Pädiatrische Notfälle in der prähospitalen Notfallmedizin

Background

In emergency medical services (EMS) systems, life-threatening pediatric emergencies comprise a rare indication but represent a particularly emotional and stressful situation for the personnel involved. This study aimed at evaluating the incidence of pediatric emergencies and the measures performed in ground-based and air-based German EMS systems and deriving the necessary skills and qualification of emergency physicians working within EMS systems.

Method

In a retrospective, multicenter study at three physician-staffed EMS systems with four ground based vehicles and one air-based EMS system the patient charts of patients over 18 years of age in 2005 and 2006 were analyzed regarding demography, the type and severity of emergency (NACA score), state of awareness (GCS) and emergency measures performed.

Results

Overall 20,386 patient charts were evaluated. Pediatric emergencies in the air-based EMS system comprised 11.5% of all missions, which is 2-3 fold higher compared to ground-based EMS system with 4.3%. The percentages of children with a NACA score of IV-VII or a GCS<9 in air-based EMS services (55.4% and 13.9%, respectively) exceeded by far the corresponding figures observed in the ground-based EMS systems (20.4%, p<0.01 and 5.8%, p<0.01). Non-traumatic emergencies represented the majority of missions in children aged <1 year and 1?? years. However, with increasing age injuries had a rising impact in the type of rescue mission. Whereas the frequency of certain emergency measures rose in both systems with increasing age of the pediatric patients, others remained constant, intubation of the trachea (7%) and emergency anesthesia (7%), or even declined along with increasing age, CPR (4% vs. 0.3%) and intraosseous access (3% vs. 0.0%). In comparison to the ground-based EMS systems, in the air-based EMS system the ECG monitoring (77% vs 32%, p<0.01), manual blood pressure measurement (80% vs. 51%, p<0.01), pulsoxymetry (96% vs. 73%, p<0.01)] and i.v. access (79% vs. 46%, p<0.01) were used more often and oxygen (73% vs. 32%, p<0.01) and drugs (80% vs. 49%, p<0.01) were administered more often. Also the frequency of intubation of the trachea and emergency anesthesia (17% vs 2%, p<0.01) was higher in air-based EMS systems than in ground-based EMS systems.

Conclusion

Ground-based and air-based EMS systems differ significantly regarding the incidence and the type of pediatric emergency missions. Despite the lower incidence of certain life-saving invasive emergency measures in ground-based EMS systems, the data indicate the necessity for both air-based as well as ground-based emergency physicians to undergo comprehensive and repetitive training in pediatric advanced life support.     

Blitzschlag und Blitzunfälle in der präklinischen Notfallmedizin

Up to 32.2% of patients in a burn center suffer from electrical injuries. Of these patients, 2–4% present with lightning injuries. In Germany, approximately 50 people per year are injured by a lightning strike and 3–7 fatally. Typically, people involved in outdoor activities are endangered and affected. A lightning strike usually produces significantly higher energy doses as compared to those in common electrical injuries. Therefore, injury patterns vary significantly. Especially in high voltage injuries and lightning injuries, internal injuries are of special importance. Mortality ranges between 10 and 30% after a lightning strike. Emergency medical treatment is similar to common electrical injuries. Patients with lightning injuries should be transported to a regional or supraregional trauma center. In 15% of all cases multiple people may be injured. Therefore, it is of outstanding importance to create emergency plans and evacuation plans in good time for mass gatherings endangered by possible lightning.     

Vorsorgedokumente in der präklinischen Notfallmedizin

Background

The handling of advance directives (AD) in prehospital emergency treatment in Germany is characterized by instability. In the project “Advance directives in preclinical emergency medical aid” (“Patientenverfügungen in der präklinischen Notfallmedizin”) the frequency and quality of ADs in emergency situations was investigated.

Aim

The aim of this study was to fill the gaps in research and to collate data on how consideration of the self-determination of patients in emergency situations can be optimized.

Material and methods

Over a period of 12 months from December 2007 to December 2008 a questionnaire was included in the emergency documentation of the medical emergency service in Aachen. Emergency patients were asked by emergency physicians to provide an AD and the quantitative as well as qualitative features of these ADs were examined. Furthermore, the study recorded what kinds of problems occurred with ADs in emergency situations and what measures were needed to correct this deficiency. The reactions of patients were documented on a numeral rating scale with a score of 1 reflecting a negative and 10 reflecting a positive reaction. In the 12-month period emergency doctors recorded 1,321 missions and after application of the exclusion criteria (e.g. missing signature, incomplete documentation and late delivery) 1,047 documented questionnaires were available for the analysis.

Results

A total of 127 out of 1,047 emergency patients provided an AD, 44 had a durable power of attorney and 27 had appointed a legal representative for healthcare. Of the emergency patients 20 had a legal attendant and 43 out of the 127 ADs could be presented to the emergency team during the emergency mission. The emergency team often encountered difficulties regarding the handling of the ADs due to the time factor and unclear wording. The latter included the following problems: misleading formulation (19.1?%), difficulty with the complexity (14.9?%) and contradicting information (4?%). Only 29 (61.7?%) of the durable powers of attorney were signed and legally binding. From the view of the emergency physicians the following information was lacking but would be helpful in emergency situations: emergency plan, hierarchy of those given power of attorney, knowledge of risks regarding ADs and medication requirements.

Conclusion

The results show that for an AD to apply in an emergency situation certain standards are necessary that assure the practicability, especially if a patient does not wish to be resuscitated. Most difficulties with ADs occurred with imprecise formulation, text length and inconsistency of statements. The following instructions were usually missing: hierarchy of those given power of attorney and specification on medication, information about the scope of the ADs, statement about resuscitation, extent and limitations of the desired treatment, especially with patients certified as terminally ill and instructions on who should decide about medical treatment in a conflict situation. A so-called emergency instruction which gives on a single page the patient’s statement on resuscitation would have been very helpful in individual cases. The results suggest that patients may need more information and education about AD to guarantee patients rights and self-determination.     

Kritische Zwischenfälle im Atemwegsmanagement der präklinischen Notfallmedizin

Background

Many patients are victims of disastrous incidents during medical interventions. One of the obligations of physicians is to identify these incidents and to subsequently develop preventive strategies in order to prevent future events. Airway management and prehospital emergency medicine are of particular interest as both categories frequently show very dynamic developments. Incidents in this particular area can lead to serious injury but at the same time it has never been analyzed what kind of incidents might harm patients during prehospital airway management.

Materials and methods

The German website http://www.cirs-notfallmedizin.de (CIRS critical incident reporting systems) offers anonymous reporting of critical incidents in prehospital emergency medicine. All incidents reported between 2005 and 2012 were screened to identify those which were concerned with airway management and four experts in this field analyzed the incidents and performed a root cause analysis.

Results

The database contained 845 reports. The authors considered 144 reports to be airway management related and identified 10 root causes: indications for intubation but no intubation performed (n?=?8), no indications for intubation but intubation attempt performed (n?=?7), wrong medication (n?=?25), insufficient practical skills (n?=?46), no use of alternative airway management (n?=?7), insufficient handling before or after intubation (n?=?27), defect equipment (n=28), lack of equipment (n?=?31), others (n?=?18) and factors that cannot be influenced (n?=?12).

Conclusions

The incidents that were reported via the website http://www.cirs-notfallmedizin.de and that occurred during airway management in prehospital emergency medicine are described. To improve practical airway management skills of emergency physicians are one of the most important tasks in order to prevent critical incidents and are discussed in the article.     

Organisationsmodelle der präklinischen Notfallmedizin

When comparing the well-established model of the functional organization structure with the model of the process-orientated organization structure, problems are perceived in the effective coordination of all system partners. A lack of communication, documentation and feedback, a large number of unnecessary emergency missions with physicians and undue costs in some areas of the system have a negative effect on motivation, efficient teamwork and satisfaction of staff and patients. Therefore, a restructuring of out-of-hospital emergency medicine towards a process-orientated approach to organization is highly recommended in the context of quality management.     

Blutstillung mittels Tourniquet in der präklinischen Notfallmedizin

Background

Until recently the use of tourniquets was considered to be obsolete due to the known side effects and complications. Tourniquet application was seen as a last resort to stop life-threatening extremity bleeding by placing “life before limb”. In the past the main reasons for complications were application errors and the use of poorly designed products.

Present situation

The actual loss of a limb due to tourniquet use is a rarity and now the positive experiences of the military conflicts in Iraq and Afghanistan are throwing a new light on this method to “stop the bleeding”. The SOP-based application of modern trusted and tested tourniquets by trained users for a period up to 2 h is considered to be a fast, safe and life-saving procedure.

Conclusions

This evidence is reflected by the current data; therefore, the civilian emergency services should be provided with commercially manufactured tourniquets. To prevent potential complications it is important that civilian medical personnel are regularly trained in the correct SOP-based use of tourniquets. Special police units should have personnel trained in tactical combat casualty care in the units who can control massive limb bleeding in a “care under fire” situation by tourniquet use before the civilian emergency medical services take over casualty care. In Germany the Tactical Rescue and Emergency Medicine Association (TREMA) has developed specific guidelines for tactical casualty care.     

Kontinuierliche Qualitätsverbesserung in der präklinischen Notfallmedizin

In this article the first implementation step of a quality management (QM) model for continuous quality improvement (CQI), in particular the PDCA cycle, by using the example of the Medical University Innsbruck emergency department and the Austrian Red Cross, Freiwillige Rettung (Voluntary Rescue) Innsbruck (FRI) is described. Using two questionnaires concerning personnel satisfaction main problem areas were identified and improvements suggested. The results serve to discuss whether the two organizations involved fulfil the necessary conditions for the QM approach of CQI.     

Methoden des Atemwegsmanagements in der präklinischen Notfallmedizin

In the majority of emergency situations definite airway control can be achieved by endotracheal intubation with or without preceding bag valve mask ventilation. However, both techniques can fail because of many different reasons. Therefore, alternative techniques for routine anaesthesia and emergency situations are required. In the present article difficulties that may arise using bag valve mask ventilation and endotracheal intubation are discussed and an overview of available alternatives is given.     

Ruhigstellung von Frakturen in der präklinischen Notfallmedizin

Notfall + Rettungsmedizin - In Deutschland ereignen sich etwa 2,6&nbsp;Mio. Verkehrsunfälle/Jahr mit einer relevanten Zahl an Extremitäten‑, Becken- und...     

Die intraossäre Punktion in der präklinischen Notfallmedizin

INTRODUCTION: The intraosseous puncture (IO) is a fast and safe alternative to the puncture of peripheral veins in emergency situations in children < or =6 years of age. The purpose of this paper is to summarize 10 years of experience on the prehospital use of the IO method by the Helicopter Emergency Medical Service (HEMS) "Christoph 22", Ulm. MATERIALS AND METHODS: This was a retrospective study from 1 January 1996 to 31 December 2005. RESULTS: Out of a total of 9,549 missions, the proportion of children was 11.1%. In 27 children (4.2% of the children < or =6 years of age) an IO puncture was performed. Patients of the IO group were younger (1.0 vs. 3.7 years of age; p<0.001) and showed a higher degree of injury severity (NACA 6 vs. 4; p<0.001) compared to the total children group. In all children of the IO group (100%), the intraosseous puncture was the method of first choice to obtain access to the vascular system by the HEMS team. In 96.4% of these cases (26/27), the first IO puncture attempt was successful - in one child, a second puncture attempt was necessary. A standardized puncture technique was performed using the proximal tibia. The time required for successful placement of the IO infusion line was 60 s or less in all cases. In 37% of the cases (10/27) the IO infusion line was used for induction of general anaesthesia; dosage and onset of administered drugs were described as being equivalent to a peripheral infusion line. In all cases, the IO needle was replaced in-hospital within 2 h by a central or peripheral iv line. No complications were observed. CONCLUSIONS: The IO infusion technique is a simple, fast and safe alternative method for emergency access to the vascular system in children < or =6 years of age in the prehospital setting.     

Patientenzufriedenheit in der pr?klinischen Notfallmedizin

Introduction

The study primarily aimed to develop a standardized, psychometrically tested and validated questionnaire to assess patient satisfaction with out-of hospital emergency care. The second aim was to analyze the quality of care provided by emergency medical services (EMS).

Methods

Accomplishment of tasks was designed in three sections a) interviews of focus groups to specify four quality categories (emergency call, emergency treatment, transport, admission to hospital) and development of a questionnaire, b) conduction of the main study and c) psychometric analysis and evaluation of the questionnaire regarding practicability, validity and reliability.

Results

A total of 437 questionnaires were evaluated and the four quality categories showed high satisfaction rates (means: 84?C94 points on a 0?C100 scale). The values correlated with the total quality score (r=0.6-0.81). In the main study transport showed the highest impact in total satisfaction, followed by emergency treatment. The item social support showed high dissatisfaction scores.

Conclusions

The psychometrically tested and validated questionnaire proved to be valuable for benchmarking studies. From the patient point of view satisfaction with out-of hospital emergency care can be improved regarding social environment and training of social and emotional skills of rescue personnel.     

Videolaryngoskopie in der pr?klinischen Notfallmedizin

Endotracheal intubation in a prehospital emergency situation represents the most challenging task for emergency physicians in the field of securing the airway. Video laryngoscopy can be utilized to optimize visualization of the airway, particularly under circumstances where external patient features or mission conditions indicate the presence of a difficult airway, to increase the chance of success for intubation and therefore patient safety. For the prehospital use under difficult intubation conditions it would appear particularly appropriate to utilize Macintosh-based video laryngoscopes. For the few isolated cases where for anatomical reasons a Macintosh-based video laryngoscope does not provide sufficient visualization of the glottis, the possibility to change to a more curved spatula blade within the same video laryngoscope system with no substantial time delay is an additional advantage.     

Notfälle in der Augenheilkunde

Notfall + Rettungsmedizin - Die hohe Bedeutung des Sehens in unserer visuellen Mediengesellschaft rückt das sensorische Organ Auge bei akuten Sehstörungen bzw. Verletzungen ins Zentrum...     

Chirurgische Atemwegssicherung in der pr?klinischen Notfallmedizin

In all of the numerous recommendations of various national as well as international medical societies on the management of a difficult airway, cricothyroidotomy is the life-saving procedure and the final ??cannot intubate?Ccannot ventilate?? option, whether in the prehospital, emergency department, intensive care unit or the operating room patient. The surgical approach to the airway in the prehospital setting is synonymous with emergency cricothyroidotomy. In the literature emergency cricothyroidotomy is described as an ??infrequent?? or ??uncommon?? procedure. In paramedic-based emergency medical services (EMS) systems, the incidence is significantly higher than in physician-based EMS systems (10.9?C14% vs. 0.1?C3.3%). A number of different techniques for performing cricothyroidotomy have been described in the literature. All these techniques can in principle be assigned to two groups: anatomical surgical techniques and puncture techniques. There is no technique which equally fulfills all requirements for emergency cricothyroidotomy in the prehospital setting (i.e. fast airway access + easy to use + low complication rate). Studies indicate complication rates for cricothyroidotomy up to approximately 40% when performed under emergency conditions. The surgical airway (cricothyroidotomy) must be part of a defined and clearly structured difficult airway algorithm. Providers have to be trained in this algorithm and especially in the technique of cricothyroidotomy. Within this context it is recommended to ??do what you can do best?? (e.g. surgeons should use the surgical technique and anesthesiologists should use the puncture technique).     

Qualitative Forschungsmethoden in der pr?klinischen Notfallmedizin

Qualitative research methods such as focus group interviews are rarely conducted in out-of-hospital emergency medicine, but such interviews are an important tool to evaluate patient satisfaction concerning the emergency treatment. Besides the medical skills of the emergency team, social, emotional and communicative skills increase the satisfaction of emergency patients and such skills can be analyzed more easily in a face-to-face contact with patients. The evaluation and improvement of these skills would enhance the quality of the emergency treatment, in particular from the perspective of emergency patients.     

Erfolgreicher Einsatz des Intubationsendoskops nach Bonfils in der präklinischen Notfallmedizin

Background

The Bonfils intubation endoscope has been available for securing difficult airways for several years. However, very little is known about its use in a prehospital setting. The aim of this study was to examine the use of the Bonfils intubation fibrescope for endotracheal intubation in a physician-led prehospital emergency medical service.

Material and methods

The Bonfils intubation endoscope was used to secure the airway in patients requiring endotracheal intubation in a prehospital setting. The success rate, total time for securing the airway and possible complications during the procedure were evaluated.

Results

A total of 30 patients were included in this study and in 26 patients (87%) endotracheal intubation was successful at the first attempt. In 3 cases (10%) intubation was successful after the second attempt and endotracheal intubation was unsuccessful in 1 patient due to a technical problem. The median total time until the airway was secured was 17 s (min.: 7 s, max.: 30 s). Vision was limited in 3 cases (10%) due to post-traumatic oropharyngeal bleeding.

Summary

The Bonfils intubation endoscope can be used with a high success rate for securing the airway in a prehospital physician-led emergency medical system. Our data suggests that the Bonfils intubation endoscope might be an alternative device to direct laryngoscopy.     

Lebensbedrohliche Notfälle in der Hals-Nasen-Ohren-Heilkunde

Notfall + Rettungsmedizin - Notärzte werden regelmäßig mit Notfallsituationen aus dem Hals-Nasen-Ohren(HNO)-Bereich konfrontiert. Deren Leitsymptome sind Blutungen, Luftnot,...     

Sepsis in der prähospitalen Notfallmedizin

Notfall + Rettungsmedizin - Die Sepsis ist eine notfallmedizinische Herausforderung&nbsp;– denn diese lebensbedrohliche Organdysfunktion, verursacht durch eine dysregulierte Wirtsantwort...     

Rechtliche Rahmenbedingungen in der präklinischen Notfallversorgung

Notfall + Rettungsmedizin - Der deutsche Rettungsdienst steht durch steigende Fallzahlen sowie den Ärztemangel in ländlichen Gebieten vor einer großen Herausforderung. Trotz dieser...