The value of pre-hospital trauma life support courses for medical personnel-a questionnaire study.

Background: The aim of the study was to determine the impact that PHTLS® course participation had on self-confidence of emergency personnel, regarding the pre-hospital treatment of patients who had suffered severe trauma. Furthermore, the goal was to determine the impact of specific medical profession, work experience and prior course participation had on the benefits of PHTLS® training. Methods: A structured questionnaire study was performed. Healthcare providers from local emergency services involved in pre-hospital care in the metropolitan area of Zurich (Switzerland, Europe) who completed a PHTLS® course were included. Altered self-confidence, communication, and routines in the treatment of severe trauma patients were examined. The impact of prior course participation, work experience and profession on course benefits were evaluated. Results: The response rate was 76%. A total of 6 transport paramedics (TPs), 66 emergency paramedics (EPs) and 15 emergency doctors (EDs) were included. Emergency paramedics had significantly more work experience compared with EDs (respectively 7.1 ± 5.7 yrs. vs. 4.5 ± 2.1 yrs., p = 0.004). 86% of the participants reported increased self-confidence in the pre-hospital management of severe trauma upon PHTLS® training completion. Moreover, according to 84% of respondents, extramural treatment of trauma changed upon course completion. PHTLS® course participants had improved communication in 93% of cases. This was significantly more frequent in EPs than TPs (p = 0.03). Multivariable analysis revealed emergency paramedics benefit the most from PHTLS® course participation. Conclusion: The current study shows that PHTLS® training is associated with improved self-confidence and enhanced communication, with regards to treatment of severe trauma patients in a pre-hospital setting, among medical emergency personnel. Additionally, emergency paramedics who took the PHTLS® course improved in overall self-confidence. These findings imply that all medical personal involved in the pre-hospital care of trauma patients, in a metropolitan area in Europe, do benefit from PHTLS® training. This was independent of the profession, previous working experience or prior alternative course participation.

The Road to Sepsis in Geriatric Polytrauma Patients-Can We Forecast Sepsis in Trauma Patients?

Background: Sepsis is a leading cause of mortality in polytrauma patients, especially beyond the first week, and its management is vital for reducing multiorgan failure and improving survival rates. This is particularly critical in geriatric polytrauma patients due to factors such as age-related physiological alterations and weakened immune systems. This study aimed to investigate various clinical and laboratory parameters associated with sepsis in polytrauma patients aged < 65 years and ≥65 years, with the secondary objective of comparing sources of infection in these patient groups. Methods: A retrospective cohort study was conducted at the University Hospital Zurich from August 1996 to December 2012. Participants included trauma patients aged ≥16 years with an Injury Severity Score (ISS) ≥ 16 who were diagnosed with sepsis within 31 days of admission. Patients in the age groups < 65 and ≥65 years were compared in terms of sepsis development. The parameters examined included patient and clinical data as well as laboratory values. The statistical methods encompassed group comparisons with Welch's t-test and logistic regression. Results: A total of 3059 polytrauma patients were included in the final study. The median age in the group < 65 years was 37 years, with a median ISS of 28. In the patient group ≥ 65 years, the median age was 75 years, with a median ISS of 27. Blunt trauma mechanism, ISS, leucocytosis at admission, and anaemia at admission were associated with sepsis in younger patients but not in geriatric patients, whereas sex, pH at admission, lactate at admission, and Quick values at admission were not significantly linked with sepsis in either age group. Pneumonia was the most common cause of sepsis in both age groups. Conclusions: Various parameters linked to sepsis in younger polytrauma patients do not necessarily correlate with sepsis in geriatric individuals with polytrauma. Hence, it becomes critical to recognize imminent danger, particularly in geriatric patients. In this context, the principle of "HIT HARD and HIT EARLY" is highly important as a proactive approach to effectively address sepsis in the geriatric trauma population, including the preclinical setting.

Can radiologic parameters used to detect cervical spinal instability be used in patients with ankylosing spondylitis?

INTRODUCTION: Cervical spinal instability can be difficult to detect in the shock room setting even with the utilization of computed tomography (CT) scans. This may be especially true in patients with cervical degenerative disease, such as ankylosing spondylitis (AS). The purpose of this study was to investigate the influence AS has on various radiologic parameters used to detect traumatic and degenerative instability of the cervical spine, to assess if CT imaging in the shock room is diagnostically appropriate in this patient population. METHODS: A matched, case-control retrospective analysis of patients with AS and controls without AS admitted at two level-1 trauma centers was performed. All patients were admitted via shock room and received a polytrauma CT. Twenty-four CT parameters of atlanto-occipital dislocation/instability, traumatic and degenerative spondylolisthesis, basilar invagination, and prevertebral soft tissue swelling were assessed. Since the study was assessing normal values, study patients were included if they had no injury to the cervical spine. Study patients were matched by age and sex. RESULTS: A total of 78 patients were included (AS group, n = 39; control group, n = 39). The evaluated cervical radiologic parameters were largely within normal limits and showed no significant clinical or morphologic differences between the two groups. CONCLUSION: In this analysis, CT measurements pertaining to various cervical pathologies were not different between patients with and without AS. Parameters to assess for atlanto-occipital dislocation/instability, spondylolisthesis, or basilar invagination in the trauma setting may reliably be used in patients with AS.

IBM WATSON Trauma Pathway Explorer© as a Predictor for Sepsis after Polytrauma - Is Procalcitonin Useful for Identifying Septic Polytrauma Patients?

IBM and the University Hospital Zurich have developed an online tool for predicting outcomes of a patient with polytrauma, the IBM WATSON Trauma Pathway Explorer® . The three predicted outcomes are Systemic Inflammatory Response Syndrome (SIRS) and sepsis within 21 days as well as early death within 72 hours since the admission of the patient. The validated Trauma Pathway Explorer® offers insights into the most common laboratory parameters, such as procalcitonin (PCT). Sepsis is one of the most important complications after polytrauma, which is why it is crucial to detect it early. This study aimed to examine the time-dependent relationship between PCT values and sepsis, based on the WATSON technology. A total of 3653 patients were included, and ongoing admissions are incorporated continuously. Patients were split into two groups (sepsis and non-sepsis), and the PCT value was assessed for 21 days (1, 2, 3, 4, 6, 8, 12, 24, 48 hours, and 3, 4, 5, 7, 10, 14 and 21 days). The Mann-Whitney U-Test was used to evaluate the difference between the two groups. Binary logistic regression was utilized to examine the dependency of prediction. The Closest Top-left Threshold Method provided time-specific thresholds at which the PCT level is predictive for sepsis. At p <0.05, the data were declared significant. R was used to conduct all statistical analyses. The Mann-Whitney U-test showed a significant difference in PCT values in sepsis and non-sepsis patients between 12 and 24 hours, including post-hoc analysis (p <0.05). Likewise, the p-value started to be significant between 12 and 24 hours in the binary logistic regression (p <0.05). The threshold value of PCT to predict sepsis at 24 hours is 0.7µg/l, and at 48 hours 0.5µg/l. The presented time course of PCT levels in polytrauma patients shows the PCT as a separate predictor for sepsis relatively early. Even later, during the 21-day observation period, time-dependent PCT values may be utilized as a benchmark for the early and preemptive detection of sepsis, which may reduce death from septic shock and other deadly infectious episodes.

Anatomical Injury Clusters in Polytrauma Patients.

Polytrauma is a major cause of death in young adults. The trial was to identify clusters of interlinked anatomical regions to improve strategical operational planning in the acute situation. A total of 2219 polytrauma patients with an ISS (Injury Severity Score) ≥ 16 and an age ≥ 16 years was included into this retrospective cohort study. Pearson's correlation was performed amongst the AIS (Abbreviated Injury Scale) groups. The predictive quality was tested by ROC (Receiver Operating Curve) and their area under the curve. Independency was tested by the binary logistic regression, AIS ≥3 was taken as a significant injury. The analysis was conducted using IBM SPSS® 24.0. The highest predictive value was reached in the combination of thorax, abdomen, pelvis and spine injuries (ROC: abdomen for thorax 0.647, thorax for abdomen 0.621, pelvis for thorax 0.608, pelvis for abdomen 0.651, spine for thorax 0.617). The binary logistic regression revealed the anatomical regions thorax, abdomen pelvis and spine as per-mutative independent predictors for each other when a particular injury exceeded the AIS ≥3. The documented clusters of injuries in truncal trauma are crucial to define priorities in the polytrauma management.

The Role of Lactate for Sepsis in Polytrauma Patients, a Time related Analysis using the IBM Watson Trauma Pathway Explorer®.

The Watson Trauma Pathway Explorer ® is an outcome prediction tool invented by the University Hospital of Zurich in collaboration with IBM®, representing an artificial intelligence application to predict the most adverse outcome scenarios in polytrauma patients: Systemic Inflammatory Respiratory Syndrome (SIRS), sepsis within 21 days and death within 72 h. The hypothesis was how lactate values woud be associated with the incidence of sepsis. Data from 3653 patients in an internal database, with ongoing implementation, served for analysis. Patients were split in two groups according to sepsis presence, and lactate values were measured at formerly defined time points from admission until 21 days after admission for both groups. Differences between groups were analyzed; time points with lactate as independent predictor for sepsis were identified. The predictive quality of lactate at 2 and 12 h after admission was evaluated. Threshold values between groups at all timepoints were calculated. Lactate levels differed from less than 2 h after admission until the end of the observation period (21 d). Lactate represented an independent predictor for sepsis from 12 to 48 h and 14 d to 21 d after admission relative to ISS levels. AUROC was poor at 2 and 12 h after admission with a slight improvement at the 12 h mark. Lactate levels decreased over time at a range of 2 [mmol/L] for 6-8 h after admission. These insights may allow for time-dependent referencing of lactate levels and anticipation of subsequent sepsis, although further parameters must be considered for a higher predictability.

New Time-Related Insights into an Old Laboratory Parameter: Early CRP Discovered by IBM Watson Trauma Pathway Explorer© as a Predictor for Sepsis in Polytrauma Patients.

The University Hospital Zurich together with IBM® invented an outcome prediction tool based on the IBM Watson technology, the Watson Trauma Pathway Explorer®. This tool is an artificial intelligence to predict three outcome scenarios in polytrauma patients: the Systemic Inflammatory Response Syndrome (SIRS) and sepsis within 21 days as well as death within 72 h. The knowledge of a patient's future under standardized trauma treatment might be of utmost importance. Here, new time-related insights on the C-reactive protein (CRP) and sepsis are presented. Meanwhile, the validated IBM Watson Trauma Pathway Explorer® offers a time-related insight into the most frequent laboratory parameters. In total, 3653 patients were included in the databank used by the application, and ongoing admissions are constantly implemented. The patients were grouped according to sepsis, and the CRP was analyzed according to the point of time at which the value was acquired (1, 2, 3, 4, 6, 8, 12, 24, and 48 h and 3, 4, 5, 7, 10, 14, and 21 days). The differences were analyzed using the Mann-Whitney U-Test; binary logistic regression was used to determine the dependency of prediction, and the Closest Top-left Threshold Method presented time-specific thresholds at which CRP is predictive for sepsis. The data were considered as significant at p < 0.05, all analyses were performed in R. The differences in the CRP value of the non-sepsis and sepsis groups are starting to be significant between 6 and 8 h (p < 0.05) after admission inclusive of post hoc analysis, and the binary logistic regression depicts a similar picture. The level of significance is reached between 6 and 8 h (p < 0.05) after admission. The knowledge of the outcome reflected by the CRP in polytrauma patients improves the surgeon's tactical position to indicate operations to reduce antigenic load and avoid an infectious adverse outcome.

Systematic Review and Meta-Analysis of 3 Treatment Arms for Vertebral Compression Fractures: A Comparison of Improvement in Pain, Adjacent-Level Fractures, and Quality of Life Between Vertebroplasty, Kyphoplasty, and Nonoperative Management.

BACKGROUND: Osteoporotic vertebral fractures (OVFs) have become increasingly common, and previous nonrandomized and randomized controlled trials (RCTs) have compared the effects of cement augmentation versus nonoperative management on the clinical outcome. This meta-analysis focuses on RCTs and the calculated differences between cement augmentation techniques and nonsurgical management in outcome (e.g., pain reduction, adjacent-level fractures, and quality of life [QOL]). METHODS: A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, and the following scientific search engines were used: MEDLINE, Embase, Cochrane, Web of Science, and Scopus. The inclusion criteria included RCTs that addressed different treatment strategies for OVF. The primary outcome was pain, which was determined by a visual analog scale (VAS) score; the secondary outcomes were the risk of adjacent-level fractures and QOL (as determined by the EuroQol-5 Dimension [EQ-5D] questionnaire, the Oswestry Disability Index [ODI], the Quality of Life Questionnaire of the European Foundation for Osteoporosis [QUALEFFO], and the Roland-Morris Disability Questionnaire [RDQ]). Patients were assigned to 3 groups according to their treatment: vertebroplasty (VP), kyphoplasty (KP), and nonoperative management (NOM). The short-term (weeks), midterm (months), and long-term (>1 year) effects were compared. A random effects model was used to summarize the treatment effect, including I2 for assessing heterogeneity and the revised Cochrane risk-of-bias 2 (RoB 2) tool for assessment of ROB. Funnel plots were used to assess risk of publication bias. The log of the odds ratio (OR) between treatments is reported. RESULTS: After screening of 1,861 references, 53 underwent full-text analysis and 16 trials (30.2%) were included. Eleven trials (68.8%) compared VP and NOM, 1 (6.3%) compared KP and NOM, and 4 (25.0%) compared KP and VP. Improvement of pain was better by 1.31 points (95% confidence interval [CI], 0.41 to 2.21; p < 0.001) after VP when compared with NOM in short-term follow-up. Pain effects were similar after VP and KP (midterm difference of 0.0 points; 95% CI, -0.25 to 0.25). The risk of adjacent-level fractures was not increased after any treatment (log OR, -0.16; 95% CI, -0.83 to 0.5; NOM vs. VP or KP). QOL did not differ significantly between the VP or KP and NOM groups except in the short term when measured by the RDQ. CONCLUSIONS: This meta-analysis provides evidence in favor of the surgical treatment of OVFs. Surgery was associated with greater improvement of pain and was unrelated to the development of adjacent-level fractures or QOL. Although improvements in sagittal balance after surgery were poorly documented, surgical treatment may be warranted if pain is a relevant problem. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Trauma Team Activation: Which Surgical Capability Is Immediately Required in Polytrauma? A Retrospective, Monocentric Analysis of Emergency Procedures Performed on 751 Severely Injured Patients.

There has been an ongoing discussion as to which interventions should be carried out by an "organ specialist" (for example, a thoracic or visceral surgeon) or by a trauma surgeon with appropriate general surgical training in polytrauma patients. However, there are only limited data about which exact emergency interventions are immediately carried out. This retrospective data analysis of one Level 1 trauma center includes adult polytrauma patients, as defined according to the Berlin definition. The primary outcome was the four most common emergency surgical interventions (ESI) performed during primary resuscitation. Out of 1116 patients, 751 (67.3%) patients (male gender, 530, 74.3%) met the inclusion criteria. The median age was 39 years (IQR: 25, 58) and the median injury severity score (ISS) was 38 (IQR: 29, 45). In total, 711 (94.7%) patients had at least one ESI. The four most common ESI were the insertion of a chest tube (48%), emergency laparotomy (26.3%), external fixation (23.5%), and the insertion of an intracranial pressure probe (ICP) (19.3%). The initial emergency treatment of polytrauma patients include a limited spectrum of potential life-saving interventions across distinct body regions. Polytrauma care would benefit from the 24/7 availability of a trauma team able to perform basic potentially life-saving surgical interventions, including chest tube insertion, emergency laparotomy, placing external fixators, and ICP insertion.

Validation of a Visual-Based Analytics Tool for Outcome Prediction in Polytrauma Patients (WATSON Trauma Pathway Explorer) and Comparison with the Predictive Values of TRISS.

Introduction: Big data-based artificial intelligence (AI) has become increasingly important in medicine and may be helpful in the future to predict diseases and outcomes. For severely injured patients, a new analytics tool has recently been developed (WATSON Trauma Pathway Explorer) to assess individual risk profiles early after trauma. We performed a validation of this tool and a comparison with the Trauma and Injury Severity Score (TRISS), an established trauma survival estimation score. Methods: Prospective data collection, level I trauma centre, 1 January 2018-31 December 2019. INCLUSION CRITERIA: Primary admission for trauma, injury severity score (ISS) ≥ 16, age ≥ 16. PARAMETERS: Age, ISS, temperature, presence of head injury by the Glasgow Coma Scale (GCS). OUTCOMES: SIRS and sepsis within 21 days and early death within 72 h after hospitalisation. STATISTICS: Area under the receiver operating characteristic (ROC) curve for predictive quality, calibration plots for graphical goodness of fit, Brier score for overall performance of WATSON and TRISS. Results: Between 2018 and 2019, 107 patients were included (33 female, 74 male; mean age 48.3 ± 19.7; mean temperature 35.9 ± 1.3; median ISS 30, IQR 23-36). The area under the curve (AUC) is 0.77 (95% CI 0.68-0.85) for SIRS and 0.71 (95% CI 0.58-0.83) for sepsis. WATSON and TRISS showed similar AUCs to predict early death (AUC 0.90, 95% CI 0.79-0.99 vs. AUC 0.88, 95% CI 0.77-0.97; p = 0.75). The goodness of fit of WATSON (X2 = 8.19, Hosmer-Lemeshow p = 0.42) was superior to that of TRISS (X2 = 31.93, Hosmer-Lemeshow p < 0.05), as was the overall performance based on Brier score (0.06 vs. 0.11 points). Discussion: The validation supports previous reports in terms of feasibility of the WATSON Trauma Pathway Explorer and emphasises its relevance to predict SIRS, sepsis, and early death when compared with the TRISS method.

Zone-dependent acute circulatory changes in abdominal organs and extremities after resuscitative balloon occlusion of the aorta (REBOA): an experimental model.

INTRODUCTION: Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be used in severely injured patients with uncontrollable bleeding. However, zone-dependent effects of REBOA are rarely described. We compared the short-term zone- and organ-specific microcirculatory changes in abdominal organs and the extremity during occlusion of the aorta in a standardized porcine model. METHODS: Male pigs were placed under general anesthesia, for median laparotomy to expose intra-abdominal organs. REBOA placement occurred in Zone 1 (from origin left subclavian artery to celiac trunk), Zone 2 (between the coeliac trunk and most caudal renal artery) and Zone 3 (distal most caudal renal artery to aortic bifurcation). Local microcirculation of the intra-abdominal organs were measured at the stomach, colon, small intestine, liver, and kidneys. Furthermore, the right medial vastus muscle was included for assessment. Microcirculation was measured using oxygen-to-see device (arbitrary units, A.U). Invasive blood pressure measurements were recorded in the carotid and femoral artery (ipsilateral). Ischemia/Reperfusion (I/R)-time was 10 min with complete occlusion. RESULTS: At baseline, microcirculation of intra-abdominal organs differed significantly (p < 0.001), the highest flow was in the kidneys (208.3 ± 32.9 A.U), followed by the colon (205.7 ± 36.2 A.U.). At occlusion in Zone 1, all truncal organs showed significant decreases (p < 0.001) in microcirculation, by 75% at the colon, and 44% at the stomach. Flow-rate changes at the extremities were non-significant (n.s). During occlusion in Zone 2, a significant decrease (p < 0.001) in microcirculation was observed at the colon (- 78%), small intestine (- 53%) and kidney (- 65%). The microcirculatory changes at the extremity were n.s. During occlusion in Zone 3, truncal and extremity microcirculatory changes were n.s. CONCLUSION: All abdominal organs showed significant changes in microcirculation during REBOA. The intra-abdominal organs react differently to the same occlusion, whereas local microcirculation in extremities appeared to be unaffected by short-time REBOA, regardless of the zone of occlusion.

Pre-hospital trauma care in Switzerland and Germany: do they speak the same language?

PURPOSE: Swiss and German (pre-)hospital systems, distribution and organization of trauma centres differ from each other. It is unclear if outcome in trauma patients differs as well. Therefore, this study aims to determine differences in characteristics, therapy and outcome of trauma patients between both German-speaking countries. METHODS: The TraumaRegister DGU® (TR-DGU) was used. Patients with Injury Severity Score ≥ 9 admitted to a level 1 trauma centre between 01/2009 and 12/2017 were included if they required ICU care or died. Trauma pattern, pre-hospital procedures and outcome were compared between Swiss (CH, n = 4768) and German (DE, n = 66,908) groups. RESULTS: Swiss patients were older than German patients (53 vs. 50 years). ISS did not differ between groups (CH 23.8 vs. DE 23.0 points). There were more low falls < 3 m (34% vs. 21%) at the expense of less traffic accidents (37% vs. 52%) in the Swiss population. In Switzerland 30% of allocations were done without physician involvement, whereas this occurred in 4% of German cases. Despite a comparable number of patients with a GCS ≤ 8 (CH 29.6%; DE 26.4%), differences in pre-hospital intubation rates occurred (CH 31% vs. DE 40%). Severe traumatic brain injuries were diagnosed most frequently in Switzerland (CH 62% vs. DE 49%). Admission vital signs were similar, and standardized mortality ratios were close to one in both countries. CONCLUSION: This study demonstrates that patients' age, trauma patterns and pre-hospital care differ between Germany and Switzerland. However, adjusted mortality was almost similar. Further benchmarking studies are indicated to optimize trauma care in both German-speaking countries.

Improved pre-hospital care efficiency due to the implementation of pre-hospital trauma life support (PHTLS®) algorithms.

PURPOSE: Pre-hospital trauma life support (PHTLS®) includes a standardized algorithm for pre-hospital care. Implementation of PHTLS® led to improved outcome in less developed medical trauma systems. We aimed to determine the impact of PHTLS® on quality of pre-hospital care in a European metropolitan area. We hypothesized that the introduction of PHTLS® was associated with improved efficiency of pre-hospital care for severely injured patients and less emergency physician deployment. METHODS: We included adult polytrauma (ISS > 15) patients that were admitted to our level one trauma center during a 7-year time period. Patients were grouped based on the presence or absence of a PHTLS®-trained paramedic in the pre-hospital trauma team. Group I (no-PHTLS group) included all casualties treated by no-PHTLS®-trained personnel. Group II (PHTLS group) was composed of casualties managed by a PHTLS® qualified team. We compared outcome between groups. RESULTS: During the study period, 187,839 rescue operations were executed and 280 patients were included. No differences were seen in patient characteristics, trauma severity or geographical distances between groups. Transfer times were significantly reduced in PHTLS® teams than non-qualified teams (9.3 vs. 10.5 min, P = 0.006). Furthermore, the in-field operation times were significantly reduced in PHTLS® qualified teams (36.2 vs. 42.6 min, P = 0.003). Emergency physician involvement did not differ between groups. CONCLUSION: This is the first study to show that the implementation of PHTLS® algorithms in a European metropolitan area is associated with improved efficiency of pre-hospital care for the severely injured. We therefore recommend considering the introduction of PHTLS® in metropolitan areas in the first world.

Development of a Visual Analytics Tool for Polytrauma Patients: Proof of Concept for a New Assessment Tool Using a Multiple Layer Sankey Diagram in a Single-Center Database.

INTRODUCTION: Early physiological assessment of multiple injured patients is crucial for decision making and has relied on personal experience of trauma experts. We have developed a new visual analytics tool (Sankey diagram, Watson Trauma Health care tool) that includes known prognostic parameters for polytrauma patients to help guide assessment and treatment decisions for physicians involved in trauma care. METHODS: A prospectively collected trauma database of a single level I trauma center (3655 patients) was used. INCLUSION CRITERIA: age >16 years, an injury severity score (ISS) >16 and presence of a complete data set in the database. Data collected included admission values of patient age, injury scoring, shock classification, temperature, acid-base and hemostasis parameters. All of these parameters were collected daily as longitudinal parameters. Endpoints of the clinical course we considered were sepsis, SIRS and early in hospital mortality (<72 h). A proof of concept of the visualization was developed over a 2-year period in a cooperation between physicians and engineers. Statistically, the most predictive parameters were selected by binary logistic regression and ROC analysis. RESULTS: A dynamic interactive multilayer Sankey diagram, based on cohort similarities, was developed in a collaboration between the University Hospital of Zurich, Department of Trauma and IBM, from August 2017 until January 2018. It is a modular tool and allows any user to add a new patient, or work with an existing case. The visualization used the data-driven documents (D3) interactive visualization library to create a responsive graphic. CONCLUSIONS: This application summarizes the experience of 3655 polytrauma patients and might serve as a guide for clinical decisions and educative purposes, as well as new scientific questions for the polytrauma patient. LEVEL OF EVIDENCE: IV.

Implementation of new standard operating procedures for geriatric trauma patients with multiple injuries: a single level I trauma centre study.

BACKGROUND: The demographic changes towards ageing of the populations in developed countries impose a challenge to trauma centres, as geriatric trauma patients require specific diagnostic and therapeutic procedures. This study investigated whether the integration of new standard operating procedures (SOPs) for the resuscitation room (ER) has an impact on the clinical course in geriatric patients. The new SOPs were designed for severely injured adult trauma patients, based on the Advanced Trauma Life Support (ATLS) and imply early whole-body computed tomography (CT), damage control surgery, and the use of goal-directed coagulation management. METHODS: Single-centre cohort study. We included all patients ≥65 years of age with an Injury Severity Score (ISS) ≥ 9 who were admitted to our hospital primarily via ER. A historic cohort was compared to a cohort after the implementation of the new SOPs. RESULTS: We enrolled 311 patients who met the inclusion criteria between 2000 and 2006 (group PreSOP) and 2010-2012 (group SOP). There was a significant reduction in the mortality rate after the implementation of the new SOPs (P = .001). This benefit was seen only for severely injured patients (ISS ≥ 16), but not for moderately injured patients (ISS 9-15). There were no differences with regard to infection rates or rate of palliative care. CONCLUSIONS: We found an association between implementation of new ER SOPs, and a lower mortality rate in severely injured geriatric trauma patients, whereas moderately injured patients did not obtain the same benefit. TRIAL REGISTRATION: Clinicaltrials.gov NCT03319381, retrospectively registered 24 October 2017.

Are Pre-hospital Trauma Deaths Preventable? A Systematic Literature Review.

BACKGROUND: The first and largest peak of trauma mortality is encountered on the trauma site. The aim of this study was to determine whether these trauma-related deaths are preventable. We performed a systematic literature review with a focus on pre-hospital preventable deaths in severely injured patients and their causes. METHODS: Studies published in a peer-reviewed journal between January 1, 1990 and January 10, 2018 were included. Parameters of interest: country of publication, number of patients included, preventable death rate (PP = potentially preventable and DP = definitely preventable), inclusion criteria within studies (pre-hospital only, pre-hospital and hospital deaths), definition of preventability used in each study, type of trauma (blunt versus penetrating), study design (prospective versus retrospective) and causes for preventability mentioned within the study. RESULTS: After a systematic literature search, 19 papers (total 7235 death) were included in this literature review. The majority (63.1%) of studies used autopsies combined with an expert panel to assess the preventability of death in the patients. Pre-hospital death rates range from 14.6 to 47.6%, in which 4.9-11.3% were definitely preventable and 25.8-42.7% were potentially preventable. The most common (27-58%) reason was a delayed treatment of the trauma victims, followed by management (40-60%) and treatment errors (50-76.6%). CONCLUSION: According to our systematic review, a relevant amount of the observed mortality was described as preventable due to delays in treatment and management/treatment errors. Standards in the pre-hospital trauma system and management should be discussed in order to find strategies to reduce mortality.

Assessment of polytraumatized patients according to the Berlin Definition: Does the addition of physiological data really improve interobserver reliability?

BACKGROUND: Several new definitions for categorizing the severely injured as the Berlin Definition have been developed. Here, severely injured patients are selected by additive physiological parameters and by the general Abbreviated Injury Scale (AIS)-based assessment. However, all definitions should conform to an AIS severity coding applied by an expert. We examined the dependence of individual coding on defining injury severity in general and in identifying polytrauma according to several definitions. A precise definition of polytrauma is important for quality management. METHODS: We investigated the interobserver reliability (IR) between several polytrauma definitions for identifying polytrauma using several cut-off levels (ISS ≥16, ≥18, ≥20, ≥25 points, and the Berlin Definition). One hundred and eighty-seven patients were included for analyzing IR of the polytrauma definitions. IR for polytrauma definitions was assessed by Cohen's kappa. RESULTS: IR for identifying polytrauma according to the relevant definitions showed moderate agreement (<0.60) in the ISS cutoff categories (ISS ≥16, ≥18, and ≥20 points), while ISS ≥25 points just reached substantial agreement (0.62) and the Berlin Definition demonstrated a correlation of 0.77 which is nearly perfect agreement (>0.80). CONCLUSION: Compared with the ISS-based definitions of polytrauma, the Berlin Definition proved less dependent on the individual rater. This underlines the need to redefine the selection of severely injured patients. Using the Berlin Definition for identifying polytrauma could improve the comparability of patient data across studies, in trauma center benchmarking, and in quality assurance.

Longitudinal study of a NoGo-P3 event-related potential component following mild traumatic brain injury in adults.

BACKGROUND: Event-related potentials have repeatedly revealed electrophysiological markers of cognitive dysfunction associated with Mild Traumatic Brain Injury (MTBI) and may represent a sensitive tool to guide cognitive rehabilitative interventions. We previously found patients with symptomatic MTBI characterized by smaller P300 (or P3) wave amplitudes in a NoGo-P3 subcomponent in the acute phase of the injury. The goal of this longitudinal study was to investigate whether this early NoGo-P3 subcomponent differs over time in symptomatic MTBI patients and healthy controls. METHODS: We included adults with a diagnosis of MTBI and individually matched healthy controls tested at 1 week, 3 months, and 1 year after the MTBI. Symptoms were assessed by the Rivermead Post-Concussion Symptoms Questionnaire. NoGo-P3 was collected by using a cued Go/NoGo task and the relevant subcomponent was extracted by independent component analysis. RESULTS: Among 53 adults with a diagnosis of MTBI and 53 controls, we included 35 with symptomatic MTBI and 35 matched healthy controls (18 females each group; mean age 34.06±13.15 and 34.26±12.98 years). Amplitudes for the early NoGo-P3 subcomponent were lower for symptomatic MTBI patients than controls (P<0.05) at 1 week post-injury. Furthermore, mixed ANOVA revealed a significant time by group interaction (P<0.05), so the effect of time differed for symptomatic MTBI patients and healthy controls. The amplitudes for MTBI patients normalized from 1 week to 3 months post-injury and were comparable to those of controls from 3 months to 1 year post-injury. However, amplitudes for 3 MTBI patients with particularly severe complaints 1 year post-injury did not normalize and were lower than those for the remaining MTBI sample (P<0.05). CONCLUSIONS: Selected event-related potentials can be used as a sensitive and objective tool to illustrate the cognitive consequences of and recovery after MTBI.

Prefrontal Cortical Thickening after Mild Traumatic Brain Injury: A One-Year Magnetic Resonance Imaging Study.

The objective of this study was to evaluate group-by-time interactions between gray matter morphology of healthy controls and that of patients with mild traumatic brain injury (mTBI) as they transitioned from acute to chronic stages, and to relate these findings to long-term cognitive alterations to identify distinct recovery trajectories between good outcome (GO) and poor outcome (PO). High-resolution T1-weighted magnetic resonance images were acquired in 49 mTBI patients within 7 days and 1 year post-injury and at equivalent times in 49 healthy controls. Using linear mixed-effects models, we performed mass-univariate analyses and associated the results of the interaction with changes in cognitive performance. Morphological alterations indexed by increased or decreased cortical thickness have been expected mainly in frontal, parietal, and temporal brain regions. A significant interaction was found in cortical thickness, spatially restricted to bilateral structures of the prefrontal cortex, showing thickening in mTBI and normal developmental thinning in controls. A discrete thickness increase that can interpreted as the absence of cortical thinning typically seen in the healthy population was associated with cognitive recovery in the GO subgroup, while the exaggerated cortical thickening in the PO patients was linked to worsening cognitive performance. Thickness of the prefrontal cortex is subject to structural alterations during the first year after mTBI. Beside beneficial neuroplasticity, a prolonged state of neuroinflammation for symptomatic patients (maladaptive neuroplasticity) cannot be excluded. If the underlying cellular processes responsible for cortical thickening following mTBI have been determined, brain stimulation or even pharmacological intervention targeting the prefrontal cortex might promote endogenous neural restoration.

Combined intra- and extraperitoneal urinary bladder rupture - a rare seat-belt injury: A case report.

INTRODUCTION: While isolated traumatic urinary bladder injuries are rare, combined intra- and extraperitoneal traumatic urinary bladder ruptures without an underlying fracture are an absolute rarity. PRESENTATION OF CASE: We report a case of combined intra- and extraperitoneal urinary bladder rupture without an underlying fracture resulting from blunt abdominal trauma during a high velocity car accident. A midline laparotomy was performed, and the intra- and extraperitoneal bladder ruptures were surgically treated. DISCUSSION: Based on the presented case the anatomical peculiarities of the urinary bladder and the different trauma mechanisms as well as the resulting lesions, the diagnostic modalities and the treatment options are discussed. CONCLUSION: Despite the rarity of traumatic urinary bladder injuries, and especially in the absence of an underlying fracture, physicians should maintain a high level of suspicion for urologic injuries in the presence of nonspecific lower abdominal pain, gross haematuria and the inability to urinate.