[Left ventricular projectile migration after an accidental close-range gunshot wound]. / Linksventrikuläre Projektilmigration nach akzidentiellem Schrotschuss aus nächster Nähe.

We report the case of a 24-year-old female after sustaining a shotgun wound in the left upper extremity and chest. Initial emergency diagnostics revealed numerous shotgun pellets scattered throughout the left-side soft tissue, chest and upper lung lobe with one pellet having migrated into the left ventricle of the heart.Due to the devastating injury pattern, gunshot wounds are interdisciplinarily challenging and should include extended initial diagnostics, such as contrast agent CT. The potential toxicity of elevated lead blood levels have to be taken into further account.

[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.

[Penetrating neck injury of a blacksmith by splitter projectile]. / Penetrierende Halsverletzung durch ein Splitterprojektil bei Schmiedearbeiten.

Laryngeal injuries are rare but potentially life-threatening injuries. Due to the topography of the neck, accompanying injuries of the greater blood vessels, cervical nerves, thoracic organs and spinal cord are common. Therefore in initial diagnostics, these must be excluded from injuries which determine the prognosis. A patient presented with ventral perforation of the larynx, initial dyspnea, hematemesis and left-sided emphysema of the neck. Cause of the findings, we treated the patient non-operatively in interdisciplinary consensus.

[Advanced Trauma Life Support (ATLS) in the emergency room. Is it suitable as an SOP?]. / Schockraummanagement von Schwerverletzten. Eignet sich ATLS als SOP?

There is clinical evidence that a standardized management of trauma patients in the emergency room improves outcome. ATLS is a training course that teaches a systematic approach to the trauma patient in the emergency room. The aims are a rapid and accurate assessment of the patient's physiologic status, treatment according to priorities, and making decisions on whether the local resources are sufficient for adequate definitive treatment of the patient or if transfer to a trauma center is necessary. Above all it is important to prevent secondary injury, to realize timing as a relevant factor in the initial treatment, and to assure a high standard of care. A standard operating procedure (SOP) exactly regulates the approach to trauma patients and determines the responsibilities of the involved faculties. An SOP moreover incorporates the organizational structure in the treatment of trauma patients as well as the necessary technical equipment and staff requirements. To optimize process and result quality, priorities are in the fields of medical fundamentals of trauma care, education, and fault management. SOPs and training courses increase the process and result quality in the treatment of the trauma patient in the emergency room. These programs should be based on the special demands of the physiology of the trauma as well as the structural specifics of the hospital. ATLS does not equal an SOP but it qualifies as a standardized concept for management of trauma patients in the emergency room.

[Artificial intelligence in orthopedics and trauma surgery]. / Künstliche Intelligenz in der Orthopädie und Unfallchirurgie.

Artificial intelligence (AI) is a very relevant topic for the medicine of the future. This article focuses on the field of AI in the context of orthopedics and trauma surgery. The main focus is on the potentials of AI in the analysis of symptoms, radiological images, clinical data sets, use in hospitals and operating theaters as well as for training and education. For the orthopedics and trauma surgery of the future AI is much more than pure fiction; however, there is still a long way to go before the potential of an optimized and individualized patient care can be utilized. Interdisciplinary and international approaches, including personnel, economic, legal and ethical aspects will play a decisive role in this respect.

[Damage Control Orthopedics. What is the current situation?]. / Damage Control Orthopedics. Was ist der aktuelle Stand?

Damage Control Orthopedics is a strategy for treatment of fractures in severely injured patients. The aim is to reduce secondary damage and thereby improve the patient's outcome. The relevant fractures are primarily stabilized with external fixators instead of a primary definitive osteosynthesis. The less traumatic and shorter surgical procedure is thought to reduce the additional trauma load and should thereby minimize the "second hit" situation. After stabilization of the patient on the intensive care unit secondary definitive ostesynthesis can then be performed after 4-14 days.The available animal studies, retrospective clinical studies and prospective cohort studies seem to support the concept of damage control. The only available randomized study shows an advantage of this strategy in a subgroup of borderline patients. A meta-analysis could not find convincing evidence that definitively proves the advantage of this concept. A new multi-center randomized study has been started to evaluate the concept of damage control in a defined group of critically injured patients with femoral shaft fractures.

Red-blood-cell to plasma ratios transfused during massive transfusion are associated with mortality in severe multiple injury: a retrospective analysis from the Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie.

BACKGROUND: To test whether an acute transfusion practice of packed red blood cells (pRBC) : fresh-frozen plasma (FFP) 1 : 1 would be associated with reduced mortality in acute bleeding multiply injury. METHODS: Retrospective analysis using the TR-DGU database (Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie 2002-2006) on primary admissions with substantial injury (Injury Severity Score > 16) and massive transfusion (> 10 pRBCs). Seven hundred thirteen patients were divided into three groups according to the pRBC : FFP ratio transfused, that is, (i) pRBC : FFP > 1.1; (ii) pRBC : FFP 0.9-1.1 (1 : 1); and (iii) pRBC : FFP < 0.9, and mortality rates were compared. RESULTS: Four hundred ninety-seven (69.7%) of patients were male, the mean age was 40.1 (+/- 18.3) years. Injury characteristics and pathophysiological state upon emergency room arrival were comparable between groups. Out of 713, 484 patients had undergone massive transfusion with pRBC : FFP > 1.1, 114 with pRBC : FFP 0.9-1.1 (1 : 1), and 115 with pRBC : FFP < 0.9 ratios. Acute mortality (< 6 h) rates for pRBC : FFP > 1.1, pRBC : FFP 0.9-1.1 (1 : 1), and pRBC : FFP < 0.9 ratios were 24.6, 9.6 and 3.5% (P < 0.0001), 24-h mortality rates were 32.6, 16.7 and 11.3% (P < 0.0001), and 30-day mortality rates were 45.5, 35.1 and 24.3% (P < 0.001). The frequency for septic complications and organ failure was higher in the pRBC : FFP 0.9-1.1 (1 : 1) group, ventilator days and length of stays for intensive care unit and overall in-hospital were highest in the pRBC : FFP < 0.9 ratio group (P < 0.0005). CONCLUSIONS: An association between pRBC : FFP transfusion ratios and mortality to favour early aggressive FFP administration was observed. Further investigation is necessary prior to recommending routine 1 : 1 or more aggressive FFP use in exsanguinating patients.

An optimization algorithm for individualized biomechanical analysis and simulation of tibia fractures.

An algorithmic strategy to determine the minimal fusion area of a tibia pseudarthrosis to achieve mechanical stability is presented. For this purpose, a workflow capable for implementation into clinical routine workup of tibia pseudarthrosis was developed using visual computing algorithms for image segmentation, that is a coarsening protocol to reduce computational effort resulting in an individualized volume-mesh based on computed tomography data. An algorithm detecting the minimal amount of fracture union necessary to allow physiological loading without subjecting the implant to stresses and strains that might result in implant failure is developed. The feasibility of the algorithm in terms of computational effort is demonstrated. Numerical finite element simulations show that the minimal fusion area of a tibia pseudarthrosis can be less than 90% of the full circumferential area given a defined maximal von Mises stress in the implant of 80% of the total stress arising in a complete pseudarthrosis of the tibia.

[Pulmonary pseudocysts. A rare entity after thoracic injury]. / Pulmonale Pseudozysten. Eine seltene Entität nach Thoraxtrauma.

Post-traumatic pulmonary pseudocyst is a rare manifestation of blunt thoracic injury. Young adults and adolescents are predominantly affected. Here we report the successful outcome of post-traumatic pseudocysts secondary to severe lung contusion with severe intrathoracic haemorrhage in both lower lobes and the upper right lobe by aggressive coagulation management, kinetic therapy/postural drainage and control of secondary infection.

New approaches to shock and trauma research: learning from multidisciplinary exchange.

BACKGROUND: Our understanding of the complex network of pathophysiology after multiple injury is limited. It is proposed to overcome the limitations of the traditional linear reductionism approach by merging the expertise of biology and medicine with other disciplines such as mathematics, physics and computer science. METHODS: We organized a two-days-workshop, where surgeons and surgical scientists explained the problem from the medical (pathophysiological) perspective to a well selected group of German applied mathematicians and computer scientists. Vice versa they presented and discussed their approaches to complex system analysis. RESULTS AND CONCLUSIONS: Physicians found it difficult to develop questions and concepts that go beyond the classic mechanistic thinking. Well formulated questions are the most important prerequisites for successful application of mathematical tools. The possibilities and borders of Artificial Neural Networks (ANN), Hidden Markow Models (HMM), Agent Based Models (ABM), differential equations for problem solving were discussed. There is no master model for all aspects of pathophysiology, however, application of the models to specific problems is mandatory. CONCLUSIONS: Future breakthroughs can only be expected if we overcome language problems between disciplines. This cross talk was considered by all participants as a most important step.

[Is implant removal after percutaneous iliosacral screw fixation of unstable posterior pelvic ring disruptions indicated?]. / Ist die Entfernung des Osteosynthesematerials nach perkutaner iliosakraler Verschraubung bei iliosakraler Sprengung oder Sakrumfraktur indiziert?

The aim of this study was to examine the indication for implant removal (IR) after percutaneous iliosacral screw fixation of unstable posterior pelvic ring disruptions by systematic literature analysis and clinical follow-up examination. Retrospective identification revealed 27 operatively stabilized patients [12 females, mean age: 35 years, ISS 22 points (range: 14-37)] between January 1996 and July 2001. Patient characteristics, AO classification, Hannover fracture scale pelvis, ISS, and DGU pelvis score points were analyzed. All cases showed a C-type lesion (C1:67%, C2:33%). A total of 21 patients were seen at follow-up, 12 with and 9 without IR. In ten cases with IR, clinical outcome improved after surgery according to the DGU pelvis score ( p=0.001, Wilcoxon's test). These mostly young patients also showed a better outcome compared with those cases without IR. Due to the good clinical results, implant removal seems to be beneficial for selected individual patients, especially when pain is present.