Markus Stuhr

Die Sepsis in der Notfallmedizin – Präklinische und frühe innerklinische Notfalltherapie

Sepsis is a complex life threatening disease whose outcome decisively depends on a fast diagnosis and treatment. Emergency Medicine is confronted with the task to identify theses septic patients reliably and initiate early goal directed therapy and treatment with antibiotics as soon as possible to avoid a dangerous delay and reduce sepsis-related mortality. This article presents a review focused on the early steps of sepsis therapy in pre-hospital and early in-hospital emergency medicine.

[Cooperation between emergency and forensic medicine - retrospective evaluation of pre-hospital emergency measures].

Emergency medical research is subject to special conditions. Emergency patients e.g. are generally considered to be non-capable of giving consent. This results in sparse emergency medical data when compared to clinical observation studies under controlled conditions. After emergency medical treatment, deceased patients are not rarely subject to forensic investigation. The cooperation between emergency and forensic medicine has not only emergency medical training potential in individual cases, but also scientific innovation potential especially with respect to the retrospective evaluation of pre-hospital emergency measures. Such partnerships (like in Berlin at the Charité - Universitätsmedizin Berlin between the Institute of Legal Medicine and the Center for Musculoskeletal Surgery or in Hamburg between the Institute for Legal Medicine at the University Hospital and the Municipal Fire Brigade with the Emergency Medical Service) are yet exceptional in Germany.

Relationship between ambient temperature and frequency and severity of cardiovascular emergencies: A prospective observational study based on out-of-hospital care data

OBJECTIVE To test the hypothesis that more cardiovascular emergencies occur at low rather than at high temperatures under moderate climatic conditions. METHODS This was a prospective observational study performed in a prehospital setting. Data from the Emergency Medical Service in Hamburg (Germany) and from the local weather station were evaluated over a 5-year period. Temperature data were matched with the associated rescue mission data. Lowess-Regression analysis was performed to assess the relationship between the temperature and the frequency of individual cardiovascular emergencies. In addition, three threshold-temperatures (0°C, 10°C, 20°C) were defined in order to determine the frequency of cardiovascular emergencies above and below each cut-off value. The severity of emergencies was assessed using the National Advisory Committee for Aeronautics (NACA) scoring system. RESULTS A total of 35,390 cardiovascular emergencies were treated by Emergency Physicians. Transient Loss of Consciousness increased at high temperatures (above 20°C): +43% (95%-CI: [27%; 59%]). In contrast, Coronary Artery Disease +26% (95%-CI: [17%; 34%]), Cardiac Pulmonary Edema +21% (95%-CI: [14%; 27%]), Hypertensive Urgency +18% (95%-CI: [10%; 25%]) and Cerebrovascular Accident +17% (95%-CI: [8%; 24%]) increased at low temperatures, particularly below 10°C (significance level for all: p<0.001). No temperature-related effect was seen in Cardiac Arrhythmia and Pulmonary Embolism and no significant correlation was found between the severity of emergencies and temperature. CONCLUSIONS Our findings suggest that some cardiovascular emergencies such as Coronary Artery Disease, Cardiac Pulmonary Edema, Hypertensive Urgency and Cerebrovascular Accident are more frequent in low temperatures even under mild climatic conditions.

Intoxications in the prehospital setting

Poisoning is an uncommon indication for the activation of the emergency medical service. Personal safety of the rescue team especially in situations with unknown toxins has highest priority. The goal of prehospital treatment includes symptom driven standard procedures as well as a specific treatment by antidotes. Hospital admission is strongly influenced by the further treatment options.

Medical coverage of a road bicycle race

Major sport events require adequate expertise and experience concerning medical coverage and support. Medical and ambulance services need to cover both participants and spectators. Likewise, residents at the venue need to be provided for. Concepts have to include the possibility of major incidents related to the event. Using the example of the Hamburg Cyclassics, a road bicycle race and major event for professional and amateur cyclists, this article describes the medical coverage, number of patients, types of injuries and emergencies. Objectives regarding the planning of future events and essential medical coverage are consequently discussed.

Molecular autopsy of sudden unexplained deaths reveals genetic predispositions for cardiac diseases among young forensic cases

Aims Coronary artery disease accounts for the majority of sudden cardiac deaths (SCD) in the older population whereas cardiomyopathies and arrhythmogenic abnormalities predominate in younger SCD victims (<35 years) with a significant genetic component. The elucidation of the pathogenetic cause of death might be relevant for the prevention of further deaths within affected families. Aim of this study was to determine the portion of underlying genetic heart diseases among unexplained putative SCD cases from a large German forensic department. Methods and results We included 10 forensic cases of sudden unexplained death (SUD) victims aged 19-40 years, who died by SCD due to forensic autopsy. DNA was analysed by next generation panel sequencing of 174 candidate genes for channelopathies and cardiomyopathies. Cardiological examinations, genetic counselling, and subsequent genetic testing were offered to all affected families. We identified within 1 year 10 cases of SUD among 172 forensic cases. Evidence for a genetic disposition was found in 8 of 10 (80%) cases, with pathogenic mutations in 3 and variants of uncertain significance in 5 of SCD cases. Subsequent selective screening of family members revealed two additional mutation carriers. Conclusion The study provides strong evidence that molecular genetics improves the post mortem diagnosis of fatal genetic heart diseases among SUD victims. Molecular genetics should be integrated in forensic and pathological routine practice.

Association between Weather-Related Factors and Cardiac Arrest of Presumed Cardiac Etiology: A Prospective Observational Study Based on Out-of-Hospital Care Data

Abstract Objective: The objective of this study was to determine the association between weather-related factors and out-of-hospital cardiac arrest (OHCA) of presumed cardiac etiology. Methods: This was a prospective observational study performed in a prehospital setting. Data from the Emergency Medical Service in Hamburg (Germany) and data from the local weather station were evaluated over a 5-year period. Weather data (temperature, humidity, air pressure, wind speed) were obtained every minute and matched with the associated rescue mission data. Lowess-Regression analysis was performed to assess the relationship between the above-mentioned weather-related factors and OHCA of presumed cardiac etiology. Additionally, varying measuring-ranges were defined for each weather-related factor in order to compare them with each other with regard to the probability of occurrence of OHCA. Results: During the observation period 1,558 OHCA with presumed cardiac etiology were registered (age: 67 ± 19 yrs; 62% male; hospital admission: 37%; survival to hospital discharge: 6.7%). Compared to moderate temperatures (5 – 25°C), probability of OHCA-occurrence increased significantly at temperatures above 25°C (p = 0.028) and below 5°C p = 0.011). Regarding air humidity, probability of OHCA-occurrence increased below a threshold-value of 75% compared to values above this cut-off (p = 0.006). Decreased probability was seen at moderate atmospheric pressure (1000 hPa – 1020 hPa), whereas increased probability was seen above 1020 hPa (p = 0.023) and below 1000 hPa (p = 0.035). Probability of OHCA-occurrence increased continuously with increasing wind speed (p < 0.001). Conclusions: There are associations between several weather-related factors such as temperature, humidity, air pressure, and wind speed, and occurrence of OHCA of presumed cardiac etiology. Particularly dangerous seem to be cold weather, dry air and strong wind.

Die akute traumatische Querschnittslähmung – Wie ist präklinisch vorzugehen?

Acute injury to the spine and spinal cord can occur both in isolation as also in the context of multiple injuries. Whereas a few decades ago, the cause of paraplegia was almost exclusively traumatic, the ratio of traumatic to non-traumatic causes in Germany is currently almost equivalent. In acute treatment of spinal cord injury, restoration and maintenance of vital functions, selective control of circulation parameters, and avoidance of positioning or transport-related additional damage are in the foreground. This article provides information on the guideline for emergency treatment of patients with acute injury of the spine and spinal cord in the preclinical phase.

Der adipöse Patient – Bedeutung für den Rettungsdienst

Nicht nur das Gewicht uberschwerer Patienten macht deren praklinische Versorgung problematisch – auch der Korperumfang fuhrt dazu, dass Rettungskrafte und Rettungsmittel haufig an ihre Grenzen stosen. Was man z. B. bei Standardmonitoring, Medikamentengabe und Atemwegsmanagement berucksichtigen sollte, lesen Sie in diesem Beitrag.

Bicycle accident on the way to school - an interactive case report

We report on the case of a multiply injured 14-year-old girl with severe open brain trauma, prehospital cardiopulmonary rescuscitation and immediate decompressive craniectomy. Despite the extremely poor prognosis, a very good outcome has been achieved. We discuss the influence of the time management on the outcome.