Bjoern Hussmann

Prehospital intubation of the moderately injured patient: a cause of morbidity? A matched-pairs analysis of 1,200 patients from the DGU Trauma Registry

IntroductionHypoxia and hypoxemia can lead to an unfavorable outcome after severe trauma, by both direct and delayed mechanisms. Prehospital intubation is meant to ensure pulmonary gas exchange. Limited evidence exists regarding indications for intubation after trauma. The aim of this study was to analyze prehospital intubation as an independent risk factor for the posttraumatic course of moderately injured patients. Therefore, only patients who, in retrospect, would not have required intubation were included in the matched-pairs analysis to evaluate the risks related to intubation.MethodsThe data of 42,248 patients taken from the trauma registry of the German Association for Trauma Surgery (Deutsche Gesellschaft für Unfallchirurgie (DGU)) were analyzed. Patients who met the following criteria were included: primary admission to a hospital; Glasgow Coma Scale (GCS) of 13 to 15; age 16 years or older; maximum injury severity per body region (AIS) ≤ 3; no administration of packed red blood cell units in the emergency trauma room; admission between 2005 and 2008; and documented data regarding intubation. The intubated patients were then matched with not-intubated patients.ResultsThe study population included 600 matched pairs that met the inclusion criteria. The results indicated that prehospital intubation was associated with a prolonged rescue time (not intubated, 64.8 minutes; intubated, 82.3 minutes; P ≤ 0.001) and a higher volume replacement (not intubated, 911.3 ml; intubated, 1,573.8 ml; P ≤ 0.001). In the intubated patients, coagulation parameters, such as the prothrombin time ratio (PT) and platelet count, declined, as did the hemoglobin value (PT not intubated: 92.3%; intubated, 85.7%; P ≤ 0.001; hemoglobin not intubated, 13.4 mg/dl; intubated, 12.2 mg/dl; P ≤ 0.001). Intubation at the scene resulted in an elevated sepsis rate (not intubated, 1.5%; intubated, 3.7%; P ≤ 0.02) and an elevated prevalence of multiorgan failure (MOF) and organ failure (OF) (OF not intubated, 9.1%; intubated, 23.4%; P ≤ 0.001).ConclusionsPrehospital intubation in trauma patients is associated with a number of risks and should be critically weighed, except in cases with clear indicators, such as posttraumatic apnea.

Influence of prehospital volume replacement on outcome in polytraumatized children

IntroductionSevere bleeding after trauma frequently results in poor outcomes in children. Prehospital fluid replacement therapy is regarded as an important primary treatment option. Our study aimed, through a retrospective analysis of matched pairs, to assess the influence of prehospital fluid replacement therapy on the post-traumatic course of severely injured children.MethodsThe data for 67,782 patients from the TraumaRegister DGU® of the German Trauma Society were analyzed. The following inclusion criteria were applied: injury severity score ≥16 points, primary admission, age 1 to 15 years old, systolic blood pressure ≥20 mmHg at the accident site and transfusion of at least one unit of packed red blood cells (pRBC) in the emergency trauma room prior to intensive care admission. As volume replacement therapy depends on age and body weight, especially in children, three subgroups were formed according to the mean value of the administered prehospital volume. The children were matched and enrolled into two groups according to the following criteria: intubation at the accident site (yes/no), Abbreviated Injury Scale (four body regions), accident year, systolic blood pressure and age group.ResultsA total of 31 patients in each group met the inclusion criteria. An increase in volume replacement was associated with an elevated need for a transfusion (≥10 pRBC: low volume, 9.7%; high volume, 25.8%; P = 0.18) and a reduction in the ability to coagulate (prothrombin time ratio: low volume, 58.7%; high volume, 55.6%; P = 0.23; prothrombin time: low volume, 42.2 seconds; high volume, 50.1 seconds; P = 0.38). With increasing volume, the mortality (low volume, 19.4%; high volume, 25.8%; P = 0.75) and multiple organ failure rates (group 1, 36.7%; group 2, 41.4%; P = 0.79) increased. With increased volume, the rescue time also increased (low volume, 62 minutes; high volume, 71.5 minutes; P = 0.21).ConclusionFor the first time, a tendency was shown that excessive prehospital fluid replacement in children leads to a worse clinical course with higher mortality and that excessive fluid replacement has a negative influence on the ability to coagulate.

Prehospital Volume Therapy as an Independent Risk Factor after Trauma

Background. Prehospital volume therapy remains widely used after trauma, while evidence regarding its disadvantages is growing. The primary objective of this study was to investigate the volume administered in a prehospital setting as an independent risk factor for mortality. Material and Methods. Patients who met the following criteria were analyzed retrospectively: Injury Severity Score = 16, primary admission (between 2002 and 2010), and age = 16 years. The following data had to be available: volume administered (including packed red cells), blood pressure, Glasgow Coma Scale, therapeutic measures, and laboratory results. Following a univariate analysis, independent risk factors for mortality after trauma were investigated using a multivariate regression analysis. Results. A collective of 7,641 patients met the inclusion criteria, showing that increasing volumes administered in a prehospital setting were an independent risk factor for mortality (odds ratio: 1.34). This tendency was even more pronounced in patients without severe traumatic brain injury (TBI) (odds ratio: 2.71), while the opposite tendency was observed in patients with TBI. Conclusions. Prehospital volume therapy in patients without severe TBI represents an independent risk factor for mortality. In such cases, respiratory and circulatory conditions should be stabilized during permissive hypotension, and patient transfer should not be delayed.

[Embolization of life-threatening intercostal hemorrhaging in a severely injured patient: a rarity in trauma care].

ZusammenfassungDie transarterielle Embolisation rupturierter Interkostalarterien aufgrund einer Massenblutung stellt eine seltene Indikation bei der Behandlung des Schwerstverletzten dar. Die aktuelle Literatur zeigt vereinzelte Falldarstellungen, Studien existieren nicht. In dem hier dargestellten Fall wird die Embolisation als Therapievariante nach einem durch eine rupturierte Interkostalarterie verursachten hämorrhagischen Schock dargestellt. Die Embolisation bewirkte ein sofortiges Sistieren der Blutung, die Vitalparameter normalisierten sich unmittelbar nach dem Eingriff. Eine chirurgische Intervention konnte vermieden werden. Der im Folgenden geschilderte Krankheitsverlauf zeigt die Wirksamkeit dieser Behandlungsform nicht nur bei blutenden Beckenfrakturen und intraabdominellen Parenchymverletzungen, sondern stellt auch bei isolierten arteriellen Blutungen anderer Körperregionen eine wichtige Therapieoption dar.AbstractTransarterial embolization of ruptured intercostal arteries due to massive bleeding represents an infrequent indication in severely injured patients. The current literature shows isolated case descriptions but no clinical trials exist. In the case depicted here embolization is represented as a form of therapy after haemorrhagic shock caused by a ruptured intercostal artery. The embolization carried out led to an immediate cessation of bleeding. The vital signs returned to normal immediately after the procedure and surgical intervention could be avoided. The course of the disease represented in the following shows the effectiveness of this type of treatment not only for bleeding due to pelvic fractures and abdominal injuries, but also for isolated arterial bleeding in other body regions.Transarterial embolization of ruptured intercostal arteries due to massive bleeding represents an infrequent indication in severely injured patients. The current literature shows isolated case descriptions but no clinical trials exist. In the case depicted here embolization is represented as a form of therapy after haemorrhagic shock caused by a ruptured intercostal artery. The embolization carried out led to an immediate cessation of bleeding. The vital signs returned to normal immediately after the procedure and surgical intervention could be avoided. The course of the disease represented in the following shows the effectiveness of this type of treatment not only for bleeding due to pelvic fractures and abdominal injuries, but also for isolated arterial bleeding in other body regions.

Epiphysäre und epiphysennahe Frakturen bei Kindern

Fractures of and near the epiphysis occur much less frequently in the lower extremities than in the upper extremities. The time required for consolidation of lower extremity fractures is twice as long as for fractures of the arm or hand. Irrespective of the longer time period for fracture healing, close attention must be paid to initial assessment of fractures regarding dislocations and deformities. Although pediatric fracture dislocations of the upper extremity can be tolerated to a great extent, the mechanisms for spontaneous compensation and even correction of posttraumatic deformities are very limited in pediatric fractures of the lower extremities. Additionally, deformities of the lower extremity skeleton result in a more severe functional impairment than would result from epiphyseal fractures of the arm or hand (with the exception of injuries to the elbow). Therefore, proper radiographic diagnostics with precise projection of the required planes are mandatory to accurately determine all further treatment options.ZusammenfassungFrakturen der Epiphysen und epiphysennahe Frakturen der unteren Extremität treten um bis zu 4-mal seltener auf als gleichartige Verletzungen der oberen Extremität. Abgesehen von den durchschnittlich um das Doppelte längeren Konsolidierungszeiten bei Brüchen der unteren Extremität muss das Augenmerk stärker auf Fehlstellungen gerichtet sein als an der oberen Extremität. Dies begründet sich auf die im Vergleich zur oberen Extremität geringere, auch wesentlich vom Alter der Patienten abhängige Ausprägung der spontanen Korrekturmöglichkeiten der Epiphysen. Belassene Fehlstellungen an der unteren Extremität, die außerhalb der möglichen Korrekturgrenzen liegen, führen zu schwerwiegenderen funktionellen Störungen, als sie nach epiphysennahen Frakturen an der oberen Extremität (Ausnahme Ellenbogen) zu erwarten sind. Eine sorgfältige nativradiologische Diagnostik in exakt eingestellten Standardprojektionen ist deswegen unverzichtbar, um mögliche Fehlstellungen und die daraus resultierenden therapeutischen Konsequenzen adäquat einschätzen zu können.AbstractFractures of and near the epiphysis occur much less frequently in the lower extremities than in the upper extremities. The time required for consolidation of lower extremity fractures is twice as long as for fractures of the arm or hand. Irrespective of the longer time period for fracture healing, close attention must be paid to initial assessment of fractures regarding dislocations and deformities. Although pediatric fracture dislocations of the upper extremity can be tolerated to a great extent, the mechanisms for spontaneous compensation and even correction of posttraumatic deformities are very limited in pediatric fractures of the lower extremities. Additionally, deformities of the lower extremity skeleton result in a more severe functional impairment than would result from epiphyseal fractures of the arm or hand (with the exception of injuries to the elbow). Therefore, proper radiographic diagnostics with precise projection of the required planes are mandatory to accurately determine all further treatment options.

Comparison of Malated Ringer’s with Two Other Balanced Crystalloid Solutions in Resuscitation of Both Severe and Moderate Hemorrhagic Shock in Rats

In preclinical treatment of polytraumatized patients crystalloids are preferentially used. To avoid metabolic acidosis, metabolizable anions like lactate or acetate are used to replace chloride in these solutions. We here studied the effects of malated Ringers in resuscitation of both shock severities in comparison to lactated and acetated Ringers. Male Wistar rats underwent severe (mean arterial blood pressure (MAP) of 25–30 mmHg) or moderate (MAP 40–45 mmHg) hemorrhagic shock. Adjacent to the shock period animals were resuscitated with acetated (AR), lactated (LR), or malated Ringers (MR) and observed for 150 min. MR improved survival compared with LR and AR in severe hemorrhagic shock whereas it was equally effective to LR and superior to AR in moderate hemorrhagic shock. In all other parameters tested, MR was also effective similar to the other solutions under these conditions. We conclude that MR is preferable to AR and LR in resuscitation of hemorrhagic shock independent of shock depth. The positive effects of MR may stem from the absence of any adverse impact on energy metabolism under both conditions.

[Kidney injury and multiple trauma: outcome, course and treatment algorithm. An organ-specific evaluation of 835 patients from the trauma register of the DGU].

BACKGROUND The relevance of renal trauma in severely injured patients within a large collective has not yet been thoroughly reviewed. This study aimed at assessing the prevalence of renal trauma in relation to the outcome and the currently established method of treatment. PATIENTS AND METHODS Altogether data of 35,664 patients of the TraumaRegister of the German Society of Trauma Surgery (DGU) (1996-2007) were interpreted retrospectively. All patients with an injury severity score (ISS) ≥16, direct admission to a trauma center and an age of ≥16 years were included. All patients with abdominal trauma (AIS(Abdomen) ≥2) were compared with patients with abdominal and renal trauma (AIS(Kidney) ≥2). RESULTS A total of 18,416 patients fulfilled the inclusion criteria of which 6,218 (34.1%) had abdominal injuries. Of these patients with abdominal injury 835 (13.3%) additionally showed a kidney injury (AIS(Abdomen) ≥2, AIS(Kidney) 2-5) and were analyzed according to the classification of the American Association for the Surgery of Trauma (AAST) organ-severity-score. AAST kidney: II°: 45.5%, III°: 31.1%, IV°: 15.6%, V°: 7.8%. Patients with leading kidney injury (grade IV and V) thereby showed a significant increase in mortality (IV: 32.3% and V: 40.0%) and an increase in the need for surgical intervention (IV: 61.5 and V: 81.5%). With an increasing grade of renal injury, however, the ISS is also increased but mortality was not increased over the expected mortality rate (RISC score) due to the additional renal injury. Dialysis rate in the surviving patients showed an increased rate depending on the degree of the kidney injury (II: 5.5%, III: 7.6%, IV: 18.8%, V: 8.3%). CONCLUSION The results presented here show the prevalence and the outcome of kidney injury in a large collective within the TraumaRegister of the DGU for the first time. Based on the current literature and the findings a treatment algorithm has been developed.

Minimal-invasive dorsale Stabilisierung der thorakolumbalen Wirbelsäule

ZusammenfassungDie dorsale Instrumentierung instabiler Wirbelsäulenverletzungen stellt in der Akutsituation nach wie vor das Verfahren der ersten Wahl dar. Während rein ventrale Stabilisierungen weiterhin die Ausnahme darstellen, erfolgt die Entscheidung über weitere operative Strategien im Sinne zusätzlicher ventraler Stabilisierungen in Abhängigkeit von der Frakturmorphologie und der sich hieraus ergebenden Stabilität. Verletzungen des thorakolumbalen Übergangs stellen zahlenmäßig die häufigste Instabilität dar. Nicht zuletzt wegen des Scheitelpunkts der Wirbelsäule stellt die Wiederherstellung des Grunddeckplattenwinkels und des bisegmentalen Skoliosewinkels bei dieser Verletzung die höchste Prämisse dar. Das offene Vorgehen wird ähnlich wie auch bei den ventralen Versorgungen zunehmend von minimal-invasiven Techniken und Systemen ersetzt. Bei den dorsalen Systemen werden mittlerweile unterschiedliche Systeme zur perkutanen Instrumentierung angeboten. Der vorliegende Beitrag beschreibt das Prinzip, die möglichen Indikationen und Limitationen der minimal-invasiven dorsalen Stabilisierung.AbstractThoracolumbar spine injuries represent the vast majority of unstable spine fractures. In common, patients are instrumented from a dorsal position while primary stabilization of those fractures using a ventral approach remains exceptional. Fracture morphology and concomitant injuries of the discoligamentous complex help to determine whether combined positions or second staged ventral positioned stabilization is indicated. While segmental stabilization and proper fracture reduction are the primary goals, the latter is of specific importance due to the angular point of the vertebral column in fractures of the thoracolumbar spine. The invasive surgical approach in open reduction and stabilization from a dorsal position seems to be replaced increasingly by less invasive angular stable internal spine fixator systems. This article describes the principle, suited indications and the limitations of one of the internal spine fixators available to achieve angular stable percutaneous dorsal stabilization.Thoracolumbar spine injuries represent the vast majority of unstable spine fractures. In common, patients are instrumented from a dorsal position while primary stabilization of those fractures using a ventral approach remains exceptional. Fracture morphology and concomitant injuries of the discoligamentous complex help to determine whether combined positions or second staged ventral positioned stabilization is indicated. While segmental stabilization and proper fracture reduction are the primary goals, the latter is of specific importance due to the angular point of the vertebral column in fractures of the thoracolumbar spine. The invasive surgical approach in open reduction and stabilization from a dorsal position seems to be replaced increasingly by less invasive angular stable internal spine fixator systems. This article describes the principle, suited indications and the limitations of one of the internal spine fixators available to achieve angular stable percutaneous dorsal stabilization.

Minimally invasive dorsal stabilization of the thoracolumbar spine

ZusammenfassungDie dorsale Instrumentierung instabiler Wirbelsäulenverletzungen stellt in der Akutsituation nach wie vor das Verfahren der ersten Wahl dar. Während rein ventrale Stabilisierungen weiterhin die Ausnahme darstellen, erfolgt die Entscheidung über weitere operative Strategien im Sinne zusätzlicher ventraler Stabilisierungen in Abhängigkeit von der Frakturmorphologie und der sich hieraus ergebenden Stabilität. Verletzungen des thorakolumbalen Übergangs stellen zahlenmäßig die häufigste Instabilität dar. Nicht zuletzt wegen des Scheitelpunkts der Wirbelsäule stellt die Wiederherstellung des Grunddeckplattenwinkels und des bisegmentalen Skoliosewinkels bei dieser Verletzung die höchste Prämisse dar. Das offene Vorgehen wird ähnlich wie auch bei den ventralen Versorgungen zunehmend von minimal-invasiven Techniken und Systemen ersetzt. Bei den dorsalen Systemen werden mittlerweile unterschiedliche Systeme zur perkutanen Instrumentierung angeboten. Der vorliegende Beitrag beschreibt das Prinzip, die möglichen Indikationen und Limitationen der minimal-invasiven dorsalen Stabilisierung.AbstractThoracolumbar spine injuries represent the vast majority of unstable spine fractures. In common, patients are instrumented from a dorsal position while primary stabilization of those fractures using a ventral approach remains exceptional. Fracture morphology and concomitant injuries of the discoligamentous complex help to determine whether combined positions or second staged ventral positioned stabilization is indicated. While segmental stabilization and proper fracture reduction are the primary goals, the latter is of specific importance due to the angular point of the vertebral column in fractures of the thoracolumbar spine. The invasive surgical approach in open reduction and stabilization from a dorsal position seems to be replaced increasingly by less invasive angular stable internal spine fixator systems. This article describes the principle, suited indications and the limitations of one of the internal spine fixators available to achieve angular stable percutaneous dorsal stabilization.Thoracolumbar spine injuries represent the vast majority of unstable spine fractures. In common, patients are instrumented from a dorsal position while primary stabilization of those fractures using a ventral approach remains exceptional. Fracture morphology and concomitant injuries of the discoligamentous complex help to determine whether combined positions or second staged ventral positioned stabilization is indicated. While segmental stabilization and proper fracture reduction are the primary goals, the latter is of specific importance due to the angular point of the vertebral column in fractures of the thoracolumbar spine. The invasive surgical approach in open reduction and stabilization from a dorsal position seems to be replaced increasingly by less invasive angular stable internal spine fixator systems. This article describes the principle, suited indications and the limitations of one of the internal spine fixators available to achieve angular stable percutaneous dorsal stabilization.

[Fractures of and near the epiphysis in children. Part II: lower extremity].

Fractures of and near the epiphysis occur much less frequently in the lower extremities than in the upper extremities. The time required for consolidation of lower extremity fractures is twice as long as for fractures of the arm or hand. Irrespective of the longer time period for fracture healing, close attention must be paid to initial assessment of fractures regarding dislocations and deformities. Although pediatric fracture dislocations of the upper extremity can be tolerated to a great extent, the mechanisms for spontaneous compensation and even correction of posttraumatic deformities are very limited in pediatric fractures of the lower extremities. Additionally, deformities of the lower extremity skeleton result in a more severe functional impairment than would result from epiphyseal fractures of the arm or hand (with the exception of injuries to the elbow). Therefore, proper radiographic diagnostics with precise projection of the required planes are mandatory to accurately determine all further treatment options.ZusammenfassungFrakturen der Epiphysen und epiphysennahe Frakturen der unteren Extremität treten um bis zu 4-mal seltener auf als gleichartige Verletzungen der oberen Extremität. Abgesehen von den durchschnittlich um das Doppelte längeren Konsolidierungszeiten bei Brüchen der unteren Extremität muss das Augenmerk stärker auf Fehlstellungen gerichtet sein als an der oberen Extremität. Dies begründet sich auf die im Vergleich zur oberen Extremität geringere, auch wesentlich vom Alter der Patienten abhängige Ausprägung der spontanen Korrekturmöglichkeiten der Epiphysen. Belassene Fehlstellungen an der unteren Extremität, die außerhalb der möglichen Korrekturgrenzen liegen, führen zu schwerwiegenderen funktionellen Störungen, als sie nach epiphysennahen Frakturen an der oberen Extremität (Ausnahme Ellenbogen) zu erwarten sind. Eine sorgfältige nativradiologische Diagnostik in exakt eingestellten Standardprojektionen ist deswegen unverzichtbar, um mögliche Fehlstellungen und die daraus resultierenden therapeutischen Konsequenzen adäquat einschätzen zu können.AbstractFractures of and near the epiphysis occur much less frequently in the lower extremities than in the upper extremities. The time required for consolidation of lower extremity fractures is twice as long as for fractures of the arm or hand. Irrespective of the longer time period for fracture healing, close attention must be paid to initial assessment of fractures regarding dislocations and deformities. Although pediatric fracture dislocations of the upper extremity can be tolerated to a great extent, the mechanisms for spontaneous compensation and even correction of posttraumatic deformities are very limited in pediatric fractures of the lower extremities. Additionally, deformities of the lower extremity skeleton result in a more severe functional impairment than would result from epiphyseal fractures of the arm or hand (with the exception of injuries to the elbow). Therefore, proper radiographic diagnostics with precise projection of the required planes are mandatory to accurately determine all further treatment options.