Overtriage in the trauma resuscitation room (TRR) is often a consequence of admission based solely on trauma mechanism criteria. As interleukin-6 (IL-6) can assess injury severity in critically injured patients, the hypothesis of this study was that IL-6 can differentiate upon admission between mild (Injury Severity Score (ISS) 0–8) and moderate (ISS 9–15) trauma and that the parameter correlates with injury severity in lower injury severity groups (ISS < 16) during the first 24 h. Subsequently, we evaluated the ability to define IL-6 cut-off values with an adequate sensitivity, specificity, and negative predictive value to distinguish between moderate and mild injuries. Fifty patients admitted to the TRR solely based on trauma mechanism criteria and with an ISS < 16 were included in the study. IL-6 was measured at admission, 1, 6, 12 and 24 h later. Thirty-one patients were mildly injured (ISS 0–8), while nineteen patients sustained moderate injuries (ISS 9–15). IL-6 correlated significantly with ISS at all time points. Moderately injured patients showed significantly higher IL-6 levels than mildly injured patients during the first 6 h. IL-6 levels at admission predicted moderate injuries for the IL-6 cut-off value of 2.9pg/ml with a sensitivity of 0.933, specificity of 0.370 and a negative predictive value of 0.970 resulting in undertriage rates of 6.6

Introduction: Effective chest compressions are a core element of cardiopulmonary resuscitation (CPR). Current guidelines recommend exchanging the person performing chest compressions every two minutes to ensure high-quality chest compressions. However, this can lead to several task interruptions, which could result in a prolonged delay until other relevant tasks, such as securing the airway or administering adrenaline, are completed. Some studies have shown that a rescuer can perform sufficient CPR continuously for more than five minutes. Therefore, this study will investigate whether chest compressions without staff changes in the initial phase of CPR result in fewer task interruptions and an earlier completion of relevant tasks. Methods and analysis: To investigate this, a prospective, randomised, monocentric, non-blinded, mannequin study will be conducted. The 32 teams will perform CPR in two simulated settings. Each team consists of four members, according to the German emergency service standard. Before entering the scenario, they will be randomised to either CPR with or without staff changes or either a shockable or non-shockable rhythm. The scenario ends with the fourth rhythm analysis. After a 20-min break, they will enter the second scenario. Teams will be informed whether they should perform continuous or alternating CPR but will not know which rhythm they have been assigned to. The primary outcome will be the time it takes to complete all relevant tasks during the initial CPR phase. Secondary outcomes include chest compression quality, task load, and number of interrupted tasks. Ethics and dissemination: The protocol was approved by the ethics committee of the University of Heidelberg (S-252/2025, June 04, 2025). It is registered with the German Clinical Trials Register (DRKS00037157, June 10, 2025). Participation will be voluntary and based on informed consent. Data will be recorded only in a pseudonymised form. After completion, data will be kept on file for 10 years. The findings will be disseminated in a peer-reviewed academic journal. De-identified data from the case report form will be made publicly available within the first publication. The study will be conducted following the Declaration of Helsinki and relevant laws.

BackgroundHospitals can experience disruption to their operations due to a variety of crisis events. To maintain operational functionality, hospitals are required to implement a hospital incident command (HIC). This study explores the process from routine operations to a staff-based HIC, analyzing how leadership communication and dynamics emerge, evolve, and are negotiated during crisis transitions. The focus lies on interactions between roles, practices, training, and structures under high operational pressure.MethodsThis qualitative, single-site study applied a Grounded Theory methodology and was based on a HIC tabletop exercise conducted following targeted training. Data comprised semi-structured post-exercise interviews with 19 HIC members from diverse professional backgrounds and observational materials (notes and protocols).ResultsThe analysis indicates that the enactment of staff-oriented HIC structures varies along a spectrum of coordination: Explicit orchestration of leadership communication was associated with a shift toward more structured coordination, reflected in clearer role articulation, defined process boundaries, and separation of briefing and operational tasks. Where orchestration was less pronounced, coordination tended to rely on routine practices, accompanied by blurred responsibilities and more fragmented coordination patterns.DiscussionDespite the importance of HIC systems, research in this area remains limited. Analytical propositions frame staff-based incident command in hospitals as an interactionally accomplished practice. Moderation is proposed as a potential enabler of coordination under time pressure and uncertainty, alongside accountability closure, material scaffolding, and boundary management. These mechanisms may be particularly salient in largely untrained hospital collectives and shift attention from formal compliance toward interactional enactment conditions.

Hyperspectral imaging (HSI) is a non-invasive technology capable of assessing microcirculatory impairment. This study evaluated whether HSI can detect early microcirculatory alterations in trauma patients and differentiate between those with hemodynamic instability or stability during initial trauma resuscitation. In this prospective single-center observational study at a German level I trauma center (01/2023-10/2024), patients underwent HSI (TIVITA® 2.0) at three time points: during the primary survey, after resuscitation room care, and 24 h after admission. HSI approximates four microcirculatory parameters: tissue oxygenation saturation (StO₂), tissue water index (TWI), tissue hemoglobin index (THI), and near-infrared perfusion index (NIR). Hemodynamic instability was defined as systolic blood pressure < 90 mmHg for > 10 min, catecholamine use > 10 min, or pronounced clinical signs of hypoperfusion. The primary outcome was the difference in StO₂ between patients with and without hemodynamic instability at the initial HSI measurement. Secondary outcomes included comparison of all HSI parameters between groups, correlations with Injury Severity Score (ISS), biomarkers (lactate, bicarbonate, base excess), and mortality. Statistical analyses comprised t-tests, receiver operator curve (ROC) analyses, diagnostic accuracy, and DeLong's test. A total of 163 patients were analyzed (18 hemodynamic instability, 145 hemodynamic stability). No significant difference in initial StO₂ was observed between groups (hemodynamic instability: 56.50 (SD 17.08) vs. hemodynamic stability: 59.48 (SD 10.92); p = 0.311). Likewise, TWI, THI, and NIR showed no significant differences. Initial elevated lactate levels (≥ 2 mmol/L) were associated with significantly lower StO2 levels (p = 0.002). ROC analysis of StO₂ for predicting in-hospital mortality showed an area under the curve of 0.677 (95% CI 0.529-0.825). The optimal mortality cut-off (StO₂ ≤ 54%) demonstrated a sensitivity of 0.70, specificity of 0.66, positive predictive value of 0.22, and negative predictive value (NPV) of 0.94. AUCs of StO₂, lactate, bicarbonate, and base excess overlapped, with no significant pairwise differences. HSI did not discriminate between hemodynamically unstable and stable patients at initial trauma assessment but correlated well with high lactate levels. However, its high NPV for mortality suggests potential value as an objective, non-invasive tool for early trauma team downgrading.Trial registration: German Clinical Trials Register (DRKS ID DRKS00030986) on 27th December 2022.

Hospitals can experience disruption to their operations, due to a variety of crisis events. To maintain operational functionality, they are required to implement a hospital incident command (HIC). This study explores the process from routine operations to a staff-based HIC, analyzing how leadership communication and dynamics emerge, evolve, and are negotiated during crisis transitions. The focus lies on interactions between roles, practices, training, and structures under high operational pressure. A qualitative single-site study was conducted applying a Grounded Theory methodology based on two consecutive HIC tabletop exercises following targeted training. Data comprised semi-structured post-exercise interviews with 19 HIC members from diverse professional backgrounds and triangulation with a series of collected observational materials (notes and protocols).The analysis indicates that the enactment of staff-oriented HIC structures varies along a spectrum of coordination: Explicit orchestration of leadership communication was associated with a shift toward more structured coordination, reflected in clearer role articulation, defined process boundaries, and separation of briefing and operational tasks. Where orchestration was less pronounced, coordination tended to rely on routine practices, accompanied by blurred responsibilities and more fragmented coordination patterns. The findings suggest that the mere presence of command structures, roles, procedures, and communication tools was often insufficient to establish coordinated staff work. Instead, their practical effectiveness appeared to depend on an interactional process, conceptualized here as orchestrating leadership communication. Moderation emerged as one important manifestation of this process, suggesting that HIC training should place greater emphasis not only on structures and procedures, but also on interactional practices.

Transesophageal echocardiography during out-of-hospital cardiac arrest can be performed during ongoing chest compressions and may improve resuscitation quality, but its prehospital use has not been systematically evaluated. To assess the feasibility, diagnostic yield, and impact of prehospital TEE on resuscitation metrics and advanced life support (ALS) interventions during OHCA. We conducted a randomized controlled trial in a physician-staffed two-tiered emergency medical service (EMS). Adults with ongoing non-traumatic OHCA were randomized 1:1 to standard ALS or ALS plus TEE. The primary endpoints were hands-off time and chest compression fraction (CCF) from EMS arrival to return of spontaneous circulation (ROSC) or resuscitation termination. Secondary endpoints included ROSC at hospital admission, survival to hospital discharge, neurological status at hospital discharge, and TEE findings. Analyses followed the intention-to-treat principle. Of 249 screened patients, 35 were randomized and 32 analyzed (TEE n = 15; control n = 17). Median hands-off time was 4 s in both groups. Mean CCF was higher in the TEE group (96.2

BackgroundIn crises, hospitals must rapidly shift from routine operations to structured crisis management, requiring the activation of an incident command system. However, empirical insight into their operational functioning during activation remains limited. Goal: to identify operational enablers and barriers influencing effective crisis response.MethodsProspective cross-sectional, qualitative, single-center study conducted after a table-top exercise within a hospital incident command system at a tertiary care university hospital (NCT06913010). Data were collected through semi-structured interviews, participant observation, and document analysis, and analyzed using a narrative-phenomenological approach.ResultsNineteen participants were included. Analysis identified nine thematic clusters shaping operational performance: (1) structure and roles; (2) communication; (3) decision-making and prioritization; (4) information management; (5) infrastructure and technology; (6) personnel and organization; (7) training, exercises, and team dynamics; (8) documentation; and (9) external communication and media. Enablers included clear role definition, structured communication, phased decision-making, and regular training. Barriers included role ambiguity, fragmented communication, insufficient prioritization, infrastructure limitations, and staffing constraints.ConclusionPreparedness frameworks are necessary but insufficient as stand-alone approaches, as operational execution determines real-world performance. Recurring deficits included unclear roles, inconsistent communication, weak prioritization, and gaps in infrastructure and personnel. A limited set of standardized practices—including a clear separation of roles, leadership intent, closed-loop communication, explicit decision cycles from information gathering to structuring to decision-making, checklists, visualization, central information management, and rapid “80% decisions”-substantially enhanced performance. Mission command (Auftragstaktik) further enabled adaptive, coordinated action. Strengthening hospital incident command is a key lever for achieving system-level resilience in crises.

Abstract Second-generation supraglottic airway devices (SADs) are widely used alternatives to endotracheal intubation in both anesthesia and emergency airway management. The newly developed LT®evo represents a redesigned version of the established Laryngeal Tube Suction Disposable (LTS-D). This study compared the ventilatory performance of the LT®evo with endotracheal intubation and three other second-generation SADs— LTS-D, Ambu® AuraGain™ and i-gel® Plus—using a controlled human cadaver model. In this prospective, randomized experiment, six thawed adult cadavers were sequentially ventilated via an endotracheal tube (ET) and four SADs under standardized mechanical ventilation (tidal volume 7 mL/kg, PEEP 5 cmH₂O, respiratory rate 10/min). Airway pressure and flow were continuously recorded (sampling rate 200 Hz) to determine inspiratory tidal volume, pressure, flow, and calculated resistance. Endotracheal intubation using fiberoptics was attempted via LT®evo , AuraGain™ and i-gel® Plus. Data were analyzed using Kruskal–Wallis tests with Holm-corrected post-hoc pairwise comparisons. From six human cadavers (60–85kg estimated body weight), 30 complete ventilation datasets were obtained. Initial fiberoptic control of SAD placement showed optimal positioning in 13 of 24 insertions. During ventilation cycles, inspiratory tidal volumes of the LT®evo (0.49 [0.46–0.52]) were similar to those of ET, AuraGain™ and LTS-D and superior to those of the i-gel® Plus (0.31 L [0.27–0.33], p < 0.001). Peak inspiratory pressure and inspiratory resistance were higher in ET when compared to LT®evo and all other SADs. Endotracheal intubation using fiberoptics was successful in all attempts via LT®evo , AuraGain™ and i-gel® Plus. In this controlled cadaver study, the newly designed LT®evo demonstrated ventilatory performance comparable to that of the LTS-D and the Ambu® AuraGainTM and was superior to the i-gel® Plus in delivering adequate tidal volumes. Additionally, LT®evo allowed for fiberoptic ET placement. Importantly, these results are specific to the cadaveric model and reflect technical variability in ventilation mechanics rather than clinical effectiveness. Clinical trial number German Clinical Trials Registry, DRKS00038309, on October 30th, 2025.

Cyberattacks on the health sector can have far-reaching consequences. In addition to data loss, such attacks can disrupt patient care, erode trust, and even lead to poorer health. The purpose of this study is to characterize cyberattacks targeting healthcare facilities compared with other critical infrastructure sectors and to examine regional differences between the EU and the US, with the aim of strengthening education, preparedness, and security strategies. We conducted a cross-sectional analysis of the European Repository of Cyber Incidents (EuRepoC). The effects of and reactions to cyberattacks on healthcare facilities with these on other critical infrastructure sectors worldwide and the cyberattacks on the health sector between Europe (EU Member States) and the US from January 2023 to December 2025 (three years) were compared. With about 74% of health sector incidents stored in the repository, the health sectors in the EU and the US are worldwide the most frequently observed to be targeted by cyberattacks. In healthcare, these attacks are mostly carried out by non-state actors, exploiting public-facing applications and valid credentials. Compared to other sectors, these incidents cause greater functional disruption and impact more sensitive data. Disclosure times are notably longer in the US. As a conclusion in addition to technical measures, for healthcare cybersecurity an “all-hazard” approach should be adopted. A culture of security in practice, regular drills, and early sharing of cyber threat intelligence may be beneficial. This could make it possible to close security gaps more quickly and prevent cascading effects of cyberattacks in the healthcare sector.

Hitzeperioden treten in Mitteleuropa häufiger und intensiver auf und führen zu einer messbaren Übersterblichkeit. Der Hitzschlag ist die schwerste hitzebedingte Erkrankung und ein zeitkritischer Notfall, dessen Prognose von der Kühlgeschwindigkeit abhängt. Betroffen sind überwiegend vulnerable, hochaltrige und multimorbide Patienten mit klassischem Hitzschlag. Darstellung der verfügbaren Evidenz zur prähospitalen Versorgung des Hitzschlags und Ableitung von Konsequenzen für den Rettungsdienst, differenziert nach klassischem und belastungsassoziiertem Phänotyp. Narrative Übersichtsarbeit mit hierarchischer Gewichtung der Evidenz: aktuelle Leitlinien und Konsensuspapiere als Handlungsrahmen, systematische Reviews und Primärstudien zu deren Prüfung und Abgrenzung. Die Empfehlungen sind über die Fachgesellschaften hinweg konsistent: Erkennung anhand der zentralnervösen Dysfunktion, rektale Kerntemperaturmessung und sofortige aktive Ganzkörperkühlung, bevorzugt als Kalt- oder Eiswasserimmersion, nach dem Grundsatz „cool first, transport second“. Die Evidenz ist beim belastungsassoziierten Hitzschlag deutlich robuster als beim klassischen. Zwischen Empfehlung und Umsetzung besteht eine erhebliche, gut belegte Lücke. Eine rettungsdienstliche Empfehlung sollte den Leitlinienkern als Standard ausweisen und Primärevidenz als Stütze oder Machbarkeitsnachweis kennzeichnen. Der klassische Hitzschlag ist häufiger und betrifft überwiegend alte, multimorbide Patienten; bei intubierten Patienten ist die Wasserimmersion kritisch abzuwägen und die Kühlung ggf. im Transport (z. B. Vakuummatratze) einzuleiten. Für den klassischen Hitzschlag bleibt die Evidenz begrenzt und erfordert explizite Adaptation.

Abstract Background Mass casualty incidents (MCIs) rapidly exceed routine hospital capacity. Full-scale exercises are essential for preparedness, but systematic, multidimensional evaluations remain scarce. This study aimed to evaluate overall team performance in triage accuracy, workflow, and individual workload throughout a MCI exercise. Methods In a prospective observational study at Heidelberg University Hospital (Germany), healthcare professionals managed 91 simulated casualties using a two-stage triage process. Patients and staff carried location tags enabling continuous spatiotemporal tracking. Objective outcomes included triage accuracy, triage duration, patient flow, and staff–patient contact frequency. Subjective workload and teamwork were assessed using the NASA Task Load Index (NASA-TLX) and the Team Emergency Assessment Measure (TEAM), respectively. Results Overall triage accuracy was 75.4%. Undertriage occurred in 11.6% of category I and 10.1% of category II cases; overtriage was infrequent (2.9%). Mean triage times differed significantly by category: ‘red’ 59 ± 25 s, ‘yellow’ 173 ± 74 s, ‘green’ 205 ± 100 s (p < 0.0001). Geotracking demonstrated consistent patient flow without detectable bottlenecks and a mean of 7.1 ± 5.7 patient contacts per staff member. NASA-TLX scores indicated high temporal demand but low frustration with an overall workload of 66.7 ± 16; specialists and staff with greater professional experience reported significantly lower perceived workload (p < 0.05). TEAM ratings were homogeneously good across all participants (79.8%). Conclusions This study provides reproducible benchmark data on simulated hospital MCI response. The integration of geotracking with subjective measures, enables a comprehensive evaluation of hospital disaster preparedness. Moreover, the ability to compare different exercises and collect reliable longitudinal data may further enhance hospital disaster response.

BackgroundThis study evaluates the use and clinical implications of prehospital packed red blood cells administered by a specialized physician-staffed Medical Intervention Car in a German emergency medical service system capable of advanced interventions such as thoracotomy and extracorporeal cardiopulmonary resuscitation.MethodsWe conducted a retrospective cohort study of all prehospital patients treated with at least one unit of packed red blood cells (pRBC) by the MIC team between August 2019 and September 2024. In the trauma cohort, we compared characteristics and interventions between those who were admitted to the hospital and those for whom resuscitation was commenced on scene. For in-hospital comparisons, patients were grouped into two categories: those who continued to receive pRBCs and those who did not. A modified blood transfusion need score (mBTNS) was retrospectively applied to assess the clinical appropriateness of transfusion.ResultsA total of 57 patients received pRBCs, including 45 with traumatic and 12 with non-traumatic hemorrhage. Among trauma patients, 78% were male, 49% sustained penetrating injuries, and 56% were in traumatic cardiac arrest. There were higher rates of primary dispatch by the dispatch center in patients admitted to the hospital (43% vs. 13%; p = 0.048). The mean number of prehospital pRBC units transfused did not differ between those admitted and those for whom resuscitation was commenced (mean 4 [2]). Patients admitted to the hospital received fibrinogen (90% vs. 47%; p = 0.003), tranexamic acid (93% vs. 47%; p < 0.001), and Calcium (67% vs. 33%; p = 0.028) significantly more often compared to those who died on the scene. A lower pH and higher glucose level were significantly linked to continuous pRBC transfusion during the first 24 h after hospital admission. In the non-trauma cohort, gastrointestinal bleeding was the predominant cause (54%).ConclusionPrehospital transfusion by a trained MIC team led to high survival rates in trauma and non-trauma patients. The frequent invasive procedures underline the need for integrated prehospital blood transfusion within advanced care. Broader adoption of structured protocols in high-acuity systems warrants prospective evaluation.

Background: Specialised paediatric emergency physicians (pedi-EP) are not subject to any statutory regulations in Germany. Although they have been established in some cities, there has yet to be a nationwide overview of their availability. Objectives: To evaluate the availability of specialised pedi-EP in Germany. Methods: An online survey of emergency medical services (EMS) directors asked about providing a pedi-EP system. Participants were able to describe their existing system. Results: The survey was completed 146 times, which corresponds to a response rate of 74%. Regardless of the exact role of the pedi-EP, only 14 EMS stated that a dedicated system is in place. Eleven EMS stated that additional hospital staff could be alerted if necessary, while 3 EMS stated that a pedi-EP is available 24/7. In addition, 3 EMS noted the availability of a medical intervention car. Almost 50% of the systems are only alerted by an ambulance on scene. Sixteen systems have established a tele-EMS system, but without a paediatrician; only one EMS is planning such a system with a paediatrician. Conclusion: This survey shows considerable differences in the prehospital care of paediatric emergencies across Germany. Only a minority of EMS have a specialised system available. Several EMS utilise hospital resources to send staff to the scene if necessary.

Spezialisierte Rettungsmittel für die Versorgung von Kindern unterliegen in Deutschland keiner gesetzlichen Vorschrift. In einigen Städten haben sich Kindernotarztsysteme etabliert, jedoch gibt es keine deutschlandweite Übersicht über deren Verfügbarkeit. Evaluation der Vorhaltung von spezialisierten Rettungsmitteln bzw. Systemen für die Versorgung von pädiatrischen Notfällen Mittels Onlineumfragestudie unter den ärztlichen Leitern Rettungsdienst (ÄLRD) wurde von Juni bis Juli 2024 die Vorhaltung von Rettungsmitteln für pädiatrische Notfälle evaluiert und deskriptiv analysiert. Die Umfrage wurde 146-mal ausgefüllt (74

Introduction:Accurate core temperature (CT) measurement is critical for staging and management in accidental hypothermia, particularly in cardiac arrest, where it guides extracorporeal rewarming decisions. Esophageal temperature monitoring is considered the reference method in the prehospital setting in patients with a secured airway, provided the probe tip is positioned in the distal third of the esophagus behind the heart. However, the effect of proximal misplacement on measurement accuracy remains unknown. We hypothesized that a probe tip positioned behind the trachea would yield falsely low readings during cold air exposure. Methods:In this randomized crossover study (May 2024 at Eurac Research, Bolzano, Italy), healthy volunteers underwent nasal esophageal probe placement using a height-based formula. Two probe positions were defined via posteroanterior chest radiographs: correct (behind the heart) and incorrect (5 cm above the tracheal bifurcation). Participants were exposed to -20 °C for 20 min in a climate chamber, once with the probe in the correct and once in the incorrect position, in randomized order, separated by a washout period. Results:Fifteen participants (7 male, 8 female) completed the study. Mean correct insertion depth was 41.1 (2.5) cm for males and 39.3 (1.5) cm for females. At baseline and throughout -20 °C exposure, mean CT was on average 0.6 °C lower when the probe was incorrectly positioned. Temperature fluctuations were also greater with proximal misplacement. Conclusion:Proximal misplacement of esophageal probes during cold air exposure results in falsely low and more variable CT readings. This may critically affect triage and treatment, particularly in hypothermic cardiac arrest.