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Introduction: Learning motivation is essential to obtain and maintain ultrasound competencies in emergency medicine. One's competencies herein and the need for ongoing training are best evaluated by self-assessment. This may be flawed by overconfidence effects - the belief to be better than others or better than tests reveal. This study aims to clarify the underinvestigated interaction of learning motivation and self-assessment in emergency point-of-care-ultrasound (POCUS)., Methods: In this cross-sectional multicenter project, physicians assessed their own and others' competence and learning motivation using the Situational Motivation Scale comprising intrinsic motivation, external and identified regulation, and amotivation. In addition, we presented eight ultrasound loops of different pathologies to emergency physicians of various specialties., Results: Overall, the motivation to learn was high, while self-assessment showed no significant overconfidence in POCUS. The rate of correct diagnoses based on the loops was relatively low. As a result, we did not detect overconfidence effects in participants who completed questions (n = 86) and tests (n = 56). Overplacing oneself above peers negatively correlated with intrinsic learning motivation and identified regulation and positively correlated to amotivation. Further analyses indicated that learning motivation was associated with the interactions of the physicians' risk perception, speciality, and self-assessment., Discussion: The absence of overconfidence effects, the complexity of learning motivation and their interaction show that prior findings in other contexts may not be easily transferable to POCUS and could be highly context-sensitive. In conclusion, this study highlights high levels of learning motivation but relatively low diagnostic accuracy in POCUS, which suggests the need for ongoing education and assessment. Ensuring that physicians continue to receive objective feedback and opportunities to refine their skills is critical for maintaining high standards of care. Despite the small sample size and other limitations of the study, the results primarily served to generate hypotheses for future research on emergency ultrasound education., Competing Interests: Declarations. Ethics approval and consent to participate: The study was conducted after approval by the ethical committee of the University of Freiburg (EK: 22-1201-S1, Decision on 14.06.22). The study was conducted in accordance with the Declaration of Helsinki and national recommendations and law. Data safety was ensured by blinding IP-Adresses. Informed consent for participation was obtained from all participants. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Introduction: Despite high vulnerability to infection, hand disinfection compliance in emergencies is low. This is regularly justified as the disinfection procedure delays life support, and instead, wearing disposable gloves is preferred. Simulation studies showed higher achievable compliance than detected in real-life situations. This study aimed to explore healthcare providers' attitudes toward hand disinfection and using gloves in emergencies., Methods: We conducted an anonymous online survey in Germany on the attitude and subjective behavior in the five moments of hand hygiene in a closed environment and an open convenience sampling survey. Statistics included paired student's t -tests corrected for multiple testing. For qualitative analysis, we employed a single-coder approach., Results: In 400 participants, we detected low priority of WHO-1 (before touching a patient) and WHO-2 (before clean/aseptic procedure) hand hygiene moments, despite knowing the risks of omission of hand disinfection. For all moments, self-assessment exceeded the assessment of colleagues ( p < 0.001). For WHO-3, we detected a lower disinfection priority for wearing gloves compared to contaminated bare hands. Qualitative analyses revealed five themes: basic conditions, didactic implementations, cognitive load, and uncertainty about feasibility and efficacy., Discussion: Considering bias, the study's subjective nature, the unknown role of emergency-related infections contributing to hospital-acquired infections, and different experiences of healthcare providers, we conclude that hand disinfection before emergencies is de-prioritized and justified by the emergency situation regardless of the objective feasibility., Conclusion: This study reveals subjective and objective barriers to implementation of WHO-1 and WHO-2 moments of hand disinfection to be further evaluated and addressed in educational programs., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier Ltd.)

Background: Paediatric emergencies are challenging for healthcare workers, first aiders, and parents waiting for emergency medical services to arrive. With the expected rise of virtual assistants, people will likely seek help from such digital AI tools, especially in regions lacking emergency medical services. Large Language Models like ChatGPT proved effective in providing health-related information and are competent in medical exams but are questioned regarding patient safety. Currently, there is no information on ChatGPT's performance in supporting parents in paediatric emergencies requiring help from emergency medical services. This study aimed to test 20 paediatric and two basic life support case vignettes for ChatGPT and GPT-4 performance and safety in children., Methods: We provided the cases three times each to two models, ChatGPT and GPT-4, and assessed the diagnostic accuracy, emergency call advice, and the validity of advice given to parents., Results: Both models recognized the emergency in the cases, except for septic shock and pulmonary embolism, and identified the correct diagnosis in 94%. However, ChatGPT/GPT-4 reliably advised to call emergency services only in 12 of 22 cases (54%), gave correct first aid instructions in 9 cases (45%) and incorrectly advised advanced life support techniques to parents in 3 of 22 cases (13.6%)., Conclusion: Considering these results of the recent ChatGPT versions, the validity, reliability and thus safety of ChatGPT/GPT-4 as an emergency support tool is questionable. However, whether humans would perform better in the same situation is uncertain. Moreover, other studies have shown that human emergency call operators are also inaccurate, partly with worse performance than ChatGPT/GPT-4 in our study. However, one of the main limitations of the study is that we used prototypical cases, and the management may differ from urban to rural areas and between different countries, indicating the need for further evaluation of the context sensitivity and adaptability of the model. Nevertheless, ChatGPT and the new versions under development may be promising tools for assisting lay first responders, operators, and professionals in diagnosing a paediatric emergency., Trial Registration: Not applicable., (© 2023. The Author(s).)

Aim of the Study: Regular refresher skill courses are necessary to maintain competence in basic life support. The utilization of these training programs strongly depends on the motivation to learn. Learning motivation may be affected by overconfidence and clinical tribalism, as they both imply a higher competence compared to others, and therefore, a lower demand for training. This study aimed to assess how overconfidence in basic life support competencies affects learning motivation., Methods: We conducted a cross-sectional, observational, multicenter, anonymous online questionnaire survey using validated psychometric tests for healthcare professionals in Germany. Further, we tested participants' knowledge and attitude regarding international basic life support guidelines. The study was conducted between March and April 2022, and healthcare providers from 22 German emergency medical services and hospitals at all levels were assessed., Results: Of 2,000 healthcare professionals assessed, 407 completed the assessment (response rate, 20.4%). We confirmed the presence of overconfidence and clinical tribalism (identity differentiation between social groups) among the 407 physicians, nurses, and emergency medical service providers who completed the survey. Three different learning-motivation groups emerged from cluster analysis: "experts" (confident and motivated), "recruitables" (overconfident and motivated), and "unawares" (overconfident and unmotivated). The three groups were present in all professional groups, independent of the frequency of exposure to cardiac arrest and educational level., Conclusions: These findings showed the presence of overconfidence effects and different learning motivation types in individuals learning basic life support, even in instructors., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Background and Aim: There are no investigations on hand hygiene during cardiopulmonary resuscitation (CPR), even though these patients are at high risk for healthcare-associated infections. We aimed to evaluate the number of indicated hand hygiene per CPR case in general and the fraction that could be accomplished without delay for other life-saving techniques through standardized observations., Materials and Methods: In 2022, we conducted Advanced Cardiovascular Life Support (ACLS) courses over 4 days, practicing 33 ACLS case vignettes with standard measurements of chest compression fractions and hand hygiene indications. A total of nine healthcare workers (six nurses and three physicians) participated., Results: A total of 33 training scenarios resulted in 613 indications for hand disinfection. Of these, 150 (24%) occurred before patient contact and 310 (51%) before aseptic activities. In 282 out of 310 (91%) indications, which have the highest impact on patient safety, the medication administrator was responsible; in 28 out of 310 (9%) indications, the airway manager was responsible. Depending on the scenario and assuming 15 s to be sufficient for alcoholic disinfection, 56-100% (mean 84.1%, SD ± 13.1%) of all indications could have been accomplished without delaying patient resuscitation. Percentages were lower for 30-s of exposure time., Conclusion: To the best of our knowledge, this is the first study investigating the feasibility of hand hygiene in a manikin CPR study. Even if the feasibility is overestimated due to the study setup, the fundamental conclusion is that a relevant part of the WHO indications for hand disinfection can be implemented without compromising quality in acute care, thus increasing the overall quality of patient care., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Bushuven, Bansbach, Bentele, Bentele, Gerber, Reinoso-Schiller and Scheithauer.)

Background: Effective analgosedation for control of dyspnoea and for toleration of prone positioning (PP) in severe coronavirus disease 2019 (COVID-19) associated acute respiratory distress syndrome (ARDS) is difficult to adjust. This study was designed to evaluate the feasibility and safety of sedation with inhaled sevoflurane in combination with intravenous esketamine during PP in patients with COVID-19-ARDS (CARDS)., Methods: All mechanically ventilated COVID-19 patients admitted to the departmental intensive care unit from March to June 2020 were included in this epidemiological cohort study. Patients were sedated with inhaled sevoflurane in combination with eske-tamine during PP and not or only lightly sedated during the supine position. Assisted spontaneous breathing was applied in both prone and supine position., Results: Adverse events were documented prospectively, and routine ventilation parameters, hemodynamic parameters, Richmond Agitation and Sedation Scale (RASS) and sevoflurane consumption were monitored. Altogether, 146 episodes of PP in 15 patients were observed. No severe sedation-related event was observed during 2610 hours of PP. In 2498 hours (96%) patients were successfully converted to a pressure-supported spontaneous breathing mode., Conclusions: Inhaled sedation with the AnaConDa-S-System (Sedana Medical AB, Danderyd, Sweden) alone is insufficient as soon as minute volume exceeds 7-8 L min-1, most likely due to technical reasons. Inhaled sedation with sevoflurane in combination with esketamine, however, safely enables prolonged prone positioning in patients with CARDS. Moreover, sedation depth was light enough to enable assisted spontaneous breathing during prone positioning.

Background: Thromboembolism and bleeding contribute to Coronavirus disease 2019 (COVID-19)'s morbidity and mortality and are also frequent complications of venovenous extracorporeal membrane oxygenation (vvECMO). As the interaction of the underlying pathologies caused by vvECMO in COVID-19 is barely understood, we designed this study to better differentiate coagulation disorders in COVID-19 patients before, during and after vvECMO-support., Methods: Observational case series, six consecutive patients with Coronavirus acute respiratory distress syndrome supported with vvECMO treated in the anaesthesiologic ICU in a third level University ECMO-centre. We measured routine coagulation parameters and assessed coagulation factors. We also conducted advanced von Willebrand factor (VWF) multimer analysis, platelet aggregometry and immunological screening., Results: We identified various phases of coagulation disorders: Initially, intensely activated coagulation with highly increased VWF and factor VIII activity in acute COVID-19, then severe acquired von Willebrand syndrome and platelet dysfunction during vvECMO leading to spontaneous bleeding and finally, hypercoagulopathy after vvECMO explantation. Five of six patients developed immunological abnormalities enhancing coagulation., Conclusions: Coronavirus-induced coagulopathy and bleeding disorders during vvECMO cannot be discriminated via 'routine' coagulation tests. Precise and specific analyses followed by the appropriate treatment of coagulation disorders may help us develop tailored therapeutic concepts to better manage the phases described above.

A 67-year-old woman with symptoms of shock was admitted to hospital with a suspected diagnosis of acute pulmonary artery embolism. After ruling out a thromboembolic event, sepsis was diagnosed by using the SOFA score. A CT scan of the chest with contrast revealed phlegmonous inflammation of the subcutis at the level of the right upper arm. After taking two pairs of peripheral blood samples, calculated antibiotic therapy with piperacillin/tazobactam was administered. After administration of an initial volume bolus, the patient could be transferred to the general medical ward in a stable condition with normal serum lactate level. On day one after hospital admission, blood cultures were positive for Pasteurella multocida, a gramnegative rod that belongs to the oral flora of dogs and cats. Intensified history revealed that the patient had been bitten on the forearm by her cat 2 weeks earlier. The patient did not present to a general practitioner. Despite antibiotic therapy, the patient developed increasing leukocytosis with progressive pain and swelling in the area of the right upper arm and the right ankle. On recommendation of the department of infectious diseases antibiotic therapy was escalated to imipenem and transesophageal echocardiography was performed. Endocarditic vegetations could be ruled out. Despite further escalation of the antibiotic regimen, spontaneous pus discharge occurred at the right ankle. A CT scan of the chest as well as the foot and the right ankle with contrast showed new abscess formations in the right thoracic wall between the pectoralis major and minor muscles as well as extensive abscesses in the extensor compartment of the right lower leg. On day 12 after admission, surgical drainage of multiple abscesses was performed, with rapid improvement in general condition and normalized leukocytes. A further six operations were necessary before the patient could be discharged home after 7 weeks of inpatient treatment., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Central principles are interdisciplinary teamwork and keeping the ratio between pulmonary vascular resistance (PVR) and systemic vascular resistance (SVR) balanced to avoid vicious circle with right heart failure and hypoxia., Competing Interests: The legal representative of the patient gave his consent for publishing the case report and the images.None., (© 2021 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.)

Objectives: Renal replacement therapy in coronavirus disease 2019 patients is complicated by increased activation of the coagulation system. This may worsen the quality of hemodialysis and contribute to a shortage of dialysis machines as well as plastic disposables during the pandemic. This study describes a simple and safe protocol of anticoagulation with low-molecular-weight heparin in combination with bedside sustained low-efficiency hemodialysis in coronavirus disease 2019 patients., Design: Monocentric observational cross-over trial investigating sustained low-efficiency hemodialysis with unfractionated heparin following sustained low-efficiency hemodialysis with low-molecular-weight heparin., Setting: Coronavirus disease 2019-ICU in a German Tertiary Care University Hospital., Patients: Three consecutive severe coronavirus disease 2019 patients receiving nine sustained low-efficiency hemodialysis therapies with unfractionated heparin followed by 18 sustained low-efficiency hemodialysis therapies with low-molecular-weight heparin., Interventions: Switch from IV unfractionated heparin to subcutaneous low-molecular-weight heparin enoxaparin in therapeutic doses for patients receiving bedside sustained low-efficiency hemodialysis., Measurements and Main Results: Nine renal replacement therapy sessions in patients anticoagulated with high doses of unfractionated heparin had to be discontinuated prematurely because of clotting of tubes or membrane and poor quality of hemodialysis. In the same patients, the switch to anticoagulation with therapeutic doses of the low-molecular-weight heparin enoxaparin allowed undisturbed bedside sustained low-efficiency hemodialysis for at least 12 hours. Quality of hemodialysis was excellent, no bleeding event was observed., Conclusions: Systemic anticoagulation with subcutaneous enoxaparin provides an effective and safe renal replacement procedure in critically ill patients with coronavirus disease 2019 and hypercoagulability. The protocol reduces the risk of filter clotting, blood loss, and poor dialysis quality and may also prevent systemic thromboembolism., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: Lung-protective ventilation and prolonged prone positioning (PP) are presented as essential in treating acute respiratory distress syndrome (ARDS). The optimal respirator mode, however, remains controversial. Pressure-supported spontaneous breathing (PS) during ARDS provides several advantages, but is difficult to achieve during PP because of respiratory depression as a side effect of sedative drugs. This study was designed to evaluate the feasibility and safety of PS during PP in ARDS patients sedated with inhaled sevoflurane., Results: Overall, we have observed 4339 h of prone positioning in 62 patients who had a median of four prone episodes during treatment. Within 3948 h (91%), patients were successfully brought into a pressure-supported spontaneous breathing mode. The median duration of each prone episode was 17 h (IQR 3). Median duration of pressure-supported spontaneous breathing per episode was 16 h (IQR 5). Just one self-extubation occurred during 276 episodes of PP., Conclusions and Implications: Pressure-supported spontaneous breathing during prolonged prone positioning in intubated ARDS patients with or without ECMO can be achieved during volatile sedation with sevoflurane. This finding may provide a basis upon which to question the latest dogma in ARDS treatment. Our concept must be further investigated and compared to controlled ventilation with regard to driving pressure, lung-protective parameters, muscle weakness and mortality before it can be routinely applied.

Long-term success of lung transplantation is limited by allograft dysfunction and frequent infections. Varicella zoster virus infection (VZV) is one of the most common opportunistic infections among solid organ transplantation recipients. However the occurrence of visceral involvement or disseminated disease, as seen after bone marrow transplantation, is rare. We report a case of a 59-year-old woman who underwent double-lung transplantation with a fatal visceral and disseminated varicella zoster virus infection., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by reversible multifocal narrowing of cerebral arteries heralded by sudden (thunderclap) headaches with or without neurological deficits, resolving within 3 months. It often occurs in the peripartum period. To date, the ideal treatment remains unclear. Here, we report the case of a 31-year-old primigravida who presented with intracranial hemorrhage and went on to develop RCVS and acute respiratory distress syndrome over the course of her illness. Her condition was further complicated by uterine atony and septic shock.We describe for the first time the use of short-acting volatile sedation for prone positioning in acute respiratory distress syndrome during RCVS.