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This paper deals with agglomeration processes in a high-shear mixer and the integration of an inline particle probe. The purpose is to determine particle size distribution continuously in real-time. High-shear mixers rotate with a very high mixing tool speed. As a result, not only a mixing effect, but also a granulating effect (under certain conditions) is obtained. This granulating effect is to be studied extensively using an inline particle probe. In the first instance, it is decisive to integrate the probe and find settings to measure and to represent the whole particle size distribution in the mixing vessel. This article will highlight some of the findings obtained from the comprehensive parameter study. Additionally, the technical implementation of the inline particle probe in a high-shear mixer will be described. [ABSTRACT FROM AUTHOR]

Sleep disorders in physicians who perform shift work can result in increased risks of health problems that negatively impact performance and patient safety. Even those who cope well with shift work are likely to suffer from sleep disorders. The aim of this manuscript is to discuss possible causes, contributing factors and consequences of sleep disorders in physicians and to identify measures that can improve adaptation to shift work and treatment strategies for shift work-associated sleep disorders. The risk factors that influence the development of sleep disorders in physicians are numerous and include genetic factors (15 % of the population), age (> 50 years), undiagnosed sleep apnea,, alcohol abuse as well as multiple stress factors inherent in clinical duties (including shift work), research, teaching and family obligations. Several studies have reported an increased risk for medical errors in sleep-deprived physicians. Shift workers have an increased risk for psychiatric and cardiovascular diseases and shift work may also be a contributing factor to cancer. A relationship has been reported not only with sleep deprivation and changes in food intake but also with diabetes mellitus, obesity, hypertension and coronary heart disease. Nicotine and alcohol consumption are more frequent among shift workers. Increased sickness and accident rates among physicians when commuting (especially after night shifts) have a socioeconomic impact. In order to reduce fatigue and to improve performance, short naps during shiftwork or naps plus caffeine, have been proposed as coping strategies; however, napping during adverse circadian phases is less effective, if not impossible when unable to fall asleep. Bright and blue light supports alertness during a night shift. After shiftwork, direct sunlight exposure to the retina can be avoided by using dark sunglasses or glasses with orange lenses for commuting home. The home environment for daytime sleeping after a night shift should be very dark to allow endogenous melatonin secretion, which is a night signal and supports continuous sleep. Sleep disorders can be treated with timed light exposure, as well as behavioral and environmental strategies to compensate for sleep deprivation. Fatigue due to sleep deprivation can only be systematically treated with sleep. [ABSTRACT FROM AUTHOR]

Sleep disorders in physicians who perform shift work can result in increased risks of health problems that negatively impact performance and patient safety. Even those who cope well with shift work are likely to suffer from sleep disorders. The aim of this manuscript is to discuss possible causes, contributing factors and consequences of sleep disorders in physicians and to identify measures that can improve adaptation to shift work and treatment strategies for shift work-associated sleep disorders. The risk factors that influence the development of sleep disorders in physicians are numerous and include genetic factors (15 % of the population), age (> 50 years), undiagnosed sleep apnea,, alcohol abuse as well as multiple stress factors inherent in clinical duties (including shift work), research, teaching and family obligations. Several studies have reported an increased risk for medical errors in sleep-deprived physicians. Shift workers have an increased risk for psychiatric and cardiovascular diseases and shift work may also be a contributing factor to cancer. A relationship has been reported not only with sleep deprivation and changes in food intake but also with diabetes mellitus, obesity, hypertension and coronary heart disease. Nicotine and alcohol consumption are more frequent among shift workers. Increased sickness and accident rates among physicians when commuting (especially after night shifts) have a socioeconomic impact. In order to reduce fatigue and to improve performance, short naps during shiftwork or naps plus caffeine, have been proposed as coping strategies; however, napping during adverse circadian phases is less effective, if not impossible when unable to fall asleep. Bright and blue light supports alertness during a night shift. After shiftwork, direct sunlight exposure to the retina can be avoided by using dark sunglasses or glasses with orange lenses for commuting home. The home environment for daytime sleeping after a night shift should be very dark to allow endogenous melatonin secretion, which is a night signal and supports continuous sleep. Sleep disorders can be treated with timed light exposure, as well as behavioral and environmental strategies to compensate for sleep deprivation. Fatigue due to sleep deprivation can only be systematically treated with sleep. [ABSTRACT FROM AUTHOR]

dults: Administer chest compressions (minimum 100/min, minimum 5 cm depth) at a ratio of 30:2 with ventilation (tidal volume 500-600 ml, inspiration time 1 s, FO if possible 1.0). Avoid any interruptions in chest compressions. After every single defibrillation attempt (initially biphasic 120-200 J, monophasic 360 J, subsequently with the respective highest energy), chest compressions are initiated again immediately for 2 min independent of the ECG rhythm. Tracheal intubation is the optimal method for securing the airway during resuscitation but should be performed only by experienced airway management providers. Laryngoscopy is performed during ongoing chest compressions; interruption of chest compressions for a maximum of 10 s to pass the tube through the vocal cords. Supraglottic airway devices are alternatives to tracheal intubation. Drug administration routes for adults and children: first choice IV, second choice intraosseous (IO). Vasopressors: 1 mg epinephrine every 3-5 min IV. After the third unsuccessful defibrillation amiodarone (300 mg IV), repetition (150 mg) possible. Sodium bicarbonate (50 ml 8.4%) only for excessive hyperkaliemia, metabolic acidosis, or intoxication with tricyclic antidepressants. Consider aminophylline (5 mg/kgBW). Thrombolysis during spontaneous circulation only for myocardial infarction or massive pulmonary embolism; during on-going cardiopulmonary resuscitation (CPR) only when indications of massive pulmonary embolism. Active compression-decompression (ACD-CPR) and inspiratory threshold valve (ITV-CPR) are not superior to good standard CPR. Children: Most effective improvement of outcome by prevention of full cardiorespiratory arrest. Basic life support: initially five rescue breaths, followed by chest compressions (100-120/min depth about one third of chest diameter), compression-ventilation ratio 15:2. Foreign body airway obstruction with insufficient cough: alternate back blows and chest compressions (infants), or abdominal compressions (children >1 year). Treatment of potentially reversible causes: ('4 Hs and 4 Ts') hypoxia and hypovolaemia, hypokalaemia and hyperkalaemia, hypothermia, and tension pneumothorax, tamponade, toxic/therapeutic disturbances, thrombosis (coronary/pulmonary). Advanced life support: adrenaline (epinephrine) 10 µg/kgBW IV or IO every 3-5 min. Defibrillation (4 J/kgBW; monophasic or biphasic) followed by 2 min CPR, then ECG and pulse check. Newborns: Initially inflate the lungs with bag-valve mask ventilation (p 20-40 cmHO). If heart rate remains <60/min, start chest compressions (120 chest compressions/min) and ventilation with a ratio 3:1. Maintain normothermia in preterm babies by covering them with foodgrade plastic wrap or similar. Postresuscitation phase: Early protocol-based intensive care stabilization; initiate mild hypothermia early regardless of initial cardiac rhythm [32-34°C for 12-24 h (adults) or 24 h (children); slow rewarming (<0.5°C/h)]. Consider percutaneous coronary intervention (PCI) in patients with presumed cardiac ischemia. Prediction of CPR outcome is not possible at the scene, determine neurological outcome <72 h after cardiac arrest with somatosensory evoked potentials, biochemical tests and neurological examination. Acute coronary syndrome: Even if only a weak suspicion of an acute coronary syndrome is present, record a prehospital 12-lead ECG. In parallel to pain therapy, administer aspirin (160-325 mg PO or IV) and clopidogrel (75-600 mg depending on strategy); in ST-elevation myocardial infarction (STEMI) and planned PCI also prasugrel (60 mg PO). Antithrombins, such as heparin (60 IU/kgBW, max. 4000 IU), enoxaparin, bivalirudin or fondaparinux depending on the diagnosis (STEMI or non-STEMI-ACS) and the planned therapeutic strategy. In STEMI define reperfusion strategy depending on duration of symptoms until PCI, age and location of infarction. Trauma: In severe hemorrhagic shock, definitive control of bleeding is the most important goal. For successful CPR of trauma patients a minimal intravascular volume status and management of hypoxia are essential. Aggressive fluid resuscitation, hyperventilation and excessive ventilation pressure may impair outcome in patients with severe hemorrhagic shock. Training: Any CPR training is better than nothing; simplification of contents and processes is the main aim. [ABSTRACT FROM AUTHOR]

BACKGROUND: Patients in hemorrhagic shock often require emergent airway management. Clinical experience suggests that oxygen desaturation occurs rapidly in these patients; however, data are scant. The hypothesis of this study was that increasing levels of hemorrhagic shock, varying levels of fraction of inspired oxygen (Fio2) for preoxygenation, and fluid resuscitation significantly affect the duration until critical desaturation occurs. METHODS: Fifteen pigs were studied in a hemorrhagic shock model with controlled hemorrhage (15, 30, and 45 ml/kg blood loss) and randomized to standard fluid resuscitation or no fluids. At each shock level, three apnea experiments (in randomized order) were performed after 5 min of preoxygenation at 21, 50, or 100% Fio2. After preoxygenation, ventilation was discontinued and the time to peripheral oxygen saturation of 70% or less was measured. RESULTS: During normovolemia, peripheral oxygen desaturation to less than 70% occurred after 33+/-7 s (Fio2=0.21, mean+/-SD), 89+/-12 s (Fio2=0.5), and 165+/-22 s (Fio2=1.0; P<0.001). During increasing blood loss, peripheral oxygen desaturation to Spo2 less than 70% occurred significantly (P<0.001) faster compared with normovolemia, but no effect of fluid resuscitation was observed. With 45 ml/kg blood loss, peripheral oxygen desaturation to less than 70% occurred after approximately 15 (Fio2=0.21) to 65 (Fio2=0.5) to 140 s (Fio2=1.0). CONCLUSIONS: Findings from this swine hemorrhagic shock model confirm that Fio2 and the level of hemorrhagic shock, but not fluid resuscitation, influence the rate of apneic desaturation. A five-fold increase in time until critical oxygen desaturation occurs can be achieved when preoxygenating with 100% oxygen compared with room air, underscoring the importance of adequate preoxygenation before emergent airway management. [ABSTRACT FROM AUTHOR]

The use of the classic laryngeal mask airway (classic LMA) in the prone position is controversial, but the ProSeal laryngeal mask airway (ProSeal LMA) may be more suitable as it forms a better seal and provides access to the stomach. In the following retrospective audit, we describe our experience with the insertion of and maintenance of anaesthesia with, the ProSeal LMA in 245 healthy adults in the prone position by experienced users. The technique involved (1) the patient adopting the prone position with the head to the side and the table tilted laterally; (2) pre-oxygenation to end-tidal oxygen >90%; (3) induction of anaesthesia with midazolam/alfentanil/propofol; (4) facemask ventilation (5) a single attempt at digital insertion and if unsuccessful a single attempt at laryngoscope-guided, gum elastic bougie-guided insertion; (6) gastric tube insertion; (7) maintenance of anaesthesia with sevoflurane/O/N2O; (8) volume controlled ventilation at 8-12 ml/kg; (9) emergence from anaesthesia in the supine position; and (10) removal ofthe ProSeal LMA when awake. Facemask ventilation was always successful. ProSealLMA insertion was successful in all patients: 237 with digital insertion and eight with bougie-guided insertion. Ventilation was successful in all patients. Gastric tube insertion was successful in all patients. Correctable partial airway obstruction occurred in three patients, but there was no hypoxia, hypercapnoea, displacement, regurgitation, gastric insufflation or airway reflex activation. Our findings suggest that the insertion of and maintenance of anaesthesia with the ProSeal LMA is feasible in the prone position by experienced users. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Outcome after trauma with severe hemorrhagic shock is still dismal. Since the majority of blood is present in the venous vessels, it might be beneficial to perform venous recruiting via the airway during severe hemorrhagic shock. Therefore, the purpose of our study was to evaluate the effects of negative expiratory pressure ventilation on mean arterial blood pressure, cardiac output, and short-term survival during severe hemorrhagic shock. DESIGN: Prospective study in 21 laboratory animals. SETTING: University hospital research laboratory. SUBJECTS:: Tyrolean domestic pigs. INTERVENTIONS: After induction of controlled hemorrhagic shock (blood loss approximately 45 mL/kg), 21 pigs were randomly ventilated with either zero end-expiratory pressure (0 PEEP; n = 7), 5 cm H2O positive end-expiratory pressure (5 PEEP; n = 7), or negative expiratory pressure ventilation (up to -30 cm H2O at the endotracheal tube during expiration; n = 7). MEASUREMENTS AND MAIN RESULTS: Mean (+/-sd) arterial blood pressure was significantly higher in the negative expiratory pressure ventilation swine when compared with the 0 PEEP (38 +/- 5 vs. 27 +/- 3 mm Hg; p = .001) and the 5 PEEP animals (38 +/- 5 vs. 20 +/- 6 mm Hg; p < .001) after 5 mins of the experiment. Cardiac output was significantly higher in the negative expiratory pressure ventilation swine when compared with the 0 PEEP (3.1 +/- .4 vs. 1.9 +/- .9 L/min; p = .001) and 5 PEEP animals (3.1 +/- .4 vs. 1.2 +/- .8 L/min; p < .001) after 5 mins of the experiment. All seven negative expiratory pressure ventilation animals, but only three of seven 0 PEEP animals (p = .022), survived the 120-min study period, whereas all seven of seven 5 PEEP animals were dead within 35 mins (p < .001). Limitations include that blood loss was controlled and that the small sample size limits the evaluation of survival outcome. CONCLUSIONS: When compared with pigs ventilated with either 0 PEEP or 5 PEEP, negative expiratory pressure ventilation during severe hemorrhagic shock improved mean arterial blood pressure and cardiac output. [ABSTRACT FROM AUTHOR]

The rationale for an arginine vasopressin (argipressin) infusion was put forward after it was discovered that patients in shock states might have an endogenous arginine vasopressin deficiency. Subsequently, several investigations impressively demonstrated that arginine vasopressin can successfully stabilise haemodynamics even in advanced vasodilatory shock. We report on physiological and pharmacological aspects of arginine vasopressin, and summarise current clinical knowledge on employing a continuous arginine vasopressin infusion in critically ill patients with catecholamine-resistant vasodilatory shock of different aetiologies. In view of presented experimental evidence and current clinical experience, a continuous arginine vasopressin infusion of ~2 to ~6 IU/h can be considered as a supplemental strategy to vasopressor catecholamines in order to preserve cardiocirculatory homeostasis in patients with advanced vasodilatory shock. Because data on adverse effects are still limited, arginine vasopressin should be reserved for patients in whom adequate haemodynamic stabilisation cannot be achieved with conventional vasopressor therapy or who have obvious adverse effects of catecholamines that result in further significant haemodynamic deterioration. For the same reasons, arginine vasopressin should not be used as a single, alternative vasopressor agent instead of catecholamine vasopressors. Future prospective studies will be necessary to define the exact role of arginine vasopressin in the therapy of vasodilatory shock. [ABSTRACT FROM AUTHOR]

Outcome measurements play a key role in professional CME (Continuing Medical Education). While assessment of delegate satisfaction and knowledge transfer is a common standard, it appears desirable to address higher levels of evidence. However, measurement of competence and performance is considered complex, difficult and expensive. The CIS (Change Impact Score) is a novel instrument to predict the relevance of the educational intervention to the professional performance of the physician, based on a standardised on-site self-assessment. [ABSTRACT FROM PUBLISHER]

Background: Crowd crushes with dozens or even hundreds of casualties have occurred several times at the Hajj in Saudi Arabia and also in soccer stadiums in Western Europe. As fatal accidents after human stampedes during mass events occur very rarely and are usually accompanied by many years of criminal court proceedings in order to identify underlying responsible mechanisms and culprits, it is very difficult to draw conclusions and formulate precautions from an emergency medical point of view.Methods: This study analyzed a fatal crowd crush which occurred on 4 December 1999 following the "Air & Style" snowboard contest with approximately 22,000 people attending in the Bergisel stadium in Innsbruck, Austria. Firstly, focused interviews were conducted with professional rescuers, police and physicians and secondly publicly available court records dealing with this incident in the district court of Innsbruck, Austria were analyzed.Results: During the snowboard contest 87 emergency medical technicians, 6 emergency physicians, 1 leading emergency physician, 21 policemen and 140 security personnel were present. Following the accident additionally some 100 emergency medical technicians, 36 emergency medical service vehicles and 4 physician-staffed emergency medical service vehicles responded to the scene. The deadly crowd crush resulting in 6 fatalities, 4 patients still in a vegetative state and 38 injured, was due to a severe crowd accumulation at one stadium exit, which was not recognized and dispersed in time. Construction of the exit in line with darkness, steep slope and slippery surface contributed adversely to this dangerous situation, although panic did not occur at any time.Conclusions: Unfortunately, there is no patent remedy to completely prevent fatal accidents by a crowd crush at mass events. If planning is initiated early, sufficient material and personnel reserves are kept in reserve and despite conflicting interests of the organizers, the host community, security, police and emergency medical services, a joint concept is designed and followed, the risk of a severe incident can be kept to a minimum. Each involved party including the spectators have to be aware of their responsibility in order to contribute to the success and safety of the mass event. A comprehensive and critical review of all facts and implementation of conclusions implies a time and financial burden but has a positive impact on the success and safety of mass events. [ABSTRACT FROM AUTHOR]

Background: Suicide rates of male and female physicians are about 3-5 times higher compared with the general public. Detailed studies about medical student suicides in the United States exist but similar current data from German speaking countries are lacking.Methods: In this study suicide among medical students in Germany, Austria and Switzerland was analyzed using Medline and Google search engines and information from insurance companies, public institutions, statistical agencies and leading scientists in Germany, Austria and Switzerland was requested. The incidence of suicide among medical students at the Medical University of Innsbruck was also examined.Results: In publications from German speaking countries some medical student suicides are mentioned but current statistics were not available. Between 2006 and 2011 the Tyrolean State Police in Austria registered 14 suicides by students of all disciplines. At Innsbruck Medical University (approximately 2,800 medical students) it was found that 6 medical students committed suicide between June 2007 and June 2012 (rate 36 per 100,000).Conclusions: The suicide risk of medical students at the Medical University of Innsbruck appears to be increased. Because of a lack of comparable data it is not possible to show whether these observations can be extrapolated to other universities. It appears that there was no single special event which triggered suicide by the medical students but a combination of individual risk factors and the environment was involved. However, this problem receives insufficient attention. [ABSTRACT FROM AUTHOR]

Background: Due to SARS-CoV‑2 respiratory failure, prone positioning of patients with respiratory and hemodynamic instability has become a frequent intervention in intensive care units (ICUs), and even in patients undergoing transfer in an ambulance or helicopter. It has become increasingly important how to perform safe and effective CPR in prone position, achieving both an optimal outcome for the patient and optimal protection of staff from infection.Materials and Methods: We conducted feasibility tests to assess the effects of CPR with an automatic load-distributing band (AutoPulse™) in prone position and discussed different aspects of mechanical chest compression (mCPR) in prone position.Results: In supine position, AutoPulse™ generated a constant pressure depth of 3cm at a frequency of 84/min. In prone position, AutoPulse™ generated a constant pressure depth of 2.6cm at a frequency of 84/min.Conclusion: We found mCPR to be feasible in manikins in both prone and supine positions. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Sublingual Microcirculatory Flow Is Impaired by the Vasopressin-Analogue Terlipressin in a Patient With Catecholamine-Resistant Septic Shock," by E.C. Boerma published in the 2005 issue of the periodical "Acta Anaesthesiology Scandinavica."

Abstract: Solid mixing processes are usually described with the help of the dispersion model. Dispersion is based on stochastic particle movements which are responsible for the concentration balance between the different components. For simplification, homogeneity adjustment of the mixture is mostly described by the axial mixing direction. In this research, the one-dimensional dispersion model is extended to three dimensions. A modified sampling strategy shows how the dispersion model can be applied to the mixing process in axial, radial, and tangential directions. Small differences between axial and radial mixing efficiencies are observed for the 45°-configuration of the mixing tool, whereas a higher mixing efficiency is detected in tangential direction. The 90°-configuration behaves differently. Anisotropic dispersion coefficients are determined for the different mixing tool configurations. These indicate that particle mobility in axial direction is lowest. [Copyright &y& Elsevier]

Aim: This study assessed the publication performance of university departments of anesthesiology in Austria, Germany and Switzerland. The number of publications, original articles, impact factors and citations were evaluated.Material and Methods: A search was performed in PubMed to identify publications related to anesthesiology from 2001 to 2010. All articles from anesthesiology journals listed in the fields of anesthesia/pain therapy, critical care and emergency medicine by the "journal citation report 2013" in Thomson Reuters ISI web of knowledge were included. Articles from non-anaesthesiology journals, where the stem of the word anesthesia (anes*, anaes*, anäst*, anast*) appears in the affiliation field of PubMed, were included as well. The time periods 2001-2005 and 2006-2010 were compared. Articles were allocated to university departments in Austria, Germany and Switzerland via the affiliation field.Results: A total of 45 university departments in Austria, Germany and Switzerland and 125,979 publications from 2,863 journals (65 anesthesiology journals, 2,798 non-anesthesiology journals) were analyzed. Of the publications 23 % could not be allocated to a given university department of anesthesiology. In the observation period the university department of anesthesiology in Berlin achieved most publications (n = 479) and impact points (1,384), whereas Vienna accumulated most original articles (n = 156). Austria had the most publications per million inhabitants in 2006-2010 (n=50) followed by Switzerland (n=49) and Germany (n=35). The number of publications during the observation period decreased in Germany (0.5 %), Austria (7 %) and Switzerland (8 %). Tables 2 and 4-8 of this article are available at Springer Link under Supplemental.Conclusions: The research performance varied among the university departments of anesthesiology in Germany, Austria and Switzerland whereby larger university departments, such as Berlin or Vienna published most. Publication output in Germany, Austria and Switzerland has decreased. Data processing in PubMed should be improved. [ABSTRACT FROM AUTHOR]

Aim: This study assessed the publication performance of university departments of anesthesiology in Austria, Germany and Switzerland. The number of publications, original articles, impact factors and citations were evaluated. Material and methods: A search was performed in PubMed to identify publications related to anesthesiology from 2001 to 2010. All articles from anesthesiology journals listed in the fields of anesthesia/pain therapy, critical care and emergency medicine by the 'journal citation report 2013' in Thomson Reuters ISI web of knowledge were included. Articles from non-anaesthesiology journals, where the stem of the word anesthesia (anes*, anaes*, anäst*, anast*) appears in the affiliation field of PubMed, were included as well. The time periods 2001-2005 and 2006-2010 were compared. Articles were allocated to university departments in Austria, Germany and Switzerland via the affiliation field. Results: A total of 45 university departments in Austria, Germany and Switzerland and 125,979 publications from 2,863 journals (65 anesthesiology journals, 2,798 non-anesthesiology journals) were analyzed. Of the publications 23 % could not be allocated to a given university department of anesthesiology. In the observation period the university department of anesthesiology in Berlin achieved most publications (n = 479) and impact points (1,384), whereas Vienna accumulated most original articles (n = 156). Austria had the most publications per million inhabitants in 2006-2010 (n=50) followed by Switzerland (n=49) and Germany (n=35). The number of publications during the observation period decreased in Germany (0.5 %), Austria (7 %) and Switzerland (8 %). Tables 2 and 4-8 of this article are available at Springer Link under Supplemental. Conclusions: The research performance varied among the university departments of anesthesiology in Germany, Austria and Switzerland whereby larger university departments, such as Berlin or Vienna published most. Publication output in Germany, Austria and Switzerland has decreased. Data processing in PubMed should be improved. [ABSTRACT FROM AUTHOR]

Background: Crowd crushes with dozens or even hundreds of casualties have occurred several times at the Hajj in Saudi Arabia and also in soccer stadiums in Western Europe. As fatal accidents after human stampedes during mass events occur very rarely and are usually accompanied by many years of criminal court proceedings in order to identify underlying responsible mechanisms and culprits, it is very difficult to draw conclusions and formulate precautions from an emergency medical point of view. Methods: This study analyzed a fatal crowd crush which occurred on 4 December 1999 following the 'Air & Style' snowboard contest with approximately 22,000 people attending in the Bergisel stadium in Innsbruck, Austria. Firstly, focused interviews were conducted with professional rescuers, police and physicians and secondly publicly available court records dealing with this incident in the district court of Innsbruck, Austria were analyzed. Results: During the snowboard contest 87 emergency medical technicians, 6 emergency physicians, 1 leading emergency physician, 21 policemen and 140 security personnel were present. Following the accident additionally some 100 emergency medical technicians, 36 emergency medical service vehicles and 4 physician-staffed emergency medical service vehicles responded to the scene. The deadly crowd crush resulting in 6 fatalities, 4 patients still in a vegetative state and 38 injured, was due to a severe crowd accumulation at one stadium exit, which was not recognized and dispersed in time. Construction of the exit in line with darkness, steep slope and slippery surface contributed adversely to this dangerous situation, although panic did not occur at any time. Conclusions: Unfortunately, there is no patent remedy to completely prevent fatal accidents by a crowd crush at mass events. If planning is initiated early, sufficient material and personnel reserves are kept in reserve and despite conflicting interests of the organizers, the host community, security, police and emergency medical services, a joint concept is designed and followed, the risk of a severe incident can be kept to a minimum. Each involved party including the spectators have to be aware of their responsibility in order to contribute to the success and safety of the mass event. A comprehensive and critical review of all facts and implementation of conclusions implies a time and financial burden but has a positive impact on the success and safety of mass events. [ABSTRACT FROM AUTHOR]

Background: Suicide rates of male and female physicians are about 3-5 times higher compared with the general public. Detailed studies about medical student suicides in the United States exist but similar current data from German speaking countries are lacking. Methods: In this study suicide among medical students in Germany, Austria and Switzerland was analyzed using Medline and Google search engines and information from insurance companies, public institutions, statistical agencies and leading scientists in Germany, Austria and Switzerland was requested. The incidence of suicide among medical students at the Medical University of Innsbruck was also examined. Results: In publications from German speaking countries some medical student suicides are mentioned but current statistics were not available. Between 2006 and 2011 the Tyrolean State Police in Austria registered 14 suicides by students of all disciplines. At Innsbruck Medical University (approximately 2,800 medical students) it was found that 6 medical students committed suicide between June 2007 and June 2012 (rate 36 per 100,000). Conclusions: The suicide risk of medical students at the Medical University of Innsbruck appears to be increased. Because of a lack of comparable data it is not possible to show whether these observations can be extrapolated to other universities. It appears that there was no single special event which triggered suicide by the medical students but a combination of individual risk factors and the environment was involved. However, this problem receives insufficient attention. [ABSTRACT FROM AUTHOR]

The best chance of survival with a good neurological outcome after cardiac arrest is afforded by early recognition and high-quality cardiopulmonary resuscitation (CPR), early defibrillation of ventricular fibrillation (VF), and subsequent care in a specialist center. Compression-only CPR should be used by responders who are unable or unwilling to perform mouth-to-mouth ventilations. After the first defibrillator shock, further rhythm checks and defibrillation attempts should be performed after 2 min of CPR. The underlying cause of cardiac arrest can be identified and treated during CPR. Drugs have a limited effect on long-term outcomes after cardiac arrest, although epinephrine improves the success of resuscitation, and amiodarone increases the success of defibrillation for refractory VF. Supraglottic airway devices are an alternative to tracheal intubation, which should be attempted only by skilled rescuers. Care after cardiac arrest includes controlled reoxygenation, therapeutic hypothermia for comatose survivors, percutaneous coronary intervention, circulatory support, and control of blood-glucose levels and seizures. Prognostication in comatose survivors of cardiac arrest needs a careful, multimodal approach using clinical and electrophysiological assessments after at least 72 h. [ABSTRACT FROM AUTHOR]

Apart from misdiagnosis, the Lazarus phenomenon, a spontaneous return of circulation after cardiac arrest, is a potential cause for false positive death certification. Because of medicolegal consequences and thus a negative publication bias, the incidence of false positive death certification is unknown. As a false positive death certification results in criminal prosecution and thus media interest, numerous media archives in Germany, Austria and Switzerland were searched for such reports. A total of nine cases of false positive death certification in these three countries were identified since the early 1990s of which eight occurred in an emergency medical service system setting. Apart from a lack of diligence of emergency physicians, a Lazarus phenomenon could be the reason for such incidents. As definite signs of death will not have developed only a few minutes after stopping CPR it might be difficult for an emergency physician to definitely certify a patient's death in an out-of-hospital setting with 100% safety. Thus, prehospital death certification poses a risk of error and subsequent legal prosecution of the emergency physician, as a Lazarus phenomenon may still occur in this phase. Delegation of death certification from emergency physicians to qualified physicians in a follow-up examination might increase both legal safety for emergency physicians in the field and patient safety. [ABSTRACT FROM AUTHOR]

To evaluate the satisfaction of clinical scientists when submitting study drafts to an ethics committee/clinical trials register (CLINICALTRIALS, EUDRACT, ISRCTN) we conducted an online survey of 240 authors publishing in anesthesia/critical care medicine (A) or in major general medical (M) journals from January to December 2007. No statistical difference between groups A and M was seen with regard to the number of studies submitted to ethics committees or registered in various clinical trials registers. On a visual analogue scale (VAS -10 to +10), the subjective evaluation of the effort required to submit a study draft to an ethics committee or enter it in a clinical trials register produced almost only negative grades in both groups. The mean different perceptions ranged from -3.5 to -0.1 in group A and from -4.4 to -0.2 (except for +0.1 and 1.9 in 2 subgroups) in group M. The authors in both groups gave a positive score to the better transparency in scientific research resulting from introduction of the clinical trials registers (+2.4 in group A, +4.8 in group M). The results of our study indicate widespread author dissatisfaction when submitting a clinical trial to ethics committees or clinical trials registers. [ABSTRACT FROM AUTHOR]

Background: Arginine vasopressin (AVP) is increasingly being used to treat advanced vasodilatory shock states due to sepsis, systemic inflammatory response syndrome (SIRS) or after cardiac surgery. There are currently no data available on long-term survival.Patients and Methods: Demographic and clinical data, length of intensive care unit (ICU) stay, 1-year survival and causes of death after ICU discharge of 201 patients who received AVP because of advanced vasodilatory shock were collected retrospectively.Results: The intensive care unit (ICU) survival rate was 39.8% (80 out of 201 patients). After ICU discharge 13 out of the 80 patients died within 1 year resulting in a 1-year survival rate of 33.3% (67 out of 201 patients). In nine patients, the cause of death was attributed to the same disease that led to ICU admission. One-year survival of patients with shock following cardiac surgery (42.1%) was higher than in patients suffering from SIRS (22.6%, p=0.005) or sepsis (28.3%, p=0.06).Conclusions: If advanced vasodilatory shock can be reversed with AVP and patients can be discharged alive from the ICU, 1-year survival rates appear to be reasonable despite severe multi-organ dysfunction syndrome (MODS). [ABSTRACT FROM AUTHOR]

The optimal strategy of stabilizing hemodynamic function in uncontrolled traumatic hemorrhagic shock states is unclear. Although fluid replacement is established in controlled hemorrhagic shock, its use in uncontrolled hemorrhagic shock is controversial, because it may worsen bleeding. In the refractory phase of severe hemorrhagic shock, arginine vasopressin has been shown to be beneficial in selected cases due to an increase in arterial blood pressure, shift of blood away from a subdiaphragmatic bleeding site toward the heart and brain, and decrease in fluid-resuscitation requirements. Especially in patients with severe traumatic brain injury, rapid stabilization of cardiocirculatory function is essential to ensure adequate brain perfusion, thus, to prevent neurologic damage and to improve outcome. In addition, despite wide distribution of highly developed and professional emergency medical systems in western industrialized countries, survival chances of patients with uncontrolled traumatic hemorrhagic shock in the preclinical setting are still poor. [ABSTRACT FROM AUTHOR]

Arginine-vasopressin (AVP) can successfully stabilize hemodynamics in patients with advanced vasodilatory shock. It has been suggested that inhibition of cytokine-induced nitric oxide production may be an important mechanism underlying AVP-induced vasoconstriction. Therefore, serum concentrations of nitrite/nitrate (NOx), the stable metabolite of nitric oxide, were measured in patients suffering from advanced vasodilatory shock treated with either AVP in combination with norepinephrine (NE) or NE alone. This trial was a separate study arm of a previously published prospective, randomized, controlled study on the effects of AVP in advanced vasodilatory shock. Thirty-eight patients were prospectively randomized to receive a combined infusion of AVP (4 U h−1) and NE, or NE infusion alone. Serum NOx concentrations were measured at baseline, 24, and 48 h after randomization. The increase in mean arterial pressure during the first hour after study enrollment was documented in all patients. No difference in NOx concentrations was found between groups throughout the study period. AVP patients demonstrated a significantly greater increase in mean arterial pressure than NE patients (22 ± 10 vs. 5 ± 9 mmHg; P < 0.001). The magnitude of pressure response to AVP was not correlated with NOx concentrations before start of AVP infusion (Pearson's correlation coefficient, −.009; P = 0.971). Cardiovascular effects of AVP infusion in advanced vasodilatory shock are not mediated by a clinically relevant reduction in serum NOx concentrations. Therefore, hemodynamic improvement of patients in advanced vasodilatory shock during continuous infusion of AVP has to be attributed to other mechanisms than inhibition of nitric oxide synthase. In addition, the magnitude of pressure response to AVP is not correlated with baseline concentrations of NOx. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the endocrinologic response to a combined arginine vasopressin and norepinephrine (AVP/NE) infusion in advanced vasodilatory shock, and to examine the relationship between baseline plasma AVP concentrations and the hemodynamic response to AVP.Design: Preliminary, prospective, randomized, controlled clinical study.Setting: Twenty-three-bed general and surgical intensive care unit.Patients: Thirty-eight patients with advanced vasodilatory shock. Hemodynamic and laboratory data of 34 patients have already been presented in a recently published prospective, randomized, controlled study.Interventions: Continuous AVP (4 units/hr) and NE infusion in study patients; NE infusion only in control patients.Measurements and Main Results: At baseline, 24 hrs, and 48 hrs after randomization, plasma concentrations of AVP, adrenocorticotropic hormone, cortisol, renin, angiotensin II, aldosterone, prolactin, endothelin I, and atrial natriuretic factor were determined. Hemodynamic variables were recorded at baseline and 1, 12, and 24 hrs after randomization. Linear mixed effects models were used to test for differences between groups. The relationship between AVP plasma concentrations and hemodynamic response to AVP was analyzed using linear regression analyses. AVP/NE patients exhibited significantly higher AVP (p <.001) and prolactin (p <.001) plasma concentrations during the study period; there were no significant differences in plasma concentrations of other hormones. No significant correlation was detected between plasma AVP concentrations and the increase in mean arterial pressure after 1 hr (Pearson's correlation coefficient =.134, p =.584) and after 24 hrs (Pearson's correlation coefficient = -.198, p =.417). There were further no correlations between AVP plasma concentrations and the 24-hr response to AVP therapy in heart rate (Pearson's correlation coefficient = -.065, p =.791), stroke volume index (Pearson's correlation coefficient = -.106, p =.687), and NE requirements (Pearson's correlation coefficient =.04, p =.869).Conclusions: The preliminary results of this study indicate that a combined AVP and NE infusion increases prolactin plasma concentrations in advanced vasodilatory shock. Hemodynamic effects of AVP infusion are independent of baseline plasma AVP concentrations. [ABSTRACT FROM AUTHOR]

Background: Complete upper airway obstruction by a foreign body is a dramatic and acute emergency situation, and can result in rapid development of hypoxia, circulatory arrest and death. Special Magill pliers with an adjustable video optical system have been developed for airway inspection to facilitate efforts to remove foreign bodies causing obstruction of the upper airway.Objective: To remove a simulated airway foreign body from a cardiopulmonary resuscitation (CPR) manikin, either with normal Magill pliers or with the newly designed video Magill pliers.Material and Methods: After a brief introduction, 81 kindergarten teachers, 51 pupils (age 10-14 years) and 52 prospective emergency physicians were asked to remove a 2 × 2 "Lego" brick from the hypopharynx of a CPR manikin using either standard Magill pliers or the newly designed video Magill pliers. The formal hypothesis was that there would be no differences between the methods. Successful removal was defined as when the first removal attempt resulted in the Lego brick passing beyond the teeth of the manikin within 60s.Results: The use of the video Magill pliers resulted in significantly higher success rates in removal of the simulated foreign airway body within 60 s compared to standard Magill pliers in kindergarten teachers (84% vs. 30%, p < 0.0001), pupils (84% vs. 18%, p < 0.0001) and prospective emergency physicians (92% vs. 40%, p < 0.0001). The time needed for removing the foreign airway body was significantly shorter in groups using the video Magill pliers (kindergarten teachers 29 ± 18s vs. 45 ± 19 s, pupils 29 ± 18s vs. 54 ± 14 s, and prospective emergency physicians 33 ± 18s vs. 45 ± 20 s; p < 0.0001). In an analogue points system (from 1 very simple to 10 extremely complicated), the user friendliness of the video Magill pliers was judged to be significantly higher than the standard Magill pliers (2.8 ± 1.6 vs. 7.8 ± 2.7 kindergarten teachers, 2.0 ± 1.3 vs. 7.2 ± 2.5 pupils and 3.2 ± 2.2 vs. 4.9 ± 3.1 prospective emergency physicians, p < 0.0001). Visibility of the airway foreign body was estimated to be significantly better employing the video Magill pliers compared to the standard Magill pliers (1.9 ± 1.4 vs. 9.8 ± 0.6 kindergarten teachers, pupils 1.3 ± 0.6 vs. 9.2 ± 1.6, prospective emergency physicians 2.3 ± 1.8 vs. 9.1 ± 2.3, p < 0.0001).Conclusion: In this study kindergarten teachers, pupils (aged 10-14 years) and prospective emergency physicians had higher success rates in less time and reported better user friendliness and visibility using video Magill pliers compared to standard Magill pliers for removing a simulated foreign body from a CPR manikin airway. [ABSTRACT FROM AUTHOR]

Background: Failed airway management is the major contributor for anaesthesia-related morbidity and mortality. Cannot-intubate-cannot-ventilate scenarios are the most critical emergency in airway management, and belong to the worst imaginable scenarios in an anaesthetist's life. In such situations, apnoeic oxygenation might be useful to avoid hypoxaemia. Anaesthesia guidelines recommend careful preoxygenation and application of high flow oxygen in difficult intubation scenarios to prevent episodes of deoxygenation. In this study, we evaluated the decrease in oxygen concentration in a model when using different strategies of oxygenation: using a special oxygenation laryngoscope, nasal oxygen, nasal high flow oxygen, and control.Methods: In this experimental study we compared no oxygen application as a control, standard pure oxygen application of 10 l·min- 1 via nasal cannula, high flow 90% oxygen application at 20 l·min- 1 using a special nasal high flow device, and pure oxygen application via our oxygenation laryngoscope at 10 l·min- 1. We preoxygenated a simulation lung to 97% oxygen concentration and connected this to the trachea of a manikin model simulating apnoeic oxygenation. Decrease in oxygen concentration in the simulation lung was measured continuously for 20 min.Results: Oxygen concentration in the simulation lung dropped from 97 ± 1% at baseline to 40 ± 1% in the no oxygen group, to 80 ± 1% in the standard nasal oxygen group, and to 73 ± 2% in the high flow nasal oxygenation group. However, it remained at 96 ± 0% in the oxygenation laryngoscope group (p < 0.001 between all groups).Conclusions: In this technical simulation, oxygenation via oxygenation laryngoscope was more effective than standard oxygen insufflation via nasal cannula, which was more effective than nasal high flow insufflation of 90% oxygen. [ABSTRACT FROM AUTHOR]

Background: An intravenous line is needed to administer anaesthesia, particularly when total intravenous anaesthesia (TIVA) is performed. A disadvantage of TIVA is that the intravenous concentration of anaesthetics cannot be easily measured compared with volatile anaesthetics. If a three-way stopcock is accidentally unscrewed, TIVA drugs cannot reach the patient's veins, thus resulting in inadequate anaesthesia levels, possibly resulting in awareness. We therefore measured the required torque to open five different brands of three-way stopcocks in an attempt to make an intravenous-line including all elements safer. Methods: The torque required to open one, two or three three-way stopcocks being connected in a perpendicular manner was measured with a biaxial servo hydraulic material testing machine. Results: The force required to open three-way stopcocks connected with an intravenous catheter ranged in five different stopcock models from 5.03±0.75 to 2.21±0.51 N respectively; with two three-way stopcocks from 2.68±0.42 to 1.31±0.59 N, respectively, and with three three-way stopcocks from 1.29±0.27 to 0.82±0.05 N, respectively. Conclusion: Turning a three-way stopcock to become loose with possibly leaking drugs requires minimal amounts of force and decreases significantly if not connected in-line. [ABSTRACT FROM AUTHOR]

Recent animal data have challenged the common clinical practice to avoid vasopressor drugs during hypothermic cardiopulmonary resuscitation (CPR) when core temperature is below 30 degrees C. In this report, we describe the case of a 19-year-old-female patient with prolonged, hypothermic, out-of-hospital cardiopulmonary arrest after near drowning (core temperature, 27 degrees C) in whom cardiocirculatory arrest persisted despite 2 mg of intravenous epinephrine; but, immediate return of spontaneous circulation occurred after a single dose (40 IU) of intravenous vasopressin. The patient was subsequently admitted to a hospital with stable haemodynamics, and was successfully rewarmed with convective rewarming, but died of multiorgan failure 15 h later. To the best of our knowledge, this is the first report about the use of vasopressin during hypothermic CPR in humans. This case report adds to the growing evidence that vasopressors may be useful to restore spontaneous circulation in hypothermic cardiac arrest patients prior to rewarming, thus avoiding prolonged mechanical CPR efforts, or usage of extracorporeal circulation. It may also support previous experience that the combination of both epinephrine and vasopressin may be necessary to achieve the vasopressor response needed for restoration of spontaneous circulation, especially after asphyxial cardiac arrest or during prolonged CPR efforts. [ABSTRACT FROM AUTHOR]

Background: There is a risk of terror attacks in the Federal Republic of Germany, which might increase in the future. A timely comprehensive strategy for treatment and care of a large number of casualties helps minimize chaos and improve the outcome of patients. Adequate training is vital for successful implementation of an emergency plan. Therefore, the effectiveness of training should be assessed and evaluated; however, data collection capabilities for training events are extremely limited, so that publications on the topic are almost impossible to find.Objective: This study aimed to collect data from a simulated terrorist attack in order to draw conclusions from a clinical point of view concerning the improvement of preclinical and clinical management, taking interface problems into consideration.Material and Methods: On 19 October 2019 the Ministry of the Interior, Digitalization and Migration of Baden-Württemberg conducted a large-scale simulation of a terrorist attack in the city center of Constance, called the Baden-Württemberg counterterrorism exercise (BWTEX). The simulation included an explosion of a car bomb as well as the use of firearms by terrorists. The large scale of the simulation with the high number of participants in combination with close cooperation between military and civil forces was unprecedented. The police force, the armed forces, civil protection forces, air rescue teams and staff from Constance, Friedrichshafen and Sigmaringen regional hospitals in southwest Germany worked together to treat simulated injuries to victims of the attack. The following parameters were recorded when the injured patients arrived at the hospital: prehospital triage time, prehospital triage score, initial treatment and quality of documentation on site as well as triage time, triage score, injury severity scale (ISS) score based on the specified injury pattern, treatment, and quality of documentation on hospital arrival.Results: Out of a total of 84 "injured patients" 55 were admitted to hospital and 80% were triaged at the scene. Injured patients of triage category 1 (TK1 red: life-threatening injury, immediate treatment) arrived at the hospital 198 ± 50 min after the attack, injured patients of triage category 2 (TK2 yellow: severely injured, urgent treatment) after 131 ± 44 min and injured patients of triage category 3 (TK3 green: slightly injured, non-urgent treatment) arrived after 157 ± 46 min. There was no significant difference in terms of arrival time at the hospital between the triage scores (r = 0.2) or between the ISS scores (r = 0.43). The authors assume that approximately 44% of TK1 patients would have died due to avoidable time delays. Prehospital medical documentation was insufficient in 78% and insufficient in 65% in the hospitals.Conclusion: A mass casualty incident resulting from a terrorist attack differs greatly from a conventional mass casualty incident. The scene of the attack has to be evacuated as quickly as possible, which means that a large number of patients arrive untreated at the nearest hospitals. The setting up of treatment facilities in city centers and areas close to the city seems to be counterproductive because the time delay may result in higher mortality rates of victims. The particularities of mass casualties caused by a terrorist attack have to be incorporated into terrorist attack training. [ABSTRACT FROM AUTHOR]

Background: This study presents a count of publications and citations for all articles published by university Departments of Anaesthesiology in Germany, Austria and Switzerland between 2011 and 2015. The results were compared with former analyses of these countries from 2001-2010 as well as similar international studies.Methods: We performed a PubMed search based on PERL-scripts for all publications originating from university Departments of Anaesthesiology in Germany, Austria and Switzerland between 2011 and 2015. According to their author's affiliation, articles were assigned to their affiliated university department. Publications were considered an original article if the category of publication was classified as original research in PubMed. Predatory journals were omitted by using PubMed-listed journals only. Data of citations was retrieved from Thomson Reuter's ISI Web of Knowledge. The following indicators were reported: the number of publications and original articles (counting each author and first authors only) and the share of original articles out of all publications. With regard to citations, we reported the overall number, the percentage of publications, which were cited at least once and the median of citations per publication and per original article as well as the calculated h-index.Results: The 47 university Departments of Anaesthesiology published 4.697 articles between 2011 and 2015, which make up 89% of all anaesthesiology research originating from Germany, Austria and Switzerland (overall 5.284 publications). Of these, 1.037 (22%) were classified as original articles. Considering only articles with first authors, equalizing a change of PubMed's affiliation field policy in 2012 to compare the numbers with previous periods, 3.709 publications and 821 original articles were published. 90% of all publications and 96% of original articles, respectively, were cited at least once. Publications were cited six times, while original articles were cited nine times. The university department of Anaesthesiology in Zurich published most (n = 245), while most original articles were published in Vienna (n = 77). The highest share of original articles was achieved by Vienna (37%). Publications from Berlin - Benjamin Franklin and Jena (11 citations per publication) and original articles from Essen (23,5 citations per original article) achieved the highest citation rates.Discussion: In contrast to the worldwide increasing trend, the number of publications of the university Departments of Anaesthesiology in Germany, Austria and Switzerland stagnated. The share of original articles out of all publications continues to decline in comparison to 2001-2010 (-6%). Despite this, original articles were cited more frequently and thus had a higher value for the scientific community. The reasons of the decrease in the number of original articles remain unclear and require further investigation to reverse this negative trend.Conclusion: Strategies to foster academic work in anaesthesiology in Germany, Austria and Switzerland are required. [ABSTRACT FROM AUTHOR]

The aim of this study was to analyse publication trends from the anaesthetic literature of the G-20 countries. We performed a literature search in Medline to identify articles related to anaesthetic departments published between 2001 and 2015, by specific G-20 countries according to the affiliation field of the authors, and to three time periods 2001-2005, 2006-2010 and 2011-2015. The number of articles, number of original articles (vs. reviews, editorials or correspondence), articles per million inhabitants, and citations per article were analysed. In total, 96,920 articles were published between 2001 and 2015 in 74 anaesthetic and in 4117 non-anaesthetic journals, with an increase of +104% absolute (i.e. from 23,028 in 2001-05 to 46,887 articles ìn 2010-15) and +85% as articles per million inhabitants. Similarly, the number of original articles increased by 21%, but the anaesthetic specialty's share of original articles (as a proportion of total articles in biomedicine) decreased from 31% in 2001-2005 to 19% in 2011-2015 (-38%). The USA published most articles (2011-15 16,016; 31% of total), second came the EU as a whole and third Japan (from 2001 to 2005) or Germany (2006-2010) until 2011-2015 when China took over the third rank. In 2011-2015, Canada published most articles per million inhabitants (68.7 articles/million inhabitants). China and India exhibited the most publication growth 11- and 9-fold, respectively, and are now among the top five countries for the number of published articles. [ABSTRACT FROM AUTHOR]

In Germany, Austria and Switzerland, anesthesiologists are the second largest group of physicians in hospitals, but this does not correspond to the amount of anesthesiology teaching that medical students receive in medical schools. Accordingly, the chances of medical students recognizing anesthesiology as a promising personal professional career are smaller than in other disciplines with large teaching components. Subsequent difficulties to recruit anesthesiology residents are likely, although many reasons support anesthesiology as a professional career.Traditional strategies to teach medical students in anesthesiology in medical school consist of airway management or cardiopulmonary resuscitation attempts in manikins. Anesthesiology is a complex interaction consisting of anatomy, physiology, pharmacology, clinical evaluation, experience, knowledge, and manual skills. While some medical schools offer teaching in high fidelity simulators, clinical teaching in the operating room is often limited. When medical students opt for a clinical rotation in anesthesiology, there is a chance to demonstrate the fascinating world of anesthesiology, but this chance has to be utilized carefully by anesthesiologists, as young talents have to be discovered, supported, and challenged.We have put together a short guide for medical students for a clinical rotation in anesthesiology in adults in order to generate basic knowledge and interest in anesthesiology as well as a sense of achievement. Basic knowledge about premedication, induction, maintenance and strategies for anesthesia is discussed. Further, the most important anesthesia drugs are discussed and manual skills, such as intravenous cannulation, mask ventilation, intubation, and regional anesthesia are featured with QR-code based video illustrations on a smartphone or personal computer. We did not discuss possible local mannerism and special patient groups (e. g., children, special medical history), local guidelines, or standard operating procedures.Medical students can be inspired by anesthesiology when not simply told about the tools of the trade and strategies, but instead by gaining knowledge and clinical skills that render a sense of achievement, likely during a clinical rotation into anesthesiology. A short theoretical instruction of anesthesiology enables rapid and targeted orientation even before a clinical rotation. Whether this subsequently results in a higher recruiting chance is currently unknown. [ABSTRACT FROM AUTHOR]

Injuries to blood vessels near the heart can quickly become life-threatening and include arterial injuries during central venous puncture, which can lead to hemorrhagic shock. We report 6 patients in whom injury to the subclavian artery and vein led to life-threatening complications. Central venous catheters are associated with a multitude of risks, such as venous thrombosis, air embolism, systemic or local infections, paresthesia, hemothorax, pneumothorax, and cervical hematoma, which are not always immediately discernible. The subclavian catheter is at a somewhat lower risk of catheter-associated sepsis and symptomatic venous thrombosis than approaches via the internal jugular and femoral veins. Indeed, access via the subclavian vein carries a substantial risk of pneumo- and hemothorax. Damage to the subclavian vein or artery can also occur during deliberate and inadvertent punctures and result in life-threatening complications. Therefore, careful consideration of the access route is required in relation to the patient and the clinical situation, to keep the incidence of complications as low as possible. For catheterization of the subclavian vein, puncture of the axillary vein in the infraclavicular fossa is a good alternative, because ultrasound imaging of the target vessel is easier than in the subclavian vein and the puncture can be performed much further from the lung. [ABSTRACT FROM AUTHOR]

Injuries to blood vessels near the heart can quickly become life-threatening and include arterial injuries during central venous puncture, which can lead to hemorrhagic shock. We report 6 patients in whom injury to the subclavian artery and vein led to life-threatening complications. Central venous catheters are associated with a multitude of risks, such as venous thrombosis, air embolism, systemic or local infections, paresthesia, hemothorax, pneumothorax, and cervical hematoma, which are not always immediately discernible. The subclavian catheter is at a somewhat lower risk of catheter-associated sepsis and symptomatic venous thrombosis than approaches via the internal jugular and femoral veins. Indeed, access via the subclavian vein carries a substantial risk of pneumo- and hemothorax. Damage to the subclavian vein or artery can also occur during deliberate and inadvertent punctures and result in life-threatening complications. Therefore, careful consideration of the access route is required in relation to the patient and the clinical situation, to keep the incidence of complications as low as possible. For catheterization of the subclavian vein, puncture of the axillary vein in the infraclavicular fossa is a good alternative, because ultrasound imaging of the target vessel is easier than in the subclavian vein and the puncture can be performed much further from the lung. [ABSTRACT FROM AUTHOR]

This report describes a case of sudden cardiac arrest and subsequent attempted cardiopulmonary resuscitation of an 11-year-old child on the shores of a swimming lake. Reports of eyewitnesses excluded the obviously suspected diagnosis of a drowning accident. The result of the autopsy was sudden cardiac death due to a congenital coronary anomaly (abnormal left coronary artery, ALCA). Favored by vigorous physical activity, this anomaly can lead to malignant arrhythmias because the ectopic coronary artery with its intramural course through the aortic wall is compressed during every systole. This pathology was not known to the boy or his family; in fact he liked sports but had suffered of a syncope once which was not followed up. Without a strong suspicion it is difficult to diagnose a coronary artery anomaly and it is often missed even in college athletes. Tragically, sudden cardiac arrest may be the first symptom of an undiagnosed abnormal coronary artery. Following syncope or chest pain during exercise with a normal electrocardiogram (ECG) cardiac imaging, such as computed tomography (CT) or angiography should be initiated in order to enable surgical repair of an abnormal coronary artery. [ABSTRACT FROM AUTHOR]