[Radioactivity in emergency medical services : Dealing with irradiation incidents-Brief guidelines for management]. / Radioaktivität im Rettungsdienst : Umgang mit Strahlenunfällen ­ ein kurzer Handlungsleitfaden.

Due to the legal regulations radiation incidents in nuclear or medical/industrial facilities are rare events. Radiation incidents are much more common in the context of road traffic accidents when sources of radiation are being transported. The handling of radiation victims is accompanied by strong feelings of fear and anxiety due to the rarity of such events and the physical characteristics of radioactive irradiation. This cannot be detected by human senses and the effects are not immediately visible. The risk and threat of radiation for rescue personnel and in hospitals can be overcome by a solid basic knowledge and by following some simple rules. This continuing medical education article imparts the necessary principles and based on an algorithm demonstrates the safe approach at the scene of the accident and the handling and transfer of the patient to the hospital. Moreover, it highlights further services and support by regional radiation protection centers.

[Systematic analysis of airway registries in emergency medicine]. / Systematische Analyse von Atemwegsregistern in der Notfallmedizin.

BACKGROUND: A myriad of publications have contributed to an evidence-based approach to airway management in emergency services and admissions in recent years; however, it remains unclear which international registries on airway management in emergency medicine currently exist and how they are characterized concerning inclusion criteria, patient characteristics and definition of complications. METHODS: A systematic literature research was carried out in PubMed with respect to publications from 2007-2017. All publications from airway registries collecting data on prehospital or emergency department (ED) airway management were included. Publications from pediatric intensive care units (PICU) were also included as long as they were the primary place of pediatric emergency care. RESULTS: A total of eleven emergency airway registries (EAR) were identified that were primarily concerned with airway management. Furthermore, reported data on emergency airway management were extracted from different, national resuscitation registries. There was only one multinational EAR which exclusively collects data on pediatric emergency airway management (NEAR4KIDS, National Emergency Airway Registry for Kids). Additionally, all emergency department airway registries identified include data on pediatric emergency airway management to varying degrees (0.2-10.5%). Published observation periods were also highly variable with a minimum of 18 months and a maximum of 156 months. The ANZEDAR (Australia and New Zealand Emergency Airway Registry) is currently the largest EAR with data from 43 participating institutions in 2 different countries, while the NEAR III (National Emergency Airway Registry) includes data on 21,374 emergency intubations over a 10-year period and thus has the largest number of emergency interventions. Reported rapid sequence induction (RSI) rates in the registries are between 27.5% and 100%. First-pass success rates vary between 69% and 89%, while the reported use of video laryngoscopy is 0-73%. CONCLUSION: This study identified eleven EARs that sometimes widely differed concerning inclusion periods, inclusion criteria, definition of complications and application of newer methods of emergency airway management. Thus, comparability of the reported results and first-pass success rates is only possible to a limited extent. The authors therefore advocate the initiation of an airway registry in emergency medicine in German-speaking countries.

[Practical training for paramedics : Transformation at the Leipzig University teaching hospital]. / Die praktische Ausbildung von Notfallsanitätern : Umsetzung am Universitätsklinikum Leipzig.

BACKGROUND: The "Notfallsanitätergesetz" (the law pertaining to paramedics), which came into effect in January 2014, has fundamentally changed the training of health personnel in German prehospital emergency medicine. The apprenticeship now takes 3 years including 720 h of practical training in eligible hospitals. To date, however, there has been little experience of how the contents of the guidelines for practical training ("Ausbildungs- und Prüfungsverordnung") can be reasonably applied in the teaching hospitals. METHODS: In a total of nine interdisciplinary working group meetings between October 2014 and June 2016, we developed a curriculum concerning the practical training of paramedics to implement the contents of the guidelines for practical training in a didactically and an organizationally meaningful way. RESULTS: The implementation of the practical training of paramedics is an excellent chance for the teaching hospitals to contribute to higher quality prehospital emergency medicine. Otherwise, the teaching hospitals face an organizational and personal effort that is not to be underestimated. Thus, a modular curriculum constitutes the possibility of standardizing practical training and simultaneously reducing the time and expenditure for the participating hospitals. CONCLUSION: The development of a unique curriculum for the practical training of paramedics may contribute to standardized, high-quality, and cost-efficient training.

Effective diameter of the aortic annulus prior to transcatheter aortic valve implantation: influence of area-based versus perimeter-based calculation.

In computed tomography (CT) evaluation prior to transcatheter aortic valve implantation area- and perimeter-based calculation of the aortic annulus diameter, the so-called effective annulus diameter (ED), is the preferred parameter for decision making regarding prosthesis sizes. Currently, it is unclear how relevant the differences between the two methods of measurement are and how they are influenced by the cardiac cycle. The aim of this study was to compare area- and perimeter-based measurements in computed tomography derived aortic annulus sizing. A total of 60 patients who underwent evaluation for transcatheter aortic valve implantation were included in this study. All patients received pre-procedural ECG gated CT. The aortic annulus area and perimeter were measured and the derived ED compared using parametric statistics and Bland and Altman analysis. The mean patient age was 80.2 ± 4 years. Systolic aortic annulus area and perimeter were higher compared to diastolic results (mean difference area 12.8 ± 24 mm(2) and perimeter 0.72 ± 1 mm; p = 0.009-0.068). Both the area- and perimeter-based ED had a good agreement within two standard deviations for systolic and diastolic measurements. Effective diameter measurements derived from the area were significantly smaller compared to perimeter-based measurements (mean difference: systolic 0.72 ± 0.3 mm and diastolic 0.81 ± 0.4 mm; p < 0.001). While the area-based ED was significantly influenced by the cardiac cycle with a mean difference of 0.4 ± 0.6 mm (p = 0.009), no significant difference was found for the perimeter-based ED (mean difference: 0.2 ± 0.4; p = 0.07). For patients undergoing CT evaluation prior to transcatheter aortic valve implantation, the perimeter-based effective annulus diameter provides a reliable parameter for annulus sizing without significant affection by the cardiac cycle and therefore facilitates annulus measurements with a single heart phase. However, perimeter-based diameters of the annulus are significantly larger than area-based diameters.

Near-infrared spectroscopy monitoring of the collateral network prior to, during, and after thoracoabdominal aortic repair: a pilot study.

OBJECTIVE: The aim of this study was to evaluate the feasibility of non-invasive monitoring of the paraspinous collateral network (CN) oxygenation prior to, during, and after thoracoabdominal aortic repair in a clinical series. METHODS: Near-infrared spectroscopy optodes were positioned bilaterally-over the thoracic and lumbar paraspinous vasculature-to transcutaneously monitor muscle oxygenation of the CN in 20 patients (age: 66 ± 10 years; men = 11) between September 2010 and April 2012; 15 had open thoracoabdominal aortic repair (Crawford II and III), three had thoracic endovascular aortic repair (TEVAR; Crawford I), and two had a hybrid repair (Crawford II). CN oxygenation was continuously recorded until 48 hours postoperatively. RESULTS: Hospital mortality was 5% (n = 1), 15% suffered ischemic spinal cord injury (SCI). Mean thoracic CN oxygenation saturation was 75.5 ± 8% prior to anesthesia (=baseline) without significant variations throughout the procedure (during non-pulsatile cooling on cardiopulmonary bypass and with aortic cross-clamping; range = 70.6-79.5%). Lumbar CN oxygenation (LbS) dropped significantly after proximal aortic cross-clamping to a minimum after 11.7 ± 4 minutes (74 ± 13% of baseline), but fully recovered after restoration of pulsatile flow to 98.5% of baseline. During TEVAR, stent-graft deployment did not significantly affect LbS. Three patients developed relevant SCI (paraplegia n = 1/paraparesis n = 2). In these patients LbS reduction after aortic cross-clamping was significantly lower compared with patients who did not experience SCI (p = .041). CONCLUSIONS: Non-invasive monitoring of CN oxygenation prior to, during, and after thoracoabdominal aortic repair is feasible. Lumbar CN oxygenation levels directly respond to compromise of aortic blood circulation.

Experience with anatomically orientated devices for transapical aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) is a new technology, which is rapidly growing to a routine procedure amenable for patients with symptomatic aortic valve stenosis and higher than average risk for conventional aortic valve surgery. The crucial disadvantage of TAVI remains the not well foreseeable risk of more than trivial degree of paravalvular leakage and a high rate of atrioventricular block and consecutive pacemaker implantation. In addition, current implantation techniques do not allow controlling the rotation of first-generation devices that might be beneficial regarding optimal physiological valve performance, optimal coronary flow and avoidance of placement of covered commissures in front of the coronary ostia. These shortcomings had pushed the development of second-generation self-expandable nitinol-based devices for subcoronary implantation that aim a reduction of paravalvular leak and AV-block by anatomical orientated positioning into the aortic root. This review focuses on the description of three different TAVI concepts, which are presently under early clinical evaluation, or have recently received commercial approval, using the transapical approach.