C.A. Kühne

Mortality in severely injured elderly trauma patients - When does age become a risk factor?

Age is a well-known risk factor in trauma patients. The aim of the present study was to define the age-dependent cut-off for increasing mortality in multiple injured patients. Pre-existing medical conditions in older age and impaired age-dependent physiologic reserve contributing to a worse outcome in multiple injured elderly patients are discussed as reasons for increased mortality. A retrospective clinical study of a statewide trauma data set from 1993 through 2000 included 5375 patients with an Injury Severity Score (ISS) ≥ 16 who were stratified by age. The ISS and Abbreviated Injury Score (AIS) quantified the injury severity. Outcome measures were mortality, shock, multiple organ failure, and severe head injury. Mortality in this series increased beginning at age 56 years, and that increase was independent of the ISS. The mortality rate increased from 7.3% (patients 46–55 years of age) to 13.0% (patients ages 56–65 years) in patients with ISS 16–24; from 23.8% to 32.1% in those with ISS 25–50; and from 62.2% to 82.1% in those with ISS 51–75 (P ≤ 0.05). Severe traumatic brain injury (sTBI) was the most frequent cause of death, with a significant peak in patients older than 75 years. The incidence of lethal multiple organ failure increased significantly beginning at age 56 years (P ≤ 0.05), but it showed no further increase in patients aged 76 years or older. In contrast, the incidence of lethal shock showed a significant increase from age 76 years (P ≤ 0.05), but not at age 56 years. However, from age 56 years, mortality increased significantly in patients who sustained multiple trauma—an increase that was independent of trauma severity.

[Trauma network of the German Association of Trauma Surgery (DGU). Establishment, organization, and quality assurance of a regional trauma network of the DGU].

ZusammenfassungDie Qualität der Schwerverletztenversorgung in Deutschland ist – bedingt durch geographische Unterschiede zwischen den Bundesländern, unterschiedliche Ressourcenallokation und Behandlungskonzepte – in den einzelnen Krankenhäusern sehr inhomogen. Um die Behandlungsqualität zu sichern und weiter zu entwickeln erscheint es sinnvoll, ein strukturiertes, qualitätsgesichertes Netzwerk von Kliniken zu knüpfen, die regelhaft mit unterschiedlichem Versorgungsauftrag an der Schwerverletztenversorgung teilnehmen.Die Voraussetzungen für ein derartiges Netzwerk auf regionaler Ebene sowie für die mit der Schwerverletztenversorgung betrauten Kliniken wurden im Weißbuch „Schwerverletztenversorgung – Empfehlungen zur Struktur und Organisation von Einrichtungen zur Behandlung von Schwerverletzten in der Bundesrepublik Deutschland“ zusammengefasst.Ziel dieser Maßnahmen ist es, jedem Schwerverletzten in Deutschland rund um die Uhr die bestmögliche Versorgung unter standardisierten Qualitätsmaßstäben zu gewährleisten. Dies setzt fachliche Kompetenz und die Bereitschaft aller Beteiligten – Leistungserbringer, Kosten- und Krankenhausträger – voraus, bestehende Versorgungskonzepte gemeinsam weiter zu entwickeln.Die DGU hat als logische Konsequenz langjähriger Erfahrung und wissenschaftlicher Erkenntnisse ein Konzept zur Einrichtung von, an die örtlichen Gegebenheiten angepassten, regionalen Traumanetzwerken von Kliniken zur Schwerverletztenversorgung entwickelt. Die daran teilnehmenden Einrichtungen übernehmen entsprechend ihrer Ausstattung und Struktur unterschiedliche Aufgaben in diesem Netzwerk.Die einzelnen Schritte zur Einrichtung und Organisation eines Netzwerks werden im Rahmen des Artikels aufgezeigt.AbstractThe quality of care in Germany for seriously injured patients varies greatly in individual hospitals due to geographic variations among States and differences in resource allocation and treatment concepts. To assure and enhance treatment quality it seems sensible to establish a structured, quality assured network of clinics, which participate in the management of seriously injured patients according to different specified assignments.The conditions necessary for this type of network on a regional scale and for the clinics charged with the care of the seriously injured were summarized in the White Paper entitled “Management of the Seriously Injured—Recommendations for the Structure and Organization of Facilities in Germany for the Treatment of Seriously Injured Persons.”The goal of this action is to ensure that every seriously injured person in Germany receives the best possible round-the-clock care in adherence to standardized quality criteria. This requires specialized expertise and the willingness of all involved parties—care providers, cost bearers, and hospital owners—to cooperate in further improving existing treatment concepts.As a logical consequence of long years of experience and scientific knowledge, the German Association of Trauma Surgery has developed a concept for establishing a regional trauma network of clinics, adapted to local conditions, for management of seriously injured patients. The participating facilities assume different responsibilities in the network depending on their equipment and structure.This article describes the individual steps toward establishing and organizing a network.

Das Traumanetzwerk der Deutschen Gesellschaft für Unfallchirurgie

ZusammenfassungDie Qualität der Schwerverletztenversorgung in Deutschland ist – bedingt durch geographische Unterschiede zwischen den Bundesländern, unterschiedliche Ressourcenallokation und Behandlungskonzepte – in den einzelnen Krankenhäusern sehr inhomogen. Um die Behandlungsqualität zu sichern und weiter zu entwickeln erscheint es sinnvoll, ein strukturiertes, qualitätsgesichertes Netzwerk von Kliniken zu knüpfen, die regelhaft mit unterschiedlichem Versorgungsauftrag an der Schwerverletztenversorgung teilnehmen.Die Voraussetzungen für ein derartiges Netzwerk auf regionaler Ebene sowie für die mit der Schwerverletztenversorgung betrauten Kliniken wurden im Weißbuch „Schwerverletztenversorgung – Empfehlungen zur Struktur und Organisation von Einrichtungen zur Behandlung von Schwerverletzten in der Bundesrepublik Deutschland“ zusammengefasst.Ziel dieser Maßnahmen ist es, jedem Schwerverletzten in Deutschland rund um die Uhr die bestmögliche Versorgung unter standardisierten Qualitätsmaßstäben zu gewährleisten. Dies setzt fachliche Kompetenz und die Bereitschaft aller Beteiligten – Leistungserbringer, Kosten- und Krankenhausträger – voraus, bestehende Versorgungskonzepte gemeinsam weiter zu entwickeln.Die DGU hat als logische Konsequenz langjähriger Erfahrung und wissenschaftlicher Erkenntnisse ein Konzept zur Einrichtung von, an die örtlichen Gegebenheiten angepassten, regionalen Traumanetzwerken von Kliniken zur Schwerverletztenversorgung entwickelt. Die daran teilnehmenden Einrichtungen übernehmen entsprechend ihrer Ausstattung und Struktur unterschiedliche Aufgaben in diesem Netzwerk.Die einzelnen Schritte zur Einrichtung und Organisation eines Netzwerks werden im Rahmen des Artikels aufgezeigt.AbstractThe quality of care in Germany for seriously injured patients varies greatly in individual hospitals due to geographic variations among States and differences in resource allocation and treatment concepts. To assure and enhance treatment quality it seems sensible to establish a structured, quality assured network of clinics, which participate in the management of seriously injured patients according to different specified assignments.The conditions necessary for this type of network on a regional scale and for the clinics charged with the care of the seriously injured were summarized in the White Paper entitled “Management of the Seriously Injured—Recommendations for the Structure and Organization of Facilities in Germany for the Treatment of Seriously Injured Persons.”The goal of this action is to ensure that every seriously injured person in Germany receives the best possible round-the-clock care in adherence to standardized quality criteria. This requires specialized expertise and the willingness of all involved parties—care providers, cost bearers, and hospital owners—to cooperate in further improving existing treatment concepts.As a logical consequence of long years of experience and scientific knowledge, the German Association of Trauma Surgery has developed a concept for establishing a regional trauma network of clinics, adapted to local conditions, for management of seriously injured patients. The participating facilities assume different responsibilities in the network depending on their equipment and structure.This article describes the individual steps toward establishing and organizing a network.

Minimally invasive polyaxial locking plate fixation of proximal humeral fractures: a prospective study.

BACKGROUND The surgical treatment for displaced humeral head fractures overlooks a broad variety of surgical techniques and implant systems. A standard operative procedure has not yet been established. In this article, we report our experience with a second-generation locking plate for the humeral head fracture that is applied in a standardized nine-step minimally invasive surgical technique (MIS). METHODS In a prospective study from May 2008 until November 2009, a cohort of 79 patients with 80 proximal humerus fractures were operated in a MIS procedure using a polyaxial locking plate. Follow-up examination at 6 weeks and 6 months postoperative included radiologic examinations and a clinical outcome analysis by the Constant Score, the Visual Analog Scale for pain, and the Daily Activity Score. RESULTS The mean patient age was 65.5 years ± 19 years. According to the Neer classification, there were 18 (22.5%) two-part (Neer III), 48 (60%) three-part (Neer IV), and 14 (17.5%) four-part fractures (Neer IV/V). The operation time averaged 65.6 minutes ± 27 minutes. In 13 patients (16.3%), revision was necessary because of procedure-related complications. After 6 months, the Visual Analog Scale for pain was 2.7 ± 1.6 and the Daily Activity Score showed 19.6 ± 6 points. The average age-related Constant Score after 6 months was 67.5 ± 24 points. CONCLUSIONS MIS surgery of displaced humeral head fractures can be performed in all types of humeral head fractures leading to low complication rates and good clinical outcome. A standardized stepwise procedure in fracture reduction and fixation is recommended to achieve reliable good results.

Nonoperative Management of Tracheobronchial Injuries in Severely Injured Patients

PurposeA rupture of the airway due to blunt chest trauma is rare, and treatment can prove challenging. Many surgeons suggest operative management for these kinds of injuries. Nonoperative therapy is reported only in exceptional cases. But there is still a lack of evidence from which to recommend surgical repair of these injuries as the first choice procedure.MethodsWe retrospectively analyzed the records of 92 multiple injured patients admitted to our trauma department between July 2002 and July 2003 for the incidence and management of tracheobronchial rupture (TBR).ResultsFive (5.4%) of 92 patients suffered from tracheobronchial injuries. The mean injury severity score was 38. There were three male and two female patients, with a mean age of 23 years. All patients had lesions <2 cm in size and were treated nonoperatively. One patient died from multiorgan failure, but the others recovered from TBR uneventfully. One patient developed acute pneumonia as a result of respirator therapy, but none of the patients had mediastinitis or tracheal stenosis within 3 months after injury.ConclusionWe believe that surgical treatment is not mandatory in patients with small to moderate ruptures, and such aggressive treatment may even have adverse effects, especially in patients with multiple injuries.

[Arthroscopically assisted reduction of acute acromioclavicular joint separations: comparison of clinical and radiological results of single versus double TightRope™ technique].

BACKGROUND The aim of this study was to compare the results of the single (STR) versus double TightRope™ (DTR) technique for stabilisation of acute separations of the AC joint with the hypothesis that DTR achieves lower CC distance. PATIENTS AND METHODS A total of 29 consecutive patients treated operatively with the TR technique (mean age 38.1 years, n=26 male) were analysed in a cohort study with a mean follow-up of 13.3 months (12.0-21.7). Acute AC joint separations types III and V according to Rockwood (R) were included; R types I, II, IV and VI were excluded. The prospective scores determined pre-op and 3, 6 and 12 months post-op and X-rays were evaluated. RESULTS Of the patients 12 suffered an R type III and 17 an R V separation; 14 were treated with STR and 15 with DTR. With STR, 8 R III and 6 R V injuries and with DTR 4 R III and 11 R V injuries were treated arthroscopically. STR achieved an increased CC distance >125% compared to the contralateral AC joint in five cases (36%). Two of them occurred as R V and three as R III injury. DTR achieved a CC distance >125% in two cases of an R V injury (13%). CONCLUSION The DTR technique provides lower CC distance compared to the STR technique, without a significant difference of CC distance and scores.

Effect of the localisation of the CT scanner during trauma resuscitation on survival -- a retrospective, multicentre study.

INTRODUCTION Whole-body computed tomography (WBCT) is increasingly becoming the standard diagnostic technique during the resuscitation of severely injured patients. However, little is known about the ideal localisation of the CT scanner within the emergency setting. We intended to analyse the potential effect of the localisation of the CT scanner on outcome. PATIENTS AND METHODS In a retrospective multicentre cohort study involving 8004 adult blunt major trauma patients out of 312 hospitals, we analysed the effect of the distance of the trauma room to the CT scanner on the outcome. Three groups were built: 1. CT in the trauma room 2. CT equal or less than 50 m away and 3. CT more than 50 m away. Using data derived from the 2007-2011 version of TraumaRegister DGU(®) and the structure data bank of the TraumaNetzwerk DGU(®) (trauma network, TNW; German Trauma Society, DGU) we determined the observed and predicted mortality and calculated the standardised mortality ratio (SMR) as well as logistic regressions. RESULTS n=8004 patients fulfilled the inclusion criteria: their mean age was 46.4 ± 21.0 years. 72.8% of them were male and the mean injury severity score (ISS) was 28.6 ± 11.8. The overall mortality rate was 16.0%. The mean time from hospital admission to whole-body CT was 17.1 ± 12.3 min for group 1, 22.7 ± 15.5 min for group 2 and 27.7 ± 17.1 min for group 3, p<0.001. Risk adjusted SMR was 0.74 (CI 95% 0.67-0.81) in group 1, 0.81 (CI 95% 0.76-0.87) in group 2, and 0.88 (CI 95% 0.79-0.98) in group 3. SMR group 1 vs. SMR group 2: p=0.130. SMR group 2 vs. SMR group 3: p=0.170. SMR group 1 vs. SMR group 3: p=0.016. SMR groups 1+2 vs. SMR group 3: p=0.046. Comparable data were found for the subgroup analysis of Level-I trauma centres only. Logistic regression confirmed the positive effect of a close localisation of the CT to the trauma room. The odds ratio (OR) was lowest for the localisation of the CT in the trauma room (OR 0.68, CI 95% 0.54-0.86, p<0.001). CONCLUSIONS It was proven for the first time that a close distance of the CT scanner to the trauma room has a significant positive effect on the probability of survival of severely injured patients. The closer the CT is located to the trauma room, the better the probability of survival. Distances of more than 50 m had a significant negative effect on the outcome. If new emergency departments are planned or rebuilt, the CT scanner should be placed less than 50 m away from or preferably in the trauma room.

Das TraumaNetzwerkD DGU 2009

In 2009, 3 years after the foundation of the Trauma Network of the German Society for Trauma (TraumaNetzwerkD DGU), the majority of German hospitals participating in the treatment of seriously injured patients is registered in regional trauma networks (TNW). Currently there are 41 trauma networks with more than 660 hospitals in existence, 18 more are registered but are still in the planning phase. Each Federal State has an average of 39 trauma centres of different levels taking part in the treatment of seriously injured patients and every trauma network has an average catchment area of 8708 km(2). The most favourable geographical infrastructure conditions exist in Nordrhein-Westfalen, the least favourable in Sachsen-Anhalt and Mecklenburg-Vorpommern. A total of 95 hospitals have already fulfilled the first audit of the structural, personnel and qualitative requirements by the certification bodies. Examination of the check lists of 26 hospitals showed shortcomings in the clinical structure so that these hospitals must be rechecked after correction of the shortcomings. A total of 59 hospitals throughout Germany were successfully audited and only one failed to fulfil the requirements. Because of the varying sizes of the trauma networks there are differences in the areas covered by each trauma network and trauma centre. Concerning the process of certification and auditing (together with the company DIOcert) it could be seen that by careful examination of the check lists of each hospital unforeseen problems during the audit could be avoided. The following article will present the current state of development of the Trauma Network of the German Society for Trauma and describe the certification and auditing process.

No further incidence of sepsis after splenectomy for severe trauma: a multi-institutional experience of the trauma registry of the DGU with 1,630 patients

ObjectiveNon-operative management of blunt splenic injury in adults has been applied increasingly at the end of the last century. Therefore, the lifelong risk of overwhelming post-splenectomy infection has been the major impetus for preservation of the spleen. However, the prevalence of posttraumatic infection after splenectomy in contrast to a conservative management is still unknown. Objective was to determine if splenectomy is an independent risk factor for the development of posttraumatic sepsis and multi-organ failure.Methods13,433 patients from 113 hospitals were prospective collected from 1993 to 2005. Patients with an injury severity score > 16, no isolated head injury, primary admission to a trauma center and splenic injury were included. Data were allocated according to the operative management into 2 groups (splenectomy (I) and conservative managed patients (II)).ResultsFrom 1,630 patients with splenic injury 758 patients undergoing splenectomy compared with 872 non-splenectomized patients. 96 (18.3%) of the patients with splenectomy and 102 (18.5%) without splenectomy had apparent infection after operation. Additionally, there was no difference in mortality (24.8% versus 22.2%) in both groups. After massive transfusion of red blood cells (> 10) non-splenectomy patients showed a significant increase of multi-organ failure (46% vs. 40%) and sepsis (38% vs. 25%).ConclusionsNon-operative management leads to lower systemic infection rates and mortality in adult patients with moderate blunt splenic injury (grade 1-3) and should therefore be advocated. Patients with grade 4 and 5 injury, patients with massive transfusion of red blood cells and unstable patients should be managed operatively.

[Significance of liver trauma for the incidence of sepsis, multiple organ failure and lethality of severely injured patients. An organ-specific evaluation of 24,771 patients from the trauma register of the DGU].

BACKGROUND The prognosis of multiple injured patients is mainly limited by initial severe hemorrhage causing hemorrhagic shock, subsequent sepsis and multiple organ failure (MOF). Although mechanisms of altered microcirculation, cytokine release etc. have been intensively investigated, little is known about the relevance of severe liver trauma as an independent predictive outcome factor in these patients. This study aimed to clarify the impact of severe liver trauma in one of the largest trauma databases. PATIENTS AND METHODS The study was based on data from the German trauma register within the German Society for Trauma Surgery (DGU) and 24,711 patients from 113 hospitals were collected for retrospective analysis between 1993 and 2005. 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 the injury pattern into I liver group (severe damage of the liver, AIS>3 and AIS abdomen <3), II Abdomen group (severe abdominal trauma AIS>3, AIS liver <3) and III Control group (liver and/or abdominal trauma AIS<3, other trauma AIS>3). RESULTS Out of 24,771 multiple injured patients from 113 trauma centers, 321 individuals were identified which matched the criteria of the liver group. Another 574 patients were allocated to the abdomen group while the majority of patients formed the trauma group (9574). Severe injury of the liver is associated with excessive demands for volume resuscitation and induces a significantly increased risk for sepsis and MOF compared to both other groups (sepsis 19.9% vs 11%; MOF 32.7% vs 16.6%). Furthermore, deleterious outcome is more frequent associated with patients with severe liver trauma (lethality 34.9%) compared to severe abdominal trauma (12%) and the control group (19.5%). CONCLUSIONS Severe liver trauma is an independent predictor for severe hemorrhage with a substantial increased risk of sepsis, MOF and trauma-related death. While conservative treatment of patients with severe liver trauma but no hemorrhage is effective, patients with hemodynamic instability seem to form a subgroup where contemporary treatment modalities are not yet sufficient.