric patients. Fatal pediatric trauma cases aged 0-18 years who underwent forensic autopsy in the Federal State of Berlin, Germany, between 2008 until 2018 were enrolled in this retrospective study. Autopsy protocols were analyzed regarding demographic characteristics, trauma mechanisms, injury patterns, resuscitation measures, survival times as well as place, and cause of death. 71 patients (73% male) were included. Traffic accidents (40%) were the leading cause of trauma, followed by falls from height > 3 m (32%), railway accidents (13%), third party violence (11%) and other causes (4%). While children under 14 years of age died mostly due to traumatic brain injury (59%), polytrauma was the leading cause of death in patients > 14 years (55%). Other causes of death were hemorrhage (9%), thoracic trauma (1%) or other (10%). A suicidal background was proven in 24%. In the age group of > 14 years, 40% of all mortalities were suicides. Cardiopulmonary resuscitation was carried out in 39% of all patients. 42% of the patients died at the scene. Children between 0 and 14 years of age died most frequently from traumatic brain injury. In adolescents between 14 and 18 years of age, polytrauma was mostly the cause of death with a high coincidence of suicidal deaths. The frequency of fatal traffic accidents and suicides shows the need to improve accident and suicide prevention for children and adolescents.

Effects of COVID-19 on a mature citizen first responder system in the German district of Gütersloh: an observational study.

BACKGROUND: The aim of this study was to examine the impact of COVID-19 on the response rate of community-first-responders (CFR) and other out-of-hospital-cardiac-arrest (OHCA) outcomes using the smartphone-first-responder-system (SFRS) "Mobile Retter." METHODS: All adult non-traumatic OHCA in the district of Gütersloh between 01.01.2018-31.12.2021 were included. Periods of interest were 1) prior to the first COVID-19-lockdown; to 2) both lockdowns; and 3) the time in between, as well as after the COVID-19-lockdowns (pre-COVID-19, COVID-19-lockdown and COVID-19-pandemic respectively). The primary outcome was the CFR response rate defined as proportion of CFR alerts that were accepted by a CFR and in which at least one CFR arrived on scene of the emergency out of all CFR alerts. Secondary outcomes included the rate of CFR alerts, defined as proportion of OHCA to which CFR were summoned by the emergency medical dispatcher, as well as the rate of return-of-spontaneous-circulation (ROSC) and rate of survival until hospital discharge. We also examined the incidence COVID-19-infection of CFR in context of the SFRS. RESULTS: A total of 1064 OHCA-patients (mean age: 71.4±14.5 years; female: 33.8%) were included in the study (Pre-COVID-19: 539; COVID-19-lockdown: 109; COVID-19-pandemic: 416). The response rate was 64.0% (pre-COVID-19: 58.7%; COVID-19-lockdown: 63.5%; COVID-19-pandemic: 71.8%, P=0.002 vs. pre-COVID-19). The alert rate was 52.7% (pre-COVID-19: 56.2%; COVID-19-lockdown: 47.7%, P=0.04 vs. Pre-COVID-19; COVID-19-Pandemic: 49.5%, P=0.02 vs. pre-COVID-19). The ROSC-rate was 40.4% (pre-COVID-19: 41.0%; COVID-19-lockdown: 33.9%; COVID-19-pandemic: 41.4%) and hospital discharge rate 31.2% (Pre-COVID-19: 33.0%; COVID-19-lockdown: 36.8%; COVID-19-pandemic: 28.7%). The use of CFR was associated with favorable effects in terms of hospital admission (odds ratio [OR]: 0.654 (CI95: 0.444-0.963), P=0.03), hospital discharge (OR: 2.343 (CI95: 1.002-5.475), P=0.04). None of the CFR became infected with COVID-19. CONCLUSIONS: "Mobile-Retter" was associated with high response rates, improved outcome in OHCA patients and no COVID-19-infections of CFR during the COVID-19-pandemic and -lockdowns.

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.

Mobile phone-based alerting of CPR-trained volunteers simultaneously with the ambulance can reduce the resuscitation-free interval and improve outcome after out-of-hospital cardiac arrest: A German, population-based cohort study.

AIM: To test the hypothesis that simultaneous mobile phone-based alerting of CPR-trained volunteers (Mobile-Rescuers) with Emergency Medical Service (EMS) teams leads to better outcomes in out-of-hospital cardiac arrest (OHCA) victims than EMS alerting alone. METHODS: The outcomes of 730 OHCA patients were retrospectively analysed, depending on who initiated CPR: Mobile-Rescuer-initiated-CPR (n = 94), EMS-initiated-CPR (n = 359), lay bystander-initiated-CPR (n = 277). An adjusted analysis of the intervention and their main outcomes (emergency response time, return of spontaneous circulation, hospital discharge rate, neurological outcomes) was performed (Propensity Score Method with patient matching). RESULTS: Recruited and trained Mobile-Rescuers (n = 740) arrived at the scene in 46% of all triggered alarms. There was a significant difference in response time between Mobile-Rescuers (4 min) and EMS teams (7 min), (p < 0.001). Compared to EMS-initiated-CPR, Mobile-Rescuer-initiated-CPR patients more frequently showed a return of spontaneous circulation, but statistical significance was narrowly missed (p = 0.056). The hospital discharge rate was significantly higher with the Mobile-Rescuer (18%) vs. EMS (7%), (p = 0.049). Good neurological outcomes (Cerebral Performance Categories Score 1 and 2) were seen in 11% of Mobile-Rescuer patients and 4% of EMS patients (p = 0.165). There were no significant differences compared with lay bystander-initiated-CPR. CONCLUSION: Simultaneous alerting of nearby CPR-trained volunteers complementary to professional EMS teams can reduce both the response time and resuscitation-free interval and might improve hospital discharge rate and neurological outcomes after OHCA.

Prehospital non-invasive ventilation in acute respiratory failure is justified even if the distance to hospital is short.

AIMS: Evaluation of the efficacy of prehospital non-invasive ventilation (NIV) in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) and cardiogenic pulmonary edema (CPE). MATERIAL AND METHODS: Consecutive patients who were prehospitally treated by Emergency Physicians using NIV were prospectively included. A step-by-step approach escalating NIV-application from continuous positive airway pressure (CPAP) to continuous positive airway pressure supplemented by pressure support (CPAP-ASB) and finally bilevel inspiratory positive airway pressure (BIPAP) was used. Patients were divided into two groups according to the prehospital NIV-treatment-time (NIV-group 1: ≤15 min, NIV-group 2: >15 min). In addition, a historic control group undergoing standard care was created. Endpoints were heart rate, peripheral oxygen saturation, breathing rate, systolic blood pressure, and a dyspnea score. RESULTS: A total of 99 patients were analyzed (NIV-group 1: n = 41, NIV-group 2: n = 58). The control group consisted of 30 patients. The majority of NIV-patients (90%) received CPAP-ASB, while CPAP without ASB was conducted in 8% and BIPAP-ventilation in 2% of all cases. Technical application of NIV lasted 6.1 ±â€¯3.8 min. NIV-treatment-time was as follows: NIV-group 1: 13.1 ±â€¯3.2 min, NIV-group 2: 22.8 ±â€¯5.9 min. Differences between baseline- and hospital admission values of all endpoints showed significantly better improvement in NIV-groups compared to the control group (p < 0.001). The stabilizing effect of NIV in terms of vital parameters was comparable between both NIV-groups, independent of the duration of treatment (n.s.). CONCLUSION: Prehospital NIV-treatment should be performed in patients with COPD-exacerbation and CPE, even if the distance between emergency scene and hospital is short.

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.

Sedation for advanced procedures in the bronchoscopy suite: proceduralist or anesthesiologist?

PURPOSE OF REVIEW: This article focuses on the issue of sedation provided either by proceduralists or anesthesiologists for advanced bronchoscopy procedures. The relative merits of both approaches are presented. Current evidence from the literature and guideline recommendations relevant to this topic are reviewed. RECENT FINDINGS: In general, patient and proceduralist satisfaction as well as patient safety are increased when intravenous sedation is provided for advanced bronchoscopic procedures. However, guidelines by various societies remain vague on defining the appropriate level of care required when providing sedation for these procedures. In addition, targeted depth of sedation varies considerably among practitioners. While in some settings, nonanesthesiologist-administered propofol sedation has been proven safe; nevertheless, its use is controversial, especially in the bronchoscopy suite. SUMMARY: The role of the anesthesiologist in sedation for advanced bronchoscopy remains undefined. When deep sedation for prolonged interventional procedures is needed or when dealing with patients who have multiple comorbidities, an anesthesiologist should be involved.

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.

Comparative Assessment of Three Approaches of Teaching Nonmedically Trained Persons in the Handling of Supraglottic Airways: A Randomized Controlled Trial.

BACKGROUND: The use of supraglottic airways has been recommended in combat trauma airway management. To ensure an adequate airway management on the battlefield, suitable training concepts are sought to efficiently teach as many soldiers as possible. Our aim was to compare three approaches of teaching laypersons in the handling of supraglottic airways in a mannequin model. METHODS: In this prospective randomized blinded study, 285 military service men without any medical background were divided into three groups and trained in the use of the Laryngeal Mask Airway Supreme (LMA) and the Laryngeal Tube Disposable (LT-D). The first group received a theoretical lecture, the second group was shown an instruction video, and the third group underwent a practical training. Immediately after instruction participants were asked to place the supraglottic airway and ventilate the mannequin within 60 seconds. The entire test was repeated 3 months later. Test results were evaluated with regard to success rate, insertion time, ability to judge the correct placement, and degree of difficulty. RESULTS: Practical training showed the highest success rate when placing supraglottic airways immediately after the instruction (lecture: 68%, video: 74%, training: 94%); (training vs. lecture and training vs. video, p < 0.001) as well as 3 months later (lecture: 63%, video: 66%, training: 78%); (training vs. lecture, p = 0.019 and training vs. video, p = 0.025). Immediately after the instruction practical training was also superior in terms of insertion time, ability to judge the correct placement, and the self-rated degree of difficulty (p < 0.001). These effects were significantly reduced 3 months after the instruction. In comparison between supraglottic airways LT-D was superior to LMA regarding all the outcome parameters mentioned above (p < 0.001). DISCUSSION: In this study, performed with personnel of the German Armed Forces, we have shown that persons without any medical and paramedical background are able to successfully place a supraglottic airway immediately following minimal instruction and after 3 months as well. Study participants achieved the best results after practical training followed by video presentation and finally lecture regardless of the airway device used. There are two possible reasons why practical training is the superior method. Firstly, the success is tied to more time spent with the learners. Secondly, practical training seems to be the best teaching method for various types of learners such as visual, auditory, reading/writing, and kinesthetic type. In addition the results of our study show that the LT-D is an ideal supraglottic airway in the hands of people inexperienced in airway management. In conclusion, our results show that practical training is the superior instruction method compared to theoretical lecture and presentation of an instruction video. Nevertheless, the presentation of an instruction video is a promising approach of teaching a maximum number of laypersons with minimal effort to correctly place supraglottic airways. To optimize the success rate of such a concept LT-Ds instead of LMAs should be used for airway management. The presented concepts hold promise for combat as well as for civilian emergency medicine.

Use of checklists improves the quality and safety of prehospital emergency care.

OBJECTIVES: High-level emergency medical care requires transfer of evidence-based knowledge into practice. Our study is the first to investigate the feasibility of checklists in improving prehospital emergency care. MATERIALS AND METHODS: Three checklists based on standard operating procedures were introduced: General principles of prehospital care, acute coronary syndrome and acute asthma/acutely exacerbated chronic obstructive pulmonary disease. Subsequent to prehospital care and immediately before transport, information on medical history, diagnostic and therapeutic procedures was obtained. Data of 740 emergency missions were recorded prospectively before (control group) and after implementation of checklists and compared using the χ-test (significance level P<0.05). RESULTS: Documentation on patients' history (pre-existing diseases: 69.1 vs. 74.3%; medication: 55.8 vs. 68.0%; allergies: 6.2 vs. 27.7%) and diagnostic measures (oxygen saturation: 93.2 vs. 98.1%; auscultation: 11.1 vs. 19.9%) as well as basic treatment procedures (application of oxygen: 73.2 vs. 85.3%; intravenous access: 84.6 vs. 92.2%) increased significantly. Subanalysis of acute coronary syndrome cases showed a significant increase of 12-lead ECG use (74.3 vs. 92.4%), administration of oxygen (84.2 vs. 98.6%), ASA (71.7 vs. 81.9%), heparin (71.1 vs. 84.0%), ß blockers (39.5 vs. 57.1%) and morphine (26.8 vs. 44.6%). In the chronic obstructive pulmonary disease subgroup, oxygen supply (78.8 vs. 98.5%) and application of inhalative and intravenous ß2-mimetics (42.4 vs. 66.7% and 12.1 vs. 37.9%) increased significantly. CONCLUSION: Introduction of checklists for prehospital emergency care may help to improve adherence to treatment guidelines. Additional efforts (e.g. team trainings) have to be made to increase quality of care.

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.

Perioperative fluid therapy: defining a clinical algorithm between insufficient and excessive.

In the perioperative scenario, adequate fluid and volume therapy is a challenging task. Despite improved knowledge on the physiology of the vascular barrier function and its respective pathophysiologic disturbances during the perioperative process, clear-cut therapeutic principles are difficult to implement. Neglecting the physiologic basis of the vascular barrier and the cardiovascular system, numerous studies proclaiming different approaches to fluid and volume therapy do not provide a rationale, as various surgical and patient risk groups, and different fluid regimens combined with varying hemodynamic measures and variable algorithms led to conflicting results. This review refers to the physiologic basis and answers questions inseparably conjoined to a rational approach to perioperative fluid and volume therapy: Why does fluid get lost from the vasculature perioperatively? Whereto does it get lost? Based on current findings and rationale considerations, which fluid replacement algorithm could be implemented into clinical routine?

[Case Report - Bilateral humeral intraosseous access for CPR in a 3-years-old child]. / Kasuistik - Bilateraler intraossärer Zugang am Humerus bei Reanimation eines 3-Jährigen.

On-scene invasive emergency procedures, such as intraosseous puncture, are often unavoidable, when indicated, and present a 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 pediatric emergencies. For the first time, this case report presents the use of intraosseous access at the humeral head with children, with reference to indication, implementation, problems and risks.

[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.