Peripartum cardiomyopathy (PPCM) is a rare type of heart failure which presents towards the end of pregnancy or in the first 5 months after delivery. Depending on the geographical location the incidence is reported in the literature as 1:300 up to 1:15,000. There are a number of known risk factors, such as multiparity and age of the mother over 30 years. The symptoms of PPCM correspond to those of idiopathic cardiomyopathy. The diagnosis is mainly carried out using echocardiography which shows a clear reduction of systolic left ventricular function. The therapeutic approach is the same as for idiopathic cardiomyopathy and in this context it is absolutely necessary to show caution concerning the state of pregnancy and the resulting contraindications for therapeutic drugs. The prognosis is dependent on recovery from the heart failure during the first 6 months postpartum. The lethality of the disease is high and is given in the literature as up to 28 %. Because of its complexity PPCM is an interdisciplinary challenge. In the peripartum phase a close cooperation between the disciplines of cardiology, cardiac surgery, neonatology, obstetrics and anesthesiology is indispensable. For anesthesiology the most important aspects are the mostly advanced unstable hemodynamic condition of the mother and the planning and implementation of the perioperative management. This article presents the case of a patient in advanced pregnancy with signs of acute severe heart failure and a suspected diagnosis of PPCM. The patient presented as an emergency case and delivery of the child was carried out using peridural anesthesia with a stand-by life support machine.

Each weekend soccer arenas attract hundreds of thousands of spectators with the German Bundesliga being one of the most attractive sport series worldwide. In 2006 when the FIFA soccer World Cup™ took place in Germany, the precautions in the participating arenas against mass casualty incidents (MCI) reached a level formerly unknown in Germany. However, it is unknown how soccer arenas are prepared to deal with such incidents in everyday life.In 2011 all German major soccer league clubs were questioned about medical precautions in case of MCIs occurring in the stadium. The questionnaire included the following items: stadium capacity, the number of paramedic personnel, emergency physicians and ambulance vehicles, the command and communication structures, the availability of MCI plans, recent MCI drills and the frequency of MCI.Out of 39, 15 (38.4 %) participated, 50 % from the first league and 20.8 % from the second league. The mean stadium capacity was 41,800 spectators (minimum 10,600, maximum 80,700). Depending on the number of spectators and the individual risk score of the match the following resources were available within the stadiums (average, minimum, maximum,): emergency medical technicians 61-67 (15, 120), emergency physicians 2.3-2.5 (1, 5) and transport capacity 5.3-5.8 patients (1, 15). In 14 arenas (93.3 %) the medical personnel were trained in mass casualty care and had prepared MCI operation schedules. All stadiums had mission control centers equipped with a variety of wired and wireless communication tools, although only eight (52.3 %) arenas used a joint command structure and five (33.3 %) arenas reported MCIs (defined as a scenario involving more than 10 patients) within the past 10 years. In 40 % of the participants the last MCI-related exercise was conducted more than 36 months ago.Most of the participating arenas were adequately staffed to manage the first phase of MCIs but in contrast command structures and transport capacities often focused on individual emergencies. Although most of the participants stated that they planned the resources provision according to well established algorithms, the resources actually available at the arenas varied considerably. The frequency of MCIs in soccer arenas was surprisingly high in contrast to the frequency of MCI-related drills.

Transfusion-related acute lung injury (TRALI) developed into the leading cause of transfusion-related morbidity and mortality after the first description by Popovsky et al. approximately three decades ago. It was the most frequent reason for transfusion-related fatalities worldwide before implementation of risk minimization strategies by donor selection. Plasma-rich blood products, such as fresh frozen plasma and apheresis platelets seem to be the leading triggers of TRALI. Hypoxemia and development of pulmonary edema within 6 h of transfusion are the diagnostic criteria for TRALI. The differentiation between cardiac failure and other transfusion-related lung injuries, such astransfusion-associated circulatory overload ( TACO) is difficult and causal treatment is not available. Therapy is based on supportive measures, such as oxygen insufflationor mechanical ventilation. The exactly pathogenesis is still unknown but the most propagated hypothesis is the two-event-model. Neutrophils are primed by the underlying condition, e.g. sepsis or trauma during the first event and these primed neutrophils are activated by transfused leukoagglutinating antibodies (immunogen) or bioreactive mediators (non-immunogen) during the second-event. Transfusion of leukoagglutinating antibodies from female donors with one or more previous pregnancies is the most frequent reason. No more TRALI fatalities were reported after implementation of the donor selection in Germany in 2009.

Electrolyte disorders are common and potentially fatal laboratory findings in emergency patients. Approximately 20 % of patients in the emergency department present with either hyponatremia or hypernatremia. Recently it was shown that disorders of serum sodium are not only an expression of the severity of the underlying disease but independent predictors for the outcome of patients. They directly influence patient daily life by causing not only gait and concentration disturbances but also an increased tendency to fall together with a reduced bone mass. Given these new data it is even more important to detect and adequately correct dysnatremia in patients in the emergency department. Acute, symptomatic dysnatremia should be corrected promptly by use of 3 % NaCl for hyponatremia and 5 % glucose for hypernatremia. A close monitoring of serum sodium concentration is, however, essential in any case of correction of hyponatremia or hypernatremia in order to avoid rapid overcorrection and subsequent complications. A profound knowledge of the mechanisms underlying the development of hyponatremia, e.g. diuretics, syndrome of inappropriate antidiuretic hormone secretion (SIADH), heart failure and cirrhosis of the liver and hypernatremia, e.g. dehydration, infusions, diuretics and osmotic diuresis is essential. The present article describes the epidemiology, etiology and correction of hyponatremia and hypernatremia on the basis of current knowledge with special emphasis on emergency department patients.

Subdural hematoma may occur as rare, although intervention- specific complications of accidental dural puncture by neuroaxial block. Bleeding may be caused by rapid cerebrospinal fluid loss related to traction on fragile intracranial bridging veins. This article reports a case of postdural puncture headache in a 43-year-old woman after accidental dural puncture during attempted placement of an epidural catheter for induction of abortion. Bed rest, analgesics, theophylline and hydration were to no avail and only a blood patch improved the headaches. The patient presented 7 weeks later with headache and left-sided hemiplegia. Magnetic resonance imaging showed a right frontoparietal subdural intracranial hematoma which had to be surgically evacuated. The patient recovered completely. Intracranial hematoma is a rare but serious complication of central neuroaxial block. According to current German jurisdiction this risk must be addressed when informed consent is obtained. Intracranial hematoma should be considered in the differential diagnosis of atypical headache and neurological signs (e.g. focal motor and sensory deficits and seizures) following neuroaxial block and adequate image diagnostics should be carried out without delay.

An update of the international guidelines for therapy of sepsis was published in February 2012 by the Surviving Sepsis Campaign (SSC). The update includes a further development of the guidelines from 2004 and 2008. The guidelines are divided into three sections, sepsis-specific therapeutic measures, recommendations on general intensive care measures for sepsis and finally special features of sepsis in pediatric intensive care medicine are presented in detail. This article discusses the most important amendments in the first two sections and delving deeper into the guidelines.