Medizinische Klinik-Intensivmedizin Und Notfallmedizin最新文献

Background: Abnormal thyroid markers are a frequent occurrence in emergency and intensive care medicine. Correct interpretation of their clinical relevance and distinction from a primary thyroid disease, particularly prior to potential administration of iodine-containing antiarrhythmic drugs such as amiodaron or radiocontrast agents, are both essential and challenging.

Objective: This article aims to present the pathophysiology of abnormal thyroid markers in acute or protracted critical disease. Their relevance for administration of amiodaron or iodine-containing radiocontrast agents is discussed, and concrete practical recommendations are presented.

Materials and methods: The current work comprises a discussion of expert recommendations, guidelines, and basic research.

Results and conclusion: Approximately one third of intensive care patients develop non-thyroidal illness syndrome (NTIS) during the course of their critical disease. NTIS is characterized by a reduction in the serum concentration of fT3 and, during the course, also in those of thyroid-stimulating hormone (TSH) and fT₄, despite an organically intact thyroid gland. A greater extent of the deviations correlates with a worse overall prognosis. The mechanisms involved are manifold and influence different levels of hormonal signaling axes. They are mediated by interaction with acute stress signals such as inflammatory factors and elevated cortisol levels and are influenced by medication. The components vary depending on disease severity and the protracted course. NTIS does not require any specific treatment; the focus is on treating the underlying disease. Latent hyperthyroidism in particular must be distinguished from NTIS. In unclear situations and high-risk constellations, perchlorate is indicated before (and after) iodine exposure.

Background: In hospitalised patients, clinical deterioration can be detected at an early stage using early warning scores (EWS), enabling timely interventions. However, it remains unclear to what extent EWS have been implemented within the network of the Initiative of Quality in Medicine (IQM), comprising 480 hospitals, and what facilitating and challenging factors have been reported in this context.

Methods: An online survey within the IQM was conducted to assess EWS-specific structures and processes, barriers, and facilitators. The degree of implementation was self-rated by participants on a numerical rating scale from 1 to 10 (10 = maximum).

Results: Of the 480 individuals contacted, 18.7% (n = 90) responded; 6.3% (n = 30) reported using EWS in clinical practice for an average of 4.3 years. Among these, the National-EWS (NEWS) was most frequently used (37.9%, n = 11), primarily on general medical wards (66.7%, n = 20). Rapid response teams were mostly formed by resuscitation teams (33.3%, n = 10). Electronic systems were used for EWS recording in 82.2% (n = 24), and documentation was most often performed in response to clinical abnormalities (56.7%, n = 17). The self-rated median implementation score was 3.5. The top three facilitating factors included committed staff, clear communication and training strategies, and technological support; barriers identified were lack of staff acceptance, insufficient technical infrastructure, and time required for training.

Conclusion: The implementation of EWS within the IQM appears to be limited and might be a challenging and complex process. The low participation rate limits the informative value of this study.

Background: Chronic habitual foreign body ingestion (chFI) in adults represents a rare but clinically relevant challenge in emergency medicine. Recurrent presentations, high resource consumption and the need for interdisciplinary care further complicate the management. To date, there is a lack of systematic data on the current care reality in German emergency departments (ED).

Objective: To evaluate the frequency, hospital resource demands and structural challenges associated with chFI as perceived by heads of medical EDs.

Methods: A nationwide anonymous online survey was conducted among medical directors of German EDs using a standardized questionnaire. Structural, clinical and organizational aspects of care were assessed. Data were analyzed descriptively. Free-text responses were evaluated using inductive category development.

Results: Of the 1081 e‑mail invitations sent 831 (77%) were successfully delivered; 167 institutions participated in the survey (response rate: 20%). A total of 45% reported ≥ 15 presentations of patients with chFI per year. In 88% of cases endoscopy was performed as an emergency procedure, mostly outside of regular working hours. In addition to the ED and endoscopy unit, intensive care (47%) and psychiatry (34%) were frequently involved. In 66% of cases further treatment took place in a psychiatric hospital or ward. Key areas for improvement included early psychiatric involvement, clear indication criteria for endoscopy, and structured interdisciplinary collaboration.

Conclusion: The chFI represents a relevant challenge in emergency medicine. Repeated presentations and the lack of interdisciplinary treatment standards highlight the need for standardized care pathways with mandatory psychiatric integration.

Congenital heart defects encompass a wide spectrum of varying anatomies and physiologies. Residuals after surgical or interventional treatment during childhood significantly shape the clinical course, as do multiple organ involvement and the development of degenerative diseases. As adults, many patients with congenital heart defects are no longer treated within specialized care structures, which is associated with a worsening prognosis and an increased frequency of emergency situations. Without appropriate expertise, emergencies in patients with complex congenital heart defects are challenging to assess. Arrhythmias and heart failure are the most common emergency scenarios in adults with congenital heart defects. Atrial tachycardias, particularly in the context of a Fontan circulation or a systemic right ventricle, should be treated promptly. Since the overall risk of sudden cardiac death is increased, syncope must always be thoroughly investigated. Depending on the specific anatomy and physiology, different therapeutic strategies must be employed for heart failure. In Eisenmenger syndrome, chronic cyanosis with reactive polycythemia and multiple organ involvement is the primary concern. Pregnancy and the peripartum period may precipitate decompensation of previously compensated conditions in patients with congenital heart disease. The ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) can generally be followed. However, without knowledge of the patient's medical history, treatment errors with potentially severe consequences can easily occur. By adding the letter F to the ABCDE scheme, the importance of the patient's Former medical history and additional information (Further information) in this vulnerable patient group is emphasized. A multidisciplinary approach and close coordination with a specialized adult congenital heart disease (ACHD) center are critical for improving the prognosis in acute situations.

Background: Syncope is a common and clinically relevant condition in the emergency department. Accurate risk stratification is essential to distinguish between benign and serious causes, guiding appropriate outpatient or inpatient management. This is crucial for preventing complications and ensuring cost-effective care.

Objective: This study evaluates the applicability of the 2018 ESC guidelines (European Society of Cardiology) in clinical practice.

Methods: A retrospective analysis was conducted at a tertiary care emergency department. Data from all patients who presented with syncope in 2022 were included.

Results: A total of 492 patients were analyzed, including 327 (62.8%) inpatients who underwent full evaluation. High-risk criteria were significantly more frequent among inpatients, while low-risk syncope was more common in the outpatient group. The high-risk criteria of the ESC guidelines demonstrated a sensitivity of 90.8% for the detection of dangerous syncope. In addition, recurrent syncope within the last 12 months was associated with an increased risk of dangerous syncope.

Conclusion: The ESC guidelines demonstrated a sensitivity of over 90%, establishing them as a reliable tool for risk stratification in patients with syncope. Recurrent syncope may represent an additional high-risk criterion that should be further investigated in future prospective studies.

Intensive care for patients with hemato-oncological diseases is a complex interplay between life-prolonging therapy and palliative care. Especially in cases with a limited prognosis, early clarification of treatment goals and transition to palliative-oriented measures become increasingly important. When is a change in treatment goals appropriate in the intensive care unit, and how can patient-centered, suffering-oriented care be implemented in a structured way? The concept of a time-limited trial (TLT) offers a structured framework to allow a limited period of intensive care treatment with clearly defined success criteria in cases of uncertain prognosis. Even more important is to make anticipatory decisions for acute situations through early communication with patients and their families. This is illustrated using the example of discussions around resuscitation attempts. The integration of palliative care, ethics consultation, and interprofessional teams contributes to avoiding overtreatment and to safeguarding patient autonomy.