[Unguis incarnatus-conservative or operative treatment? A practical treatment algorithm]. / Unguis incarnatus ­ konservative oder operative Therapie? Ein praktischer Behandlungsalgorithmus.

Unguis incarnatus, an ingrown toenail, is a common condition in primary care, which is encountered by various medical professions. Inconsistent conservative treatment and nonindicated surgical treatment often result in complications and recurrence of the disease. Patients must be thoroughly informed about the complexity of the nail organ. This is a prerequisite to prevent trivialization of the disease and to achieve appropriate patient compliance for treatment. In this article a practical diagnostic and treatment algorithm for unguis incarnatus is presented. In mild cases of acute unguis incarnatus a consistent conservative treatment is the first-line strategy showing promising results. In cases of moderate to severe forms of acute unguis incarnatus, surgical procedures that preserve the nail matrix should be applied. For cases of chronic unguis incarnatus without an acute infection, elective partial matrixectomy can be indicated. Prior to any surgical intervention, detailed informed consent must be obtained from the patients.

[Prognostic implications of stone heart syndrome in cardiac arrest]. / Stellenwert des "Stone-heart"-Phänomens bei Herz-Kreislauf-Stillstand.

The stone heart syndrome is defined as an ischemic systolic contracture of the heart and also termed contractile cardiac arrest. It was first described in 1972 by the American cardiac surgeon Denton Cooley, who observed this phenomenon during bypass surgery. It is mostly the result of prolonged cardiac arrest where myocardial cells suffer hypoxia or anoxia. Insufficient forward blood flow and a decreased pressure gradient in the central aorta lead to reduced coronary perfusion. The resulting anaerobic metabolism causes an ischemic contracture as described in the stone heart syndrome. This article presents three cases of patients with traumatic cardiac arrest (TCA) and myocardial contracture in postmortem computed tomography (PMCT) and discuss the origins of the stone heart syndrome as well as its implications in cardiopulmonary resuscitation.

[Operation preparation in trauma surgery]. / Operationsvorbereitung in der Unfallchirurgie.

The success of a surgical procedure is significantly influenced by several critical factors. The safety of the patient is the primary goal. To this end, the term surgical preparation covers a number of procedures aiming to ensure the safety for the patient and a successful surgical intervention: verifying the indications, planning the intervention, identification of potential harmful factors, risks and countermeasures, patient education and documentation. Trauma surgery poses a particular challenge to preoperative preparation, especially due to urgent surgical interventions. Here, a standardized and evidence-based preoperative evaluation ensures a successful treatment of the patient.

[Numbers of emergency room patients during the COVID-19 pandemic]. / Patientenzahlen im Rahmen der COVID-19-Pandemie in einer zentralen Notaufnahme.

BACKGROUND: Since end of March, the health care system in Germany has been placed into a state of emergency in order to gain resources for the spreading coronavirus disease 2019 (COVID-19) pandemic. The overall goal of this study is to evaluate the number of emergency room patients at the time of the pandemic in order to draw conclusions about the influence of the COVID 19 pandemic on the number of patients in an emergency department. MATERIALS AND METHODS: With this descriptive epidemiologic study we collected and analyzed anonymized patient-related data of 19,357 cases presenting to the emergency department of the Klinikum rechts der Isar (Munich) from 01 February 2019 to 30 April 2019 and from 01 February 2020 to 30 April 2020. RESULTS: Despite an increase in the number of patients from 2019 to 2020, there was a significant drop in the number of emergencies from February to March 2020 and proceeding in April to a level below that of 2019. This was particularly observed in the field of trauma surgery, with a 40% decrease in the number of patients. With regard to the individual complaint patterns in March 2020, it was found that an increased incidence of malaise (+47%) and breathing problems (+36%) was recorded, whereas back pain (-41%), wounds (-29%), thoracic (-24%) and abdominal pain (-23%) were significantly less common than in the previous year. In terms of the severity of the complaints, the decline was mainly due to complaints with a low degree of urgency. CONCLUSION: In the course of the COVID-19 pandemic we observed a significant decline in the number of patients in one of the largest emergency rooms in Munich. This has to be avoided with existing hospital capacities, in order to prevent potential damage to health caused by postponed or missing emergency presentations.

[Importance of trauma and emergency surgery for German metropolitan emergency departments-an analysis of 524,716 emergency patients]. / Stellenwert der Unfallchirurgie für die Notaufnahmen einer deutschen Millionenstadt ­ Eine Auswertung von 524.716 Notfallpatienten.

BACKGROUND: The future of emergency departments in Germany is influenced by increasing numbers of patients, demographic changes, new therapeutic concepts, current legislation and expert opinions. There is a lack of reliable data concerning the quantity and the type of injuries and diseases presenting in emergency departments. MATERIAL AND METHODS: This descriptive, epidemiological study included 14 emergency departments in Munich (1.41 million inhabitants in 2014), where 524,716 patients were treated from 1 July 2013 to 30 June 2014. 393,587 were included in this prospectively planned subgroup analysis. Patients presenting in special departments, such as gynecology or ophthalmology (59,523) or cases without a documented diagnosis (71,606) were excluded. Cases were assigned to the discipline trauma surgery or orthopedics according to the ICD-10 diagnosis chapters "injuries, poisoning and certain other consequences of external causes" and "diseases of the musculoskeletal system and connective tissue". RESULTS: Of the 393,587 cases included, 169,208 were treated due to trauma or orthopedic diseases (43%). 134,507 underwent outpatient treatment (79%) and 34,701 were admitted on the same day (21%). 29,920 patients suffered from head injuries (18%), 31,143 fractures (20%) and 24,367 deep wounds (14%) were recorded. On workdays between 8am and 10am, up to 47 patients per hour were treated and between 1pm and 3pm, up to 36 patients per hour. On weekends, most patients presented between 11am and 7pm. CONCLUSION: The present study analyzed the frequency of major diagnoses corresponding to the various medical disciplines including more than 500,000 patients. Of the emergency cases included, 43% were allocated to trauma surgery or orthopedics. These patients presented in the emergency departments around the clock and necessitate the permanent attendance of a trauma and emergency surgeon. Thereby, timely surgical care and decisions regarding indications for surgery and admission are ensured. Competence in trauma and emergency surgery is therefore essential for emergency departments.

[General principles of wound management in emergency departments]. / Grundlegende Techniken des Wundverschlusses in der Notaufnahme.

Wound management is one of the major tasks in emergency departments. The surrounding intact skin but not the wound itself should be disinfected before starting definitive wound treatment. Hair should first be removed by clipping to 1-2 mm above the skin with scissors or clippers as shaving the area with a razor damages the hair follicles and increases the risk of wound infections. Administration of local anesthetics should be performed directly through the exposed edges of the wound. After wound examination, irrigation is performed with Ringer's solution, normal saline or distilled water. The next step is débridement of contaminated and devitalized tissue. There are several wound closure techniques available, including adhesive tapes, staples, tissue adhesives and numerous forms of sutures. Management of specific wounds requires particular strategies. A bleeding control problem frequently occurs with scalp lacerations. Superficial scalp lacerations can be closed by alternative wound closure methods, for example by twisting and fixing hair and the use of tissue adhesives, i.e. hair apposition technique (HAT). For strongly bleeding lacerations of the scalp, the epicranial aponeurosis should be incorporated into the hemostasis. Aftercare varies depending on both the characteristics of the wound and those of the patient and includes adequate analgesia as well as minimizing the risk of infection. Sufficient wound aftercare starts with the treating physician informing the patient about the course of events, potential complications and providing relevant instructions.

[Retrospective computation of the ISS in multiple trauma patients: Potential pitfalls and limitations of findings in full body CT scans]. / Retrospektive Berechnung des ISS bei polytraumatisierten Patienten: Fehlerquellen und Anforderungen an den radiologischen Befund der Ganzkörper-CT.

INTRODUCTION: The Injury Severity Score (ISS) is a well-established anatomical scoring system for polytraumatized patients. However, any inaccuracy in the Abbreviated Injury Score (AIS) directly increases the ISS impreciseness. Using the full body computed tomography (CT) scan report, ISS computation can be associated with certain pitfalls. This study evaluates interpretation variations depending on radiological reports and indicates requirements to reliably determine the ISS. MATERIALS AND METHODS: The ISS of 81 polytraumatized patients was calculated based on the full body CT scan report. If an injury could not be attributed to a precise AIS cipher, the minimal and maximal ISS was computed. Real ISS included all conducted investigations, intraoperative findings, and final medical reports. The differences in ISS min, ISS max, and ISS real were evaluated using the Kruskal-Wallis test (p<0.05) and plotted in a linear regression analysis. RESULTS: Mean ISS min was 24.0 (± 0.7 SEM) points, mean ISS real 38.6 (±1.3 SEM) and mean ISS max was 48.3 (±1.4 SEM) points. All means were significantly different compared to one another (p<0.001). The difference between possible and real ISS showed a distinctive variation. Mean deviation was 9.7 (±0.9 SEM) points downward and 14.5 (±1.1 SEM) points upward. The difference between deviation to ISS min and ISS max was highly significant (p<0.001). CONCLUSION: Objectification of injury severity in polytraumatized patients using the ISS is an internationally well-established method in clinical and scientific settings. The full body CT scan report must meet distinct criteria and has to be written in acquaintance to the AIS scale if intended to be used for correct ISS computation.

[Cardiac post-resuscitation care. An indication for trauma whole-body CT?]. / Zustand nach Reanimation. Eine Indikation für die "Traumaspirale"?

We report the case of a 51-year-old male patient who sustained a liver rupture following mechanical cardiopulmonary resuscitation (CPR) with the LUCAS® system. The patient was under anticoagulation and developed an abdominal compartment syndrome. Although the use of mechanical CPR devices, such as the LUCAS® system and the load distributing band (Autopulse®), is becoming more common, there are specific complications described in the literature, which are associated with mechanical CPR. It is important to differentiate between general complications associated with CPR and those which can be attributed to the application of mechanical CPR devices. Using the example of the presented case, this article outlines and discusses these points based on the currently available literature. It should also be noted that mechanical CPR can act in a similar way to chest trauma and can necessitate an investigation with contrast enhanced computed tomography.

[Pretreatment mass casualty incident workflow analysis : Comparison of two level 1 trauma centers]. / Prätherapeutische Ablaufanalyse bei einem Massenanfall von Verletzten : Vergleich von zwei Traumazentren der höchsten Versorgungsstufe.

BACKGROUND: Mass casualty incidents (MCI) have particularly high demands on patient care processes but occur rather rarely in daily hospital routine. Therefore, it is common to use simulations to train staff and to optimize institutional processes. OBJECTIVES: Aim of study was to compare the pre-therapeutic in-house workflow of two differently structured level 1 trauma sites in the case of a simulated mass casualty incident (MCI). MATERIALS AND METHODS: A MCI of 70 patients was simulated by actors in a manner that was as realistic as possible. The on-site triage assigned 7 cases to trauma site A with relatively long in-house distances and 4 patients to an independent trauma site B in which these distances were relatively short. During in-house treatment, time intervals for reaching milestones were measured and compared using the Mann-Whitney U test. RESULTS: As no simultaneous patient arrival occurred, the Patient Distribution Matrix proved to be effective. Site A needed more time (minutes) from admission to endpoints (A: 31.85 ± 7.99; B: 21.62 ± 4.76; p = 0.059). In detail, the time intervals were particularly longer for both patient stay in trauma room (A: 8.46 ± 3.02; B: 2.73 ± 0.78, p < 0.01) and transfer time to the CT room (A: 1.81 ± 0.62; B: 0.06 ± 0.03, p < 0.01). A shorter stay in the CT room did not compensate these effects (A: 8.86 ± 1.84; B: 10.40 ± 2.89, p = 0.571). For both sites, image calculation and distribution were relatively time consuming (17.36 ± 3.05). CONCLUSIONS: Although short in-house distances accelerated pretherapeutic treatment processes significantly, both sites remained clearly within the "golden hour". The strongest potential bottleneck was the time interval until images were available at the endpoints.

[Relevance of Vascular Trauma in Trauma Care - Impact on Clinical Course and Mortality]. / Bedeutung des Gefäßtraumas für die Schwerverletztenversorgung ­ Einfluss auf Verlauf und Mortalität.

There is a lack of evidence as to the relevance of vascular trauma (VT) in patients with severe injuries. Therefore, we reviewed registry data in the present study in order to systematically objectify the effect of VT in these patients. This study aimed to provide an adequate picture of the relevance of vascular trauma and to identify adverse prognostic factors. In a retrospective analysis of records from the TraumaRegister DGU® (TR-DGU) in two subgroups with moderate and severe VT, we examined the records for differences in terms of morbidity, mortality, follow-up and prognostic parameters compared to patients without VT with the same ISS. From a total of 42,326 patients, 2,961 (7 %) had a VT, and in 2,437 cases a severe VT (AIS ≥ 3) was diagnosed (5.8 %). In addition to a higher incidence of shock and a 2 to 3-fold increase in fluid replacement and erythrocyte transfusion, patients with severe VT had a 60 % higher rate of multiple organ failure, and in-hospital mortality was twice as high (33.8 %). The massively increased early mortality (8.0 vs. 25.2 %) clearly illustrates how severely injured patients are placed at risk by the presence of a relevant VT with a comparable ISS. In our opinion, due to an unexpected poor prognosis in the TR-DGU data for vascular injuries, increased attention is required in the care of severely injured patients. Based on our comprehensive analysis of negative prognostic factors, a further adjustment to the standards of vascular medicine could be advisable. The influence of the level of care provided by the admitting hospital and the relevance of a further hospital transfer to prognosis and clinical outcome is currently being analysed.

Association between volume of severely injured patients and mortality in German trauma hospitals.

BACKGROUND: The issue of patient volume related to trauma outcomes is still under debate. This study aimed to investigate the relationship between number of severely injured patients treated and mortality in German trauma hospitals. METHODS: This was a retrospective analysis of the TraumaRegister DGU® (2009-2013). The inclusion criteria were patients in Germany with a severe trauma injury (defined as Injury Severity Score (ISS) of at least 16), and with data available for calculation of Revised Injury Severity Classification (RISC) II score. Patients transferred early were excluded. Outcome analysis (observed versus expected mortality obtained by RISC-II score) was performed by logistic regression. RESULTS: A total of 39,289 patients were included. Mean(s.d.) age was 49.9(21.8) years, 27,824 (71.3 per cent) were male, mean(s.d.) ISS was 27.2(11.6) and 10,826 (29.2 per cent) had a Glasgow Coma Scale score below 8. Of 587 hospitals, 98 were level I, 235 level II and 254 level III trauma centres. There was no significant difference between observed and expected mortality in volume subgroups with 40-59, 60-79 or 80-99 patients treated per year. In the subgroups with 1-19 and 20-39 patients per year, the observed mortality was significantly greater than the predicted mortality (P < 0.050). High-volume hospitals had an absolute difference between observed and predicted mortality, suggesting a survival benefit of about 1 per cent compared with low-volume hospitals. Adjusted logistic regression analysis (including hospital level) identified patient volume as an independent positive predictor of survival (odds ratio 1.001 per patient per year; P = 0.038). CONCLUSION: The hospital volume of severely injured patients was identified as an independent predictor of survival. A clear cut-off value for volume could not be established, but at least 40 patients per year per hospital appeared beneficial for survival.

[Mild head injury in children and adults. Diagnostic challenges in the emergency department]. / Leichtes Schädel-Hirn-Trauma bei Kindern und Erwachsenen. Diagnostische Herausforderungen in der Notfallaufnahme.

Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.

Impact of STAT/SOCS mRNA expression levels after major injury.

BACKGROUND: Fulminant changes in cytokine receptor signalling might provoke severe pathological alterations after multiple trauma. The aim of this study was to evaluate the posttraumatic imbalance of the innate immune system with a special focus on the STAT/SOCS family. METHODS: 20 polytraumatized patients were included. Blood samples were drawn 0 h-72 h after trauma; mRNA expression profiles of IL-10, STAT 3, SOCS 1, and SOCS 3 were quantified by qPCR. RESULTS: IL-10 mRNA expression increased significantly in the early posttraumatic period. STAT 3 mRNA expressions showed a significant maximum at 6 h after trauma. SOCS 1 levels significantly decreased 6 h-72 h after trauma. SOCS 3 levels were significantly higher in nonsurvivors 6 h after trauma. CONCLUSION: We present a serial, sequential investigation in human neutrophil granulocytes of major trauma patients evaluating mRNA expression profiles of IL-10, STAT 3, SOCS 1, and SOCS 3. Posttraumatically, immune disorder was accompanied by a significant increase of IL-10 and STAT 3 mRNA expression, whereas SOCS 1 mRNA levels decreased after injury. We could demonstrate that death after trauma was associated with higher SOCS 3 mRNA levels already at 6 h after trauma. To support our results, further investigations have to evaluate protein levels of STAT/SOCS family in terms of posttraumatic immune imbalance.

[Standardized telephone-assisted instructions on resuscitation by laypersons. Feasibility study using video-assisted quality analysis]. / Standardisierte Telefonanweisungen zur Wiederbelebung durch Laienhelfer. Videogestützte Qualitätsanalyse im Rahmen einer Machbarkeitsstudie.

BACKGROUND: Telephone-assisted instructions for cardiopulmonary resuscitation (T-CPR) are highly recommended by the current European Resuscitation Council (ERC) guidelines for resuscitation 2010. AIM: The aim of this study was to analyze the adherence of laypersons to T-CPR instructions given by dispatchers in a mock scenario. The dispatchers adapted international T-CPR instructions to local requirements. MATERIAL AND METHODS: An emergency "collapse in the office" with subsequent T-CPR was simulated for 10 volunteer, untrained administrative staff, as the only single emergency witness and 4 emergency medical service (EMS) dispatchers. Each volunteer was sent to a "colleague" who simulated a sudden cardiovascular event and collapsed unconscious during the description of symptoms. The local lay responder made an emergency call by landline telephone and was connected to the dispatcher. In the course of the simulation the "victim" was replaced by a CPR manikin. RESULTS: Every participant, i.e. 10 out of 10, assessed the victim, recognized the situation and telephoned for help. On the orders of the dispatchers 9 out of the 10 activated the loudspeaker of the telephone but 4 still continued to use the handset. The instructions for positioning were followed by all 10. Correct positioning of the victim required a median of 33[Symbol: see text]s with an interquartile range (IQR) of 30-39[Symbol: see text]s. Breathing control including instructions lasted a median of 54[Symbol: see text]s (IQR 49-60[Symbol: see text]s). Breathing was assessed by 8 out of 10 but only 2 out of 8 achieved a duration of 10[Symbol: see text]s as recommended by the ERC guidelines for resuscitation 2010. After a median of 202[Symbol: see text]s (IQR 196-241[Symbol: see text]s) chest compressions were started by 9 out of 10 and were performed for a median of 63[Symbol: see text]s (IQR 60-69[Symbol: see text]s). A correct technique was used by 7 but with a low rate of 80 compressions/min (IQR 72-86/min). The instructions for ventilation were understood by 9 out of 10. Mouth-to-mouth resuscitation was performed by 7 participants and technically correct by 5 of them. The ventilation cycle of the 7 active participants lasted for a mean of 25[Symbol: see text]s (IQR 24-30[Symbol: see text]s). The mean total duration of the timeframe analyzed was 340[Symbol: see text]s (IQR 334-368[Symbol: see text]s). CONCLUSION: The results demonstrate that the local T-CPR concept for untrained laypersons is feasible in a mock scenario. No substantial errors were observed for the majority of the untrained responders but the simulation also showed that not every emergency witness implemented the instructions according to the dispatcher's expectations. The T-CPR procedure was also more time-consuming than expected; therefore, every standardized T-CPR concept should be tested for local practicability. In accordance with current studies, the results suggest that the focus should be on compression-only CPR instructions in urban settings. Dispatcher education in T-CPR should incorporate videotaped mock-up scenarios with untrained local laypersons.

[Structured teaching of surgery the LMU model in Munich]. / Strukturierte Lehre in der Chirurgie am Beispiel des Humanmedizinstudiums an der Ludwig-Maximilians-Universität München.

The medical curriculum (MeCuM) of the Ludwig Maximilian University (LMU) in Munich is a dynamic curriculum aimed to support the learning process of all students with their different learning styles. It is based on interactive, activating teaching methods in order to increase students' interest, and on repetitive evaluation of teaching units to modify the teaching in order to meet students' needs and wishes. In this context the teaching of surgery at our faculty takes place. Besides interdisciplinary lessons where diseases are taught in cooperation with our colleagues from internal medicine, indications for surgery, complications and consequences of surgery for the patients are analysed in PBL tutorials, online cases, bedside teachings and practical teaching on the ward. Surgical skills like suturing are demonstrated in videos, practiced on models or during practical teaching on the ward and they are tested in OSCEs. During the "praktisches Jahr", the students in the last year of their medical studies are supposed to apply their practical skills besides repeating theoretical knowledge in order to pass the final examination. For this purpose they are taught in a revision course called "LMU-StaR" (revision course for the Staatsexamen). In this paper we describe in detail the teaching of surgery at our faculty.

[Evidence for the digital rectal examination in the emergency assessment of acute abdominal pain]. / Sinnhaftigkeit der digital-rektalen Untersuchung bei akutem Abdomen in der Notfallaufnahme.

BACKGROUND: Physical examination of patients with undifferentiated abdominal pain (UAP) in the emergency room traditionally calls for digital rectal examination (DRE). Without a DRE, many textbooks deem a clinical examination incomplete. On the other hand, patients as well as physicians often feel uncomfortable with this breach of privacy involving a DRE. Especially emergency rooms do not offer an atmosphere where a relationship with the necessary mutual trust can be built up. In this light, the objective of this analysis is to assess the evidence for DRE via a systematic search of the relevant literature. METHODS AND RESULTS: A systematic search in Pubmed, Medline coupled with manual research laid the basis for the evaluation of relevant publications from January 1990 to March 2010. Keywords for the search were: "digital rectal examination" in combination with "acute abdominal pain", "acute abdomen" or "appendicitis". From the raw data of relevant publications, we extracted results into contingency tables and completed missing data. Above all parameters, we determined the likelihood ratios (LR) with corresponding 95 % confidence intervals to assess test quality. Opinions in the evaluated literature and many national and international textbooks diverge significantly on the necessity of DRE. Six studies question the significance of DRE when evaluating patients with undifferentiated abdominal pain and appendicitis, respectively. Out of these studies, five are prospective and one is retrospective. Overall, the diagnostic test quality of DRE was low in all studies with LR + in the range from 0.78 to 1.61 and LR -  from 0.91 to 1.29, respectively. No diagnostic relevance for DRE in combination with acute abdominal pain was found in these studies. Furthermore, in none of the reviewed cases did DRE have a relevant impact on management. CONCLUSION: The recommendation of generally applying DRE in the emergency room needs to be questioned critically. No evidence for the necessity and significance was found in the reviewed literature. Independently, these findings do not touch on the unequivocal indication of the DRE as a tool for assessing other specific conditions as well as screening for prostate or rectal cancer.

Concentration kinetics of serum MMP-9 and TIMP-1 after blunt multiple injuries in the early posttraumatic period.

Metalloproteinases are secreted in response to a variety of inflammatory mediators and inhibited by tissue inhibitors of matrixmetalloproteinases (TIMPs). Two members of these families, MMP-9 and TIMP-1, were differentially expressed depending on clinical parameters in a previous genomewide mRNA analysis. The aim of this paper was now to evaluate the posttraumatic serum levels and the time course of both proteins depending on distinct clinical parameters. 60 multiple traumatized patients (ISS > 16) were included. Blood samples were drawn on admission and 6 h, 12 h, 24 h, 48 h, and 72 h after trauma. Serum levels were quantified by ELISA. MMP-9 levels significantly decreased in the early posttraumatic period (P < 0.05) whereas TIMP-1 levels significantly increased in all patients (P < 0.05). MMP-9 and TIMP-1 serum concentration kinetics became manifest in an inversely proportional balance. Furthermore, MMP-9 presented a stronger decrease in patients with severe trauma and non-survivors in contrast to minor traumatized patients (ISS ≤ 33) and survivors, initially after trauma.