Hymenoptera venom (HV) is injected into the skin during a sting by Hymenoptera such as bees or wasps. Some components of HV are potential allergens and can cause large local and/or systemic allergic reactions (SAR) in sensitized individuals. During their lifetime, ~ 3% of the general population will develop SAR following a Hymenoptera sting. This guideline presents the diagnostic and therapeutic approach to SAR following Hymenoptera stings. Symptomatic therapy is usually required after a severe local reaction, but specific diagnosis or allergen immunotherapy (AIT) with HV (VIT) is not necessary. When taking a patient\'s medical history after SAR, clinicians should discuss possible risk factors for more frequent stings and more severe anaphylactic reactions. The most important risk factors for more severe SAR are mast cell disease and, especially in children, uncontrolled asthma. Therefore, if the SAR extends beyond the skin (according to the Ring and Messmer classification: grade > I), the baseline serum tryptase concentration shall be measured and the skin shall be examined for possible mastocytosis. The medical history should also include questions specific to asthma symptoms. To demonstrate sensitization to HV, allergists shall determine concentrations of specific IgE antibodies (sIgE) to bee and/or vespid venoms, their constituents and other venoms as appropriate. If the results are negative less than 2 weeks after the sting, the tests shall be repeated (at least 4 - 6 weeks after the sting). If only sIgE to the total venom extracts have been determined, if there is double sensitization, or if the results are implausible, allergists shall determine sIgE to the different venom components. Skin testing may be omitted if in-vitro methods have provided a definitive diagnosis. If neither laboratory diagnosis nor skin testing has led to conclusive results, additional cellular testing can be performed. Therapy for HV allergy includes prophylaxis of reexposure, patient self treatment measures (including use of rescue medication) in the event of re-stings, and VIT. Following a grade I SAR and in the absence of other risk factors for repeated sting exposure or more severe anaphylaxis, it is not necessary to prescribe an adrenaline auto-injector (AAI) or to administer VIT. Under certain conditions, VIT can be administered even in the presence of previous grade I anaphylaxis, e.g., if there are additional risk factors or if quality of life would be reduced without VIT. Physicians should be aware of the contraindications to VIT, although they can be overridden in justified individual cases after weighing benefits and risks. The use of β-blockers and ACE inhibitors is not a contraindication to VIT. Patients should be informed about possible interactions. For VIT, the venom extract shall be used that, according to the patient\'s history and the results of the allergy diagnostics, was the trigger of the disease. If, in the case of double sensitization and an unclear history regarding the trigger, it is not possible to determine the culprit venom even with additional diagnostic procedures, VIT shall be performed with both venom extracts. The standard maintenance dose of VIT is 100 µg HV. In adult patients with bee venom allergy and an increased risk of sting exposure or particularly severe anaphylaxis, a maintenance dose of 200 µg can be considered from the start of VIT. Administration of a non-sedating H1-blocking antihistamine can be considered to reduce side effects. The maintenance dose should be given at 4-weekly intervals during the first year and, following the manufacturer\'s instructions, every 5 - 6 weeks from the second year, depending on the preparation used; if a depot preparation is used, the interval can be extended to 8 weeks from the third year onwards. If significant recurrent systemic reactions occur during VIT, clinicians shall identify and as possible eliminate co-factors that promote these reactions. If this is not possible or if there are no such co-factors, if prophylactic administration of an H1-blocking antihistamine is not effective, and if a higher dose of VIT has not led to tolerability of VIT, physicians should should consider additional treatment with an anti IgE antibody such as omalizumab as off lable use. For practical reasons, only a small number of patients are able to undergo sting challenge tests to check the success of the therapy, which requires in-hospital monitoring and emergency standby. To perform such a provocation test, patients must have tolerated VIT at the planned maintenance dose. In the event of treatment failure while on treatment with an ACE inhibitor, physicians should consider discontinuing the ACE inhibitor. In the absence of tolerance induction, physicians shall increase the maintenance dose (200 µg to a maximum of 400 µg in adults, maximum of 200 µg HV in children). If increasing the maintenance dose does not provide adequate protection and there are risk factors for a severe anaphylactic reaction, physicians should consider a co-medication based on an anti-IgE antibody (omalizumab; off-label use) during the insect flight season. In patients without specific risk factors, VIT can be discontinued after 3 - 5 years if maintenance therapy has been tolerated without recurrent anaphylactic events. Prolonged or permanent VIT can be considered in patients with mastocytosis, a history of cardiovascular or respiratory arrest due to Hymenoptera sting (severity grade IV), or other specific constellations associated with an increased individual risk of recurrent and/or severe SAR (e.g., hereditary α-tryptasemia). In cases of strongly increased, unavoidable insect exposure, adults may receive VIT until the end of intense contact. The prescription of an AAI can be omitted in patients with a history of SAR grade I and II when the maintenance dose of VIT has been reached and tolerated, provided that there are no additional risk factors. The same holds true once the VIT has been terminated after the regular treatment period. Patients with a history of SAR grade ≥ III reaction, or grade II reaction combined with additional factors that increase the risk of non response or repeated severe sting reactions, should carry an emergency kit, including an AAI, during VIT and after regular termination of the VIT.

Pre-clinical psychiatric emergencies are generally treated by emergency medical staff. The subsequent clinical treatment is often conditioned by interaction problems between emergency medical staff and psychiatric clinical staff.
To identify problems affecting interaction between emergency medical and psychiatric care of mentally ill patients and pinpoint aspects of optimized emergency care.
To shed light on the interaction problems an anonymous, questionnaire-based, nonrepresentative survey of 98 emergency physicians (EM) and 104 psychiatrists (PS) practicing in acute psychiatry was conducted between March 1, 2021 and October 1, 2021.
The chi-square test for multiple response sets revealed consistently significant differences (p < 0.001) between EM and PS with respect to the questions analyzed. Approximately 36% of EM reported not to be adequately qualified to handle psychiatric emergencies (p = 0.0001), while around 50% of respondents were neutral in their assessment in how to deal with psychiatric emergencies. 80% of EM reported a negative interaction (rejection of patients) with PS when referring a psychiatric emergency patient to the acute psychiatric unit. The most common reasons for refusal were intoxication (EM: 78.8%, PS: 88.2%), emergency physician therapy (EM: 53.8%, PS: 63.5%), and not resident in the catchment area of the hospital (EM 68.8%, PS: 48.2%). In the casuistry presented, most respondents would choose \"talk down\" for de-escalation (EM: 92.1%, PS: 91.3%). With respect to drug therapy, benzodiazepine is the drug of choice (EM: 70.4%, PS: 78.8%). More EM would choose an intravenously (i.v.) or a Mucosal Atomization Device (MAD) administration as an alternative to oral medication (i.v.: EM: 38.8%, PS: 3.8%, p = 0.001, MAD: EM: 36.7%, PS: 10.6%, p = 0.006). Significantly more EM would seek phone contact with the acute psychiatric hospital (EM: 84.7%, PS: 52.9%, p = 0.0107). A psychiatric emergency plan was considered useful in this context by more than 90% of respondents. The need for further training for EM with regard to treating psychiatric clinical syndromes was considered important by all respondents. In particular, the topics of \"psychogenic seizure,\" \"intoxication,\" and \"legal aspects of psychiatric emergencies\" were considered important (Mann-Whitney U test, p < 0.001).
The interaction-related problems identified in the emergency medical care of pre-clinical psychiatric patients relate to non-modifiable, structural problems, such as insufficient admission capacity and non-existent or inadequate monitoring capabilities in acute psychiatric hospitals. However, factors such as the education and training of EM and communication between EM and PS can be improved. Developing personalized emergency care plans for psychiatric patients could help to optimize their care.

Diabetes mellitus, known as the most widespread disease in the world, along with four other chronic diseases, involves major expenditures and significant human resources for care, thus representing a burden on any type of health care system especially due to its rapid evolution of acute and chronic complications. For the emergency department (ED), the requirements of patients with acute complications of diabetes, determine expenses which are three times higher than those for non-diabetic patients and their hospitalizations are four times more frequent. The acute complications for which patients with diabetes most frequently require the ED are hypoglycemic, hyperosmolar, or ketoacidosis coma as well as alterations of the general condition that is typical of hypoglycemia, diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state and new-onset hyperglycemia. Hypoglycemia and the Somogyi phenomenon are the most common complications of type 1 diabetes but they can also occur in patients with type 2 diabetes who are treated with insulin through its overdose. DKA can occur in type 1 and 2 diabetes either by administering inadequate doses of insulin or due to the existence of precipitating factors such as stress, acute myocardial infarction, infections, sepsis, and/or gastrointestinal bleeding. Hyperosmolar hyperglycemic status is the most common complication in patients with type 2 diabetes and DKA. Treating the acute complications of diabetes in the ED involves, besides taking immediate measures to assess and maintain vital functions, monitoring patients, assessing blood sugar, electrolytes, urea, creatinine, and bicarbonate, and applying appropriate immediate therapeutic measures for each type of acute diabetes complication.

OBJECTIVE: Dentists treat a wide range of patients, including patients with compromised health conditions. While rendering treatment, various medical emergencies can and do occur. To help increase the knowledge required to manage such emergencies, dental students must be trained while in dental school. This study aims to assess the level of medical emergency preparedness and knowledge among dental students at four dental schools.
METHODS: The participating dental schools were IUSD, Case Western Reserve University School of Dentistry, Marquette University School of Dentistry, and the University of Alabama School of Dentistry. Groups were designed to include 20 dental students from Years 1 to 4. Students were asked to fill out a survey and were then tested on 10 clinical medical emergency scenarios.
RESULTS: A total of 331 dental students participated in the study. The scores based on 10 case scenarios presented with a range of 4.35-8.02. There was no statistically significant difference in the level of preparedness when dental schools were compared. However, Year 1 and Year 2 dental students had significantly lower total scores than those of Years 3 and 4. The students in Years 1 and 2 demonstrated less confidence in their current knowledge to manage medical emergencies. Satisfaction with the training received ranged from 38% to 84%.
CONCLUSIONS: The results from this study indicate that students\' preparedness to manage medical emergencies at these four dental schools is statistically similar. Additional yearly training could enhance students\' preparedness in the management of medical emergencies in the dental setting.

Background: Mechanical chest compression devices are commonly used providing a constant force and frequency of chest compression during cardiopulmonary resuscitation. However, there are currently no recommendations on ventilation during cardiopulmonary resuscitation with a mechanical chest compression device using continuous mode. An effective method for ventilation in such scenarios might be a triggered oxygen-powered resuscitator. Methods: We report seven cardiopulmonary resuscitation cases from the Munich Emergency Medical Service where mechanical chest compression devices in continuous mode were used with an oxygen-powered resuscitator. In each case, the resuscitator (Oxylator®) was running in automatic mode delivering a breath during the decompression phase of the chest compressions at a frequency of 100 per minute. End-tidal carbon dioxide and pulse oximetry were measured. Additional data was collected from the resuscitation protocol of each patient. Results: End-tidal carbon dioxide was available in all cases while oxygen saturation only in four. Five patients had a return of spontaneous circulation. Based on the end-tidal carbon dioxide values of each of the cases, the resuscitator did not seem to cause hyperventilation and suggests that good-quality cardiopulmonary resuscitation was delivered. Conclusions: Continuous chest compressions using a mechanical chest compression device and simultaneous synchronized ventilation using an oxygen-powered resuscitator in an automatic triggering mode might be feasible during cardiopulmonary resuscitation.
Hintergrund: Geräte zur mechanischen Thoraxkompression werden heute routinemäßig eingesetzt, unter anderem, weil sie eine kontinuierliche Kompressionsstärke, -tiefe und -frequenz während einer kardiopulmonalen Reanimation ermöglichen. Bezüglich der Beatmung bei Reanimation mittels Thoraxkompressionsgerät in kontinuierlichem Modus gibt es aktuell keine Empfehlungen. Dafür wäre ein mit Sauerstoff betriebener triggerbarer Ventilator eventuell geeignet.Methode: Wir berichten von sieben Reanimationen im Münchner Rettungsdienst, die mittels Thoraxkompressionsgerät im kontinuierlichen Modus durchgeführt wurden und bei denen gleichzeitig ein mit Sauerstoff betriebener, automatisch auslösender Notfallventilator zur Anwendung kam. In allen sieben Fällen handelte es sich dabei um den Oxylator®, der im automatischen Modus jedes Mal in der Dekompressionsphase der Thoraxkompression einen Beatmungshub auslöst. Somit beatmet der Ventilator synchron mit dem Thoraxkompressionsgerät mit einer Beatmungsfrequenz von 100 pro Minute. Als Monitoring dienten endtidales Kohlendioxid und die Sauerstoffsättigung. Weitere Daten wurden den Rettungsdienstprotokollen entnommen.Ergebnisse: Endtidales Kohlendioxid war in allen sieben Fällen messbar, die Sauerstoffsättigung nur in vier. Bei fünf der Patienten konnte eine Wiederherstellung des Kreislaufes erreicht werden. Basierend auf den endtidalen Kohlendioxidwerten kann eine gute Qualität der kardiopulmonalen Reanimation angenommen werden sowie eine Hyperventilation als unwahrscheinlich erachtet werden.Fazit: Während einer kardiopulmonalen Reanimation mittels Thoraxkompressionsgerät im kontinuierlichen Modus war eine Ventilation mit einem sauerstoffbetriebenen, automatisch auslösenden Notfallventilator in sieben Fällen zuverlässig möglich.

暂无摘要。

Inappropriate seizure management may result in high morbidity and mortality. We assessed the adherence of health professionals in southern Rwanda to a national protocol for pharmacological management of seizures in children. A questionnaire featuring a 5-year-old child with generalized prolonged seizures was administered. The questions focused on the choice of initial treatment and the sequence of management following failure of the initial treatment choice. Benzodiazepine was chosen as initial therapy by 93.7% of physicians and 90.9% of nurses. Only 49.2% of physicians and 41% of nurses would repeat the initial treatment in case of failure of the first dose and 47% of doctors would wait 30 min to intervene. In case of refractory status epilepticus, 34% of physicians would give three doses of benzodiazepine, whereas 19% did not know what to do. These results suggest poor adherence to national protocol.