Schnittstelle Notaufnahme: Interdisziplinäre Perspektiven

Zusammenfassung: Die Notaufnahme des Basler Universitätsspitals wird interdisziplinär als "Notfallstation" geführt. Das dort praktizierte "Basler Modell" wird schlaglichtartig beleuchtet. Ethische Fragestellungen, insbesondere die Frage nach dem Sistieren einer Behandlung, sollten frühzeitig und interdisziplinär besprochen werden. Da das Ziel der Versorgung in der präklinischen Phase zumeist der möglichst rasche Transport in ein geeignetes Zielkrankenhaus ist, bietet sich oft erst im Reanimationsraum der Notfallstation erstmals die Chance, diese Fragen überhaupt auszusprechen. Hier können entscheidungsrelevante Zusatzinformationen berücksichtigt werden wie etwa der mutmaßliche Wille des Patienten, aber auch die Prognose. Die unterschiedlichen Standards der präklinischen und der klinischen Phase können an der Schnittstelle Notfallstation zu Konflikten führen. Hier ist die Kommunikation des Teamleaders mit dem Rettungsteam, aber auch mit den Kollegen der anderen Disziplinen von entscheidender Bedeutun

Activated prothrombin complex in the management of direct thrombin inhibitor-associated intracerebral haemorrhage.

Intracerebral haematoma expansion independently predicts poor functional outcome and mortality. Therefore, it is important to act quickly to arrest this expansion. Whilst a direct antidote to dabigatran remains in development, the use of factor VIII inhibitor bypassing activity may offer a practical strategy for arresting haemorrhage in individuals taking direct thrombin inhibitors.NRE is supported by a Research Training Fellowship from The Dunhill Medical Trust [grant number RTF44/0114].This is the author accepted manuscript. The final version is available from Oxford University Press at http://dx.doi.org/10.1093/qjmed/hcv219

Organisation der Notfallstation: Umfeld und Leistungsauftrag bestimmen das Organisationskonzept

Zusammenfassung: Untersuchungsziel: Organisationsformen von Notfallstationen wurden analysiert, um Gestaltungsgrundsätze abzuleiten. Methoden: Organisation und Leistungsauftrag der klinischen Notfallmedizin wurden anhand einer Literaturrecherche verglichen. Dabei wurden organisatorische Grundmuster in Abhängigkeit von der Anwesenheit von Spezialisten (Spezialisierung) und der Einbindung in die Spitalorganisation (Integration) entwickelt und aufgrund etablierter Effizienzkriterien vergleichend bewertet. Ergebnisse: Klinische Notfallstationen unterscheiden sich hinsichtlich Autonomiegrad, Leistungsbreite und Leistungstiefe. Vier Archetypen wurden abgegrenzt: Das Profit-Center als ertragsorientierte Wirtschaftseinheit, das Service-Center als auftragserfüllende Organisationseinheit, die funktionelle Organisation als fachlich abgegrenzte Einheit und die modulare Organisation, die sich durch eine zentrale Notfalleinheit und rasch mobilisierbare Spezialistenteams auszeichnet. Schlussfolgerungen: Es gibt keinen Königsweg. Jede organisatorische Lösung bietet in Abhängigkeit von Umfeldbedingungen und Leistungsauftrag Vor- und Nachteile. Die organisatorischen Grundmuster bieten eine Orientierungshilfe, wobei Leistungsvolumen und -spektrum wichtige Determinanten darstelle

Infektiologische Erstbeurteilung und erste Abklärungsschritte bei Fieber

Zusammenfassung: Die Erstbeurteilung sowie die ersten Abklärungsschritte bei Patienten mit infektiösen Erkrankungen sind wegen der breiten Differenzialdiagnose anspruchsvoll. Der klinische Ersteindruck, die Anamneseerhebung, die gewissenhafte körperliche Untersuchung und das Routinelabor ermöglichen eine vorläufige Diagnose und Therapie. Leitbeschwerden engen die Differenzialdiagnose wesentlich ein. Bei lebensbedrohlichen Erkrankungen wie Sepsis, Endokarditis, bakterieller Meningitis oder schwerer Pneumonie müssen die ersten diagnostischen und therapeutischen Schritte rasch erfolgen: Nach Abnahme bakteriologischer Proben aus Blut, Liquor und/oder Sputum ist eine empirische Antibiotikatherapie rasch zu initiieren; das der Erkrankung mutmaßlich zugrunde liegende bakterielle Erregerspektrum muss dadurch abgedeckt sein. In weniger dringlichen Fällen lohnt sich ein Abklärungsverfahren in mehreren Schritten. In dieser Situation ist es wichtig, die mikrobiologische Diagnose abzuwarten, um eine erreger- und resistenzgerechte Antibiotikatherapie durchführen zu können. Atypische Verläufe müssen eine erneute Diagnostik auslösen, wobei die Diagnose kritisch zu beurteilen und neue Differenzialdiagnosen in Betracht zu ziehen sin

Predicting mortality with pneumonia severity scores: importance of model recalibration to local settings

In patients with community-acquired pneumonia (CAP) prediction rules based on individual predicted mortalities are frequently used to support decision-making for in-patient vs. outpatient management. We studied the accuracy and the need for recalibration of three risk prediction scores in a tertiary-care University hospital emergency-department setting in Switzerland. We pooled data from patients with CAP enrolled in two randomized controlled trials. We compared expected mortality from the original pneumonia severity index (PSI), CURB65 and CRB65 scores against observed mortality (calibration) and recalibrated the scores by fitting the intercept α and the calibration slope β from our calibration model. Each of the original models underestimated the observed 30-day mortality of 11%, in 371 patients admitted to the emergency department with CAP (8·4%, 5·5% and 5·0% for the PSI, CURB65 and CRB65 scores, respectively). In particular, we observed a relevant mortality within the low risk classes of the original models (2·6%, 5·3%, and 3·7% for PSI classes I-III, CURB65 classes 0-1, and CRB65 class 0, respectively). Recalibration of the original risk models corrected the miscalibration. After recalibration, however, only PSI class I was sensitive enough to identify patients with a low risk (i.e. <1%) for mortality suitable for outpatient management. In our tertiary-care setting with mostly referred in-patients, CAP risk scores substantially underestimated observed mortalities misclassifying patients with relevant risks of death suitable for outpatient management. Prior to the implementation of CAP risk scores in the clinical setting, the need for recalibration and the accuracy of low-risk re-classification should be studied in order to adhere with discharge guidelines and guarantee patients' safet

State of Emergency Medicine in Switzerland: a national profile of emergency departments in 2006

BACKGROUND: Emergency departments (EDs) are an essential component of any developed health care system. There is, however, no national description of EDs in Switzerland. Our objective was to establish the number and location of EDs, patient visits and flow, medical staff and organization, and capabilities in 2006, as a benchmark before emergency medicine became a subspecialty in Switzerland. METHODS: In 2007, we started to create an inventory of all hospital-based EDs with a preliminary list from the Swiss Society of Emergency and Rescue Medicine that was improved with input from ED physicians nationwide. EDs were eligible if they offered acute care 24 h per day, 7 days per week. Our goal was to have 2006 data from at least 80% of all EDs. The survey was initiated in 2007 and the 80% threshold reached in 2012. RESULTS: In 2006, Switzerland had a total of 138 hospital-based EDs. The number of ED visits was 1.475 million visits or 20 visits per 100 inhabitants. The median number of visits was 8,806 per year; 25% of EDs admitted 5,000 patients or less, 31% 5,001-10,000 patients, 26% 10,001-20,000 patients, and 17% &gt;20,000 patients per year. Crowding was reported by 84% of EDs with &gt;20,000 visits/year. Residents with limited experience provided care for 77% of visits. Imaging was not immediately available for all patients: standard X-ray within 15 min (70%), non-contrast head CT scan within 15 min (38%), and focused sonography for trauma (70%); 67% of EDs had an intensive care unit within the hospital, and 87% had an operating room always available. CONCLUSIONS: Swiss EDs were significant providers of health care in 2006. Crowding, physicians with limited experience, and the heterogeneity of emergency care capabilities were likely threats to the ubiquitous and consistent delivery of quality emergency care, particularly for time-sensitive conditions. Our survey establishes a benchmark to better understand future improvements in Swiss emergency care

Anaesthesia for serial whole-lung lavage in a patient with severe pulmonary alveolar proteinosis: a case report

<p>Abstract</p> <p>Introduction</p> <p>Pulmonary alveolar proteinosis is a rare condition that requires treatment by whole-lung lavage. We report a case of severe pulmonary alveolar proteinosis and discuss a safe and effective strategy for the anaesthetic management of patients undergoing this complex procedure.</p> <p>Case presentation</p> <p>A 34-year-old Caucasian man was diagnosed with severe pulmonary alveolar proteinosis. He developed severe respiratory failure and subsequently underwent serial whole-lung lavage. Our anaesthetic technique included the use of pre-oxygenation, complete lung separation with a left-sided double-lumen endotracheal tube, one-lung ventilation with positive end-expiratory pressure, appropriate ventilatory monitoring, cautious use of positional manoeuvres and single-lumen endotracheal tube exchange for short-term postoperative ventilation.</p> <p>Conclusion</p> <p>Patients with pulmonary alveolar proteinosis may present with severe respiratory failure and require urgent whole-lung lavage. We have described a safe and effective strategy for anaesthesia for whole-lung lavage. We recommend our anaesthetic technique for patients undergoing this complex and uncommon procedure.</p

Enoxaparin for primary thromboprophylaxis in ambulatory patients with coronavirus disease-2019 (the OVID study): a structured summary of a study protocol for a randomized controlled trial.

The OVID study will demonstrate whether prophylactic-dose enoxaparin improves survival and reduces hospitalizations in symptomatic ambulatory patients aged 50 or older diagnosed with COVID-19, a novel viral disease characterized by severe systemic, pulmonary, and vessel inflammation and coagulation activation. The OVID study is conducted as a multicentre open-label superiority randomised controlled trial. Inclusion Criteria 1. Signed patient informed consent after being fully informed about the study's background. 2. Patients aged 50 years or older with a positive test for SARS-CoV2 in the past 5 days and eligible for ambulatory treatment. 3. Presence of respiratory symptoms (i.e. cough, sore throat, or shortness of breath) or body temperature &gt;37.5° C. 4. Ability of the patient to travel to the study centre by private transportation, performed either by an accompanying person from the same household or by the patient themselves 5. Ability to comply with standard hygiene requirements at the time of in-hospital visit, including a face mask and hand disinfectant. 6. Ability to walk from car to study centre or reach it by wheelchair transport with the help of an accompanying person from the same household also complying with standard hygiene requirements. 7. Ability to self-administer prefilled enoxaparin injections after instructions received at the study centre or availability of a person living with the patient to administer enoxaparin. Exclusion Criteria 1. Any acute or chronic condition posing an indication for anticoagulant treatment, e.g. atrial fibrillation, prior venous thromboembolism (VTE), acute confirmed symptomatic VTE, acute coronary syndrome. 2. Anticoagulant thromboprophylaxis deemed necessary in view of the patient's history, comorbidity or predisposing strong risk factors for thrombosis: a. Any of the following events occurring in the prior 30 days: fracture of lower limb, hospitalization for heart failure, hip/knee replacement, major trauma, spinal cord injury, stroke, b. previous VTE, c. histologically confirmed malignancy, which was diagnosed or treated (surgery, chemotherapy, radiotherapy) in the past 6 months, or recurrent, or metastatic, or inoperable. 3. Any clinically relevant bleeding (defined as bleeding requiring hospitalization, transfusion, surgical intervention, invasive procedures, occurring in a critical anatomical site, or causing disability) within 30 days prior to randomization or sign of acute bleeding. 4. Intracerebral bleeding at any time in the past or signs/symptoms consistent with acute intracranial haemorrhage. 5. Haemoglobin &lt;8 g/dL and platelet count &lt;50 x 10 &lt;sup&gt;9&lt;/sup&gt; cells/L confirmed by recent laboratory test (&lt;90 days). 6. Subjects with any known coagulopathy or bleeding diathesis, including known significant liver disease associated with coagulopathy. 7. Severe renal insufficiency (baseline creatinine clearance &lt;30 mL/min calculated using the Cockcroft-Gault formula) confirmed by recent laboratory test (&lt;90 days). 8. Contraindications to enoxaparin therapy, including prior heparin-induced thrombocytopenia and known hypersensitivity. 9. Current use of dual antiplatelet therapy. 10. Participation in other interventional studies over the past 30 days. 11. Non-compliance or inability to adhere to treatment or lack of a family environment or support system for home treatment. 12. Cognitive impairment and/or inability to understand information provided in the study information. Patient enrolment will take place at seven Swiss centres, including five university hospitals and two large cantonal hospitals. Patients randomized to the intervention group will receive subcutaneous enoxaparin at the recommended dose of 4,000 IU anti-Xa activity (40 mg/0.4 ml) once daily for 14 days. Patients randomized to the comparator group will receive no anticoagulation. Primary outcome: a composite of any hospitalization or all-cause death occurring within 30 days of randomization. (i) a composite of cardiovascular events, including deep vein thrombosis (including catheter-associated), pulmonary embolism, myocardial infarction/myocarditis, arterial ischemia including mesenteric and extremities, acute splanchnic vein thrombosis, or ischemic stroke within 14 days, 30 days, and 90 days of randomization; (ii) each component of the primary efficacy outcome, within 14 days, 30 days, and 90 days of randomization; (iii) net clinical benefit (accounting for the primary efficacy outcome, composite cardiovascular events, and major bleeding), within 14 days, 30 days, and 90 days of enrolment; (iv) primary efficacy outcome, within 14 days, and 90 days of enrolment; (v) disseminated intravascular coagulation (ISTH criteria, in-hospital diagnosis) within 14 days, 30 days, and 90 days of enrolment. Patients will undergo block stratified randomization (by age: 50-70 vs. &gt;70 years; and by study centre) with a randomization ratio of 1:1 with block sizes varying between 4 and 8. Randomization will be performed after the signature of the informed consent for participation and the verification of the eligibility criteria using the electronic data capture software (REDCAP, Vanderbilt University, v9.1.24). In this open-label study, no blinding procedures will be used. The sample size calculation is based on the parameters α = 0.05 (2-sided), power: 1-β = 0.8, event rate in experimental group, pexp = 0.09 and event rate in control group, pcon = 0.15. The resulting total sample size is 920. To account for potential dropouts, the total sample size was fixed to 1000 with 500 patients in the intervention group and 500 in the control group. Protocol version 1.0, 14 April 2020. Protocol version 3.0, 18 May 2020 Recruiting start date: June 2020. Last Patient Last Visit: March 2021. ClinicalTrials.gov Identifier: NCT04400799 First Posted: May 26, 2020 Last Update Posted: July 16, 2020 FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol

Enoxaparin for outpatients with COVID-19: 90-day results from the randomised, open-label, parallel-group, multinational, phase III OVID trial.

INTRODUCTION The benefits of early thromboprophylaxis in symptomatic COVID-19 outpatients remain unclear. We present the 90-day results from the randomised, open-label, parallel-group, investigator-initiated, multinational OVID phase III trial. METHODS Outpatients aged 50 years or older with acute symptomatic COVID-19 were randomised to receive enoxaparin 40 mg for 14 days once daily vs. standard of care (no thromboprophylaxis). The primary outcome was the composite of untoward hospitalisation and all-cause death within 30 days from randomisation. Secondary outcomes included arterial and venous major cardiovascular events, as well as the primary outcome within 90 days from randomisation. The study was prematurely terminated based on statistical criteria after the predefined interim analysis of 30-day data, which has been previously published. In the present analysis, we present the final, 90-day data from OVID and we additionally investigate the impact of thromboprophylaxis on the resolution of symptoms. RESULTS Of the 472 patients included in the intention-to-treat population, 234 were randomised to receive enoxaparin and 238 no thromboprophylaxis. The median age was 57 (Q1-Q3: 53-62) years and 217 (46 %) were women. The 90-day primary outcome occurred in 11 (4.7 %) patients of the enoxaparin arm and in 11 (4.6 %) controls (adjusted relative risk 1.00; 95 % CI: 0.44-2.25): 3 events per group occurred after day 30. The 90-day incidence of cardiovascular events was 0.9 % in the enoxaparin arm vs. 1.7 % in controls (relative risk 0.51; 95 % CI: 0.09-2.75). Individual symptoms improved progressively within 90 days with no difference between groups. At 90 days, 42 (17.9 %) patients in the enoxaparin arm and 40 (16.8 %) controls had persistent respiratory symptoms. CONCLUSIONS In adult community patients with COVID-19, early thromboprophylaxis with enoxaparin did not improve the course of COVID-19 neither in terms of hospitalisation and death nor considering COVID-19-related symptoms

Enoxaparin for outpatients with COVID-19: 90-day results from the randomised, open-label, parallel-group, multinational, phase III OVID trial

INTRODUCTION The benefits of early thromboprophylaxis in symptomatic COVID-19 outpatients remain unclear. We present the 90-day results from the randomised, open-label, parallel-group, investigator-initiated, multinational OVID phase III trial. METHODS Outpatients aged 50 years or older with acute symptomatic COVID-19 were randomised to receive enoxaparin 40 mg for 14 days once daily vs. standard of care (no thromboprophylaxis). The primary outcome was the composite of untoward hospitalisation and all-cause death within 30 days from randomisation. Secondary outcomes included arterial and venous major cardiovascular events, as well as the primary outcome within 90 days from randomisation. The study was prematurely terminated based on statistical criteria after the predefined interim analysis of 30-day data, which has been previously published. In the present analysis, we present the final, 90-day data from OVID and we additionally investigate the impact of thromboprophylaxis on the resolution of symptoms. RESULTS Of the 472 patients included in the intention-to-treat population, 234 were randomised to receive enoxaparin and 238 no thromboprophylaxis. The median age was 57 (Q1-Q3: 53-62) years and 217 (46 %) were women. The 90-day primary outcome occurred in 11 (4.7 %) patients of the enoxaparin arm and in 11 (4.6 %) controls (adjusted relative risk 1.00; 95 % CI: 0.44-2.25): 3 events per group occurred after day 30. The 90-day incidence of cardiovascular events was 0.9 % in the enoxaparin arm vs. 1.7 % in controls (relative risk 0.51; 95 % CI: 0.09-2.75). Individual symptoms improved progressively within 90 days with no difference between groups. At 90 days, 42 (17.9 %) patients in the enoxaparin arm and 40 (16.8 %) controls had persistent respiratory symptoms. CONCLUSIONS In adult community patients with COVID-19, early thromboprophylaxis with enoxaparin did not improve the course of COVID-19 neither in terms of hospitalisation and death nor considering COVID-19-related symptoms