Evaluation of Prehospital Undertriage in Relation to Trauma Team Activation-Results from a Prospective Study in 12 Level one German Trauma Centers.

Background/Objective: This prospective, multicenter observational cohort study was carried out in 12 trauma centers in Germany and Switzerland. Its purpose was to evaluate the rate of undertriage, as well as potential consequences, and relate these with different Trauma Team Activation Protocols (TTA-Protocols), as this has not been done before in Germany. Methods: Each trauma center collected the data during a three-month period between December 2019 and February 2021. All 12 participating hospitals are certified as supra-regional trauma centers. Here, we report a subgroup analysis of undertriaged patients. Those included in the study were all consecutive adult patients (age ≥ 18 years) with acute trauma admitted to the emergency department of one of the participating hospitals by the prehospital emergency medical service (EMS) within 6 h after trauma. The data contained information on age, sex, trauma mechanism, pre- and in-hospital physiology, emergency interventions, emergency surgical interventions, intensive care unit (ICU) stay, and death within 48 h. Trauma team activation (TTA) was initiated by the emergency medical services. This should follow the national guidelines for severe trauma using established field triage criteria. We used various denominators, such as ISS, and criteria for the appropriateness of TTA to evaluate the undertriage in four groups. Results: This study included a total of 3754 patients. The average injury severity score was 5.1 points, and 7.0% of cases (n = 261) presented with an injury severity score (ISS) of 16+. TTA was initiated for a total of 974 (26%) patients. In group 1, we evaluated how successful the actual practice in the EMS was in identifying patients with ISS 16+. The undertriage rate was 15.3%, but mortality was lower in the undertriage cohort compared to those with a TTA (5% vs. 10%). In group 2, we evaluated the actual practice of EMS in terms of identifying patients meeting the appropriateness of TTA criteria; this showed a higher undertriage rate of 35.9%, but as seen in group 1, the mortality was lower (5.9% vs. 3.3%). In group 3, we showed that, if the EMS were to strictly follow guideline criteria, the rate of undertriage would be even higher (26.2%) regarding ISS 16+. Using the appropriateness of TTA criteria to define the gold standard for TTA (group 4), 764 cases (20.4%) fulfilled at least one condition for retrospective definition of TTA requirement. Conclusions: Regarding ISS 16+, the rate of undertriage in actual practice was 15.3%, but those patients did not have a higher mortality.

[Plastering-A technique fallen into obscurity]. / Gipsen ­ eine in Vergessenheit geratene Technik.

Immobilization of fractures and dislocations is a basic technique in orthopedic trauma surgery care. The orthopedic surgeon should be familiar with the various materials, techniques and possible complications. Despite other techniques, the classical white plaster cast remains an integral part of orthopedic trauma surgery care. The application of such a cast must be learned as failure to observe the basic principles can result in harm to the patient. In many hospitals, the application of a plaster cast is delegated to the nursing staff according to the physician's instructions. As a result, many young medical colleagues lack the knowledge of how to apply a plaster cast. In addition to the treatment of fractures, immobilization after dislocation, inflammation and ligamentous injuries are some of the areas of application. In this article the application of a plaster cast is described based on a case study, from the indications to the execution and possible complications.

[Treatment of the wounded from the war in Ukraine in the trauma networks of the DGU-Requirement, reality and motivation over the course of 18 months ]. / Versorgung von Kriegsverletzten aus der Ukraine in den Traumanetzwerken der DGU ­ Anspruch, Wirklichkeit und Motivation im Verlauf von 18 Monaten .

BACKGROUND: The war in Ukraine and the medical treatment of the wounded in hospitals in Germany has now represented a challenge for more than 15 months. The majority of trauma patients were distributed via the general holding center (GMLZ) at the Federal Office of Civil Protection and Disaster Assistance (BBK) by the cloverleaf concept and the trauma networks. Initially, numerous offers of assistance were promoted with great solidarity. For documentation of the current motivation situation and also for identification of the potential for improvement, a 2-stage survey of senior physicians in the organized and certified hospitals in the trauma networks was carried out. MATERIAL AND METHODS: An online survey of senior physicians of the trauma network hospitals was carried out with a semistructured written questionnaire in December 2022 and a follow-up survey during the Trauma Network Meeting (TNT) Congress in September 2023 in Frankfurt. RESULTS: Of the questionnaires 113 could be evaluated in December 2022 and 70 completed questionnaires in September 2023. The answers came from national trauma centers (ÜTZ), regional trauma centers (RTZ) and local trauma centers (LTZ) each with approximately one third. On average 2.7 patients were treated in all participating hospitals up to December and up to September no more than 5 in more than half of the hospitals overall. The main challenges for all participants at both points in time were the long hospital stay, the demanding pathogen status and sometimes unclarified or not completely covered reimbursement of costs. Nevertheless, more than 80% of the specialist departments received backing from their hospital sponsors as well as their personnel for the continuing treatment of the wounded from Ukraine. CONCLUSION: The medical and professional challenges in the treatment of the wounded from Ukraine are, as expected, characterized by the demanding injury patterns of the musculoskeletal system and the colonization with multidrug-resistant pathogens. This results in a long course of treatment, where the remuneration does not always cover the costs. Despite these challenges the solidarity in the hospitals of the trauma networks is unbroken. Simultaneously, there are numerous possibilities for improvement in order to enhance the prerequisites for future comparable humanitarian assistance jointly with politics.

Severe trauma in Germany and Israel: are we speaking the same language? A trauma registry comparison.

Background: Trauma registries are a crucial component of trauma systems, as they could be utilized to perform a benchmarking of quality of care and enable research in a critical but important area of health care. The aim of this study is to compare the performance of two national trauma systems: Germany (TraumaRegister DGU®, TR-DGU) and Israel (Israeli National Trauma Registry, INTR). Methods: The present study was a retrospective analysis of data from the described above trauma registries in Israel and Germany. Adult patients from both registries treated during 2015-2019 with an Injury Severity Score (ISS) ≥ 16 points were included. Patient demographics, type, distribution, mechanism, and severity of injury, treatment delivered and length of stay (LOS) in the ICU and in the hospital were included in the analysis. Results: Data were available from 12,585 Israeli patients and 55,660 German patients. Age and sex distribution were comparable, and road traffic collisions were the most prevalent cause of injuries. The ISS of German patients was higher (ISS 24 vs. 20), more patients were treated on an intensive care unit (92 vs. 32%), and mortality was higher (19.4 vs. 9.5%) as well. Conclusion: Despite similar inclusion criteria (ISS ≥ 16), remarkable differences between the two national datasets were observed. Most probably, this was caused by different recruitment strategies of both registries, like trauma team activation and need for intensive care in TR-DGU. More detailed analyses are needed to uncover similarities and differences of both trauma systems.

Effect of surgical stabilization of rib fractures in polytrauma: an analysis of the TraumaRegister DGU®.

PURPOSE: In severely injured patients with multiple rib fractures the beneficial effect of surgical stabilization is still unknown. The existing literature shows divergent results and especially the indication and the right timing of an operation are subject of a broad discussion. The aim of this study was to determine the influence of a surgical stabilization of rib fractures (SSRF) on the outcome in a multi-center database with special regard to the duration of ventilation, intensive care and overall hospital stay. METHODS: Data from the TraumaRegister DGU® collected between 2008 and 2017 were used to evaluate patients over 16 years with severe rib fractures (AIS ≥ 3). In addition to the basic comparison a matched pair analysis of 395 pairs was carried out in order to find differences and to increase comparability. RESULTS: In total 483 patients received an operative treatment and 29,447 were treated conservatively. SSRF was associated with a significantly lower mortality rate (7.6% vs. 3.3%, p = 0.008) but a longer ventilation time and longer stay as well as in the intensive care unit (ICU) as the overall hospital stay. Both matched pair groups showed a good or very good neurological outcome according to the Glasgow Outcome Scale (GOS) in 4 of 5 cases. Contrary to the existing recommendations most of the patients were not operated within 48 h. CONCLUSIONS: In our data set, obviously most of the patients were not treated according to the recent literature and showed a delay in the time for operative care of well over 48 h. This may lead to an increased rate of complications and a longer stay at the ICU and the hospital in general. Despite of these findings patients with operative treatment show a significant lower mortality rate.

[Surgery during the SARS-CoV-2 pandemic : Recommendations on operative procedures]. / Chirurgie in der SARS-CoV-2-Pandemie : Empfehlungen zum operativen Vorgehen.

BACKGROUND: In February 2020 Germany was also hit by the SARS-CoV­2 pandemic. Even patients infected by SARS-CoV­2 or COVID-19 may need operative procedures. Currently, no uniform recommendations exist on precautions to be taken when operating on these patients. Furthermore, they may differ from one hospital to another. METHODS: The task force COVID-19 of the emergency, intensive and severely injured section of the German Trauma Society (DGU e. V.) has developed consensus-based recommendations on surgical treatment of patients with SARS-CoV­2 infections. Great importance is placed on the implementation in hospitals at all levels of care. RESULTS: The indications for surgical interventions in patients with COVID-19 infections require an extremely critical evaluation. When indicated these surgical intervention should ideally be performed in a separate operating theater. All personnel involved should wear personal protective equipment with FFP2 masks, face shields and double gloves. The emergency team in the resuscitation bay should generally wear the same personal protective equipment. Special training is mandatory and the exposure of team members should be minimized. CONCLUSION: The recommendations are principally used for all kinds of surgery and comply with the currently available knowledge. Nevertheless, all recommendations represent a compromise between maximum safety of all medical staff and practicability in the routine hospital workflow.

Factors that influence the complications and outcomes of femoral neck fractures treated by cannulated screw fixation.

To investigate the influence of various factors on the two outcome parameters "procedure - specific complication" (femoral head necrosis, infection, nonunion, femoral neck shortening, screw loosening, implant penetration) and "functional outcome" in patients with displaced and undisplaced femoral neck fracture treated by cannulated screw fixation. All cases of a femoral neck fracture, operated by cannulated screw fixation, in the period from December 2014 to December 2017 were included. The observation period of the included patients was 12 months. Information on their outcome was collected after evaluation of current x-ray images and on request from the responsible further treatment physician. Continuous data were presented as mean value ± standard deviation, categorical data as absolute and relative frequency. The effect of potential factors on endpoints was estimated with a multivariable logistic regression analysis and 95% confidence intervals calculated. The null hypothesis Odds Ratio = 1 was checked by the Wald test. The likelihood ratio test was used to test for deviation from linearity. The mean age of the 56 included patients was 72 years (36 min, 96 max), 44.5% (n = 25) were male and 55.5% (n = 25) female. The femoral neck fractures were classified as follows: Garden I: 73%, Garden II: 16%, Garden III: 11%, Pauwels I: 73%, Pauwels II: 21%, Pauwels III: 5%, 31-B1: 73%, 31-B2: 27%, 31-B3: 0%. The factor patient age showed a statistically significant influence on the outcome parameter procedure-specific complication. None of the remaining factors examined showed a statistically significant influence on both outcome parameters procedure-specific complication and functional outcome. 69% of the patients from age 80 onwards suffered a procedure-specific complication. A rate of 41% procedure-specific complications as an outcome parameter in trauma surgery shows a necessity for improvement. The increasing risk of procedure-specific complications for patients with a femoral neck fracture treated by cannulated screw fixation is associated with rising patient age. A more stable head-perserving operative method or an endoprosthetic procedure should be considered in high-risk patients (≥80 y.o.).

Emergency department thoracotomy of severely injured patients: an analysis of the TraumaRegister DGU®.

AIM OF THE STUDY: Emergency department thoracotomy (EDT) may be the last chance for survival in some severe thoracic trauma. This study investigates a representative collective with the aim to compare the findings in Europe to the international experience. Moreover, the influence of different levels of trauma care is investigated. METHODS: All emergency thoracotomies in patients with an ISS ≥ 9 from TR-DGU (2009-2014) within the first 60 min after arrival were identified. EDTs were identified separately, and mini thoracotomies and drainage systems were excluded. RESULTS: 99,013 patients with sufficient data were observed. 1736 (1.8%) received thoracotomy during their hospital stay. 887 patients had a thoracotomy within the first hour in the emergency department (ED). 52.5% were treated in supraregional trauma centers (STC), 36.4% in regional (RTC) and 11.0% in local trauma centers (LTC). The mortality rates were 39.4% (STC), 20.9% (RTC) and 20.8% (LTC). The overall mortality rate showed no significant differences for blunt (28.2%) and penetrating trauma (31.3%). In case of cardiac arrest in the ED, a survival rate of 4.8% for blunt trauma and 20.7% for penetrating trauma was determined if EDT was carried out. Those patients showed a higher rate in severe thoracic organ injuries due to penetrating trauma but less extrathoracic injuries. CONCLUSION: Just over half of EDTs were performed in STC. Emergency room resuscitation followed by EDT had survival rates of 4.8% and 20.7% for blunt and penetrating trauma patients, respectively.

Current management of open fractures: results from an online survey.

BACKGROUND: Open fractures are orthopaedic emergencies that carry a high risk for infection, non-union and soft tissue complications. Evidence-based treatment is impeded by the lack of high-quality evidence-based studies. The aim of this investigation was to elucidate the current practice of open fracture management in Germany and to determine major differences in treatment. METHODS: Surgeons were asked to complete an online questionnaire consisting of 45 items developed by an expert consensus. The first part covered questions on general principles of open fracture management. The second part included questions on soft tissue management, the preferred method of initial surgical stabilisation, microbiological testing, employment of pulsatile lavage and local antibiotics, antibiotic regimen, second-look operations, and blood testing. RESULTS: Of 653 respondents, 364 (65 %) completed the first part and 314 (48 %) completed the second part of the online survey. 55 % answered that a standard operating procedure for the diagnosis and treatment of patients with open fractures exists in their hospital. Only 25 % leave pre-hospitalisation applied dressings intact until arrival of the patient in the operating room, and 40 % make this decision depending on information provided by pre-hospitalisation emergency personnel. 84 % participants exclude the use of antibiotic-coated implants in the treatment of open fractures. The favoured stabilisation method in Gustilo type I fractures is definitive internal osteosynthesis and primary wound closure for 61 % of respondents. In Gustilo type II (74 %) and type III fractures (93 %), temporary external fixation is preferred. High-pressure pulsatile lavage is used by 22 % responding surgeons in Gustilo type I fractures, 53 % for type II fractures and 67 % for type III fractures. CONCLUSIONS: Open fracture management differs considerably among surgeons in Germany. Further studies are needed to deliver high-quality evidence concerning primary fracture stabilisation, soft tissue management and second-look operations. Existing evidence-based recommendations for general treatment, antibiotic prophylaxis and soft tissue management should be followed more strictly in clinical practice.

Retrospektive Analyse von56 Weichteildefekten nach einzeitiger Rekonstruktion unter Verwendung von Dermisersatzpräparaten.

HINTERGRUND: Der Verschluss von Wunden mit ausgeprägtem Weichteilschaden stellt eine chirurgische Herausforderung dar und erfordert häufig umfangreiche plastische Operationen sowie freie Lappenplastiken. Die Kombination von Dermisersatzpräparaten und Spalthauttransplantationen ist eine innovative Methode die zur Versorgung von komplexen Verletzungen der Extremitäten angewandt werden kann. Wir haben diese Technik in das Standard-Handwerkszeug bei komplexen Verletzungen der Extremitäten aufgenommen. Die klinischen Ergebnisse von 56 behandelten Patienten werden vorgestellt. PATIENTEN UND METHODEN: In 44 Fällen (78,6 %) wurde die beschriebene Methode an Defekten der unteren Extremitäten verwendet, einschließlich sieben Personen (12,5 %), die sich einer Stumpfdeckung nach Amputation unterzogen. Zwölf Defekte (21,4 %) befanden sich an den oberen Extremitäten. In zwei Fällen (3,6 %) wurde die Matriderm(®) -Matrix verwendet, um Nerven von unmittelbar angrenzenden chirurgischen Implantaten zu schützen. ERGEBNISSE: Bei 41 Patienten (73,2 %) kam es zur Einheilung des Transplantats ohne Komplikationen. Fünfzehn Patienten (26,8 %) zeigten eine gestörte Wundheilung nach Defektverschluss, die unter konservativer Therapie zur Ausheilung gebracht werden konnte. Ein Patient (1,8 %) zeigte ein Transplantatversagen, was eine Revisionsoperation erforderlich machte. Umfangreiche plastische Rekonstruktionen mussten bei keinem Patienten angewandt werden. SCHLUSSFOLGERUNGEN: Bei Fällen, in denen ausgedehnte plastische Operationen nicht möglich oder nicht erwünscht sind, ist die Verwendung von Dermisersatzpräparaten in Kombination mit Spalthauttransplantationen eine vielversprechende Alternative zum Wundverschluss bei ausgedehnten Weichteilschäden.

Retrospective analysis of 56 soft tissue defects treated with one-stage reconstruction using dermal skin substitutes.

BACKGROUND: The closure of wounds associated with soft tissue defects is surgically challenging, frequently requiring extensive plastic surgery and free flaps. The combination of dermal skin substitutes and split-thickness skin grafting is an innovative method used to cover such wounds. We incorporated this technique into the standard therapeutic armamentarium for complex injuries to the extremities. Clinical results of 56 patients thus treated are presented. PATIENTS AND METHODS: In 44 (78.6 %) cases, the method described was used for defects on the lower extremities, including seven (12.5 %) individuals undergoing amputation stump coverage. Twelve (21.4 %) defects were located on the upper extremities. In two (3.6 %) cases, Matriderm(®) matrix was used to protect nerves from adjacent surgical implants. RESULTS: In 41 (73.2 %) patients, the graft healed without any complication. Fifteen (26.8 %) patients displayed impaired wound healing following defect closure and were subsequently managed conservatively. One patient (1.8 %) showed graft failure, leading to revision surgery. None of the patients required extensive plastic surgery. CONCLUSIONS: In cases where plastic surgery is unavailable or undesirable, the use of dermal skin substitutes in combination with split-thickness skin grafting represents a promising alternative for covering wounds associated with soft tissue defects.

Accuracy of single-pass whole-body computed tomography for detection of injuries in patients with major blunt trauma.

BACKGROUND: Contrast-enhanced whole-body computed tomography (also called "pan-scanning") is considered to be a conclusive diagnostic tool for major trauma. We sought to determine the accuracy of this method, focusing on the reliability of negative results. METHODS: Between July 2006 and December 2008, a total of 982 patients with suspected severe injuries underwent single-pass pan-scanning at a metropolitan trauma centre. The findings of the scan were independently evaluated by two reviewers who analyzed the injuries to five body regions and compared the results to a synopsis of hospital charts, subsequent imaging and interventional procedures. We calculated the sensitivity and specificity of the pan-scan for each body region, and we assessed the residual risk of missed injuries that required surgery or critical care. RESULTS: A total of 1756 injuries were detected in the 982 patients scanned. Of these, 360 patients had an Injury Severity Score greater than 15. The median length of follow-up was 39 (interquartile range 7-490) days, and 474 patients underwent a definitive reference test. The sensitivity of the initial pan-scan was 84.6% for head and neck injuries, 79.6% for facial injuries, 86.7% for thoracic injuries, 85.7% for abdominal injuries and 86.2% for pelvic injuries. Specificity was 98.9% for head and neck injuries, 99.1% for facial injuries, 98.9% for thoracic injuries, 97.5% for abdominal injuries and 99.8% for pelvic injuries. In total, 62 patients had 70 missed injuries, indicating a residual risk of 6.3% (95% confidence interval 4.9%-8.0%). INTERPRETATION: We found that the positive results of trauma pan-scans are conclusive but negative results require subsequent confirmation. The pan-scan algorithms reduce, but do not eliminate, the risk of missed injuries, and they should not replace close monitoring and clinical follow-up of patients with major trauma.

International benchmarking of tertiary trauma centers: productivity and throughput approach.

BACKGROUND: Care process in tertiary trauma centers consists of a chain of care phases in different departments from the emergency department (ED) to post-operative rehabilitation. The historical evolution of healthcare systems and organizations has led to variations in trauma patient processes in different countries. The present study is aimed at revealing differences in the throughput and productivity of trauma patient processes between German (UKB) and Finnish (HUS) tertiary trauma centers. Problems related to the comparison of different healthcare systems were also identified. The share of patients discharged was used as a control measure. RESULTS: The biggest differences between the hospitals were found in the use of resources in the ED and in post-operative care. Despite problems in defining comparable patients and resources, ED productivity was significantly higher in UKB. Post-operative care was, on average, 41% shorter in HUS. However, the share of patients discharged was significantly higher in UKB (96.5% vs. 68.9%). Differences were also found in the pre-operative length of stay of patients with proximal femoral fractures (UKB: 0.97 days, HUS: 1.57 days). The productivity of the operating unit was quite similar in the hospitals. In terms of ED mortality, no statistically significant differences were found. CONCLUSIONS: The results of the present study showed significant differences in the use of resources and throughput times in trauma patient processes between Finnish and German hospitals. However, due to system-level differences between German and Finnish healthcare, the results cannot be directly transformed into development proposals for the organizations. On the other hand, in spite of certain differences regarding the healthcare systems, the demographic data of the trauma patients and medical procedures are comparable. Based on the present study, the ED process of severe trauma, pre-operative care, and operating unit processes were the most comparable parts of trauma care between the hospitals. The study also showed that the international benchmarking approach could be used to reveal bottlenecks in system-level policies and practices.

Real-world car-to-pedestrian-crash data from an urban centre.

BACKGROUND: Pedestrians are at a high risk for crash and injury. This study aims at comparing data from real world crashes with data gathered from experimental settings. METHODS: IMPAIR (In-Depth Medical Pedestrian Accident Investigation and Reconstruction) was a prospective, observational study performed in a metropolitan area. Data was collected on-scene, from clinical records, and interviews. Data comprise crash data, details on injury pattern and injury severity. RESULTS: Thirty-seven pedestrians (of which 19 males) with a mean 37.1 years of age were included in the study. The mean collision speed was 49.5 km/h (SD 13.7, range, 28 - 93). The mean ISS (31.0, SD 25.4) and the 24% fatality rate indicate a substantial trauma load. The most common AIS 4+ injuries were to the head (23 subjects), followed by chest (8), pelvis (4), and abdomen (2). An association of impact side and injury side (right/left) was found for abdominal, chest, pelvic, and upper limb injuries. Primary head impacts were documented on the windscreen (19 subjects), hood (10), A-pillar (2), and edge of the car roof (2). With bivariate analysis, a significant increase of MAIS 4+ head injury risk was found for collision speeds of >40 km/h (OR 9.00, 95% CI 1.96-41.36). CONCLUSION: The real-world data from this study is in agreement with previous findings from biomechanical models and other simulations. This data suggest that there may be reason to include further pedestrian regulations in EuroNCAP.

Proper estimation of blood loss on scene of trauma: tool or tale?

BACKGROUND: Visually estimated amount of blood loss may influence decision making in the prehospital setting. The purpose of this study was to determine the ability and accuracy of paramedics and emergency physicians to visually estimate a volume of external blood loss and the influence of different vital signs. METHODS: In a prospective, blinded, observational design, participants were asked to visually estimate the amount of blood in six simulated trauma scenarios. Casualties were provided with a simulated injury, and a certain amount of artificial blood that was poured on the casualties' clothing and on the floor. In addition, vital signs (i.e., blood pressure and heart rate) were given. Each two moulage patients were provided with the same injury pattern and the same simulated blood loss. Although one patient seemed to be normovolemic, the other seemed to be hypovolemeic by the given vital signs. RESULTS: With regard to all given amounts of blood loss, providing vital parameters suggesting instability (i.e., low blood pressure, high heart rate) led to a higher estimation of the lost blood volume in both paramedics and emergency physicians. However, estimations were influenced impressively by the given parameters. For both stable and unstable patients, small actual volumes were overestimated, whereas higher volumes tended to be underestimated. Neither occupational status (emergency physician or paramedic) nor gender or level of experience influenced accuracy of estimated blood loss significantly.

Primary pan-computed tomography for blunt multiple trauma: can the whole be better than its parts?

Single-pass, whole-body computed tomography (pan-CT) was proposed in the late 1990s as a new concept for the diagnostic work-up of severely injured patients. Since its introduction, it has led to considerable debate among clinicians and scientists, triggered by concerns about its immediate safety, questionable therapeutic advantages and exposure to radiation. However, it was recently shown that pan-CT scanning may be associated with a reduction in trauma mortality. In this article, we provide an overview of current knowledge of the value of this compelling concept. The diagnostic accuracy of multidetector row CT (MDCT) for clearing various anatomical regions in trauma patients is, at best, unclear. Little is known about the accuracy of pan-CT as a whole, which weakens statements about its effectiveness and prevents inferences about survival advantages. This last point may be explained by a stage-migration or "Will Rogers" phenomenon: Pan-CT increases injury severity by detecting lesions that would not have been recognized by conventional methods but still do not affect treatment decisions, thus artificially lowering the ratio of observed to expected deaths. In order to maintain the credibility of pan-CT technology for trauma, a rigorous, large-scale evaluation of its accuracy is required. Such an evaluation requires consensus about the definition of true and false positive and negative findings in the setting of blunt multiple trauma. In addition, triage criteria need to be refined to increase specificity and reduce the number of unnecessary scans.

Humane killers, human injury: functional outcome of vole captive bolt injuries.

BACKGROUND: High-pressure blast injuries to the hand due to vole captive bolt devices are serious injuries that are to a great extent unknown to emergency care operators and trauma surgeons. There is no study on the functional outcome of these patients. METHODS: We assessed the functional outcome of patients with injuries inflicted by vole captive bolt devices. Therefore, a protocol consisting of a physical examination and an assessment of static muscle power (grip and pinch strength) was performed. To capture the subjective experience of patients regarding their injury related disability and impairment, the DASH follow-up questionnaire was used. Based on clinical/radiologic findings and outcome, a classification of this unique subgroup of blast injuries was developed. RESULTS: The functional outcome of 34 patients suffering hand injuries due to captive bolt devices between 2004 and 2007 was assessed. A significant reduction of static muscle testing parameters compared with the uninjured hand was revealed. Fourteen patients lost a digit. Average time lost from work was 5.4 weeks. CONCLUSION: Vole captive bolt device-related hand injuries are followed by deterioration of hand function. The present observations alarmed national authorities. The manufacturers were required to take engineering and teaching measures to rule out handling errors that were identified as leading cause of injury.