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Zusammenfassung Hintergrund In Deutschland gibt es bisher keine Gesundheitsberichterstattung zu sektorenübergreifenden Versorgungsverläufen im Kontext einer Notaufnahmeversorgung. Das Projekt INDEED (Inanspruchnahme und sektorenübergreifende Versorgungsmuster von Patienten in Notfallversorgungsstrukturen in Deutschland) erhebt Routinedaten aus 16 Notaufnahmen, die mit ambulanten Abrechnungsdaten der Jahre 2014 bis 2017 personenbezogen zusammengeführt werden. Ziel der Arbeit Die methodischen Herausforderungen der Planung der internen Zusammenführung von klinischen und administrativen Routinedaten aus Notaufnahmen in Deutschland bis zur finalen Datenextraktion werden hier gemeinsam mit Lösungsansätzen dargestellt. Methodik Die Auswahl der Notaufnahmedaten erfolgte in einem iterativen Prozess unter Berücksichtigung der Forschungsfragen, medizinischen Relevanz und angenommenen Datenverfügbarkeit. Nach einer Vorbereitungsphase zur Klärung der Rahmenbedingungen (u. a. Datenschutz, Ethik), zur Prüfung von Testdaten und ggf. Korrekturen, erfolgte die verschlüsselte und pseudonyme Datenausleitung. Ergebnisse Die Daten der 16 kooperierenden Notaufnahmen stammten in der Regel aus dem Notaufnahme- und dem Krankenhausinformationssystem. Die Datenlage war sehr heterogen. Nicht alle Variablen waren in jeder Notaufnahme verfügbar, da sie beispielsweise nicht standardisiert und digital vorlagen oder der Extraktionsaufwand als zu hoch bewertet wurde. Schlussfolgerung Relevante Daten aus Notaufnahmen liegen unterschiedlich strukturiert und in mehreren IT-Systemen vor. Die notwendige Bildung eines klinikübergreifenden vergleichbaren Datensatzes erfordert erhebliche Ressourcen auf Seiten der Kliniken sowie der datenaufbereitenden Stelle. Dies muss für zukünftige Projekte großzügig kalkuliert werden.

BACKGROUND: Inpatient admission rates and the resources required upon admission to the hospital were studied as a function of the type of referral to the emergency department (ED) of a university hospital. METHODS: We retrospectively analyzed data concerning patients who were treated in the ED of the University of Leipzig Medical Center in 2019. The following data were recorded: process data, type of referral, hospital admission vs. discharge from the ED, and leading symptom according to classification as „trauma“ or „non-trauma.“ For all admitted patients, the Patient Clinical Complexity Level (PCCL), length of hospital stay, and intensive care (yes/no) with or without ventilation were recorded. RESULTS: Data on 34 178 patients (50.9 ± 22.2 years, 53.8% male) were analyzed; 28.8% of patients were referred because of „trauma,” and the remaining 71.2% for “non trauma”. The most common sources of referral were the rescue and emergency medical services (47.7%) and the patients themselves (self-referrals, 44.7%); 7.6% of the patients were referred by a resident doctor or general practitioner (physician). 62.6% were discharged from the ED after diagnosis and treatment, while 37.4% were admitted to the hospital. In comparison with self-referred patients as a baseline, the likelihood of inpatient admission was higher when the patient was referred by a physician (adjusted odds ratio [OR] 2.2), by the emergency rescue service without an emergency physician (OR 3.4), by an emergency physician (OR 9.3), or by the helicopter rescue service (OR 44.1). 49.1% of patients with trauma referred themselves to the ER, and 36% were referred by the emergency rescue service. Older and male patients were more likely to be admitted to the hospital, especially for non-trauma. 30.4% of the admitted patients required intensive care, and 35.5% of the patients in intensive care required ventilation. CONCLUSION: Whether a patient is admitted to the hospital depends on the source of the referral and the leading symptom on arrival in the ED. One in every six self-referred patients is admitted to the hospital, particularly when the reason for presenting to the ER is non-traumatic and some of them go on to receive intensive care. The high percentage (around 95%) of self-referred trauma patients that are discharged from the ED presumably indicates that they were referred mainly for the exclusion of dangerous conditions, and/or that appropriate care options are lacking in the community setting.

Background In this retrospective routine data analysis, we investigate the number of emergency department (ED) consultations during the COVID-19 pandemic of 2020 in Germany compared to the previous year with a special focus on numbers of myocardial infarction and acute heart failure. Methods Aggregated case numbers for the two consecutive years 2019 and 2020 were obtained from 24 university hospitals and 9 non-university hospitals in Germany and assessed by age, gender, triage scores, disposition, care level and by ICD-10 codes including the tracer diagnoses myocardial infarction (I21) and heart failure (I50). Results A total of 2,216,627 ED consultations were analyzed, of which 1,178,470 occurred in 2019 and 1,038,157 in 2020. The median deviation in case numbers between 2019 and 2020 was − 14% [CI (− 11)–(− 16)]. After a marked drop in all cases in the first COVID-19 wave in spring 2020, case numbers normalized during the summer. Thereafter starting in calendar week 39 case numbers constantly declined until the end of the year 2020. The decline in case numbers predominantly concerned younger [− 16%; CI (− 13)–(− 19)], less urgent [− 18%; CI (− 12)–(− 22)] and non-admitted cases [− 17%; CI (− 13)–(− 20)] in particular during the second wave. During the entire observation period admissions for chest pain [− 13%; CI (− 21)–2], myocardial infarction [− 2%; CI (− 9)–11] and heart failure [− 2%; CI (− 10)–6] were less affected and remained comparable to the previous year. Conclusions ED visits were noticeably reduced during both SARS-CoV-2 pandemic waves in Germany but cardiovascular diagnoses were less affected and no refractory increase was noted. However, long-term effects cannot be ruled out and need to be analysed in future studies. Graphical abstract

Background While there are clear national resuscitation room admission guidelines for major trauma patients, there are no comparable alarm criteria for critically ill nontrauma (CINT) patients in the emergency department (ED). The aim of this study was to define and validate specific trigger factor cut-offs for identification of CINT patients in need of a structured resuscitation management protocol. Methods All CINT patients at a German university hospital ED for whom structured resuscitation management would have been deemed desirable were prospectively enrolled over a 6-week period (derivation cohort, n = 108). The performance of different thresholds and/or combinations of trigger factors immediately available during triage were compared with the National Early Warning Score (NEWS) and Quick Sequential Organ Failure Assessment (qSOFA) score. Identified combinations were then tested in a retrospective sample of consecutive nontrauma patients presenting at the ED during a 4-week period (n = 996), and two large external datasets of CINT patients treated in two German university hospital EDs (validation cohorts 1 [n = 357] and 2 [n = 187]). Results The any-of-the-following trigger factor iteration with the best performance in the derivation cohort included: systolic blood pressure 80% of patients in the derivation cohort and performed better than NEWS and qSOFA scores in the internal validation cohort (sensitivity = 98.5%, specificity = 98.6%). When applied to the external validation cohorts, need for advanced resuscitation measures and hospital mortality (6.7 vs. 28.6%, p p Conclusion Our simple, any-of-the-following decision rule can serve as an objective trigger for initiating resuscitation room management of CINT patients in the ED.

Management of critically ill nontrauma (CINT) patients in the resuscitation room of the emergency department (ED) is very challenging. Detailed data describing the patient characteristics and management of this population are lacking. This observational study describes the epidemiology, management and outcome in CINT ED patients in the resuscitation room.This prospective, single center observational study included all adult patients who were consecutively admitted to the ED resuscitation room during 2 periods of 1 year (September 2014-August 2015 vs. September 2017- August 2018). Patient characteristics, out-of-hospital/in-hospital treatment, admission-related conditions, time intervals for diagnostics and interventions and outcome were recorded using a self-developed questionnaire.A total of 34,303 patients in the first and 35,039 patients in the second study period were admitted to the ED, of whom 532 and 457 patients, respectively, were admitted to the nontrauma resuscitation room due to acute life-threatening conditions. The patient characteristics did not differ significantly between the study periods (male: 58% vs. 59%, age: 68 ± 17 years vs. 65 ± 17 years). Time intervals for diagnostic and therapeutic interventions were similar. The CINT patients during the second study period were treated faster compared to the first study period (end of ED management: 53 ± 33 min vs. 41 ± 24 min, p 0.0001). The 30-day all-cause mortality was comparable (34.0% vs. 36.3%).Observation of critically ill patient management in the ED resuscitation room showed reliable results between both study periods. Structured ED management guidelines for CINT patients may provide comparable results at one institution.HINTERGRUND: Das Management von nichttraumatologischen kritisch kranken Patienten im Schockraum einer Zentralen Notaufnahme (ZNA) ist sehr anspruchsvoll. Es fehlen detaillierte Daten, welche die Patientencharakteristika und das Management dieser Population beschreiben. Ziel der Beobachtungsstudie war es, die Epidemiologie, das Management und das Behandlungsergebnis bei nichttraumatologisch kritisch kranken Patienten im Schockraum zu beschreiben.Diese monozentrische prospektive Beobachtungsstudie schloss alle erwachsenen Patienten ein, die während zweier 1‑Jahres-Perioden (September 2014 bis August 2015 vs. September 2017 bis August 2018) konsekutiv im Schockraum der ZNA aufgenommen wurden. Patientencharakteristika, prähospitale und innerklinische Maßnahmen, Aufnahmezustand, Zeitintervalle für Diagnostik und Interventionen sowie das Behandlungsergebnis wurden mittels eines selbst entwickelten Fragebogens erfasst.Insgesamt wurden 34.303 Patienten im ersten und 35.039 Patienten im zweiten Studienzeitraum in die ZNA aufgenommen, von denen 532 bzw. 457 Patienten aufgrund akut lebensbedrohlicher Zustände in den nichttraumatologischen Schockraum aufgenommen wurden. Die Patientencharakteristika unterschieden sich nicht signifikant zwischen den Studienzeiträumen (männlich: 58 % vs. 59 %, Alter: 68 ± 17 Jahre vs. 65 ± 17 Jahre). Die Zeitintervalle für diagnostische und therapeutische Interventionen waren ähnlich. Nichttraumatologische Patienten im zweiten Studienzeitraum wurden im Vergleich zum ersten Studienzeitraum schneller behandelt (Ende des Schockraummanagements: 53 ± 33 vs. 41 ± 24 min; p 0,0001). Die 30-Tage-Gesamtmortalität war vergleichbar (34,0 vs. 36,3 %).Die Beobachtung des Managements kritisch kranker nichttraumatologischer Schockraumpatienten zeigt reliabel Ergebnisse im Vergleich beider Studienzeiträumen. Strukturierte Richtlinien zum Management kritisch kranker nichttraumatologischer Schockraumpatienten können vergleichbare Ergebnisse in einer Institution liefern.

Post-mortem biochemistry of serum markers has been the subject of numerous studies, but in-situ marker stability after death has not been sufficiently evaluated yet. Such laboratory analyses are especially necessary in the cases of functional deaths without morphological evidence of the death causes and also in cardiac death cases with only very short survival times. The aim of the study was to determine the post-mortem stability of commonly-used serum markers at predefined time points. In 20 cases, peripheral venous samples were taken starting immediately after circulatory arrest and ending 48 hours after death. Serum creatinine, urea, 3-β-hydroxybutyrate, tryptase, myoglobin, troponin T, creatin kinase and creatin kinase-MB have been included. For all markers, we observed increasing marker levels for longer post-mortem intervals. Significant marker level changes began two hours after death. Excessive increases were observed for cardiac and muscle markers. Marker levels showed high intra-assay precision. Furthermore, the markers were robust enough to withstand freeze-thaw cycles. Potential contamination of arteriovenous blood did not influence the post-mortem marker levels. Post-mortem blood should be sampled as soon as possible, as increased post-mortem intervals may heavily change marker levels in-situ in individual cases, whereas the markers are mostly unaffected by laboratory conditions.

Im deutschen Rettungsdienst wird uber die kontinuierlich steigende Zahl von Notarzteinsatzen berichtet. Bisher lagen jedoch kaum Daten aus Grosstadten vor, die diese Veranderungen uber einen langeren Zeitraum darstellen. In einer retrospektiven Untersuchung wurden die Notarzteinsatze jeweils des Zeitraums 01. Januar bis 31. Marz der Jahre 2003 und 2013 der Stadt Leipzig ausgewertet. Neben der Notarzteinsatzrate (Notarzteinsatze/1000 Einwohner und Jahr) wurden die Erkrankungs- und Verletzungsschwere (National Advisory Committee of Aeronautics[NACA]-Score), der Einsatzort und der Versorgungsgrad der Zielklink erfasst. Die Zahl der Notarzteinsatze in den Beobachtungszeitraumen nahm zwischen 2003 und 2013 um 24 % (n = 6030 vs. n = 7470) und die Notarzteinsatzrate um 21 % (48 vs. 58) zu. Bei steigendem Patientenalter (66 vs. 70 Jahre) stieg der Anteil hochbetagter (Alter ≥ 85 Jahre: 11 % vs. 16 % (p < 0,01)) und der Anteil vital gefahrdeter Patienten (NACA IV–VI: 14 % vs. 16 % (p < 0,01)). Notarzteinsatze in Pflegeheimen vervierfachten sich (n = 175 (3 %) vs. n = 750 (10 %), p < 0,01); die Zahl der Krankenhauseinweisungen stieg an (n = 3049 (51 %) vs. n = 4738 (66 %), p < 0,01). Hierbei nahm masgeblich der Anteil Maximalversorgern zugefuhrter Patienten zu (n = 1742 (29 %) vs. n = 3436 (46 %), p < 0,01). Im Stadtgebiet Leipzig wurden zwischen 2003 und 2013 steigende Notarzteinsatzzahlen und ein Anstieg schwer erkrankter und geriatrischer Patienten nachgewiesen. Die im Vergleich zum Bundesdurchschnitt nahezu doppelt so hohe Notarzteinsatzrate kann jedoch auf Defizite im Bereich der ambulanten Grundversorgung und Optimierungsmoglichkeiten bei der Disposition der Rettungsleitstelle hinweisen.

Background Sepsis is defined as a life-threatening organ dysfunction due to a dysregulated inflammation following an infection. However, the impact of this definition on patient care is not fully clear. This study investigated the impact of the current definition on ICU admission of patients with infection. Methods We performed a prospective observational study over twelve months on consecutive patients presented to our emergency department and admitted for infection. We analyzed the predictive values of the quick sequential organ failure assessment (qSOFA) score, the SOFA score and blood lactate regarding ICU admission. Results We included 916 patients with the diagnosis of infection. Median age was 74 years (IQR 62–82 years), and 56.3% were males. There were 219 direct ICU admissions and 697 general ward admissions. A qSOFA score of ≥2 points had 52.9% sensitivity and 98.3% specificity regarding sepsis diagnosis. A qSOFA score of ≥2 points had 87.2% specificity but only 39.9% sensitivity to predict ICU admission. A SOFA score of ≥2 points had 97.4% sensitivity, but only 17.1% specificity to predict ICU admission, while a SOFA score of ≥4 points predicted ICU admission with 82.6% sensitivity and 71.7% specificity. The area under the receiver operating curve regarding ICU admission was 0.81 (95 CI, 0.77–0.86) for SOFA score, 0.55 (95% CI, 0.48–0.61) for blood lactate, and only 0.34 (95% CI, 0.28–0.40) for qSOFA on emergency department presentation. Conclusions While a positive qSOFA score had a high specificity regarding ICU admission, the low sensitivity of the score among septic patients as well as among ICU admissions considerably limited its value in routine patient management. The SOFA score was the better predictor of ICU admission, while the predictive value of blood lactate was equivocal.

Background Emergency airway management (AM) is a major key for successful resuscitation of critically ill non-traumatic (CINT) patients. Details of the AM of these patients in German emergency departments (ED) are unknown. This observational study describes epidemiology, airway techniques, success rates and complications of AM in CINT ED patients in the resuscitation room (RR). Methods Data was collected prospectively on adult CINT patients admitted to the RR of a single German university ED September 2014 to August 2015. Patient characteristics, out-of-hospital and in-hospital RR AM, complications and success rates were recorded using a self-developed airway registry form. Results During the study period 34,303 patients were admitted to the ED, out of those 21,074 patients for non-trauma emergencies. Suffering from severe acute life-threatening problems, 532 CINT patients were admitted to the RR. 150 (28.2%) CINT patients had received out-of-hospital AM. In 16 of these cases (10.7%) the inserted airway needed to be changed after RR admission (unrecognized oesophageal intubation: n = 2, laryngeal tube exchange: n = 14). 136 (25.6%) CINT patients without out-of-hospital AM received RR AM immediately after admission. The first-pass and overall success rate in the RR were 71 and 100%, respectively, and multiple intubation attempts were necessary in 29%. A lower Cormack/Lehane (C/L) grade was associated with less intubation attempts (C/L1/2 vs. 3/4: 1.2 ± 0.5 vs. 1.8 ± 1.2, p = 0.0002). Complication rate was 43%. Conclusions OcEAN demonstrates the challenges of AM in CINT patients in a German ED RR. We propose a nation-wide ED airway registry to better track outcomes in the future. Electronic supplementary material The online version of this article (10.1186/s13049-019-0599-1) contains supplementary material, which is available to authorized users.

Die Notaufnahmen der Krankenhauser spielen in Deutschland eine zentrale Rolle bei der ambulanten und stationaren Versorgung von Patienten mit medizinischen Notfallen. In diesem Positionspapier werden allgemeine finanzielle und organisatorischen Probleme der deutschen Notaufnahmen aufgezeigt und die Forderung aufgestellt, der medizinischen Notfallversorgung in den Notaufnahmen als einem Element der Daseinsvorsorge einen hoheren Stellenwert in dem deutschen Gesundheitssystem zu geben. Die entsprechenden Reformvorschlage beinhalten eine Anpassung der Krankenhausfinanzierung mit Berucksichtigung der Vorhaltekosten der Notaufnahmen, eine verstarkte Strukturplanung fur die regionale und uberregionale Notfallversorgung, eine intensivierte Kooperation mit den kassenarztlichen Notdiensten, eine bessere organisatorische Abbildung der Notfallversorgung innerhalb der Krankenhauser sowie eine Forderung der notfallmedizinischen Aus- und Weiterbildung.

Die notfallmedizinische Versorgung von Opfern eines Sexualdelikts ist eine besondere Herausforderung: In einer aus Patientensicht bestehenden psychischen Ausnahmesituation mussen nicht nur Verletzungen versorgt, sondern auch eine gerichtsfeste Befunddokumentation und sachgerechte Spurensicherung gewahrleistet werden.

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.

The maturation of emergency medicine (EM) as a specialty has coincided with dramatic increases in emergency department (ED) visit rates, both in the United States and around the world. ED crowding has become a public health problem where periodic supply and demand mismatches in ED and hospital resources cause long waiting times and delays in critical treatments. ED crowding has been associated with several negative clinical outcomes, including higher complication rates and mortality. This article describes emergency care systems and the extent of crowding across 15 countries outside of the United States: Australia, Canada, Denmark, Finland, France, Germany, Hong Kong, India, Iran, Italy, The Netherlands, Saudi Arabia, Catalonia (Spain), Sweden, and the United Kingdom. The authors are local emergency care leaders with knowledge of emergency care in their particular countries. Where available, data are provided about visit patterns in each country; however, for many of these countries, no national data are available on ED visits rates or crowding. For most of the countries included, there is both objective evidence of increases in ED visit rates and ED crowding and also subjective assessments of trends toward higher crowding in the ED. ED crowding appears to be worsening in many countries despite the presence of universal health coverage. Scandinavian countries with robust systems to manage acute care outside the ED do not report crowding is a major problem. The main cause for crowding identified by many authors is the boarding of admitted patients, similar to the United States. Many hospitals in these countries have implemented operational interventions to mitigate crowding in the ED, and some countries have imposed strict limits on ED length of stay (LOS), while others have no clear plan to mitigate crowding. An understanding of the causes and potential solutions implemented in these countries can provide a lens into how to mitigate ED crowding in the United States through health policy interventions and hospital operational changes.

Alle internationalen Empfehlungen zum Management des schwierigen, mit konventionellen Mitteln nicht beherrschbaren Atemweges beinhalten als „ultima ratio“ die Notfallkoniotomie. Diese invasive Notfalltechnik stellt eine relativ sichere und schnelle Moglichkeit der notfallmasigen Atemwegsicherung dar. Dennoch kann die Notfallkoniotomie insbesondere in der Prahospitalphase mit Komplikationen behaftet sein. Als Verfahren stehen die chirurgisch-anatomische Prapariertechnik und diverse Punktionsverfahren zur Verfugung. Neben der reinen Beherrschung der Notfalltechniken muss sich der potentielle Anwender bereits vor dem Notfall uber die Indikationen der Notfallkoniotomie, den entsprechenden Entscheidungsprozess und das gewahlte Vorgehen bei einer schwierigen Atemwegsicherung im Klaren sein. Diese invasive Notfalltechnik muss trainiert werden, um sie im Ernstfall effektiv einsetzen zu konnen. Hierbei eignen sich sowohl Kurse an Leichenpraparaten als auch an Phantommodellen.

Zusammenfassung: Die Koniotomie im Notarztdienst ist eine sehr invasive Methode zur Atemwegssicherung. Sie ist aber unabdingbar, wenn andere weniger invasive Verfahren der Atemwegssicherung misslingen oder sich situationsabhängig als nicht zweckmäßig erweisen. Für die Durchführung wurden verschiedene Verfahren beschrieben, die in anatomisch-chirurgische Präpariertechniken und Punktionsverfahren unterteilt werden können. Das im jeweiligen Notarztsystem bevorzugte Verfahren orientiert sich meist an abteilungsüblichen Standards, die vom klinischen Vorgehen abgeleitet werden. Ausbildungs- und Trainingsmöglichkeiten für die einzelnen Verfahren bestehen in der Intensivmedizin, am Leichenpräparat und am Phantom. In dieser Arbeit werden verschiedene Methoden der Koniotomie besprochen sowie eine anatomische Präpariertechnik und 2Punktionsverfahren im Detail dargestellt

Based on written surveys conducted during the series of workshops entitled "Invasive emergency techniques (INTECH)" the aim of this study was to characterize defined qualifications of emergency physicians and to discuss by examples whether strictly practice-oriented workshops represent a suitable means of closing the apparent gaps in training. Our data show clearly that even experienced emergency physicians indicated that they lack training in carrying out preclinical invasive emergency procedures such as chest tube, cricothyrotomy and intraosseous access. Furthermore, they are only very seldom confronted with emergency situations in which these procedures could decidedly affect the survival of a patient and which, at the same time, put them under extremely high emotional pressure. Thus, the didactic concept of continuing education workshops that are strictly practice-oriented and that focus in particular on problem areas in emergency medicine, can contribute significantly to help close the gaps in training and ensure that emergency physicians are highly qualified.

We report the case of a 30-year-old body builder who developed a gluteal abscess at the site of injection of regularly self-administered anabolic steroids. After breaking the abscess under general anaesthesia, the patient developed septic shock and fulminant adult respiratory distress syndrome (ARDS). In addition to discussing the pathogenesis, differential diagnosis, and treatment, we focus on the immunomodulatory mechanisms of anabolic substances that may have contributed to the course of the disease in this particular patient.

Background Inhaled nitric oxide (NO) is reported to prolong bleeding time in animals and humans and to inhibit platelet aggregation in persons with acute respiratory distress syndrome. In pulmonary embolism (PE), inhibition of platelet aggregation appears useful because further thrombus formation may lead to right ventricular dysfunction that results in circulatory failure. In the present study, the effect of inhaled NO on platelet aggregation after acute massive PE was investigated. Methods After acute massive PE was induced in 25 anesthetized pigs by injecting microspheres, 5, 20, 40, and 80 parts per million inhaled NO were administered stepwise for 10 min each in 11 animals (NO group). In the control group (n = 14). NO was not administered. Adenosine diphosphate-induced initial and maximal platelet aggregation were measured before PE (10), immediately after induction of PE (PE), at the end of each 10-min NO inhalation interval (t10-t40), and 15 min after cessation of NO inhalation (t55) in the NO group, and at corresponding times in the control group, respectively. Results Two animals in the control group and one in the NO group died within 10 min after PE induction and were excluded from analysis. Peaking at t40 and t55, respectively, initial (-13 +/- 6%; P < 0.05) and maximal (+44 +/- 17%; P < 0.05) platelet aggregation increased significantly after PE in the control group. In contrast, NO administration after PE led to a significant decrease in initial (maximum decrease, -9 +/- 3% at t40; P < 0.05) and maximal (maximum decrease, -15 +/- 7% at t30; P < 0.05) platelet aggregation. In the NO group, platelet aggregation had returned to baseline levels again at t55. In addition, NO administration significantly decreased mean pulmonary artery pressure and significantly increased end-tidal carbon dioxide concentration and mean systemic blood pressure. Conclusions Inhaled NO has a systemic and rapidly reversible inhibitory effect on platelet aggregation after acute massive PE in pigs. This may be beneficial in treating acute massive PE.

The maturation of emergency medicine (EM) as a specialty has coincided with dramatic increases in emergency department (ED) visit rates, both in the United States and around the world. ED crowding has become a public health problem where periodic supply and demand mismatches in ED and hospital resources cause long waiting times and delays in critical treatments. ED crowding has been associated with several negative clinical outcomes, including higher complication rates and mortality. This article describes emergency care systems and the extent of crowding across 15 countries outside of the United States: Australia, Canada, Denmark, Finland, France, Germany, Hong Kong, India, Iran, Italy, The Netherlands, Saudi Arabia, Catalonia (Spain), Sweden, and the United Kingdom. The authors are local emergency care leaders with knowledge of emergency care in their particular countries. Where available, data are provided about visit patterns in each country; however, for many of these countries, no national data are available on ED visits rates or crowding. For most of the countries included, there is both objective evidence of increases in ED visit rates and ED crowding and also subjective assessments of trends toward higher crowding in the ED. ED crowding appears to be worsening in many countries despite the presence of universal health coverage. Scandinavian countries with robust systems to manage acute care outside the ED do not report crowding is a major problem. The main cause for crowding identified by many authors is the boarding of admitted patients, similar to the United States. Many hospitals in these countries have implemented operational interventions to mitigate crowding in the ED, and some countries have imposed strict limits on ED length of stay (LOS), while others have no clear plan to mitigate crowding. An understanding of the causes and potential solutions implemented in these countries can provide a lens into how to mitigate ED crowding in the United States through health policy interventions and hospital operational changes.

BACKGROUND The recommendations still have to be implemented 3 years after publication of the S3 guidelines on the treatment of patients with severe and multiple injuries. AIM This article reiterates some of the essential core statements of the S3 guidelines and also gives an overview of new scientific studies. MATERIAL AND METHODS In a selective literature search new studies on airway management, traumatic cardiac arrest, shock classification, coagulation therapy, whole-body computed tomography, air rescue and trauma centers were identified and are discussed in the light of the S3 guideline recommendations. RESULTS The recommendations on airway management are up to date; however, recommendations on difficult airway evaluation tools, e.g. the LEMON law, should be included. The first pass success (i.e. intubation success at the first attempt) must be considered as a quality marker in the future. Video laryngoscopy is identified as a leading airway procedure in order to reach this aim. Recently estimated learning curves for endotracheal intubation and supraglottic airway devices should be implemented in qualification statements. Life-saving emergency interventions have to be performed in the prehospital setting as they do not prolong the complete treatment period for severely injured patients up to discharge from the resuscitation room. The outcome of patients suffering from traumatic cardiac arrest is better than expected. Recently developed algorithms for trauma patients have to be implemented. The prehospital trauma life support (PHTLS) and advanced trauma life support (ATLS) shock classification does not reflect the clinical reality; therefore, lactate, lactate clearance and base deficit should be used for evaluating the shock state in the resuscitation room. Concerning coagulation therapy, tranexamic acid is easy to administer, safe and effective as an antifibrinolytic therapy and should not be restricted to the most severely injured patients. Numerous studies have shown the positive effect of whole-body computed tomography on treatment time and outcome; however, clear indications for the use of whole-body computed tomography are lacking. Further investigations supported the positive effects of air rescue on the treatment outcome of trauma patients. CONCLUSION The recommendations on interdisciplinary trauma management contained in the S3 guidelines on the treatment of patients with severe and multiple injuries should be implemented into the clinical routine. Additionally, the knowledge gained from more recent scientific studies is necessary for anesthetists and emergency physicians to be able to adequately implement the core statements of the S3 guidelines for the treatment of patients with severe and multiple injuries.

Background —The results of early conventional tests do not correlate with cerebral outcome after cardiac arrest. We investigated the serum levels of astroglial protein S-100 as an early marker of brain damage and outcome after cardiac arrest. Methods and Results —In 66 patients undergoing cardiopulmonary resuscitation after nontraumatic cardiac arrest, blood samples for the evaluation of S-100 were drawn immediately after and 15, 30, 45, and 60 minutes; 2, 8, 24, 48, and 72 hours; and 7 days after initiation of cardiopulmonary resuscitation. Moreover, the serum levels of neuron-specific enolase were determined between 2 hours and 7 days. If patients survived for >48 hours, brain damage was assessed by a combination of neurological, cranial CT, and electrophysiological examinations. Overall, 343 blood samples were taken for the determination of S-100. Maximum S-100 levels within 2 hours after cardiac arrest were significantly higher in patients with documented brain damage (survivors and nonsurvivors, 3.70±0.77 μg/L) than in patients without brain damage (0.90±0.29 μg/L). Significant differences between these 2 groups were observed from 30 minutes until 7 days after cardiac arrest. In addition, the positive predictive value of the S-100 test at 24 hours for fatal outcome within 14 days was 87%, and the negative predictive value was 100% ( P Conclusions —Astroglial protein S-100 is an early and sensitive marker of hypoxic brain damage and short-term outcome after cardiac arrest in humans.

Background —Recent data suggest that inhaled NO can inhibit platelet aggregation. This study investigates whether inhaled NO affects the expression level and avidity of platelet membrane receptors that mediate platelet adhesion and aggregation. Methods and Results —In 30 healthy volunteers, platelet-rich plasma was incubated with an air/5% CO 2 mixture containing 0, 100, 450, and 884 ppm inhaled NO. ADP- and collagen-induced platelet aggregation, the membrane expression of P-selectin, and the binding of fibrinogen to the platelet glycoprotein (GP) IIb/IIIa receptor were determined before (t 0 ) and during the 240 minutes of incubation. In addition, eight patients suffering from severe adult respiratory distress syndrome (ARDS) were investigated before and 120 minutes after the beginning of administration of 10 ppm inhaled NO. In vitro, NO led to a dose-dependent inhibition of both ADP-induced (3±3% at 884 ppm versus 70±6% at 0 ppm after 240 minutes; P P 0 value; P P P Conclusions —NO-dependent inhibition of platelet aggregation may be caused by a decrease in fibrinogen binding to the platelet GP IIb/IIIa receptor.

UNLABELLED After cardiac surgery, magnesium is often administered for prophylaxis and treatment of cardiac arrhythmias. Magnesium, however, inhibits platelet function in vitro and in healthy volunteers. We performed a randomized, blinded, and placebo-controlled study to investigate the effect of magnesium on platelet function in patients after cardiac surgery. We studied patients who underwent uneventful coronary revascularization with cardiopulmonary bypass on the first postoperative day. Before and after an infusion of either 5.4 mmol magnesium (n = 19) or saline (n = 20), platelet function was investigated by means of in vitro bleeding time, platelet aggregation, and flow-cytometric assays. In addition, to investigate platelet function in vitro, 1, 5, and 10 mM magnesium were added to platelet-rich plasma before and 24 h after surgery in 30 patients. Compared with the control group, magnesium prolonged the in vitro bleeding time (22%) and inhibited ADP- and collagen-induced platelet aggregation (13% and 17%), platelet P-selectin expression (18%), and the binding of fibrinogen to the platelet glycoprotein IIb/IIIa receptor (10%). Magnesium also led to significant dose-dependent inhibition of platelet aggregation (19%), P-selectin expression (14%), and fibrinogen binding (11%) before and after surgery in vitro. Although the antithrombotic effect of magnesium may be beneficial in patients after coronary revascularization, large-dose magnesium therapy should be carefully considered in patients with impaired platelet function and co-existing bleeding disorders. IMPLICATIONS In a randomized, blinded, placebo-controlled study of patients 24 h after coronary artery bypass grafting, IV administered magnesium inhibited platelet function in vitro and in vivo.