[Indications, procedure and outcome of prehospital emergency resuscitative thoracotomy-a systematic literature search]. / Indikation, Prozedere und Outcome der präklinischen Notfallthorakotomie ­ eine systematische Literaturrecherche.

BACKGROUND: Prehospital resuscitative thoracotomy (PHRT) is a controversially discussed measure for the acute treatment of traumatic cardiac arrest (TCA) recommended by the current guidelines of the European Resuscitation Council (ERC). The aim of this work is the comprehensive presentation and summary of the available literature with the underlying hypothesis that the available publications show the feasibility and survival following PHRT in patients with TCA with a good neurological outcome. METHOD: A systematic literature search was performed in the databases PubMed, EMBASE, Google Scholar, Springer LINK and Cochrane. The study selection, data extraction and evaluation of bias potential were performed independently by two authors. The outcome of patients with TCA after PHRT was selected as the primary endpoint. RESULTS: A total of 4616 publications were found of which 21 publications with a total of 287 patients could be included in the analyses. For a detailed descriptive analysis, 15 publications with a total of 205 patients were suitable. The TCA of these patients was most commonly caused by pericardial tamponade, thoracic vascular injuries and severe extrathoracic multiple injuries. In 24% of the cases TCA occurred in the presence of the emergency physician. Clamshell thoracotomy (53%) was used preclinically more often than anterolateral thoracotomy (47%). Of the PHRT patients after TCA 12% (25/205) left the hospital alive, 9% (n = 19/205) with good neurological outcome and 1% (n = 3/205) with poor neurological outcome (according to the Glasgow outcome scale, GOS). CONCLUSION: The prognosis of TCA seems to be much better than has long been assumed. Decisive for the success of resuscitation efforts in TCA seems to be the immediate, partly invasive treatment of all reversible causes. The measures for TCA recommended by the ERC resuscitation guidelines, seem to be poorly implemented, especially in the preclinical setting. A controversy regarding the recommendations of the guidelines is the question of whether a PHRT can be successfully implemented and if the comprehensive introduction in Germany seems to be meaningful. Despite the recommendation of the guidelines, this systematic review and meta-analysis underlines the lack of high-quality evidence on PHRT, whereby a survival probability to hospital discharge of 12% was reported, of which 75% had a good neurological outcome. The risk of bias of the results in individual publications as well as in this review is high. Further systematic research in the field of preclinical trauma resuscitation is particularly necessary also for acceptance of the guidelines.

[Reasons for Emergency Department Visits: Results of a Patient Survey]. / Beweggründe für die Inanspruchnahme von Notaufnahmen ­ Ergebnisse einer Patientenbefragung.

OBJECTIVES: The number of patients visiting emergency departments (ED) is steadily increasing. The cause for this rise in Germany is unclear and less examined. This study aimed to assess the reasons of walk-in patients to visit EDs by using a direct survey. METHODS: During a period of 4 weeks, 2 010 walk-in patients were anonymously surveyed in 2 major Berlin hospitals using a standardized questionnaire. Descriptive statistics were used for data analysis. RESULTS: More than 90% of patients assessed themselves as an emergency and three-quarters of patients reported pain. The majority of patients (57%) tried to contact statutory health insurance (SHI) office-based physicians in advance and 59% of patients said they would make use of ambulatory emergency facilities if they were available and well established. However, 55% of patients were unaware of the emergency service of the association of SHI physicians. CONCLUSION: The results indicate that centralized ambulatory emergency facilities should be available 24/7 at hospitals with EDs. Therefore, future planning of emergency services should integrate providers of ambulatory and inpatient sector. International experience suggests that different instruments aiming at better coordination of care, such as integrated call centers, extended ambulatory services and facilities for less urgent cases located in or nearby hospitals with EDs should also be implemented in Germany.

[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.

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.

[Serological determination of protein S100B. Significance in emergency diagnosis of adults with mild craniocerebral trauma--meta-analysis]. / Das serologische Protein S100B. Stellenwert in der Notfalldiagnostik Erwachsener mit Verdacht auf leichtes Schädel-Hirn-Trauma--eine Metaanalyse.

OBJECTIVE: Patients presenting in the emergency department with a mild injury to the head pose a particular challenge due to their high prevalence but low rate of traumatic brain injury. However, missed traumatic brain injuries may result in fatal consequences. Therefore we investigated the diagnostic performance of serological protein S100B measurement in adult patients presenting with mild head injury and a GCS 13-15 to identify traumatic brain injury. DESIGN AND METHODS: We conducted a systematic review of the literature. Two reviewers screened potential studies for inclusion and independently extracted study data. For all included studies, we applied the QUADAS quality assessment tool for systematic reviews of diagnostic accuracy and abstracted the raw data for every included study. Included studies presented results either in 2x2 contingency tables or provided data allowing their construction. RESULTS: Of 76 studies identified, 8 met the inclusion criteria. Methodology quality was moderate and all studies fulfilled at least 50% of the QUADAS criteria. Overall, the sensitivity to detect intracranial lesions was 94% (95% CI 88-98%) and specificity was 44% (95% CI 30-58%). The subgroup analysis showed significant differences only between studies with different S100B cutoff values (0.10 µg/l versus >0.10 µg/l). The combined odds ratio was 10.3 (95 CI 4.2-24.9). CONCLUSIONS: Serological protein S100B measurement may be helpful as a screening test to identify patients with higher risk of traumatic brain injury for further diagnostic assessment.

Very early posttraumatic serum alterations are significantly associated to initial massive RBC substitution, injury severity, multiple organ failure and adverse clinical outcome in multiple injured patients.

BACKGROUND: Multiple severe trauma frequently leads to massive dysbalances of the human immune system. This phenomenon is known as "Systemic Inflammatory Response Syndrome (SIRS)". SIRS is connected to multiple organ failure and thereby entails higher morbidity and mortality in trauma patients. Pro- and anti-inflammatory cytokines such as Il-6, Il-8 and Il-10 seem to play a superior role in the development of SIRS. Several studies support the hypothesis that the very early cytokine release pattern determines the patients' subsequent clinical course. Most data about interleukins in trauma patients however refer to serum concentrations assessed sometime in the first 24h, but there is only little information about release dynamics in a small-meshed time frame in the very initial post-trauma period. PATIENTS AND METHODS: 58 multiple injured patients (Injury Severity Score > 16 points) were included. Blood samples were drawn on patient admission (not later then 90 minutes after trauma) and at 6h, 12h, 24h, 48 h and 72 h. Il-6, Il-8 and Il-10 were measured using an automated chemiluminescence assay (IMMULITE, Siemens Healthcare Diagnostics GmbH). Interleukin levels were correlated to distinct epidemiological and clinical parameters. RESULTS: Interleukin serum concentrations are thoroughly elevated after trauma. Patients with haemorrhagic shock and consecutive massive RBC substitution (n = 27) exhibit higher Il-6, Il-8 and Il-10 levels as compared to patients with minor RBC transfusion extent (n = 31). Interleukin levels also differentiate patients with MOF (n = 43) from such without MOF (n = 15) already at the earliest post trauma time (90 minutes). Il-6, Il-8 and Il-10 concentrations also significantly distinguish patients with adverse outcome (n = 11) from such with favourable outcome (n = 47). Exclusively Il-10 has significant correlation to injury severity (ISS > 35). CONCLUSION: The current study presents an image of the serum Il-6, 8 and 10 releases in multiple trauma patients in the very early post-trauma period. We could thereby demonstrate that interleukin levels can clearly differentiate the presence of hemorrhagic shock and subsequent massive blood product substitution, the development of multiple organ failure and clinical outcome. No significant connection to age, gender and brain injury could be detected. Most importantly, changes in interleukin levels can be observed in the very early posttraumatic phase, at the earliest 90 minutes after trauma.

Cerebrospinal IL-10 concentration is elevated in non-survivors as compared to survivors after severe traumatic brain injury.

OBJECTIVE: The intrathecal posttraumatic inflammation contributes to secondary brain damage as well as to the induction of neuroreparative mechanisms. In this context release of interleukin-10 (IL-10) has been reported to play a major role. However, initial IL-10 concentration in CSF remains incompletely characterized. Therefore, the aim was to analyze Il-10 in CSF and serum of patients early after TBI. METHODS: For control, 10 volunteers receiving spinal puncture were enrolled. In patients with severe TBI (GCS<8 pts.), CSF and serum was drawn within 90+/-45 min after intraventricular catheter insertion (0 h), as well as 12 h, 24 h and 48 h after TBI. Albumin for assessing Blood-Brain-Barrier (BBB) function and IL-10 (IMMULITE, DPC Biermann, Bad Nauheim, Germany) were analyzed. RESULTS: 23 patients were enrolled. 15 survived and 8 deceased within 24h. In controls, CSF IL-10 was below detection limit (<5 pg/ml). In contrast, IL-10 was elevated significantly in non-survivors at 0 h vs. survivors and controls (30+/-6 vs. 9+/-1 vs. <5 pg/mL). This was accompanied by a significant increase of serum IL-10 in both groups at 0 h vs. controls (survivors: 30+/-6 pg/mL, non-survivors: 48+/-8 pg/mL, controls: 10+/-7 pg/mL, p<0.001). Survivors revealed signs of a mild BBB dysfunction during the entire observation period. In contrast, non-survivors presented a severe BBB breakage. CONCLUSIONS: We demonstrated an analysis of IL-10 CSF and serum concentration after TBI. These data support an intrathecal IL-10 synthesis. Although the significant increase of IL-10 might indicate a bad outcome of TBI, responsible mechanisms still have to be elucidated.

Cerebrospinal s100-B: a potential marker for progressive intracranial hemorrhage in patients with severe traumatic brain injury.

OBJECTIVE: Traumatic brain injury (TBI) is associated with cerebrovascular dysfunction and changes of the blood-brain barrier (BBB) function. Although knowledge about the function of the BBB would be of high interest, non-invasive neurodiagnostic tools are still lacking. In this context it has been shown, that the astrocytic protein S100-B is a significant parameter for neuronal damage. However, there is only poor knowledge about the dynamics of S100-B in cerebrospinal fluid (CSF) and serum of patients with severe TBI. Therefore, the aim of this study was to analyze intrathecal and systemic concentrations of S100-B in patients with severe TBI in correlation to the development of progressive intracranial hemorrhage (PIH) as well as to the CSF/serum albumin ratio (Q subsetalb), as functional parameter of the BBB. PATIENTS AND METHODS: In patients, suffering from severe TBI (GCS =or<8pts) and respectively healthy control patients, albumin for calculating the CSF/serum albumin ratio (Q subsetalb) as well as S100-B protein were analyzed in CSF and serum. Samples were collected immediately after placement of a ventricular catheter and 12h, 24h, 48 h and 72 h after TBI. S100-B was quantified using Elecsys S-100 superset assay (Roche superset Diagnostics; Mannheim, Germany). Volume measurements of focal mass lesions based on CT images taken during the first 72 h after TBI were obtained according to the Cavalieri's Direct Estimator method. RESULTS: 21 TBI-patients and respectively 10 healthy controls were enrolled. In patients exhibiting a mean ICP >15 mmHg (n = 15) CSF levels of S100-B were significantly increased on admission (819 +/- 78 pg/ml) compared to patients with ICP =or<15 mmHg (n = 6, 175 +/- 12 pg/ml) as well as to the control group (n = 10, 0.8 +/- 0.09 pg/ml). In the group with ICP >15 mmHg 8 patients developed PIH A positive correlation was found between CSF S100-B and ICP (r2 = 0.925, p<0.001). Furthermore a positive correlation between serum S100-B and Q subsetalb was found for each sampling point (r superset2 = 0.793, p<0.001). CONCLUSIONS: The cerebrospinal and serum concentration of S100-B in patients with severe TBI was evaluated. Monitoring cerebrospinal S100-B might help to prospectively identify patients with PIH.

[Intraosseous infusion for adults]. / Intraossäre Infusion beim Erwachsenen.

Intraosseous (IO) infusion methods have been common for emergency treatment in infants and children for years. The role of IO access in adults is however much less clear, but its importance in this patient group is increasing, and different devices are available today. Each device has strengths and weaknesses, but all achieve rapid vascular access even in challenging situations. The potential of IO access regarding both therapeutic and diagnostic options has been shown in several operational studies in and out of hospital. Insertion times require between 1 and 2 min in most cases, while insertion and handling of the IO access devices seem to be easy and reliable. The flow rates of IO access devices for adults are lower than those of large-bore peripheral intravenous catheters, but fluid resuscitation is possible in most cases at least with pressure bag infusion systems. Most drugs administered intravenously can be given intraosseously in equivalent dosages and with the same effects. Nevertheless the limitations and risks of IO access routes need to be considered for each application. Rapid IO access is now possible in all age groups, and the 2005 AHA Guidelines favor it over drug administration via the endotracheal tube.

Point-of-Care Diagnostic Device for Traumatic Pneumothorax: Low Sensitivity of the Unblinded PneumoScan™.

BACKGROUND: Traumatic Pneumothorax (PTX) is a potentially life-threatening injury. It requires a fast and accurate diagnosis and treatment, but diagnostic tools are limited. A new point-of-care device (PneumoScan) based on micropower impulse radar (MIR) promises to diagnose a PTX within seconds. In this study, we compare standard diagnostics with PneumoScan during shock-trauma-room management. PATIENTS AND METHODS: Patients with blunt or penetrating chest trauma were consecutively included in the study. All patients were examined including clinical examination with auscultation (CE) and supine chest radiography (CXR). In addition, PneumoScan-readings and thoracic ultrasound scan (US) were performed. Computed tomography (CT) served as gold standard. RESULTS: CT scan revealed PTX in 11 patients. PneumoScan detected two PTX correctly but missed nine. 15 false-positive results were found by PneumoScan, leading to a sensitivity of 20% and specificity of 80%. Six PTX were detected through CE (sensitivity: 54,5%). CXR detected four (sensitivity: 27,3%) and thoracic US two PTX correctly (sensitivity: 25%). CONCLUSION: The unblinded PneumoScan prototype did not confirm the promising results of previous studies. The examined standard diagnostics and thoracic US showed rather weak sensitivity as well. Until now, there is no appropriate point-of-care tool to rule out PTX.

[Cardiopulmonary resuscitation in cardiac arrest following trauma]. / Reanimation nach Trauma.

For decades, survival rates of cardiac arrest following trauma were reported between 0 and 2 %. Since 2005, survival rates have increased with a wide range up to 39 % and good neurological recovery in every second person injured for unknown reasons. Especially in children, high survival rates with good neurologic outcomes are published. Resuscitation following traumatic cardiac arrest differs significantly from nontraumatic causes. Paramount is treatment of reversible causes, which include massive bleeding, hypoxia, tension pneumothorax, and pericardial tamponade. Treatment of reversible causes should be simultaneous. Chest compression is inferior following traumatic cardiac arrest and should never delay treatment of reversible causes of the traumatic cardiac arrest. In massive bleeding, bleeding control has priority. Damage control resuscitation with permissive hypotension, aggressive coagulation therapy, and damage control surgery represent the pillars of initial treatment. Cardiac arrest due to hypoxia should be resolved by airway management and ventilation. Tension pneumothorax should be decompressed by finger thoracostomy, pericardial tamponade by resuscitative thoracotomy. In addition, resuscitative thoracotomy allows direct and indirect bleeding control. Untreated impact brain apnea may rapidly lead to cardiac arrest and requires quick opening of the airway and effective oxygenation. Established algorithms for treatment of cardiac arrest following trauma enable a safe, structured, and effective management.

[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.

Does Radar Technology Support the Diagnosis of Pneumothorax? PneumoScan-A Diagnostic Point-of-Care Tool.

Background. A nonrecognized pneumothorax (PTX) may become a life-threatening tension PTX. A reliable point-of-care diagnostic tool could help in reduce this risk. For this purpose, we investigated the feasibility of the use of the PneumoScan, an innovative device based on micropower impulse radar (MIR). Patients and Methods. addition to a standard diagnostic protocol including clinical examination, chest X-ray (CXR), and computed tomography (CT), 24 consecutive patients with chest trauma underwent PneumoScan testing in the shock trauma room to exclude a PTX. Results. The application of the PneumoScan was simple, quick, and reliable without functional disorder. Clinical examination and CXR each revealed one and PneumoScan three out of altogether four PTXs (sensitivity 75%, specificity 100%, positive predictive value 100%, and negative predictive value 95%). The undetected PTX did not require intervention. Conclusion. The PneumoScan as a point-of-care device offers additional diagnostic value in patient management following chest trauma. Further studies with more patients have to be performed to evaluate the diagnostic accuracy of the device.

[Whiplash-associated disorders: a challenge for the expert in compensation claims and litigation]. / Trauma der Halswirbelsäule: Gutachterliche Herausforderungen nach Beschleunigungsverletzung der HWS.

In the literature, the association between chronic complaints of the cervical spine and sustained"whiplash trauma" is a matter of controversy. Whiplash trauma is identified as contusion, compression, and/or sprain without definite imaging proof of injury to the bone, disk, or ligaments.However, complex chronic complaints leading to permanent and significant functional limitations in daily living and work may develop. Besides the diagnostic and therapeutic challenges for the treating physician, the expert confronted with compensation claims very often must decide whether whiplash trauma of the spine may lead to significant and permanent functional limitations or loss with chronic disorders. The data from the literature dealing with this topic are contradictory and deficient. In this article, based on the present available data from the literature, we critically examine the causality between spinal whiplash trauma and possible permanent chronic complaints in order to support the process of decision making in cases of litigation and controversial compensation claims.

[Cardiac arrest following blunt chest injury. Emergency thoracotomy without ifs or buts?]. / Kreislaufstillstand nach stumpfem Thoraxtrauma. Notfallthorakotomie ohne Wenn und Aber?

In German-speaking countries, most serious thoracic injuries are attributable to the impact of blunt force; they are the second most frequent result of injury after head injury in polytrauma patients with multiple injuries. Almost one in every three polytraumatized patients with significant chest injury develops acute lung failure, and one in every four, acute circulatory failure. The acute circulatory arrest following serious chest injury involves a high mortality rate, and in most cases it reflects a tension pneumothorax, cardiac tamponade, or hemorrhagic shock resulting from injury to the heart or one of the large vessels close to it. Brisk drainage of tension pneumothorax and adequate volume restoration are therefore particularly important in resuscitation of multiply traumatized patients, as are rapid resuscitative thoracotomy to allow direct heart massage, drainage of pericardial tamponade, and control of hemorrhage. However the probability of survival described in the literature is very low for patients sustaining severe chest trauma with acute cardiac arrest. The case report presented here describes a female polytrauma patient who suffered an acute cardiac arrest following cardiac tamponade after admission in the emergency department and who survived without neurological deficits after an emergency thoracotomy. Selections from the topical literature can help the treating physician in the emergency department in making decisions on whether an emergency thoracotomy is indicated after a blunt chest injury and on the procedure itself.

[Trauma of the spine and intervertebral disk. A challenge for the expert in compensation claims after sustained "trifle trauma"]. / Trauma der Wirbelsäule und Bandscheibe. Gutachterliche Herausforderungen bei "Bagatellverletzungen".

In the literature, the association between chronic pain syndromes of the spine and sustained "trifle trauma" is a matter of controversy. "Trifle trauma" is identified as a contusion, compression and/or sprain without a definite, acute imaging sign of injury to the bone, the disk or the ligaments of the spine. Most of the time, striking isolated changes to the intervertebral disks are interpreted as preexisting without relevance to an acute injury. However, complex chronic pain syndromes causing permanent and significant functional limitations in daily life and work may occur. Besides the diagnostic and therapeutic challenge for the treating physician, the expert confronted with compensation claims very often has to answer questions as to whether "trifle trauma" of the spine may lead to significant and permanent functional limitations or loss with chronic pain syndromes, and what the importance of possible isolated changes in intervertebral disks is. The data from literature dealing with this topic is contradictory and deficient. In this article, we critically examine the causality between "trifle trauma" to the spine and possible permanent chronic complaints based on currently available data from the literature in order to support the process of decision making in questions of litigation and controversial compensation claims.

[Evidence based diagnostic procedures for the determination of suspected blunt cervical spine injuries. Development of an algorithm]. / Evidenzbasiertes diagnostisches Vorgehen bei Verdacht auf stumpfes HWS-Trauma. Entwicklung eines Algorithmus.

BACKGROUND: The aim of this study was to present existing publications, describing various diagnostic procedures as well as considering the evidence supporting them, to develop a recommendation for diagnosis. MATERIAL AND METHODS: We reviewed relevant publications between 1966 and 2004 by a systemic literature search in MEDLINE, EMBASE, National Guideline Clearinghouse, Cochrane Library as well as a manual reference search. Keywords were cervical spine, cervical vertebrae, spinal, spinal cord, injury, trauma, fracture, dislocation, imaging, radiography, flexion, extension, fluoroscopy, computed tomography, computed scanning, and magnetic resonance imaging. The selected search results were then classified into levels of evidence. RESULTS: From among a total of 10,000 publications, 137 relevant publications were stringently reviewed. The level of evidence is on the whole limited due to deficit data; therefore, only class II-III recommendations are possible. We developed an algorithm for the diagnostic approach to suspected trauma of the cervical spine. This clinical algorithm displays the complex diagnosis of cervical spine injury in a clear and logically structured process. CONCLUSIONS: The diagnostic algorithm for cervical spine injury meets the presently required standards and maximizes care for the newly injured. The development, which can be followed using evidence-based medicine, is transparent and therefore aids the decision process when choosing an adequate diagnostic procedure.