[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.

[Osteosynthesis after periprosthetic fractures of the knee joint]. / Osteosynthese nach periprothetischen Frakturen am Kniegelenk.

Periprosthetic fractures around the knee joint are of increasing relevance due to increasing numbers of total knee replacements and increasing life expectations. These fractures can be a real challenge due to an often limited patient compliance, reduced bone quality and impaired bone perfusion of potential intramedullary shafts resulting in poor healing and lack of fixation options for screws. These fractures necessitate special knowledge and approaches, which are systematically dealt with in this article, beginning with the correct diagnostics through to the most recent developments in the field of osteosynthetic techniques. The trends of minimally invasive techniques are presented and the options and limitations are described.

[Fracture arthroplasty of femoral neck fractures]. / Frakturendoprothetik der medialen Schenkelhalsfraktur.

A paradigm shift in the treatment of elderly patients has recently taken place leading to an increase in joint replacement surgery. The aim of this article is to highlight new developments and to present a treatment algorithm for femoral neck fractures. The age limit must be individually determined considering the comorbidities and perioperative risk profile. Pertrochanteric femoral fractures are nearly exclusively treated by osteosynthesis regardless of age. The situation for femoral neck fractures is more complex. Patients younger than 65 years should generally be treated by osteosynthesis but patients older than 65 years benefit from hemiarthroplasty or total hip arthroplasty. In patients aged between 65 and 75 years with high functional demands and a justifiable perioperative risk, total joint replacement is the treatment of choice. In physically less active patients older than 75 years and poor general condition, preference should be given to hemiarthroplasty.

[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.

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.

[Risk factors for failure of osteosynthesis. After periprosthetic fractures of the knee joint]. / Risikofaktoren für das Versagen von Osteosynthesen. Nach periprothetischen Frakturen am Kniegelenk.

BACKGROUND: The increasing number of implantations of total knee endoprostheses shows a correlation with an increase in revision operations and periprosthetic fractures. OBJECTIVE: This article presents strategies for prevention of complications after open reduction internal fixation (ORIF) of periprosthetic fractures in addition to the classification of periprosthetic fractures of the knee joint. THERAPY STRATEGIES: Osteosynthetic treatment is only applicable in some of the cases. Although special periprosthetic, angle locking plates are available for osteosynthesis, treatment of periprosthetic fractures of the knee joint remains a challenge with a high complication rate. If the prosthesis becomes loosened, the prosthesis should be replaced and ORIF should not be performed. RISK FACTORS: The risk factors for failure of osteosynthesis include the prosthesis model and the associated reduction of residual bone and the mostly osteoporotic bone structures.

[Mono- versus polyaxial locking plates]. / Mono- vs. polyaxiale winkelstabile Plattensysteme.

Conventional plate osteosynthesis is undergoing a period of transition. The concept of locking plate osteosynthesis is of special importance. Monoaxial locking plate osteosynthesis has shown promising results (rapid bone healing via callus, minimal soft tissue irritation, advantageous in osteoporosis). Some implants allow for polyaxial locking. The first results of comparative studies concerning biomechanics and clinical outcome of mono- versus polyaxial locking plates are presented.

[Use of regional anesthesia for preoperative analgesia for proximal femoral fractures in the emergency department : A survey on current practice in German-speaking countries and the United Kingdom]. / Anwendung regionalanästhesiologischer Verfahren zur präoperativen Analgesie bei proximalen Femurfrakturen in der Notaufnahme : Eine Umfrage zur Praxis im deutschsprachigen Raum und in Großbritannien.

BACKGROUND: Regional anesthesia (RA) techniques such as femoral nerve block (FNB) or fascia iliaca compartment block (FICB) are effective analgesia techniques in the treatment of pain from proximal femoral fractures (PFF). While in Great Britain (GB) these are already frequently used in the emergency department for preoperative analgesia, in the German-speaking D­A-CH area (Germany, Austria, Switzerland) this seems to occur much less frequently. Therefore, the aim of this study was to survey the type and frequency of RA procedures used and to compare international practice. MATERIAL AND METHODS: In the D­A-CH area as well as in GB, registered emergency departments were contacted and invited to participate in an online survey. The survey included questions on the frequency and type of RA procedures, reasons for non-use, equipment used, person performing the procedure and medications used. RESULTS: The participation rate was 17.4% (142/818 emergency departments). RA procedures for preoperative analgesia in PFF were used in 18.3% (21/115) of hospitals in the D­A-CH region and in 96.3% (26/27) in GB. The most commonly used block was the FICB in GB at 96.2% (25/26) and the FNB in Germany at 66.7% (14/21). In the D­A-CH area, RA procedures are primarily performed by anesthesiology specialists 71.4% (15/21), and in GB by emergency department residents 65.4% (17/26). DISCUSSION: RA procedures are still performed too rarely following PFF in emergency departments in the D­A-CH area. In international comparison with GB there is potential for improvement.

Immune system phenotyping of radiation and radiation combined injury in outbred mice.

The complexity of a radionuclear event would be immense due to varying levels of radiation exposures and injuries caused by blast-associated trauma. With this scenario in mind, we developed a mouse model to mimic as closely as possible the potential consequences of radiation injury and radiation combined injury (RCI) on survival, immune system phenotype, and immune function. Using a mouse burn injury model and a (137)CsCl source irradiator to induce injuries, we report that the immunological response to radiation combined injury differs significantly from radiation or burn injury alone. Mice that underwent radiation combined injury showed lower injury survival and cecal ligation and puncture (CLP) induced polymicrobial sepsis survival rates than mice with single injuries. As anticipated, radiation exposure caused dose-dependent losses of immune cell subsets. We found B and T cells to be more radiation sensitive, while macrophages, dendritic cells and NK cells were relatively more resistant. However, radiation and radiation combined injury did induce significant increases in the percentages of CD4(+) regulatory T cells (Tregs) and a subset of macrophages that express cell-surface GR-1 (GR-1(+) macrophages). Immune system phenotyping analysis indicated that spleen cells from radiation combined injury mice produced higher levels of proinflammatory cytokines than cells from mice with radiation or burn injury alone, especially at lower dose radiation exposure levels. Interestingly, this enhanced proinflammatory phenotype induced by radiation combined injury persisted for at least 28 days after injury. In total, our data provide baseline information on differences in immune phenotype and function between radiation injury and radiation combined injury in mice. The establishment of this animal model will aid in future testing for therapeutic strategies to mitigate the immune and pathophysiological consequences of radionuclear events.