45 research outputs found
Implementierung und Evaluierung zielgruppenspezifischer Simulationstechniken für Großschadenslagen
No full textZusammenfassung
HINTERGRUND Im Rahmen einer Großschadenslage (GSL) und eines Massenanfalls von Verletzten (MANV) stellen Sichtungsalgorithmen ein essentielles Werkzeug dar, um die Schwere des Ereignisses zu beurteilen und notwendige Ressourcen für Versorgung und Transport verletzter und erkrankter Personen sicherzustellen. Sowohl der gewählte Algorithmus als auch der notfallmedizinische Ausbildungs- und Erfahrungsgrad des Sichters beeinflussen die Sichtungsgüte und -dauer. Frühe taktische Entscheidungen in GSL haben eine starke Auswirkung auf die Gesamtmortalität. Die Evaluation bestehender und zu implementierender Werkzeuge und Strategien sollte mit Hilfe von Simulationen vor Eintritt einer GSL erfolgen, um mögliche Defizite und Optimierungsmöglichkeiten im Vorfeld zu identifizieren. Ungeachtet der in Deutschland aktuell überwiegenden Implementierung der Sichtungsalgorithmen mSTaRT („modified Simple Triage and Rapid Treatment“) und PRIOR („Primäres Ranking zur Initialen Orientierung im Rettungsdienst“) sind diese sowohl in ihrer Anwendung als bezüglich der Eignung für verschiedene Anwendergruppen wenig evaluiert.
FRAGESTELLUNGEN Die vorliegende Forschungsarbeit untersucht die Performance der Sichtungsalgorithmen mSTaRT und PRIOR in Sichtungssimulationen, den Einfluss verschiedener notfallmedizinscher Erfahrungsgrade (medizinische Laien, notfallmedizinisch unerfahrene und erfahrene ärztliche Sichter) auf Sichtungsgüte und -dauer und die Anwendbarkeit der dynamischen Patientensimulation (dPS) für Sichtungssimulation und -evaluation.
Material und Methoden Als Referenz der Sichtungsgüte diente eine empirische Validierungssichtung mit insgesamt 275 Sichtungen durch 11 erfahrene Notfallmediziner. 100 ärztliche Sichtungen und 56 Laiensichtungen wurden je zur Hälfte mit den Sichtungsalgorithmen mSTaRT und PRIOR an Simulationspatienten der dPS in je 2 Übungsdurchläufen durchgeführt. Die Sichtungsübungen wurden im Rahmen der Implementierung der Medizinischen Task Force (MTF) realisiert. Sichtungsgüte und -dauer der Sichtungsalgorithmen wurden untersucht. Zusätzlich wurden in einer Befragung der Übungsteilnehmer die Simulationstechnik dPS und die Sichtungsalgorithmen empirisch evaluiert. Die statistische Auswertung erfolgte mit SPSS und Excel.
ERGEBNISSE Die Validierungssichtung zeigte eine Übereinstimmung von 96% für die medianen Ergebnisse der Sichtungskategorien (SK) der dPS-Patienten mit der Vorgabe des BBK (Bundesamt für Bevölkerungsschutz und Katastrophenhilfe). Dieses Ergebnis war unabhängig von der Berücksichtigung der Transportpriorität (TP) mit einem Konsens von je mehr als 55 % für die mediane SK innerhalb der ärztlichen Validierungssichter.
In den Sichtungssimulationen zeigte PRIOR kürzere mittlere Sichtungszeiten (Mittelwert ± Standardabweichung) als mSTaRT sowohl für die ärztlichen Sichter (23 ± 13 s gegenüber 31 ± 23 s), als auch für die Laiensichter (23 ± 16 s gegenüber 32 ± 38 s). Für den unerfahrenen ärztlichen Sichter war der Unterschied signifikant (25 ± 14 s gegenüber 46 ± 24 s, (t(23) = 4.09, p < .001, d = 0.83). Der erfahrene ärztliche Sicher zeigte für beide Algorithmen und in allen Sichtungskategorien kürzere Sichtungszeiten als die anderen Sichtergruppen bei mittleren Sichtungszeiten von unter 30 Sekunden
Bezüglich der Sichtungsgüte zeigte sich bei der ärztlichen Sichtung eine Sensitivität (SE) und Spezifität (SP) von ≥ 0.83 für alle SK in beiden Algorithmen außer in 2 Fällen mit einer SE von 0.67 bei mSTaRT: SK II/erfahrener ärztlicher Sichter und SK III/unerfahrener ärztlicher Sichter. Die Laiensichtung mit PRIOR zeigte eine SE von 0.00 (SK II) bis 0.92 (SK I) und SP von 0.53 (SK I) bis 0.95 (SK III) während für mSTaRT die SE zwischen 0.70 bis 0.80 und die SP zwischen 0.85 bis 0.88 lag.
Auffallend war die Assoziation von Fehlsichtungen durch die Laiensichter mit bestimmten dPS-Items („somnolent“, „Vesikuläratmen“, „verwirrt“, „Schmerzen“) während andere dPS-Items bzw. die unterschiedliche Abfolge von Items in den Algorithmen auf keinen Effekt hinwiesen.
Während der Simulationen erhöhte sich die Gesamtübereinstimmung von Übung eins zu Übung zwei für den unerfahrenen ärztlichen Sichter um 12 % und für die Laiensichter, jedoch nur innerhalb von PRIOR, um 43 %. Nur bei dem unerfahrenen ärztlichen Sichter verringerte sich auch die Sichtungszeit, der Unterschied betrug 46 %.
Mit der Befragung der MTF-Übungsteilnehmer konnte eine veränderte Präferenz von mSTaRT zu PRIOR nach dem Training (22 % gegenüber 54 %) gezeigt werden im Vergleich zu vor dem Training (49 % gegenüber 22 %).
SCHLUSSFOLGERUNGEN Das hohe Maß an Übereinstimmung der Validierungssichtung und eine durchgehend hohe Sichtungsgüte und kurze Sichtungsdauer für den erfahrenen ärztlichen Sichter sprechen für eine primäre Sichtung/Vorsichtung durch notfallmedizinisch hoch erfahrene Ärzte.
In der ärztlichen Sichtung zeigte sich bei insgesamt hoher Güte und kurzer Dauer PRIOR mSTaRT leicht überlegen. Bezüglich der Sichtungsdauer war dieser Unterschied für den notfallmedizinisch unerfahrenen ärztlichen Sichter signifikant.
Für beide Sichtungsalgorithmen zeigte sich in der ärztlichen Sichtung ein Diskriminationsdefizit zwischen SK II (gelb, schwer Verletzte) und III (grün, leicht Verletzte) hinsichtlich der Beurteilung der Gehfähigkeit: „Eingeschränkt gehfähige“ Patienten der SK III wurden punktuell als „nicht gehfähig“ mit SK II übersichtet, wohingegen „restmobile“ Patienten der SK II als „gehfähig“ mit SK III untersichtet wurden. Besonders innerhalb von mSTaRT und abhängig vom notfallmedizinischen Erfahrungsgrad verstärkte sich dieser Effekt, wobei ein hoher notallmedizinischer Erfahrungsgrad mit Untersichtungen assoziiert war und umgekehrt. Das Item „Gehfähigkeit“ zeigt sich somit als evaluationswürdig.
Bei einer im Mittel akzeptablen Sichtungsdauer innerhalb der Laiensichtung waren die Sichtungsergebnisse in ihrer Güte grenzwertig bis unzureichend und stark abhängig vom Sichtungsalgorithmus und der dPS. Der Einfluss fehlender medizinischer Fachkenntnis in der dPS führte unmittelbar zu fehlerhaften Sichtungsentscheidungen: Die Überbewertungen von Schmerzen, Fehleinschätzung von „verwirrt“ als quantitative Bewusstseinsstörung und „Vesikuläratmen“ als pathologisch wurde bei PRIOR in Form einer SK I-lastigen Übertriage evident. Weiterhin waren für beide Algorithmen Fehleinschätzungen des dPS-Merkmals „somnolent“ als physiologisch mit einer Untertriage assoziiert und die interindividuell unterschiedliche Bewertung der Gehfähigkeit hatte Einfluss auf die Sichtungsgüte. In der Gesamtschau der vorliegenden Untersuchung zeigte sich nur mSTaRT für die Nutzung durch Laiensichter geeignet, PRIOR kann nicht ohne weitere Evaluation für die dPS oder Vorsichtung durch Laiensichter empfohlen werden. Die Laiensichtung muss in anderen Simulationsformen weiter untersucht werden, um die dPS als Confounder zu eliminieren.
Insgesamt zeigte die Anwendung der dPS positive Trainingseffekte vor allem für den unerfahrenen ärztlichen Sichter in Sichtungsgüte und –dauer und für die Laiensichter in Sichtungsdauer.Summary
BACKGROUND Within the context of Major Incidents (MI) and Mass Casualty Incidents (MCI), triage algorithms serve as essential tools to evaluate the severity of the event and provide necessary resources for the care and transport of injured and ill patients. The specific triage algorithm used and the triager´s level of medical training and experience have an impact on triage accuracy and duration. Early tactical decisions in MCI strongly influence over-all-mortality. The evaluation of existing and to be implemented tools and strategies should be conducted through pre-incident simulations in order to identify potential limitations and areas for optimization before they impact a real-life emergency response. Despite their predominant implementation in Germany mSTaRT („modified Simple Triage and Rapid Treatment“) and PRIOR („Primäres Ranking zur Initialen Orientierung im Rettungsdienst“) triage algorithms have been poorly evaluated regarding their general applicability and suitability across various user groups.
RESEARCH QUESTIONS This research investigates the performance of mSTaRT and PRIOR triage algorithms in triage simulations, the influence of various medical educational backgrounds (medical laypersons, experienced and inexperienced physicians in emergency medicine) on triage accuracy and duration and the applicability of dynamic Patient Simulation (dPS) on triage simulation and evaluation.
MATERIALS AND METHODS An empirical validation triage, involving 275 triages by 11 experienced emergency physicians, served as a reference for triage accuracy. 100 physician triages and 56 layperson triages were conducted using both mSTaRT and PRIOR algorithms on simulated patients in dPS during two training exercises. The implementation of the Medical Task Force (MTF) provided an operational environment for the simulation. Triage accuracy and duration were assessed. Additionally, participant feedback was collected through a survey to empirically evaluate the dPS simulation technique and the triage algorithms. Statistical analysis was performed using SPSS and Excel.
RESULTS The validation triage showed a 96 % level of agreement on median results of Triage Categories (TC) of dPS Patients with the premise of the Federal Office of Civil Protection and Disaster Assistance (BBK). This result was found regardless of transport priority (TP) consideration with a consensus larger than 55 % amongst the validation triagers for the median TC.
Triage simulations showed shorter average triage times (Mean ± Standard Deviation) for PRIOR compared to mSTaRT for both, physician triagers (23 ± 13 s compared to 31 ± 23 s) and layperson triagers (23 ± 16 s compared to 32 ± 38 s). In particular, for the inexperienced physician triager a significant difference was found (25 ± 14 s compared to 46 ± 24 s, (t(23) = 4.09, p < .001, d = 0.83). The experienced physician triager showed for both algorithms and all TCs shorter triage duration than the other triager groups and an average triage duration of less than 30 seconds.
Regarding triage accuracy, physician triage showed sensitivity (SE) and specificity (SP) ≥ 0.83 for all TC except for 2 cases of SE in mSTaRT being 0.67: TC II/experienced physician triager and TC III/inexperienced physician triager. Layperson triage with PRIOR resulted in SE from 0.00 (TC II) to 0.92 (TC I) and SP from 0.53 (TC I) to 0.95 (TC III). The mSTaRT algorithm demonstrated SE from 0.70 to 0.80 and SP from 0.85 to 0.88 for layperson triage.
Notably, there was an association between mis-triages by layperson triagers and certain dPS items (“somnolent”, “vesicular breathing”, “confused”, “pain”) while other dPS items or the different sequence of items in the algorithms were not clearly indicating an effect.
During the simulations, the overall agreement to the validation results increased from training one to two for the inexperienced physician by 12 % and for laypersons particularly within PRIOR by 43 %. The inexperienced physician only decreased mean triage time by 46 %.
Within the questionnaire of the MTF training, a change in preference of mSTaRT towards PRIOR was shown after the training (22 % compared to 54 %) compared to before (49 % compared to 22 %).
CONCLUSIONS The high level of consensus of the validation additionally to a consistently high accuracy in the triage results and short average triage duration for the experienced emergency physician triager suggests a conduction of triage/pre-triage primarily by highly experienced emergency physicians.
The physician triage showed an overall high level of accuracy and short duration of triage with a tendency in favor of PRIOR compared to mSTaRT. Particularly, the inexperienced physician showed a significantly decreased triage duration using PRIOR.
A discrimination deficit between TC II (yellow, major injury) and III (green, minor injury) was observed in physician triage concerning mobility assessment for both algorithms: Lightly injured individuals with 'limited mobility' (TC III) were occasionally over-triaged as ´non-walking´ TC II, whereas 'partially mobile' TC II patients were under-triaged as ´walking´ TC III. Particularly with mSTaRT and depending on the level of experience the effect exacerbated. A high level of experience was associated with under triage and conversely. Consequently, the 'mobility' item requires evaluation.
Despite a moderately acceptable triage duration on average in layperson triage, the triage outcomes were borderline to inadequate in quality and heavily contingent on the triage algorithm and the dPS. The influence of lacking medical expertise in dPS directly led to wrong triage decisions. Notably, overestimations of pain, misinterpretation of 'confused' as a quantitatively altered mental status, and 'vesicular breathing' as pathological were evident with PRIOR, leading to a high rate of over-triage within TC I. Additionally, misjudging the dPS-item 'somnolent' as physiological was associated with under-triage and the interindividual variability in assessing mobility influenced the triage quality of both, mSTaRT and PRIOR. Only mSTaRT showed acceptable accuracy results suitable for layperson application. Conversely, PRIOR cannot be recommended for dPS or pre-triage by laypersons without further evaluation. It requires further investigation in f.e. real-world simulations to eliminate dPS as a confounder.
Overall, the application of dPS simulation showed positive training effects for the inexperienced physician triager in both, triage accuracy and duration and for the layperson triager predominantly in triage duration
Declining Mortality in Patients With Acute Respiratory Distress Syndrome : an Analysis of the Acute Respiratory Distress Syndrome Network Trials
No full textOBJECTIVES: There has been multiple advances in the management of acute respiratory distress syndrome, but the temporal trends in acute respiratory distress syndrome-related mortality are not well known. This study aimed to investigate the trends in mortality in acute respiratory distress syndrome patients over time and to explore the roles of daily fluid balance and ventilation variables in those patients. DESIGN: Secondary analysis of randomized controlled trials conducted by the Acute Respiratory Distress Syndrome Network from 1996 to 2013. SETTING: Multicenter study involving Acute Respiratory Distress Syndrome Network trials. PATIENTS: Patients with acute respiratory distress syndrome.None. MEASURES AND MAIN RESULTS: Individual patient data from 5,159 acute respiratory distress syndrome patients (excluding the Late Steroid Rescue Study trial) were enrolled in this study. The crude mortality rate decreased from 35.4% (95% CI, 29.9-40.8%) in 1996 to 28.3% (95% CI, 22.0-34.7%) in 2013. By adjusting for the baseline Acute Physiology and Chronic Health Evaluation III, age, ICU type, and admission resource, patients enrolled from 2005 to 2010 (odds ratio, 0.61; 95% CI, 0.50-0.74) and those enrolled after 2010 (odds ratio, 0.73; 95% CI, 0.58-0.92) were associated with lower risk of death as compared to those enrolled before 2000. The effect of year on mortality decline disappeared after adjustment for daily fluid balance, positive end-expiratory pressure, tidal volume, and plateau pressure. There were significant trends of declines in daily fluid balance, tidal volume, and plateau pressure and an increase in positive end-expiratory pressure over the 17 years. CONCLUSIONS: Our study shows an improvement in the acute respiratory distress syndrome-related mortality rate in the critically ill patients enrolled in the Acute Respiratory Distress Syndrome Network trials. The effect was probably mediated via decreased tidal volume, plateau pressure, and daily fluid balance and increased positive end-expiratory pressure
Monitoring the efficiency of reversal on anti-Xa direct oral anticoagulants using point-of-care viscoelastic testing
No full textAbstract Bleeding events in patients receiving direct oral anticoagulation (DOAC) can be life-threatening even at therapeutic DOAC plasma concentrations, as anticoagulation impairs hemostasis and should therefore be identified immediately after hospital admission. The anticoagulatory effects of DOAC are typically not measurable in standard coagulation tests, such as PT or aPTT. Specific calibrated anti-FXa-tests allow specific drug monitoring, but they are too time-consuming for critical bleeding events and are commonly not available for 24 h/7 days in routine care. However, recent advances in point-of-care (POC) viscoelastic testing (VET) have shown a promising approach for rapid and quantitative detection of DOAC plasma concentrations using the Russell viper venom factor V activator (RVV for FXa-inhibitors) test or the ecarin clotting time (thrombin inhibitors). In acute bleeding situations, direct FXa inhibitors can be reversed by specific antidote andexanet alfa or hemostasis can be improved by prothrombin complex factor concentrates (PCCs). After reversal, confirmation of reversal efficacy is often requested, but no routine assays are currently available. Thus, the emergency management of bleeding DOAC patients is usually “blinded” with regard to reversal efficacy. POC VET laboratory assays might therefore also be helpful for measuring DOAC effects after reversal. We present a case series demonstrating the usefulness of RVV-clotting time post-DOAC reversal with andexanet alfa
Influence of anatomic conditions on efficacy and safety of combined intermediate cervical plexus block and perivascular infiltration of internal carotid artery in carotid endarterectomy: a prospective observational trial
No full textAnticoagulation in venovenous extracorporeal membrane oxygenation
No full textVenovenous extracorporeal membrane oxygenation (VV-ECMO) is a lifesaving therapy in severe acute respiratory distress syndrome (ARDS). Unfortunately, bleeding and thrombotic complications occur regularly due to coagulation disorders associated with the device, the underlying disease, and the anticoagulation management. To facilitate a personalized approach to hemostasis in individuals receiving ECMO support, it is essential to assess the coagulative state of the patient while simultaneously taking into account the underlying medical condition and administered therapies
Clinical Phenotyping in Acute Respiratory Distress Syndrome: Steps Towards Personalized Medicine
No full textAcute respiratory distress syndrome (ARDS) is a highly heterogeneous syndrome with a continuing high mortality rate. Despite intensive research, established therapies consist mainly of supportive measures, while pharmacological approaches have not yet shown any consistent survival benefits. In recent years, it has become clear that the great clinical and biological diversity of ARDS contributes significantly to the difficulty of demonstrating therapeutic effects. The phenotyping of ARDS has therefore become a central field of research. Different approaches—from clinical parameters and imaging to inflammatory and cardiovascular profiles and multi-omics analyses—have repeatedly identified reproducible subphenotypes that differ in prognosis and, in some cases, in response to therapies. Hypo- and hyperinflammatory subphenotypes have been described as particularly consistent. These are prognostically relevant and, in retrospective analyses, have also shown a differentiated response to glucocorticoids, statins, or fluid strategies. However, endotypes based on causal pathophysiological mechanisms are still largely theoretical. The concept of treatable traits illustrates the potential of personalized therapy but is currently based predominantly on retrospective findings. Future studies should use standardized terminology and multimodal approaches, take longitudinal data into account, and aim for prospective validation to define robust subphenotypes and causal endotypes. This could lay the foundation for true precision medicine in ARDS
Treatment of Acquired von Willebrand Disease due to Extracorporeal Membrane Oxygenation in a Pediatric COVID-19 Patient with Vonicog Alfa: A Case Report and Literature Review
No full textAcquired von Willebrand disease (aVWD) is frequently observed in patients with the need for extracorporeal membrane oxygenation (ECMO). aVWD can be treated by plasma-derived concentrates containing factor VIII (FVIII) and/or von Willebrand factor (VWF) and recombinant VWF concentrate as well as adjuvant therapies such as tranexamic acid and desmopressin. However, all of these therapeutic options possibly cause thromboembolism. Therefore, the optimal treatment remains uncertain. This report presents a case of a 16-year-old patient suffering from severe acute respiratory distress syndrome due to coronavirus disease 2019 with the need of ECMO support. Our patient developed aVWD under ECMO therapy characterized by loss of high-molecular-weight multimers (HMWM) and severe bleeding symptoms following endoscopic papillotomy due to sclerosing cholangitis. At the same time standard laboratory parameters showed hypercoagulability with increased fibrinogen level and platelet count. The patient was successfully treated with recombinant VWF concentrate (rVWF; vonicog alfa; Veyvondi) combined with topic tranexamic acid application and cortisone therapy. rVWF concentrate vonicog alfa is characterized by ultra-large multimers and absence of FVIII. Patient could be successfully weaned from ECMO support after 72 days. Multimer analysis 1 week after ECMO decannulation showed an adequate reappearance of HMWM
Effects of pneumatic tube systems on viscoelastic coagulation tests in septic patients and healthy individuals: protocol of the randomized controlled VETaPT-trial
No full textIntroductionRapid coagulation assessment is crucial in emergencies, especially with acute bleeding, where timely intervention prevents shock and circulatory failure. Viscoelastic tests (VET) offer real-time insights into clot formation, fibrinolysis, and overall coagulation dynamics, often surpassing conventional lab tests. To accelerate diagnostics, hospitals use pneumatic tube systems (PTS) for blood transport. However, the effect of PTS transport on VET results remains unclear, especially with newer VET technologies and in critically ill patients, who may be more vulnerable to acceleration forces.ObjectiveThe VETaPT (Viscoelastic Testing after Pneumatic Tube Transport) trial investigates whether PTS transport influences results of three next generation VET and platelet function testing in healthy volunteers and critically ill septic patients. It explores if acceleration during transport alters coagulation and platelet function parameters and whether septic patients exhibit increased susceptibility due to their altered coagulation profiles. A goal is to define an acceleration threshold above which PTS-related effects become clinically relevant. This threshold could allow assessment of transport suitability based on force data alone, supporting wider clinical application without repeated blood testing.Study designThis prospective, randomized clinical trial includes both healthy volunteers and critically ill septic patients. Paired blood samples are collected and randomly assigned to either manual or PTS transport, with each subject serving as their own control. Acceleration forces during PTS transport are continuously recorded using a three-axis accelerometer. Samples are analyzed using standard lab tests and following point-of-care devices: ClotPro®, ROTEM® sigma, Multiplate®, and TEG6s®. The primary outcome is the difference in coagulation parameters between transport methods, evaluated in the context of measured acceleration forces.Expected resultsThis is the first study to systematically compare multiple next generation VET and platelet aggregation systems in both healthy and septic patients under controlled PTS transport conditions. It is hypothesized that PTS-induced acceleration may alter test results. Identifying a critical threshold could ensure safe, rapid blood transport without compromising diagnostic quality, potentially reducing personnel needs and expediting therapy initiation.RegistrationEthics approval was obtained from the responsible committee of the Technical University Dresden (BO-EK-12012024_1). The study is registered with the German Clinical Trials Register (DRKS00036231)
