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Sonographic Assessment of the Optic Nerve Sheath in Brain Death
Abstracts 1
University Department of Neurology, University Hospital Center, Zagreb/HR, 2Clinical Institute of Chemistry, "Sestre milosrdnice" University Hospital Centre, Zagreb/HR Purpose: Impaired cerebral perfusion contributes to the etiology of both vascular (VAD) and Alzheimer’s disease (AD). Beta stiffness index (BSI) is the marker of subclinical atherosclerosis. Changes in arterial compliance can be present before the clinical manifestation of cerebrovascular disease. We aimed to assess the parameters of vascular remodeling in patients diagnosed with AD, VAD and mild cognitive impairment (MCI). Material & Methods: In all, 20 MCI, 20 AD and 20 VAD patients were recruited. Besides cognitive testing using Montreal Cognitive Assessment (MoCA)and Mini Mental State Examination (MMSE), vascular risk factors were assessed and BSI, augmentation index (AI) and IMT were measured. Results: Patients with VAD had significantly increased IMT (1,460,3 mm), AI (14,166,5) and BSI (11,363,1) when compared with MCI € patients (pE,0,05), but not when compared with patients with AD. Multiple regression analysis using AI and BSI as the dependent variables and type of cognitive decline (VAD, AD, MCI) and vascular risk factors as independent variables showed that a diagnosis of VAD was the main factor influencing AI and BSI (p 5 0.004). Global cognitive scores assessed by MMSE and MoCA were inversely associated with BSI and AI in patients with MCI and with VAD (p 5 0,03), but not in AD patients. Conclusion: Differences in vascular remodeling parameters could be used as a part of diagnostic criteria in the assessment of patients with cognitive decline.
SS 13.06 Jugular Venous Reflux in Total Global Amnesia: Simultaneous TCD Bubble Test and Carotid/Jugular Duplex Examination Z. Garami Cv Surgery, The Methodist Hospital, Houston, TX/US Purpose: We report an unusual case of venous reflux in a patient with memory loss and focal deficits who was found with an unusual flow pattern on Transcranial Doppler bubble test (TCD-BT) where venous bubbles were found and later confirmed on carotid/jugular duplex (CJD) examination. While chronic Cerebral Spinal Venous Insufficiency (CCSVI) is now a fashionable finding in Multiple Sclerosis, other neurological disease should not be forgotten. Material & Methods: A 22-year-old male presented after multiple episodes of right-side weakness and memory loss associated with repetitive questioning during these episodes. The family also reported that the patient had episodes of isolated, transient memory problems that were not associated with weakness. TCD-BT was performed with 10cc agitated saline test in sitting position. TCDBT test was performed in the supine position simultaneously with CJD. Results: TCD-BT shows venous embolization but only minimal arterial embolization in the brain, which could be a potential pitfall for Patent Foramen Ovale (PFO) detection. Carotid/jugular duplex (CJD) examinations revealed cranial flow in the jugular vein during Valsalva maneuver. Conclusion: Jugular reflux is a poorly understood mechanism of cerebral dysfunction. Cerebral congestion caused by venous reflux is reported in total global amnesia (TGA), but this is the first report on TCD bubble test. CJD assisted with understanding the unusual TCDBT finding might result in new applications for different neurological diseases.
S25
SS 13.07 The Study of Nerve Sonoanatomy for Regional Anesthesia Under Ultrasound Guidance Using the Integrated Application of Three-Dimensional Modeling Based on the Expert Segmentation of Sonographic Images R. V. Bubnov The Center Ultrasound Diagnostics and Interventional Sonography, Clinical Hospital ‘‘Pheophania’’ of State Affairs Department, Kyiv/UA Purpose: The article describes the method of three-dimensional modeling, based on integrated data from different sources of visual information to improve the study of lower limbs nerve sonoanatomy for holding regional anesthesia under ultrasound guidance. Material & Methods: Totally 31 volunteer, 18 women and 13 men (average age 34 years, range 21-56 years), were included into the study. Ultrasound parameters of the nerves of the lower extremities for the main blocks areas were obtained on the groin area (femoral block) and on the hip area (sciatic nerve block). In six patients the premanipulating modeling was performed. For data processing, registration and segmentation of ultrasound data Mimics software was used. The integrated three-dimensional modeling using photogrammetry data, animation and motion capture data by own method was applied (UA patent N u 2011 00988). Results: 3D models of the femoral nerve, arteries, veins and their branches, muscles, fascia and other body parts on basis of the ultrasound data were created. On average, 436 slices to simulate the femoral nerve and the 523 slices to simulate the sciatic were received. Models of skin and some muscles were obtained by photogrammetry and processing of CT and MRI data. Anthropometry and syntopy were conducted using models. Conclusion: Thus, the proposed method can improve the quality of diagnosis is non-invasive, accessible and informative method and can be used for educational and scientific purposes.
SS 13.08 Sonographic Assessment of the Optic Nerve Sheath in Brain Death A. Lovrencic-Huzjan,1 D. Sodec Simicevic,1 I. Martinic Popovic,1 M. Bosnar Puretic,1 V. Vukovic Cvetkovic,1 A. Gopcevic,2 M. Vucic,3 B. Rode,3 V. Demarin1 1 University Department of Neurology, University Hospital Center, Zagreb/HR, 2Department of Anesthesiology, University Hospital Center, Zagreb/HR, 3Department of Anesthesiology, University Hospital Center, Zagreb/HR Purpose: Ultrasonographical evaluation of optic nerve sheath is reliable for assessment of patients with increased intracranial pressure. The aim of this study was to present the usefulness of optic nerve sheath diameter (ONSD) measurement in patients with brain death. Material & Methods: Ten brain dead patients were evaluated ultrasonographically by ONSD measurement with a 12-MHz linear ultrasound probe (Terason T3000, Teratech Corporation, USA). The probe was adjusted to give a suitable angle for displaying the entry of the optic nerve into the globe, at the depth of 3 mm behind the globe. For each optic nerve four measurements were made, twice in transversal and twice in the sagittal plane, by rotating the probe clockwise. Mean ONSD of brain dead patients were compared with mean ONSD of 17 healthy controls. Results: Ten brain dead persons (7 males) were evaluated. Left mean ONSD was 0,71 + 0.06 cm on transversal and 0.72 + 0.04 cm on sagittal plane. Right mean ONSD was 0.73 + 0.05 cm on transversal and 0.73 + 0.06 on sagittal plane. In controls, left mean ONSD was 0,51 + 0.05 cm
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Ultrasound in Medicine and Biology
on transversal and 0.55 + 0.06 cm on sagittal plane. Right mean ONSD was 0.52 + 0.05 cm on transversal and 0.54 + 0.07 on sagittal plane. Mean ONSD in the brain dead was 0.72 + 0.05cm and 0.53 + 0.06 cm in controls (p,0.01). Conclusion: ONSD may be useful in distinguishing brain dead persons from healthy controls.
Sun, Aug 28, 2011 Hall NO SS 14 10:30-12:00 Emergency SS 14.02 Primary Ultrasound as an Imaging Method for Patients in the Emergency Department. First Results of the PRIMUS-Study (DEGUM Multicenter-Study) A. Schuler,1 D. Vasilakis,2 T. Karbe,1 M. Wuestner,3 W. Blank,4 H. P. Weskott,5 W. Kratzer,6 K. Seitz2 1 Internal Medicine, Helfenstein Klinik, Geislingen/DE, 2Abteilung f€ur Innere Medizin, Kreiskrankenhaus Sigmaringen, Sigmaringen/DE, 3 Zentrale Interdisziplinaere Sonographie, Bruederkrankenhaus, Trier/DE, 4Medizinische Klinik I, Klinikum am Steinenberg, Reutlingen/DE, 5Hannover/DE, 6Zentrum f€ur Innere Medizin, Universit€ atsklinikum Ulm, Klinik f€ur Innere Medizin I, Ulm/DE Purpose: It is important to establish rapid and accurate diagnosis for patients admitted to the emergency department to optimize medical and economical procedures. This study evaluates the effects of early performed ultrasound (within 24h) on the length of stay in Hospital and the effect on therapeutic procedures. Material & Methods: In a prospective multicenter trial from April 2010 to February 2011, patients of the emergency department examined with ultrasound were included. The group 1 with early ultrasound (,24h) was compared with group 2 having received sonography later with respect to the parameters length of stay and the influence of sonography on therapy. Results: A total number of 1203 patients were enrolled, 1087 patients in group 1 (90,4%), the other 115 (9,6%) in group 2. The length of stay in group 2 was 6,43days compared with 4,17days in group 1. This means a shortening of stay of 2,26days (35%) on average for group 1. The influence of sonography on therapy was seen in 97,6% in group 1 (indication for therapy: 51,8%, exclusion of relevant differential diagnosis: 45,8%, without relevance: 2,4%) and in group 2, in 89,6% (indication for therapy: 44,3%, exclusion of relevant differential diagnosis: 45,2%, without relevance: 10,4%). Conclusion: The initial data analysis indicates that early performed ultrasound in the emergency department helps to avoid unnecessary Hospitalisation, shortens the stay in Hospital and reveals the high influence of sonography on therapy. SS 14.03 Contrast-Enhanced Ultrasound (CEUS) in Blunt Abdominal Trauma J. Mattli Spezielle € arztliche Dienste, Spital Davos, Davos Platz/CH Purpose: To evaluate CEUS in detecting and characterising parenchymous lesions in patients with blunt abdominal trauma. Material & Methods: From December 2003 to February 2011, all patients with blunt abdominal trauma due to winter sports accidents referred to Hospital were examined using B-Mode, Colour Doppler
Volume 37, Number 8S, 2011 Sonography and CEUS (Siemens Acuson Sequoia 512, SonovueÒ). For examinations 0.8–1.4 ml SonovueÒ was used. Results: 384 patients with blunt abdominal trauma were included in the study. In 236 examinations of the spleen there were found 52 lesions in B-Mode compared with 67 lesions with CEUS. In 241 examinations of the kidneys B-Mode sonography and Colour Doppler showed 44 lesions whereas 39 lesions were found with CEUS. In 193 liver examinations 21 lesions were found with conventional ultrasound compared with 21 lesions with CEUS. In all cases CEUS showed the lesions clearer, bigger and much more illustrative than they were seen using conventional ultrasound. In 9 cases active bleeding could be demonstrated with CEUS. Only in 6 cases operations were performed (splenectomy). Only in 16 cases additional computed tomography was performed due to suspected spine, retroperitoneal or pelvic injury. Conclusion: CEUS is a valid and rapid imaging modality in the management of patients with blunt abdominal trauma. It is superior to conventional ultrasound in detecting parenchymal lesions. It is cost effective and saves radiation because it might replace computed tomography in most cases.
SS 14.04 Sonoelastography in the Differentiation of Haemorrhagic from Serous Contents of the Douglas Pouch N. Vorontsova, S. Churkina, V. Gazhonov 1 Radiology, President’s Medical Center, Moskow/RU Purpose: To determine the type of the fluid content of Douglas pouch before puncture of the posterior vaginal fornix, diagnostic laparoscopy by Sonoelastography (SE). Material & Methods: 92 patients with complaints of acute lower abdomen pain, and admitted to a Hospital urgently, were examined. In 58 cases on grey-scale US free fluid was found in the Douglas space. All patients underwent conventional US & SE on HI VISION 900, HI VISION Preirus with an endocavity transducer, 8-4 MHz frequency. We used modified Tsukuba SE classification for evaluation of the SE data. 20 diagnostic punctures and 38 diagnostic laparoscopies were performed with morphological study of the received material. US data (conventional B-mode & SE) were assessed by comparing the findings with surgery results. US data were retrospectively reviewed by 2 radiologists. Inter-observer agreement was calculated. Results: Blood content was found in 41 patients and serous in 17 patients. SE showed the typical RGB pattern in the case of serous content and the ‘‘mirror’’ RGB pattern in the cases of blood content. EVSE showed 96% sensitivity, 92% specificity, 89% PPV, and 88% NPV consecutively. Interobserver agreement for RGB sign and ‘‘mirror’’ RGB sign were high to moderate. Conclusion: SE can help in evaluation of the haemorrhagic or serous type of free fluid in the Douglas pouch.
SS 14.05 Emergency Ultrasound at the Military Hospital: Our Experience A. Stefan, E. Riedl, G. Forrai Central Radiological Diagnostic Department, Military Hospital - State Health Centre, Budapest/HU Purpose: The Military Hospital is one of Hungary’s biggest Hospitals, where our level 1 Emergency Care Unit (ECU) is of great importance due to its extensive supply area, as well as the highly developed subspecialties in the Hospital and the helicopter landing place on the top. The spectrum reaches from severely injured polytrauma patients, candidates for thrombolysis in stroke over to common abdominal diseases like appendicitis.
University Department of Neurology, University Hospital Center, Zagreb/HR, 2Clinical Institute of Chemistry, "Sestre milosrdnice" University Hospital Centre, Zagreb/HR Purpose: Impaired cerebral perfusion contributes to the etiology of both vascular (VAD) and Alzheimer’s disease (AD). Beta stiffness index (BSI) is the marker of subclinical atherosclerosis. Changes in arterial compliance can be present before the clinical manifestation of cerebrovascular disease. We aimed to assess the parameters of vascular remodeling in patients diagnosed with AD, VAD and mild cognitive impairment (MCI). Material & Methods: In all, 20 MCI, 20 AD and 20 VAD patients were recruited. Besides cognitive testing using Montreal Cognitive Assessment (MoCA)and Mini Mental State Examination (MMSE), vascular risk factors were assessed and BSI, augmentation index (AI) and IMT were measured. Results: Patients with VAD had significantly increased IMT (1,460,3 mm), AI (14,166,5) and BSI (11,363,1) when compared with MCI € patients (pE,0,05), but not when compared with patients with AD. Multiple regression analysis using AI and BSI as the dependent variables and type of cognitive decline (VAD, AD, MCI) and vascular risk factors as independent variables showed that a diagnosis of VAD was the main factor influencing AI and BSI (p 5 0.004). Global cognitive scores assessed by MMSE and MoCA were inversely associated with BSI and AI in patients with MCI and with VAD (p 5 0,03), but not in AD patients. Conclusion: Differences in vascular remodeling parameters could be used as a part of diagnostic criteria in the assessment of patients with cognitive decline.
SS 13.06 Jugular Venous Reflux in Total Global Amnesia: Simultaneous TCD Bubble Test and Carotid/Jugular Duplex Examination Z. Garami Cv Surgery, The Methodist Hospital, Houston, TX/US Purpose: We report an unusual case of venous reflux in a patient with memory loss and focal deficits who was found with an unusual flow pattern on Transcranial Doppler bubble test (TCD-BT) where venous bubbles were found and later confirmed on carotid/jugular duplex (CJD) examination. While chronic Cerebral Spinal Venous Insufficiency (CCSVI) is now a fashionable finding in Multiple Sclerosis, other neurological disease should not be forgotten. Material & Methods: A 22-year-old male presented after multiple episodes of right-side weakness and memory loss associated with repetitive questioning during these episodes. The family also reported that the patient had episodes of isolated, transient memory problems that were not associated with weakness. TCD-BT was performed with 10cc agitated saline test in sitting position. TCDBT test was performed in the supine position simultaneously with CJD. Results: TCD-BT shows venous embolization but only minimal arterial embolization in the brain, which could be a potential pitfall for Patent Foramen Ovale (PFO) detection. Carotid/jugular duplex (CJD) examinations revealed cranial flow in the jugular vein during Valsalva maneuver. Conclusion: Jugular reflux is a poorly understood mechanism of cerebral dysfunction. Cerebral congestion caused by venous reflux is reported in total global amnesia (TGA), but this is the first report on TCD bubble test. CJD assisted with understanding the unusual TCDBT finding might result in new applications for different neurological diseases.
S25
SS 13.07 The Study of Nerve Sonoanatomy for Regional Anesthesia Under Ultrasound Guidance Using the Integrated Application of Three-Dimensional Modeling Based on the Expert Segmentation of Sonographic Images R. V. Bubnov The Center Ultrasound Diagnostics and Interventional Sonography, Clinical Hospital ‘‘Pheophania’’ of State Affairs Department, Kyiv/UA Purpose: The article describes the method of three-dimensional modeling, based on integrated data from different sources of visual information to improve the study of lower limbs nerve sonoanatomy for holding regional anesthesia under ultrasound guidance. Material & Methods: Totally 31 volunteer, 18 women and 13 men (average age 34 years, range 21-56 years), were included into the study. Ultrasound parameters of the nerves of the lower extremities for the main blocks areas were obtained on the groin area (femoral block) and on the hip area (sciatic nerve block). In six patients the premanipulating modeling was performed. For data processing, registration and segmentation of ultrasound data Mimics software was used. The integrated three-dimensional modeling using photogrammetry data, animation and motion capture data by own method was applied (UA patent N u 2011 00988). Results: 3D models of the femoral nerve, arteries, veins and their branches, muscles, fascia and other body parts on basis of the ultrasound data were created. On average, 436 slices to simulate the femoral nerve and the 523 slices to simulate the sciatic were received. Models of skin and some muscles were obtained by photogrammetry and processing of CT and MRI data. Anthropometry and syntopy were conducted using models. Conclusion: Thus, the proposed method can improve the quality of diagnosis is non-invasive, accessible and informative method and can be used for educational and scientific purposes.
SS 13.08 Sonographic Assessment of the Optic Nerve Sheath in Brain Death A. Lovrencic-Huzjan,1 D. Sodec Simicevic,1 I. Martinic Popovic,1 M. Bosnar Puretic,1 V. Vukovic Cvetkovic,1 A. Gopcevic,2 M. Vucic,3 B. Rode,3 V. Demarin1 1 University Department of Neurology, University Hospital Center, Zagreb/HR, 2Department of Anesthesiology, University Hospital Center, Zagreb/HR, 3Department of Anesthesiology, University Hospital Center, Zagreb/HR Purpose: Ultrasonographical evaluation of optic nerve sheath is reliable for assessment of patients with increased intracranial pressure. The aim of this study was to present the usefulness of optic nerve sheath diameter (ONSD) measurement in patients with brain death. Material & Methods: Ten brain dead patients were evaluated ultrasonographically by ONSD measurement with a 12-MHz linear ultrasound probe (Terason T3000, Teratech Corporation, USA). The probe was adjusted to give a suitable angle for displaying the entry of the optic nerve into the globe, at the depth of 3 mm behind the globe. For each optic nerve four measurements were made, twice in transversal and twice in the sagittal plane, by rotating the probe clockwise. Mean ONSD of brain dead patients were compared with mean ONSD of 17 healthy controls. Results: Ten brain dead persons (7 males) were evaluated. Left mean ONSD was 0,71 + 0.06 cm on transversal and 0.72 + 0.04 cm on sagittal plane. Right mean ONSD was 0.73 + 0.05 cm on transversal and 0.73 + 0.06 on sagittal plane. In controls, left mean ONSD was 0,51 + 0.05 cm
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Ultrasound in Medicine and Biology
on transversal and 0.55 + 0.06 cm on sagittal plane. Right mean ONSD was 0.52 + 0.05 cm on transversal and 0.54 + 0.07 on sagittal plane. Mean ONSD in the brain dead was 0.72 + 0.05cm and 0.53 + 0.06 cm in controls (p,0.01). Conclusion: ONSD may be useful in distinguishing brain dead persons from healthy controls.
Sun, Aug 28, 2011 Hall NO SS 14 10:30-12:00 Emergency SS 14.02 Primary Ultrasound as an Imaging Method for Patients in the Emergency Department. First Results of the PRIMUS-Study (DEGUM Multicenter-Study) A. Schuler,1 D. Vasilakis,2 T. Karbe,1 M. Wuestner,3 W. Blank,4 H. P. Weskott,5 W. Kratzer,6 K. Seitz2 1 Internal Medicine, Helfenstein Klinik, Geislingen/DE, 2Abteilung f€ur Innere Medizin, Kreiskrankenhaus Sigmaringen, Sigmaringen/DE, 3 Zentrale Interdisziplinaere Sonographie, Bruederkrankenhaus, Trier/DE, 4Medizinische Klinik I, Klinikum am Steinenberg, Reutlingen/DE, 5Hannover/DE, 6Zentrum f€ur Innere Medizin, Universit€ atsklinikum Ulm, Klinik f€ur Innere Medizin I, Ulm/DE Purpose: It is important to establish rapid and accurate diagnosis for patients admitted to the emergency department to optimize medical and economical procedures. This study evaluates the effects of early performed ultrasound (within 24h) on the length of stay in Hospital and the effect on therapeutic procedures. Material & Methods: In a prospective multicenter trial from April 2010 to February 2011, patients of the emergency department examined with ultrasound were included. The group 1 with early ultrasound (,24h) was compared with group 2 having received sonography later with respect to the parameters length of stay and the influence of sonography on therapy. Results: A total number of 1203 patients were enrolled, 1087 patients in group 1 (90,4%), the other 115 (9,6%) in group 2. The length of stay in group 2 was 6,43days compared with 4,17days in group 1. This means a shortening of stay of 2,26days (35%) on average for group 1. The influence of sonography on therapy was seen in 97,6% in group 1 (indication for therapy: 51,8%, exclusion of relevant differential diagnosis: 45,8%, without relevance: 2,4%) and in group 2, in 89,6% (indication for therapy: 44,3%, exclusion of relevant differential diagnosis: 45,2%, without relevance: 10,4%). Conclusion: The initial data analysis indicates that early performed ultrasound in the emergency department helps to avoid unnecessary Hospitalisation, shortens the stay in Hospital and reveals the high influence of sonography on therapy. SS 14.03 Contrast-Enhanced Ultrasound (CEUS) in Blunt Abdominal Trauma J. Mattli Spezielle € arztliche Dienste, Spital Davos, Davos Platz/CH Purpose: To evaluate CEUS in detecting and characterising parenchymous lesions in patients with blunt abdominal trauma. Material & Methods: From December 2003 to February 2011, all patients with blunt abdominal trauma due to winter sports accidents referred to Hospital were examined using B-Mode, Colour Doppler
Volume 37, Number 8S, 2011 Sonography and CEUS (Siemens Acuson Sequoia 512, SonovueÒ). For examinations 0.8–1.4 ml SonovueÒ was used. Results: 384 patients with blunt abdominal trauma were included in the study. In 236 examinations of the spleen there were found 52 lesions in B-Mode compared with 67 lesions with CEUS. In 241 examinations of the kidneys B-Mode sonography and Colour Doppler showed 44 lesions whereas 39 lesions were found with CEUS. In 193 liver examinations 21 lesions were found with conventional ultrasound compared with 21 lesions with CEUS. In all cases CEUS showed the lesions clearer, bigger and much more illustrative than they were seen using conventional ultrasound. In 9 cases active bleeding could be demonstrated with CEUS. Only in 6 cases operations were performed (splenectomy). Only in 16 cases additional computed tomography was performed due to suspected spine, retroperitoneal or pelvic injury. Conclusion: CEUS is a valid and rapid imaging modality in the management of patients with blunt abdominal trauma. It is superior to conventional ultrasound in detecting parenchymal lesions. It is cost effective and saves radiation because it might replace computed tomography in most cases.
SS 14.04 Sonoelastography in the Differentiation of Haemorrhagic from Serous Contents of the Douglas Pouch N. Vorontsova, S. Churkina, V. Gazhonov 1 Radiology, President’s Medical Center, Moskow/RU Purpose: To determine the type of the fluid content of Douglas pouch before puncture of the posterior vaginal fornix, diagnostic laparoscopy by Sonoelastography (SE). Material & Methods: 92 patients with complaints of acute lower abdomen pain, and admitted to a Hospital urgently, were examined. In 58 cases on grey-scale US free fluid was found in the Douglas space. All patients underwent conventional US & SE on HI VISION 900, HI VISION Preirus with an endocavity transducer, 8-4 MHz frequency. We used modified Tsukuba SE classification for evaluation of the SE data. 20 diagnostic punctures and 38 diagnostic laparoscopies were performed with morphological study of the received material. US data (conventional B-mode & SE) were assessed by comparing the findings with surgery results. US data were retrospectively reviewed by 2 radiologists. Inter-observer agreement was calculated. Results: Blood content was found in 41 patients and serous in 17 patients. SE showed the typical RGB pattern in the case of serous content and the ‘‘mirror’’ RGB pattern in the cases of blood content. EVSE showed 96% sensitivity, 92% specificity, 89% PPV, and 88% NPV consecutively. Interobserver agreement for RGB sign and ‘‘mirror’’ RGB sign were high to moderate. Conclusion: SE can help in evaluation of the haemorrhagic or serous type of free fluid in the Douglas pouch.
SS 14.05 Emergency Ultrasound at the Military Hospital: Our Experience A. Stefan, E. Riedl, G. Forrai Central Radiological Diagnostic Department, Military Hospital - State Health Centre, Budapest/HU Purpose: The Military Hospital is one of Hungary’s biggest Hospitals, where our level 1 Emergency Care Unit (ECU) is of great importance due to its extensive supply area, as well as the highly developed subspecialties in the Hospital and the helicopter landing place on the top. The spectrum reaches from severely injured polytrauma patients, candidates for thrombolysis in stroke over to common abdominal diseases like appendicitis.