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Abstract Background Multiple severe trauma frequently leads to massive dysbalances of the human immune system. This phenomenon is known as "Systemic Inflammatory Response Syndrome (SIRS)". SIRS is connected to multiple organ failure and thereby entails higher morbidity and mortality in trauma patients. Pro-and anti-inflammatory cytokines such as Il-6, Il-8 and Il-10 seem to play a superior role in the development of SIRS. Several studies support the hypothesis that the very early cytokine release pattern determines the patients' subsequent clinical course. Most data about interleukins in trauma patients however refer to serum concentrations assessed sometime in the first 24 h, but there is only little information about release dynamics in a small-meshed time frame in the very initial post-trauma period. Patients and methods 58 multiple injured patients (Injury Severity Score > 16 points) were included. Blood samples were drawn on patient admission (not later then 90 minutes after trauma) and at 6 h, 12 h, 24 h, 48 h and 72 h. Il-6, Il-8 and Il-10 were measured using an automated chemiluminescence assay (IMMULITE, Siemens Healthcare Diagnostics GmbH). Interleukin levels were correlated to distinct epidemiological and clinical parameters. Results Interleukin serum concentrations are thoroughly elevated after trauma. Patients with haemorrhagic shock and consecutive massive RBC substitution (n = 27) exhibit higher Il-6, Il-8 and Il-10 levels as compared to patients with minor RBC transfusion extent (n = 31). Interleukin levels also differentiate patients with MOF (n = 43) from such without MOF (n = 15) already at the earliest post trauma time (90 minutes). Il-6, Il-8 and Il-10 concentrations also significantly distinguish patients with adverse outcome (n = 11) from such with favourable outcome (n = 47). Exclusively Il-10 has significant correlation to injury severity (ISS > 35). Conclusion The current study presents an image of the serum Il-6, 8 and 10 releases in multiple trauma patients in the very early post-trauma period. We could thereby demonstrate that interleukin levels can clearly differentiate the presence of hemorrhagic shock and subsequent massive blood product substitution, the development of multiple organ failure and clinical outcome. No significant connection to age, gender and brain injury could be detected. Most importantly, changes in interleukin levels can be observed in the very early posttraumatic phase, at the earliest 90 minutes after trauma.

The purpose of the study was to evaluate both CT image quality in a phantom study and feasibility in an initial case series using automated chest compression (A-CC) devices for cardiopulmonary resuscitation (CPR). Multidetector CT (MDCT) of a chest/heart phantom (Thorax-CCI, QRM, Germany) was performed with identical protocols of the phantom alone (S), the phantom together with two different A-CC devices (A: AutoPulse, Zoll, Germany; L: LUCAS, Jolife, Sweden), and the phantom with a LUCAS baseplate, but without the compression unit (L-bp). Nine radiologists evaluated image noise quantitatively (n = 244 regions, Student's t-test) and also rated image quality subjectively (1-excellent to 6-inadequate, Mann-Whitney U-test). Additionally, three patients during prolonged CPR underwent CT with A-CC devices. Mean image noise of S was increased by 1.21 using L-bp, by 3.62 using A, and by 5.94 using L (p < 0.01 each). Image quality was identical using S and L-bp (1.64 each), slightly worse with A (1.83), and significantly worse with L (2.97, p < 0.001). In all patient cases the main lesions were identified, which led to clinical key decisions. Image quality was excellent with L-bp and good with A. Under CPR conditions initial cases indicate that MDCT diagnostics supports either focused treatment or the decision to terminate efforts. [ABSTRACT FROM AUTHOR]

Background: In patients complaining common symptoms such as chest/abdominal/back pain or syncope, acute aortic syndromes (AAS) are rare underlying causes. AAS diagnosis requires urgent advanced aortic imaging (AAI), mostly computed tomography angiography. However, patient selection for AAI poses conflicting risks of misdiagnosis and overtesting., Objectives: We assessed the safety and efficiency of a diagnostic protocol integrating clinical data with point-of-care ultrasound (POCUS) and d-dimer (single/age-adjusted cutoff), to select patients for AAI., Methods: This prospective study involved 12 Emergency Departments from 5 countries. POCUS findings were integrated with a guideline-compliant clinical score, to define the integrated pre-test probability (iPTP) of AAS. If iPTP was high, urgent AAI was requested. If iPTP was low and d-dimer was negative, AAS was ruled out. Patients were followed for 30 days, to adjudicate outcomes., Results: Within 1979 enrolled patients, 176 (9 %) had an AAS. POCUS led to net reclassification improvement of 20 % (24 %/-4 % for events/non-events, P < 0.001) over clinical score alone. Median time to AAS diagnosis was 60 min if POCUS was positive vs 118 if negative (P = 0.042). Within 941 patients satisfying rule-out criteria, the 30-day incidence of AAS was 0 % (95 % CI, 0-0.41 %); without POCUS, 2 AAS were potentially missed. Protocol rule-out efficiency was 48 % (95 % CI, 46-50 %) and AAI was averted in 41 % of patients. Using age-adjusted d-dimer, rule-out efficiency was 54 % (difference 6 %, 95 % CI, 4-9 %, vs standard cutoff)., Conclusions: The integrated algorithm allowed rapid triage of high-probability patients, while providing safe and efficient rule-out of AAS. Age-adjusted d-dimer maximized efficiency., Clinical Trial Registration: Clinicaltrials.gov, NCT04430400., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Purpose: Blood cultures (BCs) are key for pathogen detection in septic patients. We investigated the extent to which sampling was performed and what factors were associated with the absence of general or inadequate BC sampling., Methods: We conducted a retrospective cohort study of hospitalized patients with sepsis admitted to one of three EDs in 2018. Primary outcome was the extent of general BC collection of at least 1 set. Secondary outcome was the extent of adequate BC sampling, defined as ≥ 2 sets before antibiotic therapy (AT). Multivariable logistic regression analysis was performed to identify factors associated with deficits in both outcomes., Results: 1143 patients were analyzed. BCs were collected from 946 patients. Single BCs were taken from 520 patients, ≥ 2 sets from 426 patients. Overall, ≥ 2 BCs were taken from 349 patients before AT. BC sampling before AT occurred significantly more frequently when ≥ 2 BC sets were taken rather than a single one (81.9%, versus 68.4%, p < 0.001) and this also led to the highest pathogen detection rate in our cohort (65.6%). A body temperature of ≥ 38 °C was the a supporting factor for general and adequate BC collection in all three EDs. Retrospective analysis of 533 patients showed that the qSOFA score had no influence on general or adequate BC collection., Conclusion: Data on everyday clinical practice in the pre-analytical phase of microbiological diagnostics shows considerable deficits and indicates the need for more implementation of best practice. The variations identified in BC sampling between EDs should be further investigated., (© 2024. The Author(s).)

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.)

Computed tomography (CT) represents the current standard for imaging of patients with acute life-threatening diseases. As some patients present with circulatory arrest, they require cardiopulmonary resuscitation. Automated chest compression devices are used to continue resuscitation during CT examinations, but tend to cause motion artifacts degrading diagnostic evaluation of the chest. The aim was to investigate and evaluate a CT protocol for motion-free imaging of thoracic structures during ongoing mechanical resuscitation. The standard CT trauma protocol and a CT protocol with ECG triggering using a simulated ECG were applied in an experimental setup to examine a compressible thorax phantom during resuscitation with two different compression devices. Twenty-eight phantom examinations were performed, 14 with AutoPulse ® and 14 with corpuls cpr ® . With each device, seven CT examinations were carried out with ECG triggering and seven without. Image quality improved significantly applying the ECG-triggered protocol ( p < 0.001), which allowed almost artifact-free chest evaluation. With the investigated protocol, radiation exposure was 5.09% higher (15.51 mSv vs. 14.76 mSv), and average reconstruction time of CT scans increased from 45 to 76 s. Image acquisition using the proposed CT protocol prevents thoracic motion artifacts and facilitates diagnosis of acute life-threatening conditions during continuous automated chest compression.

Background When acute aortic syndromes (AASs) are suspected, pretest clinical probability assessment and d-dimer (DD) testing are diagnostic options allowing standardized care. Guidelines suggest use of a 12-item/3-category score (aortic dissection detection) and a DD cutoff of 500 ng/mL. However, a simplified assessment tool and a more specific DD cutoff could be advantageous. Methods and Results In a prospective derivation cohort (n=1848), 6 items identified by logistic regression (thoracic aortic aneurysm, severe pain, sudden pain, pulse deficit, neurologic deficit, hypotension), composed a simplified score (AORTAs) assigning 2 points to hypotension and 1 to the other items. AORTAs≤1 and ≥2 defined low and high clinical probability, respectively. Age-adjusted DD was calculated as years/age × 10 ng/mL (minimum 500). The AORTAs score and AORTAs≤1/age-adjusted DD rule were validated in 2 patient cohorts: a high-prevalence retrospective cohort (n=1035; 22% AASs) and a low-prevalence prospective cohort (n=447; 11% AASs) subjected to 30-day follow-up. The AUC of the AORTAs score was 0.729 versus 0.697 of the aortic dissection detection score ( P =0.005). AORTAs score assessment reclassified 16.6% to 25.1% of patients, with significant net reclassification improvement of 10.3% to 32.7% for AASs and -8.6 to -17% for alternative diagnoses. In both cohorts, AORTAs≥2 had superior sensitivity and slightly lower specificity than aortic dissection detection ≥2. In the prospective validation cohort, AORTAs≤1/age-adjusted DD had a sensitivity of 100%, a specificity of 48.6%, and an efficiency of 43.3%. Conclusions AORTAs is a simplified score with increased sensitivity, improved AAS classification, and minor trade-off in specificity, amenable to integration with age-adjusted DD for diagnostic rule-out.

Background: Prehospital resuscitative thoracotomy (PHRT) is a controversially discussed measure for the acute treatment of traumatic cardiac arrest (TCA) recommended by the current guidelines of the European Resuscitation Council (ERC). The aim of this work is the comprehensive presentation and summary of the available literature with the underlying hypothesis that the available publications show the feasibility and survival following PHRT in patients with TCA with a good neurological outcome., Method: A systematic literature search was performed in the databases PubMed, EMBASE, Google Scholar, Springer LINK and Cochrane. The study selection, data extraction and evaluation of bias potential were performed independently by two authors. The outcome of patients with TCA after PHRT was selected as the primary endpoint., Results: A total of 4616 publications were found of which 21 publications with a total of 287 patients could be included in the analyses. For a detailed descriptive analysis, 15 publications with a total of 205 patients were suitable. The TCA of these patients was most commonly caused by pericardial tamponade, thoracic vascular injuries and severe extrathoracic multiple injuries. In 24% of the cases TCA occurred in the presence of the emergency physician. Clamshell thoracotomy (53%) was used preclinically more often than anterolateral thoracotomy (47%). Of the PHRT patients after TCA 12% (25/205) left the hospital alive, 9% (n = 19/205) with good neurological outcome and 1% (n = 3/205) with poor neurological outcome (according to the Glasgow outcome scale, GOS)., Conclusion: The prognosis of TCA seems to be much better than has long been assumed. Decisive for the success of resuscitation efforts in TCA seems to be the immediate, partly invasive treatment of all reversible causes. The measures for TCA recommended by the ERC resuscitation guidelines, seem to be poorly implemented, especially in the preclinical setting. A controversy regarding the recommendations of the guidelines is the question of whether a PHRT can be successfully implemented and if the comprehensive introduction in Germany seems to be meaningful. Despite the recommendation of the guidelines, this systematic review and meta-analysis underlines the lack of high-quality evidence on PHRT, whereby a survival probability to hospital discharge of 12% was reported, of which 75% had a good neurological outcome. The risk of bias of the results in individual publications as well as in this review is high. Further systematic research in the field of preclinical trauma resuscitation is particularly necessary also for acceptance of the guidelines.

Due to the symptoms, patients with acute type A aortic dissection are first seen by the ambulance service and diagnosed at the emergency department. How often an aortic dissection occurs in an emergency department per year has been studied. The incidence in the emergency department may be used as a quality marker of differential diagnostics of acute chest pain. A multi-institutional retrospective study with the municipal Berlin hospital chain Vivantes and its Department of Pathology and the Charité - University Medicine Berlin was performed. From the Berlin Hospital Society, the annual numbers of publicly insured emergency patients were obtained. Between 2006 and 2016, 631 aortic dissections were identified. The total number of patients treated in the emergency departments (n = 12,790,577) was used to calculate the "emergency department incidence." The autopsy data from six clinics allowed an estimate on how many acute type A aortic dissections remained undetected. Across all Berlin hospitals, the emergency department incidence of acute type A aortic dissection was 5.24 cases in 100,000 patients per year. In tertiary referral hospitals and, particularly, in university hospitals the respective incidences were markedly higher (6.7 and 12.4, respectively). Based on the autopsy results, about 50% of the acute type A aortic dissection may remain undetected, which would double the reported incidences. Among different hospital types the emergency department incidences of acute type A aortic dissection vary between 5.93/100,000 and 24.92/100,000. Aortic dissection; Incidence; Emergency Department; Epidemiology.

Objectives: Guidelines recommend chest radiography (CR) in the workup of suspected acute aortic syndromes (AASs) if the pretest clinical probability is low. However, the diagnostic impact of CR integration for the rule-in and rule-out of AASs is unknown., Methods: We performed a secondary analysis of the ADvISED multicenter study. Emergency department outpatients were eligible if an AAS was clinically suspected. Clinical probability was defined with the aortic dissection detection risk score (ADD-RS). CR was evaluated blindly by a radiologist, who judged on mediastinum enlargement (ME) and other signs., Results: In 2014 through 2016, a total of 1,129 patients were enrolled and 1,030 were analyzed, including 48 (4.7%) with AASs. ADD-RS/ME and ADD-RS/any CR sign (aCRs) integration were more accurate than ADD-RS alone (area under the curve = 0.8 and 0.78 vs. 0.66, p < 0.001). The sensitivity and specificity of the integrated strategies were 66.7% (95% confidence interval [CI] = 51.5% to 79.9%) and 82.5% (95% CI = 79.9% to 84.8%) for ADD-RS/ME and 68.8% (95% CI = 53.6% to 80.9%) and 76.5% (95% CI = 73.7% to 79.1%) for ADD-RS/aCRs, respectively. The sensitivity and specificity of CR per se were 54.2% (95% CI = 39.2% to 68.6%) and 92.4% (95% CI = 90.5% to 93.9%) for ME and 60.4% (95% CI = 45.3% to 74.2%) and 85.2% (95% CI = 82.9% to 87.4%) for aCRs. The agreement (κ) between attending physicians and radiologists for ME was 0.44 (95% CI = 0.35 to 0.54). ADD-RS/ME rule-in (ADD-RS ≤ 1 and ME-present, or ADD-RS > 1) applied to 204 versus 130 patients with ADD-RS > 1, including 14 with AAS and 60 false-positives (FP). ADD-RS/aCRs rule-in (ADD-RS ≤ 1 and aCRs-present, or ADD-RS > 1) applied to 264 patients, including 15 with AAS and 119 FP. ADD-RS/ME rule-out (ADD-RS ≤ 1 and ME-absent) applied to 826 (80.2%) patients, including 16 with AAS (33.3% of cases). ADD-RS/aCRs rule-out (ADD-RS ≤ 1 and aCRs-absent) applied to 766 patients (74.4%), including 15 with AAS (31.3% of cases)., Conclusions: CR integration with clinical probability assessment showed modest rule-in efficiency and insufficient sensitivity for conclusive rule-out., (© 2019 by the Society for Academic Emergency Medicine.)

Aims: The diagnosis of acute aortic syndromes (AASs) is challenging and requires integrated strategies. Transthoracic focused cardiac ultrasound (FoCUS) is endorsed by guidelines as a first-line/triage tool allowing rapid bedside assessment of the aorta. However, the performance of FoCUS in the European Society of Cardiology-recommended workup of AASs awaits validation., Methods and Results: This was a prespecified subanalysis of the ADvISED multicentre prospective study. Patients with suspected AAS underwent FoCUS for detection of direct/indirect signs of AAS. Clinical probability assessment was performed with the aortic dissection detection risk score (ADD-RS). Case adjudication was based on advanced imaging, surgery, autopsy, or 14-day follow-up. An AAS was diagnosed in 146 (17.4%) of 839 patients. Presence of direct FoCUS signs had a sensitivity and specificity of 45.2% [95% confidence interval (CI) 37-53.6%] and 97.4% (95% CI 95.9-98.4%), while presence of any FoCUS sign had a sensitivity and specificity of 89% (95% CI 82.8-93.6%) and 74.5% (95% CI 71-77.7%) for AAS. The additive value of FoCUS was most evident within low clinical probability (ADD-RS ≤1). Herein, direct FoCUS signs were identified in 40 (4.8%) patients (P < 0.001), including 29 with AAS. ADD-RS ≤1 plus negative FoCUS for AAS rule-out had a sensitivity of 93.8% (95% CI 88.6-97.1%) and a failure rate of 1.9% (95% CI 0.9-3.6%). Addition of negative D-dimer led to a failure rate of 0% (95% CI 0-1.2%)., Conclusion: FoCUS has additive value in the workup of AASs. Direct FoCUS signs can rapidly identify patients requiring advanced imaging despite low clinical probability. In integrated bundles, negative FoCUS is useful for rule-out of AASs., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Background: More than 50 million people worldwide sustain a traumatic brain injury (TBI) annually. Detection of intracranial injuries relies on head CT, which is overused and resource intensive. Blood-based brain biomarkers hold the potential to predict absence of intracranial injury and thus reduce unnecessary head CT scanning. We sought to validate a test combining ubiquitin C-terminal hydrolase-L1 (UCH-L1) and glial fibrillary acidic protein (GFAP), at predetermined cutoff values, to predict traumatic intracranial injuries on head CT scan acutely after TBI., Methods: This prospective, multicentre observational trial included adults (≥18 years) presenting to participating emergency departments with suspected, non-penetrating TBI and a Glasgow Coma Scale score of 9-15. Patients were eligible if they had undergone head CT as part of standard emergency care and blood collection within 12 h of injury. UCH-L1 and GFAP were measured in serum and analysed using prespecified cutoff values of 327 pg/mL and 22 pg/mL, respectively. UCH-L1 and GFAP assay results were combined into a single test result that was compared with head CT results. The primary study outcomes were the sensitivity and the negative predictive value (NPV) of the test result for the detection of traumatic intracranial injury on head CT., Findings: Between Dec 6, 2012, and March 20, 2014, 1977 patients were recruited, of whom 1959 had analysable data. 125 (6%) patients had CT-detected intracranial injuries and eight (<1%) had neurosurgically manageable injuries. 1288 (66%) patients had a positive UCH-L1 and GFAP test result and 671 (34%) had a negative test result. For detection of intracranial injury, the test had a sensitivity of 0·976 (95% CI 0·931-0·995) and an NPV of 0·996 (0·987-0·999). In three (<1%) of 1959 patients, the CT scan was positive when the test was negative., Interpretation: These results show the high sensitivity and NPV of the UCH-L1 and GFAP test. This supports its potential clinical role for ruling out the need for a CT scan among patients with TBI presenting at emergency departments in whom a head CT is felt to be clinically indicated. Future studies to determine the value added by this biomarker test to head CT clinical decision rules could be warranted., Funding: Banyan Biomarkers and US Army Medical Research and Materiel Command., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: The number of patients visiting emergency departments (ED) is steadily increasing. The cause for this rise in Germany is unclear and less examined. This study aimed to assess the reasons of walk-in patients to visit EDs by using a direct survey., Methods: During a period of 4 weeks, 2 010 walk-in patients were anonymously surveyed in 2 major Berlin hospitals using a standardized questionnaire. Descriptive statistics were used for data analysis., Results: More than 90% of patients assessed themselves as an emergency and three-quarters of patients reported pain. The majority of patients (57%) tried to contact statutory health insurance (SHI) office-based physicians in advance and 59% of patients said they would make use of ambulatory emergency facilities if they were available and well established. However, 55% of patients were unaware of the emergency service of the association of SHI physicians., Conclusion: The results indicate that centralized ambulatory emergency facilities should be available 24/7 at hospitals with EDs. Therefore, future planning of emergency services should integrate providers of ambulatory and inpatient sector. International experience suggests that different instruments aiming at better coordination of care, such as integrated call centers, extended ambulatory services and facilities for less urgent cases located in or nearby hospitals with EDs should also be implemented in Germany., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Traumatic Pneumothorax (PTX) is a potentially life-threatening injury. It requires a fast and accurate diagnosis and treatment, but diagnostic tools are limited. A new point-of-care device (PneumoScan) based on micropower impulse radar (MIR) promises to diagnose a PTX within seconds. In this study, we compare standard diagnostics with PneumoScan during shock-trauma-room management., Patients and Methods: Patients with blunt or penetrating chest trauma were consecutively included in the study. All patients were examined including clinical examination with auscultation (CE) and supine chest radiography (CXR). In addition, PneumoScan-readings and thoracic ultrasound scan (US) were performed. Computed tomography (CT) served as gold standard., Results: CT scan revealed PTX in 11 patients. PneumoScan detected two PTX correctly but missed nine. 15 false-positive results were found by PneumoScan, leading to a sensitivity of 20% and specificity of 80%. Six PTX were detected through CE (sensitivity: 54,5%). CXR detected four (sensitivity: 27,3%) and thoracic US two PTX correctly (sensitivity: 25%)., Conclusion: The unblinded PneumoScan prototype did not confirm the promising results of previous studies. The examined standard diagnostics and thoracic US showed rather weak sensitivity as well. Until now, there is no appropriate point-of-care tool to rule out PTX.

Background: Acute aortic syndromes (AASs) are rare and severe cardiovascular emergencies with unspecific symptoms. For AASs, both misdiagnosis and overtesting are key concerns, and standardized diagnostic strategies may help physicians to balance these risks. D-dimer (DD) is highly sensitive for AAS but is inadequate as a stand-alone test. Integration of pretest probability assessment with DD testing is feasible, but the safety and efficiency of such a diagnostic strategy are currently unknown., Methods: In a multicenter prospective observational study involving 6 hospitals in 4 countries from 2014 to 2016, consecutive outpatients were eligible if they had ≥1 of the following: chest/abdominal/back pain, syncope, perfusion deficit, and if AAS was in the differential diagnosis. The tool for pretest probability assessment was the aortic dissection detection risk score (ADD-RS, 0-3) per current guidelines. DD was considered negative (DD-) if <500 ng/mL. Final case adjudication was based on conclusive diagnostic imaging, autopsy, surgery, or 14-day follow-up. Outcomes were the failure rate and efficiency of a diagnostic strategy for ruling out AAS in patients with ADD-RS=0/DD- or ADD-RS ≤1/DD-., Results: A total of 1850 patients were analyzed. Of these, 438 patients (24%) had ADD-RS=0, 1071 patients (58%) had ADD-RS=1, and 341 patients (18%) had ADD-RS >1. Two hundred forty-one patients (13%) had AAS: 125 had type A aortic dissection, 53 had type B aortic dissection, 35 had intramural aortic hematoma, 18 had aortic rupture, and 10 had penetrating aortic ulcer. A positive DD test result had an overall sensitivity of 96.7% (95% confidence interval [CI], 93.6-98.6) and a specificity of 64% (95% CI, 61.6-66.4) for the diagnosis of AAS; 8 patients with AAS had DD-. In 294 patients with ADD-RS=0/DD-, 1 case of AAS was observed. This yielded a failure rate of 0.3% (95% CI, 0.1-1.9) and an efficiency of 15.9% (95% CI, 14.3-17.6) for the ADD-RS=0/DD- strategy. In 924 patients with ADD-RS ≤1/DD-, 3 cases of AAS were observed. This yielded a failure rate of 0.3% (95% CI, 0.1-1) and an efficiency of 49.9% (95% CI, 47.7-52.2) for the ADD-RS ≤1/DD- strategy., Conclusions: Integration of ADD-RS (either ADD-RS=0 or ADD-RS ≤1) with DD may be considered to standardize diagnostic rule out of AAS., Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02086136., (© 2017 American Heart Association, Inc.)

For decades, survival rates of cardiac arrest following trauma were reported between 0 and 2 %. Since 2005, survival rates have increased with a wide range up to 39 % and good neurological recovery in every second person injured for unknown reasons. Especially in children, high survival rates with good neurologic outcomes are published. Resuscitation following traumatic cardiac arrest differs significantly from nontraumatic causes. Paramount is treatment of reversible causes, which include massive bleeding, hypoxia, tension pneumothorax, and pericardial tamponade. Treatment of reversible causes should be simultaneous. Chest compression is inferior following traumatic cardiac arrest and should never delay treatment of reversible causes of the traumatic cardiac arrest. In massive bleeding, bleeding control has priority. Damage control resuscitation with permissive hypotension, aggressive coagulation therapy, and damage control surgery represent the pillars of initial treatment. Cardiac arrest due to hypoxia should be resolved by airway management and ventilation. Tension pneumothorax should be decompressed by finger thoracostomy, pericardial tamponade by resuscitative thoracotomy. In addition, resuscitative thoracotomy allows direct and indirect bleeding control. Untreated impact brain apnea may rapidly lead to cardiac arrest and requires quick opening of the airway and effective oxygenation. Established algorithms for treatment of cardiac arrest following trauma enable a safe, structured, and effective management.

Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.

Background. A nonrecognized pneumothorax (PTX) may become a life-threatening tension PTX. A reliable point-of-care diagnostic tool could help in reduce this risk. For this purpose, we investigated the feasibility of the use of the PneumoScan, an innovative device based on micropower impulse radar (MIR). Patients and Methods. addition to a standard diagnostic protocol including clinical examination, chest X-ray (CXR), and computed tomography (CT), 24 consecutive patients with chest trauma underwent PneumoScan testing in the shock trauma room to exclude a PTX. Results. The application of the PneumoScan was simple, quick, and reliable without functional disorder. Clinical examination and CXR each revealed one and PneumoScan three out of altogether four PTXs (sensitivity 75%, specificity 100%, positive predictive value 100%, and negative predictive value 95%). The undetected PTX did not require intervention. Conclusion. The PneumoScan as a point-of-care device offers additional diagnostic value in patient management following chest trauma. Further studies with more patients have to be performed to evaluate the diagnostic accuracy of the device.

Objective: Patients presenting in the emergency department with a mild injury to the head pose a particular challenge due to their high prevalence but low rate of traumatic brain injury. However, missed traumatic brain injuries may result in fatal consequences. Therefore we investigated the diagnostic performance of serological protein S100B measurement in adult patients presenting with mild head injury and a GCS 13-15 to identify traumatic brain injury., Design and Methods: We conducted a systematic review of the literature. Two reviewers screened potential studies for inclusion and independently extracted study data. For all included studies, we applied the QUADAS quality assessment tool for systematic reviews of diagnostic accuracy and abstracted the raw data for every included study. Included studies presented results either in 2x2 contingency tables or provided data allowing their construction., Results: Of 76 studies identified, 8 met the inclusion criteria. Methodology quality was moderate and all studies fulfilled at least 50% of the QUADAS criteria. Overall, the sensitivity to detect intracranial lesions was 94% (95% CI 88-98%) and specificity was 44% (95% CI 30-58%). The subgroup analysis showed significant differences only between studies with different S100B cutoff values (0.10 μg/l versus >0.10 μg/l). The combined odds ratio was 10.3 (95 CI 4.2-24.9)., Conclusions: Serological protein S100B measurement may be helpful as a screening test to identify patients with higher risk of traumatic brain injury for further diagnostic assessment.

Background and Purpose: Recent innovations such as CT installation in ambulances may lead to earlier start of stroke-specific treatments. However, such technically complex mobile facilities require effective methods of correctly identifying patients before deployment. We aimed to develop and validate a new dispatcher identification algorithm for stroke emergencies., Methods: Dispatcher identification algorithm for stroke emergencies was informed by systematic qualitative analysis of the content of emergency calls to ambulance dispatchers for patients with stroke or transient ischemic attack (N=117) and other neurological (N=39) and nonneurological (N=51) diseases (Part A). After training of dispatchers, sensitivity and predictive values were determined prospectively in patients admitted to Charité hospitals by using the discharge diagnosis as reference standard (Part B)., Results: Part A: Dysphasic/dysarthric symptoms (33%), unilateral symptoms (22%) and explicitly stated suspicion of stroke (47%) were typically identified in patients with stroke but infrequently in nonstroke cases (all <10%). Convulsive symptoms (41%) were frequent in other neurological diseases but not strokes (3%). Pain (26%) and breathlessness (31%) were often expressed in nonneurological emergencies (6% and 7% in strokes). Part B: Between October 15 and December 16, 2010, 5774 patients were admitted by ambulance with 246 coded with final stroke diagnoses. Sensitivity of dispatcher identification algorithm for stroke emergencies for detecting stroke was 53.3% and positive predictive value was 47.8% for stroke and 59.1% for stroke and transient ischemic attack. Of all 275 patients with stroke dispatcher codes, 215 (78.5%) were confirmed with neurological diagnosis., Conclusions: Using dispatcher identification algorithm for stroke emergencies, more than half of all patients with stroke admitted by ambulance were correctly identified by dispatchers. Most false-positive stroke codes had other neurological diagnoses.

Metalloproteinases are secreted in response to a variety of inflammatory mediators and inhibited by tissue inhibitors of matrixmetalloproteinases (TIMPs). Two members of these families, MMP-9 and TIMP-1, were differentially expressed depending on clinical parameters in a previous genomewide mRNA analysis. The aim of this paper was now to evaluate the posttraumatic serum levels and the time course of both proteins depending on distinct clinical parameters. 60 multiple traumatized patients (ISS > 16) were included. Blood samples were drawn on admission and 6 h, 12 h, 24 h, 48 h, and 72 h after trauma. Serum levels were quantified by ELISA. MMP-9 levels significantly decreased in the early posttraumatic period (P < 0.05) whereas TIMP-1 levels significantly increased in all patients (P < 0.05). MMP-9 and TIMP-1 serum concentration kinetics became manifest in an inversely proportional balance. Furthermore, MMP-9 presented a stronger decrease in patients with severe trauma and non-survivors in contrast to minor traumatized patients (ISS ≤ 33) and survivors, initially after trauma.

Oligonucleotide microarray technology has been developed to a very powerful and favorable biotechnique. However, it is an explicit challenge to judge the potential biological meaning of such extensive amounts of data. There are various-commercially available or free-software applications for pathway analyses on microarray data on the market. The aim of the present study was to test whether pathway analyses on the same data set using different commercially available devices lead to roughly comparable or massively diverging results and, if so, to give potential explanations. Two different commercially available pathway analysis programs (GeneGo and Pathway Studio 6) have been elected. The programs have been compared concerning their different analyses tools, underlying databases, database constructions, and network-building algorithms. The same data set has been uploaded into two different programs. Pathway analysis was performed according to the following three criteria: the five top networks, the five top diseases, and the five top canonical networks that are associated with the uploaded gene list. The different programs differ in extracting their information from the literature, in database construction, and network-building algorithms. The "top networks," as suggested by the programs as to be "most important," substantially differ from each other and share only one same gene. Concerning the most represented diseases in the data set, there are certain overlaps but no uniform results in the different applications. Pathway analyses of microarray data using preformed software devices offer valuable options for investigating on the biological relevance and function of a focus gene set. However, there is no standard in constructing such programs. This leads to substantial differences when investigating on the same data set using different devices. The intention of this work is to sensitize for the potentialities and also pitfalls doing pathway analysis using automated software tools.

Introduction: Current guidelines recommend intraosseous (IO) vascular access in adults if peripheral venous access is unavailable. Most available data derive from children, animal models, cadaver studies or the prehospital setting. Therefore we compared two different IO access devices in adults under resuscitation in the hospital setting., Patients and Methods: This prospective, randomized clinical study compared two different IO access devices in adults (>/=18 years of age) under trauma or medical resuscitation admitted to our emergency department with impossible peripheral venous access. Each adult was randomized to either spring-loaded BIG Bone Injection Gun or battery-powered EZ-IO. Outcome measures included success rates on first attempt, procedure times and complications., Results: Forty consecutive adults under resuscitation were enrolled. Twenty patients received the BIG, another twenty patients the EZ-IO. Over all success rate on first attempt was 85% and mean procedure time 2.0min+/-0.9. Comparing the two devices, success rate on first attempt was 80% for the BIG versus 90% for the EZ-IO and mean procedure time was 2.2min+/-1.0 for the BIG versus 1.8min+/-0.9 for the EZ-IO. The differences between both IO devices were not statistically significant. No other relevant complications like infection, extravasation or bleeding were observed., Conclusions: IO vascular access was a reliable and safe method to gain rapid vascular access for in-hospital adult emergency patients under resuscitation. Further studies are necessary regarding comparative effectiveness of different IO devices., (Copyright 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: For patients' safety reasons, current American Heart Association and European Resuscitation Council guidelines recommend intraosseous (IO) vascular access as an alternative in cases of emergency, if prompt venous catheterization is impossible. The purpose of this study was to compare the IO access as a bridging procedure versus central venous catheterization (CVC) for in-hospital adult emergency patients under resuscitation with impossible peripheral intravenous (IV) access. We hypothesised, that CVC is faster and more efficacious compared to IO access., Methods: A prospective observational study comparing success rates and procedure times of IO access (EZ-IO, Vidacare Corporation) versus CVC in adult (>/=18 years of age) patients under trauma and medical resuscitation admitted to our emergency department with impossible peripheral IV catheterization was conducted. Procedure time was defined from preparation and insertion of vascular access type until first drug or infusion solution administration. Success rate on first attempt and procedure time for each access route was evaluated and statistically tested., Results: Ten consecutive adult patients under resuscitation, each receiving IO access and CVC, were analyzed. IO access was performed with 10 tibial or humeral insertions, CVC in 10 internal jugular or subclavian veins. The success rate on first attempt was 90% for IO insertion versus 60% for CVC. Mean procedure time was significantly lower for IO cannulation (2.3 min +/- 0.8) compared to CVC (9.9 min +/- 3.7) (p < 0.001). As for complications, failure of IO access was observed in one patient, while two or more attempts of CVC were necessary in four patients. No other relevant complications, like infection, bleeding or pneumothorax were observed., Conclusion: Preliminary data demonstrate that IO access is a reliable bridging method to gain vascular access for in-hospital adult emergency patients under trauma or medical resuscitation with impossible peripheral IV access. Furthermore, IO cannulation requires significantly less time to enable administration of drugs or infusion solutions compared to CVC. Because CVC was slower and less efficacious, IO access may improve the safety of adult patients under resuscitation in the emergency department.

Background: The treatment of acute acromioclavicular (AC) joint injuries depends mainly on the type of the dislocation and patient demands. This study compares the mid term outcome of two frequently performed surgical concepts of Rockwood grade III AC joint separations: The temporary articular fixation with K-wires (TKW) and the refixation with an absorbable polydioxansulfate (PDS) sling., Findings: Retrospective observational study of 86 patients with a mean age of 37 years underwent either TKW (n = 70) or PDS treatment (n = 16) of Rockwood grade III AC joint injuries. Mid term outcome with a mean follow up of 3 years was measured using a standardized functional patient questionnaire including Constant score, ASES rating scale, SPADI, XSMFA-D and a pain score. K-wire therapy resulted in significantly better functional results expressed by Constant score (88 +/- 10 vs. 73 +/- 18), ASES rating scale (29 +/- 3 vs. 25 +/- 5), SPADI (3 +/- 9 vs. 9 +/- 13), XSMFA-D function (13 +/- 2 vs. 14 +/- 3), XSMFA-D impairment (4 +/- 1 vs. 6 +/- 2) and pain score (1 +/- 1 vs. 2 +/- 2)., Conclusion: Either temporary K-wire fixation and PDS sling enable good or satisfying functional results in the treatment of Rockwood grade III AC separations. However functional outcome parameters indicate a significant advantage for the K-wire technique.

Objective: Traumatic brain injury (TBI) is associated with cerebrovascular dysfunction and changes of the blood-brain barrier (BBB) function. Although knowledge about the function of the BBB would be of high interest, non-invasive neurodiagnostic tools are still lacking. In this context it has been shown, that the astrocytic protein S100-B is a significant parameter for neuronal damage. However, there is only poor knowledge about the dynamics of S100-B in cerebrospinal fluid (CSF) and serum of patients with severe TBI. Therefore, the aim of this study was to analyze intrathecal and systemic concentrations of S100-B in patients with severe TBI in correlation to the development of progressive intracranial hemorrhage (PIH) as well as to the CSF/serum albumin ratio (Q subsetalb), as functional parameter of the BBB., Patients and Methods: In patients, suffering from severe TBI (GCS =or<8pts) and respectively healthy control patients, albumin for calculating the CSF/serum albumin ratio (Q subsetalb) as well as S100-B protein were analyzed in CSF and serum. Samples were collected immediately after placement of a ventricular catheter and 12h, 24h, 48 h and 72 h after TBI. S100-B was quantified using Elecsys S-100 superset assay (Roche superset Diagnostics; Mannheim, Germany). Volume measurements of focal mass lesions based on CT images taken during the first 72 h after TBI were obtained according to the Cavalieri's Direct Estimator method., Results: 21 TBI-patients and respectively 10 healthy controls were enrolled. In patients exhibiting a mean ICP >15 mmHg (n = 15) CSF levels of S100-B were significantly increased on admission (819 +/- 78 pg/ml) compared to patients with ICP =or<15 mmHg (n = 6, 175 +/- 12 pg/ml) as well as to the control group (n = 10, 0.8 +/- 0.09 pg/ml). In the group with ICP >15 mmHg 8 patients developed PIH A positive correlation was found between CSF S100-B and ICP (r2 = 0.925, p<0.001). Furthermore a positive correlation between serum S100-B and Q subsetalb was found for each sampling point (r superset2 = 0.793, p<0.001)., Conclusions: The cerebrospinal and serum concentration of S100-B in patients with severe TBI was evaluated. Monitoring cerebrospinal S100-B might help to prospectively identify patients with PIH.

Objective: The intrathecal posttraumatic inflammation contributes to secondary brain damage as well as to the induction of neuroreparative mechanisms. In this context release of interleukin-10 (IL-10) has been reported to play a major role. However, initial IL-10 concentration in CSF remains incompletely characterized. Therefore, the aim was to analyze Il-10 in CSF and serum of patients early after TBI., Methods: For control, 10 volunteers receiving spinal puncture were enrolled. In patients with severe TBI (GCS<8 pts.), CSF and serum was drawn within 90+/-45 min after intraventricular catheter insertion (0 h), as well as 12 h, 24 h and 48 h after TBI. Albumin for assessing Blood-Brain-Barrier (BBB) function and IL-10 (IMMULITE, DPC Biermann, Bad Nauheim, Germany) were analyzed., Results: 23 patients were enrolled. 15 survived and 8 deceased within 24h. In controls, CSF IL-10 was below detection limit (<5 pg/ml). In contrast, IL-10 was elevated significantly in non-survivors at 0 h vs. survivors and controls (30+/-6 vs. 9+/-1 vs. <5 pg/mL). This was accompanied by a significant increase of serum IL-10 in both groups at 0 h vs. controls (survivors: 30+/-6 pg/mL, non-survivors: 48+/-8 pg/mL, controls: 10+/-7 pg/mL, p<0.001). Survivors revealed signs of a mild BBB dysfunction during the entire observation period. In contrast, non-survivors presented a severe BBB breakage., Conclusions: We demonstrated an analysis of IL-10 CSF and serum concentration after TBI. These data support an intrathecal IL-10 synthesis. Although the significant increase of IL-10 might indicate a bad outcome of TBI, responsible mechanisms still have to be elucidated.

Background: Concerning surgical management experience with locking plates for proximal humeral fractures has been described with promising results. Though, distinct hardware related complaints after fracture union are reported. Information concerning the outcome after removal of hardware from the proximal humerus is lacking and most studies on hardware removal are focused on the lower extremity. Therefore the aim of this study was to analyze the functional short-term outcome following removal of locking plate fixation of the proximal humerus., Methods: Patients undergoing removal of a locking plate of the proximal humerus were prospectively followed. Patients were subdivided into the following groups: Group HI: symptoms of hardware related subacromial impingement, Group RD: persisting rotation deficit, Group RQ: patients with request for a hardware removal. The clinical (Constant-Murley score) and radiologic (AP and axial view) follow-up took place three and six months after the operation. To evaluate subjective results, the Medical Outcomes Study Short Form-36 (SF-36), was completed., Results: 59 patients were included. The mean length of time with the hardware in place was 15.2 +/- 3.81 months. The mean of the adjusted overall Constant score before hardware removal was 66.2 +/- 25.2% and increased significantly to 73.1 +/- 22.5% after 3 months; and to 84.3 +/- 20.6% after 6 months (p < 0.001). The mean of preoperative pain on the VAS-scale before hardware removal was 5.2 +/- 2.9, after 6 months pain in all groups decreased significantly (p < 0.001). The SF-36 physical component score revealed a significant overall improvement in both genders (p < 0.001) at six months., Conclusion: A significant improvement of clinical outcome following removal was found. However, a general recommendation for hardware removal is not justified, as the risk of an anew surgical and anesthetic procedure with all possible complications has to be carefully taken into account. However, for patients with distinct symptoms it might be justified.

In the literature, the association between chronic complaints of the cervical spine and sustained"whiplash trauma" is a matter of controversy. Whiplash trauma is identified as contusion, compression, and/or sprain without definite imaging proof of injury to the bone, disk, or ligaments.However, complex chronic complaints leading to permanent and significant functional limitations in daily living and work may develop. Besides the diagnostic and therapeutic challenges for the treating physician, the expert confronted with compensation claims very often must decide whether whiplash trauma of the spine may lead to significant and permanent functional limitations or loss with chronic disorders. The data from the literature dealing with this topic are contradictory and deficient. In this article, based on the present available data from the literature, we critically examine the causality between spinal whiplash trauma and possible permanent chronic complaints in order to support the process of decision making in cases of litigation and controversial compensation claims.

Intraosseous (IO) infusion methods have been common for emergency treatment in infants and children for years. The role of IO access in adults is however much less clear, but its importance in this patient group is increasing, and different devices are available today. Each device has strengths and weaknesses, but all achieve rapid vascular access even in challenging situations. The potential of IO access regarding both therapeutic and diagnostic options has been shown in several operational studies in and out of hospital. Insertion times require between 1 and 2 min in most cases, while insertion and handling of the IO access devices seem to be easy and reliable. The flow rates of IO access devices for adults are lower than those of large-bore peripheral intravenous catheters, but fluid resuscitation is possible in most cases at least with pressure bag infusion systems. Most drugs administered intravenously can be given intraosseously in equivalent dosages and with the same effects. Nevertheless the limitations and risks of IO access routes need to be considered for each application. Rapid IO access is now possible in all age groups, and the 2005 AHA Guidelines favor it over drug administration via the endotracheal tube.

Introduction: Increased serum B-type natriuretic peptide (BNP) has been identified for diagnosis and prognosis of impaired cardiac function in patients suffering from congestive heart failure, ischemic heart disease, and sepsis. However, the prognostic value of BNP in multiple injured patients developing multiple organ dysfunction syndrome (MODS) remains undetermined. Therefore, the aims of this study were to assess N-terminal pro-BNP (NT-proBNP) in multiple injured patients and to correlate the results with invasively assessed cardiac output and clinical signs of MODS., Methods: Twenty-six multiple injured patients presenting a New Injury Severity Score of greater than 16 points were included. The MODS score was calculated on admission as well as 24, 48, and 72 hours after injury. Patients were subdivided into groups: group A showed minor signs of organ dysfunction (MODS score less than or equal to 4 points) and group B suffered from major organ dysfunction (MODS score of greater than 4 points). Venous blood (5 mL) was collected after admission and 6, 12, 24, 48, and 72 hours after injury. NT-proBNP was determined using the Elecsys proBNP(R) assay. The hemodynamic monitoring of cardiac index (CI) was performed using transpulmonary thermodilution., Results: Serum NT-proBNP levels were elevated in all 26 patients. At admission, the serum NT-proBNP values were 116 +/- 21 pg/mL in group A versus 209 +/- 93 pg/mL in group B. NT-proBNP was significantly lower at all subsequent time points in group A in comparison with group B (P < 0.001). In contrast, the CI in group A was significantly higher than in group B at all time points (P < 0.001). Concerning MODS score and CI at 24, 48, and 72 hours after injury, an inverse correlation was found (r = -0.664, P < 0.001). Furthermore, a correlation was found comparing MODS score and serum NT-proBNP levels (r = 0.75, P < 0.0001)., Conclusions: Serum NT-proBNP levels significantly correlate with clinical signs of MODS 24 hours after multiple injury. Furthermore, a distinct correlation of serum NT-proBNP and decreased CI was found. The data of this pilot study may indicate a potential value of NT-proBNP in the diagnosis of post-traumatic cardiac impairment. However, further studies are needed to elucidate this issue.