[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.

[Role of university hospitals in Bavaria during the COVID-19 pandemic]. / Die Universitätsmedizin in Bayern im Rahmen der COVID-19-Pandemie.

BACKGROUND: In early 2020 the German healthcare system was put into a state of emergency due to the coronavirus disease 2019 (COVID-19) pandemic. Bavaria had to deal with more severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections than any other German state during the first wave and currently has over 270,000 cases, accounting for about one fifth of all COVID-19 cases in Germany. The Bavarian Ministry of Interior together with the Bavarian Sate Ministry of Health and Care issued a general ruling at the beginning of the first wave that ordered the centralised organisation of hospital capacity, a redesign of the information technology (IT) management system and introduced reporting obligations for SARS-CoV-2/COVID-19. The goal of this analysis was to investigate the role that university hospitals played in the inpatient treatment of COVID-19 patients. METHODS: A retrospective evaluation of all inpatient COVID-19 cases that were reported through the "IVENA Sonderlage" (Ivena eHEALTH, [IVENA, interdisziplinärer Versorgungsnachweis, mainis IT-Service GmbH, Offenbach am Main, Germany]), a special module for the "Interdisciplinary Medical Care Capacity Management System" designed for extraordinary events and circumstances, was conducted by analysing the number of reported treatment days of all Bavarian hospitals that participated in the treatment of COVID-19 patients. RESULTS: During the first wave university hospitals provided relevant scientific contributions and played an important role in advising physicians, hospitals and politicians on the pandemic. In all, 20% of intensive care unit (ICU) and intermediate care (IMC) treatment days were provided by the university hospitals in particular for treatment of complex courses of COVID-19.

[Operation preparation in trauma surgery]. / Operationsvorbereitung in der Unfallchirurgie.

The success of a surgical procedure is significantly influenced by several critical factors. The safety of the patient is the primary goal. To this end, the term surgical preparation covers a number of procedures aiming to ensure the safety for the patient and a successful surgical intervention: verifying the indications, planning the intervention, identification of potential harmful factors, risks and countermeasures, patient education and documentation. Trauma surgery poses a particular challenge to preoperative preparation, especially due to urgent surgical interventions. Here, a standardized and evidence-based preoperative evaluation ensures a successful treatment of the patient.

[Numbers of emergency room patients during the COVID-19 pandemic]. / Patientenzahlen im Rahmen der COVID-19-Pandemie in einer zentralen Notaufnahme.

BACKGROUND: Since end of March, the health care system in Germany has been placed into a state of emergency in order to gain resources for the spreading coronavirus disease 2019 (COVID-19) pandemic. The overall goal of this study is to evaluate the number of emergency room patients at the time of the pandemic in order to draw conclusions about the influence of the COVID 19 pandemic on the number of patients in an emergency department. MATERIALS AND METHODS: With this descriptive epidemiologic study we collected and analyzed anonymized patient-related data of 19,357 cases presenting to the emergency department of the Klinikum rechts der Isar (Munich) from 01 February 2019 to 30 April 2019 and from 01 February 2020 to 30 April 2020. RESULTS: Despite an increase in the number of patients from 2019 to 2020, there was a significant drop in the number of emergencies from February to March 2020 and proceeding in April to a level below that of 2019. This was particularly observed in the field of trauma surgery, with a 40% decrease in the number of patients. With regard to the individual complaint patterns in March 2020, it was found that an increased incidence of malaise (+47%) and breathing problems (+36%) was recorded, whereas back pain (-41%), wounds (-29%), thoracic (-24%) and abdominal pain (-23%) were significantly less common than in the previous year. In terms of the severity of the complaints, the decline was mainly due to complaints with a low degree of urgency. CONCLUSION: In the course of the COVID-19 pandemic we observed a significant decline in the number of patients in one of the largest emergency rooms in Munich. This has to be avoided with existing hospital capacities, in order to prevent potential damage to health caused by postponed or missing emergency presentations.

[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.

[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.

[Importance of trauma and emergency surgery for German metropolitan emergency departments-an analysis of 524,716 emergency patients]. / Stellenwert der Unfallchirurgie für die Notaufnahmen einer deutschen Millionenstadt ­ Eine Auswertung von 524.716 Notfallpatienten.

BACKGROUND: The future of emergency departments in Germany is influenced by increasing numbers of patients, demographic changes, new therapeutic concepts, current legislation and expert opinions. There is a lack of reliable data concerning the quantity and the type of injuries and diseases presenting in emergency departments. MATERIAL AND METHODS: This descriptive, epidemiological study included 14 emergency departments in Munich (1.41 million inhabitants in 2014), where 524,716 patients were treated from 1 July 2013 to 30 June 2014. 393,587 were included in this prospectively planned subgroup analysis. Patients presenting in special departments, such as gynecology or ophthalmology (59,523) or cases without a documented diagnosis (71,606) were excluded. Cases were assigned to the discipline trauma surgery or orthopedics according to the ICD-10 diagnosis chapters "injuries, poisoning and certain other consequences of external causes" and "diseases of the musculoskeletal system and connective tissue". RESULTS: Of the 393,587 cases included, 169,208 were treated due to trauma or orthopedic diseases (43%). 134,507 underwent outpatient treatment (79%) and 34,701 were admitted on the same day (21%). 29,920 patients suffered from head injuries (18%), 31,143 fractures (20%) and 24,367 deep wounds (14%) were recorded. On workdays between 8am and 10am, up to 47 patients per hour were treated and between 1pm and 3pm, up to 36 patients per hour. On weekends, most patients presented between 11am and 7pm. CONCLUSION: The present study analyzed the frequency of major diagnoses corresponding to the various medical disciplines including more than 500,000 patients. Of the emergency cases included, 43% were allocated to trauma surgery or orthopedics. These patients presented in the emergency departments around the clock and necessitate the permanent attendance of a trauma and emergency surgeon. Thereby, timely surgical care and decisions regarding indications for surgery and admission are ensured. Competence in trauma and emergency surgery is therefore essential for emergency departments.

Closure simulation for reduction of emergency patient diversion: a discrete agent-based simulation approach to minimizing ambulance diversion.

BACKGROUND: The city of Munich uses web-based information system IVENA to promote exchange of information regarding hospital offerings and closures between the integrated dispatch center and hospitals to support coordination of the emergency medical services. Hospital crowding resulting in closures and thus prolonged transportation time poses a major problem. An innovative discrete agent model simulates the effects of novel policies to reduce closure times and avoid crowding. METHODS: For this analysis, between 2013 and 2017, IVENA data consisting of injury/disease, condition, age, estimated arrival time and assigned hospital or hospital-closure statistics as well as underlying reasons were examined. Two simulation experiments with three policy variations are performed to gain insights on the influence of diversion policies onto the outcome variables. RESULTS: A total of 530,000+ patients were assigned via the IVENA system and 200,000+ closures were requested during this time period. Some hospital units request a closure on more than 50% of days. The majority of hospital closures are not triggered by the absolute number of patient arrivals, but by a sudden increase within a short time period. Four of the simulations yielded a specific potential for shortening of overall closure time in comparison to the current status quo. CONCLUSION: Effective solutions against crowding require common policies to limit closure status periods based on quantitative thresholds. A new policy in combination with a quantitative arrival sensor system may reduce closing hours and optimize patient flow.

[Cardiopulmonary resuscitation in cardiac arrest following trauma]. / Reanimation nach Trauma.

For decades, survival rates of cardiac arrest following trauma were reported between 0 and 2 %. Since 2005, survival rates have increased with a wide range up to 39 % and good neurological recovery in every second person injured for unknown reasons. Especially in children, high survival rates with good neurologic outcomes are published. Resuscitation following traumatic cardiac arrest differs significantly from nontraumatic causes. Paramount is treatment of reversible causes, which include massive bleeding, hypoxia, tension pneumothorax, and pericardial tamponade. Treatment of reversible causes should be simultaneous. Chest compression is inferior following traumatic cardiac arrest and should never delay treatment of reversible causes of the traumatic cardiac arrest. In massive bleeding, bleeding control has priority. Damage control resuscitation with permissive hypotension, aggressive coagulation therapy, and damage control surgery represent the pillars of initial treatment. Cardiac arrest due to hypoxia should be resolved by airway management and ventilation. Tension pneumothorax should be decompressed by finger thoracostomy, pericardial tamponade by resuscitative thoracotomy. In addition, resuscitative thoracotomy allows direct and indirect bleeding control. Untreated impact brain apnea may rapidly lead to cardiac arrest and requires quick opening of the airway and effective oxygenation. Established algorithms for treatment of cardiac arrest following trauma enable a safe, structured, and effective management.

[Pretreatment mass casualty incident workflow analysis : Comparison of two level 1 trauma centers]. / Prätherapeutische Ablaufanalyse bei einem Massenanfall von Verletzten : Vergleich von zwei Traumazentren der höchsten Versorgungsstufe.

BACKGROUND: Mass casualty incidents (MCI) have particularly high demands on patient care processes but occur rather rarely in daily hospital routine. Therefore, it is common to use simulations to train staff and to optimize institutional processes. OBJECTIVES: Aim of study was to compare the pre-therapeutic in-house workflow of two differently structured level 1 trauma sites in the case of a simulated mass casualty incident (MCI). MATERIALS AND METHODS: A MCI of 70 patients was simulated by actors in a manner that was as realistic as possible. The on-site triage assigned 7 cases to trauma site A with relatively long in-house distances and 4 patients to an independent trauma site B in which these distances were relatively short. During in-house treatment, time intervals for reaching milestones were measured and compared using the Mann-Whitney U test. RESULTS: As no simultaneous patient arrival occurred, the Patient Distribution Matrix proved to be effective. Site A needed more time (minutes) from admission to endpoints (A: 31.85 ± 7.99; B: 21.62 ± 4.76; p = 0.059). In detail, the time intervals were particularly longer for both patient stay in trauma room (A: 8.46 ± 3.02; B: 2.73 ± 0.78, p < 0.01) and transfer time to the CT room (A: 1.81 ± 0.62; B: 0.06 ± 0.03, p < 0.01). A shorter stay in the CT room did not compensate these effects (A: 8.86 ± 1.84; B: 10.40 ± 2.89, p = 0.571). For both sites, image calculation and distribution were relatively time consuming (17.36 ± 3.05). CONCLUSIONS: Although short in-house distances accelerated pretherapeutic treatment processes significantly, both sites remained clearly within the "golden hour". The strongest potential bottleneck was the time interval until images were available at the endpoints.

[Relevance of Vascular Trauma in Trauma Care - Impact on Clinical Course and Mortality]. / Bedeutung des Gefäßtraumas für die Schwerverletztenversorgung ­ Einfluss auf Verlauf und Mortalität.

There is a lack of evidence as to the relevance of vascular trauma (VT) in patients with severe injuries. Therefore, we reviewed registry data in the present study in order to systematically objectify the effect of VT in these patients. This study aimed to provide an adequate picture of the relevance of vascular trauma and to identify adverse prognostic factors. In a retrospective analysis of records from the TraumaRegister DGU® (TR-DGU) in two subgroups with moderate and severe VT, we examined the records for differences in terms of morbidity, mortality, follow-up and prognostic parameters compared to patients without VT with the same ISS. From a total of 42,326 patients, 2,961 (7 %) had a VT, and in 2,437 cases a severe VT (AIS ≥ 3) was diagnosed (5.8 %). In addition to a higher incidence of shock and a 2 to 3-fold increase in fluid replacement and erythrocyte transfusion, patients with severe VT had a 60 % higher rate of multiple organ failure, and in-hospital mortality was twice as high (33.8 %). The massively increased early mortality (8.0 vs. 25.2 %) clearly illustrates how severely injured patients are placed at risk by the presence of a relevant VT with a comparable ISS. In our opinion, due to an unexpected poor prognosis in the TR-DGU data for vascular injuries, increased attention is required in the care of severely injured patients. Based on our comprehensive analysis of negative prognostic factors, a further adjustment to the standards of vascular medicine could be advisable. The influence of the level of care provided by the admitting hospital and the relevance of a further hospital transfer to prognosis and clinical outcome is currently being analysed.

[General principles of wound management in emergency departments]. / Grundlegende Techniken des Wundverschlusses in der Notaufnahme.

Wound management is one of the major tasks in emergency departments. The surrounding intact skin but not the wound itself should be disinfected before starting definitive wound treatment. Hair should first be removed by clipping to 1-2 mm above the skin with scissors or clippers as shaving the area with a razor damages the hair follicles and increases the risk of wound infections. Administration of local anesthetics should be performed directly through the exposed edges of the wound. After wound examination, irrigation is performed with Ringer's solution, normal saline or distilled water. The next step is débridement of contaminated and devitalized tissue. There are several wound closure techniques available, including adhesive tapes, staples, tissue adhesives and numerous forms of sutures. Management of specific wounds requires particular strategies. A bleeding control problem frequently occurs with scalp lacerations. Superficial scalp lacerations can be closed by alternative wound closure methods, for example by twisting and fixing hair and the use of tissue adhesives, i.e. hair apposition technique (HAT). For strongly bleeding lacerations of the scalp, the epicranial aponeurosis should be incorporated into the hemostasis. Aftercare varies depending on both the characteristics of the wound and those of the patient and includes adequate analgesia as well as minimizing the risk of infection. Sufficient wound aftercare starts with the treating physician informing the patient about the course of events, potential complications and providing relevant instructions.

[Retrospective computation of the ISS in multiple trauma patients: Potential pitfalls and limitations of findings in full body CT scans]. / Retrospektive Berechnung des ISS bei polytraumatisierten Patienten: Fehlerquellen und Anforderungen an den radiologischen Befund der Ganzkörper-CT.

INTRODUCTION: The Injury Severity Score (ISS) is a well-established anatomical scoring system for polytraumatized patients. However, any inaccuracy in the Abbreviated Injury Score (AIS) directly increases the ISS impreciseness. Using the full body computed tomography (CT) scan report, ISS computation can be associated with certain pitfalls. This study evaluates interpretation variations depending on radiological reports and indicates requirements to reliably determine the ISS. MATERIALS AND METHODS: The ISS of 81 polytraumatized patients was calculated based on the full body CT scan report. If an injury could not be attributed to a precise AIS cipher, the minimal and maximal ISS was computed. Real ISS included all conducted investigations, intraoperative findings, and final medical reports. The differences in ISS min, ISS max, and ISS real were evaluated using the Kruskal-Wallis test (p<0.05) and plotted in a linear regression analysis. RESULTS: Mean ISS min was 24.0 (± 0.7 SEM) points, mean ISS real 38.6 (±1.3 SEM) and mean ISS max was 48.3 (±1.4 SEM) points. All means were significantly different compared to one another (p<0.001). The difference between possible and real ISS showed a distinctive variation. Mean deviation was 9.7 (±0.9 SEM) points downward and 14.5 (±1.1 SEM) points upward. The difference between deviation to ISS min and ISS max was highly significant (p<0.001). CONCLUSION: Objectification of injury severity in polytraumatized patients using the ISS is an internationally well-established method in clinical and scientific settings. The full body CT scan report must meet distinct criteria and has to be written in acquaintance to the AIS scale if intended to be used for correct ISS computation.

[Cardiac post-resuscitation care. An indication for trauma whole-body CT?]. / Zustand nach Reanimation. Eine Indikation für die "Traumaspirale"?

We report the case of a 51-year-old male patient who sustained a liver rupture following mechanical cardiopulmonary resuscitation (CPR) with the LUCAS® system. The patient was under anticoagulation and developed an abdominal compartment syndrome. Although the use of mechanical CPR devices, such as the LUCAS® system and the load distributing band (Autopulse®), is becoming more common, there are specific complications described in the literature, which are associated with mechanical CPR. It is important to differentiate between general complications associated with CPR and those which can be attributed to the application of mechanical CPR devices. Using the example of the presented case, this article outlines and discusses these points based on the currently available literature. It should also be noted that mechanical CPR can act in a similar way to chest trauma and can necessitate an investigation with contrast enhanced computed tomography.