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Background and Importance: The differentiation between patients who require urgent care and those who could receive adequate care through ambulatory services remains a challenge in managing patient volumes in emergency departments (ED). Different approaches were pursued to characterize patients that could safely divert to ambulatory care. However, this characterization remains challenging as the urgency upon presentation is assessed based on immediately available characteristics of the patients rather than on subsequent diagnoses. This work employs a core set of Ambulatory Care Sensitive Conditions (core-ACSCs) in an ED to describe conditions that do not require inpatient care if treated adequately in the ambulatory care sector. It subsequently analyzes the corresponding triage levels and admission status to determine whether core-ACSCs relevantly contribute to patient volumes in an ED., Settings and Participants: Single center cross-sectional analysis of routine data of a tertiary ED in 2019., Outcome Measures and Analysis: The proportion of core-ACSCs among all presentations was assessed. Triage levels were binarily classified as "urgent" and "non-urgent," and the distribution of core-ACSCs in both categories was studied. Additionally, the patients presenting with core-ACSCs requiring inpatient care were assessed based on adjusted residuals and logistic regression. The proportion being discharged home underwent further investigation., Main Results: This study analyzed 43,382 cases of which 10.79% ( n  = 4,683) fell under the definition of core-ACSC categories. 65.2% of all core-ACSCs were urgent and received inpatient care in 62.8% of the urgent cases. 34.8% of the core-ACSCs were categorized as non-urgent, 92.4% of wich were discharged home. Age, triage level and sex significantly affected the odds of requiring hospital admission after presenting with core-ACSCs. The two core-ACSCs that mainly contributed to non-urgent cases discharged home after the presentation were "back pain" and "soft tissue disorders.", Discussion: Core-ACSCs contribute relevantly to overall ED patient volume but cannot be considered the primary drivers of crowding. However, once patients presented to the ED with what was later confirmed as a core-ACSC, they required urgent care in 65.2%. This finding highlights the importance of effective ambulatory care to avoid emergency presentations. Additionally, the core-ACSC categories "back pain" and "soft tissue disorders" were often found to be non-urgent and discharged home. Although further research is required, these core-ACSCs could be considered potentially avoidable ED presentations., Clinical Trial Registration: The study was registered in the German trials register (DRKS-ID: DRKS00029751) on 2022-07-22., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Benning, Kleinekort, Röttger, Köhne, Wehrle, Blum, Busch and Hans.)

Actively avoiding fever is the only possibility to improve neurological outcome after cardiac arrest. It is uncertain if and which patients benefit from a lower target temperature. The ERC Guidelines in 2021 recommended targeted temperature management (TTM) for all patients after in- and out-of-hospital cardiac arrest with a target temperature of 32-36 °C for at least 24 hours. These recommendations were updated in 2022 by the ERC/ESICM Guidelines suggesting to avoid fever only within the first 72 hours after the event. Divergent results of recent trials lead to these guideline changes. The large TTM2 Trial in 2021 did not show a benefit neither in survival nor in neurological outcome in the group of hypothermia at 33°C compared to normothermia. Although leading to the updated guidelines, applying these study results to the German population is restricted as the rate of bystander cardiopulmonary resuscitation (CPR) or shockable rhythms is much lower in Germany. Further studies are needed to allow a better differentiation of subpopulations and to implement a more individual classification und therapy., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

The timely integration of palliative medicine is an important component in the treatment of various advanced diseases. While a German S-3-guideline on palliative medicine exists for patients with incurable cancer, a recommendation for non-oncological patients and especially for palliative patients being treated in the emergency department or intensive care unit is missing to date. Based on the present consensus paper, the palliative care aspects of the respective medical disciplines are addressed. The timely integration of palliative care aims to improve quality of life and symptom control in clinical acute and emergency medicine as well as intensive care., Competing Interests: Die Autoren*innen haben keine im Zusammenhang mit dem vorliegenden Konsensuspapier bestehenden Interesssenskonflikte.Funktionen der Autoren*innen in den jeweiligen Fachgesellschaften und weitere Informationen befinden sich in der Online-Langversion.Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren. Alle Patienten, die über Bildmaterial oder anderweitige Angaben innerhalb des Manuskripts zu identifizieren sind, haben hierzu ihre schriftliche Einwilligung gegeben., (Thieme. All rights reserved.)

Background: Little is known about sex differences in elderly patients after out-of-hospital cardiac arrest (OHCA) with return of spontaneous circulation (ROSC) and subsequent target temperature management (TTM). Therefore, this study was designed to evaluate sex-specific differences in survival and neurological outcome in elderly patients at 28-day and 180-day follow-up., Methods: A total of 468 nontraumatic OHCA survivors with preclinical ROSC and an age of ≥ 65 years were included in this study. Sex-specific differences in survival and a favorable neurological outcome according to the cerebral performance category (CPC) score were evaluated as clinical endpoints., Results: Of all participants included, 70.7% were men and 29.3% women. Women were significantly older (p = 0.011) and were more likely to have a nonshockable rhythm (p = 0.001) than men. Evaluation of survival rate and favorable neurological outcome by sex category showed no significant differences at 28-day and 180-day follow-up. In multiple stepwise logistic regression analysis, age (odds ratio 0.932 [95% confidence interval 0.891-0.951], p = 0.002) and time of hypoxia (0.899 [0.850-0.951], p < 0.001) proved to be independent predictors of survival only in male patients, whereas an initial shockable rhythm (4.325 [1.309-14.291], p = 0.016) was associated with 180-day survival in female patients. The majority of patients (93.7%) remained in the same CPC category when comparing 28-day and 180-day follow-up., Conclusion: Our results show no significant sex-specific differences in survival or favorable neurological outcome in elderly patients after having survived OHCA, but sex-specific predictors for 180-day survival. Moreover, the neurological assessment 28 days after the index event also seems to provide a valid indication for the further prognosis in elderly patients., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Emergency personnel assess their patients as an essential part of their daily work in emergency settings. The clinical assessment can help differentiate between immediately life-threatening conditions and milder diseases in patients. This assessment is the basis for an adequate preclinical treatment and for a rational referral to the hospital providing further care. Carried out in a thoughtful manner it allows reasonable allocation of resources for inpatient care.Well-founded training, clinical experience, scores, and tools in the form of acronyms for assessing the patient lead to successful assessments according to quality standards.The preclinical initial assessment is crucial for ensuring appropriate care for patients on site with life-threatening conditions as well as those with minor problems. Prioritization of a treatment depends on the severity of the condition or injury., (© 2022. The Author(s).)

Acute gastrointestinal bleeding often leads to admission to the emergency room. Especially in elderly patients and in those with significant comorbidities it is associated with increased morbidity and mortality. Approximately 2 % of the patients with gastrointestinal bleeding present with hemorrhagic shock. This review focusses on the structured preclinical and clinical management of gastrointestinal bleeding in the emergency department., Competing Interests: Dominik Bettinger gibt Beratertätigkeit für Bayer Healthcare, Boston Scientific und Shionogi sowie Vortragstätigkeiten für Bayer Healthcare und die Falk Foundation an.Bonaventura Schmid, Hans-Jörg Busch und Robert Thimme geben an, dass keine Interessenkonflikte bestehen., (Thieme. All rights reserved.)

The complement system (CS) plays a pivotal role in Coronavirus disease 2019 (COVID-19) pathophysiology. The objective of this study was to provide a comparative, prospective data analysis of CS components in an all-comers cohort and COVID-19 patients. Patients with suspected COVID-19 infection admitted to the Emergency department were grouped for definite diagnosis of COVID-19 and no COVID-19 accordingly. Clinical presentation, routine laboratory and von Willebrand factor (vWF) antigen as well as CS components 3, 4 and activated 5 (C5a) were assessed. Also, total complement activity via the classical pathway (CH50) was determined. Levels of calprotectin in serum were measured using an automated quantitative lateral flow assay. We included 80 patients in this prospective trial. Of those 19 (23.7%) were tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Patients with COVID-19 had higher levels of CS components 5a and 4 (54.79 [24.14-88.79] ng/ml vs. 35 [23.15-46.1] ng/ml; p = 0.0433 and 0.3772 [± 0.1056] g/L vs. 0.286 [0.2375-0.3748] g/L; p = 0.0168). COVID-19 patients had significantly higher levels of vWF antigen when compared to the control group (288.3 [± 80.26] % vs. 212 [151-320] %; p = 0.0469). There was a significant correlation between CS C3 and 5a with vWF antigen (r s  = 0.5957 [p = 0.0131] and r s  = 0.5015 [p = 0.042]) in COVID-19 patients. There was no difference in calprotectin plasma levels (4.786 [± 2.397] µg/ml vs. 4.233 [± 2.142] µg/ml; p = 0.4175) between both groups. This prospective data from a single centre all-comers cohort accentuates altered levels of CS components as a distinct feature of COVID-19 disease. Deregulation of CS component 3 and C5a are associated with increased vWF antigen possibly linking vascular damage to alternative CS activation in COVID-19., (© 2021. The Author(s).)

The present document describes the possible applications of contrast-enhanced ultrasound (CEUS) in emergency examinations. Guidelines on contrast medium ultrasound in acute and emergency care and intensive care medicine have not yet been published. Evidence-based CEUS guidelines were first provided by the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and the World Federation for Ultrasound in Medicine and Biology (WFUMB). The presented recommendations describe the possible applications and protocols of CEUS in acute care., (© 2021. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Shortening the resuscitation-free interval in cardiac arrest increases the survival rate. Smartphone-based systems can locate and alert nearby rescuers., Objectives: Implementation of a first responder system, technical development and adaption to regional structures., Materials and Methods: The system "Region der Lebensretter" was successfully established in July 2018 in Freiburg. The need of optimization was evaluated every half year and realized according to the PDCA (plan-do-check-act) cycle. The necessary functions were specified (plan), programmed, tested and released (do). Afterwards the changes were evaluated (check) and, if necessary, further optimizations were implemented (act)., Results: The number of registered rescuers increased from 276 (2nd half year 2018) to 794 (1st half year 2020). The rate of alarm acceptance increased from 30% (2nd half year 2018) to 49% (1st half year 2020). The following features were designed and released: dynamic adjustment of the alarm radius (DAA), critical alert function, connection to automated external defibrillator (AED) database, digital rescuer identification (ID), feedback button "arrived on scene", choice of means of transport for algorithm optimization. The number of existing AEDs increased from 190 to 270., Conclusion: The resuscitation-free interval can be shortened by smartphone-based alerting systems. For successful operation, the total number of rescuers and the technical realization is crucial. Further studies are necessary to investigate whether the survival rate of out-of-hospital cardiac arrest can be increased. It appears extremely appropriate to adapt these systems to databases of quality management or research registers., (© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2021.)

Carbon monoxide (CO) can occur in numerous situations and ambient conditions, such as fire smoke, indoor fireplaces, silos containing large quantities of wood pellets, engine exhaust fumes, and when using hookahs. Symptoms of CO poisoning are nonspecific and can range from dizziness, headache, and angina pectoris to unconsciousness and death. This guideline presents the current state of knowledge and national recommendations on the diagnosis and treatment of patients with CO poisoning. The diagnosis of CO poisoning is based on clinical symptoms and proven or probable exposure to CO. Negative carboxyhemoglobin (COHb) levels should not rule out CO poisoning if the history and symptoms are consistent with this phenomenon. Reduced oxygen-carrying capacity, impairment of the cellular respiratory chain, and immunomodulatory processes may result in myocardial and central nervous tissue damage even after a reduction in COHb. If CO poisoning is suspected, 100% oxygen breathing should be immediately initiated in the prehospital setting. Clinical symptoms do not correlate with COHb elimination from the blood; therefore, COHb monitoring alone is unsuitable for treatment management. Especially in the absence of improvement despite treatment, a reevaluation for other possible differential diagnoses ought to be performed. Evidence regarding the benefit of hyperbaric oxygen therapy (HBOT) is scant and the subject of controversy due to the heterogeneity of studies. If required, HBOT should be initiated within 6 h. All patients with CO poisoning should be informed about the risk of delayed neurological sequelae (DNS)., Competing Interests: See Attachment 2, (Copyright © 2021 Jüttner et al.)

Checklists can improve adherence to standardized procedures and minimize human error. We aimed to test if implementation of a checklist was feasible and effective in enhancing patient care in an emergency department handling internal medicine cases. We developed four critical event checklists and confronted volunteer teams with a series of four simulated emergency scenarios. In two scenarios, the teams were provided access to the crisis checklists in a randomized cross-over design. Simulated patient outcome plus statement of the underlying diagnosis defined the primary endpoint and adherence to key processes such as time to commence CPR represented the secondary endpoints. A questionnaire was used to capture participants' perception of clinical relevance and manageability of the checklists. Six teams of four volunteers completed a total of 24 crisis sequences. The primary endpoint was reached in 8 out of 12 sequences with and in 2 out of 12 sequences without a checklist (Odds ratio, 10; CI 1.11, 123.43; p = 0.03607, Fisher's exact test). Adherence to critical steps was significantly higher in all scenarios for which a checklist was available (performance score of 56.3% without checklist, 81.9% with checklist, p = 0.00284, linear regression model). All participants rated the checklist as useful and 22 of 24 participants would use the checklist in real life. Checklist use had no influence on CPR quality. The use of context-specific checklists showed a statistically significant influence on team performance and simulated patient outcome and contributed to adherence to standard clinical practices in emergency situations., (© 2021. The Author(s).)

Systemic inflammation is a major feature of the post-cardiac arrest syndrome. The three monocyte subpopulations are thought to play an important role in this inflammatory state because they are endowed with numerous pattern recognition receptors, such as CD14, that have been associated with ischemia-reperfusion injury. By contrast, an exaggerated antiinflammatory response has also been described following cardiac arrest, which may be mediated by downregulation of antigen presentation receptor HLA-DR. We report the composition of monocyte subpopulations and the expression of CD14 and HLA-DR following cardiac arrest. Blood specimens were collected from 32 patients at three timepoints in the first 48 h after cardiac arrest. Monocyte subset composition was determined by flow cytometry based on the expression of CD14, CD16, and HLA-DR. Monocyte subset composition and the expression of CD14 and HLA-DR were correlated with patient outcomes. The results were compared to 19 patients with coronary artery disease. Cardiac arrest patients showed a significant decline in the percentage of nonclassical monocytes. Monocyte CD14 expression was upregulated after 24 h and correlated with the time to return of spontaneous circulation. Downregulation of HLA-DR expression was observed mainly among classical monocytes and significantly correlated with the dose of norepinephrine used to treat shock. Downregulation of HLA-DR among nonclassical and intermediate monocytes was significantly associated with disease severity. Our data demonstrate the disturbance of monocyte subset composition with a significant decline in nonclassical monocytes at an early stage following cardiac arrest. Our findings suggest the simultaneous presence of hyperinflammation, as evidenced by upregulation of CD14, and monocyte deactivation, characterized by downregulation of HLA-DR. The extent of monocyte deactivation was significantly correlated with disease severity.

The treatment of critically ill patients in the emergency room poses major challenges to the treatment teams. Good teamwork is essential for patient care and patient safety. Between 60 and 70% of all errors in high-risk areas-such as medicine-are assigned to the field of "human factors". In aviation, after several aircraft disasters, the concept of "Crew Resource Management" (CRM) was developed in the 1980s to avoid such errors and has since established itself in many high-security industries. In contrast to medicine, there has long been a legal obligation in aviation to conduct regular CRM training. Introduced into medicine by anesthesiologists in 1990 because of its potential, CRM training has so far found its way into emergency medicine especially, even without it being a legal obligation. For trauma room treatment of polytrauma patients, the disciplines involved already offer a specially developed training concept in which teaching of CRM principles is the main focus (HOTT®-Schockraumsimulation). In addition to dedicated private providers of CRM training and individual concepts developed at an institutional level, several common course concepts for the care of emergency patients also integrate CRM principles to varying degrees into their curricula and teaching methods. Level IA evidence for CRM training is still missing also due to systematic difficulties not only in medicine, but also in other high-risk areas. However, further implementation of regular CRM training in medicine should not be suspended for this very reason.

The emergency department (ED) is one of the crucial parts of the hospital infrastructure during all phases of the pandemic. The ED plays an important part in detecting an increasing number of new contagious diseases, which could potentially lead to an epidemic or pandemic.During a pandemic, the ED's main task is to detect infected individuals. These patients then need to be isolated and an adequate treatment is required. The ED must be prepared in order to perform well in such a situation. One major part for readiness is communication in an open manner to all partners within the department, as well as with emergency medical services and other departments of the hospital.The ED must be restructured to withstand the rising number of infected patients. These patients must be separated from other critically ill patients. Strategies for a diagnostic workup depending on the kind of infection have to be put in place. Pathways for the outpatient and inpatient management must be defined to avoid overcrowding in the ED. Depending on the number of patients, escalation and de-escalation strategies have to be set up within the hospital.Over the whole course of the pandemic, all staff members are the key resources for the ED and the entire hospital. The ED can only cope with a pandemic situation if staff are working together as a whole. This implies several important steps to get the staff prepared: Recurring, open conversations about fears, problems, and successes are critical for staff morale. Training must be continually provided, and protection strategies implemented. In the chronic phase of the pandemic the focus should shift more towards strategies on how to create possibilities for recuperation, domestic support measures, and mental health care for staff., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

COVID-19 is associated with a variety of clinical complications including coagulopathy, which frequently results in venous thromboembolism (VTE). Retrospective analyses reported a markedly increased rate of VTEs in COVID-19. However, most recent studies on coagulopathy in COVID-19 were only focused on critically ill patients, and without suitable control groups. We aimed to evaluate the rate of VTEs in an all-comers cohort with suspected COVID-19 during a 30-days follow-up period. We also studied the level of D-dimers and their association with the course of disease. In our prospective single-center study (DRKS00021206, 03/30/2020), we analyzed 190 patients with suspected COVID-19 admitted to the emergency department between March and April 2020. Forty-nine patients were SARS-CoV-2 positive (25.8%). The 141 SARS-CoV-2-negative patients served as control group. After completion of a 30-days follow-up, VTE was diagnosed in 3 patients of the SARS-CoV-2-positive group (6.1%, amongst these 2 ICU cases) versus 5 patients in the SARS-CoV-2-negative group (3.5%), however the difference was not statistically significant (p = 0.427). 30-days mortality was similar in both groups (6.1% vs. 5%, p = 0.720). Disease severity correlated with the maximum level of D-dimers during follow-up in COVID-19. The rate of VTE was numerically higher in SARS-CoV-2 positive all-comers presenting with suspected COVID-19 as compared to well-matched controls suffering from similar symptoms. VTEs in the COVID-19 group predominantly occurred in ICU courses. The maximum level of D-dimers during follow-up was associated with disease severity in COVID-19, whereas the level of D-dimers at admission was not.

In 2016, the new bedside tool quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) was presented to identify patients at high risk of developing sepsis or adverse outcome. The aim of this study was to investigate the diagnostic performance of the qSOFA scoring system as a screening in patients presenting at an emergency department (ED) of any cause. Therefore, we compared qSOFA with the systemic inflammatory response syndrome (SIRS) criteria and two modifications of qSOFA score. This is a prospective single-center study including patients presenting to the ED of any non-traumatic cause. Primary outcome was development of sepsis within 48 h, secondary outcomes were 30-day mortality and ICU stay for > 3 days. Data were collected within one hour after arrival to indicate an impression of initial medical contact. Among 1,668 patients, 105 sepsis cases were identified. 8.4% presented with qSOFA ≥ 2, 27.2% with SIRS ≥ 2 within one hour. Sensitivity of qSOFA in predicting sepsis was lower compared to the SIRS criteria. qSOFA showed better prognostic accuracy for 30-day mortality compared to SIRS (p < 0.05), but not for prolonged ICU stay (p = 0.56). Modification of qSOFA in replacing GCS by other scoring systems recording altered mental status did not improve its sensitivity. The qSOFA score has poor sensitivity to identify patients at risk of developing sepsis and can therefore not be considered as an adequate screening for sepsis in patients presenting to the ED. Furthermore, a positive qSOFA at arrival at the ED showed no sufficient reliability in detecting patients with adverse clinical course.

Background: The new pandemic coronavirus SARS-CoV-2 causing coronavirus disease-2019 (COVID-19) poses immense challenges to health care systems worldwide. In the current manuscript we summarize the strategies, organisational approaches and actions of the Task-force Coronavirus at the University Medical Center Freiburg. We also report on experiences with implementation of these approaches and treatment outcomes in the first 115 COVID patients., Methods: Retrospective, narrative process description and analysis of the time period between end of January and beginning of April 2020, performed by representatives of the involved departments and institutes. Additionally a retrospective observational cohort study with descriptive analysis of epidemiological and clinical data of COVID patients admitted until March 31st was performed., Results: A multidisciplinary Task-force Coronavirus initiated measures concerning outpatient testing and counseling, reorganisation and separation of patient flow processes alongside with substantial escalation of inpatient capacities on regular wards and intensive care units. Within the framework of the resulting dynamic care model, 115 patients suffering from COVID could be treated without shortages in staff or bed capacities., Dicussion: In the upcoming pandemic, adequate COVID management and care could be secured by a collaborative approach with inclusion of administrative departments, clinical disciplines and theoretical institutes of the University Medical Center Freiburg., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

The prevalence of patients living with long-term mechanical circulatory support (MCS) is rapidly increasing due to improved technology, improved survival, reduced adverse event profiles, greater reliability and mechanical durability, and limited numbers of organs available for donation. Patients with long-term MCS are very likely to require emergency medical support due to MCS-associated complications (e.g., right heart failure, left ventricular assist device malfunction, hemorrhage and pump thrombosis) but also due to non-MCS-associated conditions. Because of the unique characteristics of mechanical support, management of these patients is complicated and there is very little literature on emergency care for these patients. The purpose of this national scientific statement is to present consensus-based recommendations for the initial evaluation and resuscitation of adult patients with long-term MCS.

Acute bleeding is a common and challenging condition in the emergency room. The need for staff and medical resources in these patients depends on the clinical status and extent of the bleeding. The causes of acute bleeding are heterogeneous. Patients may appear in an emergency department with gastrointestinal, traumatic, intracerebral, gynecological or urological bleeding. Bleeding may be triggered or aggravated by underlying diseases or the use of anticoagulants or antiplatelet therapy. The treatment can range from general measures to complex intensive care with antidotes, blood coagulation and transfusion management. Nevertheless, the initial management in such cases is often the same.The purpose of this article is to give an overview of the different types of acute bleeding in an emergency room and how to overcome these specific challenges. Important is the initial management with appropriate general measures to stabilize the patient to avoid serious complications. It is helpful to set up structured processes for these cases., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible aetiology. Currently, there are no randomised, controlled studies on eCPR. Thus, prospective validated predictors of benefit and outcome are lacking. Currently, selection criteria and procedure techniques differ across hospitals and standardised algorithms are lacking. Based on expert opinion, the present consensus statement provides a first standardised treatment algorithm for eCPR.

For the first time, the european guidelines for cardiopulmonary resuscitation (CPR) have been updated by the ILCOR in december 2017. If new data and findings are available, these guidelines can also be updated outside the 5-year cycle. Thus, it is now recommended that, depending on the level of training of the layer, a chest-compression-only CPR or in combination with ventilation should be done. The important function of the dispatchers in the context of telephone or dispatcher-assisted CPR is emphasized by the demand of a structured training. The use of mechanical chest compression devices remains reserved only for special situations., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

The use of Point-of-care ultrasonography (POC Ultrasonography) is getting more and more important in the bedside care of patients, especially in emergency- and intensive care units. In addition to the focused sonography of the heart, lungs and abdomen, the POC Ultrasonography recently includes also cases in prehospital care. Increasingly special applications in intensive care, e.g. the assessment of weaning from mechanical ventilation or evaluation of the hemodynamics of a patient by means of sonographic control, gain meaning.The German Society for Internistic Intensive Care and Emergency Medicine e. V. (DGIIN), the German society for Ultrasound in Medicine e. V. (DEGUM) and the German Society of Cardiology e. V. (DGK) recently published a common recommendation for a training concept in POC Ultrasonography. The aim is quality assurance and accordingly the improvement of patient care in emergency- and intensive care., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a powerful arteriogenic factor in the hypoperfused rat brain. To test the pathophysiological relevance of this response, the influence of GM-CSF on brain energy state was investigated in a model of hemodynamic stroke. Sprague-Dawley rats were submitted to three-vessel (bilateral vertebral and unilateral common carotid artery) occlusion (3-VO) to induce unilaterally accentuated brain hypoperfusion. One week later, hemodynamic stroke was induced by additional lowering of arterial blood pressure. Experiments were terminated by in situ freezing of the brain. ATP was measured in cryostat sections by using a bioluminescence method. The use of 3-VO, in combination with 15 min of hypotension of 50, 40, or 30 mmHg, did not produce disturbances of energy metabolism, however, focal areas of ATP depletion were unilaterally detected after 3-VO, in combination with 15 min of hypotension of 20 mmHg. Treating such animals with GM-CSF (40 microg.kg(-1).d(-1)) during the 1-week interval between 3-VO and induced hypotension significantly reduced the hemispheric volume of energy depletion from 48.8 +/- 44.2% (untreated group, n = 10) to 15.8 +/- 17.4% (treated group, n = 8, P = 0.033). GM-CSF-induced arteriogenesis is another approach to protect the brain against ischemic injury.