Thromboelastometry for the assessment of coagulation abnormalities in early and established adult sepsis: a prospective cohort study

INTRODUCTION: The inflammatory response to an invading pathogen in sepsis leads to complex alterations in hemostasis by dysregulation of procoagulant and anticoagulant factors. Recent treatment options to correct these abnormalities in patients with sepsis and organ dysfunction have yielded conflicting results. Using thromboelastometry (ROTEM(R)), we assessed the course of hemostatic alterations in patients with sepsis and related these alterations to the severity of organ dysfunction. METHODS: This prospective cohort study included 30 consecutive critically ill patients with sepsis admitted to a 30-bed multidisciplinary intensive care unit (ICU). Hemostasis was analyzed with routine clotting tests as well as thromboelastometry every 12 hours for the first 48 hours, and at discharge from the ICU. Organ dysfunction was quantified using the Sequential Organ Failure Assessment (SOFA) score. RESULTS: Simplified Acute Physiology Score II and SOFA scores at ICU admission were 52 +/- 15 and 9 +/- 4, respectively. During the ICU stay the clotting time decreased from 65 +/- 8 seconds to 57 +/- 5 seconds (P = 0.021) and clot formation time (CFT) from 97 +/- 63 seconds to 63 +/- 31 seconds (P = 0.017), whereas maximal clot firmness (MCF) increased from 62 +/- 11 mm to 67 +/- 9 mm (P = 0.035). Classification by SOFA score revealed that CFT was slower (P = 0.017) and MCF weaker (P = 0.005) in patients with more severe organ failure (SOFA >or= 10, CFT 125 +/- 76 seconds, and MCF 57 +/- 11 mm) as compared with patients who had lower SOFA scores (SOFA <10, CFT 69 +/- 27, and MCF 68 +/- 8). Along with increasing coagulation factor activity, the initially increased International Normalized Ratio (INR) and prolonged activated partial thromboplastin time (aPTT) corrected over time. CONCLUSIONS: Key variables of ROTEM(R) remained within the reference ranges during the phase of critical illness in this cohort of patients with severe sepsis and septic shock without bleeding complications. Improved organ dysfunction upon discharge from the ICU was associated with shortened coagulation time, accelerated clot formation, and increased firmness of the formed blood clot when compared with values on admission. With increased severity of illness, changes of ROTEM(R) variables were more pronounced

Accidental Hypothermia in a Swiss Alpine Trauma Centre-Not an Alpine Problem.

BACKGROUND Research in accidental hypothermia focuses on trauma patients, patients exposed to cold environments or patients after drowning but rarely on hypothermia in combination with intoxications or on medical or neurological issues. The aim of this retrospective single-centre cohort study was to define the aetiologies, severity and relative incidences of accidental hypothermia, methods of measuring temperature and in-hospital mortality. METHODS The study included patients ≥18 years with a documented body temperature ≤35 °C who were admitted to the emergency department (ED) of the University Hospital in Bern between 2000 and 2019. RESULTS 439 cases were included, corresponding to 0.32 per 1000 ED visits. Median age was 55 years (IQR 39-70). A total of 167 patients (38.0%) were female. Furthermore, 63.3% of the patients suffered from mild, 24.8% from moderate and 11.9% from severe hypothermia. Exposure as a single cause for accidental hypothermia accounted for 12 cases. The majority were combinations of hypothermia with trauma (32.6%), medical conditions (34.2%), neurological conditions (5.2%), intoxications (20.3%) or drowning (12.0%). Overall mortality was 22.3% and depended on the underlying causes, severity of hypothermia, age and sex

[Accidents Caused by Gardening - Trivial or Serious? 5-Year Retrospective Analysis at the University Emergency Department Berne].

Accidents Caused by Gardening - Trivial or Serious? 5-Year Retrospective Analysis at the University Emergency Department Berne Abstract. Gardening is a popular leisure activity in Switzerland. Approximately 1 million non-occupational accidents are recorded each year; 600,000 of these occur at home or in pursuit of a hobby, including approx. 16,000 accidents while gardening. The aim of this study is to investigate gardening-related accidents. The data for this study were generated from the database of the management system of Berne University Hospital, Switzerland, and retrospectively analyzed. Patients were enrolled who were at least 16 years old - since younger patients in Switzerland are normally treated in specialised Emergency Departments for Paediatrics. The study was restricted to patients who suffered an accident that resulted in physical impairment while working in their own garden. The data were then analysed based on age, sex, triage category, mechanism, causing object, lesion site, diagnoses, severity of injury (monotraumatic or combined with more than one region or polytrauma), in-patient or out-patient treatment. Gardening-related accidents were mainly suffered by middle aged adults (40-69 years). Men were more often affected than women. At consultation, the injury was mostly monotraumatic and could be treated in an out-patient setting. Patients mainly complained of eye injuries and lacerations. The exposed areas of the eyes, fingers and the head or face were the most affected body regions. Falls and stumbling often led to accidents. Injuries were mainly caused by organic material or by the improper use of gardening tools. The data analysis showed that many injuries could have been avoided by simple preventive measures

Point-of-Care Ultrasound Diagnosis of Acute High Altitude Illness: A Case Report

With the advent of high-quality portable ultrasound machines, point-of-care ultrasound (POCUS) has gained interest as a promising diagnostic tool for patients with high altitude illness. Although POCUS is used successfully in hospital environments to detect interstitial pulmonary edema and increased intracranial pressure, the relationship between specific sonographic criteria and high altitude illness is still unclear. We report the case of a healthy 32-y-old male who developed acute respiratory distress and neurologic impairment at 4321 m while participating in a high altitude medical research expedition. We discuss the potential of POCUS to diagnose acute high altitude illness by lung ultrasound, optic nerve sheath diameter measurement, and echocardiography. Ultrasound in combination with clinical findings helped us to exclude relevant differential diagnoses, start on-site treatment, and organize an evacuation. We used serial clinical and ultrasound examinations to assess the patient over time. Although its role in high altitude medicine needs further investigation, we believe that POCUS can be a valuable tool to aid clinical decision-making in remote, high altitude environments

BASE Jumping in the Lauterbrunnen Valley: A Retrospective Cohort Study from 2007 to 2016.

BACKGROUND BASE jumping, and especially BASE jumping with the help of wingsuits, is considered one of the most dangerous airborne sports. The valley of Lauterbrunnen in Switzerland has become infamous for the large number of BASE jumps and the high rate of accidents and fatalities. The aim of this study was to evaluate the morbidity and mortality of BASE jumping, to determine the severity of injuries and injury patterns of BASE jumping accidents and to compare preclinical assessment with clinical diagnoses to detect under- or overtriage. METHODS This retrospective, descriptive cohort study covers a period of 10 years (2007-2016). The evaluation covered all BASE jumping incidents in the valley of Lauterbrunnen that required either a helicopter mission by the local HEMS (Helicopter Emergency Medical Service) company of Lauterbrunnen, Air Glaciers, or medical care in the regional hospital, the level I trauma centre or the medical practice of the local general practitioner. Besides demographic data, experience in BASE jumping and skydiving as well as BASE jumping technique(s) and details about the rescue missions were collected. The medical data focused on the severity of injuries, as expressed by the National Advisory Committee of Aeronautics (NACA) score in the prehospital assessment as well as the Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) retrieved from the clinical records in the hospital or medical practice setting. RESULTS The patients were predominantly young, experienced male BASE jumpers. Morbidity (injury risk) ranged from 0.05% to 0.2%, and fatality risk from 0.02% to 0.08%. Undertriage was low, with only two cases. Overtriage was significant, with 73.2% of all NACA 4-6 cases not qualifying for major trauma. CONCLUSIONS BASE jumping remains a high-risk sport and is associated with significant rates of injuries and fatalities. Comparison with previous studies indicated that the injury rate may have decreased, but the fatality rate had not. In this known BASE jumping environment, prehospital assessment appears to be good, as we found a low undertriage rate. The high overtriage rate might be an expression of physicians' awareness of high-velocity trauma mechanisms and possible deceleration injuries

BASE Jumping in the Lauterbrunnen Valley: A Retrospective Cohort Study from 2007 to 2016

Background: BASE jumping, and especially BASE jumping with the help of wingsuits, is considered one of the most dangerous airborne sports. The valley of Lauterbrunnen in Switzerland has become infamous for the large number of BASE jumps and the high rate of accidents and fatalities. The aim of this study was to evaluate the morbidity and mortality of BASE jumping, to determine the severity of injuries and injury patterns of BASE jumping accidents and to compare preclinical assessment with clinical diagnoses to detect under- or overtriage. Methods: This retrospective, descriptive cohort study covers a period of 10 years (2007–2016). The evaluation covered all BASE jumping incidents in the valley of Lauterbrunnen that required either a helicopter mission by the local HEMS (Helicopter Emergency Medical Service) company of Lauterbrunnen, Air Glaciers, or medical care in the regional hospital, the level I trauma centre or the medical practice of the local general practitioner. Besides demographic data, experience in BASE jumping and skydiving as well as BASE jumping technique(s) and details about the rescue missions were collected. The medical data focused on the severity of injuries, as expressed by the National Advisory Committee of Aeronautics (NACA) score in the prehospital assessment as well as the Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) retrieved from the clinical records in the hospital or medical practice setting. Results: The patients were predominantly young, experienced male BASE jumpers. Morbidity (injury risk) ranged from 0.05% to 0.2%, and fatality risk from 0.02% to 0.08%. Undertriage was low, with only two cases. Overtriage was significant, with 73.2% of all NACA 4–6 cases not qualifying for major trauma. Conclusions: BASE jumping remains a high-risk sport and is associated with significant rates of injuries and fatalities. Comparison with previous studies indicated that the injury rate may have decreased, but the fatality rate had not. In this known BASE jumping environment, prehospital assessment appears to be good, as we found a low undertriage rate. The high overtriage rate might be an expression of physicians’ awareness of high-velocity trauma mechanisms and possible deceleration injuries

Loss of habitat specialists despite conservation management in fen remnants 1995–2006

Many ecosystems of high conservation value have been shaped by human impacts over centuries. Today,traditional management of semi-natural habitats is a common conservation measure in Europe. However, despite traditional management, habitat remnants may still loose specialist species due to surrounding land-use change or atmospheric nitrogen deposition. To detect trends in species density (2-m2 plotscale) and habitat quality in calcareous fens in the pre-Alps of Switzerland, we surveyed 36 traditionally managed fens in 1995/97 and again in 2005/06 (five plots per fen). The fens occurred at three altitudinal levels (800–1000, 1000–1200, 1200–1400 m asl) and were either extensively grazed or mown once a year. Despite these traditional management regimes, species density of fen specialists and of all bryophytes decreased during this decade (vascular plant specialists: -9.4%, bryophytespecialists: -14.9%, all bryophytes: -5.7%). Management had no effect on the number of Red-List species and habitat specialists of vascular plants per plot. However, bryophyte species density was more strongly reduced in grazed fens. Species density of vascular plant generalists increased between the two surveys(+8.2%) but not of bryophytes. Among vascular plants, Red-List species decreased from 1.01 to 0.78 species per plot. Furthermore, between the two surveys aboveground plant biomass, mean plant-community indicator values for nutrients and species density of nutrient indicators increased, whereas mean plant indicator values for soil moisture, light and peat, and species density for peat indicators, decreased. We attribute these changes and the loss of specialist species over the past decade mainly to land-use change in the surrounding area and to nutrient inputs. Thus, despite traditional management, calcareous fens in the pre-Alps suffer from ongoing habitat deterioration and endangered plant species remain threatened. For their long-term protection, we suggest to reduce nutrient inputs and, where necessary to restore hydrology and adjust grazing management