Current Trends in Orthopaedics and Trauma in Germany.

During the Guest Nation Symposium (cobranded with the Deutsche Gesellschaft für Orthopädie und Unfallchirurgie, Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie, and Deutsche Gesellschaft für Unfallchirurgie) at the 2023 American Academy of Orthopaedic Surgeons Congress in Las Vegas, the goal was to compile nationally important content from German orthopaedics and trauma surgery. This resulted in a mix of content on the latest developments in trauma care, knee arthroplasty, spinopelvic importance for hip arthroplasty, stemless shoulder endoprostheses, joint preservation for ankle osteoarthritis, trauma education, and research. Of course, this is only a small selection of the important issues that are being driven forward in Germany.

Development of a New Emergency Medicine Spinal Immobilization Protocol for Pediatric Trauma Patients and First Applicability Test on Emergency Medicine Personnel.

OBJECTIVES: The purpose of this study was to (i) develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) perform an applicability test on emergency medicine personnel. METHODS: A structured search of the literature published between 1980 and 2019 was performed in MEDLINE using PubMed. Based on this literature search, a new Emergency Medicine Spinal Immobilization Protocol for pediatric trauma patients (E.M.S. IMMO Protocol Pediatric) was developed. Parameters found in the literature, such as trauma mechanism and clinical findings that accounted for a high probability of spinal injury, were included in the protocol. An applicability test was administered to German emergency medicine personnel using a questionnaire with case examples to assess correct decision making according to the protocol. RESULTS: The E.M.S. IMMO Protocol Pediatric was developed based on evidence from published literature. In the applicability test involving 44 emergency medicine providers revealed that 82.9% of participants chose the correct type of immobilization based on the protocol. A total of 97.8% evaluated the E.M.S. IMMO Protocol Pediatric as helpful. CONCLUSIONS: Based on the current literature, the E.M.S. IMMO Protocol Pediatric was developed in accordance with established procedures used in trauma care. The decision regarding immobilization is made on based on the cardiopulmonary status of the patient, and life-threatening injuries are treated with priority. If the patient presents in stable condition, the necessity for full immobilization is assessed based upon the mechanisms of injury, assessment of impairment, and clinical examination.

[Development and first application testing of a new protocol for preclinical spinal immobilization in children : Assessment of indications based on the E.M.S. IMMO Protocol Pediatric]. / Entwicklung eines neuen Protokolls zur präklinischen Immobilisation der Wirbelsäule bei Kindern und erste Anwendungsuntersuchung : Indikationsstellung anhand des E.M.S. IMMO Protocol Pediatric.

BACKGROUND: To protect the spine from secondary damage, spinal immobilization is a standard procedure in prehospital trauma management. Immobilization protocols aim to support emergency medicine personnel in quick decision making but predominantly focus on the adult spine; however, trauma mechanisms and injury patterns in adults differ from those in children and applying adult prehospital immobilization protocols to pediatric patients may be insufficient. Adequate protocols for children with spinal injuries are currently unavailable. OBJECTIVE: The aim of this study was (i) to develop a protocol that supports decision making for prehospital spinal immobilization in pediatric trauma patients based on evidence from current scientific literature and (ii) to perform a first analysis of the quality of results if the protocol is used by emergency personnel. MATERIAL AND METHODS: Based on a structured literature search a new immobilization protocol was developed. Analysis of the quality of results was performed by a questionnaire containing four case scenarios in order to assess correct decision making. The decision about spinal immobilization was made without and with the utilization of the protocol. RESULTS: The E.M.S. IMMO Protocol Pediatric was developed based on the literature. The analysis of the quality of results was performed involving 39 emergency medicine providers. It could be shown that if the E.M.S. IMMO Protocol Pediatric was used, the correct type of immobilization was chosen more frequently. A total of 38 out of 39 participants evaluated the protocol as helpful. CONCLUSION: The E.M.S. IMMO Protocol Pediatric provides decision-making support whether pediatric spine immobilization is indicated with respect to the cardiopulmonary status of the patient. In a first analysis, the E.M.S. IMMO Protocol Pediatric improves decision making by emergency medical care providers.

Influence of demographic factors and clinical status parameters on long-term neurological, psychological and vegetative outcome following traumatic brain injury.

PRIMARY OBJECTIVE: We evaluated the neurologic, psychological and vegetative outcome, the health status and changes of the personal and occupational status of patients after traumatic brain injuries (TBIs). Correlations between outcome parameters and basic demographic factors and initial clinical status parameters of the patients were assessed. RESEARCH DESIGN: Monocentric, retrospective follow-up analysis. METHODS AND PROCEDURES: We evaluated the neurologic, psychological and vegetative outcome and health status of patients, who survived TBI with a mean follow-up time of 54 months. Glasgow Outcome Scale (GOS), Disability Rating Scale (DRS) and a questionnaire on Quality of Life were used for outcome measurement. The personal and occupational status, trauma-derived changes to that status and medical and demographic factors that have an impact on the health condition of patients after TBI were assessed. MAIN OUTCOMES AND RESULTS: With a median GOS of 5.0 and median DRS of 3.0, our patients showed just moderate disabilities. Fifty-six per cent of the patients felt 'very good' or 'good'. Age, gender, the preclinical Glasgow Coma Scale (GCS), state of pupil reaction and surgical treatment did not seem to affect the GOS or DRS. Correlations between body mass index, age and gender and distinct neurologic, psychological and vegetative symptoms were found. The personal status did not change significantly after TBI. Changes to occupational and socioeconomic status were evident. CONCLUSIONS: One-third of the patients are heavily affected by neurological, psychological and vegetative symptoms after surviving TBI. Some demographic factors affected this integrity.

[Young doctors wanted - but how many? : Current data on the number of aspiring specialist doctors in orthopedics and trauma surgery in Germany]. / Wie viel Nachwuchs braucht das Land? : Eine aktuelle Datenerhebung zur Anzahl der Ärzte in Weiterbildung in Orthopädie und Unfallchirurgie.

There is an ongoing discussion about demographic change, a possible lack of young doctors and its impact on the healthcare system in Germany. Up to now, no valid data has been available on the exact numbers of residents in orthopedics and trauma surgery. Therefore, the aim of this study was to determine the actual number of residents in Germany in 2013/2014. We generated a database with all eligible providers of postgraduate training in orthopedics and trauma surgery in Germany. All of these were asked to fill out a questionnaire about the number of trainees, their gender and year of training. We achieved an 80% response rate (1509 questionnaires). Within these institutions, 4310 residents are trained. For Germany, this means an estimated number of about 5300 residents in the year 2013/2014. Ninety percent of postgraduate training is performed within a hospital and one-third of the residents are female. Looking at the expected number of doctors who will retire within the next five years, there seems to be enough young doctors to fill the gap. However, by 2040, an increased demand for othopedic and trauma surgeons is experted. Thus, we recommend centrally analyzing and coordinating the demand of residents in orthopedics and trauma surgery in Germany.

Level of Evidence Analysis for the Latest German National Guideline on Treatment of Patients with Severe and Multiple Injuries and ATLS.

PURPOSE: Advanced Trauma Life Support (ATLS®) is one of the world's best-known training programs for medical providers. Revisions of the ATLS manual have been evidence based for a number of years. In 2011, a level 3 (S3) evidence- and consensus-based guideline on the treatment of patients with severe and multiple injuries was published in Germany. The scope of this study was the systematic comparison of the educational content of the ATLS concept and the interdisciplinary "S3 polytrauma guideline." METHODS: A total of 123 key recommendations of the guideline were compared with the content of the ATLS manual (9th edition). Depending on the level of agreement, the recommendations were classed in the following categories: (1) Agreement. (2) Minor variation. (3) Major variation. RESULTS: An overall 86% conformity was found between the key recommendations of the guideline and the ATLS® manual. The ATLS® primary survey (ABCDE) showed an 85% conformity. The degree of conformity for the individual priorities was as follows: A (Airway) 79%, B (Breathing) 79%, C (Circulation) 86%, D (Disability) 93%, E (Exposure) 100%. The ATLS® secondary survey showed a 94% conformity. The main differences were in the areas of anesthetic induction, fluid administration, and coagulation therapy. CONCLUSIONS: According to our comparison, the educational content and manual of the ATLS are largely compatible with a high level of evidence S3 guideline. However, subsequent editions of both the ATLS® and the S3 guideline should re-examine and reassess a number of aspects.

Is the ATLS classification of hypovolaemic shock appreciated in daily trauma care? An online-survey among 383 ATLS course directors and instructors.

OBJECTIVE: For the early recognition and management of hypovolaemic shock, ATLS suggests four shock classes based upon an estimated blood loss in percent. The aim of this study was to assess the confidence and acceptance of the ATLS classification of hypovolaemic shock among ATLS course directors and instructors in daily trauma care. METHODS: During a 2-month period, ATLS course directors and instructors from the ATLS region XV (Europe) were invited to participate in an online survey comprising 15 questions. RESULTS: A total of 383 responses were received. Ninety-eight percent declared that they would follow the 'A, B, C, D, E' approach by ATLS in daily trauma care. However, only 48% assessed 'C-Circulation' according to the ATLS classification of hypovolaemic shock. One out of four respondents estimated that in daily clinical routine, less than 50% of all trauma patients can be classified according to the current ATLS classification of hypovolaemic shock. Additionally, only 10.9% considered the ATLS classification of hypovolaemic shock as a 'good guide' for fluid resuscitation and blood product transfusion, whereas 45.1% stated that this classification only 'may help' or has 'no impact' to guide resuscitation strategies. CONCLUSIONS: Although the 'A, B, C, D, E' approach according to ATLS is widely implemented in daily trauma care, the use of the ATLS classification of hypovolaemic shock in daily practice is limited. Together with previous analyses, this study supports the need for a critical reassessment of the current ATLS classification of hypovolaemic shock.

The effect of paramedic training on pre-hospital trauma care (EPPTC-study): a study protocol for a prospective semi-qualitative observational trial.

BACKGROUND: Accidents are the leading cause of death in adults prior to middle age. The care of severely injured patients is an interdisciplinary challenge. Limited evidence is available concerning pre-hospital trauma care training programs and the advantage of such programs for trauma patients. The effect on trauma care procedures or on the safety of emergency crews on the scene is limited; however, there is a high level of experience and expert opinion. METHODS: I - Video-recorded case studies are the basis of an assessment tool and checklist being developed to verify the results of programs to train participants in the care of seriously injured patients, also known as "objective structured clinical examination" (OSCE). The timing, completeness and quality of the individual measures are assessed using appropriate scales. The evaluation of team communication and interaction will be analyzed with qualitative methods and quantified and verified by existing instruments (e.g. the Clinical Team Scale). The developed assessment tool is validated by several experts in the fields of trauma care, trauma research and medical education. II a) In a German emergency medical service, the subjective assessment of paramedics of their pre-hospital care of trauma patients is evaluated at three time points, namely before, immediately after and one year after training. b) The effect of a standardized course concept on the quality of documentation in actual field operations is determined based on three items relevant to patient safety before and after the course. c) The assessment tool will be used to assess the effect of a standardized course concept on procedures and team communication in pre-hospital trauma care using scenario-based case studies. DISCUSSION: This study explores the effect of training on paramedics. After successful study completion, further multicenter studies are conceivable, which would evaluate emergency-physician staffed teams. The influence on the patients and prehospital measures should be assessed based on a retrospective analysis of the emergency room data. TRIALS REGISTRATION: German Clinical Trials Register, ID DRKS00004713.

Assessment of hypovolaemic shock at scene: is the PHTLS classification of hypovolaemic shock really valid?

OBJECTIVE: Validation of the classification of hypovolaemic shock suggested by the prehospital trauma life support (PHTLS) in its sixth student course manual. METHODS: Adults, entered into the TraumaRegister DGU(®) database between 2002 and 2011, were classified into reference ranges for heart rate (HR), systolic blood pressure (SBP) and Glasgow coma scale (GCS) according to the PHTLS classification of hypovolaemic shock. First, patients were grouped by a combination of all three parameters (HR, SBP and GCS) as suggested by PHTLS. Second, patients were classified by only one parameter (HR, SBP or GCS) according to PHTLS and alterations in the remaining two parameters were assessed. Furthermore, subgroup analysis for trauma mechanism and traumatic brain injury (TBI) were performed. RESULTS: Out of 46 689 patients, only 12 432 (26.5%) could be adequately classified according to PHTLS if a combination of all three criteria was assessed. In TBI patients, only 12.2% could be classified adequately, whereas trauma mechanism had no significant influence. When patients were grouped by HR, there was only a slight reduction in SBP. When grouped by SBP, GCS dropped from 14 to 8, while no significant tachycardia was observed in any group. In patients with a GCS less than 12, HR was unaltered whereas SBP was slightly reduced to 114 (±42) mm Hg. On average, GCS in TBI patients was lower within all shock groups. In penetrating trauma patients, changes in HR and SBP were more distinct, but still less than predicted by PHTLS. CONCLUSIONS: The PHTLS classification of hypovolaemic shock displays substantial deficits in adequately risk-stratifying trauma patients.

Flaps for closure of soft tissue defects in infected revision knee arthroplasty.

PURPOSE: Total knee arthroplasty revision has wound healing deficits of up to 20 %. Defects in the knee region of multimorbid patients are hard to treat as complete explantation and revision arthroplasty is often too burdensome for them. In this study, we present our results with flaps for the treatment of defects after knee replacement, arthrodesis or osteosynthesis. METHODS: Twenty-five patients (26 knees) with defects in the knee region were treated with flaps. Mean follow-up was 37 months (13-61) and the patients had a mean age of 72 years (49-85). A total of 39 flaps were performed (27 muscle flaps, seven fascio-cutaneous flaps and five free flaps). RESULTS: Patients with more than three comorbidities showed higher risk of complications after surgery. Fifteen patients showed no infection at last follow up. Five patients received an arthrodesis of the knee, two showed persistent infection of the implant with fistula, and three were amputated above the knee. CONCLUSIONS: Amputation could be avoided in 22 cases (85 %). The gastrocnemius muscle flap showed good results in the treatment of defects after arthroplasty or arthrodesis of the knee in multimorbid patients. This procedure can be used if further revision surgery is not indicated.

Female sex as a negative predictor of outcomes of ankle arthrodesis: a retrospective comparative monocentric study.

BACKGROUND: End-stage post-traumatic osteoarthritis of the ankle joint may require arthrodesis if conservative treatment fails and a decision against total ankle replacement is made. We aimed to compare the sex-specific differences in outcomes and objectify them using validated specific scores. METHODS: Between 2010 and 2021, 221 patients underwent ankle arthrodesis at our institution, including 143 men (MAA) and 78 women (FAA). In addition to demographic data, the aetiology of osteoarthritis, the Foot Function Index (FFI-D), the Olerud-Molander Score (OMAS), and the Short Form-12 questionnaire (SF-12) were collected in this monocentric study. The mean follow-up time was 5.8 years. End-stage osteoarthritis was mostly due to ankle fractures as a result of sprains, falls, and road traffic accidents. RESULTS: Post-operatively, the mean FFI-D for pain was 17.3 (MAA: 14.7; FAA 22.2) and 43.9 for function (MAA: 41.1; FAA 49.5); the mean OMAS was 58.2; and the mean SF-12 physical component score was 42.5. Women achieved significantly worse results in all scores; only the mental component summary of the SF-12 did not differ between the sexes (p > 0.05). Approximately 34% of women stated that the result in terms of gait pattern was worse than expected (MAA 16.1%; p < 0.05). Again, significantly more men stated that the result was better than expected (MAA: 48.3%; FAA: 31.5%, p < 0.05). CONCLUSIONS: The fact that the clinical results were significantly worse in women after ankle arthrodesis should be considered when determining the indication. However, the expectations of men and women also need to be individually adjusted.

The Shock Index revisited - a fast guide to transfusion requirement? A retrospective analysis on 21,853 patients derived from the TraumaRegister DGU.

INTRODUCTION: Isolated vital signs (for example, heart rate or systolic blood pressure) have been shown unreliable in the assessment of hypovolemic shock. In contrast, the Shock Index (SI), defined by the ratio of heart rate to systolic blood pressure, has been advocated to better risk-stratify patients for increased transfusion requirements and early mortality. Recently, our group has developed a novel and clinical reliable classification of hypovolemic shock based upon four classes of worsening base deficit (BD). The objective of this study was to correlate this classification to corresponding strata of SI for the rapid assessment of trauma patients in the absence of laboratory parameters. METHODS: Between 2002 and 2011, data for 21,853 adult trauma patients were retrieved from the TraumaRegister DGU database and divided into four strata of worsening SI at emergency department arrival (group I, SI <0.6; group II, SI ≥0.6 to <1.0; group III, SI ≥1.0 to <1.4; and group IV, SI ≥1.4) and were assessed for demographics, injury characteristics, transfusion requirements, fluid resuscitation and outcomes. The four strata of worsening SI were compared with our recently suggested BD-based classification of hypovolemic shock. RESULTS: Worsening of SI was associated with increasing injury severity scores from 19.3 (± 12) in group I to 37.3 (± 16.8) in group IV, while mortality increased from 10.9% to 39.8%. Increments in SI paralleled increasing fluid resuscitation, vasopressor use and decreasing hemoglobin, platelet counts and Quick's values. The number of blood units transfused increased from 1.0 (± 4.8) in group I to 21.4 (± 26.2) in group IV patients. Of patients, 31% in group III and 57% in group IV required ≥10 blood units until ICU admission. The four strata of SI discriminated transfusion requirements and massive transfusion rates equally with our recently introduced BD-based classification of hypovolemic shock. CONCLUSION: SI upon emergency department arrival may be considered a clinical indicator of hypovolemic shock in respect to transfusion requirements, hemostatic resuscitation and mortality. The four SI groups have been shown to equal our recently suggested BD-based classification. In daily clinical practice, SI may be used to assess the presence of hypovolemic shock if point-of-care testing technology is not available.

Training Effectiveness and Impact on Safety, Treatment Quality, and Communication in Prehospital Emergency Care: The Prospective Longitudinal Mixed-Methods EPPTC Trial.

BACKGROUND: Emergency training is designed to improve medical care teams' knowledge, practical skills, and treatment procedures in patient care to increase patient safety. This requires effective training, but the multifactorial effects of training are difficult to measure. METHODS: We assessed the impact of emergency team training on treatment procedures and quality, processes, technical skills, and nontechnical skills in simulated trauma emergencies in a longitudinal analysis, using videos that were recorded before (t0), immediately after (t1), and 1 year after the training (t2). The training was evaluated with the validated PERFECT checklist, which includes 7 scales: primary assessment, secondary assessment, procedures, technical skills, trauma communication, nontechnical skills, and a global performance scale.The primary end point was the change from before a training intervention (t0) to 1 year after training (t2), measured by a metric point score. The second end point was the impact of the intervention from before training to after and from immediately after training to 1 year later. RESULTS: A total of 146 trainings were evaluated. In simulated traumatological emergencies, training participants showed significantly better treatment capacity after 1 year (t0: 28.8 ± 5.6 points versus t2: 59.6 ± 6.6 points, P < 0.001), with greater improvement from t0 to t1 (28.8 ± 5.6 points versus 65.1 ± 7.9 points, P < 0.001). The most significant change from t0 to t2 was seen in the primary assessment, with a mean change of 11.1 ± 5.1, followed by the scale of the procedure (6.1 ± 3.0) and nontechnical skills (6.0 ± 3.0). CONCLUSIONS: Team trainings with intensive scenario training and short theoretical inputs lead to a significant improvement in simulated care of severely injured patients, especially in identifying and intervening in life-threatening symptoms, processes, and nontechnical skills, even 1 year after the course. Positive, longitudinally positive effects were also in communication and subjective safety of prehospital health care personnel.

Comparison of manual statements from out-of-hospital trauma training programs and a national guideline on treatment of patients with severe and multiple injuries.

PURPOSE: Training programs help establish evidence-based knowledge in prehospital emergency care. This study aimed to compare manual statements from prehospital trauma training programs and evidence-based guidelines on treatment of patients with severe and multiple injuries. METHODS: A systematic comparison with the primary endpoint of the highest grades of recommendation (GoR A, "must") of the current version of the German guidelines and recent recommendations of the prehospital trauma training programs International Trauma Life Support (ITLS), Prehospital Trauma Life Support (PHTLS), and Traumamanagement® (TM) based on their official textbooks was done. The recommendations were categorized as agreement or minor or major variation. The comparison was made using a rating system by experts who were blinded to the training programs. If the consensus strength of the experts was < 75%, affected statements were finalized in a Delphi procedure. RESULTS: Overall, 92 statements were compared. Fleiss-kappa of the first rating was 0.385 (p < 0.001, 95% CI: 0.376-0.393). Finally, comparable recommendations of the guideline with the training programs in principle agree with the statement of the guidelines were > 90% for all programs. The agreement with GoR A recommendations and each course program were 33.9%, 30.6%, and 35.5% (ITLS, PHTLS, and TM, respectively), p = 0.715. CONCLUSIONS: Despite small differences, the training programs showed high degrees of compliance with the guidelines and international agreement with some minor differences. Furthermore, the results did not allow any conclusions regarding the quality of the courses, the didactic methodology, and local adaptability. The practical implementation of the courses is probably even higher and closer to the guidelines.

Comparing the Short-Term Outcome after Polytrauma and Proximal Femur Fracture in Geriatric Patients.

Because of demographic change, geriatric patients are becoming a major challenge for traumatology. Multiple trauma patients and patients with proximal femoral fractures are important groups of patients in geriatric traumatology. This retrospective study compares two patient groups with different severities of injuries, and analyzes their patient characteristics and short-term outcomes, focusing on functionality upon discharge. The investigation aims to present the characterizing features of both patient groups, and to identify the potential risk factors for early functionality after trauma. The patient collective comprises two patient groups: a polytrauma group with 91 patients, and a femoral fracture group with 132 patients. Under the control of potential influencing factors, the present study showed no significant influence of belonging to either of the patient groups (multiple trauma or proximal femoral fracture) on the mobility status at discharge. Age, known dementia, pre-clinical intubation, and the lowest Hb value were identified as significant influencing factors. Despite their old age and vulnerability, the majority of geriatric patients survive accidents. Further prospective investigations concerning the maintenance or restoration of functionality after an accident are therefore desirable.

"Quod licet Chefarzt  ": The Impact of Perceived Hierarchy on Working Atmosphere and Quality of Work in Orthopaedic and Trauma Surgery. Results of a Survey Among 799 Orthopaedic and Trauma Surgeons in Germany. / "Quod licet Chefarzt  ": Der Einfluss der empfundenen Hierarchie auf Arbeitsklima und Arbeitsqualität in O und U. Ergebnisse einer Umfrage unter 799 Orthopäden und Unfallchirurgen in Deutschland.

INTRODUCTION: Surgical departments are discredited as guardians of traditional structures of hierarchy. Hierarchy and working climate have a large share in human factor, being made responsible for 70% of avoidable errors in medicine. Aim of this study was the assessment of these topics amongst physicians in the field of orthopedics and traumatology. MATERIAL AND METHODS: A questionnaire of 10 questions was digitally handed to DGOU members. 799 questionnaires were answered. RESULTS: We found significant differences in the assessment of hierarchy and working atmosphere amongst the physician groups. Working atmosphere was perceived as not appreciative by registrars only. All groups were in favor of a hierarchy rather close to, but nut absolutely on equal terms. All groups attach high influence of working atmosphere on quality of daily work. DISCUSSION: Literature shows that hierarchic differentiation can increase performance of a team, while rigid hierarchy structures can lead to mistakes. Although hierarchy in orthopedics and traumatology seems to be less pronounced than assumed, hierarchy has great influence on daily work. CONCLUSION: In order to achieve a safety oriented medical environment, it will be of great importance to define hierarchy structures in clinics and to utilize them efficiently as a part of safety culture.

Analysis of cervical spine immobilization during patient transport in emergency medical services.

PURPOSE: It remains controversial how to immobilize the cervical spine (CS) in trauma patients. Therefore, we analyzed different CS immobilization techniques during prehospital patient transport. METHODS: In this explorative, biomechanical analysis of immobilization techniques conducted in a standardized setting, we recorded CS motion during patient transport using a wireless human motion tracker on a volunteer. To interpret spinal movement a benchmark called motionscore (MS) was developed based on biomechanics of the injured spine. RESULTS: We found the best spinal motion restriction using a spine board, head blocks and immobilization straps with and without a cervical collar (CC) (MS 45 vs. 27). Spinal motion restriction on a vacuum mattress with CC and head blocks was superior to no CC or head blocks (MS 103 vs. 152). An inclined vacuum mattress was more effective with head blocks than without (MS 124 vs. 187). Minimal immobilization with an ambulance cot, CC, pillow and tape was slightly superior to a vacuum mattress with CC and head blocks (MS 92 vs. 103). Minimal immobilization without CC showed the lowest spinal motion restriction (MS 517). CONCLUSIONS: We suggest an immobilization procedure customized to the individual situation. A spine board should be used whenever spinal motion restriction is indicated and the utilization is possible. In some cases, CS immobilization by a vacuum mattress with CC and head blocks could be more beneficial. In an unstable status of the patient, minimal immobilization may be performed using an ambulance cot, pillow, CC and tape to minimize time on scene caused by immobilization.

Spinal Immobilization in the Trauma Room - a Survey-Based Analysis at German Level I Trauma Centers. / Die Immobilisation der Wirbelsäule im Schockraum ­ eine umfragebasierte Analyse in den deutschen überregionalen Traumazentren.

BACKGROUND: Spinal immobilization is a standard procedure in daily out-of-hospital emergency care. Homogenous recommendations concerning the immobilization of trauma patients during the first therapy in the emergency department do not exist. The aim of the current study was the analysis of the existing strategies concerning spinal immobilization in German level I trauma centers by an internet-based survey. MATERIALS AND METHODS: The current study is a survey-based analysis of the current strategies concerning spinal immobilization in all 107 level I trauma centers in Germany. The internet-based survey consists of 6 items asking about immobilization in the emergency department. RESULTS: The return rate was 47.7%. In 14 (28.6%) level I trauma centers the patients remained immobilized on the immobilization tool used by the professional emergency care providers. In 19 (38.8%) level I trauma centers the patients were transferred to a stretcher with a soft positioning mattress on it. Patient transfer to a spineboard or to a TraumaMattress was performed in 11 (22.4%) and 7 (14.3%) level I trauma centers, respectively. Trauma patients were never transferred to a vacuum mattress. Cervical spine protection was most of the time performed by a cervical collar (n = 48; 98.0%). In general, the survey's participants were mainly satisfied (mean = 84/100) with the current strategy of spinal immobilization. The satisfaction was best if the spineboard is used. DISCUSSION: Patient positioning during initial emergency therapy in the emergency department of German level I trauma centers is highly heterogenous. Besides complete full body immobilization, also the lack of any immobilization was reported by the survey's participants.

An explorative, biomechanical analysis of spine motion during out-of-hospital extrication procedures.

OBJECTIVES: The extrication of patients following a road traffic collision is among the basic procedures in emergency medicine. Thus, extrication is a frequently performed procedure by most of the emergency medical services worldwide. The appropriate extrication procedure depends on the patient's current condition and accompanying injuries. A rapid extrication should be performed within a few minutes, and the cervical spine (at least) should be immobilized. To our knowledge, the scientific literature and current guidelines do not offer detailed recommendations on the extrication of injured patients. Thus, the aim of the current study is to compare the effectiveness of spinal stabilization during various out-of-hospital extrication procedures. METHODS: This is an explorative, biomechanical analysis of spine motion during different extrication procedures on an example patient. Movement of the cervical spine was measured using a wireless human motion tracker. Movement of the thoracic and lumbar spine was quantified with 12 strain gauge sensors, which were positioned paravertebrally on both sites along the thoracic and lumbar spine. To interpret angular movement, a motionscore was developed based on newly defined axioms on the biomechanics of the injured spine. RESULTS: Self-extrication showed the least spinal movement (overall motionscore sum = 667). Movement in the cervical spine could further be reduced by applying a cervical collar. The extrication by a rescue boa showed comparable results in overall spinal movement compared to the traditional extrication via spineboard (overall motionscore sum = 1862vs. 1743). Especially in the cervical spine, the spinal movement was reduced (motionscore sum = 339 vs. 595). However, the thoracic spine movement was increased (motionscore sum = 812 vs. 432). CONCLUSION: In case of a suspected cervical spine injury, guided self-extrication seems to be the best option. If the patient is not able to perform self-extrication, using a rescue boa might reduce cervical spinal movement compared to the traditional extrication procedure. Since promising results are shown in the case of extrication using a patient transfer sheet that has already been placed below the driver, future developments should focus on novel vehicle seats that already include an extrication device.

Training to identify red flags in the acute care of trauma: who are the patients at risk for early death despite a relatively good prognosis? An analysis from the TraumaRegister DGU®.

BACKGROUND: In the acute care of trauma, some patients with a low estimated risk of death die suddenly and unexpectedly. In this study, we aim to identify predictors for early death within 24 h following hospital admission in low-risk patients. METHODS: The TraumaRegister DGU® was used to collect records of patients who were primarily treated in a participating hospital between 2004 and 2013 with a RISC II score below 10%. RESULTS: During the study period, 64,379 patients met the inclusion criteria. The mean RISC II score was 2.0%, and the mean ISS was 16 ± 9. The overall hospital mortality rate was 2.1%, and 0.5% of patients (n = 301) died within the first 24 h. A SPB of ≤ 90 mmHg was associated with an increased risk of death (p < 0.001). An AIS abdomen score of ≥ 3 was associated with increased risk of death within the first 24 h (p < 0.001). A high risk of early death was also seen in patients with an AIS score (thorax) ≥ 3; 51% of those who died died within the first 24 h (p < 0.005). Death in patients over 60 years was more common after 24 h (p < 0.001). Patients with an ASA score of ≥ 3 were more likely to die after the first 24 h (p < 0.001). CONCLUSIONS: Indicators predicting a high risk of early death in patients with a low RISC II score include a SPB ≤ 90 mmHg and severe chest and abdominal trauma. Emergency teams involved in the acute care of trauma patients should be aware of these "red flags" and treat their patients accordingly.