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Background: Management of critically ill non-trauma patients in the resuscitation room of an emergency department (ED) is very challenging, and it is difficult to identify patients with a higher risk of death. Previous studies have shown that lactate indices can predict survival for selected diseases and syndromes., Objective: As reported for other patient populations, we set out to determine whether admission lactate or lactate dynamics (LD) within 24 h can predict 30-day mortality in unselected critically ill non-traumatic patients., Methods: In this retrospective study over a 1-year period, admission lactate, time weighted average lactate (Lac TW ) and LD of all critically ill adult patients admitted from ED to intensive care unit were analyzed. A linear regression model was implemented to estimate lactate data 1 h after admission., Results: The admission lactate, Lac TW , and LD within 24 h were analyzed from 392 critically ill patients. The overall 30-day mortality rate was around 29%. Admission lactate (4.1 ± 4.0 mmol/L vs. 6.6 ± 6.1 mmol/L; p < 0.01) and Lac TW (1.8 ± 1.7 mmol/L vs. 4.1 ± 4.8 mmol/L; p < 0.01) were different between survivors and non-survivors. LD between survivors and non-survivors did not differ at 1 h, 6 h, 12 h, or 24 h. After excluding patients with out-of-hospital or in-hospital cardiac arrest during resuscitation room management, admission lactate and LD between survivors and non-survivors did not differ at 1 h, 12 h, and 24 h. LD at 6 h (44% ± 42% vs. 33% ± 58%; p = 0.042) and Lac TW (1.7 ± 1.6 mmol/L vs. 2.6 ± 3.0 mmol/L; p < 0.01) did differ., Conclusions: In critically ill ED patients initially requiring treatment in a resuscitation room setting, LD at 6 h and Lac TW may predict their survival beyond 30 days. These findings need to be confirmed in a prospective study design., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Central venous catheter insertion for acute trauma resuscitation may be associated with mechanical complications, but studies on the exact central venous catheter tip positions are not available. The goal of the study was to analyze central venous catheter tip positions using routine emergency computed tomography., Methods: Consecutive acute multiple trauma patients requiring large-bore thoracocervical central venous catheters in the resuscitation room of a university hospital were enrolled retrospectively from 2010 to 2015. Patients who received a routine emergency chest computed tomography were analyzed regarding central venous catheter tip position. The central venous catheter tip position was defined as correct if the catheter tip was placed less than 1 cm inside the right atrium relative to the cavoatrial junction, and the simultaneous angle of the central venous catheter tip compared with the lateral border of the superior vena cava was below 40°., Results: During the 6-year study period, 97 patients were analyzed for the central venous catheter tip position in computed tomography. Malpositions were observed in 29 patients (29.9%). Patients with malpositioned central venous catheters presented with a higher rate of shock (systolic blood pressure <90 mmHg) at admission (58.6% vs 33.8%, p = 0.023) and a higher mean injury severity score (38.5 ± 15.7 vs 31.6 ± 11.8, p = 0.041) compared with patients with correctly positioned central venous catheter tips. Logistic regression revealed injury severity score as a significant predictor for central venous catheter malposition (odds ratio = 1.039, 95% confidence interval = 1.005-1.074, p = 0.024)., Conclusion: Multiple trauma patients who underwent emergency central venous catheter placement by experienced anesthetists presented with considerable tip malposition in computed tomography, which was significantly associated with a higher injury severity.

The purpose of this study was to investigate the efficacy and safety of synthetic colloid resuscitation among severely injured patients. Fluid resuscitation of trauma patients of a nationwide trauma registry was analysed between 2002 and 2015. Effects of synthetic colloid resuscitation in the pre-hospital setting and emergency department on renal failure, renal replacement therapy and multiple organ failure were analysed among patients with ≥2 days intensive care unit stay, and in-hospital mortality was analysed among all patients. 48,484 patients with mean age of 49 years and mean injury severity score of 23 points were included; 72.3% were male and 95.5% had blunt trauma. Risk-adjusted analyses revealed that patients receiving >1,000 ml synthetic colloids experienced an increase of renal failure and renal replacement therapy rates (OR 1.42 and 1.32, respectively, both p ≤ 0.006). Any synthetic colloid use was associated with an increased risk of multiple organ failure (p < 0.001), but there was no effect on hospital mortality (p = 0.594). Between 2002 and 2015 usage of synthetic colloids dropped, likewise did total fluid intake and usage of blood products. The data from this analysis suggests that synthetic colloid resuscitation provides no beneficial effects and might be harmful in patients with severe trauma.

Background: Management of critically ill nontrauma (CINT) patients in the resuscitation room (RR) of the emergency department (ED) is very challenging. Detailed data describing the characteristics and management of this population are lacking. This observational study describes the epidemiology, management and outcome in CINT ED patients in the RR., Patients and Methods: From September 2014 to August 2015, data were collected prospectively on adult CINT patients admitted to the RR of a single German University ED. Patient characteristics, out-of-hospital/in-hospital treatment, admission-related diseases, time intervals for diagnostics and interventions plus outcome were recorded using a self-developed questionnaire., Results: A total of 34 303 patients were admitted to the ED; of these 21 074 patients were admitted for nontrauma emergencies and because of acute life-threatening problems. Five hundred and thirty-two CINT patients were admitted to the RR (median age: 71 years, 58.3% men). The main problems on admission were obstructed airway (3.8%, A), respiratory insufficiency (26.5%, B), shock (35.5%, C), unconsciousness (33.3%, D) or other (0.9%, E). Out-of-hospital and in-hospital management included intravenous access (96.8 vs. 76.9%), 12-lead ECG (50.0 vs. 86.5%), invasive airway management (30.1 vs. 27.1%), noninvasive and invasive ventilation (7.0 vs. 16.4% and 30.1 vs. 57.2%), catecholamines (16.2 vs. 24.1%), arterial line (0.2 vs. 58.1%) and cardiopulmonary resuscitation (18.4 vs. 12.2%). The mean length of stay was 34±24 min. At day 30, all-cause mortality was 34.2% (patients with and without cardiopulmonary resuscitation: 72.7 vs. 24.0%, P<0.001)., Conclusion: Observation of critically ill patients in the resuscitation room of the Emergency Department shows the challenge of care for CINT patients in the ED. With high levels of mortality, there is an urgent need for structured ED management guidelines.

This study aimes to determine the complication rates, possible risk factors and outcomes of emergency procedures performed during resuscitation of severely injured patients. The medical records of patients with an injury severity score (ISS) >15 admitted to the University Hospital Leipzig from 2010 to 2015 were reviewed. Within the first 24 hours of treatment, 526 patients had an overall mechanical complication rate of 26.2%. Multivariate analysis revealed out-of-hospital airway management (OR 3.140; 95% CI 1.963-5.023; p < 0.001) and ISS (per ISS point: OR 1.024; 95% CI 1.003-1.045; p = 0.027) as independent predictors of any mechanical complications. Airway management complications (13.2%) and central venous catheter complications (11.4%) were associated with ISS >32.5 (p < 0.001) and ISS >33.5 (p = 0.005), respectively. Chest tube complications (15.8%) were associated with out-of-hospital insertion (p = 0.002) and out-of-hospital tracheal intubation (p = 0.033). Arterial line complications (9.4%) were associated with admission serum lactate >4.95 mmol/L (p = 0.001) and base excess <-4.05 mmol/L (p = 0.008). In multivariate analysis, complications were associated with an increased length of stay in the intensive care unit (p = 0.019) but not with 24 hour mortality (p = 0.930). Increasing injury severity may contribute to higher complexity of the individual emergency treatment and is thus associated with higher mechanical complication rates providing potential for further harm.

Background. Emergency airway management (AM) is a priority when resuscitating critically ill or severely injured patients. The goal of this study was to determine the success rates of LT insertion during AM. Methods. Studies that included LT first-pass insertion (FPI) and overall-pass insertion (OPI) success by emergency medical services and in-hospital providers performing AM for emergency situations as well as for scheduled surgery published until July 2014 were searched systematically in Medline. Results. Data of 36 studies (n = 1,897) reported a LT FPI success by physicians of 82.5% with an OPI success of 93.6% (p < 0.001). A cumulative analysis of all 53 studies (n = 3,600) led to FPI and OPI success of 80.1% and 92.6% (p < 0.001), respectively. The results of 26 studies (n = 2,159) comparing the LT with the laryngeal mask airway (LMA) demonstrated a FPI success of 77.0 versus 78.7% (p = 0.36) and an OPI success of 92.2 versus 97.7% (p < 0.001). Conclusion. LT insertion failed in the first attempt in one out of five patients, with an overall failure rate in one out of 14 patients. When compared with the LT, the LMA had a cumulative 5.5% better OPI success rate.

Introduction: Intraosseous infusion is recommended if peripheral venous access fails for cardiopulmonary resuscitation or other medical emergencies. The aim of this study, using body donors, was to compare a semi-automatic (EZ-IO®) device at two insertion sites and a sternal intraosseous infusion device (FASTR™)., Methods: Twenty-seven medical students being inexperienced first-time users were randomized into three groups using EZ-IO and FASTR. The following data were evaluated: attempts required for successful placement, insertion time and flow rates with and without external pressure to the infusion., Results: The first-pass insertion success of the EZ-IO tibia, EZ-IO humerus and FASTR was 91%, 77%, and 95%, respectively. Insertion times (MW ± SD) did not show significant differences with 17 ± 7 (EZ-IO tibia) vs. 29 ± 42 (EZ-IO humerus) vs. 33 ± 21 (FASTR), respectively. One-minute flow rates using external pressures between 0 mmHg and 300 mmHg ranged between 27 ± 5 to 69 ± 54 ml/min (EZ-IO tibia), 16 ± 3 to 60 ± 44 ml/min (EZ-IO humerus) and 53 ± 2 to 112 ± 47 ml/min (FASTR), respectively. Concerning pressure-related increases in flow rates, negligible correlations were found for the EZ-IO tibia in all time frames (c = 0.107-0.366; p ≤ 0.013), moderate positive correlations were found for the EZ-IO humerus after 5 minutes (c = 0.489; p = 0.021) and strong positive correlations were found for the FASTR in all time frames (c = 0.63-0.80; p ≤ 0.007). Post-hoc statistical power was 0.62 with the given sample size., Conclusions: The experiments with first-time users applying EZ-IO and FASTR in body donors indicate that both devices may be effective intraosseous infusion devices, likely suitable for fluid resuscitation using a pressure bag. Variations in flow rate may limit their reliability. Larger sample sizes will prospectively be required to substantiate our findings.

Introduction: The current guidelines of the European Resuscitation Council (ERC) stipulate that an intraosseous access should be placed if establishing a peripheral venous access for cardiopulmonary resuscitation (CPR) would involve delays. The aim of this study was therefore to compare a manual intraosseous infusion technique (MAN-IO) and a semi-automatic intraosseous infusion system (EZ-IO) using adult human cadavers as a model., Materials and Methods: After receiving verbal instruction and giving their written informed consent, the participants of the study were randomized into two groups (group I: MAN-IO, and group II: EZ-IO). In addition to the demographic data, the following were evaluated: (1) Number of attempts required to successfully place the infusion, (2) Insertion time, (3) Occurrence of technical complications and (4) User friendliness., Results: Evaluation protocols from 84 study participants could be evaluated (MAN-IO: n=39 vs. EZ-IO: n=45). No significant differences were seen in the study participants' characteristics. Insertion times (MW+/-S.D.) of the respective successful attempts were comparable (MAN-IO: 33+/-28s vs. EZ-IO: 32+/-11s). When using the EZ-IO, the access was successfully established significantly more often on the first attempt (MAN-IO: 79.5% vs. EZ-IO: 97.8%; p<0.01). The EZ-IO was also found to have more advantages in terms of technical complications (MAN-IO: 15.4% vs. EZ-IO: 0.0%; p<0.01) and user friendliness (school grading system: MAN-IO: 1.9+/-0.7 vs. EZ-IO: 1.2+/-0.4; p<0.01)., Conclusions: In an adult human cadaver model, the semi-automatic system was proven to be more effective. The EZ-IO gave more successful results, was associated with fewer technical complications, and is user friendlier.

Introduction: Successful management of emergency patients with multiple trauma in the hospital resuscitation room depends on the immediate diagnosis and rapid treatment of the most life-threatening injuries. In order to reduce the time spent in the resuscitation room, an in-hospital algorithm was developed in an interdisciplinary team approach with respect to local structures. The aim of the study was to analyse whether this algorithm affects the interval between hospital admission and the completion of diagnostic procedures and the start of life-saving interventions. Moreover, in-hospital mortality was investigated before and after the algorithm was introduced., Material and Methods: In this prospective study, all consecutive trauma patients in the resuscitation room were investigated before (group I, 01/04-10/04) and after (group II, 01/05-11/05) introduction of the algorithm. The times between hospital admission and the end of the diagnostic procedures (ultrasound [sono], chest X-ray [CF], and cranial computed tomography [CCT]), and between hospital admission and the start of life-saving interventions were registered and in-hospital mortality analysed., Results: In the study period, 170 patients in group I and 199 patients in group II were investigated. Injury severity score (ISS) were comparable between the two groups. The intervals between admission and completion of diagnostic procedures were significantly lower after the algorithm was introduced (mean+/-S.D.): sono (11 +/- 10 min versus 7 +/- 6 min, p < 0.05), CF (21 +/- 12 min versus 12 +/- 9 min, p < 0.01), and CCT (55 +/- 27 min versus 32 +/- 14 min, p < 0.01). Moreover, the interval to the start of life-saving interventions was significantly shorter (126 +/- 90 min versus 51 +/- 20 min, p < 0.01). After introducing the algorithm, in-hospital mortality was reduced significantly from 33.3% to 16.7% (p < 0.05) in the most severely injured patients (ISS>or=25)., Conclusion: The introduction of an algorithm for early management of emergency patients significantly reduced the time spent in the resuscitation room. The periods to completion of sono, CF, and CCT, respectively, and the start of life-saving interventions were significantly shorter after introduction of the algorithm. Moreover, introduction of the algorithm reduced mortality in the most severely injured patients. Although further investigations are needed to evaluate the effects of the Heidelberg treatment algorithm in terms of outcome and mortality, the time reduction in the resuscitation room seems to be beneficial.

Background: Few studies address the care of critically ill non-traumatic patients in the emergency department (ED). The aim of this study was to assess the epidemiology, management, and outcome of these patients. Methods: In this retrospective study, we identified and analyzed data from all consecutive adult critically ill non-traumatic ED patients treated from March 2018 to February 2019. Patient characteristics, major complaint leading to admission, out-of-hospital, and in-hospital interventions and 30-day mortality were extracted from medical records of the electronic patient data management system. Results: During the study period, we analyzed 40,764 patients admitted to the ED. Of these, 621 (1.5%) critically ill non-traumatic patients were admitted for life-threatening emergencies to the resuscitation room (age: 70 ± 16 years, 52% male). Leading problem on admission was disability/unconsciousness (D), shock (C), respiratory failure (B), airway obstruction (A), and environment problems (E) in 41%, 31%, 25%, 2%, and 1%, respectively. Out-of-hospital and in-hospital measures included: intravenous access (61% vs. 99%), 12-lead ECG (55% vs. 87%), invasive airway management (21% vs. 34%) invasive ventilation (21% vs. 34%), catecholamines (9% vs. 30%), arterial access (0% vs. 52%), and cardiopulmonary resuscitation (11% vs. 6%). The underlying diagnoses were mainly neurological (29%), followed by cardiological (28%), and pulmonological (20%) emergencies. The mean length of stay (LOS) in the resuscitation room and ED was 123 ± 122 and 415 ± 479 min, respectively. The 30-day mortality was 18.5%. Conclusion: The data describe the care of critically ill non-traumatic patients in the resuscitation room. Based on these data, algorithms for the structured care of critically ill non-traumatic patients need to be developed. [ABSTRACT FROM AUTHOR]

Purpose: Evaluation of trauma patients with chest tube malposition using initial emergency computed tomography (CT) and assessment of outcomes and the need for chest tube replacement. Methods: Patients with an injury severity score > 15, admitted directly from the scene, and requiring chest tube insertion prior to initial emergency CT were retrospectively reviewed. Injury severity, outcomes, and the positions of chest tubes were analyzed with respect to the need for replacement after CT. Results: One hundred seven chest tubes of 78 patients met the inclusion criteria. Chest tubes were in the pleural space in 58% of cases. Malposition included intrafissural positions (27%), intraparenchymal positions (11%) and extrapleural positions (4%). Injury severity and outcomes were comparable in patients with and without malposition. Replacement due to malfunction was required at similar rates when comparing intrapleural positions with both intrafissural or intraparenchymal positions (11 vs. 23%, p = 0.072). Chest tubes not reaching the target position (e.g., pneumothorax) required replacement more often than targeted tubes (75 vs. 45%, p = 0.027). Out-of-hospital insertions required higher replacement rates than resuscitation room insertions (29 vs. 10%, p = 0.016). Body mass index, chest wall thickness, injury severity, insertion side and intercostal space did not predict the need for replacement. Conclusions: Patients with malposition of emergency chest tubes according to CT were not associated with worse outcomes compared to patients with correctly positioned tubes. Early emergency chest CT in the initial evaluation of severely injured patients allows precise detection of possible malposition of chest tubes that may require immediate intervention. [ABSTRACT FROM AUTHOR]

Aim: An effective airway management is pivotal for treating hypoxia and to ensure reoxygenation during cardiopulmonary resuscitation (CPR). This matched-pair analysis from the German Resuscitation Registry (GRR) investigates the outcomes of various methods of airway management used on out-of-hospital cardiac arrest (OHCA) patients.Methods: 89,220 OHCA patients were reported between 01/01/2007 and 12/31/2017. After applying exclusion and inclusion criteria, the resulting 19,196 patient's data were analyzed. Endpoints were return of spontaneous circulation (ROSC), hospital admission, 24-h survival, hospital discharge, and discharge with cerebral performance categories 1,2 (CPC1,2). Three categories of airway management were defined: endotracheal tube ("ETT"), laryngeal tube ("LT_only"), and laryngeal to endotracheal tube exchange ("LTEX"). The groups were matched with respect to age, gender, aetiology or location of OHCA, witnessing or CPR by lay people, initial rhythm, and use of epinephrine and amiodarone.Results: "ETT" versus "LT_only" was associated with higher short- and long-term outcome rates and better neurological recovery (CPC_1.2: 7.7 vs. 5.8%, OR = 1.35, 95%-CI = 1.09-1.67, n = 5552). "LTEX" versus "LT_only" showed significantly higher ROSC- and 24-h survival rate (33.7 vs. 21.8%, OR = 1.82, 95%-CI = 1.51-2.2, n = 2302). "LTEX" versus "ETT" revealed significantly higher ROSC- and 24-h survival rate (34.6 vs. 30.4%, OR = 1.21, 95%-CI = 1.03-1.42, n = 2608).Conclusion: "ETT" was associated with higher survival rates and better neurological outcomes in comparison to "LT_only". The strategy of "LTEX" versus "LT_only" or "ETT" was only associated with better short-term outcomes. Our observational registry data suggests that endotracheal intubation by physician staffed EMS is the optimal airway strategy for OHCA in our system. [ABSTRACT FROM AUTHOR]

Background: Sudden cardiac arrest is a relevant problem with a significant number of deaths in Europe.Aim: Using data from the German Resuscitation Register (GRR), we examined changes in epidemiology and therapeutic interventions over a 15-year period in order to identify key factors contributing to favourable outcome in out-of-hospital cardiac arrest (OHCA) patients.Methods: GRR data were analysed in 5-year periods (2006-2010 vs 2011-2015 vs 2016-2020) representing changes in the European Resuscitation Council (ERC) guidelines. Group comparison of OHCA patients was made for epidemiological and resuscitation-associated factors. Endpoints included 30-day survival and hospital discharge with a good neurological outcome (CPC 1,2). Matched-pair analysis compared outcomes, and multivariate binary logistic regression analysis identified variables with effects on survival.Results: A total of 42,997 GRR patients were studied (2006-2010: n = 3,471, 2011-2015: n = 16,122, 2016-2020: n = 23,404). Proportion of patients over 80 years, use of intraosseous (IO) access and supraglottic airway devices, rate of bystander CPR, and the proportion of telephone CPR increased over the study period. The 30-day survival, and hospital discharge rates with CPC1/2 were unchanged. After adjusting cohorts using matched pairs, a higher CPC1,2 rate was observed (8.8 vs 10.2%, p < 0.03). Logistic regression analysis showed that IO and SAD had an unfavourable impact on outcome.Conclusion: Despite a significant increase in bystander and telephone CPR rates, no improvement in 30-day survival and hospital discharge rate with CPC1,2 was observed. Initial rhythm (VF/VT), cardiac and hypoxic cause of CA, bystander CPR and IV access were identified as factors associated with a favourable neurological outcome. [ABSTRACT FROM AUTHOR]