[Development of a giant bulla under spontaneous breathing by self-inflicted lung injury in a patient with COVID-19 pneumonia]. / Entwicklung einer Riesenbulla unter Spontanatmung durch "patient self-inflicted lung injury" bei COVID-19-Pneumonie.

The outbreak of SARS-CoV­2 and the associated COVID-19 pandemic pose major challenges to healthcare systems worldwide. New data on diagnosis, clinical presentation and treatment of the disease are published on a daily basis. This case report describes the fatal course of severe COVID-19 pneumonia in an 81-year-old patient with no previous pulmonary disease who developed a giant bulla during non-invasive high-flow oxygen therapy. Virus-induced diffuse destruction of alveolar tissue or patient self-inflicted lung injury (P-SILI) are discussed as possible pathomechanisms. Future studies must determine whether lung-protective mechanical ventilation with high levels of sedation and paralysis to suppress spontaneous respiratory drive and to reduce transpulmonary pressure can prevent structural lung damage induced both by the virus and P­SILI in COVID-19 patients with ARDS.

Helicopter Emergency Medical Service Simulation Training in the Extreme: Simulation-based Training in a Mountain Weather Chamber.

Mountain rescue operations often confront crews with extreme weather conditions. Extremely cold temperatures make standard treatment sometimes difficult or even impossible. It is well-known that most manual tasks, including those involved in mountain rescue operations, are slowed by extremely cold weather. To lessen and improve the decrement in performance of emergency medical treatment caused by cold-induced manual impairment and inadequate medical equipment and supplies, simulation training in a weather chamber, which can produce wind and temperatures up to -22°C, was developed. It provides a promising tool to train the management of complex multidisciplinary settings, thus reducing the occurrence of fatal human and technical errors and increasing the safety for both the patient and the mountain emergency medical service crew.

Analysis of peritoneal galactomannan for the diagnosis of Aspergillus peritonitis.

Here, we report a patient developing a postoperative peritoneal infection by Aspergillus fumigatus. While galactomannan serum levels were negative throughout the time course, galactomannan levels in peritoneal fluids yielded high results. Serological testing of peritoneal fluids for fungal antigens might be a useful and easily applicable tool to support diagnosis of intraabdominal aspergillosis, which represents a rare type of invasive fungal infection.

Simulation-Based Training in Mountain Helicopter Emergency Medical Service: A Multidisciplinary Team Training Concept.

OBJECTIVE: Mountain helicopter rescue operations often confront crews with unique challenges in which even minor errors can result in dangerous situations. Simulation training provides a promising tool to train the management of complex multidisciplinary settings, thus reducing the occurrence of fatal errors and increasing the safety for both the patient and the helicopter emergency medical service (HEMS) crew. METHODS: A simulation-based training, dedicated to mountain helicopter emergency medicine service, was developed and executed. We evaluated the impact of this training by the means of a pre- and posttraining self-assessment of 40 HEMS crewmembers. RESULTS: Multidisciplinary simulation-based educational training in HEMS is feasible. There was a significant increase in self-assessed competence in safety-related items of human factors and team resource management. The highest gain of competence was demonstrated by a trend in the domain of structured decision making. CONCLUSIONS: Interprofessional simulation-based team training could have the potential to impact patient outcomes and improve rescuer safety. Simulation trainings lead to a subjective increase of self-assuredness in the management of complex situations in a difficult working environment.

Ecological effects of selective oral decontamination on multidrug-resistance bacteria acquired in the intensive care unit: a case-control study over 5 years.

PURPOSE: This case-control study investigated the long-term evolution of multidrug-resistant bacteria (MDRB) over a 5-year period associated with the use of selective oropharyngeal decontamination (SOD) in the intensive care unit (ICU). In addition, effects on health care-associated infections and ICU mortality were analysed. METHODS: We investigated patients undergoing mechanical ventilation > 48 h in 11 adult ICUs located at 3 campuses of a university hospital. Administrative, clinical, and microbiological data which were routinely recorded electronically served as the basis. We analysed differences in the rates and incidence densities (ID, cases per 1000 patient-days) of MDRB associated with SOD use in all patients and stratified by patient origin (outpatient or inpatient). After propensity score matching, health-care infections and ICU mortality were compared. RESULTS: 5034 patients were eligible for the study. 1694 patients were not given SOD. There were no differences in the incidence density of MDRB when SOD was used, except for more vancomycin-resistant Enterococcus faecium (0.72/1000 days vs. 0.31/1000 days, p < 0.01), and fewer ESBL-producing Klebsiella pneumoniae (0.22/1000 days vs. 0.56/1000 days, p < 0.01). After propensity score matching, SOD was associated with lower incidence rates of ventilator-associated pneumonia and death in the ICU but not with ICU-acquired bacteremia or urinary tract infection. CONCLUSIONS: Comparisons of the ICU-acquired MDRB over a 5-year period revealed no differences in incidence density, except for lower rate of ESBL-producing Klebsiella pneumoniae and higher rate of vancomycin-resistant Enterococcus faecium with SOD. Incidence rates of ventilator-associated pneumonia and death in the ICU were lower in patients receiving SOD.

Advanced airway management in hoist and longline operations in mountain HEMS - considerations in austere environments: a narrative review This review is endorsed by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM).

BACKGROUND: Providing sufficient oxygenation and ventilation is of paramount importance for the survival of emergency patients. Therefore, advanced airway management is one of the core tasks for every rescue team. Endotracheal intubation is the gold standard to secure the airway in the prehospital setting. This review aims to highlight special considerations for advanced airway management preceding human external cargo (HEC) evacuations. METHODS: We systematically searched MEDLINE, EMBASE, and PubMed in August 2017 for articles on airway management and ventilation in patients before hoist or longline operation in HEMS. Relevant reference lists were hand-searched. RESULTS: Three articles with regard to advanced airway management and five articles concerning the epidemiology of advanced airway management in hoist or longline rescue missions were included. We found one case report regarding ventilation during hoist operations. The exact incidence of advanced airway management before evacuation of a patient by HEC is unknown but seems to be very low (< 5%). There are several hazards which can impede mechanical ventilation of patients during HEC extractions: loss of equipment, hyperventilation, inability to ventilate and consequent hypoxia, as well as inadequacy of monitoring. CONCLUSIONS: Advanced airway management prior to HEC operation is rarely performed. If intubation before helicopter hoist operations (HHO) and human cargo sling (HCS) extraction is considered by the rescue team, a risk/benefit analysis should be performed and a clear standard operating procedure (SOP) should be defined. Continuous and rigorous training including the whole crew is required. An international registry on airway management during HEC extraction would be desirable.

Propofol-related infusion syndrome induced by "moderate dosage" in a patient with severe head trauma.

Propofol is widely used for sedating critically ill adult patients because of its rapid onset and short recovery times, even after prolonged use. Propofol may be associated with a life-threatening syndrome, propofol-related infusion syndrome (PRIS), which includes cardiac failure, severe metabolic acidosis, renal failure, and rhabodomyolysis. The pathophysiology is incompletely understood. Propofol-related infusion syndrome seems to be dose-related, and it occurs generally in patients undergoing long-term (> 48 hrs) sedation at higher doses (> 4 mg/kg/hr). A case of PRIS in a patient after severe head injury is presented.

Traumatic dissection of a coronary artery: detection by multislice computed tomography and use of tirofiban as a reversible platelet inhibitor.

We report on a trauma victim without history of or risk factors for cardiac disease, who suffered coronary artery dissection caused by blunt chest injury (BCI). Myocardial ischaemia was detected by multislice computed tomography (MSCT) promptly after trauma centre admission and managed by immediate revascularisation. Thoracic trauma may cause myocardial ischaemia in the absence of a specific risk profile. MSCT, as part of initial work-up in severely injured patients, may support differential diagnosis after BCI. Tirofiban and unfractionated heparin as short-acting anticoagulants warrant stent patency and concurrently offer the possibility of quick recovery of haemostasis in case of haemorrhage.