[Childhood emergencies-worsening healthcare bottlenecks for children in a systematic long-term analysis of the EMS system in a German metropolis]. / Der Notfall beim Kind ­ zunehmende Versorgungsengpässe für Kinder in einer systematischen Langzeitanalyse des Rettungssystems einer deutschen Metropole.

BACKGROUND: Children have the right to the best possible medical care. The lack of treatment capacity is rising steadily and increasingly leads to forced centralized allocation of patients by the emergency medical services (EMS) to pediatric emergency departments that are, officially, temporarily "closed". AIM: The aim of this study is to present trends in allocation of pediatric emergency patients in greater Munich. MATERIALS AND METHODS: Retrospective analysis of hospital admissions of children < 18 years of age collected from 01 January 2015 to 31 December 2019 by means of the web-based IT system IVENA eHealth (manis IT, Frankfurt) used by the emergency medical services. The focus of the evaluation is on patients in category II, who are likely to require inpatient admission. RESULTS: During the 5­year observation period, a total of 44,549 pediatric patients < 18 years of age (90.6% of total admissions) were admitted to a children's hospital by the ambulance service as category II (SKII) in the Munich metropolitan area. These patients showed an increase in the relative frequency of forced allocations from 1.7% (2015) to 9.4% (2019). Parallel to this, there is an increasing frequency of time intervals over the years in which all children's hospitals were temporarily closed due to lack of treatment availability, especially in the winter half-year. CONCLUSION: In the examined period from 2015 to 2019, there has been a relevant increase in the number of forced allocations to children's hospitals by the emergency medical services in the Munich area. This observed trend is likely to persist over the coming years, in view of current staff shortages and diminishing hospital capacities.

[Unguis incarnatus-conservative or operative treatment? A practical treatment algorithm]. / Unguis incarnatus ­ konservative oder operative Therapie? Ein praktischer Behandlungsalgorithmus.

Unguis incarnatus, an ingrown toenail, is a common condition in primary care, which is encountered by various medical professions. Inconsistent conservative treatment and nonindicated surgical treatment often result in complications and recurrence of the disease. Patients must be thoroughly informed about the complexity of the nail organ. This is a prerequisite to prevent trivialization of the disease and to achieve appropriate patient compliance for treatment. In this article a practical diagnostic and treatment algorithm for unguis incarnatus is presented. In mild cases of acute unguis incarnatus a consistent conservative treatment is the first-line strategy showing promising results. In cases of moderate to severe forms of acute unguis incarnatus, surgical procedures that preserve the nail matrix should be applied. For cases of chronic unguis incarnatus without an acute infection, elective partial matrixectomy can be indicated. Prior to any surgical intervention, detailed informed consent must be obtained from the patients.

[Prognostic implications of stone heart syndrome in cardiac arrest]. / Stellenwert des "Stone-heart"-Phänomens bei Herz-Kreislauf-Stillstand.

The stone heart syndrome is defined as an ischemic systolic contracture of the heart and also termed contractile cardiac arrest. It was first described in 1972 by the American cardiac surgeon Denton Cooley, who observed this phenomenon during bypass surgery. It is mostly the result of prolonged cardiac arrest where myocardial cells suffer hypoxia or anoxia. Insufficient forward blood flow and a decreased pressure gradient in the central aorta lead to reduced coronary perfusion. The resulting anaerobic metabolism causes an ischemic contracture as described in the stone heart syndrome. This article presents three cases of patients with traumatic cardiac arrest (TCA) and myocardial contracture in postmortem computed tomography (PMCT) and discuss the origins of the stone heart syndrome as well as its implications in cardiopulmonary resuscitation.

[Flawed initial treatment of dog bite injury]. / Fehlerhafte Erstversorgung einer Hundebissverletzung.

A 73-year-old male patient suffered multiple dog bites to the left hand and lower arm. The initial treatment in hospital consisted of conservative treatment with wound closure strips and bandages. For further treatment the patient was referred to the general practitioner who found a discharge of pus below the wound closure strips 2 days later. On the 3rd day the patient was admitted to a different hospital where surgical treatment with débridement, placement of vacuum bandages and subsequent flap plasty was conducted on admission. An examination 1 year later revealed stabbing pain over the carpometacarpal joint radiating into the thumb, hypoesthesia of the back of the hand, numbness of the thumb on the ulnar side, reduced range of movement in the wrist and thumb and suspected development of a neuroma. In the subsequent arbitration procedure, the patient criticized the initial treatment and claimed that the bite wounds were not cleansed and were then closed with wound closure strips without antibiotic treatment. This was assumed to have caused extensive infection, which required surgical treatment and caused lasting complaints. The arbitration board report determined an insufficient initial clinical assessment and a faulty wound care resulting in, among other things, reduced range of movement of all fingers of the left hand.

On-the-Scene Hyaluronan and Syndecan-1 Serum Concentrations and Outcome after Cardiac Arrest and Resuscitation.

BACKGROUND: It is not predictable which patients will develop a severe inflammatory response after successful cardiopulmonary resuscitation (CPR), also known as "postcardiac arrest syndrome." This pathology affects only a subgroup of cardiac arrest victims. Whole body ischemia/reperfusion and prolonged shock states after return of spontaneous circulation (ROSC) may both contribute to this devastating condition. The vascular endothelium with its glycocalyx is especially susceptible to initial ischemic damage and may play a detrimental role in the initiation of postischemic inflammatory reactions. It is not known to date if an immediate early damage to the endothelial glycocalyx, detected by on-the-scene blood sampling and measurement of soluble components (hyaluronan and syndecan-1), precedes and predicts multiple organ failure (MOF) and survival after ROSC. METHODS: 15 patients after prehospital resuscitation were included in the study. Serum samples were collected on the scene immediately after ROSC and after 6 h, 12 h, 24 h, and 48 h. Hyaluronan and syndecan-1 were measured by ELISA. We associated the development of multiple organ failure and 30-day survival rates with these serum markers of early glycocalyx damage. RESULTS: Immediate serum hyaluronan concentrations show significant differences depending on 30-day survival. Further, the hyaluronan level is significantly higher in patients developing MOF during the initial and intermediate resuscitation period. Also, the syndecan-1 levels are significantly different according to MOF occurrence. CONCLUSION: Serum markers of glycocalyx shedding taken immediately on the scene after ROSC can predict the occurrence of multiple organ failure and adverse clinical outcome in patients after cardiac arrest.

[Influence of massive blood transfusion and traumatic brain injury on TIMP­1 and MMP­9 serum levels in polytraumatized patients]. / Der Einfluss von Massentransfusion und Schädel-Hirn-Trauma auf die Seruminflammationsmarker TIMP­1 und MMP­9 bei polytraumatisierten Patienten.

BACKGROUND: The morbidity and mortality of polytrauma patients are substantially influenced by the extent of the posttraumatic inflammatory reaction. Studies have shown that TIMP­1 and MMP­9 play a major role in posttraumatic immune disorder in genome-wide mRNA microarray analyses. Furthermore, both showed differential gene expression profiles depending on the clinical parameters massive blood transfusion and traumatic brain injury. OBJECTIVE: The aim of this study was to evaluate TIMP­1 and MMP­9 serum concentrations in polytraumatized patients depending on the clinical parameters massive blood transfusion and traumatic brain injury in the early posttraumatic phase. MATERIAL AND METHODS: Polytrauma patients (≥18 years) with an "Injury Severity Score" (ISS) ≥ 16 points were enrolled in this prospective study. Serum levels of TIMP­1 and MMP­9 were quantified (at 0 h, 6 h, 12 h, 24 h, 48 h and 72 h) using an enzyme-linked immunosorbent assay (ELISA). Groups were divided according to the clinical parameter massive blood transfusion (≥10 red blood cell units [RBC units] in the first 24-hour posttrauma) and traumatic brain injury (CCT postive [cranial computed tomography]). RESULTS: Following massive blood transfusion (n = 21; 50 ± 15.7 years; ISS 39 ± 12.8 points) patients showed overall significantly increased TIMP­1 levels (p = 0.003) and significantly higher TIMP­1 values after 12-72 h. Traumatic brain injury patients (n = 28; 44 ± 19 years; ISS 42 ± 10 points) showed significantly higher MMP­9 levels (p = 0.049) in the posttraumatic period. CONCLUSION: Polytraumatized patients who received massive blood transfusions following major trauma showed significantly higher TIMP­1 levels than patients who did not receive massive transfusions. This seems to be an expression of a massively excessive inflammatory reaction and therefore represents a substantial factor in the pathogenesis of severe posttraumatic immune dysfunction in this collective. Furthermore, the significant increase in MMP­9 with accompanying traumatic brain injury reflects the pivotal role of matrix metalloproteinases in the pathophysiology of traumatic brain injury.