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Endoscopy is most frequently performed in intensive care units (ICU) for gastrointestinal bleeding; however, there are other indications for performing an endoscopy on the ICU. This article shows the indications for this, the background and the peri-interventional and postinterventional management. The endoscopic placement of a postpyloric feeding tube is a well-established procedure. For anastomotic leakage in the esophagus and rectum, the endoscopic vacuum therapy is the treatment of choice. Gastrointestinal motility disorders are a frequent phenomenon in critically ill patients and are associated with increased mortality. With a cecal diameter > 9-12 mm, endoscopic decompression can be performed; however, this is associated with an increased risk of perforation and should only be carried out after the failure of conservative treatment.

A 78-year-old patient received an interscalene plexus catheter for perioperative pain therapy during implantation of an inverse shoulder prothesis. After stimulation-assisted puncture under sonographic control, 25 ml of local anesthetic (LA) were first administered and then the catheter was placed using the through the needle technique. Immediately after the administration of another 5 ml of local anesthetic via the inserted catheter, the patient showed symptoms of total spinal anesthesia, so that she had to be intubated and ventilated. The following computed tomographic diagnostics of the neck revealed an intrathecal misalignment of the plexus catheter, the tip of which was lying dorsal to the vertebral artery at the level of the 5/6 cervical vertebrae. The catheter could then be removed without any problems and there were no neurological sequelae. The use of ultrasound with clear identification of the nerve roots C5-C7 and the surrounding structures provides additional security when installing an intrascalene catheter. The spread of the LA should be traceable at all times using ultrasound and should otherwise be immediately terminated. Furthermore, a strict adherence to the needle position while inserting the catheter without manipulation of the needle depth is necessary. The first injection of the catheter has to be performed under controlled conditions, preferably connected to surveillance monitors with neurological monitoring of the awake patient and control of vital signs with direct access to the emergency equipment.

Background: The preclinical treatment of a traumatic or spontaneous tension pneumothorax remains a particular challenge in pediatric patients. Currently recommended interventions for decompression are either finger thoracostomy or needle decompression. Due to the tiny intercostal spaces, finger thoracostomy may not be feasible in small children and surgical preparation may be necessary. In needle decompression, the risk of injuring underlying vital structures is increased because of the smaller anatomic structures. As most emergency physicians do not regularly work in pediatric trauma care, decompression of tension pneumothorax is associated with significant uncertainty; however, in this rare emergency situation, consistent and goal-oriented action is mandatory and lifesaving. An assessment of pre-existing experience and commonly used techniques therefore seems necessary to deduce the need for future education and training.

Objective: In this study an online survey was created to evaluate the experience and the favored prehospital treatment of tension pneumothorax in children among German emergency physicians.

Material and methods: An online survey was conducted with 43 questions on previous experience with tension pneumothorax in children, favored decompression technique and anatomical structures in different age groups. Surveyed were the emergency physicians of the ground-based emergency medical service of the University Medical Center Mannheim, the German Air Rescue Service (DRF) and the pediatric emergency medical service of the City of Munich.

Results: More than half of all respondents stated that there was uncertainty about the procedure of choice. Needle decompression was favored in smaller children and mini-thoracostomy in older children. In comparison with the literature, the thickness of the chest wall was mostly estimated correctly by the emergency medical physicians. The depth of the vital structures was underestimated at most of the possible insertion sites in all age groups. At the lateral insertion sites on the left hemithorax, however, the distance to the left ventricle was overestimated. The caliber of the needle selected for decompression tended to be too large, especially in younger children.

Conclusion: Even though having interviewed an experienced group of prehospital emergency physicians, the experience in decompression of tension pneumothorax in children is relatively scant. Knowledge of chest wall thickness and depth to vital structures is sufficient, the choice of needle calibers tends to be too large but still reasonable. For many providers a large amount of uncertainty about the right choice of technique and equipment arises from the challenge of decompressing a tension pneumothorax in children and therefore further theoretical education and regular training are required for safe performance of the procedure.<

Background: A sharp rise in COVID-19 infections threatened to lead to a local overload of intensive care units in autumn 2020. To prevent this scenario a nationwide relocation concept was developed.

Methods: For the development of the concept publicly available infection rates of the leading infection authority in Germany were used. Within this concept six medical care regions (clusters) were designed around a center of maximum intensive care (ECMO option) based on the number of intensive care beds per 100,000 inhabitants. The concept describes the management structure including a structural chart, the individual tasks, the organization and the cluster assignment of the clinics. The transfers of intensive care patients within and between the clusters were recorded from 11 December 2020 to 31 January 2021.

Result: In Germany and Baden-Württemberg, 1.5% of patients newly infected with SARS-CoV‑2 required intensive care treatment in mid-December 2020. With a 7-day incidence of 192 new infections in Germany, the hospitalization rate was 10% and 28-35% of the intensive care beds were occupied by COVID-19 patients. Only 16.8% of the intensive care beds were still available, in contrast to 35% in June 2020. The developed relocation concept has been in use in Baden-Württemberg starting from 10 December 2020. From then until 7 February 2021, a median of 24 ± 5/54 intensive care patients were transferred within the individual clusters, in total 154 intensive care patients. Between the clusters, a minimum of 1 and a maximum of 15 (median 12.5) patients were transferred, 21 intensive care patients were transferred to other federal states and 21 intensive care patients were admitted from these states. The total number of intensive care patients transferred was 261.

Conclusion: If the number of infections with SARS-CoV‑2 increases, a nationwide relocation concept for COVID-19 intensive care patients and non-COVID-19 intensive care patients should be installed at an early stage in order not to overwhelm the capacities of hospitals. Supply regions around a leading clinic with maximum intensive care options are to be defined with a central management that organizes the necessary relocations in cooperation with regional and superregional rescue service control centers. With this concept and the intensive care transports carried out, it was possible to effectively prevent the overload of individual clinics with COVID-19 patients in Baden-Württemberg. Due to that an almost unchanged number of patients requiring regular intensive care could be treated.

All hospitals that are defined as organ donation hospitals according to the Social Act V (SGB V), are legally bound to employ a transplant coordinator (TxB). The field of activities of the TxB includes not only the identification of donors, the diagnosis of irreversible loss of brain function, donor evaluation and organ protection but also the support of the complete organ donation process. The TxB is responsible for the establishment of in-house hospital standards as well as the organization of advanced and continuing education and is the contact person for all aspects of organ donation. Furthermore, the TxB acts as a link between the coordination center (German Organ Procurement Organization) and the allocation organisation (Eurotransplant). The activities are subject to the Transplantation Act and its implementation statutes; however, the TxB also needs corresponding knowledge of the various guidelines on organ donation and transplantation. Finally, the TxB is also responsible for the quality assurance of the organ donation process.

Background: Immobilization of the cervical spine is a standard procedure in emergency medicine mostly achieved via a cervical collar. In the emergency room other forms of immobilization are utilized as cervical collars have certain drawbacks. The present study aimed to provide preliminary data on the efficiency of immobilization in the emergency room by analyzing the residual spinal motion of the patient's head on different kinds of head rests.

Methods: In the present study biomechanical motion data of the cervical spine of a test subject were analyzed. The test subject was placed in a supine position on a mobile stretcher (Stryker M1 Roll-In System, Kalamazoo, MI, USA) wearing a cervical collar (Perfit ACE, Ballerup, Denmark). Three different head rests were tested: standard pillow, concave pillow and cavity pillow. The test subject carried out a predetermined motion protocol: right side inclination, left side inclination, flexion and extension. The residual spinal motion was recorded with wireless motion trackers (inertial measurement unit, Xsens Technologies, Enschede, The Netherlands). The first measurement was performed without a cervical collar or positioning on the pillows to measure the physiological baseline motion. Subsequently, three measurements were taken with the cervical collar applied and the pillows in place. From these measurements, a motion score was calculated that can represent the motion of the cervical spine.

Results: When the test subject's head was positioned on a standard pillow the physiological motion score was reduced from 69 to 40. When the test subject's head was placed on concave pillow the motion score was further reduced from 69 to 35. When the test subject's head was placed on cavity pillow the motion score was reduced from 69 to 59. The observed differences in the overall motion score of the cervical spine are mainly due to reduced flexion and extension rather than rotation or lateral inclination.

Conclusion: The motion score of the cervical spine using motion sensors can provide important information for future analyses. The results of the present study suggest that trauma patients can be immobilized in the early trauma phase with a cervical collar and a head rest. The application of a cervical collar and the positioning on the concave pillow may achieve a good immobilization of the cervical spine in trauma patients in the early trauma phase.