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BACKGROUND Heparan sulfate is an integral component of the glycocalyx that provides an anticoagulant layer close to the endothelium. Hypoperfusion, inflammation and sympathoadrenal activation following major trauma result in glycocalyx shedding and subsequent release of heparan sulfate into the bloodstream. The possible anticoagulant effect of this "auto-heparinization" has been suggested as a potential driver of trauma-induced coagulopathy. We investigated whether thromboelastometry can be used to detect trauma-induced auto-heparinization. METHODS This study comprised three parts. First, in a retrospective clinical study of 264 major trauma patients, the clotting time (CT) in the INTEM (intrinsic activation) and HEPTEM (intrinsic activation plus heparinase) assays were evaluated upon emergency room admission. Second, in an in-vivo experimental rat model of hemorrhagic-traumatic shock, the release of heparan sulfate was investigated with INTEM and HEPTEM analysis of whole blood. Third, in-vitro spiking of whole blood from healthy volunteers was undertaken to assess the effects of clinically relevant quantities of heparan sulfate and heparin on CT in the INTEM and HEPTEM assays. RESULTS In the first part, severe injury and hemorrhagic shock was not associated with any increases in INTEM CT versus HEPTEM CT. Part two showed that an approximate 3-fold increase in heparan sulfate resulting from hemorrhagic traumatic shock in rats did not prolong INTEM CT, and no significant differences between INTEM CT and HEPTEM CT were observed. Third, spiking of whole blood with heparan sulfate had no impact on INTEM CT, whereas heparin elicited significant prolongation of INTEM CT. CONCLUSIONS Despite structural similarity between heparan sulfate and heparin, the amounts of heparan sulfate shed in response to trauma did not exert an anticoagulant effect that was measurable by the intrinsically activated CT in thromboelastometry. The extent to which heparan sulfate contributes to trauma-induced coagulopathy is yet to be elucidated. LEVEL OF EVIDENCE III. Retrospective clinical analysis. Prospective preclinical study.

ZusammenfassungPatienten mit Schmerzen können durch den nichtärztlichen Rettungsdienst mitunter nur inadäquat versorgt werden, da aufgrund rechtlicher Einschränkungen die Anwendung stark wirksamer Schmerzmittel (Opioide) bzw. ausbildungsbedingt eine i.v.-Therapie in Deutschland und Österreich oft nicht möglich ist. Häufig müssen Notärzte für schmerzgeplagte Patienten nachgefordert werden, wodurch deren Verfügbarkeit für z. B. vitale Notfälle reduziert sein kann. Inhalativ zu verabreichende Analgetika könnten hierfür eine interessante Alternative darstellen.Derzeit steht dazu in Deutschland und Österreich Lachgas (N2O, als Livopan® im Handel) zur Verfügung, eine Mischung aus jeweils 50 % Lachgas und Sauerstoff. In Österreich ist seit 2018 auch Methoxyfluran (Penthrop®) zur Behandlung mäßiger bis starker Schmerzen nach einem Trauma für die prä- und innerklinische Anwendung bei Erwachsenen zugelassen.In der Zusammenschau der vorhandenen Literatur, jahrzehntelanger Erfahrung in der Anwendung der Sauerstoff-Lachgas-Mischung im angloamerikanischen Bereich und von inhalativem Methoxyfluran v. a. in Australien sowie aktuellen Studien aus Europa kann gefolgert werden, dass diese bei Einhaltung der Anwendungsvorschriften effektiv, sicher und nebenwirkungsarm sind. Dies bestätigt auch eine eigene Untersuchung zu Methoxyfluran im präklinischen Einsatz. Die Anwendung von Lachgas ist aufgrund des Druckgaszylinders von der Handhabung her etwas aufwendig; Methoxyfluran ist einfacher anzuwenden und bei starken Schmerzen auch wirksamer. Die Zulassung von Methoxyfluran ist jedoch auf Erwachsene beschränkt, wo es mit zunehmendem Alter deutlich besser wirkt. Der Einsatz von Lachgas und insbesondere Methoxyfluran könnte aufgrund der Datenlage wie auch eigener Erfahrungen für rettungsdienstliches Fachpersonal nach entsprechender Einweisung empfohlen werden.

BACKGROUND Trauma-induced coagulopathy (TIC) substantially contributes to mortality in bleeding trauma patients. OBJECTIVE The aim of the study was to administer fibrinogen concentrate in the prehospital setting to improve blood clot stability in trauma patients bleeding or presumed to bleed. DESIGN A prospective, randomised, placebo-controlled, double-blinded, international clinical trial. SETTING This emergency care trial was conducted in 12 Helicopter Emergency Medical Services (HEMS) and Emergency Doctors' vehicles (NEF or NAW) and four trauma centres in Austria, Germany and Czech Republic between 2011 and 2015. PATIENTS A total of 53 evaluable trauma patients aged at least 18 years with major bleeding and in need of volume therapy were included, of whom 28 received fibrinogen concentrate and 25 received placebo. INTERVENTIONS Patients were allocated to receive either fibrinogen concentrate or placebo prehospital at the scene or during transportation to the study centre. MAIN OUTCOME MEASURES Primary outcome was the assessment of clot stability as reflected by maximum clot firmness in the FIBTEM assay (FIBTEM MCF) before and after administration of the study drug. RESULTS Median FIBTEM MCF decreased in the placebo group between baseline (before administration of study treatment) and admission to the Emergency Department, from a median of 12.5 [IQR 10.5 to 14] mm to 11 [9.5 to 13] mm (P = 0.0226), but increased in the FC Group from 13 [11 to 15] mm to 15 [13.5 to 17] mm (P = 0.0062). The median between-group difference in the change in FIBTEM MCF was 5 [3 to 7] mm (P

Specific antagonists have been developed for the reversal of direct oral anticoagulants (DOAC). We investigated the impact of these reversal agents on the plasma concentration and visco-elastic test results of dabigatran and factor Xa inhibitors. After baseline measurements of dabigatran, the plasma concentration, and the visco-elastic ClotPro® ecarin clotting time (ECA-CT), we added the reversal agent Idarucizumab in vitro and these two analyses were repeated. Likewise, the baseline plasma concentration of apixaban, edoxaban, and rivaroxaban as well as ClotPro® Russell’s viper venom test clotting time (RVV-CT) were measured and reanalyzed following Andexanet alfa spiking. We analyzed fifty blood samples from 37 patients and 10 healthy volunteers. Idarucizumab decreased the measured dabigatran plasma concentration from 323.9 ± 185.4 ng/mL to 5.9 ± 2.3 ng/mL and ECA-CT from 706.2 ± 344.6 s to 70.6 ± 20.2 s, (all, p &lt, 0.001). Andexanet alfa decreased the apixaban concentration from 165.1 ± 65.5 ng/mL to 9.8 ± 8.1 ng/mL, edoxaban from 152.4 ± 79.0 ng/mL to 36.4 ± 19.2 ng/mL, and rivaroxaban from 153.2 ± 111.8 ng/mL to 18.1 ± 9.1 ng/mL (all p &lt, 0.001). Andexanet alfa shortened the RVV-CT of patients with apixaban from 239.2 ± 71.7 s to 151.1 ± 30.2 s, edoxaban from 288.2 ± 65.0 s to 122.7 ± 37.1 s, and rivaroxaban from 225.9 ± 49.3 s to 103.7 ± 12.1 s (all p &lt, 0.001). In vitro spiking of dabigatran-containing blood with Idarucizumab substantially reduced the plasma concentration and ecarin-test clotting time. Andexanet alfa lowered the concentration of the investigated factor Xa-inhibitors but did not normalize the RVV-CT. In healthy volunteers’ blood, Idarucizumab spiking had no impact on ECA-CT. Andexanet alfa spiking of non-anticoagulated blood prolonged RVV-CT (p = 0.001), potentially as a consequence of a competitive antagonism with human factor Xa.

Background Pain relief in the prehospital setting is often insufficient, as the administration of potent intravenous analgesic drugs is mostly reserved to physicians. In Australia, inhaled methoxyflurane has been in routine use by paramedics for decades, but experience in Central European countries is lacking. Thus, we aimed to assess whether user friendliness and effectiveness of inhaled methoxyflurane as sole analgesic match the specific capabilities of local ground and air-based EMS systems in Austria. Methods Observational study in adult trauma patients (e.g. dislocations, fracture or low back pain following minor trauma) with moderate to severe pain (numeric rating scale [NRS] ≥4). Included patients received a Penthrop® inhaler containing 3 mL of methoxyflurane (maximum use 30 min). When pain relief was considered insufficient (NRS reduction Results Median numeric pain rating was 8.0 (7.0–8.0) in 109 patients. Sufficient analgesia (reduction of NRS ≥3) was achieved by inhaled methoxyflurane alone in 67 patients (61%). The analgesic effect was progressively better with increasing age. Side effects were frequent (n = 58, 53%) but mild. User satisfaction was scored as very good when pain relief was sufficient, but fair in patients without benefit. Technical problems were observed in 16 cases (14.7%), mainly related to filling of the inhaler. In every fifth use, the fruity smell of methoxyflurane was experienced as unpleasant. No negative effects on vital signs were observed. Conclusion In prehospital use, inhaled methoxyflurane as sole analgesic is effective for transport of trauma patients (62%) with moderate to severe pain. Older patients benefit especially from inhaled methoxyflurane. Side effects are mild and vital parameters unaffected. Thus, inhaled methoxyflurane could be a valuable device for non-physician EMS personnel rescue services also in the central Europe region.

Background Viscoelastic coagulation testing is increasingly used to diagnose trauma-induced coagulopathy. Two fully automated analysers, TEG 6s and ROTEM Sigma, were launched recently. No previous studies have compared these devices in trauma paients. Objective The aim of this study was to evaluate whether both fully automatic devices deliver comparable results. Design Prospective observational study. Setting Level one trauma centre from August 2017 to September 2018. Patients A total of 105 blood samples from 67 trauma patients were analysed simultaneously on TEG 6s and ROTEM Sigma. Main outcome measures TEG 6s assays kaolin (CK), RapidTEG (CRT), kaolin with heparinase (CKH) and functional fibrinogen were compared with ROTEM Sigma assays INTEM, EXTEM, HEPTEM and FIBTEM. TEG 6s functional fibrinogen level was compared with plasma fibrinogen concentration, measured using the Clauss method. Correlations were classified as weak (Spearman correlation coefficient 0.20 to 0.39), moderate (0.40 to 0.59), strong (0.60 to 0.79) or very strong (≥0.80). Results The TEG 6s parameters reaction time, kinetic time and α-angle (CK, CRT and CKH assays) mostly showed strong correlations with the corresponding ROTEM parameters clotting time, clot formation time and α-angle (INTEM, EXTEM and HEPTEM assays). The exceptions were CRT reaction time vs. EXTEM clotting time, and CK α-angle vs. INTEM α-angle, which correlated moderately. Absolute values for many of these parameters showed significant differences between the two devices. Very strong correlations and similar absolute values were observed between TEG 6s maximum amplitude (CRT, CK and CKH assays) and ROTEM maximum clot firmness (EXTEM, INTEM and HEPTEM assays). Correlations were also very strong for functional fibrinogen maximum amplitude vs. FIBTEM maximum clot firmness and functional fibrinogen level vs. Clauss fibrinogen concentration, but absolute values were significantly different. Conclusion Strong to very strong correlations were observed between corresponding TEG 6s and ROTEM Sigma parameters. However, absolute values showed significant differences for most of the measurements.

OBJECTIVE To assess the impact of direct oral anticoagulant (DOAC) intake compared with Coumadin (COU) in patients suffering hip fractures (HFs). DESIGN Retrospective cohort analysis. SETTING Level 1 Trauma Center. INTERVENTION Timing of surgical hip fixation. PATIENTS Three-hundred twenty patients 65 years of age or older with isolated HF were enrolled into the study: 207 (64.7%) without any antithrombotic therapy (no-ATT), 59 (18.4%) on COU, and 54 (16.9%) on DOACs. MAIN OUTCOME MEASUREMENTS Time to surgery, blood loss, mortality, hospital length of stay, red blood cell transfusion, use of reversal agents, and Charlson Comorbidity Index. RESULTS Patients on COU and DOACs had a higher Charlson Comorbidity Index compared with the no-ATT group (P < 0.0001). Despite the fact that significantly more patients received reversal agents in the COU group compared with DOAC medication (P < 0.0001), percentage of transfused patients were similar (54.2% vs. 53.7%). Time to surgery was significantly shorter in the no-ATT group when compared with DOAC patients (12-29.5 hours, respectively). No difference in postoperative hemorrhage, intensive care unit length of stay, and mortality was observed between groups. CONCLUSIONS DOAC medication in HF patients caused long elapse time until surgical repair. We found no evidence of higher bleeding rates in HF patients on DOACs compared with COUs. Earlier HF fixation might be indicated in DOAC patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Severe bleeding remains a prominent cause of early in-hospital mortality in major trauma patients. Thus, prompt prediction of patients at risk of massive transfusion (MT) is crucial. We investigated the ability of the inflammatory marker interleukin (IL)-6 to forecast MT in severely injured trauma patients. IL-6 plasma levels were measured upon admission. Receiver operating characteristic curves (ROCs) were calculated, and sensitivity and specificity were determined. In this retrospective study, a total of 468 predominantly male (77.8%) patients, with a median injury severity score (ISS) of 25 (17–34), were included. The Youden index for the prediction of MT within 6 and 24 h was 351 pg/mL. Patients were dichotomized into two groups: (i) low-IL-6 &lt, 350 pg/mL and (ii) high-IL-6 ≥ 350 pg/mL. IL-6 ≥ 350 pg/mL was associated with a lower prothrombin time index, a higher activated partial thromboplastin time, and a lower fibrinogen concentration compared with IL-6 &lt, 350 pg/mL (p &lt, 0.0001 for all). Thromboelastometric parameters were significantly different between groups (p &lt, 0.03 in all). More patients in the high-IL-6 group received MT (p &lt, 0.0001). The ROCs revealed an area under the curve of 0.76 vs. 0.82 for the high-IL-6 group for receiving MT in the first 6 and 24 h. IL-6 ≥ 350 pg/mL predicted MT within 6 and 24 h with a sensitivity of 45% and 58%, respectively, and a specificity of 89%. IL-6 ≥ 350 pg/mL appears to be a reasonable early predictor for coagulopathy and MT within the first 6 and 24 h intervals. Large-scale prospective studies are warranted to confirm these findings.

Background Sufficient analgesia is an obligation, but oligoanalgesia (NRS> 3) is frequently observed prehospitally. Potent analgesics may cause severe adverse events. Thus, analgesia in the helicopter emergency medical service (HEMS) setting is challenging. Adequacy, efficacy and administration safety of potent analgesics pertaining to injured patients in HEMS were analysed. Methods Observational study evaluating data from 14 year-round physician-staffed helicopter bases in Austria in a 12-year timeframe. Results Overall, 47,985 (34.3%) patients received analgesics, 26,059 of whom were adult patients, injured and not mechanically ventilated on site. Main drugs administered were opioids (n=20,051; 76.9%), esketamine (n=9082; 34.9%), metamizole (n=798; 3.1%) and NSAIDs (n=483; 1.9%). Monotherapy with opioids or esketamine was the most common regimen (n=21,743; 83.4%), while opioids together with esketamine (n= 3591; 13.8%) or metamizole (n=369; 1.4%) were the most common combinations. Females received opioids less frequently than did males (n=6038; 74.5% vs. n=14,013; 78.1%; p 95%), but females more often had moderate to severe pain on arrival in hospital (n=34; 5.0% vs. n=59; 3.2%; p=0.043). Administration of potent analgesics was safe, as indicated by MEES, SpO2 and respiratory rates. On 10% of all missions, clinical patient assessment was deemed sufficient by HEMS physicians and monitoring was spared. Conclusions Opioids and esketamine alone or in combination were the analgesics of choice in physician-staffed HEMS in Austria. Analgesia was often sufficient, but females more than males suffered from oligoanalgesia on hospital arrival. Administration safety was high, justifying liberal use of potent analgesics in physician-staffed HEMS.

Background Gastric dilation is frequently observed in trauma patients. However, little is known about average gastric volumes comprising food, fluids and air. Although literature suggests a relevant risk of gastric insufflation when endotracheal intubation (ETI) is required in the pre-hospital setting, this assumption is still unproven. Methods Primary whole body computed tomographic (CT) studies of 315 major trauma patients admitted to our Level 1 Trauma Centre Salzburg during a 7-year period were retrospectively assessed. Gastric volumes were calculated employing a CT volume rendering software. Patients intubated in the pre-hospital setting by emergency physicians (PHI, N = 245) were compared with spontaneously breathing patients requiring ETI immediately after arrival in the emergency room (ERI, N = 70). Results The median (range) total gastric content and air volume was 402 (26–2401) and 94 (0–1902) mL in PHI vs. 466 (59–1915) and 120 (1–997) mL in ERI patients (p = .59 and p = .35). PHI patients were more severely injured when compared with the ERI group (injury severity score (ISS) 33 (9–75) vs. 25 (9–75); p = .004). Mortality was higher in the PHI vs. ERI group (26.8% vs. 8.6%, p = .001). When PHI and ERI patients were matched for sex, age, body mass index and ISS (N = 50 per group), total gastric content and air volume was 496 (59–1915) and 119 (0–997) mL in the PHI vs. 429 (36–1726) and 121 (4–1191) mL in the ERI group (p = .85 and p = .98). Radiologic findings indicative for aspiration were observed in 8.1% of PHI vs. 4.3% of ERI patients (p = .31). Gastric air volume in patients who showed signs of aspiration was 194 (0–1355) mL vs. 98 (1–1902) mL in those without pulmonary CT findings (p = .08). Conclusion In major trauma patients, overall stomach volume deriving from food, fluids and air must be expected to be around 400–500 mL. Gastric dilation caused by air is common but not typically associated with pre-hospital airway management. The amount of air in the stomach seems to be associated with the risk of aspiration. Further studies, specifically addressing patients after difficult airway management situations are warranted.

Analgesia and sedation are key items in intensive care. Recently published S3 guidelines specifically address treatment of patients with elevated intracranial pressure. The Austrian Society of Anesthesiology, Resuscitation and Intensive Care Medicine carried out an online survey of neurointensive care units in Austria in order to evaluate the current state of practice in the areas of analgosedation and delirium management in this high-risk patient group. The response rate was 88%. Induction of anesthesia in patients with elevated intracranial pressure is carried out with propofol/fentanyl/rocuronium in >80% of the intensive care units (ICU), 60% use midazolam, 33.3% use esketamine, 13.3% use barbiturates and 6.7% use etomidate. For maintenance of analgosedation up to 72 h, propofol is used by 80% of the ICUs, followed by remifentanil (46.7%), sufentanil (40%) and fentanyl (6.7%). For long-term sedation, 86.7% of ICUs use midazolam, 73.3% sufentanil and 73.3% esketamine. For sedation periods longer than 7 days, 21.4% of ICUs use propofol. Reasons for discontinuing propofol are signs of rhabdomyolysis (92.9%), green urine, elevated liver enzymes (71.4% each) and elevated triglycerides (57.1%). Muscle relaxants are only used during invasive procedures. Inducing a barbiturate coma is rated as a last resort by 53.3% of respondents. The monitoring methods used are bispectral index (BIS™, 61.5% of ICUs), somatosensory-evoked potentials (SSEP, 53.8%), processed electroencephalography (EEG, 38.5%), intraparenchymal partial pressure of oxygen (pO2, 38.5%) and microdialysis (23.1%). Sedation and analgesia are scored using the Richmond agitation and sedation score (RASS, 86.7%), sedation agitation scale (SAS, 6.7%) or numeric rating scale (NRS, 50%) and behavioral pain scale (BPS, 42.9%), visual analogue scale (VAS), critical care pain observation tool (CCPOT, each 14.3%) and verbal rating scale (VRS, 7.1%). Delirium monitoring is done using the confusion assessment method for intensive care units (CAM-ICU, 46.2%) and intensive care delirium screening checklist (ICDSC, 7.7%). Of the ICUs 46.2% do not carry out delirium monitoring. We found good general compliance with the recommendations of the current S3 guidelines. Room for improvement exists in monitoring and the use of scores to detect delirium.

Das Schadel-Hirn-Trauma (SHT) ist zusammen mit dem hamorrhagischen Schock die fuhrende Todesursache nach einem schweren Trauma. Die Letalitat polytraumatisierter Patienten verdreifacht sich, wenn zusatzlich ein SHT vorliegt. Faktoren, die zu einem schlechten Outcome nach einem SHT beitragen wie Hypotension, Hypoxie, Hyperkapnie, Azidose, Koagulopathie und Hypothermie werden durch Ausmas und Schwere der extrazerebralen Verletzungen weiter aggraviert. Wesentliche Eckpfeiler der SHT-Behandlung konnen zumindest temporar im Widerspruch zu den Therapiezielen der Polytraumabehandlung stehen. Zu nennen sind hier die Notwendigkeit normotensiver Blutdruckwerte trotz einer unkontrollierten Blutungssituation, die Aufrechterhaltung einer Normokapnie beim traumatischen Lungenversagen und die Thromboseprophylaxe. Da Unsicherheit hinsichtlich der Definition „normotensiver“ Blutdruckwerte besteht, ist eine CPP-gesteuerte (CPP = zerebraler Perfusionsdruck) Kreislauftherapie von zentraler Bedeutung. Unstrittig ist hingegen, dass ein unmittelbares, zielgerichtetes Gerinnungsmanagement das Outcome von SHT- und polytraumatisierten Patienten verbessert. Die Planung weiterfuhrender Operationen muss an den Verlauf der SHT-Pathologie angepasst werden. Somit erfordert die Intensivtherapie des SHT beim Mehrfachverletzen eine enge Abstimmung mit den Traumatologen im Sinne eines individualisierten Behandlungskonzeptes.

In remote and mountainous areas, helicopter emergency medical systems (HEMS) are used to expedite evacuation and provide pre-hospital advanced trauma life support (ATLS) in major trauma victims. Aim of the study was to investigate feasibility of ATLS in HEMS mountain rescue missions and its influence on patient condition at hospital admission.58 major trauma victims (Injury Severity Score ≥16), evacuated by physician staffed HEMS from remote and mountainous areas in the State of Tyrol, Austria between 1.1.2011 and 31.12.2013.Pre-hospital time exceeded 90min in 24 (44%) cases. 31 (53%) patients suffered critical impairment of at least one vital function (systolic blood pressure90mmHg, GCS10, or respiratory rate10 or30). 4 (6.9%) of 58 patients died prior to hospital admission. Volume resuscitation was restrictive: 18 (72%) of 25 hypotensive patients received ≤500ml fluids and blood pressure was increased90mmHg at hospital admission in only 9 (36%) of these 25 patients. 8 (50%) of 16 brain trauma patients with a blood pressure90mmHg remained hypotensive at hospital admission. Endotracheal intubation was accomplished without major complications in 15 (79%) of 19 patients with a Glasgow Coma Scale score10. Rope operations were necessary in 40 (69%) of 58 cases and ATLS was started before hoist evacuation in 30 (75%) of them.The frequent combination of prolonged pre-hospital times, with critical impairment of vital functions, supports the need for early ATLS in HEMS mountain rescue missions. Pre-hospital endotracheal intubation is possible with a high success and low complication rate also in a mountain rescue scenario. Pre-hospital volume resuscitation is restrictive and hypotension is reversed at hospital admission in only one third of patients. Prolonged pre-hospital hypotension remains an unresolved problem in half of all brain trauma patients and indicates the difficulties to increase blood pressure to a desired level in a mountain rescue scenario. Despite technical considerations, on-site ATLS is feasible for an experienced emergency physician in the majority of rope rescue operations.

Trauma care providers are facing an increasing number of elderly patients on direct oral anticoagulants prior to injury. For dabigatran etexilate (DAB), the specific antagonist idarucizumab (IDA) has been approved since 2015 as a reversal agent. However, only limited data regarding the use of IDA in trauma patients are available. We performed a retrospective analysis of trauma patients under DAB for whom IDA administration was deemed necessary to reverse DAB’s antithrombotic effect. A total of 15 (9 male) patients were treated with IDA during the study period. The mean age was 81 ± 10 years. Intracranial haemorrhage (n = 7) and long bone fractures (n = 5) were the most common types of injury. Three patients were diagnosed as polytrauma. In all but one patient, atrial fibrillation was the indication for DAB intake. The median dose of IDA was 2.5 g (IQR 2.5–5). IDA administration decreased DAB plasma levels from 112.4 (IQR 73.4–123.4) to 5 (IQR 4–12) ng/mL (p = 0.031), thrombin time from 114.8 ± 48.3 to 16.2 ± 0.5 s (p

Objective We compared subjectively reported sleepiness and fatigue as well as causes and management strategies for combating sleepiness among pilots working in 2 different helicopter emergency medical services operating with different shift systems. Methods Pilots from the Norwegian Air Ambulance (NAA) and Christophorus Flugrettungsverein (CFV) in Austria participated. NAA performs flight missions 24/7, whereas at the time of the study the participating CFV bases did not fly after sunset. The pilots are on duty for 1 week in both services. NAA and CFV used an identical research protocol, including questionnaires about sleep, sleepiness (Epworth Sleepiness Scale and Karolinska Sleepiness Scale), coping strategies, and work-related causes of fatigue. Results CFV pilots kept busy, whereas NAA pilots slept and did physical exercise as strategies to prevent sleepiness. The majority in both groups used napping and coffee consumption as strategies. CFV pilots reported more frequently than NAA pilots that administrative duties and environmental factors were reasons preventing napping. Conclusion Some differences existed between the 2 pilot groups regarding strategies for managing sleepiness and causes that prevented pilots from napping. Pilots in both groups were healthy, physically active, and had normal Epworth Sleepiness Scale and Karolinska Sleepiness Scale scores.

The task force Neuroanaesthesia of the Austrian Society of Anaesthesiology, Resuscitation and Intensive Care Medicine (ÖGARI) is aiming to develop and provide recommendations in order to improve neurocritical care in Austria. Thus, a survey on neurocritical care concepts in Austria regarding intensive care of subarachnoid haemorrhage (SAH) and severe traumatic brain injury (TBI) was performed to assess the current status.An online internet questionnaire comprising 59 items on current concepts of SAH and TBI critical care was sent to 117 anaesthesiology departments.The survey was answered by 30 (25.6 %) of the hospitals, 24 (80 %) of them treating patients with SAH and/or TBI. Data from ten SAH centres reveal that definitive care was achieved within 24 h in all hospitals; a case load50 per year is noted in 70 % of intensive care units (ICU). In all, 50 % of departments employ written protocols for treatment. Regarding the treatment of TBI patients, 14 answers were received, indicating that 42.9 % of departments provide care for50 patients per year. Time between arrival and CT scan is30 min in all hospitals, and 28.6 % of departments rely on written protocols. Only 14.3 % of hospitals report about routine morbidity and mortality rounds. While the neurologic status is assessed at discharge from the ICU, there is no evaluation of 1‑year outcome.Definitive care of SAH and TBI patients is achieved timely in Austria. When compared with SAH, more hospitals with lower case loads take care of TBI patients. Written guidelines and protocols at institutional level are often missing. Since routine morbidity and mortality conferences are sparse, and long-term outcome is not assessed, there is room for improvement.

Objectives:We sought to assess whether the GlideScope Ranger video laryngoscope may be a reliable alternative to direct laryngoscopy in the prehospital setting.Design:Multicenter, prospective, randomized, control trial with patient recruitment over 18 months.Setting:Four study centers operating phys

Background Neurophysiological data are lacking in the research of nerve injury during regional anaesthesia. The aim of this pilot study was to establish a large animal model in order to test the hypothesis that needle trauma alone or in combination with intraneural injection would result in measurable nerve injury. Methods The experimental set-up was elaborated in four pre-test animals. In the remaining animals (n = 11), 22 sciatic nerves were randomly assigned to one of four groups: needle trauma (n = 5) generated by ultrasound-guided forced needle advancement; intraneural injection of 2.5 ml saline (n = 6); intraneural injection of 5 ml saline (n = 6); extraneural injection of 5 ml saline (n = 5) as control group. Compound muscle action potential (CMAP) amplitudes as well as latencies were taken as outcome parameter and monitored over 180 min. Sonographic assessments were performed simultaneously. Results Following needle trauma and intraneural injection, CMAP amplitudes declined significantly over 180 min (P < 0.001). The control group showed no electrophysiological alterations. At 60 min, decreases in amplitude were significant after needle trauma (P = 0.04) and intraneural injection of 2.5 ml (P = 0.045), and highly significant after injection of 5 ml (P = 0.006) when compared to controls. Sustained nerve swelling was observed after intraneural injection, but not after needle trauma and perineural injection. Conclusions Isolated mechanical trauma caused by forced needle advancement alone or in combination with intraneural injection of saline was followed by a significant decline in CMAP amplitudes indicating conduction block due to disruption of myelin or axon loss (pseudo-conduction block).

Background Myocardial infarction is a time-critical condition and its outcome is determined by appropriate emergency care. Thus we assessed the efficacy of a supra-regional ST-segment elevation myocardial infarction (STEMI) network in Easternern Austria. Methods The Eastern Austrian STEMI network serves a population of approx. 766.000 inhabitants within a region of 4186 km2. Established in 2007, it now comprises 20 pre-hospital emergency medical service (EMS) units (10 of these physician-staffed), 4 hospitals and 3 cardiac intervention centres. Treatment guidelines were updated in 2012 and documentation within a web-based STEMI registry became mandatory. For this retrospective qualitative control study, data from February 2012–April 2015 was assessed. Results A total of 416 STEMI cases were documented, and 99% were identified by EMS within 6 (4.0–8.0) minutes after arrival. Median time loss between onset of pain and EMS call was 54 (20–135) minutes; response, pre-hospital and door-to-balloon times were 14 (10–20), 46 (37–59) and 45 (32–66) minutes, respectively. When general practitioners were involved, time between onset of pain and balloon inflation significantly increased from 180 (135–254) to 218 (155–348) minutes (p

Background Competence in emergency airway management is key in order to improve patient safety and outcome. The scope of compulsory training for emergency physicians or paramedics is quite limited, especially in Austria. The purpose of this study was to review the difficult airway management performance of an emergency medical service (EMS) in a region that has implemented a more thorough training program than current regulations require, comprising 3 months of initial training and supervised emergency practice and 3 days/month of on-going in-hospital training as previously reported. Methods This is a subgroup analysis of pre-hospital airway interventions performed by non-anesthesiologist EMS physicians between 2006 and 2016. The dataset is part of a retrospective quality control study performed in the ground EMS system of Wiener Neustadt, Austria. Difficult airway missions recorded in the electronic database were matched with the hospital information system and analyzed. Results Nine hundred thirty-three of 23060 ground EMS patients (4%) required an airway intervention. In 48 cases, transient bag-mask-valve ventilation was sufficient, and 5 patients needed repositioning of a pre-existing tracheostomy cannula. Eight hundred thirty-six of 877 patients (95.3%) were successfully intubated within two attempts; in 3 patients, a supraglottic airway device was employed first line. Management of 41 patients with failed tracheal intubation comprised laryngeal tubes (n = 21), intubating laryngeal mask (n = 11), ongoing bag-mask-valve ventilation (n = 8), and crico-thyrotomy (n = 1). There was no cannot intubate/cannot ventilate situation. Blood gas analysis at admission revealed hypoxemia in 2 and/or hypercapnia in 11 cases. Conclusion During the 11-year study period, difficult airways were encountered in 5% but sufficiently managed in all patients. Thus, the training regime presented might be a feasible and beneficial model for training of non-anesthesiologist emergency physicians as well as paramedics.

Study background Previous studies focused on the outcome of avalanche victims with out-of-hospital cardiac arrest (OHCA) after long duration of burial (>35 min); the outcome of victims with short duration (≤35 min) remains obscure. Aim of the study To investigate outcome of avalanche victims with OHCA. Methods Retrospective analysis of avalanche victims with OHCA between 2008 and 2013 in the Tyrolean Alps. Results 55 avalanche victims were identified, 32 of whom were declared dead after extrication without cardiopulmonary resuscitation (CPR), all with long duration of burial. In the remaining 23 CPR was initiated at scene; three were partially and 20 completely buried, nine of whom suffered short and 11 long duration of burial. All nine victims with short duration of burial underwent restoration of spontaneous circulation (ROSC) at scene, four of them after bystander CPR, five after advanced life support by the emergency physician. Two patients with ROSC after short duration of burial and bystander CPR survived to hospital discharge with cerebral performance category 1. None of the 11 victims with long duration of burial survived to hospital discharge, although six were transported to hospital with ongoing CPR and three were supported with extracorporeal circulation. Conclusions In this case series survival with favourable neurological outcome was observed in avalanche victims with short duration of burial only if bystander CPR was immediately performed and ROSC achieved. Strategies for reducing avalanche mortality should focus on prompt extrication from the snow and immediate bystander CPR by uninjured companions.

Background Traumatic brain injury (TBI) is the leading cause of death among trauma patients. Patients under antithrombotic therapy (ATT) carry an increased risk for intracranial haematoma (ICH) formation. There is a paucity of data about the role of direct oral anticoagulants (DOACs) among TBI patients. Methods In this retrospective study, we investigated all TBI patients ≥60-years-old who were admitted to the intensive care unit (ICU) from January 2014 until May 2017. Patients were grouped into those receiving vitamin K antagonists (VKA), platelet inhibitors (PI), DOACs and no antithrombotic therapy (no-ATT). Results One-hundred-eighty-six, predominantly male (52.7%) TBI patients with a median age of 79 years (range: 70–85 years) were enrolled in the study. Glasgow Coma Scale and S-100β were not different among the groups. Patients on VKA and DOACs had a higher Charlson Comorbidity Index compared to the PI group and no-ATT group (p = 0.0021). The VKA group received reversal agents significantly more often than the other groups (p

Verbluten stellt bei Polytraumen die haufigste potentiell vermeidbare Todesursache dar. Rasche chirurgische Intervention gepaart mit einer fruhen und aggressiven hamostatischen Therapie fuhrt nicht nur zu Uberlebensvorteilen koagulopathischer Traumapatienten, sondern senkt auch die Inzidenz von Komplikationen und dadurch Kosten. Standardgerinnungsbefunde sind wenig geeignet die Komplexitat der traumainduzierten Koagulopathie (TIC) ausreichend zu charakterisieren. Diese Tatsache hat zu einer Renaissance viskoelastischer Testverfahren, wie Rotationsthromboelastometrie (ROTEM®) und Thrombelastographie (TEG®) gefuhrt. ROTEM®/TEG sind als „Point-of-care-“ (POC-)Gerate einsetzbar. In einigen Traumazentren wurden daher Therapiealgorithmen entwickelt, bei denen sich die hamostatische Intervention auf die Ergebnisse dieser viskoelastischen Messungen stutzt. Schock und Gewebetrauma aktivieren profibrinolytische Prozesse, die zu einer vorzeitigen Auflosung eines bestehenden Gerinnsels fuhren. Die (Hyper)fibrinolyse lasst sich mit Hilfe von Tranexamsaure rasch und kostengunstig hemmen. Viskoelastische Messungen konnten zeigen, dass eine verminderte Gerinnselstarke mit einer erhohten Blutungsneigung einhergeht. Je nach Ursache kann durch die Gabe von Fibrinogen- und/oder Plattchenkonzentraten die Clotstarke optimiert werden. Die Thrombinbildung ist initial meist wenig eingeschrankt und lasst sich durch die Gabe von Plasma, Prothrombinkomplexkonzentrat oder mit Einschrankungen durch rekombinanten aktivierten Faktor VII verbessern.

Supplemental Digital Content is available in the text., Objectives: Tracheal intubation in prehospital emergency care is challenging. The McGrath Mac Video Laryngoscope (Medtronic, Minneapolis, MN) has been proven to be a reliable alternative for in-hospital airway management. This trial compared the McGrath Mac Video Laryngoscope and direct laryngoscopy for the prehospital setting. Design: Multicenter, prospective, randomized, controlled equivalence trial. Setting: Oesterreichischer Automobil- und Touring Club (OEAMTC) Helicopter Emergency Medical Service in Austria, 18-month study period. Patients: Five-hundred fourteen adult emergency patients (≥ 18 yr old). Interventions: Helicopter Emergency Medical Service physicians followed the institutional algorithm, comprising a maximum of two tracheal intubation attempts with each device, followed by supraglottic, then surgical airway access in case of tracheal intubation failure. No restrictions were given for tracheal intubation indication. Measurements Main Results: The Primary outcome was the rate of successful tracheal intubation; equivalence range was ± 6.5% of success rates. Secondary outcomes were the number of attempts to successful tracheal intubation, time to glottis passage and first end-tidal Co2 measurement, degree of glottis visualization, and number of problems. The success rate for the two devices was equivalent: direct laryngoscopy 98.5% (254/258), McGrath Mac Video Laryngoscope 98.1% (251/256) (difference, 0.4%; 99% CI, –2.58 to 3.39). There was no statistically significant difference with regard to tracheal intubation times, number of attempts or difficulty. The view to the glottis was significantly better, but the number of technical problems was increased with the McGrath Mac Video Laryngoscope. After a failed first tracheal intubation attempt, immediate switching of the device was significantly more successful than after the second attempt (90.5% vs 57.1%; p = 0.0003), regardless of the method. Conclusions: Both devices are equivalently well suited for use in prehospital emergency tracheal intubation of adult patients. Switching the device following a failed first tracheal intubation attempt was more successful than a second attempt with the same device.

Background In the European Alps emergency medical helicopter services are regularly involved in avalanche rescue missions. How the helicopter emergency medical system best supports avalanche rescue missions is controversial. Aim of the study To study advantages and limitations of the early dispatch of emergency medical helicopters after avalanche accidents. Methods Data on rescue mission characteristics and patterns and severity of medical emergencies were obtained for 221 helicopter avalanche rescue missions performed in the Austrian province of Tyrol between October 2008 and June 2011. Results A buried avalanche victim had to be searched for in only 12 (5.5%) of the 221 rescue missions, whereas medical emergencies were encountered at the scene in 24 missions (11%). Survival rate for totally buried victims extricated after helicopter arrival was significantly lower than for victims extricated before helicopter arrival (19% versus 74%, p =0.0002). In 124 missions (56%) no victim was present at the scene when the helicopter arrived. Medical emergencies involved normothermic cardiac arrest ( n =11), severe accidental hypothermia ( n =6), critical trauma ( n =7) and hypothermia combined with critical trauma ( n =1). Survival rate at hospital discharge was 27% for arrested normothermic patients and 50% for trauma and hypothermia patients. Conclusions Medical emergencies are encountered at avalanche scenes twice as often as there is need to search for totally buried victims, clearly supporting the immediate dispatch of medical crew members to the accident site. The high rate of emergency medical helicopter operations to avalanche incidents where no victim is injured or buried may be characteristic for densely populated mountainous regions and can be reduced by a restrictive dispatch policy after avalanche accidents without clear information about human involvement.

Ziel dieser Studie war die Erfassung der Epidemiologie zur Einsatzcharakteristik und praklinischen Notfalltherapie von Verbrennungen/Verbruhungen in der Luftrettung. Alle Primareinsatze (n = 88) und Sekundareinsatze (n = 17) der Luftrettung des Osterreichischen Automobil-Motorrad-Touring-Clubs (OAMTC) wurden fur thermische Verletzungen im Jahr 2009 retrospektiv ausgewertet. Insgesamt wurden 71 Primareinsatze (relative Haufigkeit bei 16.100 Gesamteinsatzen: 0,4%) fur Verbrennungen/Verbruhungen geflogen (relative Haufigkeit: Kinder 2,0%; Erwachsene 0,3%). Der Anteil von grosflachigen Verbrennungen/Verbruhungen (> 20% verbrannte Korperoberflache) war bei Kindern hoher als bei Erwachsenen (54,5 vs. 40,7%); 63,4% aller Verbrennungsopfer war potentiell lebensbedrohlich verletzt; 62% (n = 44) betrafen die Kopf-Hals-Region, 52,1% (n = 37) die obere Extremitat und 14,1% (n = 10) den Anogenitalbereich. Thermische Verletzungen sind in der OAMTC-Luftrettung selten, jedoch schwerwiegend. Kenntnisse zur Einsatzcharakteristik von thermischen Verletzungen konnen dazu beitragen, Schwerpunkte in der Ausbildung von Rettungskraften hinsichtlich der Versorgung von Brandverletzten zu setzen.

Objective: Research on helicopter emergency medical services (HEMS) in major incidents is predominately based on case descriptions reported in a heterogeneous fashion. Uniform data reported with a consensus-based template could facilitate the collection, analysis, and exchange of experiences. This type of database presently exists for major incident reporting at www.majorincidentreporting.net. This study aimed to develop a HEMS-specific major incident template. Methods: This Delphi study included 17 prehospital critical care physicians with current or previous HEMS experience. All participants interacted through e-mail. We asked these experts to define data variables and rank which were most important to report during an immediate prehospital medical response to a major incident. Five rounds were conducted. Results: In the first round, the experts suggested 98 variables. After 5 rounds, 21 variables were determined by consensus. These variables were formatted in a template with 4 main categories: HEMS background information, the major incident characteristics relevant to HEMS, the HEMS response to the major incident, and the key lessons learned. Conclusion: Based on opinions from European experts, we established a consensus-based template for reporting on HEMS responses to major incidents. This template will facilitate uniformity in the collection, analysis, and exchange of experience. © 2017 The Authors. Published by Elsevier Inc. on behalf of Air Medical Journal Associates. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ )

Background Fibrinogen concentrate (FC) is increasingly used as first line therapy in bleeding trauma patients. It remains unproven whether FC application increases post-traumatic plasma fibrinogen concentration (FIB) in injured patients, possibly constituting a prothrombotic risk. Thus, we investigated the evolution of FIB following trauma in patients with or without FC therapy. Methods At the AUVA Trauma Centre, Salzburg, we performed a retrospective study of patients admitted to the emergency room and whose FIB levels were documented thereafter up to day 7 post-trauma. Patients were categorized into those with (treatment group) or without (control group) FC therapy during the first 24 h after hospital admission. A subgroup analysis was carried out to investigate the influence of the amount of FC given. Results The study enrolled 435 patients: treatment group, n = 242 (56 %); control group, n = 193 (44 %), with median Injury Severity Score of 34 vs. 22 (P

INTRODUCTION: Arguably, the most challenging emergencies encountered by emergency medical service crews involve children. Because only scant data exist about the epidemiology of pediatric emergencies in helicopter emergency medical service (HEMS) on a population level, we sought to determine the epidemiological characteristics stratified by responding area in a large nationwide sample. METHODS: This was a retrospective cohort study including all pediatric patients (0–14 years of age) who were treated by HEMS in Austria from January 2006 to June 2007 (18 months). RESULTS: Pediatric emergencies accounted for 2207 (8.2%) of a total of 26.850 helicopter rescue missions. Of those, 69.9% (n = 1543) were not involved in life-threatening emergencies. The rate of critical pediatric emergencies was higher in urban than in rural or alpine environment (45.2%, 38.2% and 20.3%, respectively). The most common chief complaint was trauma; the frequency of injuries ranged from 54.2% (582/1074) in rural area and 60.3% (44/73) in urban area to 91.4% (969/1060) in alpine environment. Fracture and head trauma (34.9%; 557/1595 and 26.3%; 419/1595, respectively) were the most common injuries. Advanced life support measures like tracheal intubation, cardiopulmonary resuscitation and intraosseous access were rarely performed (3.7%; n = 82, 1.9%; n = 42 and 0.9%; n = 19, respectively). CONCLUSIONS: Pediatric emergencies in Austrian HEMS show different epidemiological characteristics in alpine, urban and rural operational environments. Because of challenges and infrequency of prehospital pediatric emergencies, HEMS crews need to maintain their skills in pediatric advanced life support and trauma care.

The optical Airtraq laryngoscope (Prodol Meditec, Vizcaya, Spain) has been shown to have advantages when compared with direct laryngoscopy in difficult airway patients. Furthermore, it has been suggested that it is easy to use and handle even for inexperienced advanced life support providers. As such, we sought to assess whether the Airtraq may be a reliable alternative to conventional intubation when used in the prehospital setting.Prospective, randomized control trial in emergency patients requiring endotracheal intubation provided by anesthesiologists or emergency physicians responding with an emergency medical service helicopter or ground unit associated with the Department of Anesthesiology, General Hospital, Wiener Neustadt, Austria.During the 18-month study period, 212 patients were enrolled. When the Airtraq was used as first-line airway device (n=106) vs. direct laryngoscopy (n=106), success rate was 47% vs. 99%, respectively (p.001). Reasons for failed Airtraq intubation were related to the fiber-optic characteristic of this device (i.e., impaired sight due to blood and vomitus, n=11) or to assumed handling problems (i.e., cuff damage, tube misplacement, or inappropriate visualization of the glottis, n=24). In 54 of 56 patients where Airtraq intubation failed, direct laryngoscopy was successful on the first attempt; in the remaining two and in one additional case of failed direct laryngoscopy, the airway was finally secured employing the Fastrach laryngeal mask. There was no correlation between success rates and body mass index, age, indication for airway management, emergency medical service unit, or experience of the physicians.Based on these results, the use of the Airtraq laryngoscope as a primary airway device cannot be recommended in the prehospital setting without significant clinical experience obtained in the operation room. We conclude that the clinical learning process of the Airtraq laryngoscope is much longer than reported in the anesthesia literature.

Standard coagulation tests have a low specificity and sensitivity for diagnosing disseminated intravascular coagulation. The aim of this study was to determine whether whole blood thromboelastometry (TEM) detects lipopolysaccharide (LPS)-induced changes in coagulation. Blood samples from 10 pigs were drawn at baseline, before and at the end of LPS infusion and 2, 3, 4 and 5 h after the start of endotoxinemia. Simultaneous to TEM, standard coagulation tests and extended coagulation analysis including tissue plasminogen activator (t-PA) and plasminogen activator inhibitor 1 (PAI-1) were performed. Endotoxinemia resulted in a significant acceleration of the nonactivated TEM (NATEM) clotting time 2 h after the end of LPS infusion; in contrast, the changes in international normalized ratio and activated partial thromboplastin time suggested delayed initiation of coagulation. NATEM maximum clot firmness (MCF) and fibrin-based thromboelastometry test (FIBTEM)-MCF decreased significantly from baseline until the last time point (from 64.6 ± 7.8 and 35.1 ± 12.8 mm to 52.8 ± 4.6 and 21.4 ± 11.8 mm, respectively; P = 0.01 for both parameters). A sharp, transient increase of t-PA had no effect on maximum lysis in the NATEM test. PAI-1 increased significantly 3 h after the start of LPS infusion, paralleled by a decrease in maximum lysis. In conclusion, TEM was superior to standard coagulation tests in reflecting initial activation of coagulation during endotoxinemia. TEM further suggested consumption of coagulation substrate; at the same time, inhibition of plasminogen activation was accompanied by improved clot stability. Further investigations are necessary to establish the clinical relevance of these findings.

Hintergrund Fur ein internationales sportliches Grosereignis konnten Einsatzdaten fruherer Grosambulanzen Indikatoren fur die Abschatzung des Patientenaufkommens darstellen.

We report on a severely injured trauma patient who suffered a high velocity motorcycle accident. The patient was receiving dual antiplatelet therapy with aspirin and clopidogrel.Thromboelastometry (ROTEM(®)) on admission revealed low maximum clot firmness (MCF) in the FIBTEM assay, strongly indicating impaired fibrin polymerization. Inhibition of platelet activity also was confirmed. Massive intra-abdominal bleeding caused by a liver rupture required immediate laparotomy. Haemostasis during emergency surgery was achieved through topical surgical measures and intravenous fibrinogen concentrate administration (three doses of 4 g), guided by ROTEM test results only. As platelet count decreased to 28 × 10(9) L(-1), 6 h after admission to the intensive care unit, the patient received two units of platelet concentrate. No further haemostatic therapy was necessary during the next 48 h.This case shows the potential effectiveness of fibrinogen concentrate in improving haemostasis in trauma patients receiving antiplatelet therapy.

Ventilation of a non-intubated emergency patient by inexperienced rescuers with a standard bag-valve device may result in high inspiratory flow rates and subsequently high airway pressures with stomach inflation. Therefore, a self-inflating bag has been developed that requires lay rescuers to blow up a single-use balloon inside an adult bag-valve device, which, in turn, displaces air within the bag towards the patient. This concept has been compared to standard adult bag-valve devices earlier in bench models but not in patients.An anaesthetist who was blinded to all monitor tracings ventilated the lungs of 40 apnoeic patients during routine anaesthesia induction either with a standard bag-valve device or with the mouth-to-bag resuscitator in a random order. Study endpoints were peak inspiratory flow rates, peak airway pressure, tidal volumes and inspiratory time.Peak inspiratory flow was 40+/-10lmin(-1) for the standard bag-valve device versus 33+/-13lmin(-1) for the mouth-to-bag resuscitator (P0.0001); peak airway pressure was 17+/-5cmH(2)O versus 14+/-5cmH(2)O (P0.0001); inspiratory tidal volume was 477+/-133ml versus 644+/-248ml (P0.001) and inspiratory time was 1.1+/-0.3s versus 1.9+/-0.6s (P0.0001).Employing the mouth-to-bag resuscitator during simulated ventilation of a non-intubated patient in respiratory arrest significantly decreased peak inspiratory flow and peak airway pressure and increased inspiratory tidal volume and inspiratory times compared to a standard bag-valve device.

The planning and execution of avalanche rescue missions to search for totally buried avalanche victims are mostly based on personal experience and preference, as evidence-based information from literature is almost completely missing. Hence, the aim of this study was to identify major factors determining the survival probability of totally buried victims during avalanche rescue missions carried out by organized rescue teams (Austrian Mountain Rescue Service, Tyrol). During the 12-year period studied, 109 totally buried persons (56 off-piste, 53 backcountry), were rescued or recovered; 18.3% survived to hospital discharge. Median depth of burial was 1.25 m; median duration of burial was 85 min. The majority (61.6%) of the rescue missions were conducted under considerably dangerous avalanche conditions. The probability of survival was highest when located visually and lowest for those located by avalanche transceiver; survival did not significantly differ between those found by rescue dogs and those located with avalanche probes. Multivariate analysis revealed short duration of burial and off-piste terrain to be the two independent predictors of survival. Whenever companion rescue fails, snow burial in an avalanche is associated with extraordinarily high mortality. Searching the avalanche debris with probe lines seems to be equally effective as compared to searching with rescue dogs. The potential hazard for rescuers during avalanche rescue missions comes mainly from self-triggered avalanches, hence thorough mission planning and critical risk-benefit assessment are of utmost importance for risk reduction.

INTRODUCTION Heat stroke is still an epidemiologically relevant disease with overall mortality rates as high as 15-33%. In heat stroke, hypotension is caused by relative central hypovolemia. We performed a feasibility study to determine if an inspiratory impedance threshold valve (ITDTM) set to open at -12 cm H2O would reverse systemic hypotension by enhancing venous return in hyperthermic, hypotensive, but spontaneously breathing animals. METHODS Seven anesthetized pigs weighing 30 +/- 2 kg were warmed with a heating device until a mean rectal temperature of 44 degrees C was reached, and mean arterial blood pressure (MAP) was < or = 60 mmHg. The animals were then treated with the ITD. An intravenous bolus of 200 cc of 4 degrees C normal saline was delivered 20 min after the ITD was placed, and external cooling was started. RESULTS Heat stroke criteria were achieved within 105 +/- 15 min. MAP had decreased from 105 +/- 5 to 57 +/- 5 mmHg, and respiratory rates had increased from 33 +/- 2 to 101 +/- 13 breaths/min. Addition of the ITD significantly improved MAP to 85 +/- 4 mmHg, and reduced respiratory rate to 54 +/- 6 breaths/min within 2 min. The effect was sustained until fluid replacement and external cooling were delivered 20 min later. At that point, MAP returned to baseline within 30 min, and 6/7 animals survived for an additional 30 min. CONCLUSIONS Use of an inspiratory impedance threshold device resulted in an immediate rise in blood pressure in animals in heat stroke and preserved blood pressure for at least 20 min prior to cooling and fluid replacement.

Der Stellenwert einzelner Interventionen im notfallmedizinischen Behandlungskonzept des Polytraumas ist differenziert zu betrachten. Oftmals wird die Luftrettung den bodengebundenen Rettungsmitteln gegenubergestellt. Dabei bleibt unberucksichtigt, dass die Luftrettung keine Entitat per se darstellt. Unterschiede beziehen sich vielmehr auf das fallweise schnellere Eintreffen am Notfallort, auf Umfang und Qualitat der notarztlichen Intervention und den dabei notwendigen Zeitbedarf sowie auf den schnelleren Transport in weiter entfernte Behandlungseinrichtungen. In einer Gewichtung der einzelnen Masnahmen hat der unmittelbare, zeitnahe Transport von polytraumatisierten Patienten an ein Traumazentrum die hochste Prioritat. Der Einsatz des RTH ist bei bestimmten Subgruppen (Injury Severity Score, ISS ≥12; schweres Schadel-Hirn-Trauma) mit einem deutlich besseren Patientenoutcome korreliert. Kompetente notarztliche Intervention verbessert das Kurzzeituberleben, verkurzt die notwendige Behandlungsdauer im Schockraum, auf der Intensivstation und im Krankenhaus. Die daraus resultierende Zunahme der praklinischen Behandlungszeit hat keinen negativen Einfluss auf das Outcome. Basierend auf der derzeitig verfugbaren Literatur erscheint der hohe Stellenwert der Luftrettung in der Traumaversorgung gesichert.

Die Behandlung von Patienten mit einer dekompensierten chronisch obstruktiven Lungenerkrankung („chronic obstructive pulmonary disease“, COPD), die auf bronchodilatatorische Pharmakotherapie nicht mehr anspricht, ist eine Herausforderung an die Intensivmedizin. Eine Anwendung von Inhalationsanasthetika kann in diesen Fallen manchmal die noch einzig mogliche Behandlungsoption darstellen. Es wird von einer 65-jahrigen Patientin mit einer infektexazerbierten COPD berichtet, bei der eine suffiziente Ventilation trotz umfassender pharmakologischer Intervention unmoglich war. Fur die Durchfuhrung einer Inhalationsanasthesie auf der Intensivstation wurde das „Anaesthetic Conserving Device“ (ACD, AnaConDa®) verwendet, das die Verdampfung und die Beimischung eines volatilen Anasthetikums an einem Intensivrespirator einfach und sicher moglich macht. Durch die besondere Technik des AnaConDa® wird aus dem halb offenen Intensivrespirator ein de facto halb geschlossenes Beatmungsgerat. Nach einer 48-stundigen Anwendung von Halothan verbesserte sich die stark eingeschrankte pulmonale Compliance der Patientin signifikant, sodass bei dann problemloser CO2-Elimination trotz Absetzen des Halothans auf eine nichtinvasive Beatmung umgestellt werden konnte und sich der Zustand der Patientin weiter stabilisierte. Nach abschliesender chirurgischer Sanierung eines Infektherdes konnte die Patientin nach 78-tagigem Intensivaufenthalt in die Rehabilitation entlassen werden.

Summary The effects of vasopressin on the gut in a porcine uncontrolled haemorrhagic shock model are described. In eight anaesthetised pigs, a liver laceration was performed; when haemorrhagic shock was decompensated, all animals received 0.4 IU/kg vasopressin, followed by 0.08 IU/kg min over 30 min, which maintained a mean arterial blood pressure >40 mmHg. Subsequent surgical intervention, infusion of whole blood and fluids resulted in a stable cardiocirculatory status. Three hours after stabilisation, all pigs developed non-bloody diarrhoea which converted into normal bowel movements within 24 h. All histological samples retained 7 days after the experiment revealed no histopathological changes. In conclusion, in this small observational study of uncontrolled porcine haemorrhagic shock, a resuscitation strategy that included high dose vasopressin was associated with transient diarrhoea and good long term survival.

This article compares the strategy of a fixed transfusion ratio of plasma and platelet concentrates to red blood cells to reconstitute 'whole blood' with the concept of individualized goal-directed coagulation therapy (GDCT).Current data suggest that an early and high ratio of plasma and platelet concentrate transfusion, predominantly in a fixed 1 : 1 : 1 ratio with red blood cells, is associated with improved outcome. However, the optimal ratio is still under discussion. Moreover, storage time considerably affects the hemostatic competence of these products and no universal standard for the composition of these 'transfusion packages' has been established. Some European trauma centers instituted the concept of GDCT in trauma patients, which is based on early diagnosis of the coagulation deficit using point-of-care viscoelastic tests (VETs). These tests provide rapid information about the underlying hemostatic deficiencies, allowing targeted coagulation therapy according to the individual deficits of the patient. Treatment algorithms have been established for the administration of coagulation factor concentrates, and plasma and platelet concentrate based on VET results.Individualized GDCT, guided by VET, offers several advantages over fixed ratio coagulation therapy. Studies comparing both hemostatic strategies are warranted.