Hospital preparedness for mass critical care during SARS-CoV-2 pandemic.

Mass critical care caused by the severe acute respiratory syndrome corona virus 2 pandemic poses an extreme challenge to hospitals. The primary goal of hospital disaster preparedness and response is to maintain conventional or contingency care for as long as possible. Crisis care must be delayed as long as possible by appropriate measures. Increasing the intensive care unit (ICU) capacities is essential. In order to adjust surge capacity, the reduction of planned, elective patient care is an adequate response. However, this involves numerous problems that must be solved with a sense of proportion. This paper summarises preparedness and response measures recommended to acute care hospitals.

Why do some trauma patients die while others survive? A matched-pair analysis based on data from Trauma Register DGU®.

PURPOSE: The mortality rate for severely injured patients with the injury severity score (ISS) ≥16 has decreased in Germany. There is robust evidence that mortality is influenced not only by the acute trauma itself but also by physical health, age and sex. The aim of this study was to identify other possible influences on the mortality of severely injured patients. METHODS: In a matched-pair analysis of data from Trauma Register DGU®, non-surviving patients from Germany between 2009 and 2014 with an ISS≥16 were compared with surviving matching partners. Matching was performed on the basis of age, sex, physical health, injury pattern, trauma mechanism, conscious state at the scene of the accident based on the Glasgow coma scale, and the presence of shock on arrival at the emergency room. RESULTS: We matched two homogeneous groups, each of which consisted of 657 patients (535 male, average age 37 years). There was no significant difference in the vital parameters at the scene of the accident, the length of the pre-hospital phase, the type of transport (ground or air), pre-hospital fluid management and amounts, ISS, initial care level, the length of the emergency room stay, the care received at night or from on-call personnel during the weekend, the use of abdominal sonographic imaging, the type of X-ray imaging used, and the percentage of patients who developed sepsis. We found a significant difference in the new injury severity score, the frequency of multi-organ failure, hemoglobine at admission, base excess and international normalized ratio in the emergency room, the type of accident (fall or road traffic accident), the pre-hospital intubation rate, reanimation, in-hospital fluid management, the frequency of transfusion, tomography (whole-body computed tomography), and the necessity of emergency intervention. CONCLUSION: Previously postulated factors such as the level of care and the length of the emergency room stay did not appear to have a significant influence in this study. Further studies should be conducted to analyse the identified factors with a view to optimising the treatment of severely injured patients. Our study shows that there are significant factors that can predict or influence the mortality of severely injured patients.

Anterior management of C2 fractures using miniplate fixation: outcome, function and quality of life in a case series of 15 patients.

PURPOSE: The classification systems by Anderson and D'Alonzo, Effendi, Benzel and others have limitations when it comes to morphologically categorising fractures of the second cervical vertebral body (C2) that present with or without an additional fracture of the dens or with or without an extension of the fracture line into the vertebral arch and displacement. Currently, there are no definitive recommendations for the treatment of fractures at the junction of the dens with the vertebral body of C2 on the basis of outcome and stability data. Depending on patient anatomy, either anterior or posterior approaches can be used to fuse C1 and C2 and to achieve definitive surgical stabilisation. The anterior management of C2 fractures without C1-C2 fusion has the theoretical advantage that it preserves rotational motion at this motion segment and that the anterior approach is associated with lower morbidity. In the study presented here, we followed up a group of our patients who underwent anterior miniplate fixation for C2 fractures. METHODS: Fifteen patients underwent fixation of C2 fractures with titanium miniplates (Medartis Hand fixation system, 2.0 or 2.3 mm) that were placed using a submental approach. To our knowledge, this construct has not yet been described in the literature. Where necessary, this procedure was combined with screw fixation of the dens as described by Böhler. We retrospectively analysed operative reports and medical records, evaluated the patients' health status using the Short Form (36) Health Survey (SF-36), and performed clinical follow-up examinations. RESULTS: From January 2009 to June 2015, 226 traumatic lesions of the cervical spine were managed at our institution in the inpatient setting. Ninety-two patients underwent conservative treatment. Of the 134 cases that required surgery for fractures and instability, 67 involved the C0-C3 motion segments. In 15 patients, stability was achieved using an anterior miniplate or miniscrews alone (n = 4) or in addition to other techniques (n = 11). Anderson and D'Alonzo type II and III dens fractures with involvement of the body or lateral mass of C2 accounted for eight cases. Effendi type II body fractures with or without instability were seen in four cases. There was no perioperative mortality and morbidity in this patient group. All fractures healed and stability was achieved in all cases. No patient had neurological deficits or required revision surgery. An assessment of postoperative quality of life showed that 11 patients (7 men, 4 women) with a mean age of 57 (± 5.3) years reached an SF-36 score that was normal for their age group after a mean period of 33 (± 6.3) months following their injury. Compared to a group of healthy subjects, the patients had a range of motion that was limited only at the extremes. CONCLUSIONS: In patients with appropriate indications, anterior fixation with miniplates alone or additionally is a further useful treatment option in the management of fractures at the junction of the dens with the vertebral body of C2. Since this type of treatment preserves motion at the C1-C2 motion segment after fracture healing and since an anterior approach is associated with less surgical trauma than posterior instrumentation, the technique presented here should be included in a discussion on (surgical) treatment options. These slides can be retrieved under Electronic Supplementary Material.

[Inpatient surgical treatment in mass casualty situations and disasters-Current treatment capacities depending on alarm status of the hospital and treatment concept]. / Stationäre chirurgische Versorgung in Großschadenslagen und Katastrophen ­ aktuelle Behandlungskapazitäten in Abhängigkeit von Alarmierungsstatus des Krankenhauses und Versorgungskonzept.

BACKGROUND: The functionality and treatment capacity of hospitals are decisive components to safeguard the in-hospital treatment of patients in crises and catastrophes. This is shown by the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic and the war in Ukraine. The aim of this study is the elicitation of treatment capacities of hospitals in the trauma network of the German Society for Trauma Surgery (DGU) assuming a damage situation with a multitude of trauma patients needing treatment. MATERIAL AND METHOD: The 622 hospitals in the trauma network were surveyed to elicit the current treatment capacities depending on the principles and standards of treatment. For this purpose, a questionnaire for voluntary participation in the survey was placed online via the Academy of Trauma Surgery (AUC) of the DGU and an electronic platform (SurveyMonkey). The data presented in this article represent an extract of the total data focussed on the issues involved in the study. RESULTS: A total of 252 of the 622 hospitals certified in December 2022 (40%) participated in the survey and 250 datasets could be utilized. Local, regional and supraregional trauma centers were equally represented. Using a tactical abbreviated surgical control (TASC) focussed on survival, the treatment capacities in the individual triage categories could be increased with respect to the scenarios in question. It was also clear that the availability of teams skilled in the surgical treatment of body cavity injuries still represents a challenge. CONCLUSION: The results of the survey demonstrate the extent to which treatment capacities for the care of injured and wounded patients are currently available in the hospitals of the DGU trauma network and to what extent they can be increased. In this way, due the dynamics a mass casualty incident can initially lead locally and temporarily to a decompensated crisis management. The aim of all efforts and preparations must therefore be to durably strengthen hospitals so that this can be avoided as reliably as possible and to include these considerations in the hospital structural reform.

[Inpatient surgical treatment in mass casualty situations and disasters-Principles, targets, concepts, preparation]. / Stationäre chirurgische Versorgung in Großschadenslagen und Katastrophen ­ Grundlagen, Ziele, Konzepte, Vorbereitung.

BACKGROUND: The war in Ukraine and the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic have moved the resilience of the healthcare system in Germany into the focus of a broad discussion. The preparation for such a damage situation is characterized by the relationship between the available treatment capacity and needs which go far beyond the norm. The aim of a resilient healthcare system must be to adequately react to such exceptional situations. Particularly in acute disaster and mass casualty situations, medical standards and an individualized surgical treatment must be maintained for as long as possible. MATERIAL, METHOD AND OBJECTIVE: The aim of this article is to elucidate the current terminology on medical treatment of patients in disasters from a surgical perspective, to further develop available concepts and possible concepts of crisis management based on three schematically presented scenarios. Furthermore, the general reaction possibilities for mobilization of treatment capacities are described. RESULTS: In order to uniformly collate the quality of medical treatment in a damage situation, it is meaningful to include the stages of individualized treatment, compensated crisis care and decompensated crisis care. Within the framework of a mass casualty situation or a disaster, traumatological and surgical patients are predominant and the aim must be to maintain or restore the stage of a compensated crisis management. Depending on the extent of the damage situation, this can only be realized in a timely manner independent of state boundaries and by a superordinate central management structure. For a comprehensive provision of surgical treatment capacities, the depiction of a continuous overview of the situation with current resources and structural data of the hospitals in the affected region is necessary. CONCLUSION: The aim of all efforts and preparations must therefore be to durably strengthen hospitals and to train and develop this with respect to coping with a damage situation in disaster medicine. In this respect it is important to establish a consensus on terminology, the type of treatment and the tactical strategic principles of surgical treatment to cope with a disaster or damage situation.

[Treatment of the wounded from the war in Ukraine in the trauma networks of the DGU-Requirement, reality and motivation over the course of 18 months ]. / Versorgung von Kriegsverletzten aus der Ukraine in den Traumanetzwerken der DGU ­ Anspruch, Wirklichkeit und Motivation im Verlauf von 18 Monaten .

BACKGROUND: The war in Ukraine and the medical treatment of the wounded in hospitals in Germany has now represented a challenge for more than 15 months. The majority of trauma patients were distributed via the general holding center (GMLZ) at the Federal Office of Civil Protection and Disaster Assistance (BBK) by the cloverleaf concept and the trauma networks. Initially, numerous offers of assistance were promoted with great solidarity. For documentation of the current motivation situation and also for identification of the potential for improvement, a 2-stage survey of senior physicians in the organized and certified hospitals in the trauma networks was carried out. MATERIAL AND METHODS: An online survey of senior physicians of the trauma network hospitals was carried out with a semistructured written questionnaire in December 2022 and a follow-up survey during the Trauma Network Meeting (TNT) Congress in September 2023 in Frankfurt. RESULTS: Of the questionnaires 113 could be evaluated in December 2022 and 70 completed questionnaires in September 2023. The answers came from national trauma centers (ÜTZ), regional trauma centers (RTZ) and local trauma centers (LTZ) each with approximately one third. On average 2.7 patients were treated in all participating hospitals up to December and up to September no more than 5 in more than half of the hospitals overall. The main challenges for all participants at both points in time were the long hospital stay, the demanding pathogen status and sometimes unclarified or not completely covered reimbursement of costs. Nevertheless, more than 80% of the specialist departments received backing from their hospital sponsors as well as their personnel for the continuing treatment of the wounded from Ukraine. CONCLUSION: The medical and professional challenges in the treatment of the wounded from Ukraine are, as expected, characterized by the demanding injury patterns of the musculoskeletal system and the colonization with multidrug-resistant pathogens. This results in a long course of treatment, where the remuneration does not always cover the costs. Despite these challenges the solidarity in the hospitals of the trauma networks is unbroken. Simultaneously, there are numerous possibilities for improvement in order to enhance the prerequisites for future comparable humanitarian assistance jointly with politics.

[National challenges for trauma surgery in Germany due to violence and war]. / Nationale Herausforderungen für die Unfallchirurgie in Deutschland bei Gewalt und Krieg.

Due to the war in Ukraine and the treatment of patients with war wounds in the hospitals of the TraumaNetworks of the German Society for Trauma Surgery (TraumaNetzwerke DGU®), injuries from life-threatening mission situations (LebEL), terrorism, violence and war have become a matter of daily professional life. Furthermore, the societal and global feeling of security has fundamentally changed. The much-cited term "turning point in history", the reorientation of the Armed Forces and the investigation of the resilience of the healthcare system with respect to the "fitness for war", approximate to the description of the current challenges for trauma surgery (UCH) in Germany. Based on the developments following the terrorist attacks in Paris in 2015 and in Brussels in 2016, a clarification is given as to which adaptations have already been successful and how quickly an improvement could successfully be achieved. In this context, the concept of tactical care and the course on Terror and Disaster Surgical Care (TDSC), for example, have been game changing. The main challenge currently lies in overcoming the structural alterations in the German healthcare system and professionally in the treatment of war wounded personnel from Ukraine. The knowledge gained from these two national tasks must be analyzed for the future development and adaptation of established treatment structures, e.g., of the TraumaNetzwerke DGU®, under the requirements of the increased resilience against war, terrorism and violence. The aim is to name that which has already been achieved with respect to the national challenges for UCH and at the same time to outline or discuss further necessities for improvements and elimination of possible gaps in capabilities.

[Initial in-hospital treatment of patients with penetrating trauma due to violence and war]. / Innerklinische Erstversorgung von Patienten mit penetrierendem Trauma nach Gewalt und Krieg.

BACKGROUND: Current political and social developments have brought the topics of violence, in this context attributable to terrorism and sabotage, and since February 2022 awareness of war in particular has again greatly increased. This article aims to present the contextualized dealing with penetrating injuries in terms of initial in-hospital treatment. OBJECTIVE: The question remains to be answered as to what extent penetrating injuries require special attention and to what extent the treatment priorities, options and strategies as well as surgical treatment require adaptation of the usual approach in routine clinical practice in Germany. MATERIAL AND METHOD: The experience of the authors in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of a comprehensive systematic literature review and current data from a national evaluation on the topic of preparing hospitals in Germany for such scenarios are taken into account. RESULTS AND DISCUSSION: The clinical systems need to be well-prepared for such casualties, especially if they require treatment in large numbers. This is precisely so because the majority of patients are in a relevantly threatening situation (usually in the sense of a hemorrhage), treatment must be very urgently provided and in such scenarios a lack of resources must always be overcome, at least temporarily, especially for example for blood transfusions.

[Microbiological challenges in the treatment of war injuries]. / Mikrobiologische Herausforderungen bei der Versorgung von Kriegsverletzungen.

The treatment of war injuries represents a continuing and recurrent challenge in modern reconstructive surgery. Previously, tumor resections and sepsis-related resections were mainly responsible for lengthy bone defects in Germany. In recent years another picture has increasingly emerged, particularly caused by the medical support of Ukraine. Aspects of military surgery are also becoming more important in civil hospitals, especially in the treatment of gunshot and explosion injuries. In Germany, war injuries are currently secondarily treated, as the distribution of patients is carried out according to the cloverleaf principle, weeks or months after the occurrence of the primary injury. In addition to complex bone and soft tissue defects of the extremities following such injuries, which often affect neural and vascular structures, reconstruction is often complicated by an increasing spectrum of multidrug-resistant pathogens. The definition of microbiological terms, such as contamination, colonization, critical colonization, local and systemic infections are important in the clinical routine in order to initiate a targeted treatment, especially in treatment with antibiotics. Wound swabs for determination of the spectrum of pathogens and the optimal testing of resistance are important for selecting the appropriate antibiotic agents. The concept of antibiotic stewardship (ABS) is established in many hospitals to improve the quality of antibiotic treatment and to minimize the formation of resistance. The selection of the method of reconstruction depends on the condition of the patient, the overall clinical constellation and the function to be expected after completion of treatment. The treatment of injuries due to violence and terrorism necessitates clear concepts and an interdisciplinary approach, especially with respect to microbiological challenges and increasing resistance situations.

New Recommendations for the Care of Severely Injured Patients: Revision of the S3 Guideline on Treatment of Polytrauma/Severe Injuries. / Neue Empfehlungen zur Schwerverletzten-Versorgung: die Novellierung der S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung.

Die 3. Überarbeitung der S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung wurde unter der Federführung der Deutschen Gesellschaft für Unfallchirurgie (DGU) von insgesamt 26 Fachgesellschaften und Organisationen durchgeführt und stellt eine umfassende Aktualisierung der Handlungsempfehlungen zur Schwerverletzten-Versorgung auf Basis neuer wissenschaftlicher Erkenntnisse und Studien dar. Die Leitlinie enthält 332 Kernempfehlungen unterschiedlicher Empfehlungsgrade und dazugehörige Erläuterungen, die Expertenwissen und über 2400 zitierte Literaturstellen berücksichtigen und somit das höchste Niveau (S3) einer Leitlinie erfüllen. Die Änderungen, insbesondere zur Schockraumalarmierung, sind für den Rettungsdienst von besonderer Bedeutung. Zwei neue Kapitel mit Empfehlungen für die Blutstillung und Schmerzbehandlung in der prähospitalen Versorgung wurden hinzugefügt, insgesamt bleibt die Leitlinie ein wichtiger Standard für Entscheidungsfindungen bei Diagnostik und Therapie von Schwerverletzten.

[Challenge of limb care after violence and war with a special focus on imaging procedures]. / Herausforderung der Extremitätenversorgung nach Gewalt und Krieg mit besonderer Betrachtung bildgebender Verfahren.

BACKGROUND: Injury patterns in the area of the extremities following violence and war harbor many special features and require special attention. Destructive and complex defect injuries are often present, which necessitate elaborate and special reconstruction approaches, predominantly as part of a staged and multistaged procedure. RESEARCH QUESTION: In this context, special attention must be paid to the diagnostic options as an essential aspect, as a clear diagnosis means that targeted treatment steps can be planned and implemented. MATERIAL AND METHOD: The authors' experience in this field from military operations in Afghanistan, Iraq, the Republic of Mali, Kosovo and Georgia, as well as the core content of the Terror and Disaster Surgical Care (TDSC®) course on this topic, have been contextualized and incorporated. In addition, aspects of interdisciplinary cooperation with radiological and, in particular, nuclear medicine disciplines are taken into account in the daily routine. RESULTS AND DISCUSSION: Extremity injuries in the context of violence and war are accompanied by complex bone and surrounding soft tissue defects due to the high energy impact. The principles of reconstruction familiar from everyday life can only be transferred one-to-one to a limited extent. The treatment pathways are often very long and complex and the questions of infection and tissue vitality must be answered again and again in stages. Interdisciplinary collaboration with the disciplines specialized in imaging procedures, particularly in the field of nuclear medicine, is one of the key building blocks for a successful treatment pathway.

Education and training as a key enabler of successful patient care in mass-casualty terrorist incidents.

BACKGROUND AND PURPOSE: The increase in terrorist attacks with sometimes devastating numbers of victims has become a reality in Europe and has led to a fundamental change in thinking and a reorientation in many fields including health policy. The purpose of this original work was to improve the preparedness of hospitals and to provide recommendations for training. MATERIAL AND METHODS: We conducted a retrospective literature search based on the Global Terrorism Database (GTD) for the period 2000 to 2017. Using defined search strategies, we were able to identify 203 articles. We grouped relevant findings into main categories with 47 statements and recommendations on education and training. In addition, we included data from a prospective questionnaire-based survey on this topic that we conducted at the 3rd Emergency Conference of the German Trauma Society (DGU) in 2019. RESULTS: Our systematic review identified recurrent statements and recommendations. A key recommendation was that regular training should take place on scenarios that should be as realistic as possible and should include all hospital staff. Military expertise and competence in the management of gunshot and blast injuries should be integrated. In addition, medical leaders from German hospitals considered current surgical education and training to be insufficient for preparing junior surgeons to manage patients who have sustained severe injuries by terrorist events. CONCLUSION: A number of recommendations and lessons learned on education and training were repeatedly identified. They should be included in hospital preparations for mass-casualty terrorist incidents. There appear to be deficits in current surgical training which may be offset by establishing courses and exercises.

[Care of the severely injured in mass casualty incidents : What is the difference compared to emergency room management?] / Schwerstverletztenversorgung beim Massenanfall von Verletzten : Worin besteht der Unterschied zum Schockraummanagement?

The management of a severely injured patient according to the standards and principles of individualized trauma care is a well-established procedure in many hospitals. The process is structured and standardized by the content of several course formats. In contrast, a mass casualty incident (MCI, MANV) is a rare and exceptional situation. In this case the treatment priorities and approaches are changed. The main aim in this situation is to ensure the best possible chance of survival for every casualty by organizational measures to mobilize rooms, personnel and material and to temporarily abandon the standards of individualized trauma care. To be prepared for a MCl situation it is necessary to know the realistic scenarios, to update the hospital emergency plan and to adapt all treatment procedures to the transient lack of resources. This article gives an overview of this process and summarizes the current clinical concepts to cope with a MCl situation and the current principles for the care of the severely injured involving many casualties.

Evaluation of the decision-making process within the table-top exercise of the Terror and Disaster Surgical Care (TDSC®) course.

PURPOSE: The threat of terror is omnipresent in Europe and the number of attacks worldwide is increasing. The target of attacks in Europe is usually the civilian population. Incalculable dangerous situations at the scene of the event and severe injury patterns such as complex gunshot and explosion injuries with a high number of highly life-threatening people present rescue forces, emergency physicians and subsequently hospitals with medical, organizational as well as tactical and strategic challenges. The Terror and Disaster Surgical Care (TDSC®) course trains clinical decision-makers to meet these challenges of a TerrorMASCAL in the first 24-48 h. METHODS: A table-top exercise was developed for the TDSC® course as a decision training tool, which was prospectively evaluated in six courses. The evaluation took place in 3 courses of the version 1.0, in 3 courses in the further developed version 2.0 to different target values like, e.g., the accuracy of the in-hospital triage. Furthermore, 16 TDSC® course instructors were evaluated. RESULTS: For the evaluation, n = 360 patient charts for version 1.0 and n = 369 for version 2.0 could be evaluated. Overall, the table-top exercise was found to be suitable for training of internal clinical decision makers. Version 2.0 was also able to depict the action and decision-making paths in a stable and valid manner compared to the previous version 1.0. The evaluation of the instructors also confirmed the further value and improvement of version 2.0. CONCLUSION: With this prospective study, the table-top exercise of the TDSC® course was tested for decision stability and consistency of the participants' decision paths. This could be proven for the selected target variables, it further showed an improvement of the training situation. A further development of the table-top exercise, in particular also using digital modules, will allow a further optimization. http://www.bundeswehrkrankenhaus-ulm.de.

[Safety aspects, emergency preparedness and hazard prevention in hospitals concerning mass casualty incidents (MCI)/terror-related MCI : Prospects on future challenges based on survey results from the 3rd emergency conference of the DGU]. / Sicherheitsaspekte und Vorbereitung zur Notfallvorsorge und Gefahrenabwehr in Kliniken bei MANV/TerrorMANV : Ausblick auf zukünftige Herausforderungen anhand von Umfrageergebnissen zur 3. Notfallkonferenz der DGU.

BACKGROUND: Worldwide terrorist activities since "9/11" and subsequently also in the European region have led to a rethinking in the context of the evaluation of critical infrastructure in Germany, also with respect to security at and in hospitals. OBJECTIVE: This publication deals with the evaluation of existing concepts on topics such as "alerting", "security", "communication" and "preparation" in the aforementioned context. MATERIAL AND METHODS: Based on a literature review as well as a survey among participants of the 3rd emergency conference of the DGU (German Society for Trauma Surgery), this topic and the currently existing situation are further analyzed and presented. RESULTS: The data obtained illustrate that while the majority of hospitals have a hospital alert and response planning, the frequency of updates and intrahospital communication to increase awareness show significant variation. Furthermore, the results illustrate a heterogeneity of the existing intrahospital alerting concepts as well as a lack of security concepts and cooperation with security and guard services. Furthermore, it is evident that the topic of a possible CBRN (chemical, biological, radiological, nuclear) threat is not yet adequately perceived or implemented in the risk analysis. DISCUSSION: The latent threat of terrorist activities appears to have led German hospitals to address the issue of hospital alarm and response planning in their assessment as critical infrastructure and to have implemented this for the most part; however, the subordinated areas and the consequences that can be derived from alarm planning do not yet show the necessary stringency to ultimately ensure adequate responses in these special scenarios with respect to security in and at German hospitals.

Effect of surgical stabilization of rib fractures in polytrauma: an analysis of the TraumaRegister DGU®.

PURPOSE: In severely injured patients with multiple rib fractures the beneficial effect of surgical stabilization is still unknown. The existing literature shows divergent results and especially the indication and the right timing of an operation are subject of a broad discussion. The aim of this study was to determine the influence of a surgical stabilization of rib fractures (SSRF) on the outcome in a multi-center database with special regard to the duration of ventilation, intensive care and overall hospital stay. METHODS: Data from the TraumaRegister DGU® collected between 2008 and 2017 were used to evaluate patients over 16 years with severe rib fractures (AIS ≥ 3). In addition to the basic comparison a matched pair analysis of 395 pairs was carried out in order to find differences and to increase comparability. RESULTS: In total 483 patients received an operative treatment and 29,447 were treated conservatively. SSRF was associated with a significantly lower mortality rate (7.6% vs. 3.3%, p = 0.008) but a longer ventilation time and longer stay as well as in the intensive care unit (ICU) as the overall hospital stay. Both matched pair groups showed a good or very good neurological outcome according to the Glasgow Outcome Scale (GOS) in 4 of 5 cases. Contrary to the existing recommendations most of the patients were not operated within 48 h. CONCLUSIONS: In our data set, obviously most of the patients were not treated according to the recent literature and showed a delay in the time for operative care of well over 48 h. This may lead to an increased rate of complications and a longer stay at the ICU and the hospital in general. Despite of these findings patients with operative treatment show a significant lower mortality rate.

Evaluation of a standardized instrument for post hoc analysis of trauma-team-activation-criteria in 75,613 injured patients an analysis of the TraumaRegister DGU®.

INTRODUCTION: To improve the quality of criteria for trauma-team-activation it is necessary to identify patients who benefited from the treatment by a trauma team. Therefore, we evaluated a post hoc criteria catalogue for trauma-team-activation which was developed in a consensus process by an expert group and published recently. The objective was to examine whether the catalogue can identify patients that died after admission to the hospital and therefore can benefit from a specialized trauma team mostly. MATERIALS AND METHODS: The catalogue was applied to the data of 75,613 patients from the TraumaRegister DGU® between the 01/2007 and 12/2016 with a maximum abbreviated injury score (AIS) severity ≥ 2. The endpoint was hospital mortality, which was defined as death before discharge from acute care. RESULTS: The TraumaRegister DGU® dataset contains 18 of the 20 proposed criteria within the catalogue which identified 99.6% of the patients who were admitted to the trauma room following an accident and who died during their hospital stay. Moreover, our analysis showed that at least one criterion was fulfilled in 59,785 cases (79.1%). The average ISS in this group was 21.2 points (SD 9.9). None of the examined criteria applied to 15,828 cases (average ISS 8.6; SD 5). The number of consensus-based criteria correlated with the severity of injury and mortality. Of all deceased patients (8,451), only 31 (0.37%) could not be identified on the basis of the 18 examined criteria. Where only one criterion was fulfilled, mortality was 1.7%; with 2 or more criteria, mortality was at least 4.6%. DISCUSSION: The consensus-based criteria identified nearly all patients who died as a result of their injuries. If only one criterion was fulfilled, mortality was relatively low. However, it increased to almost 5% if two criteria were fulfilled. Further studies are necessary to analyse and examine the relative weighting of the various criteria. Our instrument is capable to identify severely injured patients with increased in-hospital mortality and injury severity. However, a minimum of two criteria needs to be fulfilled. Based on these findings, we conclude that the criteria list is useful for post hoc analysis of the quality of field triage in patients with severe injury.

Use of vacuum-assisted closure negative pressure wound therapy in combat-related injuries--literature review.

Despite surgical and technological advances, managing combat-related injuries remains challenging both within and outside of the war theater. Unique characteristics of a war theater such as environmental contamination, varying evacuation procedures, and differing levels of medical care, add to the complexity. The advent of body armor has increased blast survival rates and soldiers are surviving with increasingly mangled limbs that require lengthy, multifaceted care. An inherent high risk of infection contraindicates immediate closure for these wounds. There is growing reported use of negative pressure wound therapy with reticulated open-cell foam (NPWT/ROCF) as delivered by vacuum-assisted closure (VAC) therapy (KCI Licensing Inc., San Antonio, TX) as an adjunctive therapy in these open soft-tissue combat wounds. This review evaluates the efficacy of NPWT/ROCF for adjunctive treatment of wartime wounds. Following a literature review, data are summarized and presented.

Specificities of terrorist attacks: organisation of the in-hospital patient-flow and treatment strategies.

BACKGROUND: Mass-casualty incidents are always a particular challenge not only for healthcare providers and other emergency service responders at the scene but also for receiving hospitals. Terrorism-related mass-casualty incidents can result in a wide variety of different scenarios so that hospitals and their personnel must prepare for far more complex and demanding requirements. PURPOSE: In this article, we describe and discuss in-hospital aspects of mass-casualty terrorist incidents and focus on the special medical and in particular surgical care that is required in this setting. METHODS: The overview presented here is based on the Terror and Disaster Surgical Care (TDSC®) course. The TDSC® course was mainly developed from a comprehensive and structured analysis of the literature, single expert opinions, and expert consensus conferences. The objective of this course is to train clinical decision-makers in how to manage major incidents. RESULTS: The management of a mass-casualty terrorist incident and the care of victims present multiple and unique challenges to hospitals. This applies in particular to the number and distribution of patients arriving at the hospital, injury patterns, infrastructural aspects, and personnel resources. Particular attention must be given to the surgical approach to caring for these patients, e.g., early total care, damage control surgery, or tactical abbreviated surgical care. CONCLUSION: Mass-casualty terrorist incidents are different from other mass-casualty events in many respects that require special attention. The provision of appropriate public services requires in particular that the preparation and training of personnel as well as the organisation of the in-hospital response be tailored to the incident.