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Background: Until now there has been a reported lack of systematic reports and scientific evaluations of rescue missions during terror attacks. This however is urgently required in order to improve the performance of emergency medical services and to be able to compare different missions with each other. Aim of the presented work was to report the systematic evaluation and the lessons learned from the response to a terror attack that happened in Wuerzburg, Germany in 2016., Methods: A team of 14 experts developed a template of quality indicators and operational characteristics, which allow for the description, assessment and comparison of civil emergency rescue missions during mass killing incidents. The entire systematic evaluation process consisted of three main steps. The first step was the systematic data collection according to the quality indicators and operational characteristics. Second was the systematic stratification and assessment of the data. The last step was the prioritisation of the identified weaknesses and the definition of the lessons learned., Results: Five important "lessons learned" have been defined. First of all, a comprehensive concept for rescue missions during terror attacks is essential. Furthermore, the establishment of a defined high priority communication infrastructure between the different dispatch centres ("red phone") is vital. The goal is to secure the continuity of information between a few well-defined individuals. Thirdly, the organization of the incident scene needs to be commonly decided and communicated between police, medical services and fire services during the mission. A successful mission tactic requires continuous flux of reports to the on-site command post. Therefore, a predefined and common communication infrastructure for all operational forces is a crucial point. Finally, all strategies need to be extensively trained before the real life scenario hits., Conclusion: According to a systematic evaluation, we defined the lessons learned from a terror attack in 2016. Further systematic reports and academic work surrounding life threatening rescue missions and mass killing incidents are needed in order to ultimately improve such mission outcomes. In the future, a close international collaboration might help to find the best database to report and evaluate major incidents but also mass killing events.

Background: In addition to specific treatment of the underlying cause, the therapy of acute respiratory distress syndrome (ARDS) consists of lung protective ventilation and a range of adjuvant and supportive measures., Aim: A survey was conducted to determine the current treatment strategies for ARDS in German ARDS centers., Material and Methods: The 39 centers listed in the German ARDS network in 2011 were asked to complete a questionnaire collecting data on the clinic, epidemiology as well as diagnostic and therapeutic measures regarding ARDS treatment., Results: Of the centers 25 completed the questionnaire. In 2010 each of these centers treated an median of 31 (25-75 percentile range 20-59) patients. Diagnostic measures at admission were computed tomography of the thorax (60 % of the centers), whole body computed tomography (56 %), chest x-ray (52 %), abdominal computed tomography (32 %) and cranial computed tomography (24 %). Transesophageal echocardiography was performed in 64 %, pulmonary artery pressure was measured in 56 % and cerebral oximetry in 12 %. Sedation was regularly interrupted in 92 % of the centers and in 68 % this was attempted at least once a day. A median minimum tidal volume of 4 ml/kg (range 2-6) and a maximum tidal volume of 6 ml/kg (4-8) were used. Methods to determine the optimal positive end-expiratory pressure (PEEP) were the best PEEP method (60 %), ARDS network table (48 %), empirical (28 %), pressure volume curve (16 %), computed tomography (8 %), electrical impedance tomography (8 %) and others (8 %). Median minimum and maximum PEEPs were 10 cmH2O (range 5-15) and 21 cmH2O (15-25), respectively. Median plateau pressure was limited to 30 cmH2O (range 26-45). The respiratory rate was set below 20/min in 20 % and below 30/min in 44 %. Controlled ventilator modes were generally preferred with 80 % using biphasic positive airway pressure (BIPAP/BiLevel), 20 % pressure controlled ventilation (PCV) and 4 % airway pressure release ventilation (APRV). Assisted modes were only utilized by 8 % of the centers. Recruitment maneuvers were used by 28 %, particularly during the early phase of the ARDS. Muscle relaxants were administered by 32 % during the early phase of the ARDS. Complete prone positioning was used by 60 % of the centers, whereas 88 % utilized incomplete (135°) prone positioning. Continuous axial rotation was utilized by 16 %. Spontaneous breathing tests were used in 88 % of the centers with 60 % performing these at least once a day. Supportive therapies were frequently applied and mainly consisted of nitrous oxide (44 %), prostacycline (48 %) and corticosteroids (52 %). A restrictive fluid therapy was used in 48 % and a special nutrition regimen in 28 % of the centers. Of the participating centers 22 were able to offer extracorporeal membrane oxygenation (ECMO). In this case, respiratory therapy was modified by further reducing tidal volumes (91 %), inspiratory pressures (96 %) as well as using lower respiratory rates (≤ 8/min in 31 %). Only 9 % reduced PEEP during ECMO. Regular recruitment maneuvers were used by 14 %. Positioning maneuvers during ECMO were used by 82 %., Conclusions: Lung protective ventilation with reduced tidal volumes as well as inspiratory pressures represents the current standard of care and was utilized in all network centers. Prone positioning was widely used. Promising adjuvant therapies such as the muscle relaxation during the early phase of the ARDS, fluid restriction and corticosteroids were used less frequently. During ECMO respirator therapy was generally continued with ultraprotective ventilator settings.

Background: During early in-hospital management of the arriving trauma patient the timing of the trauma team alert is an important organisational step. To evaluate the accordance of the estimated and the real arriving time we performed a retrospective data analysis at a level I German trauma centre., Methods: Retrospective data analysis. Trauma team alerts from September 2010 until March 2011 were analysed. According to the hospitals pre-alert algorithm, trauma team alert took place 10 min before the estimated time of arrival., Results: There were 165 trauma team alerts included in the analysis. The estimated arrival time coincided with the real arrival time in less than 10 % of cases. In 76 % of the cases, the patient arrived in an acceptable time frame with the trauma team waiting less than 14 min. In 3 % of the cases, the patient arrived prior to the trauma team., Conclusion: An exact estimation of the arrival time is rare. With a trauma team alert 10 min prior to the estimated time of arrival, an acceptable waiting time can be achieved. Arrival of the patient prior to the trauma team can be avoided.

Context: The Airtraq is a disposable optical laryngoscope that is available in a double-lumen tube version. Inserting a double-lumen tube is generally more difficult compared to conventional endotracheal intubation, mainly due to its configuration., Objective: The aim of this study was to compare the Airtraq with the Macintosh laryngoscope for intubation with a double-lumen tube in patients undergoing elective thoracic surgery. The main outcome was time needed for successful intubation., Design: Prospective, randomised clinical trial., Setting: A single centre, University Hospital of Würzburg, Germany, between July 2009 and June 2011., Patients: After a scout laryngoscopy with a Macintosh laryngoscope, 60 adult patients were intubated by an anaesthesiologist with either an Airtraq (n = 30) or a Macintosh laryngoscope (n = 30)., Main Outcome Measures: The time needed for correct intubation, checked by flexible bronchoscopy, was recorded. The intubation difficulty scale (IDS) and Cormack and Lehane grade were noted. Haemodynamic variables and any evidence of oropharyngeal trauma were documented as well as postoperative sore throat, hoarseness and dysphagia., Results: The mean time needed for correct intubation was 20.1 ± 16.5 s in the Airtraq group and 17.5 ± 10 s in the Macintosh group (P = 0.86). All intubations in both groups had an IDS less than 4. The Cormack and Lehane grade was I in all 30 patients in the Airtraq group; in the Macintosh group, it was I and II in 17 and 13 patients, respectively. The incidence of hoarseness was significantly higher in the Airtraq group 24 h postoperatively (P = 0.01)., Conclusion: There was no significant difference between the Airtraq and the Macintosh laryngoscopes regarding the time needed to insert a double-lumen tube during elective thoracic surgery. Only subtle enhancement of visualisation and a higher incidence of hoarseness were observed in the Airtraq group. The Airtraq device did not result in superior patient safety in this setting.

Objective: High-frequency oscillatory ventilation (HFOV) may reduce ventilator-induced lung injury in experimental neonatal respiratory distress. However, these data permit no conclusions for large animals or adult patients with acute respiratory distress syndrome (ARDS), because in neonates higher frequencies and lower amplitudes can be used, resulting in lower tidal volumes (VT) and airway pressures. The aim of this study was to compare gas exchange, lung histopathology and inflammatory cytokine expression during lung-protective pressure-controlled ventilation (PCV) and HFOV in a long-term large-animal model of ARDS., Design: Prospective, randomized, controlled pilot study., Setting: University animal laboratory., Subjects: Sixteen female pigs (55.3 +/- 3.9 kg)., Interventions: After induction of ARDS by repeated lavage, the animals were randomly assigned to PCV (VT = 6 ml/kg) and HFOV (6 Hz). After lung injury, a standardised lung recruitment was performed in both groups, and ventilation was continued for 24 h., Measurements and Results: After lung recruitment sustained improvements in the oxygenation index were observed in both groups. The mean airway pressure (mPaw) was significantly lower in the HFOV group during the experiment (p < 0.01). Histologically, lung inflammation was significantly ameliorated in the HFOV group (p < 0.05). The messenger RNA expression of IL-1-beta in lung tissue was significantly lower in the HFOV-treated animals (p < 0.01)., Conclusions: These data suggest that HFOV compared with conventional lung-protective ventilation can reduce lung inflammation in a large-animal 24-h model of ARDS. Furthermore, it was shown that lung recruitment leads to sustained improvements in gas exchange with a significantly lower mPaw when HFOV is used.

A point mutation in the gene encoding the skeletal muscle calcium release channel (RYR1) has been proposed as the probable cause of malignant hyperthermia (MH) in swine, where it segregates with the disease in all MH-prone strains investigated. The same C-to-T exchange in nucleotide position 1840 of the human RYR1 cDNA sequence was found in a few human MH pedigrees. We report a German MH pedigree where in vitro contracture test (IVCT) results and haplotypes of markers for the MHS1/RYR1 region including this base transition have yielded several discrepancies. The MH-susceptible phenotype was defined by IVCT performed according to the European standard protocol. Haplotypes were constructed for markers for the MHS1/RYR1 region on chromosome 19 and include the C1840T base exchange. Discussing the probabilities for a number of hypotheses to explain these data, we suggest that our results may challenge the causative role of this mutation--and possibly the role of the RYR1 gene itself--in human MH susceptibility, at least in some cases.