[Restructuring of inpatient emergency treatment : What will change?] / Neustrukturierung der stationären Notfallversorgung : Was ändert sich?

The resolution on the restructuring of inpatient emergency treatment was passed by the Federal Joint Committee (G-BA) on 19 April 2018 based on the Hospital Structure Act and became binding with the publication in the Bundesanzeiger on 18 May 2018. The resolution describes the future structural and qualitative prerequisites for participation of hospitals in the provision of emergency treatment in three levels: basic emergency treatment, extended emergency treatment and comprehensive emergency treatment. Furthermore, a level of nonparticipation is also planned. In addition, there are special modules, e.g. for the treatment of children and auxiliary modules for specifically equipped hospitals with highly specialized patient treatment (e.g. stroke unit). A transition regulation period of 3-5 years provides hospitals with the possibility to adjust to the new minimum requirements. The German Hospital Federation (DKG) and the National Association of Statutory Health Insurance Funds (GKV-SV) will negotiate the assessment of surcharges and deductions subsequent to the resolution.

The discriminative value of blood gas analysis parameters in the differential diagnosis of transient disorders of consciousness.

AIM: The differentiation between epileptic and non-epileptic episodes can be challenging. Our aim was to compare lactate, anion gap (AG), bicarbonate and the Denver Seizure Score (DSS) as point-of-care test (POCT) markers for episodes of transient alterations of consciousness. METHODS: The blood serum parameters were drawn at arrival in the emergency department (ED) within 2 h of the episode. After calculating AG and DSS values, the four parameters were compared retrospectively between patients with generalized tonic-clonic seizures (GTCS) (n = 165) and patients with other disorders of consciousness [syncopes (n = 43), and psychogenic non-epileptic seizures (n = 15)]. Additionally, we compared all values among men and women. RESULTS: In GTCS patients, all four parameters differed significantly compared to non-epileptic episode patients (p < 0.001). Serum lactate showed significant additional benefit over the remaining values, with an AUC of 0.947 (95% CI 0.92-0.975) and a high sensitivity and specificity for an optimal cut-off value of 2.45 mmol/l. For DSS, the AUC was 0.857 (95% CI 0.808-0.906; cut-off: 0.35), and for AG 0.836 (95% CI 0.783-0.889; cut-off: 12.45 mmol/l). In the case of serum bicarbonate, the AUC was 0.831 (95% CI 0.775-0.886; cut-off: 22.75 mmol/l). In the sex-dependent comparison, the results were similar. Men showed more significant differences in the compared values than women. CONCLUSIONS: Serum lactate is best suited as POCT marker in the differential diagnosis of epileptic and non-epileptic episodes and is superior to AG, DSS and bicarbonate. The differences among sexes may pose a challenge in their implementation and interpretation.

[Laboratory diagnostics in transient loss of consciousness : Serum lactate compared to serum creatine kinase as diagnostic indicator for generalized tonic-clonic seizures]. / Labordiagnostik bei transienten Bewusstseinsstörungen : Serumlaktatwert im Vergleich zur Serumkreatinkinase als diagnostischer Indikator für generalisierte tonisch-klonische Anfälle.

BACKGROUND: Laboratory parameters can help in the differential diagnostics of acute episodes of transient loss of consciousness. Especially serum lactate and serum creatine kinase (CK) levels may provide valuable hints to distinguish generalized tonic-clonic seizures (GTCS) from syncope. MATERIAL AND METHODS: Serum lactate levels at admission and CK levels 10-48 h after the episodes that led to admission were compared between patients with GTCS (n = 30) and those with syncope (n = 15). In addition, sensitivity and specificity of lactate and CK as diagnostic markers for syncope and GTCS were determined. RESULTS: The serum lactate and serum CK levels were significantly increased in patients with GTCS as compared to syncope patients (serum lactate: p < 0.001; CK: p < 0.005). The area under the curve (AUC) for serum lactate as an indicator for GTCS was 0.94 (95% confidence interval [CI] 0.88-1.0). For CK the receiver operating characteristics (ROC) analysis produced an AUC of only 0.77 (95% CI: 0.63-0.9). CONCLUSION: The determination of the lactate value as point-of-care diagnostics appears to be highly relevant in the rapid clarification of unclear episodes with transient loss of consciousness. The CK level at follow-up is also suitable for distinguishing GTCS from syncope but is inferior to the serum lactate value.

[Future of emergency medicine in Germany 2.0]. / Zukunft der Notfallmedizin in Deutschland 2.0.

In 2003 an article on the future of prehospital emergency medicine in Germany was published in the journal Der Anaesthesist. Emergency medicine in Germany, which at that time was almost exclusively defined as prehospital emergency rescue, has evolved and now in-hospital domains have increasingly moved into the focus. At that time, the primary goal was to connect prehospital management with a smooth transition to hospital admission and further care in the hospital and to further optimize the rescue chain from the actual emergency through to causative treatment. Now after 15 years, the authors have critically assessed the development postulated in 2003 and reevaluated it. Which aspects could be developed further and become firmly established, what is still open and which questions in preclinical and clinical emergency treatment of the population will occupy us in the coming 15 years? With a critical eye to the past, the present contribution aims to capture the essential and new topics and open questions and provide a fresh perspective for the future of emergency medicine. Regulation at the state level or even lower levels of government often stand in contrast to more sweeping and economically effective approaches at the federal level. Prehospital emergency medicine in Germany is on the whole well-positioned with respect to facilities and personnel; however, as far as the economic situation and the utilization of available systems are concerned, there is still substantial room for improvement.

[Emergency departments--2016 update]. / Zentrale Notaufnahme--Update 2016.

Acute medical care in hospital emergency departments has experienced rapid development in recent years and gained increasing importance not only from a professional medical point of view but also from an economic and health policy perspective. The present article therefore provides an update on the situation of emergency departments in Germany. Care in emergency departments is provided with an increasing tendency to patients of all ages presenting with varying primary symptoms, complaints, illnesses and injury patterns. In the process, patients reach the emergency department by various routes and structural provision. Cross-sectional communication and cooperation, prioritization and organization of emergency management and especially medical staff qualifications increasingly play a decisive role in this process. The range of necessary knowledge and skills far exceeds the scope of prehospital medical emergency care and the working environment differs substantially. In addition to existing structural and economic problems, the latest developments, as well as future proposals for the design of in-hospital emergency medical care in interdisciplinary emergency departments are described.

Analgesia by telemedically supported paramedics compared with physician-administered analgesia: A prospective, interventional, multicentre trial.

BACKGROUND: In German emergency medical services (EMS), the analgesia is restricted to physicians. In this prospective, interventional, multicentre trial, complications with and quality of telemedically delegated analgesia were evaluated. METHODS: If prehospital analgesia was necessary, five telemedically equipped paramedic ambulances from four different districts could consult a telemedicine centre. Analgesics were delegated based on a predefined algorithm. Telemedically assisted cases were compared with local historical regular EMS missions using matched pairs. The primary outcome was the frequency of therapeutic complications (respiratory/circulatory insufficiency, allergic reactions). Secondary outcomes were quality of analgesia (11-point numerical rating scale, NRS) and the frequency of nausea/vomiting. RESULTS: Analgesia was necessary in 106 telemedically assisted missions. In 23 cases, the telemedical procedure was used until an EMS physician arrived. Of the remaining 83 cases, 80 could be matched to comparable controls. Complications did not occur in either the study group or the control group (0 vs. 0; p = N/A). Complete NRS documentation was noted in 65/80 (study group) and 32/80 (control group) cases (p < 0.0001). Adequate initial pain reduction (quality indicator: reduction of NRS ≥ 2 points or NRS < 5 at end of mission) occurred in 61/65 versus 31/32 cases (p = 1.0); NRS reduction during mission was 3.78 ± 2.0 versus 4.38 ± 2.2 points (p = 0.0159). Nausea and vomiting occurred with equal frequency in both groups. CONCLUSIONS: Telemedical delegation of analgesics to paramedics was safe and led to a pain reduction superior to the published minimum standard in both groups. The documentation quality was better in the telemedicine group. WHAT DOES THIS STUDY ADD?: Little is known about the safety and quality of prehospital analgesia carried out by emergency medical services (EMS). Beside potential quality problems, in some countries meaningful pain reduction is limited by legal regulations that allow only physicians to administer analgesics. This first multicentre prospective trial for telemedically delegated analgesia demonstrates that remote analgesia is possible and safe and retains equivalent analgesic quality compared with that administered by onsite EMS physicians.

[Potential and effectiveness of a telemedical rescue assistance system. Prospective observational study on implementation in emergency medicine]. / Potenzial und Wirksamkeit eines telemedizinischen Rettungsassistenzsystems: Prospektive observationelle Studie zum Einsatz in der Notfallmedizin.

BACKGROUND: The demographic change and an increasing multimorbidity of patients represent increasing challenges for the adequate prehospital treatment of emergency patients. The incorporation of supplementary telemedical concepts and systems can lead to an improved guideline-conform treatment. Beneficial evidence of telemedical procedures is only known for isolated disease patterns; however, no mobile telemedical concept exists which is suitable for use in the wide variety of different clinical situations. AIM: This article presents a newly developed and evaluated total telemedical concept (TemRas) that encompasses organizational, medical and technical components. The use of intelligent and robust communication technology and the implementation of this add-on system allows the telemedical support of the rescue service for all emergencies. METHODS: After development of the telemedical rescue assistance system, which includes organizational, medical and technical components, a telemedical centre and six ambulances in five different districts in North-Rhine Westphalia were equipped with this new tool. During the evaluation phase of 1 year in the routine emergency medical service the rate of complications as well as differences between urban and rural areas were analyzed with respect to different target parameters. RESULTS: Between August 2012 and July 2013 a total of 401 teleconsultations were performed during emergency missions and 24 during secondary interhospital transfers. No complications due to teleconsultation were observed. The mean duration (±SD) of teleconsultations was longer in rural areas than in urban areas with 28.6±12.0 min vs. 25.5±11.1 min (p < 0.0001). In 63.2% of these missions administration of medications was delegated to the ambulance personnel (52.0% urban vs. 73.6% rural, p < 0.0001). The severity of ailments corresponded to scores of III and VI in the National Advisory Committee for Aeronautics (NACA) classification. CONCLUSION: Emergency medical care of patients with support by a telemedical system is technically feasible, safe for the patient and allows medical treatment independent of spatial availability of a physician in different emergency situations.

[Current capabilities of telemedicine in anaesthesiology]. / Heutige Möglichkeiten der Telemedizin in der Anästhesiologie.

Because of an ageing population and a relative lack of professionals, the German health system is under great pressure. In rural regions in particular, anesthesiology is also affected - nursing staff, anesthetists, intensive care physicians, and emergency physicians often have to be supported by freelancers from other regions and from abroad - at least periodically. In addition to the increasing number of treatments, the potential quality of therapy is also increasing owing to progress in medical research. Against this background the need for resources is increasing to ensure the optimal quality of treatment. This applies to all clinical disciplines, including all sections of anesthesiology - especially in economically underdeveloped regions where highly qualified experts are lacking. In various cases it is not the physical attendance or manual skills of experts that is primarily requested on-site, but rather their medical expertise and experience. Therefore, telemedicine systems are suitable for closing these gaps very effectively and efficiently. In the various anesthesiological sub-sections the number of scientific papers published to date varies. For anesthesia and pain therapy only a few telemedical applications or concepts have been reported in the literature. However, in tele-intensive care medicine and tele-emergency medicine several national and international research projects have successfully been carried out, leading to established routine systems in some cases.

[Advance directives in prehospital emergency treatment : prospective questionnaire-based analysis]. / Vorsorgedokumente in der präklinischen Notfallmedizin : Prospektive fragebogenbasierte Analyse.

BACKGROUND: The handling of advance directives (AD) in prehospital emergency treatment in Germany is characterized by instability. In the project "Advance directives in preclinical emergency medical aid" ("Patientenverfügungen in der präklinischen Notfallmedizin") the frequency and quality of ADs in emergency situations was investigated. AIM: The aim of this study was to fill the gaps in research and to collate data on how consideration of the self-determination of patients in emergency situations can be optimized. MATERIAL AND METHODS: Over a period of 12 months from December 2007 to December 2008 a questionnaire was included in the emergency documentation of the medical emergency service in Aachen. Emergency patients were asked by emergency physicians to provide an AD and the quantitative as well as qualitative features of these ADs were examined. Furthermore, the study recorded what kinds of problems occurred with ADs in emergency situations and what measures were needed to correct this deficiency. The reactions of patients were documented on a numeral rating scale with a score of 1 reflecting a negative and 10 reflecting a positive reaction. In the 12-month period emergency doctors recorded 1,321 missions and after application of the exclusion criteria (e.g. missing signature, incomplete documentation and late delivery) 1,047 documented questionnaires were available for the analysis. RESULTS: A total of 127 out of 1,047 emergency patients provided an AD, 44 had a durable power of attorney and 27 had appointed a legal representative for healthcare. Of the emergency patients 20 had a legal attendant and 43 out of the 127 ADs could be presented to the emergency team during the emergency mission. The emergency team often encountered difficulties regarding the handling of the ADs due to the time factor and unclear wording. The latter included the following problems: misleading formulation (19.1 %), difficulty with the complexity (14.9 %) and contradicting information (4 %). Only 29 (61.7 %) of the durable powers of attorney were signed and legally binding. From the view of the emergency physicians the following information was lacking but would be helpful in emergency situations: emergency plan, hierarchy of those given power of attorney, knowledge of risks regarding ADs and medication requirements. CONCLUSION: The results show that for an AD to apply in an emergency situation certain standards are necessary that assure the practicability, especially if a patient does not wish to be resuscitated. Most difficulties with ADs occurred with imprecise formulation, text length and inconsistency of statements. The following instructions were usually missing: hierarchy of those given power of attorney and specification on medication, information about the scope of the ADs, statement about resuscitation, extent and limitations of the desired treatment, especially with patients certified as terminally ill and instructions on who should decide about medical treatment in a conflict situation. A so-called emergency instruction which gives on a single page the patient's statement on resuscitation would have been very helpful in individual cases. The results suggest that patients may need more information and education about AD to guarantee patients rights and self-determination.

Employment of telemedicine in emergency medicine. Clinical requirement analysis, system development and first test results.

OBJECTIVES: Demographic change, rising co-morbidity and an increasing number of emergencies are the main challenges that emergency medical services (EMS) in several countries worldwide are facing. In order to improve quality in EMS, highly trained personnel and well-equipped ambulances are essential. However several studies have shown a deficiency in qualified EMS physicians. Telemedicine emerges as a complementary system in EMS that may provide expertise and improve quality of medical treatment on the scene. Hence our aim is to develop and test a specific teleconsultation system. METHODS: During the development process several use cases were defined and technically specified by medical experts and engineers in the areas of: system administration, start-up of EMS assistance systems, audio communication, data transfer, routine tele-EMS physician activities and research capabilities. Upon completion, technical field tests were performed under realistic conditions to test system properties such as robustness, feasibility and usability, providing end-to-end measurements. RESULTS: Six ambulances were equipped with telemedical facilities based on the results of the requirement analysis and 55 scenarios were tested under realistic conditions in one month. The results indicate that the developed system performed well in terms of usability and robustness. The major challenges were, as expected, mobile communication and data network availability. Third generation networks were only available in 76.4% of the cases. Although 3G (third generation), such as Universal Mobile Telecommunications System (UMTS), provides beneficial conditions for higher bandwidth, system performance for most features was also acceptable under adequate 2G (second generation) test conditions. CONCLUSIONS: An innovative concept for the use of telemedicine for medical consultations in EMS was developed. Organisational and technical aspects were considered and practical requirements specified. Since technical feasibility was demonstrated in these technical field tests, the next step would be to prove medical usefulness and technical robustness under real conditions in a clinical trial.

[Measurement of carbon dioxide in emergency medicine]. / Kohlenstoffdioxidmessung in der Notfallmedizin.

Expiratory carbon dioxide (CO(2)) monitoring is a valuable tool in the prehospital setting. Recent reports of misplaced endotracheal tubes in the prehospital setting make it important to ensure that tube placement is verified by CO(2) monitoring. The Euronorm 2007:1789 made provision of capnometry mandatory for all medical vehicles. However, the frequency of utilization of CO(2) monitoring after securing the airway and in patients with respiratory insufficiency is low. This article covers the terminology, physiology, technology and clinical applications of CO(2) monitoring. Monitoring of cardiac output and the efficiency of cardiopulmonary resuscitation are described and the article also highlights the importance of CO(2) monitoring in patients with severe head trauma as well as restrictive and obstructive pulmonary disorders.

External chest compressions using a mechanical feedback device : cross-over simulation study.

BACKGROUND: External chest compressions (ECC) are essential components of resuscitation and are usually performed without any adjuncts in professional healthcare. Even for healthcare professionals during in-hospital and out-of-hospital resuscitation poor performance in ECC has been reported in recent years. Although several stand-alone devices have been developed none has been implemented as a standard in patient care. The aim of this study was to examine if the use of a mechanical device providing visual feedback and audible assistance during ECC improves performance of healthcare professionals following minimal and simplified instructions. METHODS: In a prospective, randomized cross-over study 81 healthcare professionals performed ECC for 3 min (in the assumed setting of a secured airway) twice on a manikin (Skillreporter ResusciAnne®, with PC-Skillreporting System Version 1.3.0, Laerdal, Stavanger, Norway) in a mock cardiac arrest scenario. Group 1 (n=40) performed ECC with the device first followed by classic ECC and group 2 (n=41) in the opposite order. Minimal instructions were standardized and provided by video instruction (1 min 38 s). Endpoints were achievement of a mean compression rate between 90 and 110/min and a mean compression depth of 40-50 mm. In addition participants had to answer questionnaires about demographic data, professional experience and recent recommendations for ECC as well as their impression of the device concerning the ease of use and their personal level of confidence. Data were analyzed for group-related and inter-group differences using SAS (Version 9.1.3, SAS Institute, Cary, NC). RESULTS: A total of 81 healthcare professionals regularly involved in resuscitation attempts in pre-hospital or in-hospital settings took part in the study with no differences between the groups: females 35.8% (n=52), emergency medical technicians 32.1% (n=26), anesthesia nurses 32.1% (n=26), physicians (anesthesiology) 45% (n=29). In group 1 33 out of 40 (82.5%; 99.7±4.82/min; 95% confidence interval 95% CI: 98.1-101.2/min) reached the correct range for compression rate and 29/40 (72.5%; 44.0±4.95 mm; 95% CI: 42.4-45.6 mm) the correct compression depth using the assisting device. Afterwards they conducted classic ECC without the device and deteriorated significantly: correct compression rate was achieved by 12/40 (30%, p≤0.0001; 110.6±11.0/min (95% CI: 107.1-114.1/min), while 25/40 (62.5%; 44.5±5.63 mm; 95% CI: 42.6-46.3 mm) met the correct compression depth. Group 2 performed poorer in ECC without assistance and 5/41 (12.2%; 104.5±21.35/min; 95% CI: 97.8-111.3/min) reached the correct rate whereas 21/41 (51.2%; 39.6±7.61 mm; 95% CI: 37.2-42.0 mm) compressed to the appropriate depth. Using the device there was a significant improvement in the second evaluation with 34/41 (82.9%, p≤0.0001; 101.7±4.68/min; 95% CI: 100.2-103.2/min) reaching the correct rate and 36/41 (87.8%, p≤0.0001; 43.9±4.16 mm; 95% CI: 42.6-45.2 mm) the correct depth. CONCLUSIONS: The tested device is easy to use after instruction of less than 3 min and improves ECC performance of healthcare professionals in simulated cardiac arrest with respect to compression depth as well as compression rate.

[Stocked medications in emergency physician-based medical services in Germany. Reality and requirements according to guidelines]. / Vorgehaltene Medikamente auf notarztbesetzten Rettungsmitteln in Deutschland. Realität und Erfordernis nach Leitlinien.

BACKGROUND: The emergency medical service (EMS) should work according to criteria of evidence-based medicine. In Germany the EMS of each state is under the control of at least one medical supervisor known as emergency medical directors (EMD) and most states have several different EMDs responsible for one or more provinces of the state. The German Medical Association advises these supervisors to specify the pharmacological resources in store for use in physician powered EMSs. This study examines the pharmacological resources in EMSs which is provided by the EMDs in Germany. Furthermore, a comparison of the inventory analysis of stored drugs was carried out with the requirements according to guidelines for selected tracer diagnoses. METHOD: In the period of May 2008 to January 2009 a total of 148 EMDs were contacted and asked to supply drug storage lists for emergency physician-staffed rescue vehicles in their respective jurisdiction. The addresses of all EMDs who could be identified by the federal office of the National Association of Emergency Medical Director, Germany were used over the period. The evaluation was conducted anonymously. The tracer diagnoses "cardiopulmonary resuscitation", "acute coronary syndrome", "status generalized tonic-clonic seizure," "severe asthma attack", "acute exacerbation of chronic obstructive pulmonary disease", "supraventricular tachycardia", "severe brain trauma" and "acute heart failure with signs of hypoperfusion" were selected. Current and established guidelines have been identified with the homepage of the Scientific Medical Societies in Germany and supported by the leading European and International guidelines. RESULTS: The corresponding lists were returned by 95 different emergency service areas (response rate 64.2%). With a total of 39 groups of substances 142 different drugs could be identified, an average of 54±9.6 and median 55 (range 31-77). Listed are agents giving the provision in percent, for which the comparison with guidelines for tracer diagnoses could show deficits: sodium bicarbonate 75.8%, calcium 50.5%, magnesium 45.3%, noradrenaline 65.3%, adenosine 58.9%, dobutamine 57.9%, lorazepam iv 13.7%, salbutamol 41.1%, ipratropium bromide 13.7% (the last two as liquid preparations for inhalation). With a frequency of about 30-80%, depending on the respective tracer diagnosis, no medical emergency treatment according to the highest level of evidence is possible. CONCLUSION: Due to recent treatment recommendations provision with sodium bicarbonate, calcium, magnesium, noradrenaline, adenosine, lorazepam iv, dobutamine and as well with ipratropium bromide and salbutamol (both as liquid preparations for inhalation) should be improved. For the future, a federal uniform minimum standard due to evidence-based principles is desirable.

[Emergency mission documentation in simulated care. Video-based error analysis]. / Notärztliche Einsatzdokumentation in der Simulation. Videobasierte Fehleranalyse.

BACKGROUND: The aim of this study was to examine documentation quality in physician staffed emergency medical services (EMS). This study compared simulated on-site care with the associated patient records written by EMS physicians. METHODS: For this study two standardized simulated case scenarios, ST segment elevation myocardial infarction (STEMI) and major trauma with traumatic brain injury were designed by an expert committee. Overall 29 EMS teams each consisting of 1 EMS physician and 2 paramedics ran through the scenarios on high fidelity patient simulators and each scenario was videotaped. The scenarios were stopped after 12 min for STEMI and after 14 min for major trauma independent of the actions carried out and each EMS physician then had 10 min to document this initial phase on standardized protocol sheets. The videotaped scenarios were analyzed by two independent investigators. Documentation of predefined contents and all drug dosages were checked against the simulated on-site care. The data were evaluated and classified as correct, incorrect or missing documentation although action performed. RESULTS: Written consent for data analysis was provided by 28 teams. Overall 20 parameters and actions in the STEMI scenario and 16 in the major trauma scenario as well as all drug dosages were evaluated. For the scenario STEMI 469 actions were analyzed of which 271 (58%) were correct, 94 (20%) incorrect and 104 (22%) had missing documentation. A total of 140 medications were administered of which 31 (22%) were documented incorrectly and 14 (10%) were not documented. For major trauma 401 actions were analyzed of which 244 (61%) were correct, 101 (25%) incorrect and 56 (14%) had missing documentation. In this scenario the teams administered 138 medications of which 31 (22%) were documented incorrectly and 16 (12%) were not documented. Infused amounts of crystalloids and colloids were mostly documented correctly in this case (35 correct /6 incorrect/8 not documented). Documentation of several clinical parameters was carried out predominantly correctly, e.g. initial blood pressure (STEMI: 25/2/1, major trauma: 21/4/2) and initial ECG rhythm (STEMI: 27/0/1, major trauma: 26/0/1). Documentation of other clinically relevant parameters was often performed incorrectly: 12-lead ECG in STEMI (5/9/12) and capnometry in major trauma (9/4/7). No team used a pain scale to assess the level of pain in the STEMI scenario but 12 EMS physicians documented an accordant value (numerical rating scale) on the patient records. Furthermore some parameters could be identified where documentation was mostly missing although they were measured, e.g. onset of symptoms in STEMI (5/4/15) and reduced level of consciousness and bradypnea in major trauma (9/2/17). CONCLUSION: Patient safety can be reduced if relevant preclinical data are not transmitted correctly to the admitting hospital. Therefore there is a need to improve documentation quality in EMS. Electronic documentation, training of EMS staff and quality management programs might offer solutions. Because of the small sample size further studies are needed to evaluate the validity of these results.

[Medical and medical ethical basis of precautionary options]. / Medizinische und medizinethische Grundlagen der Vorsorgemöglichkeiten.

The main activities of anesthesiologists in addition to the operation theatre are intensive and emergency treatment as well as pain and palliative care. Discussions and decisions about strategies and enforcement of therapy are indispensable in all areas. Acknowledgment of the patients' wishes and protection of patient autonomy are very important in the context of medical fiduciary duty. Determination of the aim of therapy and the patient's prognosis are of special importance. Against the background of the current amendments of patient advance directives different possibilities, such as advance directive and emergency forms in different areas of anesthesiology will be discussed.

[E-health in emergency medicine - the research project Med-on-@ix]. / "E-Health" in der Notfallmedizin - das Forschungsprojekt Med-on-@ix.

There is a need for new strategies to face current and future problems in German Emergency Medical Services (EMS). Lack of quality management and increasing costs in the presence of a deficit of EMS physicians are typical challenges, resulting in an increasing deficit in medical care. In addition, information and communication technology used in German EMS is out of date. The physician-powered EMS has to be modernized to increase quality and show measurable evidence of its effectiveness. Otherwise its future existence is at serious risk. Therefore, the project Med-on-@ix was created by the Department of Anaesthesiology at the University Hospital Aachen, Germany. The aim was to develop a new emergency telemedicine service system and to implement it clinically in order to advance medical care and effectiveness in the EMS by process optimization of each scene call. This system offers EMS physicians and paramedics an additional consultation by a specialised centre of competence, thus assuring medical therapy according to evidence-based guidelines. Several prospective studies are conducted to analyse this system in comparison to the conventional EMS.

[Advanced cardiopulmonary resuscitation under special circumstances: part 2]. / Erweiterte kardiopulmonale Reanimation in besonderen Situationen: Teil 2.

Based on the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR), guidelines were published for managing basic and advanced life-saving procedures in the event of cardiac arrest. The fact that special circumstances for cardiac arrest must be considered resulted in a separate chapter. This two-part article reviews essential information as well as necessary modifications of the standard advanced life support algorithm in cases of electrolyte disorders, hyperthermia and hypothermia, cardiac arrest in pregnancy, trauma, electrical emergencies and cardiac surgery. Part 1 has already dealt with life-threatening drowning, asthma, anaphylaxis and poisoning.

[Prehospital Trauma Life Support (PHTLS): An interdisciplinary training in preclinical trauma care]. / Prehospital Trauma Life Support (PHTLS): Ein interdisziplinäres Ausbildungskonzept für die präklinische Traumaversorgung.

INTRODUCTION: There is clinical evidence that standardized management of trauma patients in the emergency department improves outcome. Standardized prehospital management has been established for stroke patients and those suffering acute coronary syndrome. Prehospital treatment of trauma patients differs quite significantly from one system to another. The data from the German Trauma Registry show that the average time from accident until arrival in the emergency department is 72 min. This needs improvement. RESULTS: PHTLS is a training course that teaches a systematic approach to the trauma patient in the preclinical setting. The aim is to rapidly and accurately assess the patient's physiologic status, treat according to priorities, and decide whether the patient is critical and needs rapid rescue and transport. Above all, it is important for caregivers to prevent secondary injury, to realize the relevance of timing in the initial treatment, and to assure a high standard of care. PHTLS provides the participant with knowledge, skills, and necessary behaviors. The course is open to persons in all specialties involved in the initial management of severely injured patients. The German Board of Emergency Technicians e.V. inaugurated the course concept in cooperation with the National Association of Emergency Medical Technicians (NAEMT) and the American College of Surgeons (ACS) and is authorized to organize PHTLS courses in Germany. CONCLUSION: PHTLS teaches a standardized and established approach to the trauma patient in the emergency department. It has been established in 36 countries and the content is reviewed regularly to consider new scientific evidence. Healthcare personnel in Germany have the chance to participate in this international standard of care and to introduce their own experiences into the review process.

[Advanced life support under special circumstances: part 1]. / Erweiterte kardiopulmonale Reanimation in besonderen Situationen: Teil 1.

Based on the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR), guidelines were published for managing basic and advanced life-saving procedures in the event of cardiac arrest. The fact that special circumstances sometimes must be considered in patient treatment resulted in a separate chapter. This first part of a two-part article reviews essential information as well as necessary modifications of the standard advanced life support algorithm in cases of life-threatening drowning, asthma, anaphylaxis, and poisoning. The second part will deal with electrolyte disorders, hypothermia, electrical emergencies, trauma, cardiac arrest during pregnancy, and cardiac surgery.