[Surgery during the SARS-CoV-2 pandemic : Recommendations on operative procedures]. / Chirurgie in der SARS-CoV-2-Pandemie : Empfehlungen zum operativen Vorgehen.

BACKGROUND: In February 2020 Germany was also hit by the SARS-CoV­2 pandemic. Even patients infected by SARS-CoV­2 or COVID-19 may need operative procedures. Currently, no uniform recommendations exist on precautions to be taken when operating on these patients. Furthermore, they may differ from one hospital to another. METHODS: The task force COVID-19 of the emergency, intensive and severely injured section of the German Trauma Society (DGU e. V.) has developed consensus-based recommendations on surgical treatment of patients with SARS-CoV­2 infections. Great importance is placed on the implementation in hospitals at all levels of care. RESULTS: The indications for surgical interventions in patients with COVID-19 infections require an extremely critical evaluation. When indicated these surgical intervention should ideally be performed in a separate operating theater. All personnel involved should wear personal protective equipment with FFP2 masks, face shields and double gloves. The emergency team in the resuscitation bay should generally wear the same personal protective equipment. Special training is mandatory and the exposure of team members should be minimized. CONCLUSION: The recommendations are principally used for all kinds of surgery and comply with the currently available knowledge. Nevertheless, all recommendations represent a compromise between maximum safety of all medical staff and practicability in the routine hospital workflow.

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

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

Change of initial and ICU treatment over time in trauma patients. An analysis from the TraumaRegister DGU®.

BACKGROUND: Clinical guidelines have been standardized for pre- and in-hospital trauma management in the last decades. Therefore, it is known that prehospital management has changed significantly. Furthermore, in-hospital course may be altered to reduce complications and length of stay (LOS). However, the development of trauma patient in-hospital management as well as LOS in the intensive care unit (ICU) has not been investigated systematically over a long-term period in Germany. Aim of our study is to examine the changes in in-hospital management and LOS in the ICU in moderately and severely injured patients. METHODS: Patients documented in the TraumaRegister DGU® (TR-DGU) of the German Trauma Society from 2000 to 2011 and admitted to ICU were included in this study. Demographic data, the pattern of injury, injury severity, duration of mechanical ventilation, LOS in the ICU, hospital LOS, and discharge destination were evaluated. The mean values and the standard deviations are shown. The constant variables were calculated with changes over time analyzed by linear regression analysis, and categorical variables were calculated with the chi-square test. RESULTS: A total of 18,048 patients were analyzed. The rate of patients being intubated at the time of ICU admission decreased from 86.8 % in 2000 to 60.0 % in 2011 (p < 0.001). The time of mechanical ventilation decreased from 7.5 ± 10.5 to 4.7 ± 8.7 days. The intensive care unit LOS was reduced from 11.7 ± 12.8 to 9.0 ± 11.3 days and the length of hospital stay from 27.9 ± 28.7 to 21.1 ± 20.4 days (both p < 0.01). The ICU LOS remained stable in the subgroup of mechanically ventilated patients (12.7 ± 13.2 day in 2000, 12,6 ± 12.9 in 2011, p = 0.6), whereas it was reduced in non-mechanically ventilated patients (5.5 ± 6.8 days in 2000, 3.6 ± 4.5 days in 2011; p < 0.001). CONCLUSIONS: The reduction LOS in the analyzed dataset is mainly explained by the relevantly reduced rate of patients being intubated at the time of ICU admission. Our data demonstrate that trauma patients' in-hospital course is influenced by reduced intubation rate at the time of ICU admission.

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.

Is the ATLS classification of hypovolaemic shock appreciated in daily trauma care? An online-survey among 383 ATLS course directors and instructors.

OBJECTIVE: For the early recognition and management of hypovolaemic shock, ATLS suggests four shock classes based upon an estimated blood loss in percent. The aim of this study was to assess the confidence and acceptance of the ATLS classification of hypovolaemic shock among ATLS course directors and instructors in daily trauma care. METHODS: During a 2-month period, ATLS course directors and instructors from the ATLS region XV (Europe) were invited to participate in an online survey comprising 15 questions. RESULTS: A total of 383 responses were received. Ninety-eight percent declared that they would follow the 'A, B, C, D, E' approach by ATLS in daily trauma care. However, only 48% assessed 'C-Circulation' according to the ATLS classification of hypovolaemic shock. One out of four respondents estimated that in daily clinical routine, less than 50% of all trauma patients can be classified according to the current ATLS classification of hypovolaemic shock. Additionally, only 10.9% considered the ATLS classification of hypovolaemic shock as a 'good guide' for fluid resuscitation and blood product transfusion, whereas 45.1% stated that this classification only 'may help' or has 'no impact' to guide resuscitation strategies. CONCLUSIONS: Although the 'A, B, C, D, E' approach according to ATLS is widely implemented in daily trauma care, the use of the ATLS classification of hypovolaemic shock in daily practice is limited. Together with previous analyses, this study supports the need for a critical reassessment of the current ATLS classification of hypovolaemic shock.

Factors influencing lengths of stay in the intensive care unit for surviving trauma patients: a retrospective analysis of 30,157 cases.

INTRODUCTION: There are many potential influencing factors that affect the duration of intensive care treatment for patients who have survived multiple trauma. Yet the respective factors' relevance to ICU length of stay (LOS) has been rarely studied. Thus, the aim of the present study was to investigate to what extent specific factors influence ICU LOS in surviving trauma patients. METHODS: We retrospectively analyzed a dataset of 30,157 surviving trauma patients from the TraumaRegister DGU® who were older than six years of age and received subsequent intensive care treatment for more than one day, from 2002 to 2011. Univariate analysis and multiple linear regression analysis were used to examine 25 categorical pre- and post-trauma parameters. RESULTS: Univariate analysis confirmed the impact of all analyzed factors. In subsequent multiple linear regression analyses, coefficients ranged from -1.3 to +8.2 days. The factors that influenced the prolongation of ICU LOS most were renal failure (+8.1 days), sepsis (+7.8 days) and respiratory failure (+4.9 days). Patients spent one additional day in the ICU for every 5 additional points on the Injury Severity Score (regression coefficient +0.2 per point). Furthermore, massive transfusion (+3.3 days), invasive ventilation (+3.1 days), and an initial Glasgow Coma Scale score ≤8 (+3.0 days) had a significant impact on ICU LOS. The coefficient of determination for the model was 44% (R2). CONCLUSIONS: Treatment regimens, as well as secondary effects and complications of trauma and intensive care treatment, prolong ICU LOS more than the mechanism of trauma or pre-trauma patient conditions. Successful prevention of complicated courses of illness, such as sepsis and renal and respiratory failure, could significantly abbreviate the ICU stay in trauma patients. Therefore, the staff's attention should be focused on preventive strategies.

Blood loss and operative duration using monopolar electrosurgery versus ultrasound scissors for surgical preparation during thoracoscopic ventral spondylodesis: results of a randomized, blinded, controlled trial.

PURPOSE: Monopolar electrosurgery is the gold standard for surgical preparation in thoracoscopic spine procedures. However, use of ultrasound scissors could decrease blood loss, accelerate the preparation time and improve patient safety, while minimizing operative costs. This trial compares both preparation techniques for ventral thoracoscopic spondylodesis. METHODS: The study design is an open, prospective, randomized, and double-blinded two-armed clinical trial performed in two centres. Forty-one patients with vertebral body fractures from T10 to L2 were included. Primary endpoint: preparation time. Secondary endpoints: blood loss, organ injuries, duration of hospitalization. RESULTS: Primary and secondary endpoints did not differ significantly between groups (p level 0.05). Increased blood loss (150 ml or more) was eliminated with ultrasound scissors (p = 0.0014). CONCLUSIONS: Primary and secondary endpoints did not differ significantly between the two preparation techniques. The use of either ultrasound scissors or electric scalpel offers safe and effective preparation for thoracoscopic spine surgery.

Assessment of hypovolaemic shock at scene: is the PHTLS classification of hypovolaemic shock really valid?

OBJECTIVE: Validation of the classification of hypovolaemic shock suggested by the prehospital trauma life support (PHTLS) in its sixth student course manual. METHODS: Adults, entered into the TraumaRegister DGU(®) database between 2002 and 2011, were classified into reference ranges for heart rate (HR), systolic blood pressure (SBP) and Glasgow coma scale (GCS) according to the PHTLS classification of hypovolaemic shock. First, patients were grouped by a combination of all three parameters (HR, SBP and GCS) as suggested by PHTLS. Second, patients were classified by only one parameter (HR, SBP or GCS) according to PHTLS and alterations in the remaining two parameters were assessed. Furthermore, subgroup analysis for trauma mechanism and traumatic brain injury (TBI) were performed. RESULTS: Out of 46 689 patients, only 12 432 (26.5%) could be adequately classified according to PHTLS if a combination of all three criteria was assessed. In TBI patients, only 12.2% could be classified adequately, whereas trauma mechanism had no significant influence. When patients were grouped by HR, there was only a slight reduction in SBP. When grouped by SBP, GCS dropped from 14 to 8, while no significant tachycardia was observed in any group. In patients with a GCS less than 12, HR was unaltered whereas SBP was slightly reduced to 114 (±42) mm Hg. On average, GCS in TBI patients was lower within all shock groups. In penetrating trauma patients, changes in HR and SBP were more distinct, but still less than predicted by PHTLS. CONCLUSIONS: The PHTLS classification of hypovolaemic shock displays substantial deficits in adequately risk-stratifying trauma patients.

Evaluation of Prehospital Undertriage in Relation to Trauma Team Activation-Results from a Prospective Study in 12 Level one German Trauma Centers.

Background/Objective: This prospective, multicenter observational cohort study was carried out in 12 trauma centers in Germany and Switzerland. Its purpose was to evaluate the rate of undertriage, as well as potential consequences, and relate these with different Trauma Team Activation Protocols (TTA-Protocols), as this has not been done before in Germany. Methods: Each trauma center collected the data during a three-month period between December 2019 and February 2021. All 12 participating hospitals are certified as supra-regional trauma centers. Here, we report a subgroup analysis of undertriaged patients. Those included in the study were all consecutive adult patients (age ≥ 18 years) with acute trauma admitted to the emergency department of one of the participating hospitals by the prehospital emergency medical service (EMS) within 6 h after trauma. The data contained information on age, sex, trauma mechanism, pre- and in-hospital physiology, emergency interventions, emergency surgical interventions, intensive care unit (ICU) stay, and death within 48 h. Trauma team activation (TTA) was initiated by the emergency medical services. This should follow the national guidelines for severe trauma using established field triage criteria. We used various denominators, such as ISS, and criteria for the appropriateness of TTA to evaluate the undertriage in four groups. Results: This study included a total of 3754 patients. The average injury severity score was 5.1 points, and 7.0% of cases (n = 261) presented with an injury severity score (ISS) of 16+. TTA was initiated for a total of 974 (26%) patients. In group 1, we evaluated how successful the actual practice in the EMS was in identifying patients with ISS 16+. The undertriage rate was 15.3%, but mortality was lower in the undertriage cohort compared to those with a TTA (5% vs. 10%). In group 2, we evaluated the actual practice of EMS in terms of identifying patients meeting the appropriateness of TTA criteria; this showed a higher undertriage rate of 35.9%, but as seen in group 1, the mortality was lower (5.9% vs. 3.3%). In group 3, we showed that, if the EMS were to strictly follow guideline criteria, the rate of undertriage would be even higher (26.2%) regarding ISS 16+. Using the appropriateness of TTA criteria to define the gold standard for TTA (group 4), 764 cases (20.4%) fulfilled at least one condition for retrospective definition of TTA requirement. Conclusions: Regarding ISS 16+, the rate of undertriage in actual practice was 15.3%, but those patients did not have a higher mortality.

Trauma registry record linkage: methodological approach to benefit from complementary data using the example of the German Pelvic Injury Register and the TraumaRegister DGU(®).

BACKGROUND: In Germany, hospitals can deliver data from patients with pelvic fractures selectively or twofold to two different trauma registries, i.e. the German Pelvic Injury Register (PIR) and the TraumaRegister DGU(®) (TR). Both registers are anonymous and differ in composition and content. We describe the methodological approach of linking these registries and reidentifying twofold documented patients. The aim of the approach is to create an intersection set that benefit from complementary data of each registry, respectively. Furthermore, the concordance of data entry of some clinical variables entered in both registries was evaluated. METHODS: PIR (4,323 patients) and TR (34,134 patients) data from 2004-2009 were linked together by using a specific match code including code of the trauma department, dates of admission and discharge, patient's age, and sex. Data entry concordance was evaluated using haemoglobin and blood pressure levels at emergency department arrival, Injury Severity Score (ISS), and mortality. RESULTS: Altogether, 420 patients were identified as documented in both data sets. Linkage rates for the intersection set were 15.7% for PIR and 44.4% for TR. Initial fluid management for different Tile/OTA types of pelvic ring fractures and the patient's posttraumatic course, including intensive care unit data, were now available for the PIR population. TR is benefiting from clinical use of the Tile/OTA classification and from correlation with the distinct entity "complex pelvic injury." Data entry verification showed high concordance for the ISS and mortality, whereas initial haemoglobin and blood pressure data showed significant differences, reflecting inconsistency at the data entry level. CONCLUSIONS: Individually, the PIR and the TR reflect a valid source for documenting injured patients, although the data reflect the emphasis of the particular registry. Linking the two registries enabled new insights into care of multiple-trauma patients with pelvic fractures even when linkage rates were poor. Future considerations and development of the registries should be done in close bilateral consultation with the aim of benefiting from complementary data and improving data concordance. It is also conceivable to integrate individual modules, e.g. a pelvic fracture module, into the TR likewise a modular system in the future.

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.

The Shock Index revisited - a fast guide to transfusion requirement? A retrospective analysis on 21,853 patients derived from the TraumaRegister DGU.

INTRODUCTION: Isolated vital signs (for example, heart rate or systolic blood pressure) have been shown unreliable in the assessment of hypovolemic shock. In contrast, the Shock Index (SI), defined by the ratio of heart rate to systolic blood pressure, has been advocated to better risk-stratify patients for increased transfusion requirements and early mortality. Recently, our group has developed a novel and clinical reliable classification of hypovolemic shock based upon four classes of worsening base deficit (BD). The objective of this study was to correlate this classification to corresponding strata of SI for the rapid assessment of trauma patients in the absence of laboratory parameters. METHODS: Between 2002 and 2011, data for 21,853 adult trauma patients were retrieved from the TraumaRegister DGU database and divided into four strata of worsening SI at emergency department arrival (group I, SI <0.6; group II, SI ≥0.6 to <1.0; group III, SI ≥1.0 to <1.4; and group IV, SI ≥1.4) and were assessed for demographics, injury characteristics, transfusion requirements, fluid resuscitation and outcomes. The four strata of worsening SI were compared with our recently suggested BD-based classification of hypovolemic shock. RESULTS: Worsening of SI was associated with increasing injury severity scores from 19.3 (± 12) in group I to 37.3 (± 16.8) in group IV, while mortality increased from 10.9% to 39.8%. Increments in SI paralleled increasing fluid resuscitation, vasopressor use and decreasing hemoglobin, platelet counts and Quick's values. The number of blood units transfused increased from 1.0 (± 4.8) in group I to 21.4 (± 26.2) in group IV patients. Of patients, 31% in group III and 57% in group IV required ≥10 blood units until ICU admission. The four strata of SI discriminated transfusion requirements and massive transfusion rates equally with our recently introduced BD-based classification of hypovolemic shock. CONCLUSION: SI upon emergency department arrival may be considered a clinical indicator of hypovolemic shock in respect to transfusion requirements, hemostatic resuscitation and mortality. The four SI groups have been shown to equal our recently suggested BD-based classification. In daily clinical practice, SI may be used to assess the presence of hypovolemic shock if point-of-care testing technology is not available.

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

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

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

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

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

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

Performing Advanced Trauma Life Support (ATLS) across Borders: Midterm Follow-Up of the Aeromedical Evacuation after Civilian Bus Accident at Madeira.

On 17 April 2019, a coach with tourists from Germany crashed in Madeira, requiring repatriation by the German Air Force. The Advanced Trauma Life Support (ATLS) concept was the central component of patient care. Data in Madeira were collected through a structured interview. The analysis of the Aeromedical Evacuation was based on intensive care transport records. In Germany, all available medical data sheets were reviewed for data collection. Quality of life (HRQoL) was evaluated by the 12-item Short Form Health Survey (SF-12). Twenty-eight prehospital patients were transported to the Level III Trauma Center in Funchal (Madeira). Five operative procedures were performed. Fifteen patients were eligible for Aeromedical Evacuation (AE). In the second hospital phase in Germany, in total 82 radiological images and 9 operations were performed. Hospital stay lasted 11 days (median, IQR 10-18). Median follow-up (14 of 15 patients) was 16 months (IQR 16-21). Eighty percent (8 out of 10) showed an increased risk for post-traumatic stress disorder (PTSD). Six key findings were identified in this study: divergent injury classification, impact of AE mission on health status, lack of communication, need of PTSD prophylaxis, patient identification, and media coverage. Those findings may improve AE missions in the future, e.g., when required after armed conflicts.

Acute management and outcome of multiple trauma patients with pelvic disruptions.

INTRODUCTION: Data on prehospital and trauma-room fluid management of multiple trauma patients with pelvic disruptions are rarely reported. Present trauma algorithms recommend early hemorrhage control and massive fluid resuscitation. By matching the German Pelvic Injury Register (PIR) with the TraumaRegister DGU (TR) for the first time, we attempt to assess the initial fluid management for different Tile/OTA types of pelvic-ring fractures. Special attention was given to the patient's posttraumatic course, particularly intensive care unit (ICU) data and patient outcome. METHODS: A specific match code was applied to identify certain patients with pelvic disruptions from both PIR and TR anonymous trauma databases, admitted between 2004 and 2009. From the resulting intersection set, a retrospective analysis was done of prehospital and trauma-room data, length of ICU stay, days of ventilation, incidence of multiple organ dysfunction syndrome (MODS), sepsis, and mortality. RESULTS: In total, 402 patients were identified. Mean ISS was 25.9 points, and the mean of patients with ISS ≥ 16 was 85.6%. The fracture distribution was as follows: 19.7% type A, 29.4% type B, 36.6% type C, and 14.3% isolated acetabular and/or sacrum fractures. The type B/C, compared with type A fractures, were related to constantly worse vital signs that necessitated a higher volume of fluid and blood administration in the prehospital and/or the trauma-room setting. This group of B/C fractures were also related to a significantly higher presence of concomitant injuries and related to increased ISS. This was related to increased ventilation and ICU stay, increased rate of MODS, sepsis, and increased rate of mortality, at least for the type C fractures. Approximately 80% of the dead had sustained type B/C fractures. CONCLUSIONS: The present study confirms the actuality of traditional trauma algorithms with initial massive fluid resuscitation in the recent therapy of multiple trauma patients with pelvic disruptions. Low-volume resuscitation seems not yet to be accepted in practice in managing this special patient entity. Mechanically unstable pelvic-ring fractures type B/C (according to the Tile/OTA classification) form a distinct entity that must be considered notably in future trauma algorithms.

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

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

Epidemiology and risk factors of sepsis after multiple trauma: an analysis of 29,829 patients from the Trauma Registry of the German Society for Trauma Surgery.

OBJECTIVES: The objectives of this study were 1) to assess potential changes in the incidence and outcome of sepsis after multiple trauma in Germany between 1993 and 2008 and 2) to evaluate independent risk factors for posttraumatic sepsis. DESIGN: Retrospective analysis of a nationwide, population-based prospective database, the Trauma Registry of the German Society for Trauma Surgery. SETTING: A total of 166 voluntarily participating trauma centers (levels I-III). PATIENTS: Patients registered in the Trauma Registry of the German Society for Trauma Surgery between 1993 and 2008 with complete data sets who presented with a relevant trauma load (Injury Severity Score of ≥ 9) and were admitted to an intensive care unit (n = 29,829). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Over the 16-yr study period, 10.2% (3,042 of 29,829) of multiply injured patients developed sepsis during their hospital course. Annual data were summarized into four subperiods: 1993-1996, 1997-2000, 2001-2004, and 2005-2008. The incidences of sepsis for the four subperiods were 14.8%, 12.5%, 9.4%, and 9.7% (p < .0001), respectively. In-hospital mortality for all trauma patients decreased for the respective subperiods (16.9%, 16.0%, 13.7%, and 11.9%; p < .0001). For the subgroup of patients with sepsis, the mortality rates were 16.2%, 21.5%, 22.0%, and 18.2% (p = .054), respectively. The following independent risk factors for posttraumatic sepsis were calculated from a multivariate logistic regression analysis: male gender, age, preexisting medical condition, Glasgow Coma Scale score of ≤ 8 at scene, Injury Severity Score, Abbreviated Injury ScaleTHORAX score of ≥ 3, number of injuries, number of red blood cell units transfused, number of operative procedures, and laparotomy. CONCLUSIONS: The incidence of sepsis decreased significantly over the study period; however, in this decade the incidence remained unchanged. Although overall mortality from multiple trauma has declined significantly since 1993, there has been no significant decrease of mortality in the subgroup of septic trauma patients. Thus, sepsis has remained a challenging complication after trauma during the past 2 decades. Recognition of the identified risk factors may guide early diagnostic workup and help to reduce septic complications after multiple trauma.

Cardiopulmonary resuscitation traumatic cardiac arrest--there are survivors. An analysis of two national emergency registries.

INTRODUCTION: Cardiac arrest following trauma occurs infrequently compared with cardiac aetiology. Within the German Resuscitation Registry a traumatic cause is documented in about 3% of cardiac arrest patients. Regarding the national Trauma Registry, only a few of these trauma patients with cardiac arrest survive. The aim of the present study was to analyze the outcome of cardiopulmonary resuscitation (CPR) after traumatic cardiac arrest by combining data from two different large national registries in Germany. METHODS: This study includes 368 trauma patients (2.8%) out of 13,329 cardiac arrest patients registered within the Resuscitation Registry, whereby 3,673 patients with a cardiac cause and successful CPR served as a cardiac control group. We further analyzed a second group of 1,535 trauma patients with cardiac arrest and early CPR registered within the Trauma Registry, whereby a total of 25,366 trauma patients without any CPR attempts served as a trauma control group. The relative frequencies from each database were used to calculate relative percentages for patients with traumatic cardiac arrest in whom resuscitation was attempted. RESULTS: Within the Resuscitation Registry, cardiac arrest was present in 331 patients (89.9%) when the EMS personal arrived at the scene and in 37 patients (10.1%) when cardiac arrest occurred after arrival. Spontaneous circulation could be achieved in 107 patients (29.1%). A total of 101 (27.4%) were transferred to hospital, 95 of whom (25.8%) had return of spontaneous circulation (ROSC) on admission. According to the Trauma Registry, the overall hospital mortality rate for cardiac arrest patients following trauma was 73% (n = 593 of 814). About half of the patients who were admitted alive to hospital died within 24 hours, resulting in 13% survivors within 24 hours. 7% of the patients survived until hospital discharge, and only 2% of the patients had good neurological outcome. CONCLUSIONS: Our present study encourages CPR attempts in cardiac arrest patients following severe trauma. When a manageable number of patients is present, the decision on whether to start CPR or not should be done liberally, using comparable criteria as in patients with cardiac etiology. In this respect, trauma management programs that restrict CPR attempts should not be encouraged.