Change of risk behaviour in young people - the effectiveness of the trauma prevention programme P.A.R.T.Y. considering the effect of fear appeals and cognitive processes.

BACKGROUND: The purpose of the present study was to examine the effectiveness of the injury awareness and prevention programme P.A.R.T.Y. (Prevent Alcohol and Risk-Related Trauma in Youth) in Germany. On a designated P.A R.T.Y. day, school classes spend a day in a trauma hospital experiencing the various wards through which a seriously injured person goes. A further goal of the study was to reveal indications of the programme's mechanism of action by testing theory-based impact models of fear appeals and cognitive beliefs. METHODS: In a quasi-experimental longitudinal study with three measurement times the participants of 19 P.A.R.T.Y. days (n = 330), as well as pupils who did not attend the programme (n = 244), were interviewed with a standardised questionnaire. They reported risk behaviour, feelings of threat and cognitive beliefs about road traffic. The data were analysed using a meta-analytical approach to estimate an average effect size across the different P.A.R.T.Y. days. Path models were used to identify possible mechanisms of action. RESULTS: For most of the parameters, small positive effects could be proven immediately after the P.A.R.T.Y. INTERVENTION: However, after four to 5 months only one statistically significant effect was found. Using path analytical models, important predictors for behavioural changes (e.g. self-efficacy) could be identified. But for these predictors no or only short-term effects were observed in the meta-analysis. CONCLUSIONS: Fear appeals as used primarily in the P.A.R.T.Y. programme appear to cause behavioural changes only to a limited extent and only in the short-term, especially if the strengthening of psychosocial resources is not given sufficient consideration. The participants must also cognitively process the experiences in the hospital. Accordingly, consideration should be given to how the P.A.R.T.Y. program could be adapted to complement the fear appeal with cognitive components.

Acute and chronic wound fluids inversely influence adipose-derived stem cell function: molecular insights into impaired wound healing.

Wound healing is a complex biological process that requires a well-orchestrated interaction of mediators as well as resident and infiltrating cells. In this context, mesenchymal stem cells play a crucial role as they are attracted to the wound site and influence tissue regeneration by various mechanisms. In chronic wounds, these processes are disturbed. In a comparative approach, adipose-derived stem cells (ASC) were treated with acute and chronic wound fluids (AWF and CWF, respectively). Proliferation and migration were investigated using 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) test and transwell migration assay. Gene expression changes were analysed using quantitative real time-polymerase chain reaction. AWF had a significantly stronger chemotactic impact on ASC than CWF (77·5% versus 59·8% migrated cells). While proliferation was stimulated by AWF up to 136·3%, CWF had a negative effect on proliferation over time (80·3%). Expression of b-FGF, vascular endothelial growth factor (VEGF) and matrix metalloproteinase-9 was strongly induced by CWF compared with a mild induction by AWF. These results give an insight into impaired ASC function in chronic wounds. The detected effect of CWF on proliferation and migration of ASC might be one reason for an insufficient healing process in chronic wounds.

Renaissance of base deficit for the initial assessment of trauma patients: a base deficit-based classification for hypovolemic shock developed on data from 16,305 patients derived from the TraumaRegister DGU®.

INTRODUCTION: The recognition and management of hypovolemic shock still remain an important task during initial trauma assessment. Recently, we have questioned the validity of the Advanced Trauma Life Support (ATLS) classification of hypovolemic shock by demonstrating that the suggested combination of heart rate, systolic blood pressure and Glasgow Coma Scale displays substantial deficits in reflecting clinical reality. The aim of this study was to introduce and validate a new classification of hypovolemic shock based upon base deficit (BD) at emergency department (ED) arrival. METHODS: Between 2002 and 2010, 16,305 patients were retrieved from the TraumaRegister DGU® database, classified into four strata of worsening BD [class I (BD≤2 mmol/l), class II (BD>2.0 to 6.0 mmol/l), class III (BD>6.0 to 10 mmol/l) and class IV (BD>10 mmol/l)] and assessed for demographics, injury characteristics, transfusion requirements and fluid resuscitation. This new BD-based classification was validated to the current ATLS classification of hypovolemic shock. RESULTS: With worsening of BD, injury severity score (ISS) increased in a step-wise pattern from 19.1 (±11.9) in class I to 36.7 (±17.6) in class IV, while mortality increased in parallel from 7.4% to 51.5%. Decreasing hemoglobin and prothrombin ratios as well as the amount of transfusions and fluid resuscitation paralleled the increasing frequency of hypovolemic shock within the four classes. The number of blood units transfused increased from 1.5 (±5.9) in class I patients to 20.3 (±27.3) in class IV patients. Massive transfusion rates increased from 5% in class I to 52% in class IV. The new introduced BD-based classification of hypovolemic shock discriminated transfusion requirements, massive transfusion and mortality rates significantly better compared to the conventional ATLS classification of hypovolemic shock (p<0.001). CONCLUSIONS: BD may be superior to the current ATLS classification of hypovolemic shock in identifying the presence of hypovolemic shock and in risk stratifying patients in need of early blood product transfusion.

Comparison of the predictive performance of the BIG, TRISS, and PS09 score in an adult trauma population derived from multiple international trauma registries.

BACKGROUND: The BIG score (Admission base deficit (B), International normalized ratio (I), and Glasgow Coma Scale (G)) has been shown to predict mortality on admission in pediatric trauma patients. The objective of this study was to assess its performance in predicting mortality in an adult trauma population, and to compare it with the existing Trauma and Injury Severity Score (TRISS) and probability of survival (PS09) score. MATERIALS AND METHODS: A retrospective analysis using data collected between 2005 and 2010 from seven trauma centers and registries in Europe and the United States of America was performed. We compared the BIG score with TRISS and PS09 scores in a population of blunt and penetrating trauma patients. We then assessed the discrimination ability of all scores via receiver operating characteristic (ROC) curves and compared the expected mortality rate (precision) of all scores with the observed mortality rate. RESULTS: In total, 12,206 datasets were retrieved to validate the BIG score. The mean ISS was 15 ± 11, and the mean 30-day mortality rate was 4.8%. With an AUROC of 0.892 (95% confidence interval (CI): 0.879 to 0.906), the BIG score performed well in an adult population. TRISS had an area under ROC (AUROC) of 0.922 (0.913 to 0.932) and the PS09 score of 0.825 (0.915 to 0.934). On a penetrating-trauma population, the BIG score had an AUROC result of 0.920 (0.898 to 0.942) compared with the PS09 score (AUROC of 0.921; 0.902 to 0.939) and TRISS (0.929; 0.912 to 0.947). CONCLUSIONS: The BIG score is a good predictor of mortality in the adult trauma population. It performed well compared with TRISS and the PS09 score, although it has significantly less discriminative ability. In a penetrating-trauma population, the BIG score performed better than in a population with blunt trauma. The BIG score has the advantage of being available shortly after admission and may be used to predict clinical prognosis or as a research tool to risk stratify trauma patients into clinical trials.

The golden hour of shock - how time is running out: prehospital time intervals in Germany--a multivariate analysis of 15, 103 patients from the TraumaRegister DGU(R).

OBJECTIVES: Although prehospital treatment algorithms have changed over the past years, the prehospital time of multiple trauma patients of some 70 min and the on-scene-treatment time (OST) of some 30 min have not changed since 1993. The aim of this study was to critically assess specific interventions and conditions at the scene in relation to their impact on prehospital rescue intervals. METHODS: We performed a retrospective data analysis of all multiple injured patients from the TraumaRegister DGU (English: German Trauma Society) from January 1993 to December 2010. Exclusion criteria were missing or implausible data regarding prehospital timelines. With OST as an independent variable, different models of multivariate regression were performed to identify parameters with relevant impact on the OST. RESULTS: 15 103 datasets were included in this study. Based on the mean OST of 32.7 (± 18.6) min and a constant absolute term of 16.2 (± 1.5) min, we identified seven procedures and nine environmental parameters with significant impact on OST. Intubation (9.3 ± 0.8 min) and being a car occupant (8.0 ± 0.8 min) were associated with the most prolonged OSTs. A Glasgow Coma Scale ≤ 8 (-4.5 ± 0.7 min) and cardiopulmonary resuscitation (-2.8 ± 1.7 min) resulted in its most relevant reduction. Admission to a Level III facility led to a reduced overall prehospital time (60.0 ± 24.6 min) compared with Level I (70.0 ± 28.5 min) and II (66.8 ± 27.4 min) trauma centres. CONCLUSIONS: This study identified characteristic interventions and conditions with significant impact on prehospital treatment times. Current treatment concepts should be re-evaluated with respect to these results.

Predicting on-going hemorrhage and transfusion requirement after severe trauma: a validation of six scoring systems and algorithms on the TraumaRegister DGU.

INTRODUCTION: The early aggressive management of the acute coagulopathy of trauma may improve survival in the trauma population. However, the timely identification of lethal exsanguination remains challenging. This study validated six scoring systems and algorithms to stratify patients for the risk of massive transfusion (MT) at a very early stage after trauma on one single dataset of severely injured patients derived from the TR-DGU (TraumaRegister DGU of the German Trauma Society (DGU)) database. METHODS: Retrospective internal and external validation of six scoring systems and algorithms (four civilian and two military systems) to predict the risk of massive transfusion at a very early stage after trauma on one single dataset of severely injured patients derived from the TraumaRegister DGU database (2002-2010). Scoring systems and algorithms assessed were: TASH (Trauma-Associated Severe Hemorrhage) score, PWH (Prince of Wales Hospital/Rainer) score, Vandromme score, ABC (Assessment of Blood Consumption/Nunez) score, Schreiber score and Larsen score. Data from 56,573 patients were screened to extract one complete dataset matching all variables needed to calculate all systems assessed in this study. Scores were applied and area-under-the-receiver-operating-characteristic curves (AUCs) were calculated. From the AUC curves the cut-off with the best relation of sensitivity-to-specificity was used to recalculate sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV). RESULTS: A total of 5,147 patients with blunt trauma (95%) was extracted from the TR-DGU. The mean age of patients was 45.7 ± 19.3 years with a mean ISS of 24.3 ± 13.2. The overall MT rate was 5.6% (n = 289). 95% (n = 4,889) patients had sustained a blunt trauma. The TASH score had the highest overall accuracy as reflected by an AUC of 0.889 followed by the PWH-Score (0.860). At the defined cut-off values for each score the highest sensitivity was observed for the Schreiber score (85.8%) but also the lowest specificity (61.7%). The TASH score at a cut-off ≥ 8.5 showed a sensitivity of 84.4% and also a high specificity (78.4%). The PWH score had a lower sensitivity (80.6%) with comparable specificity. The Larson score showed the lowest sensitivity (70.9%) at a specificity of 80.4%. CONCLUSIONS: Weighted and more sophisticated systems such as TASH and PWH scores including higher numbers of variables perform superior over simple non-weighted models. Prospective validations are needed to improve the development process and use of scoring systems in the future.

Predictive Models and Algorithms for the Need of Transfusion Including Massive Transfusion in Severely Injured Patients.

BACKGROUND: Despite improvements on how to resuscitate exsanguinating patients, one remaining key to improve outcome is to expeditiously and reproducibly identify patients most likely to require transfusion including massive transfusion (MT). This work summarizes yet developed algorithms/scoring systems for transfusion including MT in civilian and military trauma populations. METHODS: A systematic search of evidence was conducted utilizing OVID/MEDLINE (1966 to present) and the 'Medical Algorithms Project'. RESULTS AND CONCLUSIONS: The models developed suggest combinations of physiologic, hemodynamic, laboratory, injury severity and demographic triggers identified on the initial evaluation of the bleeding trauma patient. Many approaches use a combination of dichotomous variables readily accessible after arrival but others rely on time-consuming calculations or complex algorithms and may have limited real-time application. Weighted and more sophisticated systems including higher numbers of variables perform superior. A common limitation to all models is their retrospective nature, and prospective validations are urgently needed. Point-of-care viscoelastic testing may be an alternative to these systems.

Endotracheal intubation in trauma patients with isolated shock: universally recommended but rarely performed.

PURPOSE: The indication for pre-hospital endotracheal intubation (ETI) must be well considered as it is associated with several risks and complications. The current guidelines recommend, among other things, ETI in case of shock (systolic blood pressure < 90 mmHg). This study aims to investigate whether isolated hypotension without loss of consciousness is a useful criterion for ETI. METHODS: The data of 37,369 patients taken from the TraumaRegister DGU® were evaluated in a retrospective study with regard to pre-hospital ETI and the underlying indications. Inclusion criteria were the presence of any relevant injuries (Abbreviated Injury Scale [AIS] ≥ 3) and complete pre-hospital management information. RESULTS: In our cohort, 29.6% of the patients were intubated. The rate of pre-hospital ETI increased with the number of indications. If only one criterion according to current guidelines was present, ETI was often omitted. In 582 patients with shock as the only indication for pre-hospital ETI, only 114 patients (19.6%) were intubated. Comparing these subgroups, the intervention was associated with longer time on scene (25.3 min vs. 41.6 min; p < 0.001), higher rate of coagulopathy (31.8% vs. 17.2%), an increased mortality (8.2% vs. 11.5%) and higher standard mortality ratio (1.17 vs. 1.35). If another intubation criterion was present in addition to shock, intubation was performed more frequently. CONCLUSION: Decision making for pre-hospital intubation in trauma patients is challenging in front of a variety of factors. Despite the presence of a guideline recommendation, ETI is not always executed. Patients presenting with shock as remaining indication and subsequent intubation showed a decreased outcome. Thus, isolated shock does not appear to be an appropriate indication for pre-hospital ETI, but clearly remains an important surrogate of trauma severity and the need for trauma team activation.

Alcohol and trauma: the influence of blood alcohol levels on the severity of injuries and outcome of trauma patients - a retrospective analysis of 6268 patients of the TraumaRegister DGU®.

BACKGROUND: Blood alcohol level (BAL) has previously been considered as a factor influencing the outcome of injured patients. Despite the well-known positive correlation between alcohol-influenced traffic participation and the risk of accidents, there is still no clear evidence of a positive correlation between blood alcohol levels and severity of injury. The aim of the study was to analyze data of the TraumaRegister DGU® (TR-DGU), to find out whether the blood alcohol level has an influence on the type and severity of injuries as well as on the outcome of multiple-trauma patients. METHODS: Datasets from 11,842 trauma patients of the TR-DGU from the years 2015 and 2016 were analyzed retrospectively and 6268 patients with a full dataset and an AIS ≥ 3 could be used for evaluation. Two groups were formed for data analysis. A control group with a BAL = 0 ‰ (BAL negative) was compared to an alcohol group with a BAL of ≥0.3‰ to < 4.0‰ (BAL positive). Patients with a BAL >  0‰ and <  0.3‰ were excluded. They were compared with regard to various preclinical, clinical and physiological parameters. Additionally, a subgroup analysis with a focus on patients with a traumatic brain injury (TBI) was performed. A total of 5271 cases were assigned to the control group and 832 cases to the BAL positive group. 70.3% (3704) of the patients in the control group were male. The collective of the control group was on average 5.7 years older than the patients in the BAL positive group (p < .001). The control group showed a mean ISS of 20.3 and the alcohol group of 18.9 (p = .007). In terms of the injury severity of head, the BAL positive group was significantly higher on average than the control group (p <  0.001), whereas the control group showed a higher AIS to thorax and extremities (p <  0.001). The mean Glasgow Coma Scale (GCS) was 10.8 in the BAL positive group and 12.0 in the control group (p <  0.001). Physiological parameters such as base excess (BE) and International Normalized Ratio (INR) showed reduced values ​​for the BAL positive group. However, neither the 24-h mortality nor the overall mortality showed a significant difference in either group (p = 0.19, p = 0.14). In a subgroup analysis, we found that patients with a relevant head injury (AIS: Abbreviated Injury Scale head ≥3) and positive BAL displayed a higher survival rate compared to patients in the control group with isolated TBI (p < 0.001). CONCLUSIONS: This retrospective study analyzed the influence of the blood alcohol level in severely injured patients in a large national dataset. BAL positive patients showed worse results with regard to head injuries, the GCS and to some other physiological parameters. Finally, neither the 24-h mortality nor the overall mortality showed a significant difference in either group. Only in a subgroup analysis the mortality rate in BAL negative patients with TBI was significantly higher than the mortality rate of BAL positive patients with TBI. This mechanism is not yet fully understood and is discussed controversially in the literature.

Osteopetrosis--a challenge for the orthopaedic surgeon.

Osteopetrosis (OP) is a rare heterogeneous group of inherited skeletal dysplasias characterised by osteoclast dysfunction, impaired bone resorption and poor bone remodelling. Three groups can be categorised on the basis of clinical findings. These include neurological symptoms, haematological abnormalities and renal tubular acidosis in the first group. Increased bone density, osteomyelitis and frequent fractures are the clinical findings in the second group, and the third group have normal life expectancy but may develop cranial nerve compression and osteomyelitis. Fractures in patients with OP are common and require appropriate pre-, peri- and postoperative management. The long bones are most frequently affected, fractures of the femoral neck and proximal (upper third) shaft being particularly common. This case report proposes possible operative fracture treatment in a patient with OP and highlights the potential perioperative pitfalls in this rare surgical population.

The influence of an injury prevention program on young road users: a German experience.

PURPOSE: Trauma remains a leading cause of mortality and morbidity in youth. The Prevent Alcohol and Risk Related Trauma in Youth (P.A.R.T.Y.) program is an injury prevention program. The aim of the study was to analyze the influence on risk-taking behaviors and risk awareness on young road users by a pre-post-questionnaire. METHODS: A pre-post intervention study was performed using a standardized questionnaire. The questionnaire contained three sections with different items (in total 22) to identify differences regarding students' risk behavior and risk awareness. Data were analyzed using the Wilcoxon signed-rank test with significance defined as p < 0.05. RESULTS: The study sample contains 193 students (age 14-17, 44% male). We found significant differences for asking if a student "fastens his/her helmet's chinstrap when driving a motorbike" (p = 0.001) and for the question "Do you wear a helmet when you go rollerblading" (p = 0.008). After attending the program, participants would decrease the use of a mobile phone while driving (p = 0.038) and the understanding of the risk "speeding" and "cycling without a helmet" significantly increased. CONCLUSIONS: The P.A.R.T.Y. program focuses on items like "use of helmet and mobile phones" and "alcohol/drug abuse". Evaluating the program helps to uncover vulnerabilities and to enhance important effects. Some of these items are addressed by the program, whereas some are not. It will be important to improve the program according to address topics that have not shown significant improvements, so that students learn more about the dangers and the right behavior in road traffic.

Evaluating the impact of an injury prevention measure regarding different sociodemographic factors.

BACKGROUND: Road traffic collisions (RTC) remain a major problem especially among young road users. Injury prevention measures and licensing systems have increasingly been developed to counteract some of the negative effects of RTCs in youth. The Prevent Alcohol and Risk Related Trauma in Youth (P.A.R.T.Y.) program is an injury prevention program that promotes prevention through reality education. In this study, the impact of the program on different sociodemographic subgroups of school students was analyzed. The aim was to find out which subgroups were influenced the most and how improvements to the program can be made. METHODS: Evaluation was performed in a pre-post-intervention setting by means of a standardized questionnaire. The questionnaire contained three different sections with a total of 22 questions to identify students' responses regarding risk-behavior and risk-assessment. Evaluation was done at two different points on the same day (pre-and post-intervention). Data were analyzed with a focus on gender, age, residential area and level of education. Cronbach's alpha was used to check all questions for reliability. Data were analyzed using the t-test and the Wilcoxon signed-rank test with significance defined as p less than 0.05. RESULTS: The study sample contains 193 students (range 14-17 years of age, 44% male). Female students show better results regarding risk-behavior and risk-awareness. The same applies to students of a higher educational level. And students ≥ 16 years showed significantly better results in all three sections compared to younger students. CONCLUSIONS: Morbidity and mortality due to RTCs is a major problem in the group of young road users. Especially male road users between 14 and 17 years of age with a low educational level are at high risk to sustain road traffic injuries. Our results show that the P.A.R.T.Y. program has a stronger effect on young female students. Additionally, a significant effect was measured on students ≥ 16 years of age and on students with a higher educational level. Prevention measures need to be evaluated and further improved particularly in order to address the high-risk group of young, male road users with a lower educational status.

Comparison of transportation related injury mechanisms and outcome of young road users and adult road users, a retrospective analysis on 24,373 patients derived from the TraumaRegister DGU®.

BACKGROUND: Most young people killed in road crashes are known as vulnerable road users. A combination of physical and developmental immaturity as well as inexperience increases the risk of road traffic accidents with a high injury severity rate. Understanding injury mechanism and pattern in a group of young road users may reduce morbidity and mortality. This study analyzes injury patterns and outcomes of young road users compared to adult road users. The comparison takes into account different transportation related injury mechanisms. METHODS: A retrospective analysis using data collected between 2002 and 2012 from the TraumaRegister DGU® was performed. Only patients with a transportation related injury mechanism (motor vehicle collision (MVC), motorbike, cyclist, and pedestrian) and an ISS ≥ 9 were included in our analysis. Four different groups of young road users were compared to adult trauma data depending on the transportation related injury mechanism. RESULTS: Twenty four thousand three hundred seventy three, datasets were retrieved to compare all subgroups. The mean ISS was 23.3 ± 13.1. The overall mortality rate was 8.61%. In the MVC, the motorbike and the cyclist group, we found young road users having more complex injury patterns with a higher AIS pelvis, AIS head, AIS abdomen and AIS of the extremities and also a lower GCS. Whereas in these three sub-groups the adult trauma group only had a higher AIS thorax. Only in the group of the adult pedestrians we found a higher AIS pelvis, AIS abdomen, AIS thorax, a higher AIS of the extremities and a lower GCS. DISCUSSION: This study reports on the most common injuries and injury patterns in young trauma patients in comparison to an adult trauma sample. Our analysis show that in contrast to more experienced road users our young collective refers to be a vulnerable trauma group with an increased risk of a high injury severity and high mortality rate. We indicate a striking difference in terms of the region of injury and the mechanism of injury when comparing the young versus the adult trauma collectives. CONCLUSIONS: Young drivers of cars, motorbikes and bikes were shown to be on high risk to sustain a specific severe injury pattern and a high mortality rate compared to adult road users. Our data emphasize a characteristic injury pattern of young trauma patients and may be used to improve trauma care and to guide prevention strategies to decrease injury severity and mortality due to road traffic injuries.

Prehospital volume resuscitation--Did evidence defeat the crystalloid dogma? An analysis of the TraumaRegister DGU® 2002-2012.

BACKGROUND: Various studies have shown the deleterious effect of high volume resuscitation following severe trauma promoting coagulopathy by haemodilution, acidosis and hypothermia. As the optimal resuscitation strategy during prehospital trauma care is still discussed, we raised the question if the amount and kind of fluids administered changed over the recent years. Further, if less volume was administered, fewer patients should have arrived in coagulopathic depletion in the Emergency Department resulting in less blood product transfusions. METHODS: A data analysis of the 100 489 patients entered into the TraumaRegister DGU® (TR-DGU) between 2002 and 2012 was performed of which a total of 23512 patients (23.3%) matched the inclusion criteria. Volume and type of fluids administered as well as outcome parameter were analysed. RESULTS: Between 2002 and 2012, the amount of volume administered during prehospital trauma care decreased from 1790 ml in 2002 to 1039 ml in 2012. At the same time higher haemoglobin mean values, higher Quick's mean values and reduced mean aPTT can be observed. Simultaneously, more patients received catecholamines (2002: 9.2 to 2012: 13.0%). Interestingly, the amount of volume administered decreased steadily regardless of the presence of shock. Fewer patients were in the need of blood products and the number of massive transfusions (≥10 pRBC) more than halved. DISCUSSION: The changes in volume therapy might have reduced haemodilution potentially resulting in an increase of the Hb value. During the period observed transfusion strategies have become more restrictiveand ratio based; the percentage of patients receiving MT halved as blood products may imply negative secondary effects. Furthermore, preventing administration of high blood product ratios result in less impairment of coagulation factors and inhibitors and an therfore improved coagulation. CONCLUSION: The volume administered in severely injured patients decreased considerably during the last decade possibly supporting beneficial effects such as minimizing the risk of coagulopathy and avoiding potential harmful effects caused by blood product transfusions. Despite outstanding questions in trauma resuscitation, principle evidence merges quickly into clinical practice and algorithms.

The impact of severe traumatic brain injury on a novel base deficit- based classification of hypovolemic shock.

BACKGROUND: Recently, our group has proposed a new classification of hypovolemic shock based on the physiological shock marker base deficit (BD). The classification consists of four groups of worsening BD and correlates with the extent of hypovolemic shock in severely injured patients. The aim of this study was to test the applicability of our recently proposed classification of hypovolemic shock in the context of severe traumatic brain injury (TBI). METHODS: Between 2002 and 2011, patients ≥16 years in age with an AIShead ≥ 3 have been retrieved from the German TraumaRegister DGU(®) database. Patients were classified into four strata of worsening BD [(class I (BD ≤ 2 mmol/l), class II (BD > 2.0 to 6.0 mmol/l), class III (BD > 6.0 to 10 mmol/l) and class IV (BD > 10 mmol/l)] and assessed for demographic and injury characteristics as well as blood product transfusions and outcomes. The cohort of severely injured patients with TBI was compared to a population of all trauma patients to assess possible differences in the applicability of the BD based classification of hypovolemic shock. RESULTS: From a total of 23,496 patients, 10,201 multiply injured patients with TBI (AIShead ≥ 3) could be identified. With worsening of BD, a consecutive increase of mortality rate from 15.9% in class I to 61.4% in class IV patients was observed. Simultaneously, injury severity scores increased from 20.8 (±11.9) to 41.6 (±17). Increments in BD paralleled decreasing hemoglobin, platelet counts and Quick's values. The number of blood units transfused correlated with worsening of BD. Massive transfusion rates increased from 5% in class I to 47% in class IV. Between multiply injured patients with TBI and all trauma patients, no clinically relevant differences in transfusion requirement or massive transfusion rates were observed. CONCLUSION: The presence of TBI has no relevant impact on the applicability of the recently proposed BD-based classification of hypovolemic shock. This study underlines the role of BD as a relevant clinical indicator of hypovolaemic shock during the initial assessment in respect to haemostatic resuscitation and transfusion requirements.

Coagulation system changes associated with susceptibility to infection in trauma patients.

BACKGROUND: Infection following trauma is associated with increased morbidity and mortality and is common following severe hemorrhage. There is a strong interaction between the coagulation and immunity. The objective of this study was to establish if there was an association between changes in coagulation status after hemorrhage and the subsequent incidence of infection. METHODS: Prospective cohort study of adult injured patients presenting to a major trauma center during a 2-year period. Blood was drawn at 24 hours following admission and analyzed using functional thromboelastography testing and laboratory defined tests of coagulation and blood count. Patients were followed up for infectious episodes while in the hospital using Center for Disease Control definitions. RESULTS: A total of 158 patients were recruited; 71 (45%) developed infection and were older (44 years vs. 32 years, p = 0.01) and more severely injured (Injury Severity Score [ISS], 25 vs.10; p < 0.01). White blood cell counts at 24 hours were normal, and there was no difference between groups (both 9.6 × 10/(9)L). Protein C was lower in those with infection (70.2 IU/dL vs. 83.3 IU/dL, p = 0.02), with a dose-dependent increase in infection as levels of protein C decreased. Plasmin activation at 24 hours was also strongly associated with infection plasmin-antiplasmin (infection vs. no infection, 6,156 µg/L vs. 3,324 µg/L, p = 0.03). The infection cohort had overall 12% lower procoagulant levels (varied between factor VIII 6.4% and factor II 16.2%). CONCLUSION: There is a strong association between the status of the coagulation system after 24 hours and the development of infection following trauma. Improved early coagulation management may decrease infection rates in this patient group. LEVEL OF EVIDENCE: Prognostic prospective study, level III.

Administration of fibrinogen concentrate in exsanguinating trauma patients is associated with improved survival at 6 hours but not at discharge.

BACKGROUND: Despite poor evidence and high costs, fibrinogen concentrate (FC) represents one of the most frequently used hemostatic agents in exsanguinating trauma. The aim was to assess whether the administration of FC in severely injured patients was associated with improved outcomes. METHODS: Patients documented in the Trauma Registry of the German Society for Trauma Surgery (primary admissions, Injury Severity Score [ISS] ≥16) who had received FC during initial care between emergency department (ED) arrival and intensive care unit admission (FC+) were matched with patients who had not received FC (FC-). RESULTS: The matched-pairs analysis yielded two comparable cohorts (n = 294 in each group) with a mean ISS of 37.6 ± 13.7 (FC+) and 37.1 ± 13.3 (FC-) (p = 0.73); the mean age was 40 ± 17 versus 40 ± 16 (p = 0.72), respectively. Patients were predominantly male (71.1% in both groups, p = 1.0). On emergency department arrival, hypotension (systolic blood pressure, ≤90 mm Hg) occurred in 51.4% (FC+) and 48.0% (FC-) (p = 0.41), and base excess was -7.4 ± 5.3 mmol/L for FC+ and was -7.5 ± 6.2 mmol/L for FC- (p = 0.96). Patients were administered 12.8 ± 14.3 (FC+) versus 11.3 ± 10.0 (FC-) packed red blood cell units (p = 0.20). Thromboembolism occurred in 6.8% (FC+) versus 3.4% (FC-) (p = 0.06), and multiple organ failure occurred in 61.2% versus 49.0% (p = 0.003), respectively. Whereas 6-hour mortality was 10.5% for FC+ versus 16.7% for FC- (p = 0.03), the mean time to death was 7.5 ± 14.6 days versus 4.7 ± 8.6 days (p = 0.006). The overall hospital mortality rate was 28.6% versus 25.5% (p = 0.40), respectively. CONCLUSION: This is the first study to investigate the effect of FC administration in bleeding trauma. In our large population of severely injured patients, the early use of FC was associated with a significantly lower 6-hour mortality and an increased time to death, but also an increased rate of multiple organ failure. A reduction of overall hospital mortality was not observed in patients receiving FC. LEVEL OF EVIDENCE: Therapeutic study, level IV.

The trauma patient in hemorrhagic shock: how is the C-priority addressed between emergency and ICU admission?

BACKGROUND: Trauma is the leading cause of death in young people with an injury related mortality rate of 47.6/100,000 in European high income countries. Early deaths often result from rapidly evolving and deteriorating secondary complications e.g. shock, hypoxia or uncontrolled hemorrhage. The present study assessed how well ABC priorities (A: Airway, B: Breathing/Ventilation and C: Circulation with hemorrhage control) with focus on the C-priority including coagulation management are addressed during early trauma care and to what extent these priorities have been controlled for prior to ICU admission among patients arriving to the ER in states of moderate or severe hemorrhagic shock. METHODS: A retrospective analysis of data documented in the TraumaRegister of the 'Deutsche Gesellschaft für Unfallchirurgie' (TR-DGU®) was conducted. Relevant clinical and laboratory parameters reflecting status and basic physiology of severely injured patients (ISS ≥ 25) in either moderate or severe shock according to base excess levels (BE -2 to -6 or BE < -6) as surrogate for shock and hemorrhage combined with coagulopathy (Quick's value <70%) were analyzed upon ER arrival and ICU admission. RESULTS: A total of 517 datasets was eligible for analysis. Upon ICU admission shock was reversed to BE > -2 in 36.4% and in 26.4% according to the subgroups. Two of three patients with initially moderate shock and three out of four patients with severe shock upon ER arrival were still in shock upon ICU admission. All patients suffered from coagulation dysfunction upon ER arrival (Quick's value ≤ 70%). Upon ICU admission 3 out of 4 patients in both groups still had a disturbed coagulation function. The number of patients with significant thrombocytopenia had increased 5-6 fold between ER and ICU admission. CONCLUSION: The C-priority including coagulation management was not adequately addressed during primary survey and initial resuscitation between ER and ICU admission, in this cohort of severely injured patients.