Use of angioembolization, treatment modalities and mortality in association with blunt liver trauma in Germany - a data analysis of the TraumaRegister DGU®.

PURPOSE: Angioembolization (ANGIO) is highly valued in national and international guideline recommendations as a treatment adjunct with blunt liver trauma (BLT). The literature on BLT shows that treatment, regardless of the severity of liver injury, can be accomplished with a high success rate using nonoperative management (NOM). An indication for surgical therapy (SURG) is only seen in hemodynamically instable patients. For Germany, it is unclear how frequently NOM ± ANGIO is actually used, and what mortality is associated with BLT. METHODS: A retrospective systematic data analysis of patients with BLT from the TraumaRegister DGU® was performed. All patients with liver injury AIS ≥ 2 between 2015 and 2020 were included. The focus was to evaluate the use ANGIO as well as treatment selection (NOM vs. SURG) and mortality in relation to liver injury severity. Furthermore, independent risk factors influencing mortality were identified, using multivariate logistic regression. RESULTS: A total of 2353 patients with BLT were included in the analysis. ANGIO was used in 18 cases (0.8%). NOM was performed in 70.9% of all cases, but mainly in less severe liver trauma (AIS ≤ 2, abbreviated injury scale). Liver injuries AIS ≥ 3 were predominantly treated surgically (64.6%). Overall mortality associated with BLT was 16%. Severity of liver injury ≥ AIS 3, age > 60 years, hemodynamic instability (INSTBL), and mass transfusion (≥ 10 packed red blood cells/pRBC) were identified as independent risk factors contributing to mortality in BLT. CONCLUSION: ANGIO is rarely used in BLT, contrary to national and international guideline recommendations. In Germany, liver injuries AIS ≥ 3 are still predominantly treated surgically. BLT is associated with considerable mortality, depending on the presence of specific contributing risk factors.

Minimally invasive reconstruction of acute acromioclavicular joint injuries using the TwinBridge button system.

INTRODUCTION: Acute acromioclavicular joint (ACJ) injuries are among the most common shoulder injuries in active young adults. The most frequently used surgical treatments include the hook plate implantation and arthroscopic treatment using flip-button systems. The aim of this study was to evaluate the results of treating acute ACJ injuries using a new minimally invasive implant based on a flip-button system. MATERIAL AND METHODS: From January 2016 to October 2019, a total of 20 patients with acute ACJ injuries (1 × Type III, 3 × Type IV, 16 × Type V) underwent surgery using the Twinbridge implant (Smith & Nephew). It is a prefabricated construct consisting of two Endobuttons connected with an UltraTape. One button is placed under the coracoid using a special aiming device and two buttons are placed on the clavicle. Preoperatively, 1 day postoperatively, 3 months and at least 1 year postoperatively, patients were clinically examined and bilateral stress view and axial radiographs were obtained. At final follow-up, the simple shoulder test (SST), Taft score, Constant score, and ACJ instability (ACJI) score were recorded and a side-to-side ratio of the coracoclavicular (CC) distance was calculated. RESULTS: All 20 patients were contacted at final follow-up at a mean of 28 (min. 13, max 50) months. Six patients were not willing to come for a clinical and radiographic examination and were contacted via telephone. All six patients were free of complaints. Another two patients free of complaints refused radiographs at final follow-up. The patients presented a mean SST of 99.6% (20 patients, min. 91.7, max. 100), Taft score of 11.6/12 points (12 patients, min. 10, max. 12), ACJI of 85.5/90 points (12 patients, min. 78, max. 90), and a Constant score of 97.1 (14 patients, min. 81.0, max. 100) for the affected shoulder. Preoperative stress view images revealed a mean side-to-side difference of the CC distance with a ratio of 1:2.34 (min. 1:1.80, max. 1:3.33). At final follow-up, CC distance was calculated with a mean ratio of 1:1.12 (min. 1.1, max. 1:1.38). Axial images showed a proper position in all cases. A "perfect" radiological result was achieved in six patients (50%) with a side-to-side CC distance of less than 10% (ratio 1:1.1 or less). A Rockwood type II result was achieved in five patients (42%) with a distance of 10 to 25% (ratio 1.11-1.25). One (8%) presented with a Rockwood type III result with a difference of more than 25% (ratio 1:1.38) and was considered a radiological failure. CONCLUSIONS: When used correctly, the Twinbridge implant offers good-to-excellent clinical and radiographic results using a minimally invasive surgical technique. Complication rate is comparable to other button-systems.

The impact of prehospital tranexamic acid on mortality and transfusion requirements: match-pair analysis from the nationwide German TraumaRegister DGU®.

BACKGROUND: Outcome data about the use of tranexamic acid (TXA) in civilian patients in mature trauma systems are scarce. The aim of this study was to determine how severely injured patients are affected by the widespread prehospital use of TXA in Germany. METHODS: The international TraumaRegister DGU® was retrospectively analyzed for severely injured patients with risk of bleeding (2015 until 2019) treated with at least one dose of TXA in the prehospital phase (TXA group). These were matched with patients who had not received prehospital TXA (control group), applying propensity score-based matching. Adult patients (≥ 16) admitted to a trauma center in Germany with an Injury Severity Score (ISS) ≥ 9 points were included. RESULTS: The matching yielded two comparable cohorts (n = 2275 in each group), and the mean ISS was 32.4 ± 14.7 in TXA group vs. 32.0 ± 14.5 in control group (p = 0.378). Around a third in both groups received one dose of TXA after hospital admission. TXA patients were significantly more transfused (p = 0.022), but needed significantly less packed red blood cells (p ≤ 0.001) and fresh frozen plasma (p = 0.023), when transfused. Massive transfusion rate was significantly lower in the TXA group (5.5% versus 7.2%, p = 0.015). Mortality was similar except for early mortality after 6 h (p = 0.004) and 12 h (p = 0.045). Among non-survivors hemorrhage as leading cause of death was less in the TXA group (3.0% vs. 4.3%, p = 0.021). Thromboembolic events were not significantly different between both groups (TXA 6.1%, control 4.9%, p = 0.080). CONCLUSION: This is the largest civilian study in which the effect of prehospital TXA use in a mature trauma system has been examined. TXA use in severely injured patients was associated with a significantly lower risk of massive transfusion and lower mortality in the early in-hospital treatment period. Due to repetitive administration, a dose-dependent effect of TXA must be discussed.

Vancomycin-soaking of the graft reduces the incidence of septic arthritis following ACL reconstruction: results of a systematic review and meta-analysis.

PURPOSE: (1) To compare the incidence of post-operative septic arthritis following anterior cruciate ligament reconstruction (ACLR) between patients receiving routine pre-operative intravenous (IV) prophylaxis only intravenous (IV) infection prophylaxis and patients receiving additional graft-soaking in a vancomycin solution (5 mg/ml) perioperatively. (2) To review the literature regarding effects of graft-soaking in vancomycin solutions on outcomes, complication rates and tendon properties in ACLR. METHODS: To identify studies pertaining to routine pre-operative IV prophylaxis and additional usage of intra-operative vancomycin-soaked grafts in primary ACLR, the Cochrane Library, SCOPUS and MEDLINE were searched till June 2018 for English and German language studies of all levels of evidence following the PRISMA guidelines. Additionally, all accepted abstracts at the ESSKA 2018, ISAKOS 2017, AGA 2017 and AOSSM 2017 meetings were screened. Data regarding the incidence of septic arthritis were abstracted and combined in a meta-analysis. Data including outcome scores, complication rates and in vitro analyses of tendon properties were collected and summarized descriptively. RESULTS: Upon screening 785 titles, 8 studies were included. These studies examined 5,075 patients following ACLR and followed from 6 to 52 weeks post-operatively. Of those 2099 patients in the routine pre-operative IV prophylaxis group, 44 (2.1%) cases of early septic arthritis were reported. In contrast, there were no reports of septic arthritis following ACLR in 2976 cases of vancomycin-soaked grafts. The meta-analysis yielded an odds ratio of 0.04 (0.01-0.16) favouring the addition of intra-operative vancomycin-soaking of grafts. Across all available studies, no differences in clinical outcome (i.e. incidence of ACL revision, IKDC score, Tegner score), biomechanical tendon properties, or cartilage integrity between patients with and without vancomycin-soaked grafts were identified. CONCLUSION: The incidence of septic arthritis following ACLR can be reduced dramatically by vancomycin-soaking the grafts intra-operatively prior to graft passage and fixation. Within the limitation confines of this study, intra-operative graft-soaking in vancomycin appears to be a safe and effective method to reduce the incidence of septic arthritis following ACLR. Still, it remains debatable if the available data facilitate the recommendation for a universal application of vancomycin-soaking for all ACLR patients or if it should be reserved for patients at risk, including the use hamstring tendons, revision cases and in the presence of medical preconditions. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and Level IV studies.

High non-anatomic tunnel position rates in ACL reconstruction failure using both transtibial and anteromedial tunnel drilling techniques.

INTRODUCTION: Although it is well known from cadaveric and biomechanical studies that transtibial femoral tunnel (TT) positioning techniques are associated with non-anatomic tunnel positions, controversial data exist as so far no clinical differences could have been found, comparing transtibial with anteromedial techniques (AM). The purpose of the study was to analyze if graft failure following TT ACL reconstruction was more commonly associated with non-anatomic tunnel position in comparison with the AM technique. We hypothesized that, compared to AM techniques, non-anatomic tunnel positions correlate with TT tunnel positioning techniques. MATERIALS AND METHODS: A total of 147 cases of ACL revision surgery were analyzed retrospectively. Primary ACL reconstructions were analyzed regarding the femoral tunnel drilling technique. Femoral and tibial tunnel positions were determined on CT scans using validated radiographic measurement methods. Correlation analysis was performed to determine differences between TT and AM techniques. RESULTS: A total of 101 cases were included, of whom 64 (63.4%) underwent the TT technique and 37 (36.6%) the AM technique for primary ACL reconstruction. Non-anatomic femoral tunnel positions were found in 77.2% and non-anatomical tibial tunnel positions in 40.1%. No correlations were found comparing tunnel positions in TT and AM techniques, revealing non-anatomic femoral tunnel positions in 79.7 and 73% and non-anatomic tibial tunnel positions in 43.7 and 35.1%, respectively (p > 0.05). CONCLUSIONS: Considerable rates of non-anatomic femoral and tibial tunnel positions were found in ACL revisions with both transtibial and anteromedial femoral drilling techniques. Despite the potential of placing tunnels more anatomically using an additional AM portal, this technique does not ensure anatomic tunnel positioning. Consequently, the data highlight the importance of anatomic tunnel positioning in primary ACL reconstruction, regardless of the applied drilling technique.

Prehospital administration of tranexamic acid in trauma patients.

BACKGROUND: Evidence on prehospital administration of the antifibrinolytic tranexamic acid (TXA) in civilian trauma populations is scarce. The aim was to study whether prehospital TXA use in trauma patients was associated with improved outcomes. METHODS: The prehospital database of the ADAC (General German Automobile Club) Air Rescue Service was linked with the TraumaRegister of the German Trauma Society to reidentify patients documented in both registries. Primarily admitted trauma patients (2012 until 2014) who were treated with TXA during the prehospital phase were matched with patients who had not received prehospital TXA, applying propensity score-based matching. RESULTS: The matching yielded two identical cohorts (n = 258 in each group), since there were no significant differences in demographics or injury characteristics (mean Injury Severity Score 24 ± 14 [TXA] vs. 24 ± 16 [control]; p = 0.46). The majority had sustained blunt injury (90.3 % vs. 93.0 %; p = 0.34). There were no differences with respect to prehospital therapy, including rates of intubation, chest tube insertion or both administration of i.v. fluids and catecholamines. During ER treatment, the TXA cohort received fewer numbers of red blood cells and plasma units, but without reaching statistical significance. Incidences of organ failure, sepsis or thromboembolism showed no significant differences as well, although data were incomplete for these parameters. Early mortality was significantly lower in the TXA group (e.g., 24-h mortality 5.8 % [TXA] vs. 12.4 % [control]; p = 0.01), and mean time to death was 8.8 ± 13.4 days vs. 3.6 ± 4.9 days, respectively (p = 0.001). Overall hospital mortality was similar in both groups (14.7 % vs. 16.3 %; p = 0.72). The most pronounced mortality difference was observed in patients with a high propensity score, reflecting severe injury load. CONCLUSIONS: This is the first civilian study, to our knowledge, in which the effect of prehospital TXA use in trauma patients has been examined. TXA was associated with prolonged time to death and significantly improved early survival. Until further evidence emerges, the results of this study support the use of TXA during prehospital treatment of severely injured patients.

Level of Evidence Analysis for the Latest German National Guideline on Treatment of Patients with Severe and Multiple Injuries and ATLS.

PURPOSE: Advanced Trauma Life Support (ATLS®) is one of the world's best-known training programs for medical providers. Revisions of the ATLS manual have been evidence based for a number of years. In 2011, a level 3 (S3) evidence- and consensus-based guideline on the treatment of patients with severe and multiple injuries was published in Germany. The scope of this study was the systematic comparison of the educational content of the ATLS concept and the interdisciplinary "S3 polytrauma guideline." METHODS: A total of 123 key recommendations of the guideline were compared with the content of the ATLS manual (9th edition). Depending on the level of agreement, the recommendations were classed in the following categories: (1) Agreement. (2) Minor variation. (3) Major variation. RESULTS: An overall 86% conformity was found between the key recommendations of the guideline and the ATLS® manual. The ATLS® primary survey (ABCDE) showed an 85% conformity. The degree of conformity for the individual priorities was as follows: A (Airway) 79%, B (Breathing) 79%, C (Circulation) 86%, D (Disability) 93%, E (Exposure) 100%. The ATLS® secondary survey showed a 94% conformity. The main differences were in the areas of anesthetic induction, fluid administration, and coagulation therapy. CONCLUSIONS: According to our comparison, the educational content and manual of the ATLS are largely compatible with a high level of evidence S3 guideline. However, subsequent editions of both the ATLS® and the S3 guideline should re-examine and reassess a number of aspects.

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

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

Excellent results of lesser tuberosity transfer in acute locked posterior shoulder dislocation.

PURPOSE: The aim of the present study was to evaluate the clinical and radiological results of lesser tuberosity transfer in acute locked posterior shoulder dislocation with a humeral head defect between 25 and 45 %. METHODS: Clinical and radiological results of seven patients with locked posterior shoulder dislocation with a humeral head defect between 25 and 45 % which were managed with a modification of the McLaughlin procedure within 14 days after injury were evaluated retrospectively after a mean follow-up of 41 months. RESULTS: All shoulders remained stable. The results were good in one and excellent in six patients with a median absolute Constant score of 92 (range 80-98). Mean active pain-free abduction was 171.4° (SD 6.4), mean flexion was 175.7° (SD 4.9), and mean external rotation was 54.3° (SD 17.6). Internal rotation was restricted in all patients. There were no radiological signs of osteoarthritis. CONCLUSIONS: Lesser tuberosity transfer shows excellent clinical and radiographic mid-term results in acute cases of locked posterior shoulder dislocation with a reverse Hill-Sachs lesion between 25 and 45 %.

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

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

High complication rate following distal biceps refixation with cortical button.

PURPOSE: There are several methods for the refixation of the distal biceps tendon which show a variable complication rate. The aim of the present study was to evaluate the clinical outcome and complication rate after distal biceps repair in cortical button technique. METHODS: Clinical results, complications, strength of elbow flexion and supination and radiological evidence of heterotopic ossification in patients reporting persistent pain were evaluated in 27 male patients after an average of 36.1 month following distal biceps tendon repair in cortical button technique. RESULTS: The mean Mayo elbow performance score was 95.9 (SD 11.9), the mean disabilities of the arm, shoulder and hand score was 1.9 (SD 4.9) and the mean American shoulder and elbow surgeons (ASES) score was 94.6 (SD 11.6). The mean flexion and supination strength of the involved side relative to the uninvolved side was 91.7 % (SD 12.6) and 87.8 % (SD 15.9). Nine patients had 14 different complications including four transient lesions of the posterior interosseous nerve, two persistent lesions of the superficial branch of the radial nerve, one symptomatic massive heterotopic ossification and one disengaged cortical button. Three patients had six revisions. Patients with complications had a significantly lower relative supination strength, Mayo elbow performance score, ASES score, pain on VAS (p < 0.05 each) and satisfaction (p = 0.005). CONCLUSIONS: As described for other techniques there is a high complication rate of distal biceps tendon repair in cortical button technique which resulted in inferior functional results and satisfaction. Surgeons treating patients with distal biceps tendon rupture should know the specific complications and know how to avoid them. LEVEL OF EVIDENCE: Case series with no comparison group, Level IV.

[Management of a multifragmentary glenoid fracture : Case report of a two-stage surgical procedure]. / Management einer mehrfragmentären Glenoidfraktur : Fallbericht eines zweizeitigen Operationsverfahrens.

This article describes a multifragmentary glenoid fracture in a 65-year-old patient after falling from a height of 2 m. The accident led to complete Y­shaped destruction of the glenohumeral joint with a large posteroinferior fragment and a large anteroinferior glenoid fragment. The treatment consisted of a two-stage surgical procedure and a combination of open and arthroscopic techniques. First, open surgery of one fragment from the dorsal side was performed using screw osteosynthesis. Arthroscopic refixation of the anterior glenoid fragment (bony Bankart lesion) followed 4 weeks later using a guided Endobutton® technique (Smith & Nephew). Ideberg type 6 multifragmentary glenoid fractures are rare and should be treated surgically, especially with dislocated fragments, instability in the glenohumeral joint and in younger patients. Given the lack of evidence in the literature, individual surgical strategies are necessary.

Return to sport after conservative treatment of elbow dislocation in judoka.

BACKGROUND: Injuries to the elbow are frequent in judo combat, but studies on down-time and effect on performance after conservative treatments are rare. This issue is particularly relevant for elbow dislocations in high-performance patients such as elite athletes. The purpose of this study was to evaluate (1) time-loss and (2) the regained level of performance in judoka after conservative treatment of simple elbow dislocation. METHODS: In cooperation with the European Judo Union, judoka were asked to complete a 139-item survey regarding elbow injuries they suffered during their career. Besides demographics, injury data, diagnosis and treatment options, the athletes were asked about down-time and reductions in performance level. This study enrolled 108 judoka with conservative treatment of elbow dislocation out of a population of 5426 volunteers. RESULTS: 69% (n=74) reported a time-loss of less than three months; 6% reported a time-loss of more than six months. The majority (68%, n=73) reported that they had returned to their previous performance level, while 22% (n=24) suffered from a slightly reduced level of performance. In the subgroup of international and national athletes (n=54), 63% returned to judo after less than three months, with 72% achieving the same level and 15% reporting a slightly reduced performance level. Level of performance and time lost after conservative treatment for elbow dislocations were comparable for male and female judoka. CONCLUSION: Approximately two out of three judoka returned to the same level of performance after three months of down-time after undergoing conservative therapy for simple elbow dislocations. Despite the high performance level of the study population, conservative treatment of simple elbow dislocation resulted in satisfactory outcomes. The presented data can guide medical professionals and competitive-level contact-sport athletes with respect to expectations in the process of returning to sport.

Psychological readiness is related to return to sport in judo injuries: a cross-sectional study.

BACKGROUND: The aim of this study is to investigate the influence of a judoka's psychological readiness in relation to his ability to return to sport. At the present time, the relationship between physical and psychological readiness to return to sport has not been adequately elucidated. METHODS: This is a cross-sectional study. An online survey was distributed via social networks and the German Judo Association collecting data from competitive and recreational judo athletes. The survey collected data on participants' characteristics, history of injury, and psychological readiness to return to sport after injury as determined by either the Anterior Cruciate Ligament-Return to Sport after Injury Scale, the Shoulder Instability-Return to Sport after Injury Scale, or a modified version of the Return to Sport after Injury Scale depending on the respective type of injury. RESULTS: The study included 383 judo athletes (272 competitive judo athletes and 112 recreational judo athletes). Regardless of injury location, athletes who achieved return to sports (M = 70.67; SD = 16.47) had higher RSI scores than athletes that did not return to sports (M = 53.88; SD = 19.12; p < 0.0001). Male athletes (M = 65.60; SD = 19.34) did show significantly higher RSI scores than female athletes (M = 60.45; SD = 19.46). The RSI score differed for different time loss categories, F(7, 375) = 11.309, p < 0.001, η2 = .174 with decreasing RSI scores for longer time loss and lowest RSI scores in athletes, who never returned to sports. RSI scores of athletes with knee injuries differed from athletes with other injury locations (10.23, 95% CI [4.08, 16.38]). After adjusting for time loss due to injury, competitive athletes had higher RSI scores than competitive athletes (F (1, 382) = 7.250, p < 0.001, partial η2 = .02). Conservatively treated athletes (M = 66.58; SD = 18.54) had higher RSI scores than surgically treated athletes (M = 59.05; SD = 20.01; p < 0.05). CONCLUSION: Based on the data of this study, type of injury, sport level, treatment method, and gender appear to influence psychological readiness on judoka and their ability to return to sport. The multiple factors that influence a judoka and their ability to return to sport argue for individualized treatment of judoka and their psychological state after injury in the return to sport process.

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

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

Glasgow Coma Scale as a predictor for hemocoagulative disorders after blunt pediatric traumatic brain injury.

OBJECTIVE: Coagulopathy is a complication of traumatic brain injury and its presence after injury has been identified as a risk factor for prognosis. It was our aim to determine whether neurologic findings reflected by Glasgow Coma Scale at initial resuscitation can predict hemocoagulative disorders resulting from traumatic brain injury that may aggravate clinical sequelae and outcome in children. DESIGN: A retrospective analysis of 200 datasets from children with blunt, isolated traumatic brain injury documented in the Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie was conducted. Inclusion criteria were primary admission, age <14 yrs, and sustained isolated blunt traumatic brain injury. SETTING: Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie-affiliated trauma centers in Germany. PATIENTS: : Two hundred datasets of children (age <14 yrs) with blunt isolated traumatic brain injury were analyzed: children were subdivided into two groups according to Glasgow Coma Scale at the scene (Glasgow Coma Scale ≤ 8 vs. Glasgow Coma Scale >8) and reviewed for coagulation abnormalities upon emergency room admission and outcome. MEASUREMENT AND MAIN RESULTS: Fifty-one percent (n = 102 of 200) of children had Glasgow Coma Scale >8 and 49% (n = 98 of 200) had Glasgow Coma Scale ≤ 8 at the scene. The incidence of coagulopathy at admission was higher in children with Glasgow Coma Scale ≤ 8 compared to children with Glasgow Coma Scale >8: 44% (n = 31 of 71) vs. 14% (n = 11 of 79) (p < .001). Multivariate logistic regression revealed that Glasgow Coma Scale ≤ 8 at scene was associated with coagulopathy at admission (odds ratio 3.378, p = .009) and stepwise regression identified Glasgow Coma Scale ≤ 8 as an independent risk factor for coagulopathy. Mortality in children with Glasgow Coma Scale ≤ 8 at scene was substantially higher with the presence of coagulation abnormalities at admission compared to children in which coagulopathy was absent (51.6%, n = 16 of 31 vs. 5% n = 2 of 40). CONCLUSIONS: Glasgow Coma Scale ≤ 8 at scene in children with isolated traumatic brain injury is associated with increased risk for coagulopathy and mortality. These results may guide laboratory testing, management, and blood bank resources in acute pediatric trauma care.

[Treatment of severely injured patients by emergency physicians from different medical specialties : A retrospective multicenter investigation of data from the ADAC Air Recue Service and the German TraumaRegister DGU®]. / Schwerverletztenversorgung durch Notärzte aus unterschiedlichen Fachgebieten : Eine retrospektive, multizentrische Untersuchung aus Daten der ADAC Luftrettung und des deutschen TraumaRegister DGU®.

BACKGROUND AND OBJECTIVE: The level 3 guidelines on treatment of patients with severe/multiple injuries provide a defined framework for an appropriate treatment of these patients. It is presumed that prehospital diagnostic and therapeutic decisions are affected by the clinical expertise and the medical disciplines of the emergency physicians. METHODS: Retrospective, multicenter study based on data from the ADAC Air Recue Service and the TraumaRegister DGU®. In the study period 2011-2015, a total of 11,019 seriously injured patients were included. They were treated by emergency physicians from the following disciplines: anesthesiology (ANÄ), internal medicine (INN) and surgery (CHIR). RESULTS: Of the patients 81.9% were treated by ANÄ, 7.6% by INN and 10.5% by CHIR. Preclinically, 40.5% of patients were intubated (ANÄ 43.0%, INN 31.2%, CHIR 28.3%; p < 0.001), 5.5% received pleural decompression (ANÄ 5.9%, INN 4.2%, CHIR 2.8%; p = 0.004),and 10.8% were treated with catecholamines (ANÄ 11.3%, INN 8.3%, CHIR 8.3%; p = 0.022). Unconscious patients were intubated in 96.0% (ANÄ 96.1%, INN 97.7%, CHIR 93.9%; p = 0.205). The mortality was not influenced by the medical specialty of the emergency physician. CONCLUSION: In this air rescue cohort differences in indications for invasive procedures were observed between the groups. This may be caused by their clinical background. Using the example of intubation, it has been shown that guideline recommendations were closely followed irrespective of the medical specialty of the emergency physician.

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

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

Mechanism, frequency, transfusion and outcome of severe trauma in coagulopathic paediatric patients.

PURPOSE: Acute traumatic coagulopathy can result in uncontrolled haemorrhage responsible for the majority of early deaths after adult trauma. Data on the frequency, transfusion practice and outcome of severe trauma haemorrhage in paediatric patients are inconsistent. METHODS: Datasets from paediatric trauma patients were retrieved from the registry of the German trauma society (TR-DGU®) between 2009 and 2016. Coagulopathy was defined by a Quick's value < 70% (INR (international normalized ratio) > 1.4) and/or thrombocytes ≤ 100 k upon emergency room admission. Children were grouped according to age in 4 different groups (A: 1-5, B: 6-10, C: 11-15 and D: 16-17 years). Prevalence of coagulopathy was assessed. Demographics, injury severity, haemostatic management including transfusions and mortality were described. RESULTS: 5351 primary admitted children ≤ 17 years with an abbreviated injury scale (AIS) ≥ 3 and complete datasets were included. The prevalence of coagulopathy was 13.7% (733/5351). The majority of the children sustained blunt trauma (more than 90% independent of age group) and a combination of traumatic brain injury (TBI) and any other trauma in more than 60% (A, C, D) and in 53.8% in group B. Coagulopathy occurred the most among the youngest (A: 18.2%), followed by all other age groups with approximately 13%. Overall mortality was the highest in the youngest (A: 40.9%) and among the youngest patients with traumatic brain injury (A: 71.4% and B: 47.1%). Transfusion of packed red blood cells (pRBCs) and fresh frozen plasma (FFPs) occurred almost in a 2:1 ratio (or less) across all age subgroups. CONCLUSION: Traumatic haemorrhage in association with coagulopathy and severe shock is a major challenge in paediatric trauma across all age groups.

Development of a modified cross-over hop test to reduce measurement errors in return-to-competition testing.

CONTEXT: Hop tests play an important role in the rehabilitation process after injuries. A comparison of the jumping distances of both extremities allows for an evaluation of the injured limb. In the conventional cross-over hop test for distance, the jump width (medial vs. lateral) that the athlete has to cross during the jump is not standardised and therefore highly variable. This affects the absolute jump length in each jump series. HYPOTHESIS: Modifying the test may reduce the jump length variance between test series of an athlete as well as the test-dependent variations in the cross-over hop for distance. METHODS: N = 47 athletes from the German and French national Judo youth teams were included in the study (age: 15.3 years ±â€Š13-17). A modified version of the cross-over hop for distance was developed with a cross-over width of 50 cm and a fixed landing zone of 10 cm. The jump lengths of the conventional test and the modified test were documented. The change in jump length variations of the two sexes were compared. RESULTS: The mean value of the coefficient of variation decreased significantly from 4.09 % to 2.83 % (p < 0.01) due to the test modification. This resulted in an absolute improvement in accuracy of 1.26 % and a relative improvement of 30.8 %. A comparison of the limb symmetry index between the conventional and the modified cross-over hop for distance revealed no significant differences. CONCLUSION: The modified cross-over hop for distance showed a significantly lower variation in jump lengths compared with the conventional cross-over hop for distance. As a result, more accurate statements can be made regarding the patient's return-to-competition progress.