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Zusammenfassung Einleitung Die Versorgung polytraumatisierter Patienten in der Akutphase ist ein Musterbeispiel fach- und berufsgruppenübergreifender Zusammenarbeit unter besonders zeitkritischen Bedingungen. Mit der Leitlinie Polytrauma der Deutschen Gesellschaft für Unfallchirurgie (DGU) sind umfassende Anforderungen formuliert, deren Übertragung in die Praxis zusätzliche Prozessbeschreibungen erfordert. Methoden Auf der Basis der Leitlinie und anhand validierter Qualitätsindikatoren wurde die optimale Versorgungsqualität als Soll-Zustand definiert.Unter Berücksichtigung lokaler Ressourcen wurden im Konsens aller an der Versorgung Beteiligten die wichtigsten Interventionen und Entscheidungsebenen in logischer Sequenz dargestellt (klinischer Algorithmus) und personelle Zuständigkeiten mit Zeitbezug festgelegt. Ergebnisse Optimierungspotenziale wurden in Bereichen identifiziert, für die in der Leitlinie keine expliziten Empfehlungen gemacht werden. Diese bilden die zentralen Elemente des Algorithmus. Zur Gewährleistung der Kontinuität des Qualitätsmanagements wurden Indikatoren, Zeitfenster und Verantwortlichkeit für eine Reevaluation des Ist-Zustands und die Überarbeitung des Behandlungspfads definiert. Schlussfolgerungen Die Implementierung von Leitlinien erfordert auf lokaler Ebene eine problem- und prozessorientierte, arbeitsplatzspezifische Ausarbeitung im Konsens aller Beteiligten. Diese Ausarbeitung der Leitlinie zum Behandlungspfad ist die Basis der quantitativen Prozess- und Kostenanalyse. [ABSTRACT FROM AUTHOR]

Patients with potential or proven cardiovascular diseases represent a relevant proportion of the total spectrum in the emergency department. Their monitoring for cardiovascular surveillance until the diagnostics and acute treatment are initiated, often poses an interdisciplinary and interprofessional challenge, because resources are limited, nevertheless a high level of patient safety has to be ensured and the correct procedure has a major prognostic significance. This consensus paper provides an overview of the practical implementation, the modalities of monitoring and the application in a selection of cardiovascular diagnoses. The article provides specific comments on the clinical presentations of acute coronary syndrome, acute heart failure, cardiogenic shock, hypertensive emergency events, syncope, acute pulmonary embolism and cardiac arrhythmia. The level of evidence is generally low as no randomized trials are available on this topic. The recommendations are intended to supplement or establish local standards and to assist all physicians, nursing personnel and the patients to be treated in making decisions about monitoring in the emergency department., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: So-called "integrated emergency centers (IEC)" are going to be implemented in German hospitals and will be the first contact point in the emergency care setting. For early decision-making whether outpatient care or inpatient admission in the emergency department is indicated, it would be helpful to have a system to identify patients for outpatient treatment. In this study, we investigated whether the Manchester Triage System (MTS) is suitable for identifying patients who can be safely referred to emergency room patients to outpatient care., Methods: Patients in the emergency department of the "blue" MTS level were examined for the endpoint inpatient admission and were compared with the next higher MTS category "green". In a second step, the "blue" MTS category was examined for the most common criteria leading to inpatient admission., Results: After excluding patients who were presented by the emergency medical services (EMS) or after prior medical consultation, the rate of inpatient admissions in the blue MTS category was significantly lower than in the green category (10.8% vs 29.0%). The rate could be reduced to 0.9% by establishing a subgroup with the additional exclusion criteria chronic disorder and readmission after prior inpatient treatment (CEReCo-blue group: Chronic Disorder (C), Emergency Medical Service (E), Readmission (R), Prior Medical Consultation (Co))., Conclusion: The blue MTS category does not appear to be suitable for the selection of patients with indication for outpatient treatment. We propose the introduction of a subgroup, the so-called CEReCo-blue group, which could be helpful for the selection of this patient group., (© 2021. The Author(s).)

Introduction: With more than 1400 COVID-19 inpatients, the university hospital of Essen is the main regional caregiver during COVID-19 pandemic. We present outcome data of our inpatients during the first 12 months of pandemic and our derived clinical care concepts., Methods: Retrospective analysis of all 1396 COVID-19 inpatients presenting between March, 1 st of 2020 and February, 28 th of 2021 for comorbidities, survival and complications. Group comparison between patients receiving standard care and those requiring intermediate/ intensive care., Results: Mortality rate of all inpatients was 19,8 % (277/ 1396), whereas 10.6 % (93/877) of the patients with standard care and 35.5 % (184/519) of those with intermediate/intensive care died during hospital stay. Age above 60 years, obesity, need for mechanical ventilation, nitric oxide therapy, ECMO and acute renal failure as well as stroke during the clinical course were independent predictors of mortality., Conclusions: The mortality of both patient groups ranges within the numbers published by other international groups. The vast impact of usual comorbidities could be observed as well as the high rate of complications in serious ill COVID-19 patients. The mean age of both patient groups was lower than expected (60 years standard care versus 63 years intermediate/ intensive care). A maximum of patient and staff protection measures, a fast and efficient testing strategy during primary triage, standardized concepts from emergency department to intensive care units and dynamic adjustment of resources to daily changing needs can ensure a high quality of care even during peak of pandemic., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background: Treatment after cardiac arrest has become more complex and interdisciplinary over the last few years. Thus, the clinically active intensive and emergency care physician not only has to carry out the immediate care and acute diagnostics, but also has to prognosticate the neurological outcome., Aim: The different, most important steps are presented by leading experts in the area, taking into account the interdisciplinarity and the currently valid guidelines., Materials and Methods: Attention was paid to a concise, practice-oriented presentation., Results and Discussion: The practical guide contains all important steps from the acute care to the neurological prognosis generation that are relevant for the clinically active intensive care physician.

Introduction: Data about optimal initial assessment in patients with suspicion for COVID19-infection or already confirmed infection are sparse. Especially, in preparation for expected mass casualty incident it is necessary to distinguish early and efficiently between outpatient and inpatient treatment including the need for intensive care therapy., Methods: We present a model for a safe and efficient triage, which is established and used in the university hospital of Essen, Germany. It is intended for a non-disaster situation. This model is a combination of clinical assessment by using vital parameters and Manchester triage scale (MTS). Possible additional parameters are POCT (point-of-care-testing) values, electrocardiogram, CT pulmonary angiography, SARS-Cov2-PCR as well as detailed diagnostic of laboratory values. The model was validated by 100 consecutive patients. We demonstrate three patients to illustrate this model., Results: During the first two weeks after implementing this model in our normal operation at the emergency department, we had an efficient selectivity between need for inpatient and outpatient treatment. 16 patients were classified as "inpatients" according to initial assessment. Among 84 patients who were initially classified as "outpatients", 7 patients returned to our emergency department within 14 days. Three of these patients returned due to complaints other than COVID19. One female patient had to be admitted due to progressive dyspnea., Conclusions: This introduced triage-model seems to be an efficient concept. Adjustment might be necessary after further experience and after a growing number of patients., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Loss of consciousness is a frequent cause for an emergency call to the emergency medical services (EMS). It can be associated with life-threatening conditions. A distinction must be made between transient loss of consciousness (TLOC) and syncope, which is of cardiovascular origin by definition. Initial assessment in prehospital emergency care should follow the ABCDE algorithm including a 12-lead ECG. The presence of important risk factors such as occurrence in supine position, physical stress, palpitations, history of heart diseases, and any abnormalities in the ECG warrants hospital admission. Initial treatment without admission to an emergency department may only be acceptable for healthy patients without any risk factors and injuries, when vital signs are normal and an orthostatic etiology seems most likely.

Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible etiology. Currently there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome which might guide the indication for eCPR are lacking. Currently selection criteria and procedures differ across hospitals and standardized algorithms are lacking. Based on expert opinion, the present consensus statement provides a proposal for a standardized treatment algorithm for eCPR.

The standards of treatment of patients suffering cardiac arrest is defined by international guidelines for cardiopulmonary resuscitation, that are updated every five years. Scientific knowledge is continuously increasing and recent studies should be considered and discussed to improve the results of daily emergency care. There are some leading topics of the ongoing discussion concerning airwaymanagement, mechanical ventilation, mechanical cpr-devices and extracorporal life support. The strategies of postresuscitation care are also in the focus of interest. This review presents and discusses the value of recent investigations on resuscitation science., (© Georg Thieme Verlag Stuttgart · New York.)

Oxygen is the best known and well accepted medication in emergency medicine. In most emergencies high doses of oxygen are an essential part of treatment and seemed to be nearly free of adverse effects. Studies of the last two decades show hints to possible adverse effects of hyperoxia during post-resuscitation-care and myocardial infarction. These results should be critically reviewed and may lead to a rational use of oxygen in emergency care., (© Georg Thieme Verlag Stuttgart · New York.)

Daily routine procedures in anesthesia may be associated with critical events including cardiac arrest. Therefore every anesthesiologist must be informed completely about standards and guidelines for resuscitation to provide adequate patient safety. In October 18 (th), 2010, new international guidelines for resuscitation were published. The main changes in these resuscitation guidelines are described., (© Georg Thieme Verlag Stuttgart · New York.)

Local and regional anaesthesia procedures are common in most surgical practices. Continuous regional anaesthesia techniques may improve the outcome and significantly reduce postoperative pain. Epidural anaesthesia is recommended for abdominal and thoracic surgery, whereas continuous peripheral regional anaesthesia via a catheter is advantageous for limb surgery. Although these techniques are very safe, emergency treatment of life-threatening complications must be available.

The prehospital management of patients with severe trauma should focus on stabilization of vital signs. Major goal is the early transport in a specialized trauma center. After immobilization of cervical spine maintenance of oxygen delivery is the primary and most important intervention. Unconscious patients and patients with respiratory distress should receive endotracheal intubation and controlled ventilation on scene. Amounts of Infusion should be decided on blood loss, patients with traumatic brain injury need at least a normotensive blood pressure. Patients with uncontrolled severe bleeding should not receive excessive infusion before urgent surgical treatment can be performed. Prehospital induction of anesthesia must be carefully considered because of the enhanced risk.

The use of peripheral catheter techniques for regional anaesthesia and analgesia is quite common today. Although electrical nerve stimulation facilitates the correct placement of the insertion cannula, nobody knows where exactly the tip of the advanced catheter will be located after insertion. With the help of stimulation nerve catheters the stimulation of the target nerve via the tip of the catheter during insertion enables a placement nearby the nerve without additional devices. These new catheter systems require--in comparison to the conventional--a modified insertion technique. This article illustrates how to use these catheters in clinical practice and provides information about investigations to success rate and failure.

The ex-utero intra-partum (EXIT) procedure enables the surgeon to perform invasive procedures in an infant during cesarean section before clamping the umbilical cord. Specific anesthesiological concepts are necessary for ensuring sufficient umbilical perfusion. We report the case of a 33-year-old female undergoing cesarean section in the 36th week of pregnancy because of a large fetal cervical tumor. The EXIT procedure was performed in order to secure the infant's airway during delivery. The anesthesiological management and interdisciplinary tasks are discussed in the literature review.

Objective: The use of 0,9 mg/kg Rocuronium allows endotracheal intubation within 60 seconds and therefore might be an alternative to succinylcholine for rapid sequence induction. We investigated the use of high-dose Rocuronium for RSI in prehospital emergency medicine., Methods: Rocuronium was used in two physician staffed units of emergency medical service for RSI in 79 patients aged 4 - 81 yrs (mean 46 yrs). Anesthesia was induced with etomidate/fentanyl or ketamine and 1 mg/kg of rocuronium. Recorded data were number of intubations, time interval application rocuronium-intubation, rating of intubation conditions and side effects., Results: In 75 of 79 (94,9 %) patients intubation could be performed at the first attempt. In three (3,8 %) patients a second attempt and in one pt. a third attempt was necessary. In 78 (98,7 %) patients intubation could be performed within 60 seconds, in one patient intubation was completed within three minutes. The intubation conditions were estimated as excellent (n = 69; 87,3 %) or good (n = 10; 12,7 %) in all patients. No specific side effects could be observed., Conclusions: The use of muscle relaxants improves the intubation conditions and may help to avoid unnecessary high doses of anesthetics in hemodynamic unstable emergency patients. This study shows that rocuronium might be an alternative to succinylcholine for RSI also in prehospital emergency medicine, if succinylcholine is contraindicated.

Introduction: The treatment of polytraumatized patients in the acute period is an exemplary model of multidisciplinary cooperation in a very critical timeframe. Implementing standards formulated in the clinical guidelines of the German Association of Traumatology requires a detailed description of "how to do it.", Methods: Based on the guidelines and validated quality indictors, the optimal standard of care as the goal was defined. A clinical algorithm was developed and personal responsibilities and time limits were clearly assigned to each decision step and action. Checklists, documentation charts, and a full text supplement the algorithm. The complete pathway was adopted by representatives of all occupational groups involved in early trauma care in a consensus process., Results: Improvement potentials were identified in those areas for which the guidelines did not provide explicit recommendations. These represent the key elements of the algorithm. Pathway-specific review criteria (quality indicators) were defined for scheduled reevaluation., Conclusions: Implementing clinical guidelines at the local level requires a problem-oriented and management-oriented elaboration towards a clinical pathway as the basis for a quantitative process and cost analysis.

Objective: Investigation of blood gas analysis during hospital-to-hospital transport of ventilated ICU-patients to detect critical events, changes of gas exchange and reliability of non-invasive monitoring., Methods: 47 ventilated patients (age 9-76 years, mean 50 years, diagnosis: ARDS = 16, intracranial bleeding = 14, severe trauma = 4, acute hemodynamic failure = 3, others = 10), transported by a special physician staffed intensive care ambulance using invasive hemodynamic monitoring. Blood gas analysis was performed before and during transport every 30 minutes and respirator mode, vital signs and events were documented., Results: In 19 (40.4%) patients there were critical events during transport (paO2 < 70 mmHg, paCO2 < 25 mmHg, paCO2 > 55 mmHg, pH < 7.30, pH > 7.55). In 4 patients with PaO2 < 70 mmHg there was SpO2 > or = 97% (by pulsoximetry), correlation between SaO2 (invasive) and SpO2 (by pulsoximetry) was r = 0.81 (P < 0.001) with a maximum difference of 8 percent. In several patients critical changes of condition could be recognized in an early stage by blood gas analysis., Conclusions: Blood gas analysis during hospital-to-hospital transport of ICU-patients can be performed easily and allows to optimize artificial ventilation and to recognize earlier and safer severe problems of gas exchange.