[Emergency intervention rate in the emergency room depending on the alerting criteria : Prospective data analysis of a supraregional trauma center]. / Notfallinterventionsrate bei Schockraumpatienten in Abhängigkeit von den Alarmierungskriterien : Prospektive Datenanalyse eines überregionalen Traumazentrums.

Trauma team alert (TTA) to the emergency room (ER) takes place in the event of disturbed vital signs or serious injuries (A criteria) or after a dangerous accident (B criteria). Due to low specificity and limited personnel resources, TTA is questioned for B criteria. The consequences would be an increase in undertriage and thus endangering patients. Due to the lack of data it is unclear whether adapted ER teams would be a solution to the problem.The aim of the study was to describe ER patients according to the TTA criteria and to collect the corresponding emergency intervention rates in ER.Over 1 year, all TTAs of a supraregional trauma center were prospectively recorded, categorized according to TTA criteria (A, B and NULL criteria) and compared descriptively. NULL criteria were TTAs for which neither A nor B criteria were met. Treatment data were documented according to the TraumaRegister DGU® standard form. Emergency interventions were intubation, chest tube, cardiopulmonary resuscitation, transfusion, coagulation substitution, external pelvic stabilization and surgical hemostasis.The TTA due to A, B and NULL criteria were performed in 19.5%, 51.2% and 29.3%, respectively. The mean injury severity (ISS ± standard deviation) was 20.6 ± 21.3 for A criteria, significantly higher than for B criteria (8.0 ± 7.1) and NULL criteria (5.6 ± 8.2). The emergency intervention rate for A , B and NULL criteria was 75%, 6% and 2.1%, respectively.Differentiation according to the TTA criteria results in patient collectives with different injury severity and emergency intervention rates. This result justifies considerations to adjust team composition based on TTA criteria, as long as it is ensured that critical conditions can be identified and remedied by adapted teams.

[Future perspective of the TraumaRegister DGU® : Further development, additional modules and potential limits]. / Zukunftsperspektiven des TraumaRegister DGU® : Weiterentwicklung, Zusatzmodule und potenzielle Grenzen.

Since its founding in 1993 the TraumaRegister DGU® has become one of the largest registries especially in terms of data diversity. Since the introduction of the TraumaNetzwerk DGU®, the TraumaRegister DGU® has enabled a quasi-nationwide picture of the quality of care of severely injured patients in Germany. The register is subject to constant development, under the guidance of the working groups of the German Society for Trauma Surgery (DGU). The first modular expansion of special injury entities (craniocerebral trauma and complex hand injuries) is currently taking place. The future developments will involve the extension of the register to certain injury patterns. The existing registry will also be supplemented with other recorded qualities (from the supplementary serum database up to the quality of life). This makes the TraumaRegister DGU® a tool for quality assurance and science which is well prepared for the future.

[Current standard of care for initial management of open fractures in emergency departments : A nationwide survey in German trauma centers]. / Realität initialer Versorgung offener Frakturen in deutschen Notaufnahmen : Eine Umfrage aus der Sektion NIS der DGU.

BACKGROUND: Limiting the morbidity of open fractures requires highly specific initial treatment. In addition to a stringent surgical strategy, correct antibiotic prophylaxis seems to be associated with an improved outcome. In the current literature, the duration and type of antibiotic prophylaxis are under discussion. The aim of the study was to survey the current initial treatment regimes for open fractures in German emergency departments. MATERIAL AND METHODS: With an online-based anonymous 16-item questionnaire all 3006 members of the German Trauma Society were surveyed. A total of 585 questionnaires (19.5 %) were returned completed. This article presents a descriptive analysis of the current state of treatment. RESULTS: Mainly specialists (35 %), senior physicians (30 %) and chief physicians (17 %) answered as well as interns (8 %) and out-patient practitioners (10 %). Of the participants 65 % did not accept the classification of emergency services; however, 93 % carried out urgent or emergency surgery, 84 % started an antibiotic prophylaxis in the emergency department and 63 % used a standard operating procedure (SOP). A total of 60 % used 1 antibiotic drug, 25 % used 2 and 15 % used 3 or more substances. An antibiotic treatment for more than 3 days was performed by 60 % of participants. CONCLUSION: The early initiation of antibiotic prophylaxis seems to be the standard practice in German emergency departments as well as early surgery. Strategies to improve the communication between prehospital and in-hospital teams, as well as graded antibiotic prophylaxis depending on the severity of soft tissue damage are needed.

[Essential measures for prehospital treatment of severely injured patients: The trauma care bundle]. / Wesentliche Maßnahmen zur prähospitalen Versorgung schwerverletzter Patienten: Das Trauma Care Bundle.

BACKGROUND: In order to ensure adequate treatment and to avoid complications, care bundles are increasingly being implemented. These are comprehensive and evidence-based procedures for the treatment of individual diseases or injuries which should be carried out for every patient. The aim of this study was to define a care bundle for the prehospital treatment of severely injured patients. MATERIAL AND METHODS: The scientific contents of the bundle were gathered from the interdisciplinary evidence-based S3 guidelines for the treatment of severely injured patients by the German Trauma Society. The ABCDE scheme suggested by the prehospital trauma life support (PHTLS®) and the advanced trauma life support (ATLS®) functioned as a matrix for the individual elements in the bundles. The identified elements were finalized by a consensus process. RESULTS AND DISCUSSION: A bundle of six elements was suggested and a comprehensive summary of key items during prehospital management of severely injured patients was identified. In a next step the effectiveness of the care bundle should be evaluated in a clinical trial.

[Current practice in coagulation and transfusion therapy in multiple trauma patients: A German nation-wide online survey]. / Stand der Gerinnungs- und Transfusionstherapie beim Schwerverletzten : Eine deutschlandweite Online-Umfrage.

BACKGROUND: In recent years, the treatment of trauma-associated coagulopathy and bleeding has advanced enormously. The aim of this study was to assess the current practice of coagulation and transfusion management in Germany. PATIENTS AND METHODS: From October 2011 until January 2012 we conducted a survey via online-questionnaire that was sent per E-Mail to all members of the German Society for Trauma Surgery. It comprised 12 questions with respect to current treatment of coagulopathy and haemorrhage in trauma patients. RESULTS: The response rate was 145/3006 (5 %). The respondents had following specialties: 77.2 % trauma surgery 15.9 % anesthesiology, 6.9 % others. 64 % of respondents were employed by a Level 1 trauma centre, wheras 17 % worked in a local level 3 centre. The majority (94 %) claimed to treat hypothermia regularly. Only about half of the participants reported to follow a massive transfusion protocol in their institution. The potential components of these protocols were reported in varying rates, being it well-established components (e.g. FFP 78 %; Fibrinogen 75 %) or therapies with poor evidence in multiple trauma (Desmopressin 39 %, rFVIIa 47 %). Calcium was provided by only 48 % of respondents although generally recommended in all guidelines. CONCLUSION: The current study suggests that in Germany strategies and principles regarding management of trauma-associated coagulopathy are standardized only poorly. Level 1 centres appear to apply a more advanced approach, however to much variability exists with respect to the components of the transfusion protocols. The low response rate indicates that most German trauma surgeons consider coagulation and hemorrhage as "expert-topics" beyond their field of duty.

[New aspects of polytrauma treatment - current facts and developments: report of the first annual conference of the Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS)]. / Neuigkeiten aus der Polytraumaversorgung: aktuelle Fakten und Entwicklungen: Bericht vom 1. Jahreskongress der Sektion Notfall-, Intensivmedizin und Schwerverletztenversorgung (Sektion NIS).

Taking care of severely injured patients is a complex and ambitious mission. The committee on emergency medicine, intensive care and trauma management of the German Society of Trauma Surgery (Sektion NIS) has accepted this challenge. On the occasion of the release of the annual report of the TraumaRegistry DGU®, the committee held its first annual congress in order to provide members and an intrigued audience with current trends and results from the latest research in national trauma care ranging from the animal facility to the S3 guidelines. Topics of focus were new realizations based on data from the TraumaRegistry DGU® and means of quality assurance in trauma care. This article gives a report on the meeting and summarizes the major results of the presented studies and the latest deployments in this field of trauma research.

[Interhospital transfer of severely injured patients in Germany. Evaluation of the DGU trauma register]. / Verlegungsrealität schwerverletzter Patienten in Deutschland. Eine Auswertung im TraumaRegister DGU.

BACKGROUND: The TraumaNetzwerk(D) DGU was founded 3 years ago and since then the majority of trauma centers have been registered and organized into regional trauma network services (TNW). Within these networks assessment criteria for transferring patients to higher level hospitals are defined. The purpose of this study was to evaluate the incidence, causes, implications and quality of care for patients with major trauma who were transferred for definitive treatment before implementation of the TraumaNetzwerk(D) DGU in Germany. PATIENT AND METHODS: The data of 19,035 patients listed in the German Trauma Register of the German Society for Trauma Surgery (DGU, 2002-2007) were analyzed. Patients with an injury severity score (ISS) >9 and a blood pressure documented on admission were included into the study. Data were allocated according to patients where therapy was performed completely in the primary hospital of admission (group I; n=16,033; 84.2%) and patients transferred after primary care from one hospital to another centre for definitive care (group II; n=3,002; 15.8%). Comparative parameters were the pattern and severity of injury, physiological state on admission and clinical outcome. RESULTS: Mean ISS and percentage of patients with an ISS ≥25 did not differ significantly between groups. Of the patients who were transferred to a higher level trauma centre (group II) 20.7% needed catecholamines on admission, 10.1% were in shock (blood pressure <90 mmHg) and 2.5% of the patients underwent resuscitation in the emergency department. Patients of group II had a considerably longer hospital stay (31.2±35.5 days) than patients of group I (24.8±27.1 days). Furthermore, treatment costs were significantly higher for group II (I: EUR 23,870; II: EUR 26,054). CONCLUSIONS: A relevant percentage of patients transferred from one hospital to another were hemodynamically and clinically unstable. To what extent the quality of patient transfer and therefore major trauma care is improved by the implementation of regional trauma networks in Germany remains to be seen over the next years.

[Trauma research net of the German Society for Orthopaedics and Trauma Surgery]. / Netzwerk Traumaforschung der Deutschen Gesellschaft für Orthopädie und Unfallchirurgie.

A first meeting of the recently founded "Trauma Research Net" of the German Society for Orthopaedics and Trauma Surgery (DGOU e.V.) took place at the Reisensburg Castle, Günzburg, from 24 to 26 February 2011. Numerous representatives of trauma-related Research Institutes and University Hospitals in Germany demonstrated their main research foci. There was also an open discussion of current problems in trauma research, especially the lack of junior researchers and nationwide collaborations as well as limited information about the research topics of individual research groups. The overall research efforts of the "Trauma Research Net" apparently focus on fracture, multiple injury and inflammation on an organ and cellular level. Furthermore, an up-to-date matrix of the existing methods has been generated which is now provided for the networker. The common middle-term goal of the "Trauma Research Net" is the inclusive, intensive scientific exchange as well as the generation and workup of common hypotheses using standard operating procedures. In the long term, the resulting clustered research activities are intended to address and resolve clinically relevant questions in the field of trauma research.

[Platelet-rich plasma combined with autologous cancellous bone : An alternative therapy for persistent non-union?]. / Platelet-rich-Plasma in Kombination mit autologer Spongiosa : Eine Alternative bei therapierefraktären Pseudarthrosen?

BACKGROUND: In addition to a stabile osteosynthesis autologous cancellous bone graft remains an essential therapy option in persistent non-union. Despite this therapy regimen persistent non-union can occasionally occur. The aim of this study was to evaluate the treatment of persistent non-union with a combination of platelet-rich plasma (PRP) and autologous cancellous bone. MATERIAL AND METHODS: In this prospective study 17 patients with persistent non-union of long bones were treated by a combination of PRP and autologous iliac crest bone. Inclusion criteria were a minimum of one previously failed cancellous bone transplantation and an atrophic non-union persisting for 6-14 months (mean 9 months). The patients were examined clinically and radiologically at intervals of 3, 6 and 9 months postoperatively. RESULTS: After an average time of 17 months (range 15-23 months) the patients were treated by a combination of PRP and autologous cancellous bone. In all cases the non-union was successfully treated and osseous bridging was found radiologically after an average of 5 months (range 4-7 months) without any complications. CONCLUSION: The combination of PRP and autologous cancellous bone appears to be a safe and effective method for treatment of persistent non-union. The use of PRP does not result in substantial additional costs. Allergies and graft versus host reactions are not expected because of the autologous origin.

[Measurability of the quality of care of the severely injured]. / Messbarkeit der Qualität in der Schwerverletztenversorgung.

The care of severely injured patients is characterized by the heterogeneity of the clinical picture and the time-critical aspects of many forms of treatment in the acute phase, so that quality measurement and assessment is always complex. In order to be able to operate a meaningful and structured quality management the quality must be validly measured and it must be defined what quality is. To handle this complex picture the quality of care for the severely injured is divided into three levels: structural quality, process quality and outcome quality. With respect to structural quality there are clear guidelines for personnel and structural equipment of hospitals for the optimal care of severely injured patients. This is regularly checked in Germany through trauma center certification as part of the TraumaNetzwerk DGU®. Process quality can also be measured in the care of severely injured patients. With the TraumaRegister DGU® annual report in 2017, 14 newly developed quality indicators were introduced. Due to the comprehensive participation of hospitals in the TraumaRegister DGU® structured external quality assurance is possible in addition to internal process analysis. With respect to the quality of the outcome patient reported outcome measures (PROM) have become increasingly more important in addition to the mortality. The PROMs that are used to assess the consequences of injuries are typically multidimensional and capture not only aspects of physical health but also enable self-assessment of the mental health status by the patient.

[Fractures of the patella]. / Patellafrakturen.

Fractures of the patella account for approximately 0.5% to 1.5% of all skeletal injuries. The diagnosis is made by means of the mechanism of injury, physical and radiological findings. The kind of treatment of patella fractures depends on the type of fracture, the size of the fragments, the integrity of the extensor mechanism and the congruity of the articular surface. Independent of the kind of treatment an early rehabilitation is recommended. Modified tension band wiring is the most commonly used surgical treatment for patella fractures and can be used for almost every type of fracture. Due the superior stability in biomechanical studies two parallel cannulated lag screws combined with a tension band wiring are the treatment of choice for horizontally displaced two-part fractures. In comminuted fractures a partial or total patellectomy may be necessary. However, since the loss of quadriceps muscle power and the poor outcome total patellectomy should be considered as a salvage procedure.

[Interruption of the diagnostic algorithm and immediate surgical intervention after major trauma--incidence and clinical relevance. Analysis of the Trauma Register of the German Society for Trauma Surgery]. / Abbruch der Schockraumdiagnostik und Notfalloperation beim Polytrauma--Inzidenz und klinische Relevanz. Eine Auswertung des TraumaRegisters der DGU.

BACKGROUND: Life-threatening situations after multiple trauma which require interruption of the diagnostic algorithm and immediate surgical treatment after admission are a challenge for the multidisciplinary trauma team. The purpose of this study was to evaluate the incidence, causes, implications and relevance of life-threatening situations for major trauma patients after admission to trauma centers. PATIENT AND METHODS: Data of 12,971 patients listed in the German Trauma Register of the German Society for Trauma Surgery (DGU, 2002-2007) were analyzed. Patients with an injury severity score (ISS) > 16, no isolated head injury and primary admission to a trauma center were included. Data were allocated according to patients where the diagnostic algorithm in the resuscitation room was interrupted to perform emergency surgery (group Notop, n = 713, 5.5%) and patients who received early surgical care after completed diagnostics (group Frühop, n = 5,515, 42.5%). Comparative parameters were the pattern and severity of injury, physiological state and clinical outcome. RESULTS: Patients receiving emergency surgery showed an average ISS score of 39 ± 15 points, whereas patients receiving early surgery showed an average ISS of 31 ± 12 points. On admission patients in the emergency surgery group (44%) suffered from hemodynamic shock considerably more often than patients in the early surgery care group (15%, p < 0.001). This was indicated by the significant differences in systolic blood pressure on admission, amount of preclinical substituted volume, base excess on admission and substituted erythrocyte concentrates in early clinical course. Mortality was 46% in the emergency surgery group and 13% in the early surgical care group (p < 0.001). Severe injuries (AIS ≥ 4) of the thorax, abdomen and extremities (including the pelvis) were encountered considerably more often in the emergency surgery group. There was no statistical difference in occurrence of severe head injuries between the groups. Emergency surgery consisted of 50.5% laparatomy, 19.8% craniotomy, 10.0% thoracotomy and 9.3% pelvic surgery. CONCLUSION: Life-threatening situations after major trauma which require immediate surgical intervention in the resuscitation room rarely occur in Germany. Nevertheless, they are associated with a high mortality and prolonged and complex clinical course if primarily survived. Indications and decision-making processes of these challenging situations have to be practiced with standardized algorithms and should be considered for the future education of orthopedic surgeons in Germany.

[Surgical management of life-threatening injuries]. / Chirurgisches Management vital bedrohlicher Verletzungen.

Life-threatening situations after multiple trauma which then require interruption of the diagnostic algorithm and immediate surgical treatment after admission are a challenge for the multidisciplinary trauma team. Emergency surgery after trauma may be necessary for the abdomen, the pelvis, the chest as well as the head. Therefore, several disciplines may be involved. Damage control surgery is the leading surgical strategy in emergency surgery in unstable trauma patients. The main aspects of damage control surgery are outlined in this article. The goal of damage control surgery is to gain control of bleeding as soon as possible without additional surgical trauma. Packing plays a central role in damage control surgery of the abdomen and the pelvis. Surgical decision-making occurs under unfavorable circumstances and extreme time pressure. However, surgical interventions in the shock room rarely occur in the German health system. Therefore, indications and decision-making processes of these challenging situations have to be practiced with standardized algorithms. The "Definitive Surgical Trauma Care" (DSTC)- courses may contribute to a straightforward performance in an emergency operation.

[Fractures of the shaft of the femur]. / Femurschaftfrakturen.

The femur is the largest, longest and strongest bone in the human skeleton. Fractures of the shaft of the femur can result from high energy as well as low energy trauma and 30% of patients have multiple injuries. In the clinical diagnostic special attention must be paid to the peripheral neurovascular status as well as the possibility of a compartment syndrome. Fractures of the femur shaft are defined according to the AO classification. Treatment is as a rule operative, except for children up the end of 4 years old. Medullary nailing is nowadays the method of choice and the nails can be implanted in an anterograde or retrograde direction. The introduction of nails after boring out the medullar is associated with an increased healing rate in comparison to non-boring techniques. Various techniques are available for the often promising method of repositioning and the intraoperative controls. Plating is reserved only for special situations. External fixation is of great value in adults for temporary fixation of fractures of the femur shaft. Full weight bearing is possible immediately following the operation depending on the type of fracture and method of treatment. Uncomplicated fracture healing does not result in a reduction in the ability to work. Despite the generally good prognosis and improvement in design and technology of implants, fractures of the femur shaft still represent a special challenge for the treating casualty surgeon.

Immune response of severely injured patients--influence of surgical intervention and therapeutic impact.

BACKGROUND: [corrected] Severe injury leads to a severe deterioration of the patients' immune response. The changes of the immune response after severe injury include a broad range of immune functions and may result in a status of immunosuppression, which could favor infectious complications. Therefore, immunostimulating therapies have been introduced in the therapy for severely injured patients in clinical and experimental settings. OBJECTIVES: The article summarizes actual immunomodulating approaches in the treatment of trauma patients and therapeutic strategies avoiding additional immune deteriorations. RESULTS: Examples for an immunostimulating approach in trauma patients are interferon gamma and the granulocyte macrophage-colony-stimulating factor (GM-CSF), which are summarized in this review in detail. However, the effect of such an interference in the patients' immune response with all its different cellular targets is not yet clearly understood, and most studies focus on the reaction of circulating monocytes. In addition, further immunomodulating strategies, including nutritional support, are addressed. However, clinically established therapeutic immunomodulating strategies in trauma care so far do not exist. The impact of the accidental and also an additional surgical trauma on the immune response has been clearly demonstrated. Therefore, the idea of a "damage control orthopedic surgery" (DCOS) is not only necessary to prevent further deterioration of the homeostasis of, e.g., the coagulating system, but is also desirable in terms of minimizing the burden on the immune system. In addition, also the timing of secondary surgical treatment in trauma patient care should include an evaluation of the immune response, although the most reliable markers still need to be identified. CONCLUSION: Immunomodulating therapies in trauma patients exist on an experimental level with inconsistent results. The general management of trauma patients includes strategies that have been developed also on the basis of immunological considerations.

[Preclinical and intrahospital management of mass casualties and terrorist incidents]. / Prä- und innerklinisches Management bei MANV und Terroranschlag.

Due to the recent terrorist attacks in Paris, Brussels, Ansbach, Munich, Berlin and more recently Manchester and London, terrorism is realized as a present threat to our society and social life, as well as a challenge for the health care system. Without fueling anxiety, there is a need for sensitization to this subject and to familiarize all concerned with the special kind of terrorist attack-related injuries, the operational priorities and tactics and the individual basic principles of preclinical and hospital care. There is a need to adapt the known established medical structure for a conventional mass casualty situation to the special requirements that are raised by this new kind of terrorist threat to our social life. It is the aim of this article, from a surgical point of view, to depict the tactics and challenges of preclinical care of the special kind of terrorist attack-related injuries from the site of the incident, via the advanced medical post or casualty collecting point, to the triage point at the hospital. The special needs of medical care and organizational aspects of the primary treatment in the hospital are highlighted and possible decisional options and different approaches are discussed.