There is increasing evidence that use of ECMO is beneficial in major trauma patients with refractory organ failure. Hence, increased numbers of ECMO support following major trauma are reported. We set out to determine the use of ECMO among major trauma patients submitted to the TraumaRegister DGUr® as well as patient features associated with ECMO support. The TraumaRegister DGU® is a multinational database compiling trauma related health care data from point-of-injury, initial and critical care to outcome. Major trauma cases (AIS ≥ 3 irrespective of injury location) with subsequent critical care as well as respiratory and/or circulatory failure (SOFA score ≥ 3 per respective category) enrolled in the TraumaRegister DGU® between 2015 and 2022 were reviewed. A logistic regression model was carried out to evaluate patient features associated with ECMO support. 410/ 22,548 individuals (1.8

INTRODUCTION:External bleeding is the leading cause of preventable trauma-related death. In certain circumstances, tourniquet application over clothing may be necessary. Therefore, the aim of this study was to assess the effectiveness of tourniquets over different clothing setups.METHODS:Three windlass tourniquets (CAT, SAMXT, SOFTT-W) were applied over nine different clothing setups and without clothing on the Hapmed™ Tourniquet Trainer. We compared each tourniquet in each clothing setup to the tourniquet trainer that was not dressed, and we compared the three tourniquets within each clothing setup concerning blood loss, applied pressure and application time. Regression analysis of the effect of thickness, mean weight, mean deformation, application time, and applied pressure on blood loss was performed.RESULTS:Although blood loss was significantly greater in the CAT and SAMXT tourniquets when they were applied over leather motorcycle trousers, the overall findings showed that the clothing setups significantly reduced or did not affect blood loss. The mean blood loss was the lowest with CAT and the highest with SOFTT-W. The measured mean pressures were lower than 180 mmHg in four out of nine clothing setups with SOFTT-W, but CAT and SAMXT always exceeded this threshold. CAT had the fastest application time. Blood loss was significantly influenced by applied pressure and application time but was influenced to a far lesser degree by clothing parameters.CONCLUSION:The effects of the clothing setups were of little clinical relevance, except for leather motorcycle trousers. The effects of rugged protective equipment, e.g., hazard suits, are conceivable and need to be tested for specific garments with the tourniquet intended for use. No clothing parameter for predicting tourniquet effectiveness could be identified.

ZusammenfassungDie prähospitale Notfallversorgung erfährt seit Jahren zunehmende Einsatzbelastungen. Der Einfluss des demografischen Wandels auf regionalspezifische Unterschiede von Notärzt*innen sowie deren Motivation zum Verbleib im aktiven Notarztdienst ist unklar.Deutschlandweite Umfrage unter Notärzt*innen zu demografischen und weiteren, für den Notarztdienst relevanten Angaben.Der Anteil an Notärzt*innen ≥ 60 Jahren (10,1 vs. 4,5% [städtisch], p < 0,001) sowie derer, die angaben, binnen 5 Jahren den Notarztdienst beenden zu wollen (19,8 vs. 14,7%, p = 0,006), war in ländlichen Rettungsdienstbereichen höher. Die multivariate Analyse ergab eine angemessene Vergütung (p = 0,002) und eine Zufriedenheit mit den Arbeitsbedingungen (p < 0,001) als Motivatoren für einen längeren Verbleib als aktive Notärzt*innen.Unterschiede zwischen Notärzt*innen im ländlichen und städtischen Raum sind bei der Personalbindung zu berücksichtigen. Als mögliche Steuerungsinstrumente konnten Vergütung und Zufriedenheit mit den Berufsbedingungen identifiziert werden, um einem absehbaren Notarztmangel zu begegnen.

Gunshot and blast injuries are extremely rare in the emergency services. However, in the context of the increasing threat of terrorist attacks, the possibility of these traumas is also coming into focus. This article provides an overview of the various entities and the corresponding treatment principles for penetrating injuries.

Although evacuations of hospitals are considered rare events, they might be more frequent than often thought. Recent research revealed 158 evacuations of hospitals in the USA within 17 years (mean 9.3/year). Leading causes for evacuations might be natural disasters, technical issues or man-made threats like bomb or active shooter events. Evacuations of hospitals are resource-intensive and might be time-critical. Logistical and coordination challenges for efficient deployment of rescue personnel and material must be met. Management of these situations requires efficient leadership and coordination between hospital employees and rescue organizations such as fire departments or emergency medical services. Therefore, a robust concept for evacuation of hospitals is needed. Our publication describes hospital evacuations and appropriate concepts in Germany.

BACKGROUND:For trauma patients with subsequent immediate surgery, it is unclear which surgical disciplines are most commonly required for treatment, and whether and to what extend this might depend on or change with "hypotension on arrival". It is also not known how frequently damage control protocols are used in daily practice and whether this might also be related to "hypotension on arrival". METHODS:A retrospective analysis of trauma patients from a German level 1 trauma centre and subsequent "immediate surgery" between 01/2017 and 09/2022 was performed. Patients with systolic blood pressure > 90 mmHg (group 1, no-shock) and < 90 mmHg (group 2, shock) on arrival were compared with regard to (a) most frequently required surgical disciplines, (b) usage of damage control protocols, and (c) outcome. A descriptive analysis was performed, and Fisher's exact test and the Mann‒Whitney U test were used to calculate differences between groups where appropriate. RESULTS:In total, 98 trauma patients with "immediate surgery" were included in our study. Of these, 61 (62%; group 1) were normotensive, and 37 (38%, group 2) were hypotensive on arrival. Hypotension on arrival was associated with a significant increase in the need for abdominal surgery procedures (group 1: 37.1 vs. group 2: 54.5%; p = 0.009), more frequent usage of damage control protocols (group 1: 59.0 vs. group 2: 75.6%; p = 0.019) and higher mortality (group 1: 5.5 vs. group 2: 24.3%; p 0.027). CONCLUSION:Our data from a German level 1 trauma centre proof that abdominal surgeons are most frequently required for the treatment of trauma patients with hypotension on arrival among all surgical disciplines (> thoracic surgery > vascular surgery > neurosurgery). Therefore, surgeons from these specialties must be available without delay to provide optimal trauma care.

Die Sicherung des Atemwegs stellt eine lebensrettende Kompetenz in der präklinischen Notfallmedizin dar. In seltenen Fällen kann sie auch die Etablierung eines chirurgischen Atemwegs erfordern. Aufgrund der seltenen Notwendigkeit eines invasiven Atemwegs kann im Rahmen der klinischen Tätigkeit keine Handlungskompetenz erlangt werden. Der vorliegende Beitrag soll notwendiges Hintergrundwissen vermitteln und die theoretischen Grundlagen vertiefen, die eine Voraussetzung für die erfolgreiche Schaffung eines chirurgischen Atemwegs beim erwachsenen Patienten in der präklinischen Versorgung sind. Zunächst wird die relevante Anatomie beschrieben. Im Anschluss werden die Indikation zur präklinischen chirurgischen Atemwegssicherung und das präferierte Verfahren unter Berücksichtigung aktueller Leitlinien und verfügbarer Literatur erörtert. Basierend hierauf wird eine Schritt-für-Schritt-Empfehlung zur Durchführung einer offen-chirurgischen Koniotomie ausgesprochen, wobei mögliche Stolpersteine aufgezeigt werden, um die Handlungssicherheit hinsichtlich dieser selten notwendigen invasiven Maßnahme zu erhöhen.

Background Over recent decades, emergency medical services in Germany experience rising mission numbers. So far, effects on EMS physician staffing in urban and rural areas by demographic changes in Germany remain unclear. Methods Online survey among EMS physicians in Germany evaluating demographic and further parameters critical for EMS physician staffing. Results EMS physicians older than 59 years (10,1 vs. 4,5% [urban], p < 0,001) as well as such physicians who tend to quit service within 5 years (19,8 vs. 14,7%, p = 0,006), are more frequent in rural areas. A multivariate analysis revealed appropriate salaries (p = 0.002) as well as satisfaction with prehospital job settings (p < 0.001) to be associated with longer intended service time. Conclusion This study provides novel insights into demographic differences between EMS physicians in German urban and rural areas. Anticipating factors identified here such as appropriate job settings might improve staff retention.

Gunshot and blast injuries are extremely rare in the emergency services. However, in the context of the increasing threat of terrorist attacks, the possibility of these traumas is also coming into focus. This article provides an overview of the various entities and the corresponding treatment principles for penetrating injuries.

BACKGROUND:The military has used topical hemostatic agents to successfully treat life-threatening external bleeding for years. In contrast to the military environment, the general population are increasingly prescribed anticoagulants. There are only few comparative evaluations of topical hemostatic agents with anticoagulated human blood. It is important to understand the impact of these agents on those who take anticoagulants.STUDY DESIGN AND METHODS:Citrated blood of patients treated with enoxaparin, heparin, and acetylsalicylic acid, apixaban or phenprocoumon was incubated with different hemostatic agents (QuikClot Gauze, Celox Granules, Celox Gauze, Chito SAM 100, WoundClot Trauma Gauze, QuikClot Gauze Moulage Trainer and Kerlix) and rotational thromboelastometry was performed with non-activated thromboelastometry (NATEM reagent).RESULTS:All tested agents improved the onset of coagulation in all anticoagulants, mostly to a significant degree. Most significant improvements were produced by QuikClot Gauze and QuikClot Gauze Moulage Trainer, followed by the tested chitosans (Celox Granules, Celox Gauze, Chito SAM 100). Of the anticoagulant groups, the most significant improvements were seen in enoxaparin. This was followed in order by apixaban, heparin, and acetylsalicylic acid, and phenprocoumon.DISCUSSION:All the hemostatic agents tested were able to activate the clotting cascade earlier and initiate faster clot formation in anticoagulated blood. A definitive head-to-head comparison is not feasible, because of the limitations of an in-vitro analysis. However, the sometimes-presented hypothesis that kaolin-based hemostatic agents are ineffective in anticoagulated blood is inaccurate according to our data. Hemostasis with hemostatic agents appears most challenging with phenprocoumon.

ZUSAMMENFASSUNG Die Anzahl von Touristen und Freizeitsportlern in Bergregionen nimmt zu. Im Verhältnis dazu steigt auch die Zahl an Notfallsituationen wie Herz-Kreislauf-Stillstand. Wiederbelebungsmaßnahmen in diesen Umgebungsbedingungen sind anspruchsvoll. Eine besondere Bedeutung in diesem Rahmen hat die prolongierte kardiopulmonale Reanimation.

The number of tourists and recreational athletes in alpine regions is rising. Thus, the number of emergency situations like cardiac arrests is also growing. Resuscitation in these circumstances is challenging. Prolonged cardiopulmonary resuscitation is of particular importance in this context.

Cold weather warfare is of increasing importance. Haemorrhage is the most common preventable cause of death in military conflicts. We analysed the pressure of the Combat Application Tourniquet® Generation 7 (CAT), the SAM® Extremity Tourniquet (SAMXT) and the SOF® Tactical Tourniquet Wide Generation 4 (SOFTT) over different military cold weather clothing setups with a leg tourniquet trainer. We conducted a selective PubMed search and supplemented this with own experiences in cold weather medicine. The CAT and the SAMXT both reached the cut off value of 180mmHg in almost all applications. The SOFTT was unable to reach the 180mmHg limit in less than 50% of all applications in some clothing setups. We outline the influence of cold during military operations by presenting differences between military and civilian cold exposure. We propose a classification of winter warfare and identify caveats and alterations of Tactical Combat Casualty Care in cold weather warfare, with a special focus on control of bleeding. The application of tourniquets over military winter clothing is successful in principle, but effectiveness may vary for different tourniquet models. Soldiers are more affected and impaired by cold than civilians. Military commanders must be made aware of medical alterations in cold weather warfare.

Gemeinsam mit 25 Fachgesellschaften und Berufsverbänden hat die Deutsche Gesellschaft für Unfallchirurgie (DGU) die S3-Leitlinie Polytrauma und Schwerverletztenversorgung überarbeitet. Ziel dieses Beitrags ist es, die wichtigsten Neuerungen für die prähospitale Versorgung anhand eines Fallbeispiels darzustellen und die getroffenen Maßnahmen den entsprechenden Empfehlungen der Leitlinie zuzuordnen. Mit der aktuellen Überarbeitung wurde ein eigenes Kapitel „Stop the Bleed“ für die prähospitale Phase in die Leitlinie eingeführt. Hämodynamisch und mechanisch instabile Beckenringverletzungen können den Patienten durch exsanguinierende Blutungen bedrohen. Deshalb soll bereits prähospital eine vorsichtige Stabilitätskontrolle des Beckens erfolgen. Bei polytraumatisierten Patienten können häufig schwere Hypoxämien in kürzester Zeit entstehen. Dem soll durch Einleitung einer Notfallnarkose und eine konsekutive Atemwegssicherung und Beatmung begegnet werden. In einem zusätzlich in die Leitlinie aufgenommenen Kapitel zur Analgesie wird die Notwendigkeit zur Analgesie bei Traumapatienten definiert. Da Patientensicherheit im Vordergrund steht, verweist die Leitlinie auf die Notwendigkeit eines regelmäßigen Trainings für Notfallnarkose und Atemwegsmanagement inklusive aller alternativen Methoden zur Atemwegssicherung.